NURSING 3125 WEEK 6 OCT 21, 2019

Chapter 6: COMMUNITY MENTAL HEALTH NURSING

The continuum of Care in Mental Health:
The MH movement to Community:
Recovery: described as the ability of the individual to work, live, and participate in the community
1950s:
 improvements in pharmacological management of symptoms
 Largely institutional nursing
1960s-1970s
 Transition from institution into community hospitals
1970s-1980s
 Shorter inpatient stays in hospital
 Movement towards deinstitutionalization
 Lack of resources and planning “falling through the cracks”
1990-present
 Advocacy, recovery, national mental health strategies
Nursing priorities of Care
Acute care settings:
 Milieu management
o Safety
o Suicide risk
o Behavioral management
 Admission / physical health assessment
 Structured activities
 Documentation
 Medication & symptom management
Community Settings:
 Problem solving and clinical skills
 Cultural competence
 Knowledge of community resources
 Autonomy / accountability
 Roles / functions of community MH nurse:
o Biopsychosocial assessment: guides the nursing assessment and interventions in a holistic
manner, taking a comprehensive view of the clients including their biology, social environment
and skills, psychological characteristics
o Case management: refers to care coordination activities the nurse does with or for the patient
and includes referrals, assistance with paperwork applications, connection to resources, and
overall navigation of health care system
o Promoting continuation / maintenance of treatment: “non-compliance”- the health care
provider and the client= shared decision making
o Interprofessional team member
Levels of Prevention
 Primary: Prevent injury of illness before it begins; control of casual factors
 Secondary: Reduce impact of injury or illness; control of symptoms
 Tertiary: Management of long-term injury or illness; retrain, rehabilitate or re-educate
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Areas of concern- acute community
 What was the reason for the hospitalization?
o Crisis, medication adjustment, social problem?
 What lifestyle changes need to be made?
o Illness / medication education, social supports, ongoing counseling / therapy
 Who needs to be involved in the community mental health system?
o Case management approach?
 What basic supports are needed?
o Maslow’s hierarchy
 Assertive Community Treatment (ACT): an intensive type of case management developed in response
to the community living needs of people with serious, persistent psychiatric symptoms; referred due to
repeated hospitalization
Discharge planning should include:
 Accommodations: Home, group home, assisted living, homeless?
 Finances: AISH, employed, Persons with Developmental Disabilities (PDD)
 Follow-up therapy: Counseling, outpatient therapies
 Employment or daytime activity: Work schedule, access to services, transportation
 Social life: Role models, support systems
 Medication: Education, availability, affordability, compliance
Chapter 20: PERSONALITY DISORDERS:
- display significant challenges in self-identity or self-direction, and they have problems with empathy or
intimacy within their relationships; treating is difficult because people have difficulty recognizing or
owning the fact that their difficulties are problems of their personality.
- People with personality disorders may injure themselves
 enduring pattern of inner experience and behavior
 deviates from expectations of culture / social norms
 pervasive and inflexible
 onset in adolescence / early adulthood
 stable over time
 leads to distress or impairment
Common features of all disorders:
 rigid, maladaptive, fixed personality traits
 affects cognition, behavior, interpersonal interactions
 irritable, hostile, demanding, fearful, “manipulative”
 inadequate coping, disturbed self-image, poor impulse control
 maladaptive perceptions of self and environment
 Inappropriate range of emotions
 reduced occupational functioning
Etiology:
Biological factors: Genetics, Neurobiology + neurochemistry
Psychosocial factors: Psychological factors: maladaptive practices based on modelling and reinforcement,
Environment factors
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Diathesis Stress Model: Diathesis: genetic and biological vulnerabilities and includes personality traits and
temperament. Temperament is tendency to respond to challenges in predictable ways (laid back, uptight,
etc.). Stress: past, experiences= maladaptive personality resulting in emergence of a personality disorder
WEIRD odd + eccentric: Cluster A: General Characteristics: Pervasive distrust, social detachment, perception
distortions, cognitive impairment, subsequent impairment in social and occupational functioning
o Social isolation and detachment
o Perception distortions, unusual levels of suspiciousness
o Schizotypal personality disorder: expressed in strikingly odd characteristics, including magical thinking,
derealization, perceptual distortions, and rigid peculiar ideas; people firmly believe their
interpretations, social cues are inappropriate
o Eccentricity: odd or unusual beliefs and thought processes; social detachment (social isolation
preference) and unwarranted suspiciousness or anxiousness  hard to maintain relationships
o Genetically linked- higher incidence of schizophrenia-related disorders in family members of
people with STPD

