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This study explores mental health nurses’ and psychiatrists’ perceptions of their work. It was carried out in five mental health Trusts in the West Midlands, UK. Three groups were surveyed: psychiatrists, hospital-based nurses and community mental health nurses (CMHNs). Results showed that CMHNs’ sources of job satisfaction and dissatisfaction were more similar to those of psychiatrists than to those of their hospital-based counterparts. All three groups cited the intrinsic worthwhileness of their work, autonomy, the scope for creativity, the variety their job offered and their contact with clients as contributing to their overall job satisfaction. Hospital-based nurses listed the support they received from colleagues as their second source of job satisfaction, whereas CMHNs and psychiatrists cited the provision of care to patients. Excessive administrative duties and the absence of or poor quality of management were perceived by all three groups as sources for dissatisfaction with their work. Hospital nurses cited job insecurity as a principal concern more frequently than CMHNs and psychiatrists. The paper concludes by discussing recommendations for changes to improve the nature of the work in mental health services and in the work environment. Changes must reflect the concerns of the different groups of mental health professionals.
People are not marely passive recipient of enviromental events. They can (and do) make conscious choices to respond to the demands of the world. Many life events tend to be unpredictable and may have an impact for which people are unprepared. Despite the widely held lay view that stress is always a negative experience, some degree of stress is actually productive-it serves to keep people alert, save focused on the task at hand (see chapter 2).when stress experienced, it is a ‘manageable’ rather than a ‘controllable’ phenomenon. To expect to be able to ‘control’ stress is not helpful. Stress is an inevitable by product of daily life and we need to develope the capacity to occasionally tolerate quite high levels. Therefore, while the appropriate applications of stress reduction strategies can reduce the unpleasant effects of stress to a level that is manageable, it would be fruitless to attempt to remove all experience of stress.
MANAGEMENT OF STRESS
A key point for managing stressors is to be able to identivy and use appropriate strategies and also to recognise that sometime the strategy selected may not work as efficientlyas hopped and/or may not take effects immediatly. At such times, flexibility in approach is needed. This raises an important point about stress management: personal expectations. It is quite common for people to set fairly unrealistic standards for themselves-and, for the matter, for that matter, for others standards which represent perfection (e.g. striving to attan 100 % all the time). When an individual is unwilling to compromise idealistic standards, dissapointment and even maladaptation may result. In this case, the person will feel a failure,or attribute blame for the failure elsewhere. It is more productive to take a step back, to look a little more realisticcally at self impossed standards and to consider appropriate stress management options.
It is common for people to want immediate relief from their distressing symptoms. Sometimes, more or less immediate symptomatic relief is possible. For example, by the use of prescribed and non prescribed drugs. Howefer, it is useful to recognise that these remedies offer only temporary symtomatic relief, and the situations that generated the distress are unlikely to be affected by such action. This is an important point to consider in developing successful stress management strategies.
Pharmacological means
Caffeine, alcohol, prescibed and non-prescibed drugs, especially the antianxienty drugs (more properly called the anxiolytics). These are palliative rather than curative. All save to decrease awareness of the environment and, thus, hae no direct on stressor.
These drugs have effects on the ‘stress related’ hormones such as :
• Adrenocorticotrophic hormone (ACTH)
• Adrenaline, also known as epinephrine (E)
• Dopamine (DA)
• 5 hydoxytrymtamine (5HT)
• Gamma-aminobutyric acid (GABA)
• Prolactin (PRL)
• Growth hormone (GH)
Behavioural strategies
Bihavioural techniques are based on the concepts of lerning, conditioning and reinforcement. Outcomes, which depend on the selected behaviour, will reinforce the frequency (and likalihood) of that behaviour recurring. Some peple engage in behavioural techniques that are not neccesserily healthy: social isolation, ‘throwing oneself into work’, the use of non-prescribed drugs, smoking or overating are sometimes used as stress reducers. These have obvious detrimental effects. Other techniques, such as jogging or breathing exercises, produce positive physiological effects that decrease the stress response.
Improved behavioural skill such as improved communication, assertiveness training, hyperventilation control, exercise, time management and career development are useful physicological interventions for stress management. One of these techniques-hyperventilation control- has a biological basis it also has the important psychological consequence of distraction. At times of high anxiety, breathing rates can change dramatically. This technique uses slowe inspiration and expiration cycles, typically of 5 seconds duration. Thus, one complete respiratory cycle will last 10 seconds, compared to a normal resting rete about 5 seconds.
Cognitive streategies
Cognitive techniques aim at cognitive (or thingking) skills, and can provide stress reduction benefits. These techniques are based on the assumption that stress responses often result from individual’s past experiences in appraising threatening situations. These perceptions do not necceserellyating, reflect the environment accurately. A person may extarnalise or internalise ‘blame’ for the events; engage in anxiety-producing thoughts (exaggeratingcatastrophising,negativsm) or developed unrealistic beliefs.
Some examples of these techniques are :
• Distraction
• Thought stopping
• Attention switching (from internal to an external focus)
• Exchanging negative catastrophic thoughts for neutral/positivr ones;and
• Covert familiarises, in which the person learns to plan ahead. In each case, practise familiarises the routine for the oerson, and successful stress reduction provides the positive reinforcement needed to unsure that he desired cahanges are continued.
Environmental strategies
Some physical structures of the enviroment, as well the values attached to it, can be modified or manipulated, or manipulated, and thus decrease advent he focus may be shifted from individual to group responses. This change of emphasis of stressful stimull. Making aspects of the environment more attractive usually makes people feel better about it and more inclinned to tolerate day-to-day stressors.
Control or management of environment stressors may require making some change, in which the focus may be shifted from individual to group responses. This change of emphasis capitalises on the buffering or supportive nature of group activities.
Psychosocial strategies incorporate personal management techniques that may improve the psychosocial settings in which people operate, and are thus of value in stress management.
