Mental Health Nursing A South African Perspective
LUys (Editor) L Middleton (Co-editor)
JUTA A C A D E M I C
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Mental Health Nursing A South African Perspective
LUys (Editor) L Middleton (Co-editor)
JUTA A C A D E M I C
DISCLAIMER In the writing of this book, every effort has been made to present accurate and up-to-date information from the best and most reliable sources. However, the results of nursing individuals depend on a variety of factors that are beyond the control of the authors and publishers. Therefore, neither the authors nor the publishers assume responsibility for, nor make any warranty as regards to, the outcomes achieved from the procedures described in this book.
Mental Health Nursing - A South African Perspective ©Juta &Co. Ltd 2004 P O Box 24309 Landsdowne 7779 Cape Town South Africa This book is copyright under the Berne Convention. In terms of the Copyright Act 98 of 1978, no part of this book may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording or by any information storage and retrieval system, without permission in writing from the publisher. ISBN-10:0 7021 66421 ISBN-13:978 07021 66426 Reprinted February 2007 Project management: Fiona Wakelin Copy editing and proofreading: Mariaan Nel Indexing: Mariaan Nel Cover design: Pumphaus Design Studio DTP and design: Charlene Bate Printed and bound in the Republic of South Africa by Paarl Print
Contents
Foreword
xiii
About the Authors
xiv
Section 1: Frameworks & Foundations
1
CHAPTER 1: THE HISTORY OF MENTAL HEALTH NURSING
3
LRUys Objectives
3
Introduction
3
1.1
3
The early period up to the Renaissance
1.2 The Reformation
4
1.3 The nineteenth century
4
1.4 The twentieth century
6
Conclusion
12
Web resources
13
References
13
CHAPTER 2: A CONCEPTUAL FRAMEWORK FOR MENTAL HEALTH NURSING
14
L R Uys Objectives
14
Introduction
14
2.1
Defining mental health nursing
15
2.2
Lifestyle functioning
19
2.3
Patterns of fulfilling biophysical needs
28
2.4
Patterns of building and maintaining relationships
29
2.5
Patterns of participation in group and community life
30
2.6
Patterns of participation in work
31
2.7
Patterns of utilizing resources
32
2.8 Guidelines for practice
34
2.9 The nurse and the multiprofessional team
36
Conclusion
38
Web resources
38
References
38
CHAPTER 3: COMPREHENSIVE MENTAL HEALTH CARE
39
LRUys Objectives
39
Introduction
40
3.1 Comprehensive mental health care
41
3.2
46
Secondary prevention
3.3 Tertiary prevention 3.4
Planning programmes
50
3.5
Implementing programmes
54
3.6
Evaluating programmes
55
Conclusion
57
Web resources
57
References
58
CHAPTER 4: MENTAL HEALTH CARE IN THE HEALTH CARE SYSTEM
59
LRUys Objectives
59
Abbreviations used
59
Introduction
59
4.1 Overview of the district health system
60
4.2 The integration of mental health care into primary health care 4.3 Description of primary mental health care
64 67
4.4 Team functioning skills
68
Conclusion
70
Web resources
71
References
71
CHAPTER 5: THE CONSUMERS IN MENTAL HEALTH
73
LRUys Objectives
73
Introduction
73
5.1 The stigma of being mentally ill
74
5.2
75
Consumers' perceptions on recovery from mental illness
5.3 The family or 'carer' perspective
77
5.4 Support groups for consumers
82
Conclusion
86
Web resources
86
References
86
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CHAPTER 6: LEGAL STRUCTURE
88
E Madela-Mntla Objectives
88
Introduction
89
6.1
Mental Health Care Act
89
6.2
Criminal Procedure Act
107
6.3
Medicines and Related Substances Control Act
108
6.4
Prevention and Treatment of Drug Dependency Act
110
6.5
Child Care Act
111
6.6
Acts governing the education of intellectually disabled children
112
6.7
Choice on Termination of Pregnancy Act
113
6.8
Sterilization Act
114
6.9
Health Professions Act
115
Conclusion
116
Web resources
116
References
116
CHAPTER 7: THE MANAGEMENT OF ETHICAL DILEMMAS IN MENTAL HEALTH
117
L van Rhyn Objectives
117
Introduction
117
7.1
Ethical theories
119
7.2
The structure of a dilemma
121
7.3
Specific ethical problems in psychiatry
123
7.4
Patient rights
127
Conclusion
128
Web resources
128
References
129
CHAPTER 8: AFRICAN TRADITIONAL CONCEPTS OF HEALTH AND HEALTH CARE
129
A Pienaar I Manaka-Mkwanazi Objectives
129
Introduction
129
8.1
A particular world and life view
130
8.2
African traditional health and mental health care
134
8.3
Guidelines in mental health care delivery to African traditional people
137
Conclusion
139
Web resources
139
References
140
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Section 2: The Mental Health Nursing Process
141
CHAPTER 9: THE MENTAL HEALTH NURSING PROCESS
143
LRUys Objectives
143
Introduction
143
9.1
Interpersonal nursing attitudes
143
9.2
Interpersonal nursing competencies
149
9.3
The nurse-patient relationship
157
9.4
The nursing process
159
Conclusion
160
Web resources
161
References
161
CHAPTER 10: ASSESSMENT OF THE PSYCHIATRIC PATIENT
162
G E Pietersen L Middleton Objectives
162
Introduction
162
10.1 Assessment of own learning needs
163
10.2 A context for psychiatric nursing assessment and diagnosis
166
10.3 Assessment for a medical diagnosis
169
10.4 Assessment for a nursing diagnosis
183
10.5 Doing a quick assessment using a time-event chart
188
10.6 Nursing diagnosis
190
10.7 Group assessment
191
10.8 Example of a psychiatric report
194
Conclusion
201
Web resources
201
References
201
CHAPTER 11: NURSING INTERVENTIONS LRUys
202
Objectives
202
Introduction
202
11.1 Functional assessment and skills training
202
11.2 Group therapy
211
11.3 Mental health education
216
11.4 Social skills teaching
220
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11.5 Psychoeducation 11.6 Milieu therapy
222
11.7 Counselling 11.8 Crisis intervention
229 234
11.9 Symptom management
240
11.10 Case management
245
11.11
Dealing with aggression
225
254
Conclusion
265
Web resources
266
References
266
Section 3: Psychopatholoey & Nursing .f .& oy c? Interventions
267
CHAPTER 12: NURSING THE PATIENT WITH AN ANXIETY DISORDER
269
L Middleton Objectives
269
Introduction
269
12.1 Understanding anxiety
270
12.2 The anxiety response
275
12.3 Normal and pathological anxiety
278
12.4 Classification of anxiety disorders: DSM-IV-TR
278
12.5 Working with the anxious patient 12.7 Intervening in anxiety
287 290 293
Conclusion
316
12.6 Assessing anxiety
Web sites
316
References
316
CHAPTER 13: NURSING THE PATIENT WITH A MOOD DISORDER
318
M Jarvis L Middleton Objectives
318
Introduction
318 319
13.1 Depression 13.2 Nursing assessment and intervention 13.3 Suicide 13.4 Bipolar disorders
322 348
13.5 Nursing assessment and intervention
356 357
Conclusion
363
Web Resources
364
References
364
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CHAPTER 14: NURSING THE PATIENT WITH SCHIZOPHRENIA
366
LRUys Objectives
366
Introduction
366
14.1 Diagnosis and treatment
367
14.2 Facilitation of a healthy lifestyle
373
Conclusion
392
Web resources
393
References
393
CHAPTER 15: NURSING THE PATIENT WITH A SUBSTANCE-RELATED DISORDER
395
LRUys 0 Adejumo Objectives
395
Introduction
396
15.1 Alcohol-related disorders
402
15.2 Other common dependence-producing substances 15.3 Treatment of substance-dependent people
428 434
Conclusion
435
Web resources
436
References
436
CHAPTER 16: NURSING THE PATIENT WITH A COGNITIVE DISORDER
438
L Middleton LRUys Objectives
438
Introduction
438
16.1 Understanding cognitive disorders
439
16.2 Patterns of lifestyle functioning associated with cognitive disorders
445
16.3 Working with the organically impaired person
450
16.4 Intervening in cognitive disorders
458
16.5 Intervening within the family situation
472
16.6 Psychopharmacology
473
16.7 Epilepsy and coping: principles for psychosocial nursing intervention
475
16.8 HIV/Aids and mental health
482
Conclusion
484
Web resources
484
References
484
viii Juta & Co.
CHAPTER 17: NURSING CARE OF PERSONS WITH INTELLECTUAL DISABILITIES
486
LRUys Objectives
486
Introduction
486
17.1 Prevention
488
17.2 Intellectual disability
490
17.3 Assessment
492
17.4 Support of the parents of children with an intellectual disability
498
17.5 Stimulation of development
502
17.6 Institutional care
531
17.7
Management of problem behaviour
17.8 The adult person with an intellectual disability
534 534
Conclusion
536
Web resources
537
References
537
Section 4: Care of Special Groups CHAPTER 18: MENTAL HEALTH NURSING OF CHILDREN AND ADOLESCENTS
539 541
L van Rhyn L Middleton Objectives
541
Introduction
541
18.1
542
Mental health disorders in children and adolescents
18.2 The assessment of children with mental health disorders
566
18.3 Managing emotionally and behaviourally disturbed children
579
Conclusion
582
Web resources
583
References
584
CHAPTER 19: NURSING FORENSIC PSYCHIATRIC PATIENTS
585
LRUys Objectives
585
Introduction
585
19.1 Historical background
586
19.2
587
Current legal provisions in South Africa
19.3 Services provided for a mentally ill offender
591
19.4 Classification of forensic psychiatric patients
591
19.5 The nurse in the observation unit
592
ix Juta & Co.
19.6 The nurse in the security unit
594
Conclusion
598
Web resources
598
References
599
CHAPTER 20: NURSING THE PATIENT WITH A PERSONALITY DISORDER
600
DHook Objectives
600
Introduction
600
20.1 Understanding the person with a personality disorder
601
20.2 Using a transactional analysis model when treating patients with personality disorders 20.3 Working with patients with specific personality disorders
605 618
Cluster A personality disorders
618
Cluster B personality disorders
628
Cluster C personality disorders
647
Conclusion
657
Web resources
657
References
658
CHAPTER 21: PEOPLE WHO HAVE EXPERIENCED TRAUMA
659
B Meintjes Contributing editor: B J Kill/an Objectives
659
Introduction
659
21.1 Understanding trauma
660 668
21.2 Trauma intervention and counselling 21.3 Loss and bereavement
682
21.4 Domestic violence
685
21.5 Specific traumas or groups
689
21.6 Children affected by trauma
692
21.7 Working with groups affected by trauma 21.8 Care of caregivers
6987 702
Conclusion
704
Web resources
704
References
704
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Section 5: Appendices
707
Appendix 1: Inpatient Evaluation Scale
709
Appendix 2:
University of Natal Functional Assessment Scale (UNFAS)
718
Appendix 3:
Examples of Questions Used in a Psychiatric History
724
Appendix 4:
Evaluation of Group Work
727
Appendix 5: Evaluation of Mental Health Education
730
Appendix 6: Time-event Chart for a Patient with Anxiety Symptoms
732
Appendix 7:
Hamilton Anxiety Rating Scale
733
Appendix 8:
Beck Depression Inventory
740
Appendix 9: Classification of Psychiatric Disorders of Infancy, Childhood and Adolescence
744
Appendix 10: Glossary of Psychiatric Terms
747
Index
759
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Foreword
This is the fourth edition of a textbook which has amply proven its worth in mental health nursing education and training for over a decade. What has changed? First, all chapters were brought up to date, and a number of chapters needed additions to reflect changes in society and in diagnostic practices. For instance, the chapter on drug dependence required expansion in order to reflect the increase in the extent of drug abuse and the variety of substances available to the people of Southern Africa. Similarly, owing to the increasing prevalence of the conditions of childhood and adolescence, these are now dealt with more extensively. Trends in service delivery are reflected for the first time in this edition. An important addition is the inclusion of references to the Essential Drug List, which governs the prescription of medications in the public sector. Another incorporates the move, internationally, towards evidence-based practice, which is reflected in references to the Cochrane Review and the Joanna Briggs Collaborations. The book now follows a more formal approach to nursing diagnoses, which allows learners to see how these innovations can be used in practice. Another addition is the chapter on the management of trauma, which draws on the experiences of consumers, on the focus of mental health programmes in the Department of Health, and on the needs of service providers in practice. This chapter, written by a practitioner steeped in the topic, is sure to make a valuable contribution to the preparation of mental health nurses. It is hoped the inclusion of Web resources in each chapter will encourage further reading and networking, and facilitate topic-specific research. Revising a textbook is an essential task, and one that takes much time and effort. In this case, tutors using the book were asked to advise the authors on recommended additions and improvements, and we would like to thank them for their thought-provoking comments. Although many of the original authors of this book worked on the new edition, a number of new authors were also approached for their contributions. To all those who assisted in preparing the revised text, our sincere thanks. We would like to thank the Juta Academic team for their professionalism and friendly assistance. With this book we do our best to address the true needs of mental health nurses in Africa and, through them, the varied needs of their clients. The authors Cape Town 2003
xiii Juta & Co.
About the Authors
De Oliyinka Adejumo completed his Bachelor's and Master's degrees in Psychology in Nigeria, before completing his PhD with UNISA. He has worked in several countries, and is currently Associate Professor of the School of Nursing, University of Natal. His research area is substance abuse. Elsa Giliomee obtained her basic degree in nursing at the University of Port Elizabeth and her Master's degree at the Rand Afrikaans University. She has had experience in psychiatric nursing in the Eastern Cape, as well as at the Sterkfontein Hospital and the Witrand Care and Rehabilitation Centre. Her Master's degree studies were in the area of intellectual disability. Antoinette Gmeiner completed both her under- and postgraduate studies at the Rand Afrikaans University. She worked at the Sterkfontein Hospital for a few years before taking up first a full-time and later a part-time lectureship at the Potchefstroom University for Christian Higher Education. Erika Hiddema (nee Styrbicki) obtained the B. Cur. degree at the University of Port Elizabeth, after which she took a Master's degree at the Rand Afrikaans University while working in psychiatric service in Gauteng. Dale Hook did her basic and psychiatric nursing training In KwaZulu-Natal, and her basic degree at UNISA. She then moved to East London, where she worked in a private psychiatric clinic. She is currently working in a psychiatric hospital in the UK. Anne larvis completed her general training at Addington Hospital in Durban where, in her final year, she was awarded the gold medal of the Natal Provincial Administration. She has worked mainly in psychiatric service since her training as a psychiatric nurse at the Iris Marwick College in Pietermaritzburg and remains deeply involved in training. Edith Madela-Mntla holds a B. Cur. degree from MEDUNSA and the M. Cur and D. Cur. degrees from Rand Afrikaans University, as well as a Certificate in Advanced Health Management from the University of Pretoria. In 1997 she was appointed to the post of Deputy-Director: Medical Services at the National Department of Health. She was involved in the development of the Skills Development Act, was recently appointed a member of the National Essential Drugs Committee and is a representative in the Central Drug Authority for South Africa. She is a member of various professional bodies, amongst others the South African Nursing Council, the Psychiatric Nurse Specialists' Association of South Africa and the Democratic Nurses' Organisation of South Africa (DENOSA).
xiv Juta & Co.
Isabel Manaka-Mkwanazi received all her professional clinical qualifications at the King Edward VIII Hospital in Durban and then completed a Master's degree in clinical psychology through UNISA. She is currently principal of the King Edward Campus of the Natal College of Nursing. Berenice Meintjes is a clinical psychologist working for Sinani/KwaZulu-Natal Programme for Survivors of Violence. She served as director of the organization for five years. She completed her Master's degree at the University of Natal, Pietermaritzburg. She is passionate about training and materials development for frontline mental health workers. Lyn Middleton, born and bred in KwaZulu-Natal, was principal of the Iris Marwick College of Psychiatric Nursing at the Midlands Hospital Complex in Pietermaritzburg before joining the University of Natal to run the decentralized programmes in Psychiatric Nursing. She did her Honours Degree at the University of Natal and is currently researching constructions of psychiatric nursing in practice. Elize Pietersen completed her training as a nurse at the University of the Orange Free State, where she also obtained a Master's degree in psychiatric nursing. She taught psychiatric nursing at her alma mater for a number of years, making clinical teaching her main focus. She is in a research position in the Western Cape at present. Peggy Shibes obtained extensive experience in the psychiatric unit at King George V Hospital before she moved to her current position at Addington Hospital. Marinda Steyn obtained her Bachelor's and Master's degrees from the Rand Afrikaans University. She works in the psychiatric unit of the J G Strydom Hospital in Johannesburg. Leana Uys took a Bachelor's degree in nursing at the University of Pretoria and a Master's degree and doctorate in psychiatric nursing at the University of the Orange Free State. She lectured at the University of the Orange Free State and is now Professor of Nursing at the University of Natal in Durban. She was the author of the first South African textbooks on psychiatric nursing in 1979. Guizelle van Reenen obtained a Bachelor's and a Master's degree at the Rand Afrikaans University. She specialized in the psychiatric nursing of children for the Master's degree, and gained experience in children's and adolescent units on the Reef. Lily van Rhyn obtained a Bachelor's degree in nursing at the University of Potchefstroom, a Master's degree in psychiatric nursing at the University of Pretoria, and a doctorate in the psychiatric nursing of children at the University of the Orange Free State. She has spent some time studying and practising in the U.S.A. She currently has a part-time private practice and is senior lecturer at the UOFS.
xv Juta & Co.
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SECTION 1
Frameworks & Foundations
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CHAPTER ONE
The History of Mental Health Nursing -RUYS
Objectivea After studying this chapter the learner should be able to: Describe in broad terms the history of mental health nursing up to the twentieth century. Identify the most important historical trends in the development of psychiatry in the twentieth century. Describe how international trends have influenced psychiatry in South Africa. Identify important events in the development of mental health services and mental health nursing in South Africa.
INTRODUCTION The history of mental health services and mental health nursing is closely related to social and scientific development and to the prevailing views of society. The events must therefore be seen against the wider background of history. 1.1 THE EARLY PERIOD UP TO THE RENAISSANCE A number of civilizations flourished in ancient times and during the period before Christ. The aetiology of mental illness was generally considered to be supernatural. Methods of treatment were of a physical and religious nature. Physical treatments included, among others, baths and venesection. The aim of some methods was to make the body so uncomfortable for the strange spirit that it would leave. Examples of such methods were to heat the patient to such a degree that the spirit would flee the discomfort, or to entice the spirit out of the body with beautiful music. Religious treatment concentrated on rituals.
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MENTAL HEALTH NURSING - A SOUTH AFRICAN PERSPECTIVE
Patients were free to come and go in the community as long as they were not a burden or dangerous. The family was primarily responsible for their care. The traditional treatment of mentally ill people in Africa is still based on this model. Traditional healers, such as sangomas, are aware of the wide range of mental disorders treated by modern psychiatrists, but their methods consist mainly of herbal treatments, fortune-telling, exorcism and rituals. The priests of the African churches are a modern development of this traditional care system. In these churches Christian doctrine has been adapted to create a hybrid that is typical of African culture. The priests encourage faith in the supernatural and often become involved, especially by faith healing, in the treatment of mentally ill people. To return to the European history of psychiatry: During the Middle Ages possession by demons was considered to be the cause of mental illness. Treatment supported this view and many psychiatric patients were burned at the stake. The idea gradually developed that the care of these people was the responsibility of the state. There was a belief that they should be isolated from normal society and this viewpoint led to the founding of institutions. Groups of patients were sometimes handed over to seafarers to be put ashore on uninhabited islands and the expression 'a ship of fools' originated from this practice. 1.2 THE REFORMATION The rise of science led to a more sophisticated classification of mental disorders. Large institutions which harboured all types of people, from prostitutes, the indigent, unmarried mothers to the mentally ill, were at one time a common phenomenon. Conditions in these institutions were very bad and in the late eighteenth century Turk in England and Pinel in Paris began to separate the mentally ill from the others and to treat them with respect and compassion. Their treatment, known as 'moral treatment', was most successful and resulted in the large-scale establishment of institutions called 'asylums' or 'sanctuaries'. In colonial South Africa wealthy patients with mental disorders were usually cared for at home, while those who were poor were sometimes placed with families who were reimbursed by the church. Slaves and dangerous patients were kept in prison and visited by deaconesses of the church. When general hospitals were opened, mentally ill patients, mainly employees of the Dutch East India Company, were also admitted. 1.3 THE NINETEENTH CENTURY This period was marked by a tremendous increase throughout the world in the number of institutions for the mentally ill. In the United States of America, Dorothea Lynde Dix, a teacher who later became a nurse, was responsible for an international effort to provide better hospital facilities for psychiatric patients. She was directly and indirectly responsible for the increase in the number of psychiatric hospitals from 13 in 1843 to 123 in 1880. In South Africa too the first psychiatric hospitals were opened at this time. The prison on Robben Island was turned into an institution for lepers, the chronically sick and
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The History of Mental Health Nursing
psychiatric patients in 1846. The custodial care given there was evidently of a high standard and the 1891 report of the Resident Medical Officer mentions the training of nurses and assistants. Psychiatric institutions were, in time, erected throughout the country and legislation was passed for the management of psychiatric patients. The establishment of psychiatric hospitals in South Africa is set out in Table 1.1. It is noteworthy that many of these institutions were not, in the first place, designed for this purpose and that many of them are now more than a hundred years old. Table 1.1 Establishment of psychiatric hospitals in South Africa Year
Name
Place
1846
-
Robben Island
1875
Grahamstown Lunatic Asylum (Later Fort England)
Grahamstown (Old military barracks)
1875
Pietermaritzburg Lunatic Asylum (Later Town Hill)
Pietermaritzburg (Temporary building moved to permanent building in 1882)
1883
Bloemfontein-Zielziekehospitaal (Later Oranje Hospital)
Bloemfontein
1889
Port Alfred Lunatic Asylum (Later Kowie)
Port Alfred (Old military barracks)
1892
Pretoria Krankzinnegengesiicht (Later Weskoppies)
Pretoria
1894
Fort Beaufort Lunatic Asylum
Fort Beaufort (Old military barracks)
1891
Valkenberg Lunatic Asylum
Observatory (Old reformatory)
1922
Queenstown Mental Hospital (Later Komani)
Queenstown
1927
Fort Napier Hospital
Pietermaritzburg (Old military barracks)
1943
Sterkfontein Hospital
Krugersdorp
1946
Tara - the H Moross Centre
Randburg (Old military barracks)
1962
Stikland Hospital
Bellville
1966
Bophelong Hospital
Mafikeng
1972
Thabamoopo Mental Hopital
Pietersburg District
1980
Umzimkulu Hospital
Umzimkulu (Farm converted to a prison)
1986
Lentegeur Hospital
Mitchells Plain
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MENTAL HEALTH NURSING - A SOUTH AFRICAN PERSPECTIVE
1.4 THE TWENTIETH CENTURY International developments The tremendous increase in the number of psychiatric hospitals resulted in a change from small centres, where moral treatment was given, to enormous, overpopulated institutions, where hopelessly inadequate numbers of staff tried to manage patients by the use of shackles, mechanical restraints and isolation cells. Custodial care was no longer therapeutic. In 1908 a discharged patient, Clifford Beers, published a book entitled A Mind that Found Itself, in which he described his appalling experiences in American psychiatric hospitals. The publication of this book led to the founding of the first Mental Hygiene Society, which grew to become a national organization within a year. It later became internationally known as 'The Mental Health Society'. In the 1950s the pressure exerted by this society - together with the help of a few influential psychiatrists and certain social scientists who, by means of a number of studies, illustrated the negative consequences of custodial care - led to a renewed focus on the social environment in which treatment takes place. This development, which was called Social Psychiatry, emphasized the creation of a therapeutic environment in wards, and the avoidance of high fences, locked doors, restraints and isolation. The strong sedatives that were dramatically to change the manner of control of psychotic patients were developed at the same time. This greatly increased the possibility of discharge and led to the largescale deinstitutionalization of psychiatric patients and the transfer of treatment to the community. In the USA psychiatric nursing was a subdiscipline with an upward trend from the 1950s to the 1980s. This development took place under the leadership of Hildegard E Peplau, who is regarded as the mother of mental health nursing. She played a tremendous part in the development of the therapeutic role and abilities of psychiatric nurses in American state psychiatric hospitals. She developed a model of interpersonal relationships in nursing, which was published in 1952 as Interpersonal Relations in Nursing, and for years she was the Head of the Department of Nursing at the University of Rutgers in New Jersey. Another nurse who played a prominent role during the same period was Ida J Orlando, whose thorough study of the interaction between nurse and patient appeared in 1972 under the title The Discipline and Teaching of Nursing Process. These two psychiatric nurses and many others ensured that mental health nursing was at the forefront of professional, educational and clinical development in the profession. Mental health nursing content was incorporated as part of basic nurse training. Psychiatric nurses began to act as consultants to their medico-surgical colleagues in general hospitals, helping with the emotional problems of patients, and many nurses specialized in mental health nursing. South Africa Mental health The mental health movement also spread to South Africa. A committee was established in Cape Town in 1913 to look after the interests of people with intellectual disabilities. The activities of this committee soon spread to the mentally ill and the committee immediately
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The History of Mental Health Nursing
began working to bring about better legislative provision for the management of psychiatric patients. This action led directly to the promulgation of the Mental Disorders Act of 1916. By 1920 the group had grown into the National Council for Mental Health. The Council moved its headquarters to Johannesburg in 1922 and, with the help of affiliated mental health societies, played an important role in the development of services such as child guidance clinics, training centres for people with intellectual disabilities, and juvenile courts. Control Control of psychiatric institutions was transferred from the Department of Health to the Department of Internal Affairs in 1909, as they were not regarded as hospitals. In 1943 they were returned to the jurisdiction of the Department of Health, while all other hospitals were by now the responsibility of the Provincial Administrations. This placement of psychiatric hospitals led to their isolation from the mainstream of medical development and to large-scale stagnation of the services. The isolation was only broken in 1988 when psychiatric hospitals were placed under the control of the Provincial Administrations. Quality of care As was the case overseas, psychiatric hospital care at mid-century was poor. Miss Iris Marwick was appointed correspondent to the International Council of Nurses regarding mental health in South Africa. Her reports began appearing in the Nursing Record in 1933. In these she sketched a picture of serious over-population, extremely poor working conditions for nursing staff and acute staff shortages. In 1944, 38 % of the nursing posts were vacant, and in 1948 the government allocated only 35 % of the amount granted to psychiatric services in 1945 to this sector. The salaries of psychiatric nurses were lower than those of nurses in other branches of the profession, working hours were longer, and less leave was granted. The quality of board and lodging was also poor. In this climate Miss Marwick and Dr H Moross developed Tara Hospital in the northern suburbs of Johannesburg into a progressive psychiatric centre. Tara was originally a military hospital, but it was transferred to the Provincial Administration in 1946. Although it was, in effect, a psychiatric hospital, it did not admit certified patients. It could, therefore, be developed under the auspices of the Provincial Administration. Modern methods of treatment, such as therapeutic milieu therapy, an open-door policy and day care were implemented here and the hospital became the leader in the field of psychiatry. In 1946 Miss Marwick became the first nurse to be appointed Organizer of Nursing Services in the Department of Health. She made an enormous contribution to mental health services in general, and mental health nursing in particular, while she held this post. Nursing training Mental health nursing training became the responsibility of the South African Medical Council in 1928, although many nurses still wrote the examination of the Royal Medico-
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Psychological Association of Britain until this practice was ended by legislation in 1932. In 1931 the regulations were published for two qualifications leading to registration in mental nursing and the nursing of people with intellectual disabilities. When the South African Nursing Council was established in 1944, the admission level was raised to Standard 8 (the equivalent of today's Grade 10) in order to place mental health nursing on a par with other branches of the profession. However, the numbers dropped so dramatically that the level was again lowered to Standard 6 (now Grade 8). Psychiatric nurses were often recruited from industrial schools. The training was poor: there were no classrooms, specific lecture periods or trained tutors. Regulations were promulgated as far back as 1954 for a one-year course in mental health nursing which would combine the previous two diplomas, but the course was only implemented in the 1960s. The first psychiatric nurses commenced their training as tutors in 1965, and this small group made a far-reaching contribution to the development of psychiatric nurse training in South Africa. Standard 10 (Grade 12) was finally laid down as the minimum admission level for training in 1975. In 1970 two universities (Orange Free State and Pretoria) initiated a basic, integrated degree course that included mental health nursing, and this integrated approach was accepted as the model for all basic training in the country in 1986. This development finally broke the isolation of mental health nursing and made it part of the broader health service. It also opened the way for postgraduate programmes in mental health nursing, and the first nurses to receive clinical Masters' degrees in this branch of nursing did so in 1976. Community services
Although social workers of the Mental Health Association throughout the country started to give after-care to psychiatric patients in the community in the early 1920s, the first effort by a psychiatric hospital itself to work outside the confines of the institution was made in 1957 by the Tara Hospital under the guidance of Dr M B Feldman, Miss I Marwick and Miss C Haines of the local government of Johannesburg. They initiated an after-care service for discharged patients of the Tara Hospital. This service was so popular that, after an investigation by the Department of Health, it was extended to other metropolitan areas. This co-operation between the psychiatric hospital, local government and the Mental Health Association, as well as the active involvement of the psychiatric nurse, established the pattern for the rapid development of the community service. Outpatient departments were developed at all the large psychiatric hospitals in the 1970s, and inpatient populations began to decline. The radical type of deinstitutionalization, which resulted in the revolving-door syndrome of repeated discharge and readmission in the United States, was never practised in South Africa. Outpatient clinics were gradually opened throughout the country and patients were carefully discharged according to their ability to lead a dignified existence outside the institution. This dramatic change in the service necessitated a change in legislation and resulted, in 1973, in the promulgation of the Mental Health Act, which facilitated admission
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without isolation, as well as legalized outpatient treatment. The changing pattern is illustrated in Figure 1.1.
Figure 1.1 Changing patterns in SA mental health services 1960-1987 (Adapted from the National Health report)
Apartheid The National Party government, which came to power in 1948, placed racism on the statute book. Over the years this was to have a profound influence on mental health problems in the country, as well as on the development of services. As regards general mental health, the other-than-white groups suffered under a policy which: broke up family life by virtue of the fact that urbanization of families was prohibited by enforcing migrant labour; promoted pauperization by controlling admission to the free economy, land ownership, quality education and job opportunities; intensified stress in the community by the forced removal of people from familiar to strange environments, prosecution and intimidation by the enforcement of laws such as the Influx Control Act and race classification on an unwilling population, and by suppressing popular leadership.
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As a result of all these factors the morbidity pattern of these population groups differs radically from that of whites. For instance, the incidence of alcoholism is far higher among black and coloured people than it is among white people, and intellectual disability due to the serious malnutrition and undernutrition of children shows the same pattern. Moreover, South Africa has one of the highest suicide rates in Africa. The quality of services to the various population groups also differs considerably. Criticism of the racist nature of the psychiatric services in South Africa led, in 1979, to a visit by members of the American Psychiatric Association to certain services in this country. They found that the death rate among black patients in psychiatric hospitals was unnecessarily high, that the care was substandard, that the provision of professional staff was hopelessly inadequate, and that there were signs of the abuse of patients. The differences between the services for black and white patients were often defended by reference to cultural differences, but the delegation dismissed this as unfounded. There is still a great difference between the services for the various population groups. The availability of services such as training centres for children with intellectual disabilities, child guidance clinics, school psychologist services and psychotherapeutic services are but a few examples. The generally negative position of the disadvantaged population groups naturally also influences psychiatric services. There are, for instance, very few black doctors, which leads, percentage-wise, to an acute shortage of black psychiatrists. Black people are under-represented in professions such as occupational therapy, clinical psychology and social work, and this in turn hampers the functioning of multiprofessional teams in psychiatric services. The creation of the Tricameral Parliament resulted in the control of mental health services, particularly community services, being divided among the three Houses. This fragmentation was not implemented to the same extent in all the provinces, but in many regions it led to a serious duplication of services, while access to their nearest service was suspended for some patients. Maldistribution of staff resulted in less than optimum functioning of services. In 1994 the first democratically elected government came into power. The period since has been characterized by major changes in the health services and in society. In their 1999 analysis of what was achieved during the first four years under the new government, Flisher, Fisher and Subedar point to the following: the development of mental health service norms; the development and implementation of the Essential Drug List which promotes the availability of standard drugs for the treatment of mental illness at all Primary Health Care (PHC) clinics; the promulgation of a number of Acts affecting mental health care, such as the Criminal Matters Act of 1998. Flisher, Fisher and Subedar also point to national pilot projects, such as the training programme for PHC practitioners in Victim Empowerment, and the Deinstitutionalization projects.
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Current issues in mental health nursing Two major health care movements currently exert an influence on mental health nursing. The first is a move towards primary health care and the second is a greater focus on psychosocial rehabilitation in community psychiatric care. In the second half of the twentieth century the realization dawned the world over that hospital-centred health care services were not effective in promoting health and were far too expensive for the limited resources of many communities. In 1978, during a meeting in Alma-Ata, Kazakhstan, the World Health Organization adopted the declaration that primary health care was the way to go in order to ensure health for all by the year 2000. This declaration resulted in the South African government's accepting as its policy a comprehensive primary health care approach. This fundamental change has not been easy so far and it was not implemented with any great enthusiasm in the past. However, the new government is committed to this approach and changes can be expected. This has important implications for mental health services. In the initial Alma-Ata declaration, psychiatric/mental health care is not included among primary health care services. This oversight probably stems from the historic position of psychiatry as the stepchild of health services, coupled with the fact that the declaration was adopted before the enormous growth in the science of neurology of the past two decades. It may also stem from an underestimation of the seriousness and extent of mental illness. Whatever the reasons, the advantages of including psychiatric/mental health care in primary health care are as follows: 1. Nurses and other health professionals in community settings will learn to understand mental health better, which will enable them to be positive role models in their communities, thereby combating the stigma attached to psychiatric patients and their families. 2. Early detection and treatment in the primary health care setting will be possible, so that treatment will cause the least possible disruption in the role-functioning of the patients. 3. Even should hospitalization sometimes be necessary, there will be a local professional involved in the procedure of admission. This will increase the involvement of the family and local social network in the treatment of the patient. It will provide the hospital team with more information regarding the patient and his/her situation and in this way improve treatment. 4. Rehabilitation will also be possible within the community in which the patient lives. At the moment many patients, particularly black people from rural or informal settlement areas, have no formal address to which families can be traced. They can therefore not be discharged and consequently spend many years in a hospital when they could easily have been living with their families. 5. The availability of psychiatrically trained staff in community clinics has the potential to improve the community's understanding of mental illness and to combat the stigma attached to sufferers.
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With this in mind, it is important that more nurses be trained in mental health nursing, so that this knowledge and these skills may become more widely available. This will ensure that psychiatric care is provided by adequately trained people and that the quality of this care will not be lower than that of other aspects of primary health care, such as midwifery. In the primary health care debate nurses should also be strong advocates for the inclusion of psychiatric care in primary health care. The second change is the move towards rehabilitation as the focus of community mental health services. When deinstitutionalization occurred in the 1970s, patients were transferred to the community without preparing the community for the influx. Psychiatric staff were still concentrated in hospitals, while most of the patients were to be found within the community. Alternative housing and vocational rehabilitation services were not available in the community. Staff working in outpatient settings did not have the necessary skills to help people in this new situation. Families became the main providers of care, as patients were often dumped on them with little notice or preparation. Although patients were therefore discharged and living in the community, the situation caused as many problems as it solved and often did not lead to an improved quality of life for the patients or their families. Gradually community mental health staff and consumers (mostly family members, but also the patients themselves) formulated their problems, developed strategies to cope with these problems and became more vocal in demanding services that satisfied their needs. This change is now called the rehabilitation era. The groups involved identified the following services as essential for the care of a mentally ill person in the community: Case management Psychiatric rehabilitation Crisis intervention Treatment Basic support Enrichment Rights protection. The move from the community psychiatric era to the rehabilitation era has not yet been completed in South Africa. The focus of most community psychiatric services is still on treatment rather than rehabilitation. Nurses currently in training are fortunate to be able to participate in this movement. CONCLUSION In the past, mental health services were shaped by many factors within as well as outside the country's borders and this trend may be expected to continue. It will be interesting to see how this service develops in future. One can only hope that well-informed nurses will play a leading role in these developments.
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WEB RESOURCES http://www.dhhs.state.nc.us/mhddsas/DIX/dorothea.html Provides a brief history of this remarkable woman, with a picture. www.epub.org.br/cm/n04/hisoria/shock_i.htm\ Website of the electronic journal 'Brain and Mind', which gives a fascinating history of the use of shock treatment in psychiatry; includes not only Electro-Convulsive Therapy but other types of shock treatments, such as Insulin Shock Treatment. REFERENCES American Psychiatric Association. 1979. Report of the Committee to visit South Africa. American Journal of Psychiatry, 136(2), 1498-1506 Anthony, W, Cohen, M & Frakas, M. 1990. Psychiatric Rehabilitation. Boston: Boston University Brownlee, E B I. 1986. South African Nurses of Distinction. Pretoria: SA Nursing Association Crostwaithe, MM. 1926. History of mental health services in South Africa. South African Nursing Record, November, 22-28 Dear, M J & Taylor, S M. 1982. Not on Our Streets: Community Attitudes to Mental Health Care. London: Pion Publishers Dolan, J A. 1978. Nursing in Society: A Historical Perspective. Philadelphia: W B Saunders Company Flisher, A, Fisher, W & Subedar, H. 1999. Mental Health, in South African Health Review 1999. Durban: Health Systems Trust Le Roux, M M. 1985. Die Wordingsweg van Psigiatriese Maatskaplike Werk in Staatspsigiatriese Inrigtings in die RSA (unpublished DSocSci thesis, University of the Free State, Bloemfontein) Manfreda, M L M. 1973. Psychiatric Nursing. Philadelphia: F A Davis Company Marwick, 11. 1948. International Congress of Mental Health. South African Nursing Journal, XV(1) Marwick, 11.1948. South African Trained Nurses Association Report. South African Nursing Journal, November, 27 & 32 Minde, M M. Mental Health Services in South Africa, Vol II Odejide, A O, Oyewunmi, L K & Ohaeri, J U. 1989. Psychiatry in Africa: An overview. American Journal of Psychiatry: 146(6), 708-716 Roscher, C I. 1972. Resume of Symposia. Symposium on community health care. lohannesburg: Squibb Laboratories Roscher, C I. 1975. Psigiatriese verpleging in Suid-Afrika: 'n Oorsig. SA Verplegingstydskrif, XLII (3) Searle, C. 1965. The History of the Development of Nursing in South Africa, 1652-1960. Pretoria: The South African Nursing Association Uys, L R. 1979. Die Opleiding van Blanke Verpleegkundiges in Psigiatrie in die Republiek van SuidAfrika: 'n Evalueringstudie (unpublished DSocSci thesis, University of the Free State, Bloemfontein) Vogelman, L. 1986. Apartheid and Mental Health. Johannesburg: Proceedings of the OASSSA National Conference
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C H A P T E R Two
A Conceptual Framework for Mental Health Nursing LRUYS
Objectives After studying this chapter the learner should be able to: Define mental health nursing and explain the definition. Define lifestyle functioning and explain what the components of a lifestyle are. Discuss the nursing interventions for the different levels of lifestyle functioning.
INTRODUCTION In South Africa, mental health nursing is seen as part of the basic (pre-registration) education of professional nurses in order to equip them to work as generalist nurses in the comprehensive health services of the country. Most students coming into nursing, however, have only a vague idea of what this subdiscipline is all about. While most of them have visited general hospitals, few have ever seen the inside of a psychiatric hospital. Neither do they usually choose nursing with the mental health component as their ultimate goal. It is therefore an unfamiliar experience to many, when they start their mental health nursing studies, to enter these facilities. Some students and qualified nurses who move from the general and midwifery areas into mental health settings, experience a culture shock. Mental health nursing seems to them to be very different from the other areas in the following respects: The pace seems to be much slower and the pressure of physical work much less. Nurses feel as though they are doing nothing. It takes some time to see how much interpersonal activity is actually going on. When they do get involved in, for example, stimulating an entire unit full of patients to perform at a higher level than is their natural choice, the emotional demands are enormous.