Interventions:
- Support is important
- If they would like to be alone for some periods, respect and allow it
WILD: dramatic + emotional: Cluster B: General Characteristics: instability or unpredictability, conflict with
society due to impulsive behaviours, interpersonal relationship problems, limited insight into illness, may be
considered “manipulative”, thought to function somewhere bet ween neurosis and psychosis
o Responding to life’s demands with dramatic, emotional, or erratic behaviour; problems with impulse
control, emotion processing and regulation, and interpersonal difficulties
o To get needs met they may resort to desperate measures, acting out, committing antisocial acts, or
manipulating people or circumstances
o Antisocial personality disorder: “socio or psychopaths”: antagonist behaviours such as deceit,
manipulativeness for personal gain, and hostility if the person’s needs are blocked
o Inhibited behaviours such as risk taking, disregard for responsibility, and impulsivity.
o Conduct disorder as children: no remorse for hurting others, repeatedly neglect responsibilities,
tell lies, perform destructive or illegal acts without developing insight into consequences
o Difficulty with intimacy and exploit others, focus on own gratification
o Genetically linked and twin studies indicate predisposition; predisposition is set into motion in
childhood environment of inconsistent parenting, significant abuse, and extreme neglect
o Borderline personality disorder: severe impairments in functioning, high mortality rate and extensive
use of health care services; negative affect: emotional lability: moods that alternate quickly from one
extreme to another; mood that are out of proportion- pathological fear of separation, intense sensitivity
to perceived personal rejection
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o Impulsivity (damaged relationships, suicide attempts) and antagonism (hostility, anger,
irritability in relationships)
o Ineffective and harmful self-soothing habits (cutting, promiscuous sexual behaviour, numbing
with substance
o es)  chronic suicidal ideation is common and can cause accidental death
o Splitting: primary defense or coping mechanism, inability to incorporate positive and negative
aspects of oneself or others into whole image; ex. idealize person at beginning of relationship
but at first point of disappointment the individual quickly shifts to devaluation and despising.
o Develops as a result of early abandonment which results in an unstable view of self and others;
made more intense by biological predisposition and heritability (twin studies 69%)
o Narcissistic personality disorder: least frequent; less associated with impairment of daily functioning
and quality of life than others. Primary feature: arrogance and grandiose view of self-importance.
o Need for constant admiration, along with lack of empathy for others, which strains most
relationships- can result in exploitation of others particularly vulnerable population.
Underneath they feel intense shame and fear of abandonment; afraid of own mistakes as well
as those of others: may seek help for depression or validation by therapists for emotional pain
for their efforts or special qualities.
o May be result of childhood neglect and criticism; child doesn’t learn that other people can be
source of comfort and support. As adults they hide feelings of emptiness with an exterior of
invulnerability and self-sufficiency.

Interventions: clear boundaries, negotiation, rules in place or flexibility

- BTW keep in mind: Transference: they think of u as someone they know countertransference: you see
them as someone you know
- If patient is going through DBT therapy and calls and says I feel empty and want to hurt myself: instead
of admitting them into emergency or inpatient, provide them with coping strategies to manage the
situation
WORRIED fearful + anxious: Cluster C: General Characteristics: Fearful, restricted affect; unrealistic
expectations of others; difficulty expressing feelings; inability to be assertive and make decisions; need for
order; rigid behavioural patterns
o Patterns of anxious and fearful behaviours, rigid patters of social shyness, hypersensitivity, need for
orderliness, and relationship dependency
o Avoidant personality disorder: extreme sensitivity to rejection robust avoidance of interpersonal
situations; a timid temperament in childhood may be associated with this;
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o Poor self-confidence and prone to misinterpreting other’s feedback because overly sensitive to
rejection; They strongly desire close relationships but avoid them
o Linked with parental and peer rejection and criticism; a biological predisposition to anxiety and
physiological arousal in social situations; genetically may be part of a continuum of disorders
related to social phobia (social anxiety disorder).
o Obsessive Compulsive Disorder: highest burden of medical costs and affect workplace productivity
losses. Main pathological traits: rigidity and inflexible standards of self and others along with
persistence to goals long after necessary even if it self-defeating and harmful to relationships.
o Feel genuine affection for friends and family but do not have insight about their own difficult
behaviour; internally they are fearful of imminent catastrophe. They reverse over and over how
will they respond in social situations. Do not have full blown obsessions or compulsions but may
seek treatment for anxiety or mood disorders.
o Excessive parental criticism, control and shame; child responds negatively by trying to control
his or her environment through perfectionism and orderliness. Heritable traits such as
compulsivity, oppositionality, lack of emotional expressiveness, and perfectionism have all be
implicated in this disorder.