They include :
• Social support
• Providing information about management of day-to-day probblems
• Flexibility in work hours, thus accommodating individual requirements for child care and other care services.
These approaches may focus or stressors, including thse which may be generated outside one’s environment (e.g. the workplace), but which transferinto it. The focus of these broader approaches can range from general counselling services to specific individualised programs (e.g. weight reduction, anti smoking programmes, and other aimed at reducing alcohol or oother subtance use and abuse).
The options shown in box 11.1 are primarily in effect, and probabbly have the greatest utility when they assist an individual to manage unavoidable enviromental demands. Psychological methods (see box 11.2) are designed to improve adaptive moderation (whether behavioural or cognitive) of exaggerated or innappropriate psychological response to stress. The enviromental approach, shown in box 11.3, deals deals with facers of the immediate envireonment that can be change or modified to reduce high levels of stress. The thrust of the psycholosocial approaches (see box 11.4) is to provide a more suportive sociocultural group in which to foundation.
MANAGEMENT OF MENTAL DISORDERS
From time to time some people suffer from major pro blems that affect their mental their. Howefer, in order to justify a clinical diagnosis of mental disorder, cleary defined criteria must be met. These criteria include a rainimum time period for which the symptomps must be experienced (see chapter 10). Fortunately, only a relatively small numbers of people meet these clinical criteria. Even the mental disorders that are most obviously connected to stress and coping (the anxiety disorders, particuraly post-traumatic stress disorder) have explicit criteria that must be fullfilled for a specified time period.
Medical-biological interventions
The medical-biological model in psychiatry originated from the xystematic observatio, naming and clasifications of symptomps. According to this model, behavioural distruptions, including abnormal behaviour, are attributtable to organic factors such as a disease process, probabbly origination in the central nervous systerm. Examples of organic factors are lesions, neuropatologic conditions, toxins from outside the body, and biochemical abnormalities of neurotransmitters and enzymes. This indicates that like any other disease, there is a process operating; the condition is likely to follow a predictable course and the prognosis can be estimated. If the causes can be identified and treated, the symptomatology will subside. Treatment depends on diagnosis and frequently includes somatic therapies in addition to interpersonal therapies. How much treatment is appropriate will depend on how the client’s symptomps respond to interventions. There is a wide body of avidence for a biological basis for many mental diorders and this forms the core component of commonly prescribed somatic intervention.
Neuroleptics
This group of drugs are most widely used in treatment of psychotic conditions.they detrive their name from their capacity to affects several integrating systems of the brain, including the ability to produce movement disorders.
The neuroleptics are frequently used in the management of a variety of disturbed behaviours, including behaviour that is classified as psychotic. These compounds were formally known as major tranquillers or antipsychotic drugs. The term ‘neuroleptic’ reflects their ability to selectively reduce emotionally and pschomotor activity (feldman & Quenzer 1984).
They are palliative, not curative. All classes of neuroleptics are thought to exert their potent antipsychotic antion by blocking DA in certain areas of the brain (Synder 1976, 1980), even though most of them block NE to some extent. More specifically, their antipsychotic potency correlats with their ability to nhibit DA-sensitive enzymes that are required to drive natural pumps (like the NA+ pump in DA-activated nerons in the mesolimbic system of the brain).
As with all pharmacological agents, the neuroleptic drugs have many effects in addition to their principal therapeutic effects, and these can be seen pheriperally as well as centrally. For instance, the DA-blocking action which they exert on the mesolimbic system of the brain probably accounts for their antipschotic effects, while the same DA antagonism on yhe nigrostriatal pathway probabbly accounts for the unwanted parkinsonian symptomps that result from prolonged administration (Synder 1976). This is because there are also cholinergic neurons in the stratium that are normally inhibited by DA. If there is DA deficientcy, the cholinergic neurons become overactive and may contribute to the parkinsonism.
Cloapzine
A compound that is receiving increasing attention in the treatmant of schizophrenia is clozapine (clozaril). First synthesised in 1959, clozapine was withdrawn from unrestricted use in 1975 atfer eight people in fingland developed agranulocytosis (an acute disease in which there is a sudden drop in the production of white blood cells, leaving the body defencelless against bacterial infection) and died (Chatterton 1994,p.86). its use has been slowly reintroduced since 1988 for the treatmant of schizophrenia unresponsive to other compouds (treatmant-resistant schizophrenia).
Clocapine is contraidicated in the following situations:
• when there is a history of drug-induced agranulocytosis;
• bone marrow disorders;
• circulatory collapse;
• depression of the central nervous system (CNS);
• alcohol or toxic psychoses;
• drug intoxication;
• coma;
• uncontrolled epillepsy;
• several renal, hepatic or cardiac disease;
Antidepression
The applications of antidepressants (see box 11.6) are more widespread than just the depressive disorders. This is because their pharmacologic activity includes anticholinergic, antihistamic, hypothermic and antiemic action. They may be prescribed for adjusment disorders, atypcal depression, panic disorders; also for selective use in subtance related disorders.
Nurses should be aware of the time lag between the initation of therapy with antidepressant and the clinical effects. This dalay has important implications for management of the depressed client and must be taken into consideration by the nurses involved. While clients receiving either TCAs or MAOIs warrant education on the expected effects of their prescription, those receiving the MAOIs require particular consideration because of possible adverse side effects, and the drug’s potential for interaction with dietary tyramine.
These agents consits of several broad groups, of which the tryciclic antidepressants (TCAs) and the monoamine oxidase inhibitors (MAOIs) are commonly encountered in psychiatric-mental health care settings. Neither of these two subgroups is a CNS stimulant; rather, their therapeutic effects are achied by their influence on neunoral uptake of biogenic amines. Use of the MAOIs relates to their ability to block the degradation of NE and 5HT, which effectivelly increases the available quantities of these neurotransmitters.