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All the patients seem to be chronic, with only very small improvements taking place, and none of the dramatic results that one sees in other nursing areas are present. This is true, of course. The acute settings, where rapid improvements are often seen, make up a very small proportion of the student's experience. Most of the patients in community services and in long-term units are seen over many years. This is something that might appear to be negative at first, but it does make the service very personal and rewarding in the long run. Some parts of the learning experiences are frightening and distressing. Students often find it upsetting to work with children with profound intellectual disabilities or with emotionally disturbed patients very close to their own age. This is understandable and, by using mature coping strategies, can usually be worked through. The extremes of emotions that patients sometimes exhibit can be very frightening and upsetting, especially when it all seems to be aimed personally at the student. In this regard it is important to understand from the beginning that it is the patient who has a problem and that the target of the emotion is usually not important. In other words, it should not be taken personally. This is an important lesson because the nurse often also has to help the family and friends of the patient to understand this. The normal reaction for people who are confronted with behaviour in others which they cannot understand or condone is withdrawal or aggression. This is so ingrained through socialization that we do it almost automatically. It is therefore important for student mental health nurses to carefully explore their own reactions to what they experience, so that this natural reaction does not render them ineffective as mental health nurses. Mental health patients are in pain and the last thing they need from the helping professionals is more of the rejection they have experienced before. Just as working with the body of another human being is a privilege and a responsibility, so is working with their emotional pain. One might think that this part of nursing is confined to psychiatric hospitals. This is a definition mental health nurses do not appreciate much, since they believe that mental health nursing cannot be contained within the walls of psychiatric institutions and that their skills and knowledge apply wherever there are people with emotional problems people who are found in all health services and out in the community, in schools, in the workplace, in families. In all these settings the nurse with mental health knowledge and skills is a useful member of the health service team. 2 1 DEFINING MENTAL HEALTH NURSING Mental health nursing is an interpersonal process in which counselling is aimed at supporting and facilitating healthy lifestyle functioning. An interpersonal process. Defining this area of nursing in such a way emphasizes the fact that the major knowledge and skills involved deal with the intrapersonal and interpersonal dynamics of human beings. It is an intensely personal human process. Aimed counselling. This part of the definition makes it clear that mental health nursing is based on knowledge of human behaviour both in sickness and in health. It is not
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merely doing what comes naturally; it is a planned, controlled, targeted action on the part of the nurse. Supporting and facilitating. Mental health nursing has two important components: supporting people at a reasonable level of functioning which they cannot maintain independently; and facilitating a higher level of functioning in people for whom this is possible. Supportive activities refer to all those that merely maintain what is already there, without any demands being made on the person. An example of supportive intervention is a nurse sitting quietly with a patient who is highly anxious, in order to support the person simply by being present. Facilitating, by contrast, refers to all those activities that require patients to function at a level higher than they are exhibiting at that stage. The nurse stimulates the patients to do something more, through activating, demanding and promoting effort and better functioning. An example of this kind of intervention is a nurse working out a behaviour modification programme aimed at increasing the socialization of a patient; not only is the current level of socialization supported, the patient is actively stimulated to do better. Healthy lifestyle functioning. This means that people can become involved independently with themselves, with others and with issues and tasks in a flexible and constructive wa and that they can maintain this involvement according to related expectations and demands. For instance, healthy lifestyle functioning as far as work is concerned would be a person independently choosing and finding a job, carrying it out constructively in the way that the job demands and keeping the job over a reasonable period of time. In defining health as healthy lifestyle functioning, it is seen as a complex pattern of behaviour and not as a simplistic list of characteristics. Neither is it seen as an all-or-nothing commodity, but as a pattern of functioning that can be anywhere on the health-illness continuum. The lifestyle functioning of a person is composed of different sets of patterns. A pattern is a consistent, observable way in which elements are arranged. If one element of a pattern changes, the entire pattern changes, although it is often still recognizable. A group of patterns forms a style. As patterns change, the total lifestyle is affected to a larger or smaller extent, depending on the degree to which the patterns change. The lifestyle of an individual, the continuum of possible lifestyle functioning and the demands these place on the mental health nurse are illustrated and summarized in Figure 2.1. It has always been difficult for psychiatric nurses to conceptualize and explain what their role really is. Psychiatric nurses are involved in so many activities in an inpatient setting: they manage the physical facilities, supervise the domestic and clerical staff, serve meals, hand out medication, admit patients, restrain violent patients, respond to queries from family members, and see that patients get to occupational and other therapies. Looking at all these activities, some people have defined the nurse's role as that of a coordinator. Others have talked about a mother surrogate. Peplau (O'Toole & Welt 1989) views the matter very differently. She sees the central role of the mental health nurse as being that of counsellor. This means that nurses make use of every opportunity provided by their unique position in the unit to counsel the
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patient about intrapersonal and interpersonal patterns. Counselling can be compared with psychotherapy in the same way that clinical teaching can be compared with classroom teaching, as shown in Table 2.1. Table A comparison of counselling and psychotherapy Counselling (similar to clinical teaching)
Psychotherapy (similar to classroom teaching) Differences
Based on direct experiential learning Intervenes as situations happen, unplanned Involves the immediate processing of events, often based on mutual observations
Intervenes at scheduled sessions, regularly according to the contract Involves processing of past events at scheduled times Uses mainly patient self-reports in processing
Similarities Based on psychodynamic theories Uses psychotherapeutic interventions Aims at improved functioning
The main function of nurses is therefore to use their unique position in the patient's environment for prolonged periods of time in different situations to counsel the patient. All other functions are subordinate to this. The counselling function can be compared to the rest of the duties of the nurse by using the microscope as a model. The most important part of the microscope is the lens. It is this small part that performs the task for which a microscope exists. However, when you look at the microscope, you sometimes do not even see the lens. You see all kinds of other parts, which are there, however, only to keep the lens in the exact spot that it needs to be to do its job of magnifying in focus. In the same way, everything else psychiatric nurses do is meant only to keep them in position to do their most important task of counselling. Now that the psychiatric nurse's main function has been identified, the principles of mental health nursing can be described. These principles are the most important fundamentals psychiatric nurses should keep in mind when going about their work. Focus Counselling according to interpersonal and intrapersonal patterns is the main focus of mental health nursing. Nurses should not become distracted by other things and neglect this role. If they do, they cease to be mental health nurses and become managers, co-ordinators or something else instead.
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Figure 2,1 Mental health nursing conceptual model
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Analyse Negative patterns in the patient's functioning should he identified and analysed as a first stage in changing them. Identifying patterns implies careful observation and listening. Analysis means that threads are followed, implications drawn, questions asked, more observations made and more cues followed. It is the process of investigating intelligently. Refrain Automatic reactions and explanations interfere with the identification and analysis of patterns. The more nurses react on minimal data in an automatic way, based on socialization, prejudice or a hunch, the less they are able to remain open to what may really be happening. Name Correct linkage of concepts with phenomena can assist in obtaining more information and in resolution. Using the correct theoretical concept to describe a situation or pattern can direct the nurse to further observation and analysis and can also direct the nurse to possible solutions to the problem. For instance, in observing and analysing the behaviour of a patient, nurses may link the concept 'frustration' to the pattern they are observing. This opens up questions like 'What is blocking the patient's progress towards achieving his/her goals?' and'Which method has the patient tried to get rid of the obstruction?' Such questions lead to better analysis of the situation. Further questions can be 'Can the goals be changed?', 'Since aggression has not removed the obstacles, will negotiation perhaps do it?' and 'Does the patient have the skills to negotiate?' Such questions will be part of finding solutions to the problem. Self The nurse is part of the pattern that should be analysed. It is very easy to forget that the patient might be influenced by the nurse and not only by other people. Nurses are therefore part of the patterns that form and reform in the unit and their role should form part of the analysis. If nurses are not aware of their own needs, feelings and reactions and of their influence on the people around them, including the patients, they will often not be able to understand what is happening in the therapeutic setting. These five principles spell the word FARNS - not quite FERNS, but close! 2 2 LIFESTYLE FUNCTIONING All the patterns discussed in this next section help to make up the lifestyle of an individual. No lifestyle is totally healthy or totally unhealthy; an individual who basically has a healthy lifestyle may have a few indicators that are not optimal, while a person with an unhealthy lifestyle shows a few adaptive patterns. Lifestyles can be arranged in a continuum. Healthy and independent. Such a person, if in contact with the health care system, needs only enriching activities to help maintain his/her healthy lifestyle throughout
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his/her lifespan. Preparation for retirement by a healthy 60-year-old is an example of such an activity. Problematic, with some unhealthy patterns. In this case, a person might need some supportive problem solving from a nurse to promote healthier patterns. For instance, a widow who used to unwind after a day's work by having a sundowner and a chat with her husband, now starts the same ritual at about five in the afternoon, but without her husband. This deteriorates into a drinking and crying session that ends only when she goes to bed. Short-term dependent and disorganized. This person might need crisis intervention and short-term counselling so that he/she can return to a healthy lifestyle as soon as possible. An example is a rape victim who is severely traumatized by the experience, which is affecting both her work and her marriage. Crisis intervention would be indicated. Long-term dependent, limited and handicapped. This person needs long-term support from the health system, preferably on an outpatient basis. This support should be aimed at rehabilitating the person to as healthy a lifestyle as possible. 2,2,1
PSYCHODYNAMIC PATTERNS
The psychodynamic patterns of a person's personality can be seen as a layered whole: the sense of self or self-concept forms the centre; the defence mechanisms (which are unconscious mechanisms) are built round the self-concept, and coping strategies form the more visible behaviour based on all the other components. Sense of self (self-concept) When a baby is born, an inherited genetic pattern is already present, which greatly influences the patterns of the baby's future life. In addition, the baby is born into a family with established cultural, religious, economic and interpersonal patterns, which further form the child as a person during his/her early years. The formative interaction between the individual and the environment is not a passive process, since even babies interact actively with their environment. The first pattern that develops in a baby is a sense of self. Although a baby is born with a whole range of dispositions, no sense of self is present. Through active interaction with the people in the environment, and by being stimulated and maintained by his/her attachment behaviour, the baby gradually realizes that he/she is a separate entity. The child then builds up a whole set of beliefs about who and what he/she is, still based on his/her active interaction with the environment. This is called self-conceptand is one of the most basic and enduring psychodynamic patterns of a person, although it can and does change throughout his/her lifespan. There is a difference between self as seen by oneself and as seen by others, although there is a distinct interaction. Johari (Stuart & Sundeen 1987) has developed a way of distributing the different aspects of self in a visual way, which is known as the Johari window (Figure 2.2). In this window, area 1 is the open area, also called the arena. This area
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is known by both self and others in, for instance, 'I am rather short/She is a small person'. Area 2 is called the blind spot and consists of those things that other people know about a person but which the person is not conscious of, for instance, 'I am easy to get along with/He has a very short temper and a very long memory'. Area 3 is known as the masked area, the content of which is known by self but which is withheld from the view of others. An example of the content of this area may be 'I am not very smart/She comes across as very confident of her own abilities'. The last area (4) is hidden from both self and others (in other words, it is an unknown area) and consists of repressed content, such as suppressed anger or fear.
Figure2.2 Johari window People who have a lot of self-knowledge and are open to learning about themselves from feedback have a Johari window that looks like A below, while those who have little accurate understanding of themselves and are rigid in their interpretation of outside stimuli have a window that looks like B.
Figure 2.3 Johari windows
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There is a difference between the ideal self and self-concept. The ideal self is what a person believes he/she should be like, should be doing and should be able to do, while selfconcept is what the person thinks he/she is actually like, is doing and can do. The overlap between these two perceptions forms self-esteem; if the ideal self is close to the self-image, self-respect is high, and vice versa. The major components of self-esteem are a sense of competence, significance, virtue and power. Self-esteem therefore refers to how positive the self-image is or how satisfied a person is with his/her having, relating and being. Low self-esteem has been linked by researchers to phenomena such as dependency, the need for approval, depression, anxiety, submissiveness, a vulnerability to interpersonal problems and poor general health. In contrast, people with a high self-esteem are more accepting of others, can better tolerate internal and external distress, are less sensitive to criticism, anticipate more success and enjoy better relationships and general health. Defence mechanisms Another important psychodynamic pattern is that of defence mechanisms. A baby is born with the ability to express different emotions but can, at that stage, probably experience only a generally positive or a generally negative feeling. By the age of one year the baby has enough of a sense of self to begin experiencing 'I am angry' or 'I am glad'. The emotions of childhood are quite intense, undifferentiated and difficult to control, but over the years they are blended and moulded into more subtle, articulated feelings full of shades of meaning, which progressively come under cognitive control. During this process people use certain defence mechanisms to deal with the pressure of emotions originating in their unconscious mind. A defence mechanism is an unconscious psychological manoeuvre with which people deceive themselves about the actual conditions of reality so that they can view reality as non-threatening instead of threatening. The behaviour associated with defence mechanisms is rigid and stereotyped and usually follows a particular environmental stimulus automatically. It also represents an undue influence of the past on the present and rarely leaves a person feeling good; instead, the person is left with a vague, low-level anxiety that he/she cannot explain. Example Sally is a 10-year-old who has just come last in the 100-metre race. She says that she is not disappointed at all because, had she won, she would have had to attend another athletics meeting on Saturday and she prefers to go to town with her family. In this case Sally has learned to use rationalization and denial automatically when faced with the unpleasant feeling of anxiety due to failure. When confronted with the possibility of feeling disappointed, she rigidly keeps to her defences, but she is disgruntled for the rest of the day. Defence mechanisms evolve as a person matures, so that a mechanism such as denial is normal in a person before the age of five, but in an adult it would be seen as problematic. In adults the following continuum can be used to distinguish healthy patterns of defence from the more unhealthy patterns.
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Most likely to be healthy: Sublimation Altruism Humour Suppression Anticipation Most likely to be unhealthy: Dissociation Reaction-formation Displacement Repression Fixation Regression Intellectualization Passive-aggressive behaviour Hypochondria Fantasy Compensation Identification Projection Distortion Denial These defence mechanisms can be defined as follows. Sublimation. This means that needs which are unacceptable according to society's standards are gratified in a way that is socially acceptable, such as an aggressive person becoming a surgeon. Altruism. This is the gaining of gratification by being of genuine service to others and thereby getting satisfaction from the fact that they are benefiting. Humour. This involves the overt expression of feelings in a way that masks the discomfort and pain of the feelings and makes it possible to talk about things that would otherwise be too painful. An example is the use nurses and doctors make of humour when discussing distressing aspects of their work. Suppression. This consists of a conscious or semi-conscious decision to postpone thinking about something for a time but to remember to confront and handle it later. For instance, a mother gets a disturbing phone call at work from her child but, since
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she is involved in difficult and important negotiations, she puts her worries about the child out of her mind until after work, when she deals with the matter. Anticipation. This entails realistic planning for future discomfort or problems, such as preparing for retirement, the loss of a loved one, or surgery. The defence mechanisms just described are considered to be mature and healthy. The ones that follow are less healthy. Dissociation. This involves the drastic, although temporary, modification of one's sense of identity in order to deal with stress. Examples include loss of memory (conversion reactions) and the use of drugs to alter consciousness and so numb unhappiness. Reaction-formation. With this mechanism a person defends himself/herself from unacceptable urges by overtly taking the diametrically opposite stance. An example is an adolescent girl's fervent assertions that she hates a boy whom she actually finds physically attractive. Displacement. This means that feelings are transferred from one object or person to another safer object or person. A classic example is that of an employee who gets angry with her boss, but cannot express this for fear of losing her job. She then goes home and kicks the cat. Repression. This serves to get rid of threatening thoughts or memories, although they sometimes show themselves through slips of the tongue. A woman who remembers her father as warm and loving and 'forgets' that he abused her uses repression. Fixation. This is the arrest of development or maturation at a certain stage due to a refusal to deal with the roles associated with the more mature stage. Regression. In contrast to fixation, regression is a return to an earlier stage, as when a hospitalized child who has been toilet trained starts needing nappies again. Intellectualization. With this mechanism a person defends himself/herself against threatening events by thinking about them only in an emotionless, formal way that keeps emotions under control. There are a few mechanisms that can be included under the heading of intellectualization, but rationalization and undoing are the most common examples. Rationalization means that a person gives a plausable explanation for unacceptable feelings or events in order to mask them. Undoing means that guilt is relieved by the performance of some ritual act, which in reality does not change the situation at all. An example of undoing is a husband who relieves guilt about cheating on his wife by giving her a present. Acting out. This consists of discomfort being directly expressed in impulsive, automatic actions in order to block out consciousness or analysis of underlying feelings. Delinquent behaviour, self-injury, temper outbursts and chronic drug use are examples of acting out. Passive-aggressive behaviour. This entails aggression towards others expressed by failure to act and may also include masochism. The refusal of an anorexic girl to eat or the
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failure of a child to do homework are both examples of passive-aggressive behaviour directed at the parents. Hypochondria. This means that feelings of unhappiness or anger are gradually translated into physical symptoms, so that a person can inflict pain on others and ask for attention without feeling guilty. Fantasy. The imagination is used in a semi-conscious way to fulfil wishes that cannot be gratified in reality, such as a girl who builds up elaborate daydreams in which she is loved by a highly desired boy who is out of her reach in reality. Compensation. This is a person attempting to make up for a weakness by making an extra effort to overcome it (such as an underdeveloped young man who achieves a black belt in karate) or by substituting achievement in another field (such as the same young man becoming a chess champion). Identification. This involves gratification being achieved by attributing to oneself achievements and positive qualities inherent in another person. Examples are a parent who identifies with the success of a child or a child who identifies with the strength of the father or mother. Projection. This is the opposite of identification in that a person assigns his/her own undesirable or unacceptable characteristics to others. A crook who always suspects others of cheating is a good example. Distortion. This entails reshaping the external environment according to internal needs. Examples include unrealistic appraisals, such as a student who continues to believe that he/she is doing well, even though all objective feedback proves the contrary. Denial. This is the inadmission to consciousness of certain aspects of the external environment, such as a person who denies that his/her illness is serious, even though he/she has been told that it is terminal. A certain amount of denial is part of many other defence mechanisms. The selective use of defence mechanisms may go a long way towards relieving pain and discomfort, but it may also be catastrophic for personal adaptation if it is used so inflexibly and frequently that it virtually excludes the use of appropriate behaviour to cope with real threats. Cognitive patterns The third important set of psychodynamic patterns is the cognitive patterns a person develops as he/she matures. When a person is faced with a situation, he/she immediately appraises it cognitively and decides whether it is a dangerous/negative/threatening situation or not. This decision greatly influences how he/she then reacts to the situation. This appraisal is dependent on the habitual thought patterns of the person; if he/she constantly sees the world as negative, he/she usually sees a new situation as a negative and reacts accordingly or vice versa. The habitual thought patterns of a person develop in the same way that self-concept develops: through an active process of interaction between the
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individual and the environment. The cognitive set is strongly influenced by and based on self-concept. Cognitive scientists have described the following unhealthy cognitive patterns that negatively influence a person's adaptation: All-or-nothing thinking. This cognitive pattern leads a person to think only in black and white terms, with no grey areas allowed. It is absolute thinking, which allows no middle path. For instance, if an employee with such dichotomous thinking does not get an expected promotion, he/she perceives it to mean that he/she has no future in that firm or in that career and is unable to see it merely as a temporary setback. Overgeneralization. A person with this cognitive pattern concludes from one specific negative event that other negative events are inevitable, thus generalizing dissimilar situations in an unjustifiable fashion. For instance, a woman who has been rejected by one man perceives this as proof that she is totally unacceptable to all people. Selective abstraction. With this pattern a person selects a small part or parts of a situation, ignoring others that are contradictory and more salient. For instance, a lecturer's report on a student's essay mentions a few good points but says that the introduction is too long. The student responds with 'You did not like my essay'. Arbitrary inference. This means that a person reaches a conclusion based on irrelevant evidence or no evidence at all, such as a husband deciding that his wife is probably deceiving him because he telephoned home and she was not there. Catastrophizing. This is a cognitive pattern that consists of thinking the worst of every situation. Every one of the above examples is also an example of catastrophizing. Cognitive patterns assist a person to function by helping him/her to come to a decision about situations quickly and to react promptly. However, if a person develops a negative cognitive set, it can colour all subsequent experiences. Coping strategies The next important psychodynamic pattern is the coping strategies that a person uses. Coping is the process by which an individual attempts to alleviate, relieve or remove stress or threat and may consist of a large array of covert and overt behaviour. In other words, coping refers to what people do when they have or expect to have a problem. This is usually a conscious process. The list of coping behaviour is never-ending but is typically either active or passive and involves a person moving towards other people (dependence behaviour), moving against other people (aggressive behaviour) or moving away from other people (withdrawal behaviour). In each case the strategy chosen depends on the following factors: the person's assessment of the threat or problem; his/her self-concept and cognitive set; his/her physical health and energy level at the time; the external resources available to him/her, such as people, money and tools.
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Coping behaviour Active Dependence behaviour Talking things over with a friend. Seeking professional help Phoning someone and making an appointment Confronting a person about behaviour Aggressive behaviour Fighting with a person who insulted you. Slapping a person's face Calling a bully's bluff at a meeting Withdrawal behaviour Problem solving on your own Allowing adolescent children more freedom Adjusting to a reduction in sex life during pregnancy Passive
Dependence behaviour Asking another person to solve a problem Crying and clinging Physical complaints and symptoms Aggressive behaviour Sabotaging actions Malignant gossip or nameless letters Destroying a machine after a reprimand Withdrawal behaviour Avoiding a problem Going to sleep Hiding the vase you have broken Research seems to indicate that people do not need many coping techniques - just a few good ones. Coping strategies are developed by trial and error and by following role models from the environment. If a coping strategy is successful, it is repeated and becomes part of the person's repertoire. If coping strategies are not defined strictly as being only conscious processes, defence mechanisms can also be seen as a category of coping strategies. The process of coping is illustrated in Figure 2.4.
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Figure 2,4 The process of coping (Adapted from Garland & Bush 1982)
23
PATTERNS OF FULFILLING BIOPHYSICAL NEEDS
Every person has basic biophysical needs from birth. As children cannot usually meet these needs themselves, they are dependent on adult assistance. Human beings have a particularly long period of dependence but, by the time they are young adults, they are normally independent in this respect. Adults usually value this independence greatly. This area of functioning includes the following: patterns of activity (exercise) and rest and sleep; eating, drinking and other elimination patterns; hygiene patterns;
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housing; illness behaviour, in other words a person's patterns of behaviour in dealing with symptoms and health problems, including taking medication; smoking and alcohol intake patterns. 2 4 PATTERNS OF BUILDING AND MAINTAINING RELATIONSHIPS Owing to the long dependence of human infants on others, relationship patterns are essential to the survival of humans. It has been shown that babies do not thrive and may even die if they do not have the opportunity to bond with an adult care-giver. Babies show attachment behaviour immediately after birth. Attachment behaviour includes all behaviour and strategies used for maintaining contact with the attachment figure and is manifested in grasping and crying and later in smiling, gurgling, following and clinging. By the age of one to two years, with the progressive development of crawling, walking and language skills, the child begins to explore the environment. This exploration takes place initially only in the presence of the attachment figure. Later, this figure can be somewhere accessible without being physically present all the time and, still later, short separations are well tolerated. The child no longer consistently needs the actual physical presence of the attachment figure, because cognitive development has taken place to such an extent that he/she can remember previous separation experiences in which the attachment person came back and because he/she can actually carry a cognitive representation of the attachment figure in his/her mind. This gradual moving away from the attachment figure is called detachment and in humans takes many years to complete. If attachment has not taken place satisfactorily, it sometimes interferes with exploration behaviour. This first process of attachment and detachment sets the pattern for future relationships, although later experiences can alter the pattern. Erikson (1963) says that this is the trust-mistrust phase of development, which perhaps best identifies its importance for future relationships. As the child grows, sibling relationships and then peer relationships and relationships with those in authority (mainly teachers) become important. During puberty and adolescence, relationships with the opposite sex become the main focus of attention, this being the very important final stage of the detachment stage that started with the toddler's first steps. During this stage of life the adolescent has to establish himself/herself as a person with an identity separate from that of the family, which to a large extent had given him/her an identity up until then. This process of emotional and physical detachment from the parents and family is sometimes very traumatic for all concerned. During the twenties, relationships with colleagues become the focus of much of the attention of young people in jobs, while the relationship with a permanent partner of the opposite sex (wife or husband) also requires much emotional energy. The pattern of group friendships or friendships with peer groups of the same sex has to change to allow sufficient space for the primary husband-wife relationship to grow and develop. At the same time the claims of the families-of-origin of both partners on them have to diminish
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so that a new family can be formed. In cultures where the extended family holds sway and where the newly married couple is fully integrated into the existing family, it is more difficult to establish close relationships within the new family. As children are born, the pattern of the relationship between the parents has to change to include the children. The marital relationship should still remain the most important one to both partners, however, since a child can never supply the emotional needs of an adult; the parents need to satisfy each other emotionally. If one of the parents allows one or more of the children to invade the space of the marital relationship, the whole family becomes unbalanced. There should therefore be a solid distinction between the roles and privileges of children and adults in a family. From this it becomes apparent that every person lives at the centre of a whole network of relationships, some very primary (parents, siblings, spouse and children) and others more secondary (colleagues, friends, relations and acquaintances). A healthy pattern of relationships means the following: The relationships are relatively free of serious and constant conflict. They supply adequate emotional support for the people involved, even in times of crisis. They allow everyone involved the freedom to develop as a person. They are balanced in terms of what is offered and what is demanded. When a person becomes ill and seeks professional help, a relationship is also established with the health care providers. This may be a long-term relationship, such as one between a clinic nurse and a patient with a chronic condition, or a short-term relationship, such as one involving a nurse and a patient in an inpatient setting. Such a relationship is more one-sided than social and family relationships, since it focuses exclusively on the needs of the patient. The quality of these relationships has important consequences for the care of the patient. 2.5 PATTERNS OF PARTICIPATION IN GROUP AND COMMUNITY LIFE A society is the basic large-scale human group that is characterized by continuity, complex relationships and a composition that includes men, women and children who share several major goals, such as self-preservation and self-perpetuation. A community is a subgroup of a society and has the same basic characteristics except on a smaller scale. The individuals in a community have common characteristics, such as that their children all go to the same school or that they all live in a certain town. A person might therefore belong to more than one community, for instance, a residential community, a work community and a church community. From the time that children start exploring their environment more independently, they become part of the group and community life around them. At first children become part of an informal playgroup consisting of children living close to one another. When they go to school they become part of the school community and of a wide variety of
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groups such as sports teams, the group travelling on the same bus, the group forming the school prefects, and many more. As a person matures, your membership usually increases as life experience increases. Some people have a strong loyalty to groups, choosing to maintain affiliation over long periods, while others are more migrant, changing allegiance frequently. For most adults the following groupings are important aspects of their lives: the church/religious community; cultural groups, including hobbies and sport; political affiliations. Patterns of participation are sometimes rigid, as is the case with a child who is a passive spectator in all groups, while at other times they are more flexible, as is the case with a child who is a spectator in sports but very active in social groups. Participation can be classified as passive or active according to the function of a person in a group. The following group roles have been identified: Initiator. A person who initiates group activities. Follower/supporter. A person who follows the lead of others in a group. Joker. A person who relieves tension in a group by making jokes. Peacemaker. A person who reconciles people and smooths over rough patches. Confronter. A person who confronts a group with problems they are not facing, someone who brings hidden things to the surface. Stirrer. A person who stirs up a group by manipulation, gossip and other strategies for breaking up stable groupings. Helper. A person who looks after the weaker members, assisting and encouraging them. Leader. A person who is the recognized leader, taking the position of honour and strongly influencing the decisions of the group. Worker. A person who makes sure that plans are executed, work is done, tasks are completed and deadlines are met. Observer. A person who is always there but never gets involved. There are many more possible roles for group participation and the pattern of participation people choose depends on their psychodynamic patterns, as well as the expectations of the group or community and the characteristics of the group. 2 6 PATTERNS OF PARTICIPATION IN WORK In the broader sense of the word, work is part of the lives of most people. This does not include only paid occupations but also a child going to school, a mother caring for her children and husband, a husband caring for the house and garden and a retired person assisting in community projects.
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The work that a person does has an enormous influence on his/her life: economically it determines his/her living standards to a large extent; socially it determines his/her social status, not only indirectly through its economic impact but also more directly through the social desirability of the job; personally through the satisfaction or dissatisfaction it gives. For a family the kind of work the parents do has many implications. The shift work of a parent might mean that there is little contact between child and parent, and if a parent is a migrant worker, this might mean a parent who is all but absent from family life. Without work, one has a limited structure to one's day, which many people find difficult to handle. An able-bodied person has a lot of natural energy, which needs to be utilized, and finding positive outlets for it without the structure of a job may be very difficult. This may lead to emotional and social problems and, of course, may have serious economic results. Many people who are handicapped receive disability grants to assist with living expenses. This income-without-effort is an essential part of the service to the handicapped but, at the same time, is a factor limiting motivation for rehabilitation. Work behaviour includes the following abilities: understanding a task; organizing activities so that the task can be completed; completing the task in the given time and to an acceptable quality; social skills to maintain working relationships. 2.7 PATTERNS OF UTILIZING RESOURCES The two main resources people have, other than their own health and abilities, are time and money. Of course there are many more - such as resources of water, and some have already been dealt with in other sections, such as resources of human support - but these are less important to the mental health of a person. The more developed a community becomes, the more free time the individuals within the community have. This is due to greater technological support. However, the sophistication to utilize this extra time constructively does not come automatically. Furthermore, in many developed communities people are increasingly living outside family groups, so that loneliness is becoming a serious problem. People who spend all their free time in bored isolation have unhealthy lifestyle functioning. Those who spend their free time constructively engaged in an enjoyable, stimulating or relaxing activity enhance their lifestyle. Money is an essential part of every person's life. It can either be used economically and wisely to enhance the lifestyle or lead to increased stress and a deterioration in all other aspects of lifestyle functioning. A person who wastes money on non-essentials and then gets into debt and commits fraud to stay out of trouble, or someone building relationships on the pretence of prosperity, may very well end up with a depression or even a suicide
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attempt. Money management is a pattern of life that has an enormous influence on the rest of a person's life. Table 2.2 Summary of patterns making up a lifestyle Pattern
Major aspects
1. Psychodynamic patterns
Sense of self Self-knowledge Self-esteem Defence mechanism Healthy Unhealthy Cognitive mechanisms Healthy Unhealthy Coping strategies Active Passive
2. Patterns of fulfilling biophysical needs
Activity, rest and sleep Eating, drinking and elimination Hygiene Housing Illness Smoking and alcohol
3. Patterns of building and maintaining relationships
Primary (parents, siblings, spouse, children) Secondary (colleagues, friends, relations) Health care providers
4. Patterns of participation in group and community life
Peer groups of children and adolescents Church/religious community Cultural groups - Societies - Sports Political affiliation
5. Patterns of participation in work
Paid occupation Unpaid occupation Voluntary activities
6. Patterns of utilizing resources
Time Money
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2.8 GUIDELINES FOR PRACTICE Nurses work within a framework of guidelines and directives coming from scientific and policy sources. The nurse has to keep up to date with such directives and implement them intelligently in practice. Evidence-based Practice (EBP) A strong influence on all clinical practice in the 21st century is the Evidence-based Practice (EBP) approach. Evidence-based Practice is 'the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients' (www.sahealthinfo.org/evidence/2003). The evidence is gained from systematic reviews of all available literature. A good nurse will make use of both his\her clinical expertise and the best available external evidence; used on its own neither of these two aspects is enough. External evidence can inform, but it can never replace individual clinical expertise. The individual clinician's expertise is that which decides whether or not the evidence he or she has gathered is applicable to a particular patient, and if so, how it should be integrated into the appropriate clinical decision. Evidence-based practice builds on but can never replace clinical skills, clinical judgement and clinical experience (Sackett et al. 1997). New types of evidence are being generated which, when we understand them, create frequent, major changes in the way patients are being cared for. With the advent of the randomized controlled trial came a change in the way clinicians establish the clinical basis for diagnosis, prognosis and therapeutics. By conducting randomized trials the efficacy of many treatments have been confirmed. The flipside of this coin is that the uselessness or harmfulness of many others have also been confirmed. Secondly, although this new evidence is needed on a daily basis, clinicians usually fail to get it. Even clinicians who try to keep up to date with clinically important information, do not always manage it, as direct observations have shown. Trying to overcome clinical deterioration through traditional continuing professional education programmes does not improve the clinician's clinical performance. In the very busy society we live in, other ways need to be found and developed to improve clinical performance. It has been shown that a different approach to clinical learning keeps practitioners more up-to-date. This approach is evidence-based practice, abbreviated as EBP. The practice of EBP is a process of lifelong, self-directed learning in which caring for your patients creates the need for clinically important information - about diagnosis, prognosis, therapy and other clinical and health care issues - in which you: 1. Convert your information needs into answerable questions. 2. Track down, as efficiently as possible, the best evidence with which to answer them (whether from the clinical examination, the diagnostic laboratory, the research evidence or other sources). 3. Critically appraise the retrieved evidence for its validity (closeness to the truth) and usefulness (clinical applicability).
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4. Apply the results of this appraisal in clinical practice. 5. Evaluate your own professional performance, (www.sahealthinfo.org/evidence/) The world-wide web (www) is the most potent source of reviews of current evidence. A worldwide collaborative effort to make reliable review of the evidence available to practitioners, is the Cochrane Collaboration. These are available in abstract form on the Cochrane website. Another growing source for nurses is the Joanna Briggs Collection, which is an organization in Australia doing nursing reviews. These two sources will be used in this volume to introduce nurses to EBP. The Cochrane Collection How to access and use the Cochrane collection Go to the Cochrane home page at www.cochrane.com and click on Library. Click on 'How to get access' and then click on 'South Africa'. This brings you to the www.sahealthinfo.org/evidence/ page. Or go directly to the www.sahealthinfo.org website and click on 'Evidence'. Once there, you will have to subscribe in order to access documents. (This should be no problem for South Africans, and other users can still access all the abstracts on the Cochrane website.) Having logged in, you arrive on the work page, with buttons at the top, a 'content' section on the left, and a 'document' section on the right. Click on 'Topic': You will now see a list of all the Cochrane groups on the left side of the page. Click on the group dealing with your topic of interest. On the left side of the page you will now see the topics, with a number of protocols or reviews bracketed. Click on the topic you want. You will see the document titles dealing with the particular topic (still on the left side of the page and with small page signs for each document). Click on the document you want. The abstract of the document will now appear on the right side of the page. There are two kinds of documents: A protocol: This is a problem statement, but the review has not yet been done. A review: In this case the review has been done, and the abstract tells you how many good studies they found, and what the results indicate in terms of the question addressed. The Joanna Briggs website provides Best Practice guidelines based on integrative reviews of the literature. The reviews themselves are only available to subscribers. While the Cochrane reviews rely heavily on random controlled trials (RCT), since this is seen as the best possible evidence, the Joanna Briggs group works with all levels of evidence. All studies are categorized according to the strength of the evidence based on the following classification system: Level I Evidence obtained from a systematic review of all relevant randomized controlled trials.
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Level II Evidence obtained from at least one properly designed, randomized controlled trial. Level III. 1 Evidence obtained from well-designed controlled trials without randomization. Level 111.2 Evidence obtained from well-designed cohort or case control analytic studies, preferably from more than one centre or research group. Level 111.3 Evidence obtained from multiple time series with or without the intervention. Dramatic results in uncontrolled experiments. Level IV Opinion of respected authorities, based on clinical experience, descriptive studies or reports of expert committees. Although the Joanna Briggs group also values RCTs very highly, they take into account other levels of evidence in their reviews. This does not happen in Cochrane reviews. The Essential Drug List (EDL) The National Drug Policy of South Africa has outlined a system aimed at ensuring that everybody gets the pharmacological treatment they need, that drugs are administered safely, effectively and that they are used rationally. Expert groups were established to develop a set of treatment guidelines and essential drug lists and to implement these guidelines for all common health problems seen at Primary Health Care clinics. The policy is that the drugs mentioned in these guidelines (the Essential Drug List) will be available at each clinic. The criteria for selecting drugs for the EDL is that the drugs be the most economical, the best researched, preferably be manufactured locally, and have good pharmacokinetic properties and good patient compliance. The policy states, 'Essential drugs are those that satisfy the needs of the majority of the population. They should therefore be available at all times, in adequate amounts, and in the appropriate dosage forms'. (Department of Health 1998 p. XV) Where appropriate, the stipulations of the EDL are referred to in this text. 2.9 THE NURSE AND THE MULTIPROFESSIONAL TEAM If one studies Figure 2.5, it becomes clear that the mental health nurse is involved with a patient over a very wide field; it is the total functioning of the patient that is the nurse's concern. However, the psychiatric nurse also works in a multidisciplinary team where other team members focus on specific aspects of a patient's functioning. For instance, the
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occupational therapist focuses specifically on patterns of work or occupational behaviour, while the clinical psychologist focuses specifically on the psychodynamic pattern of a patient and its influence on other patterns, and the psychiatric social worker focuses on the utilization of resources. In settings where all these team members are available, the nurse focuses mainly on biophysical patterns and patterns of participation in group and community life. In settings where other team members are not available - and this is mostly the case - the nurse focuses on the whole range of patterns.
Figure 2.5 Interaction between the roles of the psychiatric multiprofessional team members The mental health nurse is essentially a mental health generalist who occasionally works with a team of mental health specialists. Even when the specialists' services are available, however, the nurse is the only team member in inpatient settings whose involvement and observations cover 24 hours, which is what allows for a generalist approach. The interaction between the role of the mental health nurse and that of other team members is illustrated in Figure 2.5. The diagram shows the roles of all team members being open at the top, signifying the continual growth in the practice of all the members. It further indicates that the nurse has the strongest role in respect of custodial care, with the psychiatrist contributing in respect of legal requirements. The role of the mental health nurse with regard to therapeutic care overlaps somewhat with that of all the team members. This means that the same or similar knowledge and skills are used. It is the role of the nurse, however, that is more encompassing than that of any other single profession. The mental health nurse specialist shares a larger portion of the roles of the other professionals in the field, but again this role is more extensive than that of the other professionals.
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The role of the mental health nurse can be compared with the connective tissue in the body or that of oil in a machine: it is essential for normal functioning, but is often overlooked or taken for granted. CONCLUSION It is often said that a nurse is unsure of his/her role because it is so diffuse (Stark et al. 2002). It is therefore important that nurses have a clear idea of what they are doing with and for the mental health client and how they fit into the total system. Without such clarity it is impossible for nurses to fulfill this important role. WEB RESOURCES
http://www.mindtools.com This website contains a number of training programmes on psychosocial topics, such as stress management and time management. It is useful to refer clients to it and to use it yourself. http://www.pbhi.com The website of Pacific Care Behavioural Health has two sections that are useful for promoting healthy lifestyle functioning: 'Me and my family' and 'My workplace'. Both provide tips and information and address important issues. REFERENCES Erikson, E. 1963. Childhood and Society, 2 ed. New York: W W Norton Co Inc Garland, L M & Bush, CT. 1982. Coping Behaviors and Nursing. Reston: Reston Publishing Co Inc O'Toole, A W & Welt, S R (eds). 1989. Interpersonal Theory in Nursing Practice: Selected Works of HE Peplau. New York: Springer Publ Co Stuart, G W & Sundeen, S J. 1987. Principles and Practice of Psychiatric Nursing. Toronto: C V Mosby Co
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CHAPTER THREE
Comprehensive Mental Health Care LRUYS
Objectives After studying this chapter the learner should be able to: Discuss the seriousness of mental illness as a health problem. Define comprehensive health services. Differentiate between primary, secondary and tertiary prevention. Differentiate between primary, secondary and tertiary health care and prevention. Differentiate between the health promotion approach and the high-risk approach to primary prevention of psychiatric illness. Describe the life skills approach to primary prevention. Describe the gatekeeper approach to secondary prevention, and discuss the problem of PHC workers in terms of gatekeeping for psychiatric conditions. Define psychosocial rehabilitation and distinguish this from treatment. Describe the basic elements of rehabilitation interventions, and the major interventions used in this field. Define what a psychiatric or mental health programme is. Distinguish between ad hoc and rational planning and between problem-based and service-based planning. Describe the process of planning a programme. Distinguish between change forces, resistance forces and hindrance forces. Contrast and compare different methods of evaluating a mental health programme. Debate the need for programme evaluation.