Assessment: preferred method for determining a diagnosis is semi-structured interview obtained by clinicians.
- Have standard questions and standard format for asking questions; go beyond asking patient to self-
report on symptoms because their behaviours there may be a lack of insight into behaviours and
motivations.
- One way to elicit more objective information: ask if friends or family have different perception
- Cultural norms and expectations
- Personality often assessed through identifying pathology within one or more personality dimensions
o 5 main dimensions: extraversion vs. introversion, antagonism vs. compliance, constraint vs
impulsivity, emotional dysregulation vs emotional stability, and unconventionality vs closedness
to experience
- Open-ended or subjective interviews which don’t have standard questions or format are more likely to
result in biased and culturally based decisions about diagnosis
- Patient history: full medical history: assess if problem is psychiatric or medical or both; hx of suicidal pr
aggressive ideation or actions, current medication uses and illegal substances, ability to handle money
and legal hx.
- Further hx: abuse levels; at times immediate interventions may be needed to ensure safety
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- Indicating prior medication use is important gives evidence of other contacts the person has made
for help and indicates how health care provider found the person at that time.
- Self-assessment: for individuals with borderline personality disorder, therapeutic alliance often follows
an initial upward curve of idealization (sometimes preceded by brief initial rejection) by the person
towards caregivers. This reaction is then followed by devaluation of the caregivers because the patient
is disappointed by the treatment team failing to meet his or her unrealistic expectations. This process
is often acted out in treatment milieu and can interrupt delivery of care. Ex. female patient may
idealize nurse an believe they are the best…awareness of and monitoring one’s own stress responses
to people behaviours facilitate therapeutic intervention
1. Assess for suicidal or homicidal feelings: immediate attention
2. Medical disorder or psychiatric disorder that may be responsible for the symptoms (esp substance
disorder)
3. Personality functioning from background; 4. Recent important loss of significant peoples
4. Evaluate for change in personality that signals the need for medical work up or unrecognized
substance use disorder
Diagnosis:
- Symptoms of co-morbid disorders, dangerous behaviour, court ordered treatment; emotions such as
withdrawal, paranoia and manipulation are among the most frequent concerns that HC workers must
address
Planning:
- May be difficult forming relationships with individuals; when they blame other nurses must understand
context, that is these attacks spring from being threatened;
- They require a sense of control over what is happening to them: giving them realistic choices (ex.
selection of particular group activity) may enhance self-adherence to treatment. Important to plan
within context of family.
Implementation:
- People with borderline personality: impulsive (ex. suicidal, self-mutilating), aggressive, manipulative,
and even psychotic during periods of stress.
- People with ASPD: are often involuntarily admitted and are manipulative, aggressive, and impulsive.
- Safety and teamwork: management of person’s affect in group context (community meetings, coping
skills groups, etc.) are helpful; dealing with emotional issues that arise in the milieu require a calm,
united approach by the staff to maintain safety and enhance self-control;
- when patients actively take part in developing treatment plans, they take responsibility and implement
plan = more successful
- having limits and being confronted by staff about negative behaviour Is better accepted If staff
members first employ empathetic mirroring (ex. reflecting back to the person an understanding of the
person’s distress without a value judgement)
- final approach that is useful for people with BDP: relates to response to superficial self-destructive
behaviours; let person write down their actions so they can reflect rather than ventilating their
feelings.
Pharmacological Interventions:
 personality disorders may be helped by a broad array of psychotropic drugs, all geared at maintaining
cognitive function and relieving symptoms
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 depending on chief complaint, anti-depressant, anxiolytic, or antipsychotic medication may be ordered
for symptom relief and improved quality of life, but the treatment efficacy of these medications
remains questionable, as they do not specifically treat the underlying personality disorder.
 Schizotypal personality disorders: benefit from low-dose atypical antipsychotic agents for their
psychotic like symptoms and day-to day functioning
 Antisocial personality disorders: respond to mood-stabilizing medications like lithium to help
aggression and impulsivity
 Borderline personality disorder: respond to anti-convulsant mood stabilizing medications, low dose
antipsychotic medications and omega 3 supplementation for mood and emotion dysregulation
symptoms
 Avoidant personality disorder: respond positively to similar medications for anxiety disorders such as
SSRIs like citalopram (celexa) and SNRIs such as duloxetine (Cymbalta)
 Pharmacological evidence is lacking for treatment for people with narcissistic and OCD.
Case Management Goals:
1. To gather pertinent hx from current or previous providers
2. Support reintegration from family or loved ones as appropriate
3. To ensure appropriate referrals to outpatient care (including substance disorder treatment, if needed)
 In long term outpatient setting objectives include reducing hospitalization by providing resources for
crisis service and enhancing social support system
Psychotherapy:
 DBT: dialectal behaviour therapy: to treat chronically suicidal people with BPD esp.
o Combines cognitive and behavioural techniques with mindfulness, which emphasizes being
aware of thoughts and actively shaping them.
- Goals: to increase person’s ability to manage distress and improve interpersonal
effectiveness. Treatment focuses on behavioural targets, begins with identification of
and intervention for suicide behaviours then progressing to a focus on interrupting
destructive behaviours; emotional regulation, distress
- Targets: suicidal behaviour, destructive behaviours, quality of life