Prozac
Although the tryciclic antidepressants are the most widely used compounds in the treatment of depression, they are associated with unsatisfactory side effects. Newer antidepressants such as Prozac (fluoxetine), have better side effect profiles and longer halv-lifes. The half-life for prozac is 2 to 3 days, whereas the half-life for the tryciclics is 10-14 hours. Therefore, prozac is commonly administrated once daily, in the morning. The therapeutic effect of prozac is atrribute to its ability to combine to the cholinergic, histaminergic and alpha-1 adrenergic receptors with minimal affinity. It is a selective serotonin (5HT) re-uptake inhibitor (SSRI) that is particulary effective in the treatment of major depressive disorders where other therapy is inappropriate or ineffective. Client must not be transfered to treatment with MAOIs to prozac for two weeks after ceasing MAOIs. Adverse effects enclude CNS disturbances, drowsiness, sweating and gastrointestinal disturbances. Initially 1 capsule (20mg) is given daily in the morning. The dose is incresed to 40mg daily after two weeks if necessery. This dose can be divided-20mg in the morning and 20mg at noon. The maximum daily dose is 80mg.
Lithium carbonate
All clients receiving lithium require serum level assesment-at least monthly during mantenence therapy, and mlre frequently during intiation of therapy. Serum levels of lithium need to be maintened within fairly defined ranges for both acute therapeutic response and long-term maintenence therapy. Representative values are indicated in table 11.3. blood samples are obtained 12 hours after the last dose received. If serum lithium results>1.5mEq/L, or if litium carbonate (LiCO3) is the only specific anti-manic compound available at present. In normal subjects, this compound has no obviously psychotropic action. It is used in the treatment of the manic phase of bipolar disorder and for long-term maintenece therapy, as t reduces the severity and frequency of bipolar episodes. When mania is mild, lithium alone may be an effective treatmant but, in severe cases, it is almost always prescribed conjunction with one of the neuroleptic may be cassed and lithium maintenences therapy. It is not always the case that maintenence is coplex and the benefits of continuation must outweight the risks of adverse reaction and comulative toxity. It is also impotantn to consider the frequency, duration and severity of episodes, as well as the clients insight and compliance.
Relevance of pharmacological knoledge to nursing
Nurses often perform a crucial role in the selection and administration of appropriate medication (it is often nurses’ history-taking, obserfation, administration, and recomendations that contribute significantly to the selection of the drug and the dosage). It is, thus, important for nurses to maintain an up-to-date knowledge of these agents. High on the list of nursing responsibilities is the recognition that clients with mental disorders frequently display a wide variety of behaviours; some may be quite subtle and requirecareful observation to identify, and some are much more obvious. Nurses, thus, have a responsibility for the accurate assessment of client and their behaviours is psychotropic medication is to be used effectively and appropriately.
Psychoanalytic therapy
This model is usually credited to the Vinnese physician, sigmund freud. Freud’s premise was that all psychological and emotionalevents, however obscure, were understandable. Freud explained behaviour by analysing childhood experiences, which he believed could cause adult neuroses. Therapy, in this model, consists of claryfing the meaning of events, feelings and behaviours, and, in doing so, gaining insight about them.
Psychoanalytic therapy is based on an alliance with the client which utilises the phenomena of transference and countertransference. Behviour is interpreted in the light of apparent earlier traumatic conflicts and experiences, and these interpretations are meant to be considered by the client. The therapist remains aloof from the client to encourage the development of transference. Therapy is, thus, aimed at resolving the conflict and uncovering the roots of that conflict in the unconscious. Psychotherapy is based on the view that release of represed feelings associated with the conflict will cause the conflict to be resolved and the symptomps will disappear.
Relevance of psychoanalysis to nursing
Many of terms arisin from Fraud’s work have passed into common usage. Such expressions as conflict,id,ego, rejection, repretion egocentricity, sibling rivalry,phallic symbol and castration complex are freely used, possibly with no real comprehension of the concepts behind them. Psychoanalytic cocepts have permeated the education and practice of some clinician so widely that they have come to be regarded as a fundamental part of understanding mental disorders. Nurse need to be aware of some of the psychoanalytic languange, concept and speculation about client dynamic in order to participate as equal members of the psychiatric team. Nevertheless, the role available to nurses who practise in a setting where a psychoanalytic framework previle is probabbly rather limited. Psychoanalytic requires years of specialist training and is, by nature, a protacted process, proving highly dependent on the development an exploitation of the spesific relationship between therapist and client. Interpretation of the hidden meanings and symbolic nature of experience is usually the prerogative of the therapist and traditionally takes place within the confines of the one-to-one relationship. It is important to apreciate that over the past 50 years there has been a proliferation of post-freudian psychoanalytical approaches to conselling and group work.
Cognitive-behavioural therapy
This model draws on both psychology and neuropsychology . to the behaviouralist, the conditioned or learned response is viewed as the basic unit of learning, reinforced by the outcome of behaviour. Deviations is behaviour occur because of the power of the association between the undisirable behavioural habit and reinfocement, and are considered to be prepetued because of the asociated reduction in axiaty.
The prespective assets that human beings are merely complex animals with the power of conceptual thought, propotional languange and the ability to attach meaning to hypothetical or metaphorical concepts. These abilities are all fully attributable to complex psyology, rather than to some non-meterial source. Who we are (self) simply reflects the total of past learning-our behavioural repertoire. Cocepts such as ‘counsiouness’ and ‘self’ can only be inferred from behaviour which can be observed, descibed and recorded. Behaviour is reinfoced by conditions in the environment, so the self is a structure of stimulus-response chains (habits). The symptomps of disorder are, in fact, the subtance of the person’s troubles. Since behaviours can be learned, it can be unlearned.
The aim of behaviour therapy is to change behaviour. In many behavioural settings, clients follow prescribed schedules for daily living and are rewarded for desired behaviour. Behavioural deviations are not rewarded;more productive behaviours are reinforced. Thus, acceptable behaviours can be learned, or deviance are subtitude for the undersirable ones.