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INTRODUCTION Before looking at the mental health care system, it is important to understand the context and the extent of the problem. Mental illness has always been a neglected area of health care, because its economic and other results are not immediately visible. In the past, mortality figures were the most common way of estimating the seriousness of a condition. In those terms, mental illness did not look very important. Even when a person committed suicide because of depression or schizophrenia, it was not documented as morbidity of schizophrenia or depression, but was reported under the heading 'suicide' (Desjarlais, Eisenberg, Good & Kleinman 1995). More recently, a new measure has been developed to estimate the seriousness of the consequences of an illness. It is called the Global Burden of Disease (GBD) and it is measured in Disability Adjusted Life Years (DALYs). A DALY refers to the number of years during which the quality of life is impaired - in other words, the years during which a person cannot function properly due to illness. In terms of DALYs, mental illness is one of the greatest causes of hardship resulting from ill health, being responsible for 8,1 % of the GBD (Desjarlais et al. 1995:4). The seriousness of the problem of mental illness is heightened by the following factors: It affects a large proportion of the population. About one in five people will suffer from a mental disorder sometime in their lives (Regier, Boyd, Burke et al. 1988). (See Table 3.1 for some prevalence figures.) It affects people in the prime of their lives, and often cannot be cured in the short term. This is especially true of schizophrenia, one of the most serious mental illnesses, which attacks adolescents and young adults. It causes long-term disability. The adverse effects of mental illness are often worse than those of physical illness, since mental illness involves the brain, which is the centre of a person's personality and life. People with mental illness are the most difficult group to rehabilitate in terms of vocational activity (Brolin & Brolin 1982). The stigma attached to mental illness is almost universal and greatly increases the suffering of patients and their families. There are other factors mitigating against mental illness's being taken seriously. For instance, up until very recently, psychiatric diagnoses were often vague and unreliable. This led to the conception that mental illness was not 'real' illness. Newer methods of studying the brain (such as PET scans) and research-based diagnostic classifications (such as the DSM-IV-TR) are gradually eliminating such misconceptions. Another factor which often confuses health workers who are used to the 'medical model' is the greater emphasis in mental health care on the psychosocial context of illness and treatment. Desjarlais et al. (1995) explain why the social context of disease is important: Tn emphasizing the social context, we do not imply that social problems are the sole or even the principal cause of mental disorders.' However, a brain disorder such as epilepsy may very well be the result of a blow to the head received during civil unrest. And even if the epilepsy is the result of hereditary factors, social factors will determine
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Table 3,1 The frequency of some mental conditions in Primary Health Care (PHC) in Kenya * Condition
Frequency
Conspicuous psychiatric morbidity Anxiety Depression
29,1%
Alcoholism
18,7 %
Personality disorders Affective disorders Psychosis
Disability
25% 25% 4,1 %
16,6 % 6,25 %
Moderate to high Moderate to high Moderate to high Low to moderate Severe Severe
(Dhadphale, Ellison & Griffin 1982) * Please note that, since this study was done in 1982, some classifications no longer correspond with those used today.
whether or not the family will be able to obtain anticonvulsive treatment for the child and so avoid complications. Social factors therefore exert an influence on all illnesses and health care. Psychological factors play an equally important role. The presentation of any disease, its progress and its outcomes, are profoundly influenced by the person who has the disease. A person suffering from schizophrenia expresses his or her own personality, life experience and culture in the context of hallucinations, although the hallucinations may be completely biological in nature. Eisenberg (1986) calls mental health care which does not take psychological factors into consideration 'mindless biological psychiatry', and psychological care which underestimates the influence of biological factors 'brainless social psychiatry'. 3.1 COMPREHENSIVE MENTAL HEALTH CARE The comprehensiveness of the services offered to a population can be described and evaluated in many ways. One way is to say that the services should address all the health problems of persons 'from the cradle to the grave'. This approach defines comprehensiveness in terms of the recipients of the care, and more specifically in terms of the lifespans of such recipients. Another way of looking at comprehensiveness is to look at it from the perspective of the process of illness. Health care can then be viewed in terms of'from before illness comes, to after it has disabled a person'. This is the approach that we will follow in this chapter. If a health service is comprehensive in these terms, it includes primary prevention (before illness), secondary prevention (during illness) and tertiary prevention (after illness). It is important not to confuse these concepts with the levels of health care, which are often also described as primary health service, secondary health service, and tertiary
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health service. These terms refer to the level of specialization in the service and have nothing to do with the prevention level. It is a mistake to think, therefore, that in Primary Health Care only primary prevention is undertaken. All levels of health care should perform primary, secondary and tertiary prevention. Primary prevention Primary prevention is aimed at decreasing the incidence of psychiatric morbidity in the community. This demands health promotion, which includes illness prevention. These strategies are aimed at people who are basically healthy and who seek the development of community and individual lifestyles that can maintain and enhance a state of well-being. Since primary prevention strategies are aimed at people who are essentially healthy, it is a sector of health care in which volunteers and natural community support networks can be used most successfully. This is an important part of organizing primary prevention, because the sheer demand for secondary prevention often prevents health professionals from giving adequate attention to primary prevention. Without this focus, it is doubtful whether primary prevention will be able to attain the goal of reducing mental illness. The following mechanisms protect people from becoming mentally ill or emotionally distressed (Rutter 1995): 1. Those that involve a reduction in the personal impact of risk experiences. For example, the risk which divorce holds for children can be greatly diminished by not drawing them into the conflict around the marriage break-up. Another example is that the influence of high-risk environments on adolescents can be greatly reduced if they join a positive peer group. 2. Those that reduce negative chain reactions. An example of this mechanism is the debriefing of a group after a traumatic experience, which breaks the chain of more and more restrictive defence mechanisms being used. Another example is teaching adolescents social skills, which allows them to deal with conflict by using humour or diversion, thus preventing escalation into violence. 3. Those that promote self-esteem and self-efficacy. This includes not only feeling good about yourself but also about your ability to handle life. The development of these abilities and this attitude of mind during childhood and adolescence is dependent on secure and supportive relationships, successful taking of responsibility and successful task accomplishment, as well as coping with manageable stress. 4. Those that open up positive opportunities. Opportunities for education and sport, which take young people away from stressful, deprived and crime-ridden environments, fall in this category. For older people, a geographical move or the attainment of literacy may open up new opportunities. There are three approaches to primary prevention, and these need not be mutually exclusive.
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The health promotion approach This approach targets the total population of a region or country and aims to deliver a message about a measure which is known to prevent a specific disease in some people and which is believed to be health-promoting for others (Newton 1992). This kind of approach is appropriate in the following circumstances: When there is reliable evidence that the targeted factor causes at least one disease (for example, smoking causes lung cancer; unprotected contact with contaminated blood products, secretions or objects [for example, needles] causes the Ebola virus to spread. When the disorder either affects a large number of people (smoking and lung cancer) or it affects a relatively small number of people, but is usually fatal (unprotected contact and Ebola) When the disease is serious and the necessary prevention strategy is simple enough and cheap enough to be implemented on a wide scale (stopping smoking, washing hands, wearing gloves, sterilizing objects are both cheap and simple preventive measures). When those not at risk will not be harmed by the prevention strategy (for example, not smoking or wearing protective clothing does not harm anybody). This approach fits in well with the Primary Health Care approach, which has the total development of communities as its target. This is a multisectoral approach and involves all sectors of the public service in fulfilling the basic needs of the population. Improved housing and nutrition, clean water, basic education and literacy are the aims of this approach. Meeting these basic needs will undoubtedly result in a decrease in depression and anxiety. High-risk approach This approach targets individuals who may be susceptible to a specific disorder. Such people are identified on the basis of aetiological research, which describes the factors characterizing those people most likely to experience the disorder (Newton 1992). This kind of approach is particularly appropriate in the following circumstances: The important risk factors for a disorder are known (for example, negative social plus negative psychological factors greatly increase the risk of depression in women). The group at risk can be identified relatively cheaply and easily (for example, a brief checklist can enumerate those factors identifying women who are at risk for depression). The prevention strategy is too difficult or too expensive to implement for the whole population (for example, a support group for women who are at risk for depression cannot be run for all women in the country). Most primary prevention strategies in mental health demand trained professionals and a great deal of time. This makes these interventions expensive and, in the face of an increasing scarcity of professionals, very difficult to implement on a population-wide basis. This approach is therefore very appropriate in the field of mental health.
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Table 3.2 summarizes those factors that could be used to draw up different prevention programmes.
Evidence-based Practice Primary prevention for alcohol misuse in young people Twenty of the 56 studies included showed evidence of ineffectiveness. No firm conclusions about the effectiveness of prevention interventions in the short-term and medium-term were possible. Over the longer-term, the Strengthening Families Program (SFP) showed promise as an effective prevention intervention. The Number Needed to Treat (NNT) for the SFP over four years for three alcohol initiation behaviours (alcohol use, alcohol use without permission and first drunkenness) was nine (for all three behaviours). One study also highlighted the potential value of culturally focused skills training over the longer term (NNT=17 over 3,5 years for 4+ drinks in the last week).
Reviewers' conclusions 1. Research into important outcome variables needs to be undertaken. 2. Methodology of evaluations needs to be improved. 3. The Strengthening Families Programme (SFP) needs to be evaluated on a larger scale and in different settings. 4. Culturally-focused interventions require further development and rigorous evaluation. 5. An international register of alcohol and drug misuse prevention interventions should be established and criteria agreed for rating prevention intervention in terms of safety, efficacy and effectiveness. Foxcroft D R, Ireland D, Lister-Sharp D J, Lowe G & Breen R. Primary prevention for alcohol misuse in young people (Cochrane Review). In: The Cochrane Library, Issue 2, 2003. Oxford: Update Software.
Life skills approach The life skills approach focuses on the transitions from one life stage to another, and endeavours to help people cope with the demands of each successive stage. Most people go through a predictable series of stages: preschool, school, puberty and adolescence, leaving home and young adulthood, parenting, retiring, old age. Although most people make these transitions without major problems, a life skills approach to primary prevention hypothesizes that mental illness can be prevented by equipping people better to cope with the different stages. The life skills approach, or anticipatory guidance, is a teaching approach which can be used successfully with the total population (for example, putting all people due to retire through a retirement preparation course), or with the high-risk approach (for example, identifying mothers who seem to be having trouble with
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parenting and offering them a support group experience). This approach is described more fully in Chapter 11 under the heading 'Mental health education'. Table 3.2 Factors to be targeted in illness prevention programmes Antecedent WOMEN Early loss of mother (past support) Absence of close other (current support) Present negative relationship MIDWIFERY SERVICE Low birth weight High life changes Inability or unwillingness to care for the baby Diffuse social problems Marital problems Chronic ill health
Disorder
Strategy
Depression in women
Group or individual intervention to: Improve self-concept Establish new close relationships Break free from negative relationships
Child abuse Postpartum depression
POST-THREAT Counselling Practical support
THREAT For example: Going for HIV test Pregnancy after several miscarriages CRISIS For example: HIV test positive Another miscarriage Rape Violence ADOLESCENTS Children who have had many different carers Poor planners Act helpless Poor participation in extracurricular activities
Referral to primary health practitioner Telephone number and assurance of support given A supportive discussion with mother Support group for mothers, with or without skills teaching
Depression Anxiety, especially PTSD
Early pregnancy Poor parenting Child abuse Anxiety depression
POST-CRISIS Debriefing Crisis intervention Environmental manipulation to ensure safety Encourage extracurricular activity Life skills training programmes in high schools to improve planning and self-esteem
(Newton 1992)
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3,2 SECONDARY PREVENTION Secondary prevention aims to decrease the prevalence of psychiatric disease through early diagnosis and effective treatment. McLaughlin (1982) calls this kind of programme 'health supervision and early detection', but this does not make it clear that the treatment of disease is included. Early detection of psychiatric illness demands a great deal of public education to make people in general more aware of the signs of mental illness. Since the education of the whole population is so expensive, the gatekeeper approach is often used. This means that professionals and non-professional groups who work in a helping or protecting capacity with a great number of people can be taught how to identify early signs and symptoms. For instance, teachers can be used to identify child and adolescent problems; parents can be taught about the signs and symptoms of drug abuse in adolescents; and police can be taught to identify the abuse of women and children. Gatekeepers are also taught to whom they can refer persons with possible problems. Nurses working in primary health care settings also play an important role in case finding. It has been shown that 20-50 % of patients attending PHC clinics suffer from psychiatric morbidity (Editorial 1988). The psychiatric condition is often concealed under the cover of ill-defined somatic conditions that repeatedly bring the patient to general medical services, with no positive results. This is called Hidden Psychiatric Morbidity(HPM), and should be distinguished from Conspicuous Psychiatric Morbidity (CPM), such as psychosis, which is seldom missed. If undetected, the patients with HPM will either get negative labels such as 'neurotic' and receive little attention, or a great many expensive investigations and treatments will be undertaken unnecessarily. These patients therefore increase the burden on PHC services and increase expenses, while their suffering is not alleviated. Some studies have indicated that as many as 80 % of such HPM patients are not detected by PHC staff (Reeler 1987a). This is particularly true of African (black) patients, who rarely present with depression or anxiety, but rather with somatic complaints (Odejide, Oyewunmi & Ohaeri 1989). A study in four developing countries found that patients complaining of three or more physical symptoms are twice as likely to have a psychological disorder as a physical disorder (Harding, De Avango & Balthazer 1980). Somatic symptoms often shown by patients with HPM include weakness, dizziness, back pain, fertility problems, headache, abdominal pain and chest pain (Reeler 1987b). These symptoms often indicate the presence of real physical disease, and the confusion they cause PHC workers can therefore be understood. What makes the problem worse, however, is that in about 20 % of cases the psychological distress presents in patients who are actually suffering from a physical condition at the same time (Dhadphale, Ellison & Griffin 1982). To improve the detection of Hidden Psychiatric Morbidity (HPM) in Private Health Care (PHC) clinic patients, it is recommended that PHC nurses use the Self-Reporting Questionnaire (SRQ) for screening those patients whom they think may have a psychiatric disorder. A screening test such as the SRQ is not intended to be diagnostic, but rather to facilitate sifting out persons who seem to be well from those who are probably not well.
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This questionnaire contains 20 questions and, if the patient replies in the affirmative to eight or more, a full psychiatric history should be undertaken. It may be necessary to translate the questionnaire into the patient's home language. If the patient is African, it may not be customary for such a person to answer questions with a 'yes or 'no' only. In this case, the interviewer will have to interpret whether the discursive answer given by the patient indicates a positive or a negative response. Self-Reporting Questionnaire (SRQ) 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17.
Do you often have headaches? Is your appetite poor? Do you sleep badly? Are you easily frightened? Do your hands shake? Do you feel nervous, tense or worried? Is your digestion poor? Do you have trouble thinking clearly? Do you feel unhappy? Do you cry more than usual? Do you find it difficult to enjoy your daily activities? Do you find it difficult to make decisions? Is your daily work suffering? Are you unable to play a useful part in life? Have you lost interest in things? Do you feel that you are a worthless person? Has the thought of ending your life been in your mind?
18.
Do you feel tired all the time?
19. Do you have uncomfortable feelings in your stomach? 20. Are you easily tired? (Kortman 1987) 3 3 TERTIARY PREVENTION Psychiatric illness is one of the most devastating illnesses one can have (}udd 1990). The adverse effects of mental illness are often worse than those of physical illnesses such as coronary artery disease or arthritis. Furthermore, the risk of suicide is 18 times that of the general population. This group is also the most difficult of all the disabled to get back to work (Brolin & Brolin 1982). The seriousness of the impairment, and the fact that the patients are at home for the greatest part of their illness, place an enormous burden on the family (Howard 1994). The unanticipated task of caring for a mentally ill person often totally disrupts and dominates the lives of parents and even siblings.
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Intensive and sustained efforts are therefore necessary to rehabilitate these patients. However, in the South African context, psychiatric community services are mostly still in the deinstitutional era: the focus is on treatment and not on rehabilitation. Psychosocial rehabilitation involves improving the functioning of a person with a psychiatric disability in a specific environment. It is important to distinguish between rehabilitation and treatment - two processes which occur simultaneously in cases of longterm mental illness. Table 33 Differences between rehabilitation and treatment Rehabilitation
Treatment
Mission
Improved functioning and satisfaction in specific environments
'Cure', symptom reduction, or the development of therapeutic insights
Causal theory
None
Based on a variety of causal theories which determine the nature of intervention
Focus
Present and future
Past, present and future
Diagnostic content
Assess present and future skills and support
Assess symptoms and possible causes
Primary techniques
Increasing skills and skills use Increasing understanding and support Increasing resources and resource use
Psychotherapy and pharmacotherapy
(Anthony, Cohen & Farkas)
Central to rehabilitation is the reintegration of the disabled person into the community. Therefore, although a range of institutions may be used in the rehabilitation process, it is essentially community-based. In terms of the health care system, it would be a function mainly of primary health care clinics and community health centres. Psychosocial rehabilitation technology The basic elements of rehabilitation interventions can be summarized as follows: Increasing skills. This can be general life skills, or specific vocational skills, and it can refer to skills in the patient or in his/her family. An increase in skills assists the whole network to cope better with stress and, in some instances, can prevent stress.
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Increasing support. Any action which can increase the support which the patient and family receives, assists in preventing breakdown and promoting health. This refers to entitlements, material assistance and psychosocial support. Manipulating resources. This may include aspects such as marketing the patient to a service, or marketing a service to a client. But it may require going further and negotiating changes in the service to make it more appropriate to the client. It may also mean advocating service improvement or creation. Optimalizing symptom control The successful rehabilitation of the patient is very dependent on optimal symptom control. This is usually done through medication, although psychotherapy may play a role. Symptom control, which is adequate when staying at home, may not be suitable when working. Therefore the rehabilitation worker must work closely with the person who is treating the patient. Education of the general public. Reintegration of the patient into society is dependent on the attitudes of the general public, and specific groups within that general grouping, such as employers. Changes in attitudes need to be addressed purposefully and specifically and complement increasing support for the patient and his/her family. The major technologies that have been developed in this field or incorporated into it are listed below. These technologies form the basic building blocks of a community-based rehabilitation programme. They combine the basic elements of rehabilitation to address the needs of the patient, often in a specific area. Psychoeducation. This means that consumers (patients and their families) are taught about mental illness, its treatment and management, so that they can cope better with community-based care. Currently patients and their families are provided with very little information, often not even a diagnosis. Vague terms such as 'nervous breakdown' are still frequently used. 'Psychoeducation' refers to an intensive and responsive teaching process. It empowers the family and the patient with knowledge and skills and has been proved to make a dramatic difference to the long-term outcome for the patients. Case management. This is an approach to long-term care which addresses all the needs of the disabled person and is aimed at assessing such needs, linking the person to a variety of services, and co-ordinating service use to achieve a successful outcome. Although there are different models of case management, it would seem that the generalist model is most appropriate for the South African situation. In this model one person, who may belong to any of the helping professions, deals with the problems of the patient, without keeping strictly to professional boundaries (Levine & Fleming 1987). It provides the consumer with the same, identifiable helper in the complex health system. Skills teaching. This is the structured teaching of the deficient life skills required in the specific social, vocational and living environment of the disabled person. This can be done during day programmes or group sessions.
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Vocational rehabilitation. This process enables the disabled person to secure and retain suitable employment and to make satisfactory progress in the chosen field. The aim is integrated and competitive employment. This means that the person works for at least minimum wages (or better), with non-disabled co-workers, at a job which offers scope for advancement in a setting that produces valued goods and services. The favoured way of achieving this is through supported employment (SE). A disabled person in supported employment works in the open labour market, but with ongoing support, and under working conditions that have been specially negotiated (Wehman, Sale & Parent 1992). An individual is placed in a work setting and a job coach works with him/her until he/she can manage. After this, visits from the coach continue, in case problems crop up. Appropriate housing. The housing of the disabled person should suit his/her own needs and lifestyle, and optimize social and vocational functioning. This necessitates a range of housing options, from group homes to single accommodation. 3,4 PLANNING PROGRAMMES Planning means that future actions are decided upon in order to solve a present or anticipated problem or to achieve certain objectives. In health services, nurses may observe the following operation. Ad hoc planning In this type of planning decisions are made only when problems have actually occurred and the decision is then made instantly, based on the information that is superficially available. An example of ad hoc programme planning would be a unit in which there are increasing problems with patient violence. The registered nurse in charge mentions this in a conversation with the nurse administrator and they decide to change one single room into a seclusion room. In this planning there is no thorough collection of data about the problem and no serious consideration of different possible causes or solutions. The less forward planning there is in a service, the more instant decisions have to be made every day. Since these decisions are often not good ones, they lead to increased resistance to change in the system. Rational planning This means that systematic data collection is done in regard to possible alternatives and probable effects are intelligently anticipated before decisions are made. Taking the above example, it would mean that the incidents of violence would be carefully documented for a specific period, noting the type of violence, who is involved, what the context was and which interventions were used. Possible alternatives, such as increasing the opportunities for gross motor activities in the daily programmes of patients, giving staff in-service training in the prevention of violence, increasing or changing medication or establishing a behaviour modification programme with the use of a seclusion room, would be investigated in literature and through local discussions and needs assessments.
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In the light of all this information a decision would be made, involving as far as possible those who would actually implement the plan. When a planner plans programmes, a wide range of factors influence the decisions to be made, but the main areas of influence are political factors and clinical factors. Idealistic nurse planners often think that only clinical factors, those which are best for the patients, should be considered. That is not possible, however, since administrative factors must be taken into account, such as whether resources necessary for the implementation of a plan have been budgeted for, whether enough staff can be made available when needed for implementation, or whether agency policies allow this kind of programme. Even when a proposed programme is administratively possible and clinically desirable, however, it may still be doomed by political factors. This means that powerful individuals or groups might oppose it because they see it as a threat to their interests. A planner therefore needs to look at every alternative, not only in terms of whether it is good for the patients and whether it is administratively possible but also in terms of whether enough support can be lobbied for it from people in power to get it approved. Consultation with people for whom the programme is being planned is also important, especially in community programmes. People are more likely to support the programme if they are actually involved in planning it. The process of programme planning Nurses encounter the task of programme planning in one of two circumstances: 1. They can be faced with a specific problem and decide to plan a programme to address the problem. For instance, a psychiatric community nurse finds that the service is continually being asked to assist with chronic alcoholic patients who have been treated repeatedly by all the available services. None of these services now want to be involved with these patients, because they see it as useless and a waste of resources. Instead of continually going through the motions and getting frustrated by the lack of a satisfactory answer, the nurse decides to initiate a programme for this kind of patient. This kind of programme planning is problem-based. 2. Nurses can do programme planning for any service that they are allocated to in order to enhance the effectiveness of the service. For instance, a nurse who is put in charge of an outpatient clinic can plan to bring a range of programmes into being to ensure that the unit reaches its goals. This approach is service-based. The process of programme planning differs for the two types of approaches, although, in many respects, there are some similarities. Problem-based programme planning 1. Define the problem operationally so that everybody concerned understands it in the same way. In the example mentioned above, the problem can be defined as that of alcoholics who are not acceptable to the main treatment, or assistance programmes for alcoholics because of their repeated relapses. This definition makes it clear that the
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patients are a problem due to their labelling by the main service and not merely due to their relapse rate. This kind of definition makes it easier to get clarity on exactly what the problem is. 2. Do a needs assessment to establish the extent of the problem. This includes a survey of how many patients are involved over a specific period of time and perhaps also what percentage they form of the total patient population. The severity of the problem also needs to be outlined in terms of current outcomes. What are the results of nonintervention? Sometimes a thorough needs assessment indicates that the problem is not large enough to warrant special attention, while in other cases it might underline the need for action. 3. Survey existing services to establish which of them currently address the problem and to what extent and in what way they do so. In order to prove that a gap exists in the service, it is essential that you thoroughly check what is already available. Sometimes relevant programmes are available, but they might not be able to cater for the numbers involved or they might be inaccessible. The survey should make all this clear. 4. Survey similar programmes nationally and internationally. It is not necessary to reinvent the wheel. If your service is experiencing a problem, chances are very good that some other service has had a similar problem and has experimented with solutions. Contact other services in this country by letter or by phone and ask about the problem and possible solutions. Do a literature review to see how it has been tackled overseas. 5. Based on all the information gathered, develop a model that includes: the aims and objectives of the programme; the activities included in the programme; the resources necessary (cost, staff and space); the time frame for the programme; and proposals for finding the resources. You have already considered the different alternatives at this stage and have made a selection based on clinical, administrative and political considerations. You can include different alternatives in a programme proposal. Table 3.4 gives a model of a programme in a community setting. In this table the last two elements of the programme (time frame and proposals for finding the resources) are not included. 6. Plan for the evaluation of the programme. Unless evaluation is part of the initial planning, it might be impossible later, since the necessary data might not have been collected appropriately. Service-based programme planning 1. In this case the first step is to analyse the situation. In a community service this includes a community profile as well as a service profile, while in an inpatient service it includes only a service profile. A service profile consists of a numerical description of the service (including admission, discharge and readmission figures, demographics of the patient
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population, staff figures and all other relevant statistics), as well as an anecdotal description of the main features of the service. 2. Analyse the data to answer the following questions: 'Is the service addressing the most serious problems of the community or patient population?' 'Is the service sensitive to the needs around it?' 'Are there any gaps in the service?' 'Could the task be done more effectively or efficiently?' This step corresponds roughly with step 2 of the problem-based approach to planning. If you experience problems, follow the steps of that approach. Table 3,4 A model of a programme for battered women Programme aims To enable battered women to handle the situation in a way that increases both their own and their children's well-being. Programme objectives To increase community knowledge of the programme. To increase patient knowledge of how to improve their own and their family's health in relation to family violence. To increase the patient's ability to solve problems of family violence. Activity sequence Objectives
Activity
Resources
Increased patient numbers
Design handbill Send to gatekeepers Organize radio interviews with all stations Make personal contact with police and casualty wards
Staff time Printing cost Graphic art cost
Increased knowledge and skills
Teach patients about: Family violence in relation to family health, community resources and legal issues Problem-solving skills
Staff time to prepare teaching material and to teach Outside lecturers
Decreased anxiety and depression Increased selfconfidence
Provide social support through: Encouraging extended family interviews Teaching in groups, allowing exploration of feelings
Group time Staff time for family interviews
(Adapted from Budgen 1987)
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3,5 IMPLEMENTING PROGRAMMES The implementation of anything new in a service is always a difficult task. It is not enough to have a good plan and enthusiasm. Great skill and wisdom and careful planning are imperative in order to achieve change in a system. The more bureaucratic the system is, the more difficult it is to effect change. Lewin (in Gillies 1989) postulates that in any stable situation there is dynamic balance between the forces for change and those against change. The process of change in such a situation consists of: 1. unfreezing the forces that preserve the status quo; 2. implementing the change process by which the current system is changed to the future system; and 3. refreezing the situation, so that the new system becomes the accepted routine. During the phase of unfreezing, efforts are made to weaken support for the status quo by raising the consciousness of people in the system about the limitations of the present situation and possibilities for change. This involves specifically strengthening the forces for change as listed in the first arrow in Figure 3.1, while at the same time decreasing the strength of the restraining forces listed in the other two arrows.
Change forces Internal dissatisfaction Obvious discrepancies External pressure Needs of people in the system
Resistance forces General resistance to change Specific resistant to change Resistance to person introducing change Loyalty to resistance group
Hindrance forces Task inherent in change too difficult System too rigid People have too few skills, ideas for knowledge
Cost
Figure 3.1 Motivating forces for change
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Example You are in charge of an outpatient unit and you would like the two registered nurses to see long-term patients in groups. You could increase factors supporting change by bringing to the attention of staff information that indicates that many of the long-term patients are not functioning well in the community, as well as giving them articles that describe innovative group approaches to the problem. This should increase their dissatisfaction with the current system. At the same time you could involve the nurse administrator, who is supportive of the idea, to provide some external pressure. You find that the registered nurses have never had training in group therapy and that the psychologist in the unit is opposed to nurses getting involved in such therapy. To decrease the power of these opposing forces, you could organize in-service training for the nurses and ask the chief psychologist to move the particular psychologist to another area. When the system is ready to implement the change, it is important to choose an opportune time. You are setting yourself up for failure if you start something new when, for example, one registered nurse is going through a divorce, the unit is being renovated and there are workers all over the place, and the hospital is getting ready for a centenary celebration! It is also important to start on a small scale and to try out the innovation first, so that you can identify and eliminate problems. Once the change has been implemented, it needs to be frozen, so that it will be continued even if you leave the area. This can be done by collecting evidence of the success of the change and by giving this kind of feedback to the staff promptly and frequently. It is also important to ensure that the new behaviour is rewarded by social recognition, improved working conditions, more interesting assignments, monetary recognition or any other result that makes it worthwhile for the staff. Most people find change unsettling or even threatening, but without change the quality of the service inevitably deteriorates. Change, as an essential part of working in a health service, therefore has to be handled with patience and sensitivity, but also with determination. 3.6 EVALUATING PROGRAMMES
It is necessary to evaluate current and innovative new programmes for many reasons. Among these are: Evaluation helps staff to identify weaknesses in programmes, which can then be corrected. It identifies strong programmes, which can then be duplicated in other settings. Positive evaluations act as rewards for staff involved; it assists in making effective planning decisions. Results can be used to support requests for increased resources. Evaluation is part of being accountable for public money spent, as well as of professional accountability.
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Evaluation of a whole programme is not an easy task. A programme often consists of a complex series of activities that take place over a long period, often involving more than one service setting and a changing staff component. Furthermore, evaluation takes time and money and these commodities are always in short supply. Nevertheless, evaluation of one's own practice is an essential part of being a professional and should not be neglected. There are four main methods of programme evaluation: 1. Recipient judgement. In this method the recipients of the programme are asked to evaluate the programme, usually by means of a questionnaire or an interview. This could involve patients, their families or community groups. The problem with this method is that people are often dependent on the service and are therefore reluctant to criticize it, or that they give the answers that they think are expected, instead of saying what they really think. The results of this kind of evaluation may therefore not be valid. 2. Expert judgement. There are different ways in which a person or persons can be used to evaluate a programme. One of these is called a peer review, which means that the people running the programme select people outside their group or system whom they see as their peers to come in and evaluate what they have done. They supply the peer evaluators with written material on the programme and the group also conducts an on-site visit to look at programme activities. A discussion is then held between the peer evaluators and programme staff to discuss findings and recommendations. A written report is provided after the discussion. This method is often chosen by staff because they can select the evaluators and, since the evaluators are peers, they are in a similar situation to the programme staff and can evaluate with understanding. A different form of expert judgement involves choosing a person or persons who are expert(s) in the field and then going through the same process as with the peer group. In this case the judges have much more knowledge and experience than the programme staff and might therefore give useful advice. However, this kind of evaluation can be very threatening to staff. 3. The quality assurance process. This method consists of the following steps: setting standards for a programme or service; identifying ways in which the standards can be measured; doing the measurement; identifying problem areas and implementing remedial action; repeating the measurement. This methodology has been used extensively in nursing and is useful in that the programme is measured against standards set by the staff themselves or by a peer group. It is also more structured than the peer review and staff know in advance against which standards they will be evaluated. 4. The research approach. In this method the programme is evaluated by using the steps of the research process. This can be either a qualitative or a quantitive approach. In the
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qualitative approach an in-depth analysis is done of the programme by describing how it actually functions. In a quantitive approach different forms of numeric data and statistics are used to analyse how the programme is working. This could include morbidity data, utilization statistics or need/demand statistics. Morbidity does not include only primary impairment in the form of physical or psychological symptoms and signs, but also secondary impairment in terms of quality of life and productivity. Secondary impairment can be measured through diagnostic surveys, attitude surveys and functional assessment scales. This is a very useful method and to a certain extent it is part of every other method. It is becoming increasingly difficult to claim that one is delivering a quality service without some form of evaluation being done. Such unsubstantiated claims are seen as both unscientific and unprofessional. CONCLUSION It is an important role of the nurse to develop new programmes. This includes the planning, implementation and evaluation of such programmes. Without this skill it is impossible for the nurse to lead a nursing team or to run a health service. The total role of the nurse in a primary health care setting can really be summed up by saying that primary, secondary and tertiary prevention programmes should be planned, implemented and evaluated. In actual fact, this is a massive task, involving many sectors of society, many professions and lay people, and demanding great skill and knowledge. However, having a programme focus in the service allows the practitioner to plan actions programme by programme, and to take small steps to achieve the overall goals. WEB RESOURCES
http://www.iaprs.org This website belongs to the International Association for Psychosocial Rehabilitation. In the section 'PSR resources' you will find a list of topics, each leading to other sites and more information. http://www.prosci.com/mod 1 .htm This website has a range of tutorials on change management, for instance, the 'Change Management series' and the 'Effective Project Planning and Start-up' tutorial. The site is sponsored by the Quality Leadership Centre. http://www.ifad.org To understand just how important international funding organizations think programme evaluation is, you can go to this website and click on 'Evaluation'. The website belongs to the International Fund for Agricultural Development and they set out clearly why and how they evaluate programmes.
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REFERENCES Anthony, W, Cohen, M & Farkas, M . 1990. Psychiatric Rehabilitation. Boston: Boston University Brolin, D E & Brolin, J C. 1982. Vocational Preparation of Persons with Handicaps, 2 ed. Columbus: Charles E Merrill Publ Co Budgen C M. 1987. Modelling: A method for program development. JONA, 17(12),19-25 Desjarlais, R, Eisenberg, L, Good, B & Kleinman, A. 1995. World Mental Health Problems and Priorities in Low-income Countries. New York: Oxford University Press Dhadphale, M & Omolo, O E. 1988. Psychiatric morbidity amongst khat chewers. East African Medical Journal, 65, 355-359 Editorial. 1988. Psychiatric disorders in the primary health care clinics in Kenya. East African Medical Journal. 65, 69 Eisenberg, L. 1986. Mindlessness and brainlessness in psychiatry. British Journal of Psychiatry. 148, 497-508 Gillies, D A. 1989. Nursing Management: A Systems Approach. 2 ed. Philadelphia: W B Saunders Co Howard, P B. 1994. Lifelong maternal caregiving for children with schizophrenia. Archives of Psychiatric Nursing. 8(2), 107-114 Judd, L L. 1990. Putting mental health on the nation's agenda. Hospital and Community Psychiatry. 41(2) Levine, I S & Fleming, M. 1987. Human Resources Management: Issues in Case Management. Baltimore: University of Maryland McLaughlin, J S. 1982. Toward a theoretical model for community health programs. Advances in Nursing Science. October, 7-27 Newton, J. 1992. Preventing Mental Illness in Practice. London: Routledge Odejide, A O, Oyewunmi, L K & Ohaeri, J U. 1989. Psychiatry in Africa: An overview. American Journal of Psychiatry. 146(6), 708-716 Reeler, A P. 1987a. Psychological disorders in Africa II: Clinical issues. Central African Journal of Medicine. 33(1), 15-19 Reeler, A P. 1987b. Psychological disorders in Africa III: Service delivery. Central African Journal of Medicine. 33(2), 37-41 Regier, D A, Boyd, J H, Burke, J D, Rasis, M S, Myers, J K, Kramer, M, Robins, L N, George, L K, Karmo, M & Locke, B Z. 1988. One month prevalance of mental disorders in the United States: based on five epidemiological catchment area sites. Archives of General Psychiatry. 45, 977-986 Rutter, M. 1995. Psychosocial adversity: risk, resilience and recovery. Southern African Journal of Child and Adolescent Psychiatry. 7(2), 75-88 Wehman, P, Sale, P & Parent, W. 1992. Supported Employment. Boston: Andover Medical Publishers
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C H A P T E E FOUR
Mental Health Care in the
Health Care System LRUYS
objectives After studying this chapter the learner should be able to: Briefly outline the district health system. Distinguish between mental health care offered at various levels of the health care system: primary health care, secondary health care, and tertiary health care. Describe how a primary mental health service should function. Demonstrate skill in consulting specialists, and in referring patients to them, OR (if you are the specialist) in dealing with referrals from other team members, and acting as consultant.
INTRODUCTION In South Africa, mental nursing is seen as part of the basic education of professional nurses in order to equip them to work as generalist nurses in the comprehensive health services of the country. The health services of this country are going through a major change due to the new Health Act, which provides for the establishment of what is generally known as the district health system (DHS). In this system, mental health care is incorporated into primary health care (PHC) for the fist time. It is important to understand how mental health care fits into this service, and to develop the skills necessary to function adequately at the primary health care level.
4 . . 1 OVERVIEW OF THE DISTRICT HEALTH SYSTEM The district health system (DHS) is a way of referring to a model for planning and organizing a health system using the district as the basic unit.
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The basic unit A district is a coherent, geographically defined area in which all health services are coordinated by one district health authority, which is part of the lowest level of government. A district should be small enough to allow for effective community participation, but also large enough to allow for efficient comprehensive community and first-level hospital care in such an area. The population (number of people) served by a district varies and is not the only determinant of district boundaries. For instance, the populations of the proposed districts for the Greater Durban area vary from 100 000 to 448 000. Some districts are very densely populated, and others are more rural and difficult to access. However, a population of about 250 000 per district would be about average. Ideally, the boundaries of the health districts should coincide with administrative and political boundaries. For example, local authority election boundaries should be the same as those of districts. The boundaries delineating other sectors, such as education or policing, should also coincide with the health district boundaries. The codetermination of boundaries will facilitate the administration of multisectoral activities. One of the basic tenets of the DHS is that people in each district know their own situation best and should therefore have maximal autonomy in management decisions. This means that financial, staff and service decisions should be the responsibility of the staff of the local institution and not be controlled provincially. This approach will be effective only if a more participatory management style can be adopted by managers, allowing staff and the community to be increasingly involved in decision-making. The basic principles It is envisaged that the district health system will allow a PHC approach to be implemented that will adhere to the following principles: equity in the services supplied to all consumers; comprehensiveness, which includes intersectoral collaboration, promotive, preventive, curative, rehabilitative and multidisciplinary health services at all levels of care; community participation and empowerment, which promotes community development, is accountable to the community, and engages the community in the planning, implementation and evaluation of health services; affordability and sustainability in terms of the country's resources; efficiency, which means that the service should function with minimum waste and maximum goal attainment.
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The levels of structure, functions and service In each province the following levels of health care will exist: The community level Community services will be delivered from a community health centre (CHC), or a community clinic (CC) serving a designated community, and will be governed by a health committee representative of that community. The CC will be staffed by nurses, whereas the CHC will have a basic multidisciplinary team. Most CCs will render a 40-hour-per-week service, while CHCs will render a full-time service (24 hours, 7 days). (See Table 4.1 for the proposed tasks of each level of service.) In terms of mental health care, each clinic should render a comprehensive service, including diagnosing and treating the most common conditions, community-based rehabilitation, and preventive and promotive services. If a condition falls outside the capabilities of clinic staff, or if there is an intractable problem, they can consult with support staff at the CHC or the district hospital, who form their support system. These are also the two services to which they may refer patients.
Table 4,1 Functions at the various levels (Technical Planning Committee) Community level (CL) Environmental health Promotive & health education
District level (DL)
Regional level (RL)
All the services in the first column plus:
Services in relation to districts:
Family planning
Planning of health services for district
Allocate resources to districts
Antenatal, delivery, post- and neonatal
Development of communitylevel services
Ensure equity
Comprehensive for children & school health
Provision of essential medicines to CL
Comprehensive for communicable and other diseases, & optometry
Transport for district
Treatment of common illnesses and injuries
Maintenance of equipment, facilities, etc.