Chapter 31: Living with Recurrent and Persistent Mental Illness

 Older Adults:
o Institutionalized: became dependent on services and structure of institutions making it hard to
function independently outside); became hard to distinguish whether behaviours were result of
disease process or altered responses from institutionalization therefore today’s goal is to
allow patients to express their wishes
 Younger Adults:
o People young enough never have to be institutionalized usually do not have problems of
passivity and dependency;
o TX: via series of short-term hospitalization: limited experience with formality causing them to
not truly believe they are ill or perhaps impairment of the illness itself (anosognosia).
o At risk for: legal difficulties, substance abuse and unemployment
 Rehabilitations vs Recovery:
o Rehabilitation: managing patient’s deficits and helping patients learn to live with their illnesses
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o Recovery model: patient-or consumer- centered and involves active partnership with care
providers
 Hopeful, empowering and strength focused model: achieve highest quality of life
possible; patient independence and self determination
 Allows patients to gain more control over their loves and make choices about
treatments while being supported by professionals and family.
 Issues confronting those with Serious Mental Illness (SMI)
o Establishing a meaningful life
o Co-morbid conditions (physical disorders, depression and suicide, substance abuse)
o Social problems (stigma, isolation & loneliness, victimization)
o Economic problems (unemployment and poverty, housing instability, caregiver burden)
o Treatment issues (nonadherence, anosognosia; medication adverse effects; Tx inadequacy;
residual symptoms; relapse, chronicity &loss
 Each relapse can cause loss of relationships, employment, and housing= ++ stress
Resources for people with SMI
 Comprehensive community Tx: can have long wait times, not locally available
o Community services and programs: ex. Assertive Community Treatment (ACT)
 Substance abuse treatment: crisis intervention, detoxification, medication (ex. methadone)
Evidenced Informed treatment approaches:
 Assertive Community Treatment (ACT): caring for person with SMI in community, provides intensive
treatment services
o Model of care for ACT is structure of treatment and rehab as well as support services that
enhance ability of person with SMI to live successfully in the community.
o Small patient to staff ratios is important
 Cognitive Behavioural therapy: allows patients to cope with SMI and reduce and cope with auditory
hallucinations
o Focuses on thinking and “self-talk”: identifies cognitive distortions and guides patient to more
positive enforcement
 Cognitive enhancement therapy (CET): principle that brain is able to change and that compromised
neurological functions can be assumed by healthier areas of the brain
o Involves many hours of computer-based drills that incrementally challenge functions (ex.
focusing attention, recalling information, etc.)
o Studies show it sustains improvement in functional areas and improves social and vocational
functioning
 Family support and partnerships: treatment is enhanced; conflict reduced (empathetic partners)
 Social skills training: teaching wide variety of social and activities of daily living (ADL) skills
 Supportive psychotherapy: stresses empathetic understanding and non-judgemental attitude and
development of therapeutic alliance to improve long term recovery prospects in patients with SMI.
 Vocational rehabilitation and related services:
o Vocational rehab: vocational training, financial support for attaining employment, or supported
employment services
o Supported employment model: rapid job placement, on the job support, and provision of job
coach who is linked to mental health team
Other potentially beneficial services or treatment approaches:
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 Consumer run programs: informal clubhouses which offer socialization, recreation, etc.
 Wellness and Recovery action plans
 Exercise: reduce anxiety and depression, enhance self-esteem, weight control or loss
Nursing Care:
Assessment:
 Signs of risk to self or other, depression or hopelessness, signs of relapse (increased impulsivity,
paranoia, diminished reality testing, increased delusions or hallucinations)
 Inadequate nutrition, clothing and medical care, carelessness when driving, smoking or cooking
 Signs of treatment nonadherence or impeding relapse (early detection and correction of relapse
reduces intensity and duration as well as prevents hospitalization
 Physical health problems
 Co-morbid illness
Intervention Strategies:
 Empowerment by involving them in goals and treatment; emphasizing quality of life; develop and
maintain relationships are keys to anosognosia and achieving treatment adherence
 Supportive psychotherapy aids in maintaining rapport and help patient maintain self-esteem and cope
effectively
 HALLMARK of SMI: impaired reality testing, contributes to hallucinations and delusions: encourage
patient to seek independent information on whether experiences are real or not can help patient
identify these experiences as part of illness and respond accordingly
 Support groups: stigma of SMI creates loneliness
 Education and reinforcement
 Care for whole person is important with SMI
Current issues:
Involuntary treatment: treatment mandated by a court and delivered without patient’s consent
- Began with Community Treatment Orders: mandatory treatment in less restrictive setting: may
facilitate patient engagement with community services and improve access to supportive housing
Criminal Offences and Incarceration: people with SMI may commit crimes out of desperation, impaired
judgement, or impulsivity,