The cognitive prespective therapy broadens this viewpoint. Behaviour does not occur in a vacum; rather, people think about the stimull they receive, this thingking may occur rapidly and without awareness. Nevertheless, when sensory stimull and received, they are processed, interpreted and compared with idealised and stored memories. The cognitive theorist indicate that it is cognitive process such as thingking, memorry, and recall that influence behavioural rsponses.
Relevance of cogitive-behavioural therapy to nursing
Nurses have a role in teaching cognitive-behavioural principles to client to enable them to act as their own changes agents. Non-profesionals can be taught to use behaviour that often accompanies long-term mental disorder. In general, behavioural modifications offer a rapid, efficient anf effective system of nursing intervention.
SOCIAL INTERPERCONAL THERAPY
This model developed because of general dissatisfaction with other models. It is a combination of a social model and an interpersonal model. The social model suggest that social and enviromental factors creatte stress, which then causes anxiety. Symptomps develope as a result of this anxiety. However, what has been called ‘deviant’ behaviour is considered to be merely a reflection of society views; labelling behaviour as deviant is a way of meeting the needs of social and political system. This view argues that mental disorder is a label earned by certain behaviours that violete that rules of conduct imposed by significant others. The interplay between individuals and their social context is cruial, since it is the social models is directed towards helping to client to deal with the social sysyem more effectivelt. New resources are created when neccessary to help the client interact with the social environment more successfully.
The interpersonal view intergrates prespective on the organism and the milieu, and suggests that relationship with other people lagely determine behaviour. Positive interpersonal relationships protect against the insecurity, dissatisfaction and anxiaty that rejection generates. If we can be helped to improve the quality of our interpersonal relationship, oue feelings of security increase, therapy, according to this model, relies on estabilishing a trusting therapeutic relationship interpersonal experience.
The combined social-interpersonal model foccuses on the larger and more general context of deviance and on the process by which an individual comes to be called as deviant. Therapeutic interventions include programs for social change, political involenment, advocacy, community organisation, social planning, familly support groups and education. Clients are approached in a holistic way, reflecting the interelation and interaction of the biopshcal, psychological and socioeconomis-cultural dimension of live. This holistic approach increases the number of factors that must be assessed when caring for a client.
When planning interventions for any client with an enduring and disabling mental disorder, it is neccessery to regnise sensitifity to change and failure, and to set realistic goals for cliant change. Priotising the most troublesome areas of client functioning, and setting short-term goals that can increament to achieve longer-term goals, is a satisfactory approach that reinforces client invilonment and achiefment. (see chapter 13 and 17 for detailed examples of this process).
There are some general priciples that guide the interventions of mental health nurses. It is important that they be applied in ways that respect the fundamental rights and responsibilities of people with mental disorders, are well those withou.
Assistance with grooming and hygiene
Some clients will require help in estabilishing and maintining personal care habits, and this may necessitate teaching and motivating clients to use these skills.
Promoting adequate and appropriate communication
Communication with people with disabling mental disorders such as schizophrenia may, by virtueof the condition, be difficult and expressing for carers. Howeverm the sufferers, like all other human beings, try to communicate observations about their environment, needs and concerns. While the nature of disorder may impede communication, lack of respect for clients means the career is unlikely to make honest attemps to understand their messages and is less likely to make honest attemps to understand their messages and is less likely to respond in a way that enchaces those capacities that are intact.
Promoting organised behaviour
In those clients for whom a mental disorder significantly disurpts appropriate and acceptable behavioural patterns, direction and limit setting may be required to help these clients make their actions more effective and goal-directed.
Encouraging social interaction
Social isolation is a predominant feature of many mental disorders, especially the severaly disorganising disorders, and may be heavly reinforced by past interpersonal relationship difficulties as well as fear of rejection. Therefore, mental health nurses need to respect the clients anxiety about social contact. Giving encouragement to try out new behaviours that are to promote success leads to small increaments in behavioural change.
Promotng reality-based perceptions
In some clients, distored perceptions can be frightening. Reassurance of their safety, maintiniting a seve enfironment, validating accurate perceptions, and helping to distinguish realty from misperpection can all help clients attend to real rather than internal stimull. This reality-grounding helps to orient clients to the real situation, protects them from acting on perceptual distubances in ways that might harm themselves or others, and reduces impulsive behaviour tat may otherwise occur in response to distorted perceptions.
Promoting compliance with medical regimen
Psythropic medications play an important part in the treatmant of many mental disorders. The range of medication used to diminish the focal symptomps of disorders (e.g. perceptual distubances, anxiety, mood disturbance, somatic distress) has increased exponentially in recent decades. Many of the ‘new generation’ drugs have far grater pharmacological effects and fewer trubleesome side effects; consequently, the expected therapeutic response may appear to be ever more predictable. However, individuals may respond in unique ways to such medications. Thus, in addition to administration of medication, it is still neccessery to observe clients for evidence of therapeuic, and adverse effets, to teach clients about the therapeutic and possible untoward effects, to teach clients about the therapeutic and possible untoward effects, to help them take action to prefent untoward effects (e.g. maintenance of fluid intake to minimise postural hypotension) and to evaluate their objective to the medication and atitude towards continued use.
Promoting family understanding and involvement
Many people with mental disorders live with other peple- in families, groups and communities. Appropriate sharing of information, encouregement and involvement in current, future and post-discharge planning all require the involvement of clients and their immediate families or carers(see chapter 12).
Promoting community contacts
Community support and potential treatment programs available to clients with various mental disorders are vital to the success of treatment. Familiarisation of the client with the suport system available will help the transition from inpatient care back to the community.