Community rehabilitation Community mental heath
Monitoring and evaluation of health services in district
Community geriatric
Health information system
Community nursing and home care
Human resource development
DL environmental health Provision of facilities
Monitoring and evaluation of health services Provision of support services Capacity development and training Establishing district health services Ambulance and emergency RL environmental health Ensuring effective referral systems
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Community level (CL) Oral health Accident and emergency Medical social work Basic laboratory and diagnostics, including X-rays Health monitoring Occupational health Basic medico-legal
District level (DL) Training and research Co-operation with other districts Ensuring co-operation within the district
Regional level (RL) Integrated health information systems Integrated planning
District level Each district will have a designated district hospital (level 1 hospital), at which nonspecialist inpatient services are provided, as well as the usual range of community services. In essence, then, a district hospital is a CHC with inpatient facilities. As far as mental health care is concerned, in view of the shortage of members of the multidisciplinary team, such as clinical psychologists and occupational therapists, this may be the first level at which a team of 'specialists' could be made available for referral and consultation. Joanna Briggs: Recommendations Nurse responsibifity 1. The rural and remote area nurse is responsible for ensuring a knowledge of pharmacology, have skills related to medications, and be familiar with resources available for reference. 2. Rural and remote area nurses should also have a sound knowledge of laws relating to medication use. 3. To ensure that this knowledge is current and appropriate, rural and remote area nurses should be assessed for competency at regular intervals. 4. Registered nurses should only initiate, administer and supply medications where current protocols are in place. Employer responsibility 1. The manager of a health service should provide a work environment that complies with law pertaining to administration and supply of medications in rural and remote areas. 2. The manager should also ensure that registered nurses are safe and competent to practice in rural and remote areas in relation to medication use. 3. The manager should ensure that policies and protocols regarding medications are in place.
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4. Where policies and protocols do not exist, they must be developed. 5. The manager should clarify, with written and dated protocols and policies, the lines of authority and accountability in relation to administration and supply of medications in rural and remote areas. 6. The manager should ensure that the list of medications appropriate for inclusion in protocols used by registered nurses be developed using an interdisciplinary process that includes registered nurses, medical practitioners and pharmacists. 7. The manager should establish a policy pertaining to the ordering, storage, transport and disposal of medicines which is consistent with statute laws and safe practice. 8. The manager should supply secure storage places for all medications and pharmaceutical supplies consistent with statute laws. 9. The manager should ensure that a process of stock control be implemented to aid in the monitoring of medication use. 10. Employers must provide structural support to ensure that delegated nursing work responsibilities can be fulfilled in rural and remote areas. 11. The employer should ensure 24-hour access to an appropriate medical practitioner and appropriate access to pharmacy supply and advice. Others' responsibility 1. Medical practitioners and pharmacists should ensure the safe use of medications in the practice setting. 2. Education providers should work in partnership with service providers to ensure that course content is consistent with contemporary best practice. Joanna Briggs Best Practice The administration and supply of medications by registered nurses in rural and remote areas. Level of evidence: Mainly level IV
These could also be used for special programmes such as outreach or preventive projects. Ideally, there should also be a service for children and adolescents, at least at this level. Regional level Regional hospitals (level 2 hospitals) will be required to provide at least the following specialist services: medicine, surgery, obstetrics and gynaecology, paediatrics, psychiatry, anaesthetics and orthopaedic surgery. This will mean that each regional hospital will have at least an acute psychiatric unit, which should take care of most of the hospitalization needs of that region. It might also be possible to have regional rehabilitation centres.
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Provincial level At this level, provincial hospitals (level 3 hospitals) provide the final referral service for the whole province, where a wider range of specialities and sub-specialities is available. Forensic psychiatry will probably be handled mainly at this level. Level 4 hospitals are those that supply a service on a national level, for example Groote Schuur, which supplies a heart transplant service to the whole country. It is envisaged that the various provinces will supply different national services. 4,2 THE INTEGRATION OF MENTAL HEALTH CARE INTO PRIMARY HEALTH CARE The first mechanism mentioned in the government's Health Plan, under the heading 'Mental Health', proposes 'Improved integration of mental health care, including mental disorders, especially at primary level ...'. This is in line with the recommendations of the World Health Organization (1984: 32-33), which reads: 'that governments should take all necessary steps to improve mental health care at every organizational level, but especially at community level, through integration with the primary health care system, supervision being provided by more skilled personnel and referral services being available for the more difficult types of cases' According to Abiodun (1990) and Freeman (1992), this integration will have the following benefits: It will improve coverage of the population. It will reduce the cost of health care, as psychiatric/mental health care will be provided by the clinic staff. The service will be nearer to the consumers, and therefore more accessible and economical to them. The rehabilitation of patients will be improved, since it will allow for families to be involved in treatment (Ngubane & Uys 1994). The current provision of psychiatric care is very different from this ideal: 1. In most settings, psychiatric services are provided by a specialized psychiatric team, which visits primary health clinics on specific days or at specific times. This team consists of psychiatrically trained nurses and sometimes a physician and social worker. The team is based at a psychiatric hospital. 2. In other settings, community health nurses offer the psychiatric service, but at specific times. Not all of these nurses have psychiatric training, and no other special training has been given. 3. The service consists of supplying the patient with psychiatric medication, assessing the effectiveness of the medication and organizing admission when necessary. The social worker may assist in obtaining Disability Grants for the patients. No case finding, rehabilitation or primary prevention activities are involved.
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4. If the patient comes outside the times set for psychiatric services, the nurse will decide whether or not it is possible to attend to the patient. Patients are often turned away and asked to return at the scheduled time. 5. When a new patient comes to the clinic, he/she is referred to the hospital. From there he/she may be sent to a psychiatric hospital in the province, or put on medication by the local physician. This may involve travelling long distances from an outlying area, or a long period of hospitalization far from home. The problem is therefore how to transform the current system into one where comprehensive psychiatric/mental health care (CPMHC) will be incorporated into every primary health care (PHC) setting. The difficulties related to this transformation are numerous: 1. The current staff may not have the necessary skills and knowledge to cope with this task. According to SA Nursing Council statistics for 1993, only 12,4 % of nurses registered with this Council have a registration in mental health nursing. Furthermore, most of the nurses with mental health nursing training did this training in psychiatric hospitals and their skill in community-based approaches is limited. 2. If nurses have to make diagnoses and put patients on medication, legal provision will have to be made for these tasks. The current scope of practice regulations of the SA Nursing Council (Reg R 2598, as amended up to 1991) does not prohibit nurses from diagnosing and prescribing. However, although the Medicines and Related Substances Control Amendment Act (94 of 1991) makes provision for regulations to be made authorizing nurses to do this, these regulations have not been promulgated. 3. The current primary health care system is inadequate as it is. Adding new responsibilities to an already faltering system may cause a total breakdown. 4. The hospitals, which should provide the back-up for the community-based service, themselves seldom provide quality psychiatric care. Abiodun (1990) points out that all over Africa psychiatric hospitals are understaffed, far from the homes of patients, and give only traditional custodial and chemical treatment. To a large extent this is also true of many South African hospitals. Freeman (1989) has identified many problems undermining the psychiatric services, such as the fact that the patient to staff ratio is currently 1 : 1 135 in this country, as opposed to the 1 : 80 in the United States of America and 1 : 190 in the United Kingdom. He quotes the example of a population of 1,5 million people who are served by three hospitals with no psychiatrist or clinical psychologist. 5. Health care workers often have a negative attitude towards psychiatric patients and their care, and this may make it very difficult to obtain their co-operation with regard to the proposed changes. Mavundla (1993) surveyed the attitudes of nurses in a general hospital toward psychiatric patients and found that 90 % held negative views. 6. It might be difficult to convince policy makers of the importance of putting additional resources into psychiatric/mental health care. Popular causes, such as maternal and child services, or more dramatic problems such as AIDS, are often regarded as greater priorities.
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Petersen, Bhagwanjee and Parekh (2000) proposed a five-tier system to facilitate districtbased health care. It is summarized in Table 4.2. Table 4,2 Proposed tiers of mental health services Tier and human resources Tier 5: Tertiary Specialist tertiary hospital team (all disciplines)
Tier 4: Secondary Regional mental health team: (Specialist psychiatric nurse, occupational therapist, social worker and consultant psychiatrist)
Tier 3: Primary 3 Psychiatric nurse (a district mental health programme co-ordinator) District medical officers
Tier 3: Primary 2 Primary health care nurse
Tier 3: Primary 1 Traditional healers, community health workers, social workers
Functions
Provide long-term inpatient care Provide outpatient care Provide training, support and back-up to district teams Plan and develop mental health services in the regions Provide short-term inpatient care Assess, diagnose, prescribe, revise and initiate psychopharmacological treatment Provide support and referral service to mental health programme co-ordinators Plan and develop mental health services for the districts in conjunction with psychiatric nurses in PHC settings Assess, diagnose, prescribe and initiate treatment Revise treatment Develop and implement community-based mental health programmes Referral to specialist and regional hospitals Consultancy-liaison service for PHC nurses More specialized counselling Implementation of a health information system Screening for mental health problems Emergency treatment of mentally ill persons Counselling and basic rehabilitation Psychoeducation and follow-up medication Referral to tier 3:3 Promotion of mental health Recognition of mental health problems and referral to 1.2 Basic counselling, support and rehabilitation Monitor adherence to treatment
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This model makes it clear that nurses at all levels need to be involved in mental health care. According to a study done by Lund et al. (2000), a comprehensive mental health service for 100 000 of the population needs 38 hospital beds, and 24 psychiatric nurses, two occupational therapists, three social workers, two clinical psychologists and four psychiatrists. Of the 24 nurses, 17 should work in hospitals, and seven in ambulatory care, while one should be a manager. These calculations are based on a World Health Organization (WHO) model for the calculation of needs. 43
DESCRIPTION OF PRIMARY MENTAL HEALTH CARE
In order to address the needs of consumers at the primary health care level, a comprehensive approach, including primary, secondary and tertiary prevention strategies, is essential. A focus only on primary medical care, or on secondary prevention, will not address the needs of most consumers. In this regard, the 10 essential components for a community support system (CSS), identified by the National Institute of Mental Health in the USA, may be a useful checklist (Stroul 1989): Identification of the target population and outreach to offer appropriate services to those willing to participate. Assistance in applying for entitlements. Crisis stabilization services in the least constrictive setting possible, with hospitalization in the community when other options are unavailable. Psychosocial rehabilitation services including (but not limited to): - goal-directed rehabilitation evaluation; - training in community living skills in a natural setting; - opportunities to improve employability; - appropriate living arrangements; - opportunities to develop social skills, interests and leisure time; and - activities to provide a sense of participation and worth. Supportive services of indefinite duration, including supported living or working. Medical and mental health treatment and care. Back-up support to families, friends and community members. Involving concerned community members in planning and offering housing or working opportunities. Protection of client rights, both in hospitals and in the community. Case management to ensure continuous availability of appropriate forms of assistance. Primary health care staff cannot be taught to provide comprehensive care for patients with all types of conditions. There has to be a limitation of practice, according to the prevalence of mental illness and the level of skill needed to treat different conditions. These PHC
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practitioners, therefore, have to be skilled in the process of identifying who they can help, and who should be referred to the secondary health system (SHS). It is accepted that at PHC clinics nurses will be the only professionals available for the next decade, while at community health centres (CHCs) there might be additional staff members such as a social worker or doctor. They may act as consultants to clinic staff. The secondary health care back-up team for the PHC service providers will mainly be based at the district hospital level. It is hoped that at this level at least a specialist psychiatric nurse, a social worker and an occupational therapist will be available. These people act as consultants to the PHC staff and not as supervisors. They are also the expert team to whom the PHC staff refer patients. The greatest perceived need of communities seems to be the control of serious mental illness. The priority given to treating the severely mentally ill is seen as a strong point in the services of developing countries (Lefley 1990). The WHO also makes this the first priority of the integrated service (1984) in terms of handling psychiatric emergencies and treating chronic psychiatric conditions. Rehabilitation is the second part of the comprehensive mental health service. Again, the WHO strongly recommends that the task of managing chronic mental illness be delegated to primary health care centres (1984: 12). In a study using case management for a black outpatient group in South Africa, it was found that, although this intervention is very useful, vocational rehabilitation is one of the main problems in the rehabilitation process (Uys & Zulu 1996). In a study of a group of psychiatric outpatients in Durban, Fish (in Uys, Dlamini & Mabandla 1995) found that only 5 % were employed, and 60 % received disability grants. In a group of Transkei psychiatric outpatients, the percentage receiving disability grants was much lower, totalling 17 % (Uys, Dlamini & Mabandla 1995). Clearly, financial support and vocational rehabilitation require urgent attention. Case finding must also be added to the tasks at primary level. The WHO points out that as many as 20 % of those attending general health care facilities do so because of emotional problems (1984: 13). Unless they are identified and helped appropriately, unnecessary suffering and inappropriate interventions will result. The National Institutes for Mental Health (NMIH) in the USA also identify client identification and outreach as an essential component of a comprehensive, community-based mental health system. With regard to primary prevention, the WHO (1984: 13) recommends that high-risk groups should be identified and community resources mobilized to counter the problems causing breakdown. If one looks at the morbidity statistics and the clinical description of syndromes, it would seem that there are two main crisis periods: early childhood and adolescence. In early childhood parenting skills are particularly important, while in adolescence it is the life skills of the individual which are especially relevant. 4,4 TEAM FUNCTIONING SKILLS It is not easy to make multiprofessional teams work well to the advantage of clients. In a recent study of the literature, Stark et al. (2002) found that the following problems arise when different professions try to work together as a team:
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There is a lack of a coherent and shared vision. Each profession maintains independent systems of information, leading to communication problems and poor planning. They do not agree on what it means to work together. There is a superficial understanding of or appreciation for the roles of the others. Most mental health professionals believe that good teamwork will improve care, but few know how to achieve this. At a minimal level it demands clear communication between professions about the client, both when referring and consulting. But it also demands getting to know the role and strengths of the other professionals and respecting and using their expertise. Consultation The term consultation can be used in many ways. According to Caplan (1970), it refers to a process of communication between two professional persons, the consultant and the consultee. The consultant is a specialist, and the consultee asks for the consultant's help with regard to a current work problem which he/she is experiencing and which he/she has decided falls within the other's area of specialization. In the district health system, the consultee will usually be the PHC nurse, and the consultant will be one of the multidisciplinary team members at the secondary health system level. Consultation is an empowering process due to the following factors: The consultant accepts no direct responsibility for the interventions which the consultee finally undertakes. The patient remains the responsibility of the consultee. The consultee remains free to accept or reject the advice of the consultant. The consultant engages in the process not only to help with the current problem, but also to increase the knowledge and skill of the consultee. The need for consultation should therefore gradually decrease. Consultation is not supervision. The secondary health service staff are not the supervisors of the PHC staff. The SHC staff are also not there to evaluate the performance of the PHC staff. This allows PHC staff to use the consultants without fear of jeopardizing their positions. A consultant may offer helpful clarification, diagnostic formulations, or advice on treatment. In order for the consultant to give the best possible advice, the consultee must provide all the relevant information. At the same time, the consultee should remember that the consultant also has other work to do, so the consultation should take up the least time possible. It is important, therefore, to prepare carefully for a telephonic consultation, so that all the information is available and the consultee knows exactly what he/she wants. When you plan to consult a specialist it is also important to decide which of the multidisciplinary team members will be the most appropriate. For instance: a diagnosis or medication problem: psychiatrist or psychiatric nurse;
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a counselling or behavioural problem: psychologist or social worker; a financial or legal problem: social worker. Referral Referral means that you transfer responsibility for the patient's care to another institution or person. There are different reasons for a referral, for example: The patient does not fit into any of the psychiatric diagnoses with which the practitioner is familiar. The patient is not responding to treatment, even after an adjustment of medication. In this case, the PHC practitioner may consult a specialist on the case first, especially if a telephone is available, before the patient is referred to a hospital. The patient requires assistance which the PHC centre is unable to deliver, for example, a patient who needs to see a social worker about a childcare grant. The patient is a danger to himself/herself or to others and cannot be contained in a community setting, for example, a suicidal patient. When doing a referral, a standardized form may be used. This should be addressed either to the doctor or the appropriate professional. A copy of the referral letter should be kept in the patient's file. The following components are essential parts of a referral: patient's name; referring clinic/service; person making the referral; diagnosis of the patient (if available); treatment the patient is currently receiving; the reason for the referral, for example: 'The patient does not seem to be responding to the medication and continues to report symptoms as bad as those suffered two months ago when treatment was initiated'; what is requested, for example: 'Please admit and stabilize on effective medication'. When a patient is referred back to the service, which previously referred him/her, a reply letter or form should be sent by the SHS team member who dealt with the patient. This should include the following: the findings, or what treatment was given; whether they did what was requested and if not, why not; any advice for further management which may be required by the PHC provider. CONCLUSION The target for the South African health services has been set. It is clear that an accessible, effective service for all communities in this country is what we are aiming for. However,
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we are just at the beginning of the journey to this goal. Whether we reach it or not is heavily dependent on whether the nurses in primary health care settings can master the skills and knowledge they need in order to implement comprehensive PHC. They are crucial to the success of the whole plan. WEB RESOURCES
http://www.who.int/en/ This useful website belongs to the World Health Organization. Try the 'Health Topics' with its comprehensive list of topics and information (fact sheets), each with associated links. The 'Publications' section provides a catalogue and a summary of World Health Reports. http://gov.za/ or www.doh.gov.za This is the website of the South African government, and you can find very useful information there. The Department of Health website offers a wide range of documents, as well as facts and statistics. http://www.modmh.state.mo.us/cps/ If you want to see what a totally different health system looks like, look at what the Missouri (in the USA) Department of Mental Health has to offer. Their services are described on this site, including their Suicide resources. REFERENCES Abiodun, O A. 1990. Mental health and primary care in Africa. East African Medical Journal. 67(4), 273-278 Caplan, G. 1970. The Theory and Practice of Mental Health Consultation. New York: Basic Books Inc Freeman, M. 1989. Mental Health Care in Crisis in South Africa. Johannesburg: Centre for the Study of Health Policy, University of the Witwatersrand Freeman, M. 1992. Providing Mental Health Care for All in South Africa - Structure and Strategy. Johannesburg: Centre for the Study of Health Policy, University of the Witwatersrand Lefley, H P. 1990. Rehabilitation in mental illness: insights from other countries. Psychosocial Rehabilitation Journal. 14( 1), 5-11 Lund, C, Flisher, A L, Lee, T, Portens, K & Robertson, B. 2000. A model for estimating mental health service needs in South Africa. ,SA Medical Journal 90(10): 1019-1024. Mavundla, T R. & Uys L R. 1997. The attitudes of nurses towards mentally ill people in general hospital settings in Durban. Curationis 20(2): 3-7. Ngubane, V G & Uys, L R. 1994. The social support network for black psychiatric inpatients. Curationis, 17(2), 6-9 Petersen, I, Bhagwanjee, A & Paekh, A. 2000. From policy to praxis - a framework for the delivery of district mental health care in KwaZulu-Natal. SA Medical Journal 90(8): 798-804. Stark S, Skidmore, 1), Warne, T & Stronach, I. 2002. A survey of'teamwork' in mental health: is it achievable in practice? British Journal of Nursing 11(3): 178-189. Stroul, B A. 1989. Community support systems for persons with long-term mental illness: A conceptual framework. Psychosocial Rehabilitation Journal12(3), 5-8
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Technical Planning Committee. 1995. Durban Functional Region Draft Health Plan. KwaZulu/Natal Provincial Administration The South African Nursing Council. 1993. Statistical Returns for the Calendar Year 1993. Pretoria: SANG Uys, L R, Dlamini, N K, Mabandla, SF. 1995. A profile of selected psychiatric outpatients in South Africa. Curationis 18(1), 22-25 Uys, L R & Zulu, R N. 1996. An evaluation of the implementation and the effectiveness of case management in the rehabilitation of psychiatric outpatients in South Africa. SA Journal of Psychology 26(4) World Health Organization. 1984. Mental Health Care in Developing Countries: A Critical Appraisal of Research Findings. Geneva: World Health Organization
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CHAPTER FIVE
The Consumers in Mental Health L R UYS
Objectives After studying this chapter the learner should be able to: Discuss the problem of stigma and how it can be addressed in communities in South Africa. Identify the factors associated with successful recovery from mental illness, as perceived by consumers. Describe the stages through which the family of a mentally ill person has to pass. Compare and contrast the models families use to explain mental illness and how these influence their coping strategies. Describe how families can assist a family member who is mentally ill towards recovery. Debate the value of support groups for consumers and describe how these can be formed and maintained. Describe the advocacy role of consumers.
INTRODUCTION
Consumer movements are not new to the field of mental health: the Mental Health Society was founded by Clifford Beers as early as 1908. However, the influence and strength of these organizations has increased greatly since the dawn of the community psychiatric era. Since the change in approach which resulted in psychiatric patients spending most of their time outside hospitals - many of them in the care of their families families have organized themselves to address their common problems. At the same time, patients themselves have become more active participants in the treatment and rehabilitation process, and this has led to groups of patient consumers forming themselves into support groups. Strictly speaking, only those persons who have been or who are being
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treated in the mental health system can be regarded as consumers. However, families are often so closely involved in this process that they can also be seen as consumers of the care. 5.1 THE STIGMA OF BEING MENTALLY ILL There are many first-hand accounts of persons who have experienced the suffering of mental illness. Such reports, appearing in the popular press and in professional journals, as well as in book form, greatly enrich our understanding of this illness. South African literature does not contain many such accounts, although there are a few (Du Toit 1999; Bielovich 1993). However, the story of Lily Moya is a particularly poignant account of a patient in one of our psychiatric hospitals. It describes the correspondence between Lily, a young girl from Transkei with great dreams and ambitions, and a wonderful way of expressing herself, and Dr Mabel Palmer, administrator at the University of Natal. The correspondence stretches over three years, and allows us to get to know the vivid person that Lily was before mental illness claimed her and turned her into another grey figure in a back ward. Here, for instance, is Lily's description of her experiences as a substitute teacher at the age of 15 at a village school at Ncambele in 1949: It was a great shock to me, that I should teach. The Principal teacher was quite amazed - he did not know that I was so small, indeed, the students are very big in that school ... lust imagine how I nearly lost my senses, and how I shivered from toe to hair when I found myself standing in front of such big students, very old indeed for such classes ... What would you have done if you would have been myself? Would you have gone to the classrooms or ran back home? This incidence [sic] brought a great change to this prolonged monotonous life ...' (Marks 1987: 10)
But the orphaned Lily could not find the support she needed, and the stress and alienation of her life became too great. By 1951 she was acutely depressed and, after seeking help from traditional healers, she was admitted to Sterkfontein Hospital, where she was diagnosed as having schizophrenia. She spent the next 25 years of her life in psychiatric hospitals before the deinstitutionalization policy released her in 1976. The experience itself is one of the most frightening and alienating a person can endure. While every other life experience can be 'managed' or 'coped with' by means of one's mental powers, in this case the brain itself is the centre of the problem, making management and coping so much more difficult. While the person looks physically healthy, and life circumstances may even be positive, the whole fabric of his/her personality and life is undermined by the insidious processes in the mind. What makes the experience even more difficult is the stigma attached to people suffering from these conditions. The word stigma comes from the mark branded on a slave and refers to an imputation which stains or scars a person's reputation. In other words, it is something that brands a person in a negative way in the eyes of society. Society regards people with mental illness as dangerous, not always physically, but in a more nebulous way. They make people uncomfortable, act strange, and do not react to people in a predictable way. Other members of society see them as 'weak'. They should 'pull themselves together'
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and all will be well. They are ungrateful to be depressed when they have so much to be grateful for. Or they are lazy - a big young man lying around all day doing nothing! All these perceptions are based on a lack of knowledge and understanding of what mental illness is and how it is treated. But it is not easy to combat, since people avoid what they do not understand, and they often do not want to know. Their misconceptions are often also fed by the media, which stereotypes mentally ill persons as violent. For instance, while ordinary people are portrayed on television as violent 35 % of the time, the mentally ill are portrayed as violent 80 % of the time (Carter 1990). This is part of the reason why many psychiatric patients and their families are socially shunned, and why persons with mental illness cannot find work, or housing, or friends. This vicious cycle keeps on repeating itself: the person has symptoms of the mental illness, and feels strange and weird. People react to him/her in an exaggerated way because of the symptoms, but also because of the stigma. This reinforces the patient's perception that he/she is not acceptable, deepening the suffering and Hhdrawal. Consumers would like specific measures to be taken to decrease the stigma. One of these is that they should be treated in general hospitals, and not in separate 'mental hospitals'. In the same way, they want to be able to go to the same primary health clinic that other people use, on the same days as others do, so that they do not stand out as different. Any intervention in the community, such as a forced admission, should take the resultant stigma into consideration, and not do anything that will increase it. The stigma against psychiatric patients is common in South Africa. In a small pilot study in a township outside Durban, Sapepa (1991) found that 80 % of the respondents would not like to live in the same block of flats as a mentally ill person or have a mentally ill person as a neighbour. More disconcerting is Mavundla's (1993) finding that most nurses (95 %) working in a general hospital in Durban had negative attitudes about psychiatric patients, with those of registered nurses being significantly more negative! Stigma goes beyond mere attitudes. At a recent World Psychiatric Association meeting in Johannesburg, the way in which South African medical aids and state-funded health systems discriminate against mental illnesses were highlighted (Depression and Anxiety Support Group 2001). In a survey often medical aid companies, they found that only four did not discriminate against mental illnesses. Such problems as not paying for hospitalization resulting from suicide attempts, or covering hospitalization for other illnesses up to R800 000 while covering hospitalization due to mental illness only up to R6 000 were identified. The importance of stigma was again highlighted when the United Kingdom made it one of the seven 'standards' for mental health care identified in their 1999 National Service Framework for Mental Health (Nursing Times 1999). 5 2 CONSUMERS' PERCEPTIONS ON RECOVERY FROM MENTAL ILLNESS Over the last two decades, patient consumers of mental health services have expressed some very definite views regarding the process of recovery. It is important that health care workers should take note of their unique perspective.
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In a study in the USA, Sullivan (1992) found that consumers regard the following factors as contributing to success in recovering from mental illness. The factors are listed in decreasing order of priority here: Medication Community support and case management Self-will and self-monitoring Vocational activity, including studying Spirituality and religion Knowledge about and acceptance of the illness Mutual aid groups, and supportive friends Significant others The mix of physical, social, psychological and spiritual factors in this list again emphasizes that illness is an experience of the total human being and, as such, demands interventions which are equally comprehensive. Frese (1993), in addressing the problem of how to cope with schizophrenia from a consumer perspective, mentions many of these factors, but also emphasizes other important aspects, such as not mixing street (illegal) drugs with medication. He points out that many people who suffer from a mental illness have physiologically based needs to function in a manner which is not acceptable in polite society. These compulsions may include talking to themselves or ritualistic behaviour. The consumer should excuse him/herself in such circumstances and go to a place where the behaviour can be indulged in privately. He also addresses the issue of whether or not to be open about having a mental illness. One strategy he suggests is to share a story or article about a mentally ill person at work. If the reaction is supportive, one might consider going public; if not, it might be wiser to keep quiet. In general, however, the younger the consumer is, the better it is to keep quiet about a psychiatric disorder. Periods of unemployment or hospitalization can be explained by using terms such as 'working freelance' or 'lost my job'. The consumer organization Schizophrenics Anonymous has devised a programme to help cope with this serious illness, based on the steps devised by Alcoholics Anonymous. The steps are: 1. I surrender - I admit that I need help; I cannot do it alone. 2. I choose - I choose to be well. I take responsibility for the choices that I make. 3. I believe - I believe that I have great inner resources and I will try to use these resources to help myself and others. 4. I forgive - I forgive myself for the mistakes that I have made. I also forgive and release everyone who has injured or harmed me in any way. 5. I understand - I understand that erroneous self-defeating thinking contributes to my problems, failures, unhappiness, and fears. I will work toward a more constructive belief system.
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6, I decide - I make a decision to turn my life over to the care of God, as I understand him, surrendering my will and false beliefs. (See the website of this group at sanonymous.org/) The active role of the patient in the process of recovery is clearly demonstrated in these steps. Most of these things cannot be done for the patient - the process is totally dependent on the patient himself or herself. 5 3 THE FAMILY OR 'CARER' PERSPECTIVE
The families of people with mental illness usually shoulder the greatest part of the burden of caring for them. Between 70 % and 93 % of outpatients live with their families (Uys, Dlamini & Mabandla 1995). Other studies have shown that the burden which this creates for the family is significant. However, the fact remains that the family is the main resource of the person suffering from mental illness. Families act as care givers, they support other families with similar problems, they teach and educate other consumers and the public at large, they participate in research and they advocate improved services both for the individual and for patients in general (Spaniol, Zipple & Lockwood 1992). Stages of care-giving Howard (1994) has identified the following stages experienced by mothers of persons suffering from serious mental illness. Stage 1: Perceiving a problem. At this stage the parent or spouse realizes that something is wrong with the person concerned. Slowly they come to see that the problem is serious and is not going to go away. In some cases this stage takes months, but in exceptional cases it can go on for years. The family then goes into a crisis with the shock of a 'breakdown' or the first hospitalization, or a similar drastic event, which confirms all their fears. Stage 2: Searching for solutions. During this stage the families search for information and assistance. They have to learn to use a totally different assistance network, often one that is poorly developed and difficult to access. They grapple with episodes of illness, and suffer acutely from the emotional stress of the process through which they and their loved one are passing. Often families are given very little information, even to the extent of never being given a diagnosis for the problem, but only vague statements about a 'nervous breakdown'. Stage 3: Enduring the situation. This stage is similar to the previous one, but the family is more focused. They often have a diagnosis by this time, and they have a better idea of what they have to deal with. They often get their information from personal experience, and a few use support groups. They very seldom get their information from the health system. It is still a very distressing phase, and the family reaches out to each other, and to friends, co-workers, health care providers and religious leaders for assistance and support. They also continue to give care to the patient.
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Stage 4: Surviving the experience. Survival is linked to acceptance. It is often triggered by the knowledge that serious mental illness is biological, and not caused by bad mothering. This decreases the guilt, and increases support and understanding. It is a time of hope and of determination in the face of ongoing stress. The family also experiences ongoing grief over the 'loss' of their old life, and of the person that the patient was and could have been. Understanding these stages could assist health workers in giving families appropriate support. It could also help families to understand their own feelings. Ways in which families explain mental illness The way people deal with something depends on how they understand and explain it; this is also true of the way in which families deal with mental illness. This relationship was revealed in Solombela and Uys's study (1994) on the relapse of patients with schizophrenia. It was found that patients in the relapsed group - and their families - still believed that they were ill because they had been bewitched and were possessed by evil spirits; on the other hand, the group which had not suffered a relapse had changed to a belief in the Western disease and treatment model, although they had originally held traditional beliefs. In a more elaborate study of explanatory models of families, Chesla (1989) distinguished the following models in a USA sample: Strong biologic model. These families see mental illness as a brain disease and all symptoms as caused by chemical malfunction in the brain. Such a belief leads families to concentrate in their coping behaviours on medicine, nutrition, rest and exercise and on other physical strategies. Rational control model. These families believe that if patients can be influenced to think differently, they can act differently. An attempt is therefore made by means of argument or persuasion to cure the mentally ill person of delusions, hallucinations, beliefs and rituals. The families try to operate in a rational way in the irrational world which the patients often create. Normalizing model. These families believe that symptoms can be reduced by identifying those circumstances which cause negative symptoms and by recreating those circumstances which stimulate a more positive response. They believe that the environment plays a major role in increasing or decreasing symptoms, and strive to create an environment that is as normal and as age-appropriate as possible for the person concerned. Such families might keep patients from having contact with other mentally ill persons, and carefully screen conversations and events to avoid stimuli which have caused problems in the past. Survival-through-symptoms model. These families interpret all symptoms as coping strategies which the mentally ill person uses to deal with the pain and confusion caused by the malfunctioning of the brain. They therefore gently support the patient and try to decrease the pain and suffering; they do not expect the patient to change or conform
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to expectations. Families with these beliefs express great personal distress about the patient's condition. The belief systems of American families may not be totally relevant to South African families, but these models may serve to increase the sensitivity of health workers to this important aspect of carers and their role in the treatment and rehabilitation of patients. Guidelines for families living with a family member who is mentally ill There are three pillars that can guide families living with a person who has a serious mental illness: Create an environment with low stress It is clear that stress plays a major role in the process of mental illness. It is therefore important for families to identify sources of stress for the patient and try to eliminate or limit such sources. It is important to remember that all people have different stress levels, and one should therefore not assume that what is stressful to you is also stressful to someone else. The following strategies to decrease stress may be useful. Keep to a predictable schedule. This decreases decisions and adjustments and seems to have a calming effect on people in emotional distress. Develop appropriate expectations. Considerable stress can result when families expect more of the patient than he/she can manage. Many families do not understand that the lack of motivation which is a feature of many mental illnesses is not laziness. They cling to the expectation which they had of the person during the premorbid period and fail to adapt. Expectations should therefore be pitched low, and the patient's tolerance tested gradually. This means having less rather than more: fewer activities, fewer people, fewer expectations, fewer demands. Sometimes the patient himself or herself may have high expectations; the family must then caution the patient to take small steps towards the ultimate goal, or to postpone big projects. Speak simply and clearly. Since people with mental illnesses often have problems processing information, they find it difficult to follow long, loud, rapid and complicated sentences. Speaking in short, simple sentences, slowly and clearly, may be all that is necessary. However, it might be necessary to listen quietly, without correction and interruption, to a highly agitated patient. Plan for stressful situations. This is often the best policy to avoid stressful situations. However, it is not always possible with, for example, essential things like going for a job interview or for a test. In such cases families can reduce the stress by preparing the patient for the situation. Patients need to know what to expect, and should be well prepared for their role in the procedure. They should be allowed plenty of time to enter the situation, for instance, leaving for the interview in good time. They should even be allowed to retreat temporarily if necessary. Avoid over-involvement. Although families mean well, patients often cope better if the family manages to keep some distance between them. Families find that the more they
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approach the patient, the more the patient withdraws. Constant enquiries and 'hovering' increase stress. Families should therefore try to limit face-to-face contact, and make sure that they develop outside interests to take their minds off the patient and give him/her time by himself/herself. Deal actively with one's own stress. Families often experience feelings of guilt, anger and anxiety, which can be transmitted to the patient. It is therefore important that families find positive and active ways of decreasing these negative feelings in themselves. Support groups can play a very important role in this regard, as can time away from the patient. Manage disturbing behaviour successfully In a study of black families caring for members suffering from schizophrenia, most families described the passive withdrawn behaviour and the violent behaviour as the most difficult to deal with (Ngcobo 1990). Withdrawn behaviour sometimes meant withdrawal even from the family, but, in other cases, the patients put enormous social demands on family members, since they were the only 'friends' the patients had. Violence and aggression were often directed at family members and often kept families living in fear. The third set of behaviours mentioned was delusions, especially persecutory delusions aimed at the family. In an American study, the following behaviours were mentioned by more than 70 % of respondents: Lack of motivation Poor eating/sleeping behaviours Difficulty completing tasks Isolation from others Poor handling of money (Hatfield, Coursey & Slaughter 1994). The following interventions may be useful to families trying to deal with the disturbing behaviours resulting from mental illness: Persistent inactivity. Some families deal with this problem by leaving the patient to his/her own devices. This is not a good solution in the long term, since it does not enhance social reintegration. A more useful approach is to plan a schedule of a few simple activities and then to add others later as the patient manages to keep to the schedule. One could start with self-care activities, and add household tasks later. The patient should understand clearly what is expected, and the family should insist on adherence without lecturing or nagging. Rewards can be used to promote activities. If the patient continues to be lethargic, it may be necessary for the family to talk to the treatment team about adjusting the medication. However, the family must also be careful not to assist the patient when it is not necessary, since this reinforces the helpless role. Refusal of treatment. It may be very difficult for families to intervene when a patient who is obviously in need of treatment refuses either to go to the clinic or to take the
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medication. A discussion with the treatment team may be useful, since they may be able to initiate and maintain medication treatment through home visits. Msomi (1993) has found home visits extremely effective in improving treatment involvement. Changing to intramuscular medication instead of oral tablets may also prove useful. Another approach the treatment team could follow is a course of patient and family education, especially with other consumers. This approach has a very positive effect on treatment utilization. Aggressive behayiour. Aggressive behaviour can be very difficult to handle and is very disruptive of home life. The first step in managing such behaviour is to analyse the circumstances of the violence, since the precursors to violence influence the way in which one should deal with it (see below). - In the case of aggressive behaviour, it must be remembered, firstly, that people who are mentally ill sometimes have legitimate grievances and may have valid reasons for getting angry. One should therefore listen to what they say and find out what their anger is all about. - In cases where the violence is the result of relapse, the patient should display other symptoms which indicate an acute phase of the illness. In such cases intervention with medication and/or hospitalization is indicated. - A third reason for aggression could be that the patient is using threats or aggression to get his/her own way. If people tend to be intimidated by the patient, and give in to demands, things can only get worse. In such cases the following steps should be followed: Step 1: Convene a meeting of family and health workers during a calm period and decide which demands will no longer be accepted. Step 2: Tell the patient in a calm way what will not be tolerated and what the consequences will be if he/she acts aggressively. The consequences should be appropriate to the type of aggression, for example, mild acting out can be followed by loss of privileges, while serious aggression may lead to being forced to leave home. Step 3: Be fully prepared to carry out the plan when the confrontation comes. Have telephone numbers ready, people ready to assist, and do not try to bluff. Step 4: Evaluate how well the plan worked, and change it if necessary. Do not expect everything to change at once, but keep on trying. - A fourth reason for aggression is that the person loses control over him/herself. Patients often find self-control very difficult and lash out when cornered. They are not trying to manipulate others as in the previous category, but simply cannot control themselves. The following steps are useful in such cases. Step I: Learn to identify the signs which show that the person is beginning to lose control. Step 2: Give the patient space by suggesting that the issue be discussed later. Give the patient physical space as well; do not touch or approach him/her.
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Step 3: Preserve your own safety, especially if the person remains very agitated. Phone for help, lock a door, stay outside or call neighbours. Step 4: When things are calmer, discuss the issue, and do not give in just to keep the peace. Promote social reintegration and rehabilitation In the long run it is not enough simply to try to deal with and prevent problems. One also has to consider the quality of life of the mentally ill family member and try to promote functioning in the usual social roles which his/her age prescribes. One of the goals a family can set is to try to enlarge the life experience of the patient. A first step could be to involve the patient in daily activities, or to share a hobby or joy. This might stimulate further interest and involvement. People have different strengths and, if the strengths of the patient can be identified, they can provide the springboard to a richer life. An interest in music could be used to motivate the patient to join a music appreciation course or a small band; an interest in animals could lead to involvement in an animal shelter. Often the most difficult part is to get the patient to take the first step. Sometimes taking the first step with him/her may help, while at other times a group activity might be more acceptable. Convincing the patient just to 'try it once', and allowing the inherent reward of the activity to prompt further participation, could also prove successful. Another important area of endeavour is to encourage independent living skills. Although the patient may currently be living with the family, this situation may not always be possible or ideal. It is therefore important that an effort be made over time to improve the patient's functioning in areas such as money management, personal hygiene and maintaining an acceptable environment. These are skills that can be learnt if a systematic and patient approach is used. When working with the family member, it is important to remember that the person is still an adult, notwithstanding the severe disability the mental illness may have caused. Patronizing remarks about 'being good' or 'pleasing Mom' are not appropriate for adults. Scolding, nagging or moralizing also seldom have the desired effect. Respect, and the positive comments which build self-respect, are more likely to succeed. 5 4 SUPPORT GROUPS FOR CONSUMERS According to the National Alliance for the Mentally 111 (NAMI), an organization of families, patients and professionals in the USA, the most effective support groups are grass-roots organizations of consumers (families, patients or both) which organize and govern themselves (Straw 1982). Although professionals may have initiated some of these groups, it is important for consumers to take charge to ensure the survival of the group when professionals leave and to ensure that the group addresses the needs of the members. The growth of support groups over the last two decades has its roots in the community psychiatric movement, as well as the self-help ideology which is part of the primary health care approach (Hatfield 1987). Consumers have come to be recognized as equal partners of health workers in all aspects of care provision.