Conclusion
According to the biopsycosocial model, the clinician’s approach to the client incorporates three interacting demensions of the clients functioning: biological, psychological, and social. It may not be always necessery or practical to pursue fully all three aspects of the biopsychosocial model with each client. Although clincians should retain the biosychosocial resprentive, they must also be flexible and individualise diagnosis assesment and interventions. For example, if a clint’s problems clearly reflect a primary biological process, it is appropriate to focus on the biological dimension in the biopsychiological assesment. The psychodynamic, cognitive-behavioural, social-interpersonal, and biological models provide mental earth professionals with the means of organising information about human behaviour, and a conceptual framework which helpes to formulate plans for treatment.
People are not marely passive recipient of enviromental events. They can (and do) make conscious choices to respond to the demands of the world. Many life events tend to be unpredictable and may have an impact for which people are unprepared. Despite the widely held lay view that stress is always a negative experience, some degree of stress is actually productive-it serves to keep people alert, save focused on the task at hand (see chapter 2).when stress experienced, it is a ‘manageable’ rather than a ‘controllable’ phenomenon. To expect to be able to ‘control’ stress is not helpful. Stress is an inevitable by product of daily life and we need to develope the capacity to occasionally tolerate quite high levels. Therefore, while the appropriate applications of stress reduction strategies can reduce the unpleasant effects of stress to a level that is manageable, it would be fruitless to attempt to remove all experience of stress.
MANAGEMENT OF STRESS
A key point for managing stressors is to be able to identivy and use appropriate strategies and also to recognise that sometime the strategy selected may not work as efficientlyas hopped and/or may not take effects immediatly. At such times, flexibility in approach is needed. This raises an important point about stress management: personal expectations. It is quite common for people to set fairly unrealistic standards for themselves-and, for the matter, for that matter, for others standards which represent perfection (e.g. striving to attan 100 % all the time). When an individual is unwilling to compromise idealistic standards, dissapointment and even maladaptation may result. In this case, the person will feel a failure,or attribute blame for the failure elsewhere. It is more productive to take a step back, to look a little more realisticcally at self impossed standards and to consider appropriate stress management options.
It is common for people to want immediate relief from their distressing symptoms. Sometimes, more or less immediate symptomatic relief is possible. For example, by the use of prescribed and non prescribed drugs. Howefer, it is useful to recognise that these remedies offer only temporary symtomatic relief, and the situations that generated the distress are unlikely to be affected by such action. This is an important point to consider in developing successful stress management strategies.
Pharmacological means
Caffeine, alcohol, prescibed and non-prescibed drugs, especially the antianxienty drugs (more properly called the anxiolytics). These are palliative rather than curative. All save to decrease awareness of the environment and, thus, hae no direct on stressor.
These drugs have effects on the ‘stress related’ hormones such as :
• Adrenocorticotrophic hormone (ACTH)
• Adrenaline, also known as epinephrine (E)
• Dopamine (DA)
• 5 hydoxytrymtamine (5HT)
• Gamma-aminobutyric acid (GABA)
• Prolactin (PRL)
• Growth hormone (GH)
Behavioural strategies
Bihavioural techniques are based on the concepts of lerning, conditioning and reinforcement. Outcomes, which depend on the selected behaviour, will reinforce the frequency (and likalihood) of that behaviour recurring. Some peple engage in behavioural techniques that are not neccesserily healthy: social isolation, ‘throwing oneself into work’, the use of non-prescribed drugs, smoking or overating are sometimes used as stress reducers. These have obvious detrimental effects. Other techniques, such as jogging or breathing exercises, produce positive physiological effects that decrease the stress response.
Improved behavioural skill such as improved communication, assertiveness training, hyperventilation control, exercise, time management and career development are useful physicological interventions for stress management. One of these techniques-hyperventilation control- has a biological basis it also has the important psychological consequence of distraction. At times of high anxiety, breathing rates can change dramatically. This technique uses slowe inspiration and expiration cycles, typically of 5 seconds duration. Thus, one complete respiratory cycle will last 10 seconds, compared to a normal resting rete about 5 seconds.
Cognitive streategies
Cognitive techniques aim at cognitive (or thingking) skills, and can provide stress reduction benefits. These techniques are based on the assumption that stress responses often result from individual’s past experiences in appraising threatening situations. These perceptions do not necceserellyating, reflect the environment accurately. A person may extarnalise or internalise ‘blame’ for the events; engage in anxiety-producing thoughts (exaggeratingcatastrophising,negativsm) or developed unrealistic beliefs.
Some examples of these techniques are :
• Distraction
• Thought stopping
• Attention switching (from internal to an external focus)
• Exchanging negative catastrophic thoughts for neutral/positivr ones;and
• Covert familiarises, in which the person learns to plan ahead. In each case, practise familiarises the routine for the oerson, and successful stress reduction provides the positive reinforcement needed to unsure that he desired cahanges are continued.
Environmental strategies
Some physical structures of the enviroment, as well the values attached to it, can be modified or manipulated, or manipulated, and thus decrease advent he focus may be shifted from individual to group responses. This change of emphasis of stressful stimull. Making aspects of the environment more attractive usually makes people feel better about it and more inclinned to tolerate day-to-day stressors.
Control or management of environment stressors may require making some change, in which the focus may be shifted from individual to group responses. This change of emphasis capitalises on the buffering or supportive nature of group activities.
Psychosocial strategies incorporate personal management techniques that may improve the psychosocial settings in which people operate, and are thus of value in stress management.
They include :
• Social support
• Providing information about management of day-to-day probblems
• Flexibility in work hours, thus accommodating individual requirements for child care and other care services.
These approaches may focus or stressors, including thse which may be generated outside one’s environment (e.g. the workplace), but which transferinto it. The focus of these broader approaches can range from general counselling services to specific individualised programs (e.g. weight reduction, anti smoking programmes, and other aimed at reducing alcohol or oother subtance use and abuse).
The options shown in box 11.1 are primarily in effect, and probabbly have the greatest utility when they assist an individual to manage unavoidable enviromental demands. Psychological methods (see box 11.2) are designed to improve adaptive moderation (whether behavioural or cognitive) of exaggerated or innappropriate psychological response to stress. The enviromental approach, shown in box 11.3, deals deals with facers of the immediate envireonment that can be change or modified to reduce high levels of stress. The thrust of the psycholosocial approaches (see box 11.4) is to provide a more suportive sociocultural group in which to foundation.