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Functions of support groups In the USA support groups started small and then grew to formidable organizations. NAMI has over 100 000 members, while other support groups render extensive consumerrun services with enormous budgets (Chamberlin, Ellison & Rogers 1994). In a survey of support groups in the mental health field in South Africa, Makhale (1995) has identified 14 functioning groups, mostly aimed at people with depression and schizophrenia. These groups listed their activities as including: social and recreational activities; protection or advocacy efforts on behalf of individual consumers; advocacy efforts on behalf of all persons with psychiatric disability; assistance with housing; assistance with legal problems; - assistance with employment; - transportation; - food assistance; - temporary shelter; - assistance with activities of daily living; - provision of information; - therapeutic interventions, for example, skills teaching; - fundraising. NAMI has identified three levels of needs and advises that support groups should try to address all three of these levels at each meeting: Head out of the sand. On this level a consumer or family has just begun to accept the mental illness. They are still shocked and grieving and may still be denying the reality at times. They need support and education from the group to deal successfully with this stage. Learning to cope. The second level refers to families and patients who have lived with mental illness for some time. They have been frustrated by the lack of information and help, and disgusted by the stigma. They are tired of the struggle and angry at the system. They need continued support and further information, as well as assistance and encouragement to work toward independence for the mentally ill person. Change. At this level families who have accepted the illness, and learned to cope, may now want to do something to improve the services or change the system. They need to be involved in social action, policy-making, lobbying and other activities which could bring about change. Starting a support group One consumer (family or patient) or one professional can start a support group. Asking service providers such as clinics, private practitioners and hospitals to hand out letters of
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invitation to consumers may prove successful. The local radio may also be willing to advertise such a group. Once a few consumers have been identified, a date, time and place can be set for the first meeting. It is important to find an accessible place for the meeting and to set a convenient time. A Saturday or Sunday might be the most appropriate for many people, as long as the venue is accessible by public transport even on a Sunday. A family home might be the best place to meet if the group is small. If people have telephones, it would be a good idea to give them an encouraging call the day before the meeting. The group should be run by the consumers themselves; they should begin by structuring themselves by electing a chairperson, secretary and treasurer. A name may also be chosen. NAMI recommends that a group choose a name that does not use a euphemism for mental illness, so as to fight stigma. The group then decides on goals and a mission, and may later develop a complete constitution. Early on, the group members should exchange names, addresses and phone numbers, so that they can form an accessible support network for each other. It is important that the business part of the meeting be kept short, so that there is enough time for sharing and caring. Consumers are encouraged to share their problems and experiences, while others support and assist with empathy, information and even concrete assistance. Groups usually meet once a month, and deal with business, support and information. Later in the life of the group, social action will be included. At that stage more frequent meetings may be necessary. The following factors ensure the growth of a strong support group (Straw 1982): Give all members a sense of ownership of the group. Listen to their ideas; use them, involve them in activities, and address their needs. Ensure a rapid turnover of leadership. A diversity of leaders leads to diverse activities and to the development of people. Create an appropriate structure. Structures such as membership requirements, a committee, an annual general meeting, a bookkeeping system and a bank account are essential for a fully functioning group. Have regular meetings with interesting speakers discussing diverse topics. Keep on trying to broaden the membership base and participation. Recruitment should be an ongoing activity. Try to build continuity on the committees by staggering the terms of office. In this way, the committee members will never all be new and inexperienced. Establish committees to work on specific issues such as stigma, housing, etc. Hold different kinds of meetings at different times. This could include general meetings with a speaker, an open house at a new facility, an outdoor meeting, a workshop, a forum, etc.
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Produce a brochure on your group as soon as possible, even if it consists of only one typed page. This can be used in recruitment and in obtaining financial support. Give credit where and when credit is due. Hold an annual evaluation and planning meeting, so that the group stays on track. Advocacy by consumers Advocacy means to 'plead in support of something or somebody. Advocacy has become one of the main tasks of consumer groups worldwide. Straw (1982: 13) explains the need for consumers to become active in advocacy as follows: 'the consumer played no part in setting up this bureaucracy that is called the mental health system. We have a system that is not responsive to our needs and we have to make changes.' She further points out that consumers need to know where the power is, where the decisions are made and what influences these decisions; only then can they learn to impact on these decisions and become a power in the field of mental health care. Advocacy is usually aimed at legislators (politicians) and top administrators in the services. The methods of advocacy A newsletter can be a useful tool for communicating with political representatives and other opinion formers. It need not be long, but there should be a focus on policy issues and on the needs of consumers. Testifying at public hearings, in front of parliamentary committees, and commissions is another useful method. At first one may not have much skill, but the first-hand stories of consumers are powerful tools and can have an impact which a scientific document lacks. Letters can be written to local newspapers, politicians and administrators. Letters should be short and to the point and, even if a whole group decides to write about a single topic, each should use his/her own words. Petitions or group letters are not as effective. The media can play an important role in airing topics that need attention. Groups should get to know health reporters at local papers, as well as presenters of health programmes on radio. Television is a difficult medium to access, but also a powerful one. Serving on boards is an important way of putting consumers in positions of power. Psychiatric hospitals are all required by law to have hospital boards, and it would be useful for consumer groups to ensure that they are represented on these bodies. In the near future, clinics will also be setting up committees, and districts will have health committees. All these bodies could do with a mental health consumer representative. An interview with a representative or administrator is often a very effective way of dealing with an important issue. Identify and keep to a few important issues, so that the interview does not become a general gripe session. Make sure of your facts about all these issues and decide what you want the person to do about each one. Select as main spokesperson an articulate member of the consumer group who can speak with confidence. He/she should, however, involve the other members of the delegation
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strategically. A diverse group of consumers (for example, parents, siblings, patients, spouses) will have greater impact. Usually delegations number about five people. CONCLUSION A mental health team which leaves out consumers is a weak team. Consumers are a force to be reckoned with - either for good, towards support and recovery, or for bad, towards alienation and defeat. Consumers, both patients and their families, need to be seen as team members. Their activities require emotional and material support from the formal health sector. WEB RESOURCES
http://nami.org This is one of the most extensive websites available to consumers of mental health services. It belongs to the National Alliance for the Mentally 111 (NAMI) and has chat rooms, advice lines, information on illnesses and treatment, links to other sites, and much more. http://home.vicnet.net.au/~nnaami/ This website belongs to the National Network of Adult and Adolescent Children who have a Mentally 111 Parent/s (NNAAMI) in Australia. It has many first-person stories, chat lines and information for families and professionals. http://www.angelfire.com/home/comic This website is dedicated to the children of mentally ill consumers. It has information, also on the implications for children of having mentally ill parents. http://www.phoenixperch.org/reviews.html This website lists books available to support consumers and rates them using a star system. REFERENCES Bielovich, F. 1993. NIP beyond the barrier. Sandton: Lynx Publ Carter, R. 1990. Media can help erase mental illness stigma. USA Today. October 18, 9A Chamberlin, J, Rogers, E S & Ellison, M L. 1994. Self-help Programs: A Description of their Characteristics and their Members. Psychiatric Rehabilitation Journal. 19(3): 33-42 Chesla, C A. 1989. Parents' illness models of schizophrenia. Archives of Psychiatric Nursing. 111(4): 218-225 Depression and Anxiety Support Group. 2001. Discrimination for mentally ill. SA Medical Journal. 91(12): 1019 Du Toit, E. 1999. Swing Hi Swing Lo. Hermanns: The Book Cottage Frese, F J. 1993. Twelve aspects of coping for persons with schizophrenia. Innovations and Research. 2(3), 39-46 Hatfield, A B. 1987. The National Alliance for the Mentally 111: The meaning of a movement. International Journal of Mental Health. 15(4):79-93
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Hatfield, A B, Coursey, R O & Slaughter, J. 1994. Family responses to behavior manifestations of mental illness. Innovations and Research. 3(4), 41-49 Howard, P B. 1994. Lifelong maternal caregiving for children with schizophrenia. Archive of Psychiatric Nursing. VIII(2), 107-114 Makhale, M S. 1995. An Analysis of Support Groups for the Mentally III People as A Psychiatric Intervention Strategy in the Communities of South Africa (unpublished MCur thesis, University of Natal, Durban) Marks, S. 1987. Not Either an Experimental Doll: The Separate Worlds of Three SA Women. Pietermaritzburg: University of Natal Press Mavundla, T R & Uys L R. 1997. The attitudes of nurses towards mentally ill people in general hospital settings. Curationis. 20(2): 3-7 Msomi, M M. 1993. The Effect of Home Visits on the Relapse Rate of Black Psychiatric Out-patients. (unpublished BSocSc (Hons) project, University of Natal, Durban) Ngcobo, A. 1990. Experiences of Black Families in Umlazi Who Give Care to a Schizophrenic Family Member (unpublished BSocSc (Hons) research project, University of Natal, Durban) Nursing Times. 1999. What is the mental health national service framework? Nursing Times. 95(41): 16 Sapepa, P N. 1992. An Investigation into Attitudes of People in Clermont Township (near Durban) toward Chronic Mentally III People, (unpublished BSocSc (Hons) thesis, University of Natal, Durban) Solombela, P W & Uys, L R. 1994. Factors influencing the relapse of outpatients with schizophrenia in the Kentani area of Transkei. Curationis. 17(3), 24-28 Spaniol, L, Zipple, A M & Lockwood, D. 1992. The role of the family in psychiatric rehabilitation. Innovations and Research. 2(4), 27-33 Straw, P. 1982. Awakenings: Organizing a Support/Advocacy Group. Washington: NAMI Sullivan, L. 1992. Families: One of the most important things to happen in the history of mental illness. The Decade of the Brain. 3(3), 1-2. Arlington VA: NAMI Uys, L R, Dlamini, N K & Mabandla, S P. 1995. A profile of selected psychiatric outpatients in South Africa. Curationis. 18(1), 22-25
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Six
Legal Structure E MADELA-MNTLA
Objectives After studying this chapter the learner should be able to: Explain the most important terms used in the Mental Health Care Act 17 of 2002. Compare and contrast the various ways in which a person may be admitted to a psychiatric hospital. Describe and debate the success of the measures in the Mental Health Care Act 17 of 2002 aimed at: - regulating mental health care and access to and provision of mental health care, treatment and rehabilitation services - clarifying the rights and obligations of mental health care users and the obligations of mental health care providers; and - regulating the manner in which the property of persons with mental illness and persons with severe or profound intellectual disability may be dealt with by a court of law. Explain the detention of a State patient in terms of the Criminal Procedure Act 51 of 1977. Explain the provisions of the Medicines and Related Substances Control Act 101 of 1965 as amended, which provides guidelines to psychiatric nurses regarding the possession, supply, administration and prescription of medicines. Identify the substances listed in Schedules 1-9, with specific reference to psychiatric medication. Explain the admission procedure and detention of a person who is dependent on a dependenceproducing substance or substances. Explain how the Child Care Act 74 of 1983 as amended protects children and refer to the role of psychiatric nurses in the application of the Act. Discuss the legislation dealing with the training of intellectually disabled children. Discuss the Sterilization Act 44 of 1998, with specific reference to its importance to mental health nursing practice. Explain the provisions of the Health Professions Act 56 of 1974 as amended, which allows nurses to perform certain activities for which they are not criminally liable in terms of this Act.
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INTRODUCTION Psychiatric nurses in South Africa function within the structure of certain laws. These include the: Mental Health Care Act 17 of 2002; Criminal Procedure Act 51 of 1977, as amended; Medicines and Related Substances Control Act 101 of 1965, as amended; Child Care Act 74 of 1983, as amended; Mentally Retarded Children's Training Act 63 of 1974, as amended; Education and Training Act 90 of 1979, as amended; Sterilization Act 44 of 1998; Health Professions Act 56 of 1974, as amended. Correctional Services Act 111 of 1998 Constitution of the Republic of South Africa, Act 108 of 1996 All these Acts are discussed with particular reference to sections controlling the practice of psychiatric nurses. The Health Act and the Nursing Act will not be discussed here, as they are fully discussed in other subjects in the curriculum.
6.1 MENTAL HEALTH CARE ACT Introduction The Mental Health Care Act No 17 of 2002 should be read with the regulations that have been developed for it. Together these two documents regulate mental health services in this country. There are a number of innovations in this new Mental Health Care Act. These include: 1. This is the first time a mental health Act includes care, treatment and rehabilitation explicitly in its provision for mental health care users. The three terms are used consistently throughout the document, making it clear that a comprehensive approach to mental health care is being supported by this Act. 2. In the regulations, this Act is the first to make community-based care central to the delivery of mental health care. In chapter 1 it outlines the pathway to care, starting at a primary health care level service. This is very different from previous acts, which referred only to hospitals and outpatient care. The Act also refers in some detail to home visits and community care. 3. Furthermore, the regulations of the Act refer to non-governmental organizations and volunteer and consumer groups in the formal list of facilities. To support such services, provision is made for subsidies from government to such service providers. It also involves other government departments, such as the Department of Education, which is charged with providing educational facilities to people in mental hospitals.
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4. The regulations of the Act make it the first to make provision for involuntary patients to be treated on an outpatient basis. According to article 18, a person can be given a schedule of conditions for outpatient care, treatment and rehabilitation, the format of which is described in the Act, and a custodian appointed. If the client accepts the conditions, she/he can be discharged. If the person does not comply with the conditions, she/he will be handled as having absconded, and be returned to the hospital. 5. The regulations of the Act spell out, more explicitly than any previous legislation, the involvement of the South African Police with regard to custody of mental health care users. This refers mainly to dealing with involuntary patients who abscond (articles 28 and 29) and policing maximum-security facilities (article 41). 6. Review Boards (chapter 3) replaces the old hospital boards and are charged with dealing with appeals against any decision made by providers of services. 7. There are a number of anti-stigma measures evident in this Act. For instance, the terminology used - 'mental health user', instead of'patient' - supports a communitybased approach that recognizes that people may need care and rehabilitation without labeling them 'sick' by calling them 'patients'. 8. The regulations of the Act spell out the fee structure. Involuntary patients are cared for free, while others may be charged, depending on their means (article 55). This is beneficial for involuntary patients, but might mitigate against people coming for help early on a voluntary basis. Purpose of the Act The purpose of the Mental Health Care Act is: to provide for the care, treatment and rehabilitation of persons who are mentally ill; to set out different procedures to be followed in the admission of such persons; to establish Review Boards in respect of every health establishment and determine their powers and functions; to provide for the care and administration of the property of mentally ill persons; to repeal certain laws; and to provide for matters connected therewith. The enactment of this legislation is a result of the process to revise the Mental Health Act No 18 of 1973, which was viewed by many as not being human-rights sensitive. The process started with submissions received from different stakeholders in mental health, followed by extensive stakeholder consultations. Complaints from the submissions were also confirmed by the report of the Minister's Commission - set up in 1995 to investigate complaints on the abuse of human rights in psychiatric institutions - which completed its work in 1996. What the Act recognizes Health is a state of physical, mental and social well-being and mental health should be provided as part of primary, secondary and tertiary health services.
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The Constitution of the Republic of South Africa (Act 108 of 1996) prohibits against unfair discrimination of people with mental or other disabilities. The person and property of a person with mental disorders or mental disabilities may at times require protection, and members of the public and properties may similarly require protection from people with mental disorders or mental disabilities. There is a need to promote the provision of mental health care services in a manner which promotes the mental well-being of users of mental health care services and communities in which they reside. The Act provides for the regulation of mental health care in a manner that: makes the best possible mental health care, treatment and rehabilitation services available to the population equitably, efficiently and in the best interest of mental health care users within the limits of the available resources; co-ordinates access to mental health care, treatment and rehabilitation services to various categories of mental health care users; and integrates the provision of mental health care services into the general health services environment. Definition of main concepts used in the Act Mental health care user. A person receiving care, treatment and rehabilitation services or using a health service at a health establishment aimed at enhancing the mental health status of a user, State patient, mentally ill prisoner, and where the person concerned is under the age of 18 years or is incapable of taking decisions and in certain circumstances may include: - a prospective user; — the person's next of kin; - a person authorized by any other law or court order to act on that person's behalf; - an administrator appointed in terms of this Act; and - an executor of a deceased person's estate and user have a coresponding meaning. Assisted mental health care user is defined as a mental health care user who is incapable of making informed decisions due to his/her mental health status and who does not refuse the health interventions. Voluntary mental health care user is a mental health care user who is capable of making informed decisions and does not refuse the health interventions Involuntary mental health care user is a mental health care user who is incapable of making informed decisions due to his/her mental health status and who refuses health interventions but requires such services for his/her own protection or for the protection of others. State patient is a person so classified by a court directive in terms of section 77 (6) (a) or 78 (6) of the Criminal Procedure Act.
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Mentally ill prisoner is a prisoner as defined in section 1 of the Correctional Services Act, in respect of whom an order has been issued in terms of section 52 (3) (a) to enable the provision of care, treatment and rehabilitation services at a health establishment designated in terms of section 49 of this Act. Mental illness means a positive diagnosis of a mental health related illness in terms of accepted diagnostic criteria made by a mental health care practitioner authorized to make such diagnosis. Severe or profound intellectual disability means a range of intellectual functioning extending from partial self-maintenance under close supervision, together with limited self-protection skills in a controlled environment through limited self care and requiring constant aid and supervision, to severely restricted sensory and motor functioning and requiring nursing care. Health establishment is an institution, facility, building or place where persons receive care, treatment and rehabilitation assistance, diagnostic or therapeutic interventions or other health services, and includes facilities such as community health and rehabilitation centres, clinics, hospitals and psychiatric hospitals. Care and rehabilitation centres are health establishments for the care, treatment and rehabilitation of people with intellectual disabilities. Medical practitioner is a person registered as such in terms of the Health Professions Act. Mental health care practitioner is a psychiatrist, registered medical practitioner or nurse, occupational therapist, psychologist or social worker who has been trained to provide prescribed mental health care, treatment and rehabilitation services. Mental health care provider is a person providing mental health care services to mental health care users and includes mental health care practitioners. Head of health establishment means a person who manages the establishment concerned. Mental Health Review Board means a body established as such by the member of the Executive Council responsible for health services in a province in terms of section 18 of this Act. Types of facilities for services to people with mental health problems Section 5 of the Act calls for the designation of health establishments or part of a health establishment under the auspices of the State as psychiatric hospitals or care and rehabilitation centres. These facilities must provide any person requiring mental health care with treatment and rehabilitation services within their professional scope of practice, and if necessary, refer such persons to a health establishment that provides the appropriate level of the required service. These establishments may not cause a mental health care user to receive psychiatric medication for more than six months unless authorized by a mental health care practitioner who is designated to provide medication and review psychiatric treatment.
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Table 6,1 Admission and discharge of voluntary, assisted and emergency health care users Procedure
Process
Conditions/information
1. Voluntary patient (article 25) Admission
Anyone older than 18 years or guardian of patient younger than 18 years. Superintendent decides patient requires treatment.
Discharge
Doctor discharges patient.
Person understands application.
2. Assisted mental health (article 26 to 31) Admission
Discharge
Guardian, spouse, near relative or registered health worker applies. , Examination by two MHC practitioners Superintendent decides. Superintendent reports to Review Board within 7 days. Review Board report to province. Person who applied for admission. Doctor evaluates fitness for discharge. Fit: discharge OR Dangerous to self or others:
Person not opposed to admission but does not understand meaning sufficiently to be able to apply legally.
| Patient may apply personally if I he/she now understands.
obtain reception order.
3. Emergency admission (article 8) Admission
Take to the nearest clinic or health facility for treatment. The clinic should refer the patient immediately if necessary. The involuntary admission process is used.
Article 34 allows for admission for a period of 72 hours while application is made.
Psychiatric hospitals may admit, care for, treat and rehabilitate voluntary mental health care users in special programmes, assisted mental health care users, involuntary mental health users, State patients, mentally ill prisoners, persons referred by courts for psychiatric observation in terms of the Criminal Procedure Act, and persons admitted for a long period as part of their care, treatment and rehabilitation. Care and rehabilitation centres may conduct assessments of intellectual abilities, and provide care, treatment and rehabilitation services to persons with severe or profound intellectual disabilities, including assisted and involuntary mental health care users. See Figure 6.1 for the care and treatment of involuntary users (excluding State patients and mentally ill prisoners).
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Figure 6.1 Admission, care and treatment of involuntary mental health care users
Legal Structure
Seventy-two hour assessment and subsequent provision of further involuntary care, treatment and rehabilitation Where the application for involuntary care, treatment and rehabilitation services has been submitted, the head of the health establishment must: ensure that the user is given appropriate care, treatment and rehabilitation services; admit the user and request a medical practitioner and another mental health care practitioner to assess the physical and mental health status of the user for a period of 72 hours in the manner prescribed; and ensure that the practitioners also consider whether involuntary interventions must be continued; and whether these interventions may be provided on an outpatient or inpatient basis. The findings of the assessment must be made available to the applicant within 24 hours after the expiry of the 72-hour assessment period, after which the head of the health establishment must make a decision whether the mental health care user: does not warrant involuntary care, treatment and rehabilitation services, in which case the user must be discharged immediately, unless the user consents to the interventions warrants further involuntary care, treatment and rehabilitation services on an outpatient basis, in which case (i) the user must be discharged according to the prescribed conditions or procedures, and (ii) the Review Board is informed in writing warrants further involuntary care, treatment and rehabilitation services on an inpatient basis, in which case the head of the health establishment must: - submit a written request to the Review Board to approve further involuntary interventions within seven days after the expiry of the 72-hour assessment period on an inpatient basis; and - give notice to the applicant of the date on which the relevant documents were submitted to the Review Board. If at any time after the expiry of the 72-hour assessment period, the head of the health establishment is of the opinion that the user who was admitted on an involuntary inpatient basis is fit to be an outpatient, he or she must: discharge the user according to the prescribed conditions or procedures; and inform the Review Board in writing. Periodic review and annual reports on assisted and involuntary health care users Six months after the commencement of care, treatment and rehabilitation services, and every 12 months thereafter, the head of the health establishment concerned must ensure that the mental health status of an assisted mental health care user or an involuntary mental health care user is reviewed.
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The review must: state the capacity of the mental health care user to express himself or herself on the need for care, treatment and rehabilitation services; state whether there are other care, treatment and rehabilitation services that are less restrictive or intrusive on the right to movement, privacy and dignity of the user; make recommendations regarding a plan for further care, treatment and rehabilitation services; and in the case of an involuntary mental health care user, also state whether the mental health care user is likely to inflict serious harm on himself or herself or other people;. Transfer of mental health care users to maximum security facilities The allows for the head of a health establishment to submit a request in writing to the relevant Review Board for an order for transfer of an assisted or involuntary mental health care user to a health establishment with maximum security facilities if the user has: previously absconded or attempted to abscond; or inflicted or is likely to inflict harm on others in the health establishment. The Review Board may not approve the request if: there is proof that it is needed in order to punish the mental health care user concerned; or it is not satisfied that the mental health status of the user warrants a transfer to maximum security facilities. Intervention by members of the South African Police Service Section 40 of the Act deals with the role of the members of the South African Police Service in regard to mentally ill people, as follows: 1. If a member of the South African Police Service has reason to believe, from personal observation or from information obtained from a mental health care practitioner, that a person due to his or her mental illness or severe or profound intellectual disability is likely to inflict serious harm to himself or herself or others, the SAPS member must apprehend the person and arrange for that person to be: (a) taken to an appropriate health establishment administered under the auspices of the State for assessment of the mental health status of that person; and (b) handed over into custody of the head of the health establishment or any other person designated by the head of the health establishment to receive such persons. 2. If an assisted or involuntary mental health care user has absconded or is deemed to have absconded or if the user has to be transferred under any section of this Act, the head of the health establishment may request assistance from the South African Police Service to: (a) locate, apprehend and return the user to the health establishment concerned; or (b) transfer the user in the prescribed manner.
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3., A person apprehended in terms of this Act may be held in custody at a police station for such period as prescribed to effect the return or the transfer in the prescribed manner. 4. A member of the South African Police Service may use such constraining measures as may be necessary and proportionate in the circumstances, when apprehending a person or performing any function in terms of this Act. Mental Health Review Boards Chapter 4 of the Act deals with the establishment of Mental Health Review Boards, a major shift from the Mental Health Act 18 of 1973. The Act obliges the member of the Executive Council (MEC) responsible for health services in a province to establish a Review Board in respect of every health establishment providing mental health care, treatment and rehabilitation services in that province. The Review Boards may be established for a single, a cluster or all health establishments providing mental health care services in that province. Subject to the laws governing public service, the relevant government department may appoint, second or designate employees, and provide the necessary resources to the Review Board for performance of its administrative functions. A member of the Review Board may at any time be removed from office by the relevant member of the Executive Council under certain conditions ascertained through an inquiry. The Act requires that a Review Board consist of no fewer than three persons and no more than five persons who are South African citizens appointed by the relevant member of the Executive Council in each province; and must include: a mental health care practitioner; a magistrate, an attorney or an advocate admitted in terms of the law of the Republic; and a member of the community concerned. Powers and functions of a Review Board The powers and functions of a Review Board are outlined in section 19 of the Act. These include: (a) consideration of appeals against decisions of the head of a health establishment; (b) making decisions with regard to assisted or involuntary mental health care, treatment and rehabilitation services; (c) consideration of reviews and making decisions on assisted or involuntary mental health care users; (d) considering 72-hours assessment made by the head of the health establishment and making decisions to provide further involuntary care, treatment and rehabilitation; (e) considering applications for transfer of mental health care users to maximum security facilities; and (f) considering periodic reports on the mental health status of mentally ill prisoners.
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The Review Board may, when performing its functions, consult or obtain representations from any person, including a person or body with expertise. Dealing with state patients Section 41 of the Act calls for the designation of health establishments which may admit, care for, treat and provide rehabilitation services to State patients. The procedure for such admission is outlined in Figure 6.2. Transfer of State patients between designated health establishments A State patient may be transferred between designated health establishments within the province or in another province only if it is necessary for the care, treatment and rehabilitation of the State patient concerned. Despite the determination of the national department, a relevant Review Board may order the State patient to be transferred to another designated health establishment with maximum security facilities: if the State patient has or is likely to inflict harm on others; and on receipt of a written application, from the head of the health establishment at which the State patient is detained, setting out the facts on which the request is based. A State patient who absconds If a State patient has absconded or is deemed by the head of the relevant designated health establishment to have absconded, the head of that health establishment must: (a) in writing, immediately notify and request the South African Police Service to locate, apprehend and return the patient to the relevant health establishment, including whether the patient is dangerous; and the Registrar or Clerk of the court concerned and the official curator ad litem, within 14 days of having notified the South African Police Service. (b) hold an apprehended patient in custody for such period as prescribed to effect the return. A member of the South African Police Service may use such constraining measures as may be necessary and proportionate in the circumstances when apprehending any person or performing any function in terms of this section of the Act. Leave of absence from designated health establishments The head of a health establishment may, in writing, grant leave of absence to a State patient from a designated health establishment. Written notice of leave of absence must state: the commencement and the return date of the State patient to the health establishment and must be submitted to the head of the national department; and terms and conditions to be complied with during the period of leave.
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Court issues order. Copy sent to:
Official curator ad litem
Officer in charge of detention centre
Notifies
Copy sent to Head of National Health Department within 14 days
Head of National Health Department determines which health facility and ensures arrangments for admission
State patient transferred to health establishment
FORM 23
Transfer to another health establishment with maximum security. Request Review Board FORM 19
Transfer to another health establishment without maximum security FORM 24
Notice to official curator ad litem FORM 21
Decision of Review Board FORM 20
Head of National Department determines which facility and ensures arrangements for admission
State patient transferred. Notice to official curator ad litem FORM 21
Figure 6.2 Procedures for State patients: admission to health facility and
transfer The head of the health establishment may, during the period of leave, if he or she has reason to believe that the State patient does not comply with the terms and conditions applicable to such leave, cancel the leave and direct as to when the State patient must return to the health establishment. If the State patient fails to return to the health
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establishment on the return date, he or she will be deemed to have absconded, and correct procedures should be followed. Periodic review of mental health status of State patients The head of a health establishment where a State patient is admitted, or if on leave of absence or conditional discharge, must cause the mental health status of the State patient to be reviewed after six months from the date on which care, treatment and rehabilitation services were commenced, and every 12 months thereafter. The review is done to make recommendations on: a plan for further care, treatment and rehabilitation service; the merits of granting leave of absence; or the discharge of the State patient. Discharge of State patients The Act allows for any of the following persons to apply, in a prescribed form, to a judge in chambers for the discharge of a State patient: (a) The State patient self; (b) an official curator ad litem; (c) an administrator, if appointed; (d) the head of the health establishment at which a State patient is admitted; (e) the medical practitioner responsible for administering care, treatment and rehabilitation services to a State patient; (f) a spouse, an associate or a next of kin of a State patient; or (g) any other person authorized to act on behalf of a State patient. The procedure for the application is outlined in Figure 6.3 opposite. Dealing with mentally ill prisoners Section 49 of the Act calls for the designation of health establishments which may admit, care for, treat and provide rehabilitation services to mentally ill prisoners. The procedure for admission of these patients is outlined in Figure 6.4. Transfer of mentally ill prisoners between designated health establishments The head of the national department may from time to time order the transfer of a mentally ill prisoner from one health establishment designated in terms of this Act to another if it is necessary for the care, treatment and rehabilitation of the mentally ill prisoner. Despite the determination of the national department, the relevant Review Board may only order the transfer of a mentally ill prisoner to another designated health establishment. This should follow a written application by the head of the health
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Application to Judge in Chambers FORM 29 (if applicant is not official curator ad litem) FORM 30 (if applicant is official curator ad litem)
Decision by Judge in Chambers. If conditional discharge ordered. FORM 31
Applications by State patient for amending conditions of unconditional discharge. FORM 35
Six monthly report on conditionally discharged State patient. FORM 32
Unconditional discharge if conditions adhered to. FORM 33
If State patient does not comply with conditions, HHE may apply to Registrar of court to amend conditions or revoke conditional discharge. FORM 34
Figure 83 Discharge of a State patient
establishment at which the mentally ill prisoner is detained, setting out the facts on which the request is based. This may only be done if: the mentally ill prisoner previously absconded or attempted to abscond; or has inflicted or is likely to inflict harm on others. A mentally ill prisoner who absconds If a mentally ill prisoner has absconded or is deemed by the head of the relevant designated health establishment to have absconded, the head of that health establishment must: in writing, immediately notify and request the South African Police Service to locate, apprehend and return the patient to the relevant health establishment, including whether the patient is dangerous; hold an apprehended patient in custody for such period as prescribed to effect the return. A member of the South African Police Service may use such constraining measures as may be necessary and proportionate in the circumstances when apprehending any person or performing any function in terms of this section of the Act.
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Head of prison believes prisoner to be mentally ill
After enquiry, if person can be cared for in a prison, head of prison must ensure treatment is given
Causes person to be assessed and has findings reported.
After enquiry, if a prisoner is recommended to be treated in a non-prison health establishment, Head of prison requests Magistrate to cause a subsequent enquiry
FORM 36
j Magistrate must commission enquiry into the mental health status of the prisoner. FORM 36
If enquiry suggests that prisoner can be treated in prison, Magistrate must issue an order to ensure care, treatment and rehabilitation are provided. FORM 37
If enquiry suggests that prisoner be transferred to a non-prison health establishment, Magistrate must order such transfer. FORM 37
Head of prison forwards a copy of order to:
Administrator if appointed
Head of National Health Department with request to transfer
Head of National Health Department determines health establishment where prisoner is to be sent and ensures arrangements to effect transfer FORM 23 and notifies:
Administrator if appointed
Head of Prison who causes transfer of mentally ill prisoner within 14 days.
Figure 6.4 Procedure for admission of a mentally ill prisoner to a health institution
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Periodic reviews of mental health status of mentally ill prisoners The head of a health establishment in which a mentally ill prisoner is detained has a duty to have the mental health status of that mentally ill prisoner reviewed every six months from the date on which the prisoner was received in that health establishment. The review must: specify the mental health status of the mentally ill prisoner; and set out recommendations regarding a plan for further interventions and the merits of returning the mentally ill prisoner to the prison from where he/she was detained. Recovery of mental health status of mentally ill prisoners If the head of a health establishment has proof that a mentally ill prisoner has recovered from the mental illness to such an extent that the prisoner no longer requires mental health interventions or that these can be appropriately given at a prison, the head of the establishment must: compile an appropriate discharge report; inform the head of the prison that the prisoner is ready for discharge and collection by the prison officials; and inform the relevant magistrate in writing. Procedure on expiry of term of imprisonment of mentally ill prisoners A mentally ill prisoner must be released from prison or a health establishment designated on expiry of the term of imprisonment to which that prisoner was sentenced, under the following conditions: An application made according to the relevant provisions of this Act, at least 90 days before expiry of the term of imprisonment, to the head of the health establishment for the provision of assisted or involuntary care, treatment and rehabilitation, as the case may be, of the prisoner. An application made to a magistrate, at least 30 days before the expiry of the term of imprisonment, for the continued detention of a mentally ill prisoner in the designated health establishment pending the finalisation of the application referred to above. Clarification of rights and obligations Chapter 3 of the Act deals with the rights and obligations of mental health care users in relation to their care, treatment and rehabilitation. It also deals with the obligations of mental health care providers in relation to the care, treatment and rehabilitation of mental health care users. The rights and duties of persons, bodies or institutions set out in this Chapter are in addition to any rights and duties that they may have in terms of any other law, and they must be executed with regard for what is in the best interests of the mental health care user. This section also obliges every health care provider to inform a mental health care user in an appropriate manner, before administering any service, of his or her
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rights, unless the user has been admitted under circumstances referred to in section 9 (l)(c)oftheAct. (i) Respect, human dignity and privacy The person, human dignity and privacy of every mental health care user must be respected. Every mental health care user must be provided with care, treatment and rehabilitation services that improve the mental capacity of the user to develop to full potential and to facilitate his or her integration into community life. The care, treatment and rehabilitation services administered to a mental health care user must be proportionate to his or her mental health status and may intrude only as little as possible to give effect to the appropriate care, treatment and rehabilitation. (ii) Consent to care, treatment and rehabilitation services and admission to health establishments According to the Act, these may be provided or a mental health care user admitted only if: (a) the user has consented to the care, treatment and rehabilitation services or to admission; (b) authorized by a court order or a Review Board; or (c) due to mental illness, any delay in providing care, treatment and rehabilitation services or admission may result in the death or irreversible harm to the health of the user; user inflicting serious harm to himself or herself or others; or user causing serious damage to or loss of property belonging to him or her or others. The Act obliges any person or health establishment providing these interventions under the prescribed circumstances to report this fact in writing in the prescribed manner to the relevant Review Board; and may not continue to provide such interventions for longer than 24 hours unless an application is made for voluntary, assisted or involuntary interventions within the 24-hour period. (Hi) Unfair discrimination The Acts forbids unfair discrimination against a mental health care user on the grounds of his or her mental health status. It requires that every mental health care user receive care, treatment and rehabilitation services according to standards equivalent to those applicable to any other health care user. Care must be taken to ensure that policies and programmes aimed at promoting the mental health status of a person are implemented with regard to the mental capacity of the person concerned. (iv) Exploitation and abuse The Act obliges every person, body, organization or health establishment providing care, treatment and rehabilitation services to a mental health care user to ensure that users are
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protected from exploitation, abuse and any degrading treatment; are not subjected to forced labour; and that care, treatment and rehabilitation services are not used as punishment or for the convenience of other people. Any person witnessing any form of this abuse against a mental health care user has a duty to report such in the prescribed manner. (v) Determinations concerning mental health status The Act requires that any determination concerning the mental health status of any person must be based on factors exclusively relevant to that person's mental health status or for the purposes of giving effect to the Criminal Procedure Act, and not on sociopolitical or economic status, cultural or religious background or affinity, and such determination may only be made or referred to for purposes directly relevant to the mental health status of that user. (vi) Disclosure of information A person or health establishment is forbidden from disclosing any information which a mental health care user is entitled to keep confidential in terms of any other law. However, it allows for the head of the national department, a head of provincial department or the head of a health establishment concerned to disclose such information if failure to do so would seriously prejudice the health of the mental health care user or of other people. A mental health care provider may temporarily deny mental health care users access to information contained in their health records, if disclosure of that information is likely to seriously prejudice the user or result in the user conducting himself or herself in a manner that may seriously prejudice him or her or the health of other people. (vii) Limitation on intimate adult relationships The Act allows the head of a health establishment, subject to conditions applicable to service provision in health establishments, to limit intimate relationships of adult mental health care users only if, due to mental illness, the ability of the user to consent is diminished. (viii) Right to representation The Act entitles a mental health care user to a representative, including a legal representative, when: submitting an application; lodging an appeal; or appearing before a magistrate, judge or a Review Board, subject to the laws governing rights of appearances at a court of law. This also applies to legal aid provided by the State in respect of any proceeding instituted or conducted according to various sections of this Act.
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(ix) Discharge reports The Act requires the head of a health establishment, in a prescribed format, to issue a discharge report to the user who was admitted for purposes of receiving care, treatment and rehabilitation services. Regulation with regard to the property of persons under care Chapter 8 of the Act outlines procedures and circumstances for dealing with the property of persons with mental illness and persons with severe or profound intellectual disability. The Act allows for a Master of a High Court to appoint an administrator to care for and administer the property of a mentally ill person or person with severe or profound intellectual disability. This can happen under one of two conditions, that is: following an application for this process by any person over the age of 18, in writing, under oath or solemn affirmation, attaching proof that a copy of the application has been submitted to the person who is the subject of the application, or an order made by a High Court after an appeal or an enquiry, stating that such a person is incapable of managing his or her property and that an administrator be appointed. The application referred to in the first instance must: (a) set out the relationship of the applicant to that person, or if not related, the reason why the spouse or next of kin did not make the application; and if the relatives are not available to make the application, what steps were taken to establish their whereabouts before making the application; (b) include all available mental health related medical certificates or reports relevant to the mental health status of that person and to his or her incapability to manage his or her property; (c) set out the grounds on which the applicant believes that such person is incapable of managing his or her property; (d) state that, within seven days immediately before submitting the application, the applicant had seen that person; (e) state the particulars of that person and his or her estimated property value and annual income; and (f) give the particulars and contact details of persons who may provide further information relating to the mental health status of that person. After consideration and processing of such an application, the Master of the High Court may: appoint an interim administrator if the case needs to be investigated first; or appoint an administrator right away, if - the estimated property value and annual income of that person is below the prescribed amount; and
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satisfied that sufficient good grounds exist to make the appointment.