MANAGEMENT OF MENTAL DISORDERS
From time to time some people suffer from major pro blems that affect their mental their. Howefer, in order to justify a clinical diagnosis of mental disorder, cleary defined criteria must be met. These criteria include a rainimum time period for which the symptomps must be experienced (see chapter 10). Fortunately, only a relatively small numbers of people meet these clinical criteria. Even the mental disorders that are most obviously connected to stress and coping (the anxiety disorders, particuraly post-traumatic stress disorder) have explicit criteria that must be fullfilled for a specified time period.
Medical-biological interventions
The medical-biological model in psychiatry originated from the xystematic observatio, naming and clasifications of symptomps. According to this model, behavioural distruptions, including abnormal behaviour, are attributtable to organic factors such as a disease process, probabbly origination in the central nervous systerm. Examples of organic factors are lesions, neuropatologic conditions, toxins from outside the body, and biochemical abnormalities of neurotransmitters and enzymes. This indicates that like any other disease, there is a process operating; the condition is likely to follow a predictable course and the prognosis can be estimated. If the causes can be identified and treated, the symptomatology will subside. Treatment depends on diagnosis and frequently includes somatic therapies in addition to interpersonal therapies. How much treatment is appropriate will depend on how the client’s symptomps respond to interventions. There is a wide body of avidence for a biological basis for many mental diorders and this forms the core component of commonly prescribed somatic intervention.
Neuroleptics
This group of drugs are most widely used in treatment of psychotic conditions.they detrive their name from their capacity to affects several integrating systems of the brain, including the ability to produce movement disorders.
The neuroleptics are frequently used in the management of a variety of disturbed behaviours, including behaviour that is classified as psychotic. These compounds were formally known as major tranquillers or antipsychotic drugs. The term ‘neuroleptic’ reflects their ability to selectively reduce emotionally and pschomotor activity (feldman & Quenzer 1984).
They are palliative, not curative. All classes of neuroleptics are thought to exert their potent antipsychotic antion by blocking DA in certain areas of the brain (Synder 1976, 1980), even though most of them block NE to some extent. More specifically, their antipsychotic potency correlats with their ability to nhibit DA-sensitive enzymes that are required to drive natural pumps (like the NA+ pump in DA-activated nerons in the mesolimbic system of the brain).
As with all pharmacological agents, the neuroleptic drugs have many effects in addition to their principal therapeutic effects, and these can be seen pheriperally as well as centrally. For instance, the DA-blocking action which they exert on the mesolimbic system of the brain probably accounts for their antipschotic effects, while the same DA antagonism on yhe nigrostriatal pathway probabbly accounts for the unwanted parkinsonian symptomps that result from prolonged administration (Synder 1976). This is because there are also cholinergic neurons in the stratium that are normally inhibited by DA. If there is DA deficientcy, the cholinergic neurons become overactive and may contribute to the parkinsonism.
Cloapzine
A compound that is receiving increasing attention in the treatmant of schizophrenia is clozapine (clozaril). First synthesised in 1959, clozapine was withdrawn from unrestricted use in 1975 atfer eight people in fingland developed agranulocytosis (an acute disease in which there is a sudden drop in the production of white blood cells, leaving the body defencelless against bacterial infection) and died (Chatterton 1994,p.86). its use has been slowly reintroduced since 1988 for the treatmant of schizophrenia unresponsive to other compouds (treatmant-resistant schizophrenia).
Clocapine is contraidicated in the following situations:
• when there is a history of drug-induced agranulocytosis;
• bone marrow disorders;
• circulatory collapse;
• depression of the central nervous system (CNS);
• alcohol or toxic psychoses;
• drug intoxication;
• coma;
• uncontrolled epillepsy;
• several renal, hepatic or cardiac disease;
Antidepression
The applications of antidepressants (see box 11.6) are more widespread than just the depressive disorders. This is because their pharmacologic activity includes anticholinergic, antihistamic, hypothermic and antiemic action. They may be prescribed for adjusment disorders, atypcal depression, panic disorders; also for selective use in subtance related disorders.
Nurses should be aware of the time lag between the initation of therapy with antidepressant and the clinical effects. This dalay has important implications for management of the depressed client and must be taken into consideration by the nurses involved. While clients receiving either TCAs or MAOIs warrant education on the expected effects of their prescription, those receiving the MAOIs require particular consideration because of possible adverse side effects, and the drug’s potential for interaction with dietary tyramine.
These agents consits of several broad groups, of which the tryciclic antidepressants (TCAs) and the monoamine oxidase inhibitors (MAOIs) are commonly encountered in psychiatric-mental health care settings. Neither of these two subgroups is a CNS stimulant; rather, their therapeutic effects are achied by their influence on neunoral uptake of biogenic amines. Use of the MAOIs relates to their ability to block the degradation of NE and 5HT, which effectivelly increases the available quantities of these neurotransmitters.
Prozac
Although the tryciclic antidepressants are the most widely used compounds in the treatment of depression, they are associated with unsatisfactory side effects. Newer antidepressants such as Prozac (fluoxetine), have better side effect profiles and longer halv-lifes. The half-life for prozac is 2 to 3 days, whereas the half-life for the tryciclics is 10-14 hours. Therefore, prozac is commonly administrated once daily, in the morning. The therapeutic effect of prozac is atrribute to its ability to combine to the cholinergic, histaminergic and alpha-1 adrenergic receptors with minimal affinity. It is a selective serotonin (5HT) re-uptake inhibitor (SSRI) that is particulary effective in the treatment of major depressive disorders where other therapy is inappropriate or ineffective. Client must not be transfered to treatment with MAOIs to prozac for two weeks after ceasing MAOIs. Adverse effects enclude CNS disturbances, drowsiness, sweating and gastrointestinal disturbances. Initially 1 capsule (20mg) is given daily in the morning. The dose is incresed to 40mg daily after two weeks if necessery. This dose can be divided-20mg in the morning and 20mg at noon. The maximum daily dose is 80mg.
Lithium carbonate
All clients receiving lithium require serum level assesment-at least monthly during mantenence therapy, and mlre frequently during intiation of therapy. Serum levels of lithium need to be maintened within fairly defined ranges for both acute therapeutic response and long-term maintenence therapy. Representative values are indicated in table 11.3. blood samples are obtained 12 hours after the last dose received. If serum lithium results>1.5mEq/L, or if litium carbonate (LiCO3) is the only specific anti-manic compound available at present. In normal subjects, this compound has no obviously psychotropic action. It is used in the treatment of the manic phase of bipolar disorder and for long-term maintenece therapy, as t reduces the severity and frequency of bipolar episodes. When mania is mild, lithium alone may be an effective treatmant but, in severe cases, it is almost always prescribed conjunction with one of the neuroleptic may be cassed and lithium maintenences therapy. It is not always the case that maintenence is coplex and the benefits of continuation must outweight the risks of adverse reaction and comulative toxity. It is also impotantn to consider the frequency, duration and severity of episodes, as well as the clients insight and compliance.
Relevance of pharmacological knoledge to nursing
Nurses often perform a crucial role in the selection and administration of appropriate medication (it is often nurses’ history-taking, obserfation, administration, and recomendations that contribute significantly to the selection of the drug and the dosage). It is, thus, important for nurses to maintain an up-to-date knowledge of these agents. High on the list of nursing responsibilities is the recognition that clients with mental disorders frequently display a wide variety of behaviours; some may be quite subtle and requirecareful observation to identify, and some are much more obvious. Nurses, thus, have a responsibility for the accurate assessment of client and their behaviours is psychotropic medication is to be used effectively and appropriately.
Psychoanalytic therapy
This model is usually credited to the Vinnese physician, sigmund freud. Freud’s premise was that all psychological and emotionalevents, however obscure, were understandable. Freud explained behaviour by analysing childhood experiences, which he believed could cause adult neuroses. Therapy, in this model, consists of claryfing the meaning of events, feelings and behaviours, and, in doing so, gaining insight about them.
Psychoanalytic therapy is based on an alliance with the client which utilises the phenomena of transference and countertransference. Behviour is interpreted in the light of apparent earlier traumatic conflicts and experiences, and these interpretations are meant to be considered by the client. The therapist remains aloof from the client to encourage the development of transference. Therapy is, thus, aimed at resolving the conflict and uncovering the roots of that conflict in the unconscious. Psychotherapy is based on the view that release of represed feelings associated with the conflict will cause the conflict to be resolved and the symptomps will disappear.
Relevance of psychoanalysis to nursing
Many of terms arisin from Fraud’s work have passed into common usage. Such expressions as conflict,id,ego, rejection, repretion egocentricity, sibling rivalry,phallic symbol and castration complex are freely used, possibly with no real comprehension of the concepts behind them. Psychoanalytic cocepts have permeated the education and practice of some clinician so widely that they have come to be regarded as a fundamental part of understanding mental disorders. Nurse need to be aware of some of the psychoanalytic languange, concept and speculation about client dynamic in order to participate as equal members of the psychiatric team. Nevertheless, the role available to nurses who practise in a setting where a psychoanalytic framework previle is probabbly rather limited. Psychoanalytic requires years of specialist training and is, by nature, a protacted process, proving highly dependent on the development an exploitation of the spesific relationship between therapist and client. Interpretation of the hidden meanings and symbolic nature of experience is usually the prerogative of the therapist and traditionally takes place within the confines of the one-to-one relationship. It is important to apreciate that over the past 50 years there has been a proliferation of post-freudian psychoanalytical approaches to conselling and group work.
Cognitive-behavioural therapy
This model draws on both psychology and neuropsychology . to the behaviouralist, the conditioned or learned response is viewed as the basic unit of learning, reinforced by the outcome of behaviour. Deviations is behaviour occur because of the power of the association between the undisirable behavioural habit and reinfocement, and are considered to be prepetued because of the asociated reduction in axiaty.
The prespective assets that human beings are merely complex animals with the power of conceptual thought, propotional languange and the ability to attach meaning to hypothetical or metaphorical concepts. These abilities are all fully attributable to complex psyology, rather than to some non-meterial source. Who we are (self) simply reflects the total of past learning-our behavioural repertoire. Cocepts such as ‘counsiouness’ and ‘self’ can only be inferred from behaviour which can be observed, descibed and recorded. Behaviour is reinfoced by conditions in the environment, so the self is a structure of stimulus-response chains (habits). The symptomps of disorder are, in fact, the subtance of the person’s troubles. Since behaviours can be learned, it can be unlearned.
The aim of behaviour therapy is to change behaviour. In many behavioural settings, clients follow prescribed schedules for daily living and are rewarded for desired behaviour. Behavioural deviations are not rewarded;more productive behaviours are reinforced. Thus, acceptable behaviours can be learned, or deviance are subtitude for the undersirable ones.
The cognitive prespective therapy broadens this viewpoint. Behaviour does not occur in a vacum; rather, people think about the stimull they receive, this thingking may occur rapidly and without awareness. Nevertheless, when sensory stimull and received, they are processed, interpreted and compared with idealised and stored memories. The cognitive theorist indicate that it is cognitive process such as thingking, memorry, and recall that influence behavioural rsponses.
Relevance of cogitive-behavioural therapy to nursing
Nurses have a role in teaching cognitive-behavioural principles to client to enable them to act as their own changes agents. Non-profesionals can be taught to use behaviour that often accompanies long-term mental disorder. In general, behavioural modifications offer a rapid, efficient anf effective system of nursing intervention.