In addition, the Master must, in writing, inform the applicant and the mentally ill person or person with severe or profound intellectual disability of his or her decision and the reasons thereof, who in turn may appeal against the decision of the Master if not satisfied. Persons who may consent to medical treatment or operations In terms of the Act certain persons may consent to an operation or medical treatment of a mentally ill patient if the patient is incapable of giving consent. Provision is made for a priority list of persons who may give consent: the curator, the spouse, a parent, a major child, a brother or a sister. These people will have priority in this order, unless consent is unreasonably withheld or the treatment is urgent and the first person on the list is not available, in which case the following person may give consent. Should none of the listed persons be available, tb ^ superintendent of the institution may give written consent if he/she is convinced that the patient's health is at risk (section 60 A). The superintendent may not consent to a sterilization from a convenience point of view or to an abortion unless the health or life of the woman is in danger. The supervising medical practitioner and relevant therapists may not take unlimited decisions regarding treatment. Regulation 7 was issued in terms of section 77(1) to regulate the performance of leucotomy, to which far more stringent conditions apply than to more common surgery. Protection of the community provided by the Act By means of certain stipulations, the Act prevents mentally ill persons from becoming a risk or a nuisance to the community. Duty of medical practitioner regarding notification of dangerous persons If a medical practitioner examines or treats a person who, in his/her view, is mentally disturbed to such a degree that he/she poses a threat to others, the practitioner must immediately report the matter in writing to the magistrate or a police officer. Dangerous patients A State patient or someone in respect of whom a reception order has been issued and who has been found to be dangerous by two medical practitioners, one of whom must be a psychiatrist, shall be referred to a maximum security facility according to the different sections of the Act. 6 2 CRIMINAL PROCEDURE ACT The purpose of this Act (51 of 1977, and its amendments) is to make provision for procedures and related matters in criminal proceedings. The Act contains a number of
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points of contact between the psychiatric service and the legal system. It also guides the practice of people who work in forensic psychiatric units. Of particular importance to a mental health nurse are sections 77 and 78. Section 77 concerns the capacity of an accused person to understand the court proceedings. If this is not the case, the court has to direct that the matter be enquired into and be reported on according with the relevant sections of the Act. Section 78 deals with a person who is suffering from mental illness while he/she commits an act or makes an omission constituting an offence, and as a result is unable to appreciate the wrongfulness of such a commission or omission or is unable of acting in accordance with an appreciation of the wrongfulness of such a commission or omission. The Act declares that such a person shall not be criminally responsible for such act. If there is any doubt as to the mental condition of an accused, he/she is referred to an institution for the mentally ill for a maximum of 30 days, during which time his/her mental condition is examined. Should the charge be for a less serious crime, the examination is performed by the medical superintendent of the institution or by a psychiatrist nominated by the superintendent. If the charge is for a serious crime, the examination is performed by a panel consisting of the medical superintendent (or a psychiatrist nominated by the medical superintendent), a psychiatrist who is not in the full-time service of the State and who is nominated by the accused. 63 MEDICINES AND RELATED SUBSTANCES CONTROL ACT This Act (101 of 1965, as amended) controls the possession, supply, administration and prescription of medicines by registered nurses and other professionals. The Act regulates the control of medicines listed in Schedules 1 to 9. The particular schedule in which a medicine is listed is determined by the dependence-producing potential of a single dose or of long-term use. Provisions of the Act According to the Act: (i) No person may acquire, use, possess, manufacture or supply any Schedule 7 or Schedule 8 substance, or manufacture any specified Schedule 5 or Schedule 6 substance unless he or she has been issued with a permit by the Director-General of Health for such acquisition, use, possession, manufacture, or supply. (ii) The Director-General may, subject to such conditions as he or she may determine, acquire or authorize the use of any Schedule 7 or Schedule 8 substance in order to provide a medical practitioner, analyst, researcher or veterinarian therewith on the prescribed conditions for the treatment or prevention of a medical condition in a particular patient, or for the purposes of education, analysis or research. (iii) No person shall import or export any specified Schedule 6, Schedule 6, Schedule 7 or Schedule 8 substance or other substance or medicine prescribed for that purpose unless
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a permit has been issued to him or her by the Director-General in the prescribed manner and subject to the prescribed conditions determined bv the Director-General. (iv) Any person may possess a Schedule 3, Schedule 4, Schedule 5, Schedule 6 or Schedule 7 substance if he or she is in possession of a prescription issued by an authorized prescriber. Schedule 9 substances are illegal in South Africa in terms of the Act. They are allowed only for research purposes, in which case a permit is required. This group of substances includes opium, cannabis, heroin, cocaine (Schedule 8) and amphetamines (Schedule 9). Schedule 1 substances, such as Codis and Panado, may be purchased from a pharmacy or store but not by anyone who appears to be younger than 16 years. Schedule 2 substances, such as Benelyn Expectorant, may be purchased only from a pharmacy under the supervision of a pharmacist. Substances listed in Schedules 3 and 4 may be obtained only from a pharmacy under the supervision of a pharmacist, upon a written prescription of a medical practitioner, dentist or veterinarian, or on the verbal instructions of such a professional, who is known to the pharmacist. Schedule 5 substances may not be administered or used for other than medicinal purposes. They may be obtained only from a pharmacy under the supervision of a pharmacist, upon a written prescription of a medical practitioner, dentist or veterinarian. Psychiatric medications are listed in schedules 2 to 5. All medications prescribed for psychiatric patients in the community are packed, labelled and sealed by the pharmacy staff. The prescribed medications, together with their treatment cards, are given to the nursing staff of the psychiatric community service for delivery to the patients. The pharmacy does, however, provide the nursing staff with a bag containing limited amounts of psychiatric medications that may be used if a psychiatrist changes a patient's prescription during an examination. The supply of medications in the bag is checked and topped up by the pharmacist every day. Psychiatric nurses must make sure that they know the regulations regarding the possession and administration of medications in psychiatric hospitals. In terms of the Medicines and Related Substances Control Amendment Act 59 of 2002, the DirectorGeneral may grant a person, organization, group or category of persons the right to prescribe medication (section 22A, subsection 9). This will be done after consultation with various bodies, and will be gazetted, together with the regulations governing such rights. This article opens the door for nurses to gain prescriptive rights. Regulations in this regard should be studied and adhered to. The Nursing Council has also been engaged in the process of securing adequate powers for nurses to prescribe where required. The Essential Drugs Programme (1998), subject to revision by the Department of Health, contains the Standard Treatment Guidelines and Essential Drugs List (EDL) which outlines the treatment guidelines for common mental health conditions. The different volumes will cover the management of mental health conditions at every level of care, from primary health care upwards.
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Table 6.2 Psychiatric medicines. Schedules 2 to 5 Phenothiazirte Examples: Chlorpromazine (Largactil)
Schedule 5
Thioridazine (Melieril) Tricyclic antidepressants Examples: Imipramine (Tofranil)
Schedule 5
Amitriptyline (Tryptanol) Benzodiazepine Examples: Diazepam (Valium) Nitrazepam (Mogadon)
Schedule 5
Lorazepam (Ativan) Anti-epileptic drugs Examples: Carbamazepine (Tegretol) Phertytoin (Epanutin)
Schedule 5
Phenobarbitone (Garoin) Sodium valproate (Epilim) Antimanic drugs Example: Lithium carbonate (Camcolit)
Schedule 3
Muscle relaxants Example: Orphenadrine (Disipal)
Schedule 3
Anti-Parkinsonism drugs Example: Biperiden (Akineton) Drugs to combat alcoholism Example: Disulfiram (Antabuse)
Schedule 4
Schedule 4
6.4 PREVENTION AND TREATMENT OF DRUG DEPENDENCY ACT This Act has been repealed by the Abuse of Dependence-producing Substances and Rehabilitation Centres Act, No 41 of 1971. The prevention and treatment of substance abuse has been put under the control of the Prevention and Treatment of Drug Dependency Act, No 92 of 1992, amended by the Welfare Laws Amendment Act, No 106 of 1996, and the Prevention and Treatment of Drug Dependency Amended Act, No 14 of 1999. The Act: 1. clearly separates the care of mentally ill people from that of people dependent on substances;
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2. promotes the establishment of treatment centres for the reception and treatment, including any training, of people dependent on substances; 3. makes provision for a Central Drug Authority, a body established to advise the relevant Ministers on matters governing the abuse of drugs and promote measures relating to the prevention and combating of the abuse of drugs and treatment of persons dependent on drugs; 4. makes provision for the National Drug Master Plan, a national drug strategy setting out the policy and strategies against the abuse of drugs and adopted by Cabinet; 5. makes provision for the development of programmes for prevention and treatment of drug dependency, which are aimed at: (a) prevention of drug dependency; (b) information to the community on the abuse of drugs; (c) the education of the youth in regard to the abuse of drugs; (d) observation, treatment and supervision of persons in a treatment centre and those who have been released; 6. makes provision for the registration of treatment centres; 7. makes provision for the establishment of hostels for the purpose of providing homes for persons receiving treatment for dependency from, released or on leave of absence from treatment centres or any approved institution; 8. makes provision for the Director-General to appoint staff for the proper management and control of treatment centres and hostels, which include a social worker, medical practitioner, psychiatrists, clinical psychologist, or nurse as superintendent; 9. puts the public prosecutor or magistrate in control of the process for bringing persons elible for admission to a (registered) treatment centre; 10. stipulates that any person who has been ordered to be detained in a (registered) treatment centre in terms of this Act will be detained until they are released on licence, discharged, transferred or returned following the right procedures. 6 5 CHILD CARE ACT Main purposes of the Act The main purpose of the Child Care Act 74 of 1983 as amended, is to provide: for the establishment of Children's Courts and the appointment of commissioners of child welfare; for the protection and welfare of certain children; for the adoption of children; for the establishment of certain institutions for the reception of children and for the treatment of children after such reception; for contribution by certain persons towards the maintenance of certain children for incidental matters concerning children.
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Children's Courts The Act makes provision for establishment of children's courts for the area of jurisdiction at every magistrate's court. These courts are to be held in a room other than that in which any other court sits, unless no such room is available and suitable. These are meant to protect children when they have to appear in court for whatever reason. Following an enquiry, a children's court may: order that the child be returned to or remain in the custody of his/her parents or guardian; order that the child be placed in the custody of a suitable foster parent designated by the court under supervision of a social worker; order that the child be sent to a children's home designated by the Director-General; order that the child be sent to a school of industries designated by the Director-General. Abused children Any dentist, medical practitioner or nurse, social worker or teacher, or anyone employed by or managing a children's home, place of care or shelter, who examines, attends or deals with any child in circumstances giving rise to the suspicion that the child has been illtreated or suffers from any injury the cause of which might be deliberate, or suffers from a nutritional deficiency disease, is obliged, in terms of section 42 of the Act, to inform the Regional Director of Social Development or Welfare of the circumstances in writing. Prevention of abuse In terms of section 50 of the Act, the parent, guardian or attendant of a child shall be guilty of an offence if he or she: ill-treats that child or allows it to be ill-treated; or abandons that child. 6.6 ACTS GOVERNING THE EDUCATION OF INTELLECTUALLY DISABLED CHILDREN
The care of these children - previously governed by the Mentally Retarded Children's Training Act 63 of 1974 and similar, repealed by the Education Affairs Act 70 of 1988 (House of Assembly) - has now been placed under the South African Schools Act 84 of 1996. According to this Act, a handicapped child means a child who in the opinion of the Head of Education is able to benefit from a specialized education programme for handicapped children, but who deviates to such an extent from the majority of the children of his/her age group in body, mind or behaviour that he/she: cannot benefit sufficiently from the instruction provided in the ordinary course of education; needs specialized education to facilitate his/her adaptation in the community;
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should not attend an ordinary class in an ordinary school, because such attendance may be harmful to him/herself or to other learners in such a class. The Act outlines specialized education, comprehensive enough to suit the needs of handicapped children, as well as their psychological, medical, and other physical needs. Section 29 of the Act declares certain educational institutions as state-aided schools, to ensure the provision or the continued provision of specialized education at an educational institution other than a public school. These schools may be established by the Minister of Education at any place, and managed and controlled by governing bodies. Age requirements for specialized education Admission to a specialized school is only possible between the ages of six and 19 years. The Act does not allow any person after the age of 21 to attend a school for specialized education. Admission to a specialized school may be effected through a request by a parent, subject to the opinion of the Head of Education. A children's court established under the Child Care Act 74 of 1983 may also direct that a child be referred to the Head of Education in order to determine whether the child is handicapped, with the aim of getting him/her admitted into specialized education. 5.7 CHOICE ON TERMINATION OF PREGNANCY ACT
The purpose of the Act (92 of 1996) is to determine the circumstances and conditions under which the pregnancy of a woman may be terminated, and to provide for related matters. The Act repealed the Abortion and Sterilization Act, 1975 (Act No 2 of 1975), which was seen as restrictive and inaccessible. The present Act provides for and promotes reproductive rights and extends freedom of choice by affording every woman the right to choose whether to have an early, safe and legal termination of pregnancy according to her individual beliefs. Termination of a pregnancy is defined in the Act as the separation and expulsion, by medical or surgical means, of the contents of the uterus of a pregnant woman. Circumstances and conditions under which pregnancy may be terminated according to this Act: Upon request of a woman during the first 12 weeks of the gestation period of her pregnancy; From the 13th up to and including the 20th week of the gestation period if a medical practitioner, after consultation with the pregnant woman, is of the opinion that - the continued pregnancy would pose a risk of injury to the woman's physical or mental health; or - there exists a substantial risk that the foetus would suffer from a severe physical or mental abnormality; or - the pregnancy resulted from rape or incest; or - the continued pregnancy would significantly affect the social or economic circumstances of the woman;
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After the 20th week of the gestation period if a medical practitioner, after consultation with another medical practitioner or a registered midwife, is of the opinion that the continued pregnancy: - would endanger the woman's life; — would result in a severe malformation of the foetus; or - would pose a risk of injury to the foetus. The termination of a pregnancy may only be carried out by a medical practitioner, except for a pregnancy under 12 weeks of gestation, which may also be carried out by a registered midwife who has completed the prescribed training course. Counselling Section 4 of the Act provides for the provision of non-mandatory and non-directive counselling by the State, before and after the termination of a pregnancy. Section 5 requires that the termination of a pregnancy only take place with the informed consent of the pregnant woman, unless certain conditions prevail, including where a woman is severely mentally disabled to such an extent that she is completely incapable of understanding and appreciating the nature or consequences of a termination of her pregnancy. In these circumstances, other procedures have to be followed. Participation in abortion A nurse may, notwithstanding any service contract or other legislation, refuse to take part or assist in an abortion or sterilization. 6,8 STERILIZATION ACT
This Act (44 of 1998) was formulated following the passing of the Choice on Termination of Pregnancy Act (92 of 1996), which separated matters of termination of pregnancy from those of sterilization. The purpose of the Act is to restore, protect and promote the human dignity of persons, in particular those who are incapable of consenting or who are mentally disabled, by ensuring that decisions about sterilization are made in a manner that is responsible and considerate. Sterilization is defined in section 1 of the Act as a surgical procedure performed for the purpose of making the person on whom it is performed incapable of procreation, but does not include the removal of any gonads. Sterilization may be performed only on people who are competent to consent to the operation. No person is prohibited from having sterilization performed on him or her if he or she is: capable of consenting; and 18 years or above. The Act prohibits the performance of sterilization on a person who is under the age of 18 years, except where failure to do so would jeopardize the person's life or seriously impair his or her physical health.
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Person incapable of consenting or incompetent to consent due to severe mental disability For the purposes of this Act 'severe mental disability' is defined as a range of functioning extending from partial self-maintenance under close supervision, together with limited self-protection skills in a controlled environment through limited and requiring constant aid and supervision, to severely restrained sensory and motor functioning and requiring nursing care. Sterilization may be performed on any person who is incapable of consenting or incompetent to consent: 1. upon a request to the person in charge of a hospital and with the consent of a (a) parent; (b) spouse; (c) guardian; or (d) curator; 2. if a panel contemplated in terms of this Act, after considering all relevant information, concurs that sterilization may be performed; and 3. if the person is mentally disabled to such an extent that such a person is incapable of(a) making his or her own decision about contraception or sterilization; (b) developing mentally to a sufficient degree to make an informed judgement about contraception or sterilization; and (c) fulfilling the parental responsibility associated with giving birth. The panel for consideration of an application for sterilizing a mentally disabled person must consist of: a psychiatrist, or a medical practitioner if no psychiatrist is available; a psychologist or a social worker; and a nurse. Where a person to be sterilized is in custodial care, no member of the panel may be an employee of the custodial institution. If sterilization is to be performed in a private health care facility, the members of the panel may not be employees of, or have a financial interest in, that facility. 6.9 HEALTH PROFESSIONS ACT
This Act (56 of 1974) with its numerous amendments, establishes the Health Professions Council. It also provides for control over the training, registration and practices of practitioners of health professions other than nurses, and other matters of concern to these professions. However, two sections refer to certain acts that may specifically be performed by nurses.
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Section 37 (2) of the Act mentions certain acts that may be performed only by a clinical psychologist. Nurses are among the persons and bodies exempted from these directions. Section 37 (1)(C) stipulates that nurses may diagnose, treat or prevent any mental defect, illnesses or deficiency in any person during the normal course of their practice in terms of the Nursing Act. Section 37 (l)(f) further stipulates that the nurse may prescribe or supply any medicine, substance or thing in respect of such defects, illnesses or deficiencies according to the provisions of the Nursing Act. In terms of section 52(A) of the Act, the Director-General of National Health may authorize a registered or enrolled nurse in the employ of a medical practitioner to provide a patient, who is being treated by the medical practitioner, with prescribed medication (Schedule 1, 2, 3 or 4). The nurse may issue only prescribed medicines. CONCLUSION A law is only as effective as its implementation. Psychiatric nurses function within the structure of the laws discussed in this chapter and they must keep abreast of the amendments that are announced and of the promulgation of new laws relevant to the practice of mental health in South Africa. WEB RESOURCES
www.gov.za/dept/ This page provides a list of government departments. Click on the home page of the one you need. There you will usually find a topic called 'documents', under which you can find current legislation. www.hyperguide.co.uk/mha/ If you want to compare our Mental Health Act with another, try this site, which explains the Act of the United Kingdom. REFERENCES Child Care Act 74 of 1983 Choice on Termination of Pregnancy Act 92 of 1996 Criminal Procedure Act 51 of 1977, as amended Education Affairs Act 70 of 1988 (House of Assembly), amended by the South African Schools Act 84 of 1996 Medicines and Related Substances Control Act 101 of 1965, as amended Mental Health Care Act 17 of 2002 Prevention and Treatment of Drug Dependency Act No 20 of 1992 Sterilization Act 44 of 1998
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SEVEN
The Management of Ethical Dilemmas in Mental Health L VAN RHYN
Objectives After studying this chapter the learner should be able to: Describe the structure of an ethical dilemma. Apply a specific theory to the reasoning out of an ethical dilemma.
INTRODUCTION Not all dilemmas in life are ethical - an ethical dilemma occurs when moral claims come into conflict. A dilemma may be defined as: a problem for which there is apparently no satisfactory solution; or a situation in which a choice must be made between two equally unsatisfactory alternatives. Questions such as the following arise: 'What ought I to do?' 'What are the advantages and disadvantages of this decision or action?' 'To whom does it apply?' An example is a situation in which something considered to be 'good' is not necessarily 'right'. Conflict arises between two moral values - virtue and duty. Euthanasia may be considered by some to be good (a virtue), but not right (a duty). Bioethical dilemmas arise out of health care situations where the answers are anything but clear. Ethical dilemmas exist at the nurse/patient/family level of interaction, in the hospital as well as in the community, and also at the policy-making level of institutions and communities. Bioethics incorporates choices and conflict relating to health care problems, for instance, a long lifespan versus freedom from pain; full versus partial disclosure of information; the rights of individuals versus the rights of the community.
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7.1 ETHICAL THEORIES Ethical theories and reasoning do not solve ethical dilemmas. They do suggest ways in which the theories may be structured to provide objectivity. Utilism Utilism is sometimes seen as a form of teleological ethics. It focuses on the consequences of actions - on the greatest amount of happiness or the least harm to the largest number of people. It is, therefore, concerned with the end product of actions. It is a communityoriented theory in which all people are equal. Consequences for future generations, as well as other living individuals and groups, are taken into account. Utilism is in conflict with the traditional approach in medicine which believes that all that is humanly possible should be done for the patient and that all available resources should be mobilized for individual patients. Egotism People with an egotistical approach search for solutions that will be to their own benefit. A solution need not necessarily be to the advantage of the patient, since patients are not the primary concern. Nurses with this standpoint will make decisions that are the most advantageous to themselves and will not consider the patients, their families or anyone else.
Problem
List alternatives
Compare
List rules or principles
One alternative consistent with rules or principles
Various alternatives consistent with rules or principles
Alternative consistent with one rule or principle but in conflict with others
Various right actions (may choose any for comfort or preference)
Apply principle at higher level to resolve conflict
One right action
Claim successful One right action
Claim unsuccessful
?
Figure 7.1 Deontological schema for solving an ethical dilemma
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Deontology In this case both the action itself and the relevant principles and rules are important. Examples of rules or principles are: never lie; never do to others what you do not want done to you. Kant's principle of universality is relevant in this connection - one must act in terms of a specific basic principle only if it can be applied in any similar situation. According to Kant it is duty that determines the moral value of an action. People are not subject to the will of others, they are only subject to their own will on condition that it is rational and respects the law. Kant considers autonomy, freedom, dignity, self-respect and respect for individual rights to be important values. The Christian approach The fundamental convictions of the biblical faith of Christianity are the beliefs in creation, the fall of man, redemption and fulfilment. Within this framework Christians 'read' their situation. For Christianity the highest purpose in life is that the kingship of God be proclaimed over every sphere of creation. Christianity stresses that order in society depends on obedience to the normative structures of creation ordained by God for marriage, the family, the state and the church. Human beings are created in the image of God, and in Christianity the focus is predominantly on normative obedience to God and the duties that emanate from this. Christianity has much in common with other monotheistic religions (Judaism and Islam) and much of what is said about Christianity is also true of the approach of these religions. The essential feature of the ethical modality is love. The term 'love' has little to do with a sentimental feeling. Love is an attitude rather than a feeling. Love is respect for people, taking people to heart and treating them as people. When one understands that the opposite of love is not hate but indifference, the true meaning of ethics becomes clear. Love applies to the total person in all his/her relationships. (For instance, patients should not be regarded as total entities in themselves only - their families should be included.) Example Shaun is a 25-year-old man who has suffered from schizophrenia for the past six years. He was hospitalized for five years but has been treated as an outpatient for the past year. Stelazine tablets twice a day have been prescribed for him. He lives with his parents and goes to the sheltered workshop (where he functions well) every day from 08:00 to 12:00. In the afternoons he works at home at his hobby of making wooden toys, which he sells. Sometimes he goes to town with his mother; she does not work. He has a girlfriend with whom he spends some evenings and weekends. He has no other friends. For the past month Shaun has been causing problems: he has withdrawn from his parents and girlfriend and no longer wants to go to the sheltered workshop. Some days he does not want to get out of bed. His personal hygiene has deteriorated and when his mother remonstrates with him, vehement arguments ensue. He talks to himself at times. He has also lost interest in his hobby. His parents suspect that he has stopped taking his medication, although he assures them that he does take it. His mother takes him to the
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outpatient department for a follow-up examination, where a decision must be taken about readmitting him. Shaun is opposed to admission and his parents are uncertain, as they feel that it will be detrimental to his rehabilitation, but they find it difficult to cope with his present behaviour. Utilism. If action is based on the utilistic viewpoint, the patient will probably be hospitalized, since he may pose a threat to the community. Utilism focuses on the greatest amount of happiness or the least harm to the largest number of people. Egotism. In terms of the egotistical approach, both the therapist and the parents will be in agreement about the need to hospitalize the patient, because it will be the easiest way of handling the problem. Deontology. The operative rule here is to do one's duty towards the patient. Duty is interpersonal and therefore one cannot institutionalize the patient. The deontological approach does not allow the patient to be used as a means to an end. For instance, the hospital will not use him as a research object, neither will his parents try to get rid of him in order to have more free time. The Christian approach. The first consideration in this case would be not to hospitalize the patient. For love of the patient, both the parents and the nurses would treat him with respect, honour his wishes and uphold his right to autonomy and selfdetermination as far as possible. The Christian approach would entail trying to keep the family structure intact as far as possible. However, the Christian approach does not exclude utilism, and if the patient makes many people unhappy and constitutes a threat to them, he must be hospitalized. Both the parents and the family must also be considered. 7.2 THE STRUCTURE OF A DILEMMA
One way of structuring a dilemma is to divide it into three elements: situational facts; decision-making questions; and underlying ethical theories. These elements are then evaluated within the framework of time and value systems. The personal and professional value systems of the decision-makers and those who will be affected by the decision are based on these three elements. For instance, one person may believe that death is the worst thing that can happen to one, while someone else in the same situation may consider a handicapped life to be the worst alternative should there be a choice. Other values that could be important to nurses are obedience to a professional code and the patient's own choice. Time is another dimension in the clarification of dilemmas. Some dilemmas demand immediate action. If more time is available, there is a better opportunity for evaluating information and considering alternatives. Situational facts The following questions should be asked in order to establish a database:
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Who are the people involved? What is the nature of their involvement? What is the proposed action? What is the context of the proposed action? What is the purpose of the proposed action? What other alternatives or choices are available? What are the possible implications or consequences of the proposed action? Decision-making facts Although a database is an essential component in the consideration of an ethical dilemma, decisions cannot be made purely on the grounds of data. Decision-making demands a decision-making theory: Who is to make the decision - the doctor, the nurse, the patient, the family or a committee? Why? For whom is the decision to be taken? Is it for yourself, for a holder of a power of attorney or for others? What criteria should be used - social, judicial, physiological, economic, psychological or others? Why? What degree of consent must be obtained from the patient - free, forced or none? Which moral principle, if any, will be reinforced or denied by the proposed action self-determination, charity, justice or autonomy? Ethical principles The last task in the structuring of an ethical dilemma is to begin reasoning about ethical theories or positions in order to examine alternatives. The limitations of a specific theory must always be considered in such reasoning. Example Aletta is a 16-year-old girl with a slight intellectual disability. She lives with her parents. She has an IQ of 65 and was, at first, in a special class in a normal school, but she made no progress and now attends a training centre for people with intellectual disabilities, where she is doing very well. She is well groomed and at first glance looks like any other teenager. At home she does household tasks and is generally responsible and thorough in the performance of her duties. Her parents have no problems with her and she socializes well with two girlfriends. Aletta has been menstruating for the past two years and her parents are worried that she might fall pregnant. They have spoken to her about this, but she does not appear to understand very well. She would like to marry and have children and does not realize the concomitant implications and responsibilities. She requires help with hygiene during her periods. Her parents are considering a hysterectomy and have consulted you for guidance. In this case, the parents, Aletta, a mental health nurse and the gynaecologist should be involved in making a decision.
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The proposed action is a hysterectomy. The context is a girl of 16 who is well adapted and socialized, and living in a stable home environment. She has normal life expectations, and lacks insight into her limitations. The objectives of the action are to ensure that Aletta does not have a baby for whom she cannot take responsibility, and to stop her menstruating, which is difficult for her to manage. Other alternatives are: - putting her on a depo-contraceptive which will prevent pregnancy and menstruation; - teaching her the necessary skills which will enable her to handle menstruation and to deal responsibly with sexual needs. The possible implications of the proposed action include all the dangers involved in major surgery, anger and distrust from Aletta, and irresponsible sexual behaviour, since she will still lack understanding. All these factors should be taken into account and any decisions that are made must be tested against the ethical principles of self-determination, charity and justice. 7.3 SPECIFIC ETHICAL PROBLEMS IN PSYCHIATRY In a study in Sweden amongst nurses working with long-term mentally ill people in the community, Liitzen et al. (2003) identified moral stress as a problem for nurses. They defined moral stress as occurring when one knows the right thing to do, but institutional or environmental constraints makes it nearly impossible to pursue the right course of action. This is a kind of ethical problem most nurses will find very familiar. It happens in many situations, and presents differently in each case. However, there are also a few widely recognized issues in mental health care which are common enough to demand attention. Forced admission The problem of informed consent is receiving a great deal of attention in health care circles and the absence of consent in the case of forced admission of psychiatric patients is a serious problem. People often think that doctors misuse compulsory treatment to enforce their authority and power. Clinicians are accused of depriving patients of their freedom. The question, however, is 'Which freedom?'. Are the freedoms of movement and of association the most important freedoms? These freedoms may be taken away only if the patient no longer experiences personal freedom. What he/she does not have cannot be taken away. What he/she is deprived of is taken away precisely for the sake of his/her personality development, which has been impaired by a particular condition. However, it is often difficult to decide which patients no longer have personal freedom or integrity of personality and therefore qualify for compulsory treatment.
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The most radical view regarding forced admission is that of Szasz (Clare 1979). According to him, no treatment may be given against the patient's wishes. Birley holds the opposite view: 'Compulsory psychiatric care is not a threat but a right. Every citizen should have the right to be admitted against his will to the care of a first-class service' (Clare 1979). The issue at stake is the individual's ability to take responsible decisions and the risk to self and others is questioned. The fact that judgement is clouded by disease is recognized by psychiatrists worldwide. In practice, however, the forecasting of danger to the patient and others creates serious problems. Such a decision is a professional (to decide what the possible risk is) and an ethical one (to decide whose rights are going to be put at risk, those of the community or those of the individual). Doctors often have a broader concept of danger than the merely physical aspect. According to the 'MIND' report (Clare 1979), only actual physical danger to others must serve as a basis for compulsory treatment, and there must be evidence of recent overt actions. Graham and Young (Clare 1979) support the forced admission of individuals who have behaved violently in the past. They do, however, find it unacceptable that a mentally ill person who has never been violent should be compelled to submit to treatment because of a possible risk of aggressive behaviour in the future. The implications of being certified mentally ill are manifold. Certified patients may be admitted to a psychiatric hospital against their will, they may be treated without their consent, they may not manage their own financial affairs or sign contracts and they forfeit state pensions. The severe curtailment of their patients' basic human rights demands that doctors and nurses exercise their powers in this regard with the utmost care. Patients' rights should be given back to them as soon as possible. The more dependent patients are, the greater the responsibility of care-givers to treat them with respect. Electroconvulsive therapy This method of treatment is considered by some people to be dehumanizing. The treatment entails the administration of an electric shock of 70 to 130 volts for 0,1 to 1,0 seconds to the brain. It is performed under general anaesthetic and the only side effect is transient loss of memory of recent events. Criticism of this treatment is mainly due to misrepresentations and ignorance. The amnesia may become permanent if the treatment is repeated too often, but such misuse is rare. ECT is used to good effect in cases of severe depression, puerperal psychosis, schizophrenia (especially the catatonic type) and hypomania that is resistant to medication. It is at present regarded as the last expedient in a treatment regimen after other forms of therapy have proved to be ineffective. Informed consent must be sought for ECT. The procedure must be explained to the patient and his/her family and written consent obtained from either the patient or his/her family once it has been ensured that they understand the purpose, nature and implications of the treatment. A doctor gives consent in the case of certified patients. Drugs that alter consciousness Pharmacological agents are often used in psychiatric practice to: normalize a negative mood (for example, antidepressants);
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calm an anxious person or promote sounder sleep (for example, sedatives and narcotics); and suppress psychotic symptoms (for example, neuroleptics). Criticism of these drugs in professional circles relates to the hazards of addiction, the treatment of symptoms rather than the disease itself, and the suppression of the patient's personality. In the first place, Lennard (Uys & Smit 1985) points out that people today are taught from an early age to try to solve any problem with a pill: 'As a result many patients now expect their doctors to prescribe psychotropic agents for problems which are insoluble by drug therapy.' Doctors who use this treatment model - usually because diagnosis and the management of the real problem are so much more difficult and take so much more time - perpetuate an unhealthy and futile habit. Furthermore, patients are not helped to develop their personality by a healthier solution to the problem. In the second place, the use of many of the narcotics and sedatives leads to drug dependency. Drug dependency is a condition of physical and psychological dependence on a substance that may lead to withdrawal symptoms if the substance is withheld. More and more of the substance must be taken to obtain the desired effect. Drug dependency has a negative effect on physical and psychological health and on normative behaviour. In the third place, tranquilizers, sedatives and neuroleptics suppress feelings and thoughts, as well as consciousness of reality, and therefore also the user's personality. These drugs are, of course, taken specifically because they suppress certain negative feelings and thoughts. Confidentiality The promise to respect confidential information relating to patients appears in many professional codes. This matter has been complicated by technological advances in recordkeeping and the storage and reproduction of material (photocopying, computer storage, video tapes). The situation can become even worse if all the team members do not handle confidential information in the same manner. Patients' notes are usually available to all the members of the multidisciplinary team and to students of the various disciplines. What type of information must an individual team member share with the rest of the team and when must it be shared? How carefully is sensitive information handled within the multidisciplinary team? People with an intellectual disability People with an intellectual disability are often admitted to care and rehabilitation centres for life. In such cases, the chronic restriction of freedom may lead to the dehumanization of the patients. This in turn results in a secondary illness (institutional neurosis) or phenomena such as regression, aggression and masturbation. Dehumanization often takes the form of denial of the basic rights of people with an intellectual disability.
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These rights are: The right to live as normal a life as possible, for example, the right to relationships, holidays, a normal routine for every day or week and recognition of personal events such as birthdays. The right to privacy. The right to be treated as a unique individual with one's own needs. The right to be treated with dignity. The right to utilize opportunities to develop one's potential. Child psychiatry Children in long-term individual psychotherapy enter into an intense relationship with an adult and this relationship may take on a parental nature. Depending on the therapist's conceptual framework, this role and its attendant advantages may be viewed from many angles. The way in which therapists act is consistent with the type of change they endeavour to bring about in their patients and it is unlikely that values and attitudes will not be transferred to their patients. Differences in the attitudes of therapists and parent may cause a great deal of confusion to the child and dilemmas in connection with therapy. The dilemmas may hamper the progress of the treatment. These days family therapy is combined with individual therapy. Therapists who treat the family as a unit ('organism1) may evade their responsibilities to individual members of the family. The identified patient may improve but other children may be negatively influenced or the marriage relationship may suffer. It is important to be aware of the fact that a therapeutic focus on a family as a unit may change an individual child's condition or needs. The health and integrity of a family as a unit can be maintained at the expense of an individual child. There is a delicate balance that demands a flexible approach. In some sessions family members are encouraged to express negative feelings to one another. This results in an intensified level of expression of emotions in the family. Research has shown that the expression of negative feelings between parents when a child is about three years old can be an important indicator of later behavioural problems (Green & Stewart 1987). The family structure can become so unbalanced during treatment that the family may find the situation unacceptable and unmanageable. Unless paradoxical techniques are used correctly, the family may experience a feeling of spuriousness. Research involving mentally ill or disabled people There are no laws governing the research participation of people, but there are a number of international and national protocols. One of the most basic principles in such research protocols is that adults should give informed consent on a totally voluntary basis to be involved in research. Clearly, a problem arises when the person lacks the capacity to understand information about the research or to make decisions about their own participation.
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In the interest of empowering consumers, every effort should be made to explain research to clients, and to obtain their consent. The explanation might have to be at a very simple level in the case of a person with an intellectual disability, but often some level of understanding and agreement is possible. In most cases there is an expectation that consent will be obtained from the person caring for the client or being responsible for his/her best interest. This might be the parent or spouse, a treating psychiatrist, or the manager of a residential facility. In such cases the best interest of the client has to be considered. According to the recommendations of the Mental Incapacity Research Committee in the UK, people incapable of giving their own consent should only be included in research under the following conditions: The research is about the causes, treatment or care of the condition by which the person is affected or may be affected. The object of the research cannot be effectively achieved without the participation of persons who do not have the capacity to give consent. The research will expose participants to no more than negligible risk, invasion or restriction (Dimond 2002). 7,4 PATIENT RIGHTS Although the Department of Health of South Africa has published a Patient Rights Charter (DOH 2003), it does not refer specifically to people with a mental illness or disability. In 1989 the World Federation for Mental Health published a Declaration of Human Rights and Mental Health. This document emphasizes the place of mental health in achieving basic human rights. It also states that 'the fundamental rights of persons who are labelled, or diagnosed, treated or defined as mentally or emotionally ill or distressed, shall be the same as those of all other citizens' (1989). It then goes on to list a wide-ranging set of rights. This group is not the only one to address the rights of persons with mental illness. Amnesty International and the World Health Organization have produced similar documents. The following set of patients' rights was formulated in a way which patients can understand by the province of Nova Scotia in Canada: As a person receiving treatment in the National Health Service, you have rights that are outlined in the Hospitals Act of Nova Scotia: 1. You have the right to be treated with courtesy, dignity and respect in an environment that is safe and supportive. 2. You have the right to receive information about the types of treatment available in the hospital and in the community. 3. You have the right to participate in the development of a treatment plan suited to your needs. 4. You have the right to confidentiality.
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5. You have the right to have visitors, use the telephone and send or receive mail. 6. You have the right to appeal to the Review Board [in South Africa this would be the Hospital Board] if you disagree with: (a) Your formal status (The decision to keep you hospitalized against your wishes) (b) Your capacity (The decision regarding your ability to consent to your own treatment) (c) Your competence (The decision regarding your ability to manage your own money) 7. You have the right to receive help from the hospital staff to contact the Review Board about your status, capacity or competency. 8. You have the right to legal counsel and the right to receive help from the hospital staff to contact a lawyer These rights are clearly important human rights and, if they are made known to patients, they will ensure humane treatment. CONCLUSION The modification of a person's behaviour, whether it be psychotic, socially unacceptable, overdependent or destructive, is inherent in the interventions of psychiatric nurses, but when is behaviour sick? Who determines the criteria for mentally ill behaviour? What are these criteria? According to whose standards - those of the patient, the therapist, the community? - are decisions made to change behaviour? What factors play a role in the causation of this behaviour? Are these factors considered when the behaviour is altered? The alteration of behaviour is not necessarily immoral in itself, but many ethical questions, which nurses dare not ignore, arise in the process. WEB RESOURCES http://www.ethics.org/au/ethics_forum This website allow access to chat-rooms on different ethical topics. Some of these are introduced by a philosopher, others are free for all comers. There is usually some chat going on in the area of mental health ethics. http://biomedcentral.com/bmcmedethics The Biomedcentral websites publish online articles, peer reviewed and covering a wide range of topics. This particular one addresses Medical Ethics and offers useful articles addressing current topics. http://www.doh.gov.za/ Department of Health, South Africa (2003) The Patients' Rights Charter
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REFERENCES Clare, A W. 1979. Ethical issues in psychiatry. The Practitioner 223, July, 89-S Department of Health. 2003. The Patients' Rights Charter (see website above) Dimond, B. 2002. Legal aspects of consent 20: research/children/incapable adults. British Journal of Nursing 11(2): 126-128 Green, J & Stewart, A. 1987. Ethical issues in child and adolescent psychiatry. Journal of Medical Ethics 13,5-11 Liitzen, K, Cronqvist, A, Magnusson, A & Andersson L. 2003. Moral stress: synthesis of a concept. Nursing Ethics 10(3): 312-322 Uys, L R & Smit, J H. 1985. Kliniese Etiek. Johannesburg: Juta & Co Ltd Veatch, R M. & Fry, S T. 1987. Case Studies in Nursing Ethics. Philadelphia: J B Lippincott Co World Federation for Mental Health. 1989. Declaration of Human Rights and Mental Health
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CHAPTER
EIGHT
African Traditional Concepts of Health and Health Care A PIENAAR | MANAKA-MKWANAZI
Objectives After studying this chapter the learner should be able to: Describe the traditional African cultural perspectives on health, illness and mental health. Demonstrate an appreciation for the perspective by expressing empathy and respect in therapeutic interactions with indigenous African persons.
INTRODUCTION Traditional healing practice has been, and still is in one form or another, a facet of life in many societies. An African traditional healer is a combination of herbalist, psychologist, psychiatrist, priest and historian and patients are viewed within the context of culture. There is the belief amongst some traditional healers that supernatural causation explains extraordinary illnesses or misfortune. Writing in the 1970s, Gumede and Mankazana, both medical doctors, were of the opinion that traditional beliefs and practices with regard to mental health and illness were still being upheld among both rural and urban black people. Traditional beliefs should therefore be recognized and taken into account by Western-trained professionals because these beliefs have a meaning within the sociocultural and environmental context of African people. It should also be recognized that traditional healers incorporate the world-view of the culture within which they work and that their ministrations are therefore consonant with the prevailing beliefs of the community.