SOCIAL INTERPERCONAL THERAPY
This model developed because of general dissatisfaction with other models. It is a combination of a social model and an interpersonal model. The social model suggest that social and enviromental factors creatte stress, which then causes anxiety. Symptomps develope as a result of this anxiety. However, what has been called ‘deviant’ behaviour is considered to be merely a reflection of society views; labelling behaviour as deviant is a way of meeting the needs of social and political system. This view argues that mental disorder is a label earned by certain behaviours that violete that rules of conduct imposed by significant others. The interplay between individuals and their social context is cruial, since it is the social models is directed towards helping to client to deal with the social sysyem more effectivelt. New resources are created when neccessary to help the client interact with the social environment more successfully.
The interpersonal view intergrates prespective on the organism and the milieu, and suggests that relationship with other people lagely determine behaviour. Positive interpersonal relationships protect against the insecurity, dissatisfaction and anxiaty that rejection generates. If we can be helped to improve the quality of our interpersonal relationship, oue feelings of security increase, therapy, according to this model, relies on estabilishing a trusting therapeutic relationship interpersonal experience.
The combined social-interpersonal model foccuses on the larger and more general context of deviance and on the process by which an individual comes to be called as deviant. Therapeutic interventions include programs for social change, political involenment, advocacy, community organisation, social planning, familly support groups and education. Clients are approached in a holistic way, reflecting the interelation and interaction of the biopshcal, psychological and socioeconomis-cultural dimension of live. This holistic approach increases the number of factors that must be assessed when caring for a client.
GUILDING PRINCIPLES OF NURSING INTERVENTIONS
When planning interventions for any client with an enduring and disabling mental disorder, it is neccessery to regnise sensitifity to change and failure, and to set realistic goals for cliant change. Priotising the most troublesome areas of client functioning, and setting short-term goals that can increament to achieve longer-term goals, is a satisfactory approach that reinforces client invilonment and achiefment. (see chapter 13 and 17 for detailed examples of this process).
There are some general priciples that guide the interventions of mental health nurses. It is important that they be applied in ways that respect the fundamental rights and responsibilities of people with mental disorders, are well those withou.
Assistance with grooming and hygiene
Some clients will require help in estabilishing and maintining personal care habits, and this may necessitate teaching and motivating clients to use these skills.
Promoting adequate and appropriate communication
Communication with people with disabling mental disorders such as schizophrenia may, by virtueof the condition, be difficult and expressing for carers. Howeverm the sufferers, like all other human beings, try to communicate observations about their environment, needs and concerns. While the nature of disorder may impede communication, lack of respect for clients means the career is unlikely to make honest attemps to understand their messages and is less likely to make honest attemps to understand their messages and is less likely to respond in a way that enchaces those capacities that are intact.
Promoting organised behaviour
In those clients for whom a mental disorder significantly disurpts appropriate and acceptable behavioural patterns, direction and limit setting may be required to help these clients make their actions more effective and goal-directed.
Encouraging social interaction
Social isolation is a predominant feature of many mental disorders, especially the severaly disorganising disorders, and may be heavly reinforced by past interpersonal relationship difficulties as well as fear of rejection. Therefore, mental health nurses need to respect the clients anxiety about social contact. Giving encouragement to try out new behaviours that are to promote success leads to small increaments in behavioural change.
Promotng reality-based perceptions
In some clients, distored perceptions can be frightening. Reassurance of their safety, maintiniting a seve enfironment, validating accurate perceptions, and helping to distinguish realty from misperpection can all help clients attend to real rather than internal stimull. This reality-grounding helps to orient clients to the real situation, protects them from acting on perceptual distubances in ways that might harm themselves or others, and reduces impulsive behaviour tat may otherwise occur in response to distorted perceptions.
Promoting compliance with medical regimen
Psythropic medications play an important part in the treatmant of many mental disorders. The range of medication used to diminish the focal symptomps of disorders (e.g. perceptual distubances, anxiety, mood disturbance, somatic distress) has increased exponentially in recent decades. Many of the ‘new generation’ drugs have far grater pharmacological effects and fewer trubleesome side effects; consequently, the expected therapeutic response may appear to be ever more predictable. However, individuals may respond in unique ways to such medications. Thus, in addition to administration of medication, it is still neccessery to observe clients for evidence of therapeuic, and adverse effets, to teach clients about the therapeutic and possible untoward effects, to teach clients about the therapeutic and possible untoward effects, to help them take action to prefent untoward effects (e.g. maintenance of fluid intake to minimise postural hypotension) and to evaluate their objective to the medication and atitude towards continued use.
Promoting family understanding and involvement
Many people with mental disorders live with other peple- in families, groups and communities. Appropriate sharing of information, encouregement and involvement in current, future and post-discharge planning all require the involvement of clients and their immediate families or carers(see chapter 12).
Promoting community contacts
Community support and potential treatment programs available to clients with various mental disorders are vital to the success of treatment. Familiarisation of the client with the suport system available will help the transition from inpatient care back to the community.
Conclusion
According to the biopsycosocial model, the clinician’s approach to the client incorporates three interacting demensions of the clients functioning: biological, psychological, and social. It may not be always necessery or practical to pursue fully all three aspects of the biopsychosocial model with each client. Although clincians should retain the biosychosocial resprentive, they must also be flexible and individualise diagnosis assesment and interventions. For example, if a clint’s problems clearly reflect a primary biological process, it is appropriate to focus on the biological dimension in the biopsychiological assesment. The psychodynamic, cognitive-behavioural, social-interpersonal, and biological models provide mental earth professionals with the means of organising information about human behaviour, and a conceptual framework which helpes to formulate plans for treatment.
Bibliography
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- Doenges, M. E., Townsend, M. C., & Moorhouse, M. F. (1995). Psychiatric care plans (3rd ed.).
- yosep, iyus. "keperawatan jiwa(edisi : revisi)" . 2007. PT revika aditama :
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