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8.1 A PARTICULAR WORLD AND LIFE VIEW In the African traditional way, the human being is viewed as a collective being (Umntu ngumntu ngabantu: a person is a person through other people). The human being is seen as part of a family, which includes the extended family. A person is also seen as part of the community he/she grew up in, as well as a part of the ethnic group he/she belongs to. Humanity is based on collectivism. Ubuntu (humanity in the African context), is interpreted as a collective concept of mercy, care, compassion, tolerance and fairness. Ubuntu is not only a value but a virtue of those who practice it. Health includes mental health and is defined as well-being that is culturally defined according to the individual's belief system. Health implies respect for the belief in custom and the specific rituals and ceremonies which sustain and create a holistic equilibrium within the person. Many African people consult both Western and African health care providers concurrently. Natural and supernatural exist in the African context and both health care systems are consulted to clarify the 'how', 'where', 'when' and 'why' of their illness. Consulting the traditional health care provider clarifies especially the 'why and who' of an illness. The collective perspective of humanity means that one member of a family may consult an African health care provider on behalf of all family members. Therefore, in consultation, the traditional healer or the faith healer looks at the individual, family and social context as a system. Causes of illness Illness is seen to be intentionally caused by certain agents, resulting in disequilibrium. People believe illness has a cause ('why and who') and that causes differ; for example, in traditional Zulu communities, an illness may be caused by the ancestors and God, evil spirits, witches and sorcerers, pollution/taboos and germs, as discussed below: Ancestors and God: Ancestors are seen as spirits of the forefathers who are taking care of people still on earth. God is seen as the unknown super-being, while the ancestors are seen as the intermediaries. These ancestors are honoured and when they are not happy with an individual's lifestyle, they cause illness, for example, bad luck or depression. God, when displeased, also sends people illnesses as punishment. Traditionally the ancestors and God are seen as main causes of mental illness. Evil spirits (mafofonyane). An evil spirit, known as 'mafofonyane', possesses a person and causes mental derangement that results in destructive, mischievous and malevolent behavior - 'psychotic behavior' from a Western perspective. Evil spirits are often associated with witches and sorcerers, who use antisocial medicines and curses to get people to act antisocially. This belief is based on the supernatural belief system. Witches and sorcerers cause strained relationships and misfortune and sorcery makes use of medicine or magical substances to harm people. Since sorcerers are believed to be directly or indirectly in contact with supernatural forces of evil and practising negative medicine, they are feared and generally disliked.
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Witchcraft. Involves manipulation of psychic powers, usually through the medium of mythical monsters called familiars (Ngubane 1977). The commonly used familiar is the impundulu (the lightning bird), which has the power of becoming invincible and changing into many forms. This bird is said to be highly sexual. Other familiars used by the Zulu sorcerers are infene (baboon); imikhavu (zombies) and umamlamba (a snake). Yet other familiars that are used include cats, rats, wolves and tokoloshes. Mkhize (1981) stresses the importance of knowing these familiars in clinical practice, especially in the area of psychological testing, because those African patients, who perceive most of the Rorschach pictures to be these animals, might be struggling within themselves with the possibility of being bewitched. Mkhize (1981) also mentions that when a black patient says, T know I've been bewitched', that person is expressing an unshakeable belief that is as certain, if not more so than, the scientific medical diagnosis of the illness. Witchcraft and sorcery are seen to be the evil work of human beings, who, driven by envy and malice, harm their fellow human beings. In African traditional society sorcery is a malpractice, an abuse of skill, and an offence punishable even by death. In order to survive the dangers, everyone must be frequently strengthened to develop and maintain resistance. Small incisions, called gcaba in Zulu, are usually made around joints (joints are said to be vulnerable points through which evil elements can enter the body) and medicines are applied in the incisions to serve as a protective measure. Pollution and taboos. Pollution occurs when a person finds himself or herself in a state of ritual impurity through no fault of their own, for example, a widow who is not cleansed by rituals, or a woman who has miscarried. Ceremonial cleansing must take place to purify the person. Sometimes taboos can lead to mental illness, for example, according to the African belief, a man having sexual intercourse with a woman during menstruation will experience delirium. Poisons. Some Africans believe that one of the many ways in which illnesses can be caused is by slipping poisonous substances into food. These poisons can kill a person or cause mental illness or misfortune. Eating poisons or medicinal preparations in food is called idliso. Some of the substances put in a person's food can intensify feelings of love towards a partner. These substances are regarded as love potions. Some poisonous substances used to cause illnesses are not put into a person's food, but are spread across the doorway of a house at night. When person steps out of the house in the morning, the medicine strikes through the feet and causes sickness or paralysis. The technique of placing harmful medicine across someone's path is known as umbhulelo. Contracting disease by stepping over dangerous medicine is known as umeqo. Germs. Some illnesses are believed to be caused by germs, for example, influenza, which can be treated by vitamin-rich plants or by Western medicine. Many people therefore hold the traditional belief that sickness, accidents or misfortunes are intentionally caused by persons or personified beings and do not accept the hypothesis
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of chance or accident as the final explanation of misfortune. The ultimate intention of any occurrence must be sought and it is through the process of divination that the spiritual forces behind a calamity can be determined. Diviners are therefore consulted when people feel that they are being bewitched. Types of illness Naturally occurring illnesses Most illnesses that are naturally caused are known as umkhuhlane. This is a comprehensive term referring to diseases that range from a common cold to serious epidemics. Many people readily consult Western-trained professionals for treatment of the diseases in the umkhuhlane category. Diseases in this category do not result from any personal malice or fault on the part of the patient and the measures used to cure umkhuhlane are therefore not ritualized. Reputable traditional healers readily accept that natural illnesses can be treated by Western-trained professionals and may refer patients to hospitals and clinics. Illnesses of the African people On the other hand, there are illnesses referred to by Ngubane (1977) as ukufa-kwaBantu, that is, 'diseases of the African people', because the philosophy of causality is based on African culture. This does not mean that the diseases, or rather their symptoms, are seen as associated with African people only; it is simply that their interpretation is bound up with a particular way of viewing health and disease. The illnesses in the ukufa-kwaBantu category are caused by witchcraft, sorcery or ancestral displeasure and they do not respond to Western types of treatment. The ancestral belief system Ancestors are believed to be very influential in the African traditional world-view. They are responsible for the explanation of the meaning of existence. The ancestral belief rests on the view that death is not the end of a person's life but a transition into a spiritual world that is, in certain respects, the replica of the person's earthly existence. It is for this reason that Mbiti (1970) calls the departed the 'living dead'. In other words, the dead person is still alive in the memory of his/her relatives on earth and it is the task of the people to remember their departed. According to this belief system, therefore, the deceased possess the capacity to continue having an influence on the fortunes of their nearest relatives. This involves influence not only for good things but also for evil (Berglund 1976); the ancestors are capable of punishing their living relatives by illness or even by death if the relatives arouse their displeasure. One of the ancestral functions is to protect the living against powers of sorcerers or other evil forces, hence ceremonies for ancestors are protective, and neglect of them triggers anxiety and leads to psychosomatic and psychological illnesses (Ngubane 1977).
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The ancestors are further believed to be responsible for the maintenance of health and moral order. According to Ngubane (1977), good health or ill health is regarded 'as a net result of a delicate and intricate balance between a person's family and his/her relationship with the ancestors'. The ancestors are believed to withdraw their protection and gifts of good fortune from erring descendants and show their anger and displeasure by inducing illness and misfortune. Ngubane (1977: 51) confirms the above: When good things in life are realized people say the ancestors are with us (Abaphansi banathi). When misfortune happens they say the ancestors are facing away from us (Abaphansi basifulathela). Without their protection the descendants become vulnerable to all sorts of misfortune and disease.
The anger of the ancestors is appeased by the sacrifice of an animal (an ox for major occasions and a goat for lesser occasions). Beer is always brewed before the sacrifice because the ancestors ask for both meat and beer. During such ritual sacrificescustom is strictly adhered to and, if the taboo is violated, the sacrifice will be rejected by the ancestors. Such sacrifices are therefore carried out with the utmost care and with minimal noise or quarrelling within the home. The sacrifices are a prayer-like bond between the living and the dead. Constant sacrifice is necessary for maintenance of that bond. Observance of ritual is part of preventive therapy in a tribal context (Mbiti 1970). The use of armlets and iziphandla (goatskin bangles) by the Zulu people after the sacrifice of an animal (a cow or a goat) is a material reminder of the existence of the bond between the living and the dead, as well as the assurance of eventual recovery from illness. These bangles must be respected when patients are admitted to hospital, as they are important to them. According to Gumede (1974), the issue of ancestors can be one of antiquarian interest to non-Africans, but it is one of life and death to most African people. It is important to understand that, contrary to common Western belief, Africans do riot worship ancestors. The sacrifices and the giving of food to ancestors are tokens of fellowship, hospitality and respect. It is thus almost blasphemous to describe these acts of the strengthening of family relationship as worship (Mbiti 1970). There is one particular rite that runs through most sacrifices and this is the use of gall, a liquid found in the gall bladder. The gall is always used specifically in order to achieve special contact with the ancestors, because it is believed the ancestors have a particular liking for the smell and taste of gall. In all sacrifices the gall is sprinkled on certain people to single them out for ancestral contact. These sacrifices are of crucial psychological significance in most traditional African communities, because they help to prevent imbalances between the person, the family and the ancestors. Failure to obey the cultural duty of sacrificing regularly to the ancestors leaves the person and the family vulnerable to ancestral wrath and loss of protection from noxious influences. As long as a person has a successful life with a satisfactory economic situation, he/she considers him/herself to be enjoying adequate protection, love and blessings from the ancestors (Ngubane 1977).
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Disease is therefore seen as a phenomenon constructed by people through the agency of the spirits, or a visitation by the ancestors as a punishment for failure to fulfil certain obligatory rites. Good health and good fortune are a rich reward for good behaviour and constant sacrifice to the ancestors. Ill health is a punishment for neglect and denunciation of these ancestral dignatories. 8 2 AFRICAN TRADITIONAL HEALTH AND MENTAL HEALTH CARE The process of traditional care does not draw a clear distinction between physical and mental health care. The process of consultation reveals the nature and extent of the problem and its corresponding treatment strategies. Therefore, although the term mental health care is used here, it is important to remember that the process of consultation is one of consultation for health. The stakeholders responsible for providing mental health care in an African traditional context are the family, the traditional healer (nyanga/ isangoma/ngaka ya ditola) and the faith healer (prophet). The family In the African traditional context, when the primary family has problems, for example, marital problems or problems with a child, the parents of the husband or wife are first consulted. If it is the wife that reports the problem, she normally consults the parents of the husband, and if it is the husband reporting, he normally consults the parents of the wife. Depending on the severity of the problem, the extended family (uncles, aunts and grandparents) might also be involved. The family has a meeting (also called family lekgotla/indaba)where one of the uncles chair and facilitate the meeting. Both the husband and wife state their side of the problem. The facilitator then allows each family member an opportunity to comment and/or give an opinion. During the process of this discussion, members of the family, including the husband and wife, have freedom of speech; if their views differ, the situation is debated. The facilitator finally concludes the meeting and the husband and wife decide the way forward. These discussions remain in the family and no family member is permitted to divulge information about the proceedings or outcome. The above set-up serves as a support and venting ground for a family with problems. The traditional healer A traditional healer is a person chosen by the ancestors to become a diviner or healer, and the ancestors bestow clairvoyant powers upon her/him. The traditional healer relies to a large extent on divination to discover the cause of discomfort. The traditional healer acquires comprehensive knowledge of traditional medicines from a trainer but, in addition, some medicines are said to be revealed to her/him by the ancestors. Traditional healers may or may not belong to a particular church, but their healing is said to come directly from the ancestors. Occasionally the traditional healer can be found in the townships wearing a green cloak with a cross on the back, similar to that worn by
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the Zionist prophets. One such diviner has said that on Sundays she attends the Zionist church services because she gets her 'strength' from them. She also belongs to the Methodist church and never misses the Methodist service on Sunday mornings. The training of a traditional healer is a long, arduous process, lasting from five to seven years. True healers have extrasensory perception and are diagnosticians, soothsayers and interpreters of the ancestors. When people are faced with unknown and unpredictable situations, it is through consultation with the traditional healer that they learn the will of the ancestors; doubts are removed and anxiety is reduced. The traditional healer is also consulted for unsuccessful endeavours and various events that suggest a manipulation of power. The process of divination determines the spiritual forces behind a calamity. Patients can therefore move from Western treatment, which focuses on the physical, to visits to the traditional healer to deal with emotional tension and interpersonal conflict. The traditional healer answers very pertinent questions for clients in a way that they can understand. Their cosmology contains spirits and powers that are real, ancestors who can see and experience what we cannot. All these powers have a direct bearing on a patient. An individual in doubt turns to someone who is supremely confident that he/she can explain the cause and, furthermore, bring about the desired results. It is believed that divination provides an answer to ancestral instructions. It ends the agony and the anxiety of indecision and uncertainty. The traditional healer gives definite answers and this is what matters psychologically. The patients look upon the healer with reverence and implicitly believe in and act upon what the healer prescribes (Ngubane 1977). The consultation The traditional healer, according to Mkhize (1981), always functions in full view of the patient's extended kin system. The patients are never treated in isolation but as integral components of a family and of a community at large. Traditional healing is directed at the whole person and embraces all aspects of life. The consultation may last from a few hours to days. The person either goes to the traditional healer, or the traditional healer comes to the house of the person. The person states his/her problem and the traditional healer listens attentively and clarifies where he/she does not understand. The process of consultation is divided into supernatural divination and the removal of the hostile source or cause of the illness. The divination process includes the following components: Throwing of bones. In general, the person consulting the traditional healer breathes into the bag of bones which the healer keeps throwing until they point to the problem or matter at hand. The traditional healer interprets the bones for the person who may then consult with another traditional healer to confirm the interpretation. Listening to the ancestors. Sometimes the traditional healer listens to the ancestors with or without the throwing of bones. The traditional healer whispers softly to the ancestors
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to open the problem to him/her. Sometimes the traditional healer will speak out loud, giving the person an opportunity to join in and agree, for example, if the traditional healer says, 'Vumani', the person will show his/her agreement by saying 'Si ya vuma. Ventriloquism/'whistling great ancestors'. The ancestor's spirit will communicate with the person by whistling out words that are meaningful to the listener. The traditional healer interprets the whistling and is able to diagnose the source of the illness and who to consult for the restoration of the health of the person. The second part of the consultation process is the removal of the hostile source or cause of the illness. Here the traditional healer makes recommendations as to how to alleviate the illness, for example, in the case of epilepsy the traditional healer might say the person is being called to become a traditional healer; the healer might recommend training for the person. Other techniques to remove the hostile source or cause of illness include rituals (such as 'preparation of the feast during initiation of the youth'), ceremonies (cleansing ceremonies) and appeasing the ancestors (mphoya badimo}. The traditional healer uses plants as medication or offers animal fat during rituals to remove bad luck and bring holistic healing. Not every traditional healer gains the trust of the person, hence the advice of two or three traditional healers may be sought. If their findings agree, their advice and diagnoses are generally accepted as true and valid. The prophet A prophet (umprofethi) is a healer who belongs mainly to the Zionist church and has the ability to predict, heal and divine, while the faith healer (umthandazi) belongs to a mission or an independent church. Prophets belong to a church and they therefore draw their healing powers directly from God or via guiding ancestors. A prophet undergoes training, purification and specific initiation by another prophet. The prophet in an African traditional context does not use bones, medication or animal fat in his/her healing processes. The prophet usually prays through the known ancestors to the unknown god (God). Once the person or family has stated the problem, the prophet will pray and ask the person/family to open the Bible. The prophet will then read from the Bible and focus a scripture on the life or the problem of the person. Correlations are made from a biblical perspective. Instead of medicine, the prophet uses water over which he/she has prayed. Sometimes the prophet also makes use of rituals for healing. The herbalist In addition to the traditional diviner and doctor, Chonco (1974) mentions the presence of other specialists whose skills concern the preparation of medicines to heal particular types of physical or mental illnesses. These are the herbalists, the inyanga and the isangoma,who
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have detailed knowledge of herbs and roots, which they sell to the public, The herbalist is the traditional pharmacist, a practitioner (or a 'traditional empiricist') who has studied the local herbs and evolved a system of classification in terms of the properties and actions of the medicinal plants. 8.3GUIDELINES IN MENTAL HEALTH CARE DELIVERY TO TRADITIONAL AFRICAN PEOPLE According to Vacc, De Vaney and Wittmer (1995: 10-12), the counsellor (mental health care practitioner) ought to be aware of his/her own culture in order to deliver appropriate mental health care in diverse population groups. They caution that the lack of knowledge of own culture, as well as that of others, can lead to prejudice and a tendency to impose own or inappropriate values on the client. Cultural-unawareness of the counsellor can lead to a limited management plan. In order to become more aware of these issues, the practitioner can encourage persons to talk about themselves, their family, community and belief systems. Listening to clients discussing their social setting might also help to identify differences, which can then be explored and clarified. If someone seems unsure about the mental health care practitioner and/or the focus and effectiveness of the approach they should be encouraged to verbalize these concerns. It might be helpful to visit homes of people (either clients or others) in the community, in order to learn about the culture in-situ. Cultural differences The following differences between the Western and the African approaches in mental health care have been identified: Passive participation versus active participation: The mental health care practitioner should be aware that in certain traditionally African communities, people tend to be passive. It is important not to read anything personal into passivity during consultation. Visual aids. Concrete examples, life-like illustrations and objects (instead of diagrams) are useful tools when sharing information. Tightness. Each culture has its norms, values and rules about right and wrong. Traditional cultures have tight rules and norms, which must be respected. Individualism and collectivism. Individual cultures are known for the development of the self, while collective cultures support a collectivistic self (ubuntu). Traditional African people are known for their collectivism where the progress of the group is more important than the progress of the individual. Vertical versus horizontal cultures. In vertical cultures there is a clear hierarchy, while in horizontal cultures there is an equal structure in communication. Many African traditional cultures are vertical, because there are several respect lines, for example, the elderly, men, women.
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Emotional expression or suppression. Different cultures express emotion in different ways. Caution should be exercized in labelling clients. Masculinity versus femininity of cultures. A masculine culture is one in which the dominant values of the people are success and achievement; a feminine culture is one in which the dominant values are based on caring for others. Many African cultures are feminine, because their values are embedded in caring for others. Cross-cultural communication Strategies of communication and culture can facilitate or interfere with the culture competence of the mental health practitioner. Here are a few tips for improving crosscultural communication: Greetings. From an African traditional perspective, the person who initiates the greeting plays an important role. The person of higher status (for example, the chief) greets first and the other person then responds in a respectful manner, such as with a respectful bow. In the therapeutic relationship pertaining to the person and mental health care practitioner, the mental health care practitioner is the person of higher status and should therefore greet first. Gestures. Some groups prefer contact and might greet you with a hug or by bowing; others may have a substantial personal space and will greet you with a very relaxed hand, or with a short verbal response and without any eye contact. Voice. Some people will speak up even when in close proximity to each other in order to show anyone in the vicinity that they are not gossiping. Personal space. Personal space is divided into three categories, that is, territory, touch and distance. As mentioned earlier, concepts of space differ among ethnic groups. The nurse should assess personal space according to the comfort level of the client. Certain gestures may interfere with the trust relationship between the mental health care practitioner and user - for example, holding your hands behind your back while speaking to the client. The client should be able to see your hands, to allay certain fears that you are holding 'bewitching' medication behind you back. Amongst some people it is seen as respectful to pass something to a person with the right hand instead of the left hand, for example, medication. And, when you have medication for two patients, you will break the relationship of trust if, in handing it to them, you happen to cross your hands. When a person enters an office or consulting room, he/she may show respect by sitting down immediately. Negative gestures include pointing to someone with a finger, and are seen as disrespectful. Many African people do not eat with people whom they do not trust. Therefore, in establishments where there are persons known to be experiencing some form of conflict, they should be allocated to different tables and not be forced to eat together.
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CONCLUSION Traditional healers have proven effective in alleviating both physical and mental disturbances and therefore represent a major therapeutic resource within society, despite the increasing availability of treatment based on the Western model of sickness and disease. Many patients go to both the traditional healer and the hospital in order to complete the cure (Cheetham & Griffiths 1982). While Western medicine might not be able to explain the 'why' of the sickness phenomenon adequately, the isangoma is able to provide assurances and explanations that are consistent with the person's world-view. Researchers advocate that Western-trained professionals should follow a policy of neutrality, allowing patients to go to the traditional healer while encouraging them to continue with the particular treatment that they prescribe. It is the opinion of many researchers, among others Buhrmann (1974), Cheetham and Griffiths (1982), and Gumede (1974), that getting to know and understand some of the practices of the traditional healer enriches the training of all health professionals. It is thus recommended that workshops or seminars be set up at regular intervals where Westerntrained health professionals and traditional healers can work together and exchange information and experiences. The traditional healer needs to be educated about conditions that call for referral to the hospital and perhaps the hospital could refer to and/or consult with reputable traditional healers in therapy-resistant cases of culture-bound syndromes. This would help in the utilization of the traditional healer as a primary health worker. It is also recommended that belief in indigenous aetiology be included as part of the patients' admission records. These records could serve as a valuable indicator of the patients' vulnerability to somatic ills. The mental health care nurse must realize that it is often the traditional healer who has the final word. The assurance that the traditional healer, in particular one of standing and of high repute, says only what has been revealed by the ancestors is taken as proof enough that it is the truth. Sensitivity to transcultural issues is of paramount importance in the professional setting of mental health promotion and the treatment of mental illnesses. Consequently, it is important that Western-trained professionals understand the viewpoint of their patients, especially values and goals concerning promotion of health and equilibrium. WEB RESOURCES
http://www.celyn.net/healing Traditional healing is not restricted to developing countries; every culture has its traditional healing practices. This site is a private practice in Wales, dealing with methods such as Alexander Therapy and others. http://www.nihb.org and http://www.upenn.edu/museum/Exhibits/indianmedicine.html Both of these sites deal with the traditional medicine of the Native Americans. The first one belongs to the National Indian Health Board, and has very little information on
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actual health care practice. The second one is part of the University of Pennsylvania site and includes good pictures, information on medication and health practices. REFERENCES Berglund, A I. 1976. Zulu Thought Patterns and Symbolism. Cape Town: David Philip Biihrmann, M V. 1974. Exploration of the meaning of songs sung during an inthombe. Journal of Analytical Psychology 26(4), 41-57 Cheetham, R W S & Griffiths, J A. 1982. Sickness and medicine - an African paradigm. South African Medical Journal 62, 877-879 Chonco, M. 1974. The African traditional healers. In African Therapeutic Systems, (ed. Z A Ademugan, J Allocide, E Harrison & D Warren), 21-32. USA: Crossroads Gumede, M V. 1974. Traditions and customs. The Leech. Vol. 2, 35-38 Mankazana, E M. 1971. A case for the traditional healer in South Africa. South African Medical Journal 2, 1003-1007 Mbiti, J S. 1970. African Religion and Philosophy. London: Longman Mkhize, H. 1981. Traditional Healing Methods and Western Psychotherapies (unpublished MA thesis, University of Natal, Pietermaritzburg) Ngubane, H. 1977. Body and Mind in Zulu Medicine: An Ethnography of Health and Disease in Nyuswa Thought Pattern and Practice. London: Academic Press Vacc, N A, De Vaney, S B & Witmer, J. 1995. Experiencing and counseling multiculturally diversed populations. Bristol: Accelerated Development
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SECTION
2
The Mental Health
Nursing Process
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CHAPTER NINE
The Mental Health Nursing Process LRUYS
Objectives After studying this chapter the learner should be able to: Work in a systematic way with clients with mental health problems. Describe and cultivate in yourself the three basic interpersonal attitudes essential in mental health nursing. Distinguish between different levels of empathy. Discuss therapeutic responding skills and use these effectively in interaction. Discuss the importance of self-awareness in mental health nursing.
INTRODUCTION According to the definition of mental health nursing given in Chapter 2, this field of nursing is an interpersonal process in the first instance. It is therefore essential that the mental health nurse is interpersonally competent and can build such competence into a systematic process of care. 9.1 INTERPERSONAL NURSING ATTITUDES These attitudes, elucidated by Carl Rogers in the 1960s in his development of personcentred therapy, involve the rather diffuse and undefmable basic attitude of the therapist (in our case the mental health nurse) by means of which the nurse communicates care to the patient. It is hypothesized that any patient's personal growth, psychic and emotional well-being is facilitated by a therapist who demonstrates warmth, caring and a nonjudgemental understanding of the patient. The basic attitude of the mental health nurse to a patient is made up of congruence, acceptance and empathy, and these are underpinned by the nurse's own self-awareness.
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Congruence The term congruence, also known as 'genuineness', refers to the nurse's ability to be aware of the way in which he/she experiences interaction with the patient, as well as to the nurse's ability to communicate this to the patient. The crucial issue here is that the nurse does not adopt a facade or play a role in any way but rather presents him/herself to the patient authentically. This means that what the nurse says to the patient and how the nurse says it are consonant with his/her momentto-moment inner experience of that patient This provides the patient with a consistent reality base that he/she can grow to trust, since the nurse does not confuse or mislead him/her with, for example, avoidant social niceties such as 'Don't worry, it'll all look better in the morning'. Congruence constantly infuses and is infused by the nurse's unconditional positive regard for the patient. Acceptance Acceptance, otherwise termed 'unconditional positive regard', refers to the nurse's ability to avoid making any judgement of the mental health care user - either positive or negative, overt or covert. Implied in the concept of acceptance is the notion that the nurse trusts the patient's own actualizing tendency, which is the inherent tendency, ability and need of the patient to develop in ways that enhance and maintain personal growth. If the nurse trusts a patient's propensity for growth, he/she is able to listen to whatever the patient says without wishing to direct him/her to other 'more important' matters, since the nurse know that the patient is undergoing the growth process in the particular way that is best for him/her. The patient may come to trust the nurse's faith in his/her own potential for growth and for that reason come to believe in this possibility himself/herself. The patient comes to see that thoughts and feelings previously deemed unacceptable and intolerable can, in fact, be accepted and tolerated, and, furthermore that their expression in the context of the relationship with the therapist can be an important part of the growth process. Empathy The term empathy refers to the nurse's capacity to perceive the nature of a patient's frame of reference accurately. To do this the nurse places him/herself in the patient's shoes and attempts to understand his/her experience as if he or she were actually in the same situation. The nurse then monitors his/her own response to that experience in the patient's world and communicates this to the patient. The nurse communicates this empathic understanding of a patient by means of reflecting the experience (to be discussed below). This can occur at different levels, which are known as levels of empathy. Primary-level empathy means that the nurse reflects initial and basic understanding of what the patient feels. Thus the nurse lets the patient know that he/she understands what the patient has explicitly shared about him/herself (Egan 1982: 88), for example:
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Patient: I'm so glad to be back in Johannesburg where all my family and friends are. Nurse: Being at home in these familiar surroundings makes you feel really secure.
Advanced-level empathy refers to how the nurse may reflect not only what the patient implicitly states about him/herself, but also what the patient implies or leaves only half-stated or expressed. The therapist may even intuitively become aware of what the patient does not reveal or say about him/herself, for example: - Patient: I've been having a lot of trouble with my car. It really isn't running well at all these days; the exhaust has fallen off and the ignition has also just broken ... Nurse: I wonder if you might feel rather like that broken car, unable to get going and perform well...? Empathy means putting yourself in another person's shoes as if those shoes are your own. This means that you must be able to identify the affective message (emotion) in the other person's communication with you. Four major emotions are happiness, anger, fear and sadness, although each of these subdivides into many subtle nuances. Table 9.1 gives examples of words from the main groups of emotions you can use to convey empathy. Table 9,1 The nurse-patient empathy functioning scale Happiness
Anger
Fear
Sadness
excited glad happy love pleased proud relieved satisfied grateful capable
hate bored guilty angry accused want to get even frustrated sarcastic
doubt frightened guilty anxious worried incapable apprehensive
disappointed hopeless hurt left out miserable put down sad unhappy worthless discouraged
The level of empathy shown by a nurse can be measured in terms of the nurse-patient empathy functioning scale, which consists of the following categories. Category 0 The nurse ignores both the conspicuous, surface feelings and the deeper, hidden feelings of the patient. The nurse may be bored, apathetic, disinterested, indifferent, unconcerned, detached, thinking of other matters, giving advice or offering examples from his/her own experiences, but is definitely not communicating awareness of the feelings of the patient. The nurse functioning at this level can be harmful to the patient and cause him/her to become less integrated or adjusted than before their encounter.
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Example Nurse: Good morning, Mrs Smith. Here's your breakfast tray. (Mechanically - the nurse is bored.) Patient: No, you just go on and take that tray back. I'm not going to eat. Nurse: Well, Mrs Smith, you'll never recover if you don't start eating. (Sarcastically - the nurse is ignoring the patient's feelings.) Patient: I'm not going to eat. You needn't try to make me because I'm not going to! (Turns head to wall, away from nurse.) Nurse: (Glances at empty chair by bedside - disinterested and is ignoring the patient's feelings.) I wonder where your clean sheets are. Didn't they leave them? (Casually.) Patient: (Crying softly, turns towards nurse.) Don't bother with me. Nurse: All right, forget it. (Leaves with tray - the nurse is unconcerned and is ignoring the patient's feelings.) Category 1 The nurse sometimes communicates an accurate awareness of the conspicuous current feelings of the patient, but at other times is inaccurate in his/her perceptions of these surface feelings. The nurse may misinterpret the essence (content) or strength (intensity) of the patient's expressions and ignores any feelings that are hidden and below the surface. In category 0 the nurse completely ignores the patient's conspicuous feelings; in category 1 the nurse is not able to grasp their full meaning. The nurse classified in this category still does not help the patient, for he/she is not in tune with the patient. Example Patient: Are you the nurse who will be taking care of my Eddy? (Excitedly.) Nurse: Yes. Why? Patient: (Speaking rapidly.) I don't know what I'm going to do. Eddy with this, this, um sickness, and my husband is so upset, I uh, don't know what, what to say to him (stammering). I just... Nurse: (Interrupting.) Your husband wants to find out what's wrong with Eddy? (Inaccurate identification of conspicuous feelings.) Patient: Yes, he knows it's something with the water ... Nurse: Mmm. Patient: He was playing and came in and ... (starts to cry.) ... he said his tummy hurts and then he went to the bathroom and there was (crying harder.) blood in his potty, I don't ... (crying so much she can't continue talking). Nurse: I know how you feel, but Dr lones is a very competent urologist. I'm sure he's going to do everything he can for Eddy. (Gentle, warm, but inaccurate identification of essence and strength of conspicuous feelings.)
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Category 2 This represents the mid-point of the continuum of empathic communication and is the stage where the nurse begins to be of help to the patient. The nurse communicates an accurate awareness of the conspicuous current feelings and their meanings to the patient. The nurse realizes the presence of hidden feelings, but is not accurate in defining their essence or strength and does not know what they mean to this particular patient. The nurse does, however, express interest in understanding the patient's hidden feelings and communicates T am trying to understand'. The provisional nature of the reflections of those hidden feelings the nurse attempts to express allows the patient to refuse those perceptions. Example Patient: The doctor told me I was going to be well enough to go home soon. (Flatly.} Nurse:
How do you feel about going home? (Fact-finding to get more information.}
Patient: Well (pauses momentarily}, they want me to go to a nursing home. (Sadly). Nurse:
Oh? (Sits down in chair beside the patient's bed and looks at patient, communicating conspicuous feelings non-linguistically.}
Patient: I've heard terrible things about nursing homes. They say they don't give you the right food ... (pauses} and they, uh, don't treat you well. I certainly don't want to go to a place like that. Nurse:
You don't want to go there because you don't think you will treated well. (Reflects conspicuous feelings accurately.}
Patient: Yes. They say if you don't want to eat at certain times you don't get food at all! (Pauses.) And also they think you should do everything they want you to do and, besides, yon don't have much to do there anyway. Nurse:
Perhaps you're worried about having enough to do to fill up the hours? (Reflects conspicuous leelings accurately.}
Patient: Yes, and, uh ... (pauses}, well, my children, uh, they don't come to see me very much; they're so busy, and I'll be, uh, uh, alone. (Voice becomes almost inaudible.} Nurse:
You want your children to come and see you, don't you, so you won't be so lonely? You wish they weren't so busy? (Reflects conspicuous feelings accurately but identifies hidden feelings inaccurately.}
Category 3 The nurse responds accurately to the current conspicuous feelings and their meanings to the patient. In this category, the nurse expresses an accurate perception of hidden feelings in their appropriate essence and strength. These are the feelings that the patient has not yet conveyed or expressed. However, the nurse moves only slightly beyond the patient's conspicuous feelings and thus feelings are present that the nurse is not aware of.
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Example Patient: I have always been dependent on myself only. Nurse:
You're afraid you may have to go and live with someone? Is that right? (Reflects slightly hidden feelings.)
Patient: Yes, probably one of my sons. And they really don't have room for me and I would be putting them out and being a burden to them. Nurse:
It sounds as though you feel that after a while they might come to resent you because you moved in. (Reflects hidden feelings.) Patient: Um hmm. Very much so. Because, like I said, they work and have their own problems, and, ah, they don't need another one. Nurse:
You feel that you would be more or less moving into their lives, butting in, so to speak, and this bothers you because you think they would take you in out of obligation rather than because they really wanted you? (Reflects slightly hidden feelings but does not reflect the deepest feelings.)
Category 4 The nurse communicates accurately, without reluctance or uncertainty, the current conspicuous and hidden feelings of the patient. The nurse perceives and reflects in appropriate words, voice tone and non-verbal behaviour, feelings that are far below the surface - those that the patient is not able to express or was not able to before the interaction with the nurse. If the patient is already exploring those deepest feelings, the nurse is very much with him/her in these deepest moments. The difference between categories 3 and 4 is that, in the latter, the deepest, most hidden feelings are understood and expressed by the nurse. In category 3 only those hidden feelings slightly beyond the patient's conspicuous feelings are understood. Also, in category 4, the nurse is so infallibly in tune with the patient that he/she does not hesitate in responding. Table 9,2 The nurse-patient empathic functioning scale A schematic presentation level of patient's feelings Categories of nurse empathetic functioning
Conspicuous current feelings
Hidden current feelings
Category 0
Ignores.
Ignores.
Category 1
Communicates an awareness that is accurate at times and inaccurate at other times.
Ignores. Communicates an awareness of the presence of hidden feelings, but is not accurate in defining their essence or strength. An effort is being made to understand.
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Category 2
Communicates a complete and accurate awareness of the essence and strength of the feelings.
Communicates an accurate awareness of the hidden feelings slightly beyond what the patient expresses.
Category 3
Same as category 2.
Category 4
Same as category 2.
Communicates without uncertainty an accurate awareness of the deepest, most hidden feelings.
(Kalisch 1973: 1549-1552)
Example Patient: I just don't feel like having a bath this morning. (Flatly.) Nurse:
It really makes you mad to have people telling you what to do all the time, doesn't it? (Reflects deep hidden feelings.)
Patient: Yes! Someone comes in here every other minute telling me to go eat, go to OT, take a bath and anything else they can pick out of their minds! (Heatedly.) Nurse: You really wish they would just leave you alone and stop treating you like you were a helpless child! (Angrily - reflects deep hidden feelings.) Patient: Yes, that's right! (Angrily.) It reminds me of my mother, (Slight pause.) Even when I was 16 years old she told me what clothes to wear; she even went out and bought them without me! She dictated where I went; I couldn't even go to dances. (Voice becomes softer and she begins to cry.) Nurse:
She really made you feel helpless and useless. (Softly and sadly - reflects deep hidden feelings.) Patient: Yes, as if I weren't capable of going to the bathroom by myself. (Continues to cry.) Nurse: And now the very people who are supposed to be helping you, turn around and treat you the same way. (Reflects deep hidden feelings.) (Poggenpoel 1985)
9.2 INTERPERSONAL NURSING COMPETENCIES
The term interpersonal nursing competencies refers to the particular techniques of communication that the mental health nurse uses with a patient. It is these techniques that make the communication between nurse and patient qualitatively different from that between friends, lovers, student and teacher, parent and child, and so on. These communication skills may require considerable discipline and practice before being integrated by the nurse to become part of a personal communication style. The purpose of using these therapeutic communication competencies is to help create a relationship with the patient that he/she experiences as safe, consistent and trustworthy. Once this has
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been established, the patient can explore his/her world-view, relationships and whatever else may be causing difficulty and pain. Let us examine some essential therapeutic communication competencies and attempt to understand how these help to establish a therapeutic nurse-patient relationship. Listening Listening may imply that the nurse is somewhat passive in the patient's presence. Listening in the therapeutic sense, however, requires the nurse to listen actively to what the patient might be saying both verbally and non-verbally. This includes using all one's perceptual capacities, whether they be one's eyes, ears or general intuition, in order to understand the patient better. The question then becomes 'what to listen for?'. Listening to non-verbal messages This involves perceiving the patient's body movements, facial expression, quality and tone of voice, gestures, and so on. Sometimes non-verbal messages contradict (or confirm) what the patient is saying. For example, the patient may fidget continuously or wring his/her hands while saying 'I never get anxious'. Listening to verbal messages The nurse may listen for two types of verbal messages, namely cognitive and affective messages. Cognitive messages. In listening to the patient, the nurse may hear what factual information the patient is conveying, for example, if the patient says, 'The tree fell over the road again!', the nurse is able to hear what happened in the patient's life. Affective messages. The nurse may also hear feelings of what the patient conveys. This is sometimes more difficult to perceive because the patient may not actually state how he/she feels (by saying, for example, 'I am angry'), so the nurse has to listen between the lines for the patient's feelings. Let us take the same example again. If the patient says, 'The tree fell over the road again!', he/she may also be conveying his/her anger and frustration at this event. The nurse may want to encourage the patient to continue talking, show interest in what the patient is saying and generally be there for the patient, without interrupting while he/she might be disclosing information and feelings about him/herself. The nurse can do this by using the minimal verbal response method, for example, by saying 'hmm ...', 'yes ...?', 'and ... ?' and so on. The nurse can also demonstrate interest and presence by maintaining eye contact with the patient, nodding his/her head, using his/her hands and leaning forward. Similarly, the nurse may want to indicate confusion about what the patient is saying without interrupting, for example, by frowning, raising his/her eyebrows or gesturing with his/her hands.
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Responding Having listened, the nurse can then convey to the patient his/her understanding of the patient. The nurse does this by reflecting the patient's feelings, his/her experience and/or the content of his/her message back to him/her in his/her own words. Reflecting feelings Reflecting feelings involves feeding back to the patient, in the nurse's own words, the feelings conveyed to him/her by the patient. Once again the patient may not explicitly state how he/she feels and the nurse may have to read between the lines and/or observe the patient's non-verbal messages. In learning this skill initially, it is useful to start with the words, 'You feel ...' For example, if the patient says, 'The tree fell over the road again!', the nurse may reflect, 'You feel angry that this has happened again.' Although the task of reflecting the patient's feelings may seem rather simple, the nurse is likely to encounter some difficulty in developing this skill. Stereotyping In reflecting the patient's feelings, it is important that it be done in a natural and genuinely warm way, so that the patient does not experience the nurse's responses as monotonous and stilted. Thus, the nurse should not start every reflection that he/she uses with 'You feel' once he/she has mastered the skill, but instead should learn to vary the style of reflecting, tor example by saying, 'You feel angry', 'You seem to be angry', 'I can hear you saying how angry you feel', 'This has really made you angry', 'I am very aware of your anger right now', and so on (Brammer 1985: 73). Timing It is important to determine the patient's readiness before reflecting his/her feelings. This implies many things: One waits for the patient to finish a sentence and for a reasonable amount of time to elapse before making a reflection, thus giving the patient adequate time to hear the reflection. One does not have to reflect every feeling that the patient experiences in the therapeutic relationship; this would require one to reflect every statement that the patient makes. On the other hand, it is also ineffective to let the patient deliver a long monologue before trying to reflect every feeling that the patient might have experienced during that time. Depth It is important to determine the patient's ability to receive reflections before going ahead and reflecting feelings to him/her. Patients are often not ready to hear how sad, angry or
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anxious they are and might experience such reflections as anxiety-provoking and threatening. This is especially true in the initial phase of a therapeutic relationship, when it is important to be tentative in reflecting feelings. It may be appropriate simply to make a mental note of what the patient may be feeling without reflecting at all. Language and terminology The language that the nurse uses must be appropriate to the culture, level of education and intellectual ability of the patient. Paraphrasing Paraphrasing means that the nurse restates the patient's basic message in similar, but usually fewer, words. The nurse 'translates' for the patient the raw data that he/she is expressing into more precise words, without adding new ideas to the message. Example Patient: My mother and I have such fun cooking together - we really laugh and giggle all the time. But sometimes she gets really nasty and impatient and then I wonder what to think. Nurse:
You're sometimes confused by your mother's behaviour towards you.
Clarifying Sometimes the nurse cannot make sense of the patient's message and needs to clarify this with the patient. Alternatively, the patient may have given the nurse a lot of information, which needs to be clarified with the patient if the nurse is to be sure that he/she has heard it all correctly. The nurse may respond by saying, 'I'm somewhat confused, can we just clarify this', or 'Let me just make sure you're saying Focusing
Focusing is a technique used to direct the attention and conversation between patient and nurse to an important topic or detail. The patient may be rambling along vaguely or in a circular fashion and become confused as to what he/she really wants to say. The nurse is then able to focus the patient by saying, 'You're talking about many different things today: your mother, your wife, your new house, etc. How would you like it if we chose one of those aspects to talk about in this session?' Focusing is also a way of helping the patient to get in touch with his/her feelings. One would focus on feelings by saying, 'You mentioned how difficult the funeral was for you. Let's talk about that... maybe you'd like to take yourself back to the funeral right now and describe how you were feeling', or 'You describe a real pain at the memory of your grandmother. Can you locate the pain? Where can you feel it?' Focusing is sometimes done by picking out a particular word that the patient has used and repeating it in a way that invites him/her to explore the issue further. For example, a
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patient talking rather generally about a 'problematic relationship with the doctor' might be enabled to focus on this concern if the nurse were simply to say, 'Problematic ...?' in a gentle, enquiring tone. Focusing may reduce the patient's confusion and distress by enabling him/her to address manageable aspects of an overwhelming issue, rather than becoming entangled in an incoherent array of thoughts and feelings. However, it must be noted that, in focusing the patient, the nurse should not force him/her to talk about problems that provoke too much pain. In such a case, the nurse could, for example, simply reflect, 'This seems too difficult to talk about.1 Questioning It is generally accepted that questions should be used sparingly and carefully in a therapeutic conversation lest they become substitutes for the reflection of the patient's feeling and/or listening, which both convey empathy and understanding to the patient. The patient may easily be 'lost' in the face of a barrage of questions for which he/she may not have answers and this may well leave him/her feeling interrogated and attacked. Questions starting with 'why' are especially accusatory, as they easily imply criticism and moral judgement. Questions do have some use in gathering information about the patient, however particularly during the initial phase of the therapeutic relationship or during the assessment interview. It is important to use an effective technique when questioning the patient, so that the above-mentioned problems may be avoided. A common technique involves the use of open-ended questions. These are questions asked by the nurse to which the patient cannot answer yes or no. Questions starting with 'how' or 'what' often tend to elicit elaborated answers from the patient, for example, 'How is it that you came to be admitted today?' instead of 'Why were you admitted?' (which sounds accusatory and judgemental) or 'What do you mean when you say "painful"?' Using silence Silences inevitably occur during a therapeutic conversation between nurse and patient. Although they often make the patient (and therapist) feel uncomfortable, they can be used for a variety of purposes. They allow both patient and nurse to think, gather their thoughts and explore issues further. They often motivate the patient to talk and share thoughts or feelings. Angry, anxious, depressed or introverted patients may experience a silence as supportive, accepting and caring. Silences can sometimes result in a power struggle, however, and it is often useful for the nurse to break such a silence by calling attention to it, for example by saying, 'You've been quiet for a while now - I wonder what you're thinking about?'
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Confrontation Confrontation is an act on the part of the person who is confronting that stimulates the person who is being confronted to reflect on or change some aspect of behaviour. Although this kind of interaction is usually unpleasant in the short term, it can be extremely beneficial in the long run. In the process of confrontation the nurse brings to the attention of the patient a discrepancy, which can be in one of the following areas: unrecognized strengths, where there is an underestimation by the person of him/herself; unrecognized weaknesses, where there is an overestimation by the person of abilities in a specific area; the real intent of the patient, where it is distinguished by words or other means. An example is the patient who keeps on promising to stop drinking but actually continues to do so. Confrontation is more effective in persuading the patient willingly to examine his/her own behaviour if: it focuses on behaviour rather than on motivation, since behaviour is observable and less vague than motivation; it is done within a healthy, meaningful relationship between the nurse and the patient; it is done with the motivation of promoting growth in the patient and not in anger, to punish or to humiliate; it is done empathically; or it slows down the pace of the interaction between nurse and patient and hence allows issues to be explored in a more moderate, regulated fashion. Probing The patient may find it relatively easy to explore problems and spontaneously disclose information about him/herself in the empathic atmosphere of a therapeutic relationship. It does, however, sometimes become necessary for the nurse to prompt and/or probe in order to understand the patient and/or problem better (or simply to help the patient release pent-up feelings). The nurse may do this in the following ways. You mention that you love Peter. I wonder what love means to you? You mentioned that you lead a difficult life with your mother. I wonder what is most difficult for you about living with her? You never talk about your father's role in your unhappy childhood. I wonder what your feelings towards him are? Assertiveness An effective nurse is one who can express her/his thoughts and feelings comfortably and confidently in a positive, honest and open manner. This is called assertiveness and it shows
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that you respect yourself enough to expect respect from others for you, your thoughts and your feelings. Assertive behaviour allows others to know where you stand, and prevents you from becoming a victim who is manipulated and hurt by others. Table 9.3 Contrasting assertive, aggressive and acquiescent behaviour Behaviour
Aggressive
Assertive
Acquiescent
Aim
To dominate others.
To share thoughts and feelings.
Not to rock the boat.
Characteristics of message
You-messages, accusing, sarcastic, absolutes (e.g. always, never, ought to).
l-messages. Specific.
Does not take a stand, gives no personal opinion.
Non-verbal behaviour
Frown, raise voice, stare down the other.
Level look, neutral facial expression, clear voice.
Looks down, fidgets, talks softly, frequent smiling, speak hesitantly.
Beliefs
I know best Others are fools How dare she/he!
I have equal rights to others. It is important to share thoughts and feelings. I have a right to refuse.
Others know better than I do. I cannot refuse. I cannot hurt him/her.
Results
Gets isolated from others. Problems remain for others.
Feel good about self. Problems often get solved. Gets closer to others.
Blames others. Manipulates to get what you want. Gets angry and hurt, but hides it. Problems remain.
Assertive behaviour is based on an assertive view of self and others. This behaviour is based on the following 'assertiveness rights': The right to have opinions and feelings and stand up for these. The right to say 'No' or 'Yes' without feeling guilty. To decide what to do with own body, time and property. To make mistakes and take responsibility for them. To ask for what you want. To be treated with respect. To be listened to.
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If you believe you have to be right all the time, or that others have to approve of what you say or do all the time, or that others always come first, and you last, it is almost impossible to act in an assertive manner. One of the central techniques used in an assertive communication style is the c l-message'. An T-message' consists of the four R's: Report. Here you describe exactly what is happening in a non-blaming manner. Relate. You relate or explain how this is affecting you, using T, not 'You'. Request. You ask in concrete terms for what you need changed. Result. You spell out the positive and negative results if the change is made or is not made.
Example Report: Pat, over the last two weeks you have twice taken my textbooks from my room without asking me. Relate: When I needed them, they were not there, and this wastes my time and makes me angry. Request: Please do not remove books unless you have asked me before the time. Result: I can then plan my work so that we can both use the books. Otherwise, I will have to lock my room. The same incident will be handled as follows in an aggressive manner: 'Pat, you are really making me furious by forever stealing my stuff from my room. If you cannot keep your hands off my books and stuff, then please stay out of my room!' A compliant person might say: 'I was late with my assignment today, because I could not find my midwifery textbook last night!' Unless nurses master assertiveness, they find it difficult to cope with interpersonal situations, with colleagues and with clients. It is also a competence clients often need, and the nurse should role model it for them. Self-awareness The mental health nurse enters the therapeutic relationship with the patient along with his/her world-view - his/her unique values, beliefs, cognitive and affective styles, as well as moral and spiritual orientations. The patient, in turn, enters the relationship with a worldview that may be quite different or even alien to that of the nurse. An important concern of the nurse then becomes how to facilitate the patient's personal growth without allowing material from his/her own frame of reference to interfere with or obstruct this process. The solution to this problem lies in the nurse's developing a significant degree of selfawareness - a concept best illustrated by example. One of the most debilitating characteristics of patients with conditions such as depression and schizophrenia is a very low level of motivation, and one of the mental
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health nurse's treatment goals would be to improve this. A nurse who has a need to be regarded (by him/herself and/or others) as an accomplished and effective practitioner may become very frustrated and angry with the patient's ongoing lack of motivation. This may result in his/her giving up on the patient and developing a conflicting relationship with him/her. If, on the other hand, the nurse is aware of the need for achievement, he/she may not demand that the patient be motivated and may then be able to regard the demotivation not as a personal insult but as part of the patient's condition. Such awareness may allow the nurse to be warm, caring and non-judgemental, as is required in supportive therapy. Countless other examples could be given. This points to the important conclusion that the development of self-awareness is a lifelong process - each patient whom the mental health nurse encounters will make unique demands upon him/her. Self-awareness is cultivated by reflectiveness; thinking about what has happened, why it happened, how you responded, and why. It can also be cultivated by role-playing different roles, and analyzing your responses afterwards. The more the mental health nurse is aware of the values, hopes, fears, needs, expectations, demands and anxieties that constitute his/her own frame of reference, the greater the nurse's capacity for keeping these issues in the background while attempting to understand the patient from within his/her particular frame of reference. In short, the greater the nurse's self-awareness, the greater the capacity for congruence, acceptance and empathy. It will become apparent to the reader as we discuss these points that the characteristics of the mental health nurse's basic therapeutic attitude overlap with one another and are, indeed, essentially inseparable. It is important that these characteristics be read in conjunction with one another and not as discrete entities. 9.3 THE NURSE-PATIENT RELATIONSHIP
The relationship between nurse and patient depends on a range of factors, such as the personality and other characteristics of each of them (nurse and patient), the time they have spent and will spend together, the objectives of the contact, and situational factors. According to different authors, there are three types of nurse-patient relationships. Table 9.4 sets out the differences between the three types. In essence the difference lies in the level of intimacy involved. The clinical/instrumental relationship is appropriate when the nurse sees the patient for a short time, for a minor or routine matter. The therapeutic/protective level is appropriate for most patients being cared for in a hospital, or in a long-term outpatient setting. The nurse mainly sees the patient as a patient, but has some understanding of the patient as a person. In the connected/reciprocal relationship the nurse and patient see each other as persons in the first instance, and being a nurse and a patient comes secondary. This type of relationship usually develops over time, and not with all patients. It is a choice that both people make, and control in this kind of relationship is much more equal than in the two previous types.
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Table 9,4 Three levels of nurse-patient relationships
Type of knowing
Listening
Understanding
Exploring
Intervening
Clinical/instrumental
Therapeutic/protective
Connected/reciprocal
General (case)
General and more specific
Case, patient and person
knowledge.
patient knowledge.
knowledge.
Content and obvious
Content and underlying
feeling.
feeling.
clinical situation.
External and some internal patient response.
patient's perspective.
Factual data.
Factual data and patient's
Personal meanings both
perception of the
of the situation and the
immediate situation.
effect on the patient's life.
Explanations and
Sharing information.
factual information. Reassuring presence
Mobilizing resources.
Sharing own interpretations.
Content.
External view of the
and manner.
Primary internal, from
Providing support. Concrete and specific feedback.
(From Stein-Parbury 2000: 40)
All relationships develop through a number of stages, although not all pass through every stage. Table 9.5 summarizes the tasks in each stage. It is important that the nurse be aware of how the relationship is progressing and whether goals are being met. Table 9,5 Tasks and stages of nurse-patient relationships Stage
Critical tasks
Preparing
Gather information. Prepare self to prevent labeling or stigmatizing.
Establishing
Establishing trust. Assess each other - allow patient to assess as well. Manage the first interview to achieve relationship and information goals. Negotiate the future.
Building
Develop a way of sharing control over what happens in the relationship. Empower the patient.
Ending
Discuss the emotions involved. Review the relationship.
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There are a number of problems that might occur in nurse-patient relationships. The first is that the patient might not be willing to engage in a relationship with the nurse, or the nurse might be unwilling to engage with the patient. A nurse who dislikes a patient might be unwilling to admit it, since it is against the socialization message of nursing. The nurse might then ignore these feelings, rationalize or overcompensate. These feelings should be acknowledged and discussed with a colleague or supervisor. If a patient dislikes the nurse, it might be possible for another nurse to take over the client. However, if it is a general dislike related to the illness of the patient, patience and respect are the only options. A second problem might be that the relationship becomes social instead of professional. A professional relationship does not mean a distant, formal relationship. It only means that one keeps in mind the therapeutic and care goals, and works towards these. A social relationship has no therapeutic or care goals, and may therefore be superficially friendly, or focus on non-threatening topics. While this might be comfortable for both the patient and the nurse, it may leave the patient without the professional assistance needed. Lastly, the nurse might become over-involved with the patient. In such a case, the nurse reacts emotionally, becoming either a personal friend, or a rescuer taking over all the patient's problems. In these cases the nurse loses control over herself and the relationship and can no longer empower the patient or give the professional assistance needed. 9.4 THE NURSING PROCESS The nursing process, a systematic approach to patient care, has become an institution in nursing over the last 30 years. It is used in mental health nursing in a way that is similar to that of other areas of nursing. The nurse commences with the assessment of the patient or group and makes a nursing diagnosis. This is followed by the planning of care, and its implementation. Evaluation takes place throughout the process, and this can lead to further assessment, a revision of the diagnosis, new plans, and additional actions. Assessment and possible interventions are described in the following two chapters. More specific assessment tools and interventions are described in the chapters dealing with specific mental illnesses. However, more needs to be said about nursing classification systems. Such classification systems exist for nursing phenomena, which lead to diagnoses, for nursing actions and for nursing outcomes. The most comprehensive classification system is the International Classification for Nursing Practice (ICNP), which includes all three aspects. It was developed by the International Council of Nurses and published in 2001. Classification systems were developed to establish a common language for describing nursing practice, in order to enable comparison across time and space and to promote research and quality management. A nursing diagnosis can be defined as a problem or issue that is the focus of nursing interventions. According to the North American Nursing Diagnosis Association's (NANDA) diagnostic system, it always involves a response to a problem. A diagnosis in
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this system involves a two-part statement: the actual problem, the aetiological factors and the defining characteristics. The phrases 'related to' and 'evidenced by' are useful to link the identified problem with the causes and the characteristics. For example, impaired social interaction (actual problem) related to a lack of appropriate social skills and confidence (aetiological factors) evidenced by having no friends, and taking part in no social activities involving others (defining characteristics). In the case of a problem that is only a risk, and not an actual problem, the diagnosis has only two parts, namely the problem, and the risk factors. For example, risk of impaired social interaction related to the following risk factors: long hospitalization, low motivation, limited income. The International Classification for Nursing Practice (ICNP) identified eight components to a nursing diagnosis, which also act as outcome classification. They describe the following components to a nursing action: The action type. For example, counselling. Target. For example, the entity affected by the action. Means. The instruments or services used or provided, for example, group therapy. Time. The points in time and/or the time intervals of the actions, for example, weekly until discharge. Topology. The anatomical region in relation to the median or the total where it occurs, for example, partial or total. Location. The anatomical region of the body, for example, arm, leg. Routes. The pathway through which a nursing action is performed, for example, oral or intramuscular. This is a very comprehensive approach to the nursing actions and seems more applicable to computer systems and research than to written nursing records. Townsend (1990) developed a nursing diagnostic system based on the NANDA approach, but combined with the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR), which identifies the most common nursing diagnoses associated with different psychiatric conditions. Her approach will be followed in this book with reference to nursing diagnosis. Reference will be made to the ICNP as far as nursing interventions are concerned. CONCLUSION The skilled mental health nurse is one who practises the three basic interpersonal attitudes consistently. He/she can also systematically use interpersonal competencies in a systematic way to assess, plan for and assist clients. This is indeed the core of mental health nursing and, without it, knowledge of the different conditions will be useless.
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WEB RESOURCES
v/ww.psychological-hug.com/ This website was developed by Dr Lawrence Bookbinder and has very useful information about empathy. It gives you an example of an empathetic conversation and links to other sites on the topic. www.nanda.org/ This is the website of the North American Nursing Diagnosis Association, where you can find the most recent information about their nursing diagnostic taxonomy. www.icn.ch This is the website of the International Council of Nurses (ICN) and it links to the ICNP classification system. The ICN invites you to submit views, participate in research and get involved in other ways. REFERENCES Brammer, L M. 1985. The Helping Relationship. New Jersey: Prentice-Hall Inc Dainow S. 1986. Believe in yourself. Nursing Times. June 25: 49-51 Egan, G. 1982. The Skilled Helper. California: Brooks/Cole Publishing Co Kalish, B. What is empathy? American Journal of Nursing. 73, 1548-1552 International Council of Nurses. 2001. International Classification for Nursing Practice. Geneva: JCN Poggenpoel, M. 1985. Psychiatric Nursing Methods and Skills. Johannesburg: Juta & Co Ltd Stein-Parbury, J. 2000. Patient and person. Developing interpersonal skills in nursing. (2nd ed.) Sydney: Harcourt Townsend, M C, 1990. Nursing diagnoses in Psychiatric Nursing. Philadephia: F A Davis Co
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CHAPTER TEN
Assessment of the Psychiatric Patient G E PIETERSEN L MIDDLETON
Objectives After studying this chapter the learner should be able to: Assess the complete range of the lifestyle functioning of an individual on an in- or outpatient basis, taking into account all the indicators of the patterns of functioning. Elicit specific psychopathologies during assessment. Identify and interpret the characteristics of the psychopathologies about which enquires are made. Differentiate between the uses and value of alternative assessment methods. Determine the position of a particular patient on the continuum of lifestyle functioning. Compile a scientifically justifiable nursing care plan for all identified problems.
INTRODUCTION This chapter is divided into four sections: 10.1 Assessment of own learning needs with respect to the process of psychiatric nursing evaluation. This section briefly outlines how the process of critical reflection can assist the nurse in working through what is often described as the 'maze' of psychiatric assessment. 10.2 Developing a context for psychiatric assessment and diagnosis. This section briefly outlines one model for understanding the course and outcome of mental illness and mental health in order to provide a context within which the cure-approach of the biomedical model and the care-approach of psychiatric nursing can be effectively integrated in psychiatric nursing assessment. 10.3 Assessment for a medical diagnosis. This section deals with the collection of information required for a tentative diagnosis (according to the DSM-IV-TR). It may be collected and used by any team member.
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10.4 Assessment for a nursing diagnosis. Nursing assessment is based on the conceptual framework for mental health nursing, discussed in a previous chapter. Specific information, in addition to that already available, is required to form the basis of nursing care and this information is gathered and used only by nurses. Assessments by nurses and other team members should be viewed as complementary and not as separate entities. 10.5- Alternative assessment methods. Nurses use alternative assessment methods when 10.7 the assessment pattern that is generally used is not compatible with the cultural background ot the person about whom information is being gathered. 10.1 ASSESSMENT OF OWN LEARNING NEEDS Consider whether you are able to answer the following questions, relating to the process of psychiatric assessment, to your own and your supervisor's satisfaction. 1. What is the difference between subjective and objective data? 2. How can a relationship of trust be built up during a data-gathering interview? 3. What are the phases of a data-gathering interview? 4. What are the directive and non-directive techniques used during an active datagathering phase? 5. What are the requirements for interviewing? 6. What adjustments must be made during an interview with a patient who is: quiet; talkative; angry or aggressive; confused; nervous; tired; or evasive? 7. What evils must be avoided during an interview? 8. What general framework can a nurse use to ensure that an interview runs smoothly? (Based on the theory in Uys & Viljoen, 1987, General Nursing: Medical and Surgical Textbook, Part 1.) Analyse your prior knowledge and skills in the area of psychiatric assessment by answering the questions in the Task Description (in Figure 10.1) and cross referencing to the decision-making aids. Decision-making aid 1 1. 2. 3. 4. 5.
You have difficulty in obtaining information from the patient. You find it difficult to keep the patient to the point of the interview. The patient gives innumerable irrelevant details during the interview. You do not know what information you want from the patient. You do not want to delve too deeply into the patient's history.
6. The contents of the interview deal mainly with you. 7. Your verbal responses do not result in the patient's volunteering further information. 8. You do not respond to the cues that the patient gives.
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9. 10. 11. 12.
You do not know the seven techniques of verbal communication. You do not know the criteria for active listening. You are not familiar with the four levels of empathy. You cannot distinguish between therapeutic and antitherapeutic communication.
Areas of deficiency: You lack knowledge about conducting an interview. You lack skills in conducting an interview. You do not think that you are capable of conducting an interview. You lack theoretical knowledge of specific (psychiatric) disorders.
A
Do you have the necessary knowledge and skills to conduct an assessment interview?
Yes
Start
Conduct an assessment interview with the patient.
No
Decisionmaking aid 1
Determine the area in which you lack knowledge or skills.
B
Do you have all the information required to make a tentative diagnosis and identify the patient's problems?
Obtain the necessary knowledge or practice skills. Make a tentative diagnosis and record it according to the multi-axis system.
Decisionmaking aid 2
Determine where you can find more information about the patient.
Obtain the missing information A B
Figure 10,1 Task description
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Decision-making aid 2 You want to know more about the following aspects regarding the patient. 1. Reason for referral 2. Main complaint 3. History of present complaints 4. Personal history 5. Family history 6. Medical history or present physical condition 7. Work history 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21.
Marital history Legal matters Premorbid personality Present psychopathology Functioning at industrial or occupational therapy Ability to perform physical activities Special investigations performed Psychological tests performed Present and past medications Socio-economic background and future Functioning in the ward Response to nursing care Diet Theory about possible disorders
Contact the: Doctor Social worker Occupational therapist Physiotherapist Dietician Nurse Psychologist Family Employer Spouse Patient's file
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10.2
A CONTEXT FOR PSYCHIATRIC NURSING ASSESSMENT AND DIAGNOSIS
The process of psychiatric assessment is derived from a biomedical understanding of mental illness. This model has as its starting point, a 'disease-cure' understanding of mental illness. Psychosocial factors are considered, but only in as much as they relate to the underlying disease process. The focus of assessment is therefore on identifying the presence of specific symptom clusters for the dual purposes of psychiatric multiracial diagnosis and treatment. Historically, the construction of mental health as a medical problem conferred upon psychiatry the knowledge-generating values traditionally associated with the scientific process of medicine. Notions of objectivity, truth, logic and reason underpin the highly ordered processes of assessment, problem-statement generation, solution-seeking, intervention and evaluation. While this approach may suit the 'disease-cure' discipline of psychiatry, it has not necessarily served the best interests of psychiatric nursing practice. Psychiatric nursing is usually characterized as a caring rather than a curing profession. Emphasis is given to the needs of the 'whole person' and, within each subsystem of wholeness, to developing strengths and remedying deficits. This approach or even aspects of it are often difficult to operationalize in practice settings where the biomedical model predominates. This biomedical approach to care is reflected in psychiatric nursing as it is practised in many psychiatric clinics and hospitals. Although this approach is important, it is only one aspect of psychiatric nursing practice. There are other aspects, which if considered as a part of the assessment process, might go some way to offering a quality of interpersonal care in the same time that it takes to ask the routine questions associated with the biomedical model, such as: 'how are you, any problems, how is your medication, do you have any side-effects, how are you eating/sleeping/getting on with people at home?' The stress-vulnerability perspective of the course and outcome of mental illness This model provides a practical perspective on the relationship between the course and outcome of mental illness and professional intervention. It offers a framework within which to ground both the biomedical and psychosocial dimensions of psychiatric nursing assessment and intervention. According to this model, the onset of an illness episode results from interactions among four factors: Basic vulnerabilities; Environmental stress; Personal and environmental protectors; An underlying neurological or psychological vulnerability makes people vulnerable to developing an illness. Examples of vulnerabilities are genetic predisposition, damage or alteration to the anatomical and/or physiological and chemical systems of the neurological system and psychological vulnerabilities such as a disturbance in sense of self (see Section 2.2 in Chapter 2, 'Sense of self).
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Vulnerability is triggered and psychiatric symptoms emerge when environmental stressors overwhelm or exceed the protective effects of the person's personal coping skills and environmental protectors and supports (protective factors). Stressors are defined as transient or ambient events that demand adaptive changes from the individual and that challenge their existing coping and competence. Stressors include a range of events, situations and experiences which the individual perceives as stressful. Coping refers to the process of striving to master environmental stressors or challenges (Pratt et al. 1999). People draw upon personal coping behaviours and environmental resources in striving to cope. Personal and environmental protectors are resources which act as a buffer against the effects of stress on vulnerability. Personal protectors include self-competent beliefs about self, competency in illness-management, medication management, problem-solving, activities of daily living, managing emotions, interpersonal relations, vocational or work related tasks and a sense of hope, mastery, love and belonging. Environmental protectors are resources outside of the patient and which confer some degree of protection against stress. These are supportive family members, friends and supportive work and living environments; the availability of illness management training programmes for family members and patients, skills training programmes for any or all of the activities associated with each of the patterns of healthy life-style functioning, for example, budgeting, cooking, starting a conversation, using a taxi, finding a job; facilitated access to sustainable supportive networks, including access to physical health care, entitlement (grant) and social welfare resources; the presence of professional attitudes and behaviour which demonstrate respect and regard for the patient and family; the availability of professional psychiatric services including counselling, regular and competent psychiatric symptom assessment and diagnosis reviews and on-going medication monitoring. The person may further develop a functional disability if symptoms persistently interfere with his/her ability to function effectively in the different roles and tasks expected of a person within a given social environment. Because of the many factors involved in this dynamic system, it is difficult to be precise about what amount of change in stressors or protectors will initiate the trajectory toward illness or relapse in a given person at a particular time. However, the effects of vulnerability and stressors on symptoms, coping and functional abilities are lessened by the presence and action of personal and environmental protective factors that exist within the person and their environment. The goal of professional intervention is therefore to assist the person to engage with the process of recovery by increasing and sustaining the presence and action of a range of protective factors in his/her life. Implications for psychiatric nursing assessment A full personal, medical, social and family history is necessary to identify the presence of basic vulnerabilities.
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A full history of the patient's presenting problem and psychiatric illness pattern, together with an outline of the possible stressors preceding the emergence or worsening of symptoms is necessary. A thorough assessment of the person's functional abilities is necessary to understand the impact the psychiatric symptoms may have on the person's lifestyle functioning. A thorough assessment of the presence and action of the personal and environmental protective factors at work in the patient's life is necessary to determine the focus of intervention. The implications of this model suggest that both a deficit and a strengths-related assessment of the patient is needed in order for a medical and a nursing assessment and diagnosis to be developed. Each of these forms of assessment and diagnosis is discussed separately later in the chapter. However, a brief outline of how they could be integrated in practice is given below. A medical diagnosis is made on five points or axes. Axis I
Axis II
Axis III
Axis IV
AxisV
Deals with naming the patient's specific symptom cluster (mental condition). (Information derived from an analysis of the illness pattern and its effect on functional abilities.) For example: Schizophrenia Deals with identifying personality traits or developmental disorders that are present and which may be related to the mental disorder. (Information derived from an analysis of the personal, social and family history.) For example: None identified Deals with naming medical conditions that are directly and indirectly related to the mental condition. For example: Medically healthy Deals with the psychosocial stressors which may have precipitated the illness episode. (Information derived from an analysis of the symptom-stressor relationship.) For example: Lost his job five months ago. Girlfriend broke off the relationship two months ago. Parents are becoming increasingly irritated with his withdrawn behaviour at home and are refusing to support him financially. Uses a specific scale to provide a global assessment of the patient's functioning in terms of the impact of symptoms on overall functional ability. (Information derived from an assessment of functional abilities.) For example: GAF 60-51 (See the scale for the global assessment of functioning, ; page 182.) If we were to integrate the deficit and strengths model of assessment and analysis, a further axis could be added to the multi-axial system:
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Axis VI
Outlines the presence of protective factors at work in the patient's life. (Information derived from a protective factor analysis.) For example: Has two close male friends. Medication is reducing the intensity of the symptoms. Biophysical needs are cared for. Parents are willing to continue to support him financially. Literate and therefore able to benefit from educational pamphlets.
10.3 ASSESSMENT FOR A MEDICAL DIAGNOSIS The assessment of human behaviour and motivation is a complex process. For this reason specific, concrete, objective data must be gathered from which logical conclusions can be drawn. Changes in the functioning of a patient must be noted when information is gathered. Data can be collected within a few minutes or over a longer period. There are two levels of assessment: information-gathering during initial contact with a patient in order to determine immediate needs; and information-gathering over a period during which the team member or nurse attempts to understand the patient while gathering information. When deviations from behavioural norms are identified, their characteristics must be recognized. These must be associated with a description of the deviation that will enable the team member to devise a therapeutic plan. Psychiatric assessment interview A complete psychiatric assessment interview consists of the following three parts: 1. The patient's history: the natural course of the disorder, the social and personal history and the premorbid personality and stress factors. 2. The patient's mental condition. 3. The patient's physical condition. The history supplies information about the patient's biological and social functioning and previous psychiatric treatment, and the mental condition supplies information about the patient's present psychological functioning. The patient's history and mental condition are not two separate entities; there will be an overlapping of information, depending on the course of the interview. People doing a psychiatric interview for the first time sometimes think they should follow the format of the psychiatric report, that is, first assess the presenting problem, then explore childhood events and later explore the person's current functioning and mental state. In most instances assessing the problem involves asking specific questions about the mental state and the person's current functioning. The psychiatric report is a tool the nurse uses once the interview is complete to organize the information into a clear, coherent picture of the patient's life story.
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When interviewing a patient for a psychiatric assessment, think of yourself as a 'therapeutic detective' finding the 'facts' (symptoms and problems), and the feelings and behaviours associated with the 'facts'. This means exploring each symptom and problem the patient mentions in terms of: Frequency, for example: How often do you hear the voices in a day/week? Duration, for example: When did the voices first start? If the patient cannot remember, ask: Do you have any children? If yes, ask: How old is the last-born? How old was the last-born when you first fell ill/heard the voices/had strange thoughts? If no children, ask: How old are you? How old were you when the trouble started? Context or situation, for example: In what situations are the voices more troublesome/ less troublesome? Content, for example: What do the voices say? Feelings, for example: How do you feel when you hear the voices? Behaviours, for example: What do you do when you hear the voices? The purpose of exploring each symptom and problem in such detail is to make a psychiatric diagnosis. The diagnostic criteria for most psychiatric conditions spell out the following aspects: The length of time for which the patient must have had the symptom or symptoms. For example, for the diagnosis of schizophrenia the patient must have displayed the characteristic psychotic symptoms in the active phase for at least one week (unless they are successfully treated) and continuous signs of the disturbance (active phase with or without specific residual or prodromal symptoms) for at least six months. How often the patient experiences the symptoms in a day/week. For example, for the diagnosis of major depression the patient must experience specific symptoms (such as a depressed mood, loss of interest or pleasure) most of the day and nearly every day. Without this kind of exploration it is almost impossible to make an accurate diagnosis. Psychiatric history The information gathered during an assessment interview may be organized as described overleaf. Identifying information This information may be obtained by means of a questionnaire or from the patient's file. Name
Sex Age Race Marital status
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Occupation Address Religion Previous admissions Obtain any further information necessary. Main complaint Give a concise exposition of the problem or reason for referral. Describe the main complaint and present problem in your OWN words. Listen to HOW the patient presents the problem. Listen to WHAT the patient says about the problem. What the patient says and what the nurse knows about the problem do not always correspond. Sometimes the patient's discussion of the problem sounds realistic, but there is no mention of the real reason for the interview. If the information was not given by the patient, record from whom it was obtained. History of present problem Give a concise history in chronological order of the development and course of the symptoms or behaviour for which the patient has come to seek help. Describe the present symptoms. State whether change occurred suddenly or gradually. Name the precipitating stress factor at the commencement of the illness. - 'How long have you had this symptom/complaint?' - 'What made you decide to seek help?' - 'What problems resulted in your admission to hospital?' Determine whether there is a relationship between physical and psychological symptoms. Determine when the symptoms were first noticed, the severity of the symptoms and whether they are always present or occur sporadically. Determine whether the patient obtains secondary gain from the illness. Determine how the symptoms influence social functioning: - School - Work - Church - Community use of free time - Sexual activities Determine the patient's sources of support and present strong points.
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Previous illnesses Emotional or mental disorders Symptomatology Type of treatment Names of hospitals Duration of illness Effect of treatment Patient compliance Psychosomatic disorders Hay fever Rheumatoid arthritis Ulcerative colitis Asthma Hyperthyroidism Gastrointestinal discomfort Recurrent colds Skin disorders Medical disorders Question the patient about the general medical condition. Use the systems as guidelines to obtain a comprehensive history. Neurological disorders Craniocerebral trauma Convulsions Tumours Personal history This information provides insight into the origin and course of the psychiatric disturbance. The reason for taking a personal history is to obtain a precise picture and historical perspective of the patient's developmental process. This information also helps the nurse to understand the nature of the symptoms and what they mean to the patient. Finding out about the person's personal history helps to identify factors that have made the person vulnerable to developing a psychiatric condition. The more vulnerability factors present in the person's history, the greater the likelihood of his/her becoming ill in times of stress, particularly if the person feels that he/she lacks the necessary skills to cope with the stress.
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Vulnerability factors include the following: Biological factors In a longitudinal study done by Mednick et al. (in Bootzin & Acocella 1988) comparing normal children of schizophrenic mothers (high-risk group) with normal children of non-schizophrenic mothers, it was found that complications during pregnancy and birth had occurred in 70 % of the high-risk group who later became ill. Genetic factors There is evidence to suggest that hereditary factors play a role in mental illness. However, this does not mean that a person with a family history of mental illness will become ill. - Except for panic disorder, the genetic evidence for heredity in the anxiety disorders is not strong. - First-degree relatives of people with bipolar mood disorders are far more likely than other people to develop this disorder (10-20 % prevalence, as opposed to 0,4-0,8 % prevalence in the general population). - Relatives of schizophrenics are at a greater risk of developing the disorder themselves, for example, a child of one schizophrenic parent has a 13,8 % chance of becoming a schizophrenic as compared with a prevalence of 1—2% in the general population. Early psychosocial factors Persistent, negative early childhood experiences may result in the development of a poor self-concept which is not 'strong' enough to weather the stresses of life. A negative self-concept is evident in the early personality of the child, the way he/she performs at school, relates to other people, behaves in social and other situations. Exploring the developmental history can also help to determine the person's prognosis. For example, people with a long premorbid history (level of functioning before the onset of the illness) of inadequate social, sexual and occupational adjustment are more likely to have a poorer prognosis than those whose history shows that they fitted in at school, showed no behavioural problems, had friends, got on well with people, completed their education and were able to hold down a job. Note throughout the interview whether there are spontaneous lapses of memory regarding personal history and whether there are emotions associated with the phase of life: pain, stress, conflict. Prenatal history (developmental history) Pregnancy and birth: Abnormalities during birth Birth injuries Planned or unplanned infant
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Early childhood (birth to 3 years of age) Feeding habit: Bottle-fed Breast-fed Feeding problems Early development: When were developmental milestones reached? Note any indication of: unfulfilled needs, separation anxiety, and maternal deprivation. Toilet training Question the patient about feelings associated with toilet training. Symptoms of behavioural problems Question about thumb-sucking, tantrums, head-bashing, nightmares, bed-wetting, nail-biting and masturbation. Personality as a child Shy, restless, overactive, withdrawn, nagging, friendly, not interested in sport, play pattern. Early or recurrent dreams or fantasies Mid-childhood (3 to 11 years of age) School history Question about feelings on school, adjustment, sexual identification, relationships, nightmares, phobias, enuresis, pyromania, cruelty to animals and punishment. Late childhood (puberty to adolescence) School history Relationship with teachers, specific aptitudes, extramural activities, standards passed. Connect problems or symptoms with other school periods. Social relationships Good friends, leader or follower, popularity, participation in gangs or groups, idealized figures, patterns of aggression, passivity, anxiety, antisocial behaviour. Cognitive and motor development Learning ability and motor skills. Learning problems Effect on the child. Emotional and physical problems Nightmares, phobias, masturbation, enuresis, running away from home, crime, smoking, use of drugs and alcohol, anorexia, bulimia, weight problem, feelings of inferiority.
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Psychosexual history From whom was information obtained? Concept of sexuality Sexual experiences Religious background Type of religion in family Own involvement Adulthood Occupational history: training for occupation, number of jobs and duration of service, job changes, present job Note ambitions, conflict situations and relationships with authority figures, peer group and subordinates. Social relationships and activities Note intellectual and physical interests, depth of relationships with the same and opposite sex and the duration and quality of relationships. Adult sexuality Premarital relationships jVlarital history Role played by spouse during courtship, age when married, family planning. Attitude to pregnancy and attempts, number of children and ages Note any problems in any area of sexuality. National service Note any malfunctioning during national service. Family history Provide information about family customs, child-rearing methods and present support systems. Give information about: composition of the family (note the patient's response when the family is discussed); physical and emotional health; genetic hereditary patterns in the family; economic circumstances; occupation of parents; relationships in the iamily; and parents' personalities. If the patient is unable or unwilling to give information, obtain permission to get information from other family members and sources. The information supplied by the
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patient and that obtained from other sources may differ. The information should therefore be checked with someone. Evaluation of a patient's mental status A patient's mental status is evaluated mainly by observation. The evaluation elicits evidence of dysfunction and assists in the identification of aetiological factors of psychopathology. The success and validity of the information gathered during this phase of the assessment is closely associated with the way in which the interviewer approaches the patient; the latter may regard some of the interviewer's questions as strange or absurd. The psychopathology that may be identified may be classified as follows: Area
Normal findings
Abnormal findings
Neat, clean.
Slovenly, unkempt, neglected, wears excessively bright or dull colours, dirty clothes.
General description Appearance
Anxious, panic-stricken, apathetic, confused, uncomfortable, excessively male/female.
Conduct, psychomotor activity
Normal weight for height. Normal skin colour.
Overweight/underweight. Flushed, cyanotic
Maintains eye contact. Normal.
Looks at floor, ceiling. Mannerisms, gestures, stereotypes, echopraxy, clumsiness, tic, rigidity, wariness, hyperactivity, pugnaciousness. Unsteady on feet, drags feet, stoops.
Normal gait.
Speech
Speech can be followed, is relaxed, flowing conversation, logical sequence, dear volume, tone of voice congruent with content of conversation, normal reaction, time adequate vocabulary.
Attitude to interview
Is co-operative, pays attention, is interested, is frank.
Very slow/too rapid Slurred speech, stuttering. Too loud/too soft, mumbles. Impaired/exaggerated. Pressured speech, emotional, monotone, echolalia. Defensive, hostile, playful, evasive, guarded, seductive, intrusive.
Sensorium and Cognition Level of consciousness
Lucid, alert,
Drowsy, confused, stuporous, unconscious, lethargic, in fugue state.
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Area
Normal findings
Abnormal findings
Sensorium and Cognition (continued) Follows simple instructions.
Unable to follow simple instructions.
Orientation
Oriented to time, place, person. If in hospital, knows length of stay. Behaves as if aware of here and now.
Disoriented to one/all three areas (time and/or place and/or person).
Attention, concentration
Maintains attention, concentration during interview.
Cannot maintain attention, concentration during interview.
Able to do 100-7-7-7 with ease.
If too difficult, try simple task: 4 x 9; 5 x 4.
Both short-term and long-term memory good.
Short-term and/or long-term memory impaired/absent.
Memory
Impairment concealed by: - confabulation - denial - circumlocution depending on whether registration, retention, recall of memory is impaired. Long-term memory
Data about childhood - important events, neutral information.
Short-term memory
Past few days -What did the patient do yesterday? What did the patient have for breakfast/lunch/dinner?
Immediate retention and recall
Ability to repeat six figures after interviewer and, after a few minutes' conversation about something else, to repeat same figures; ask patient to repeat your name (level of anxiety and concentration are tested in this way).
Intelligence Average/above-average. Subnormal/intellectual disability. Note level of formal education, self-education; note ability to function at level of basic aptitude; test ability to calculate; test general knowledge; ask questions about level of education, cultural background Mood
Appropriate for situation.
Labile, exaggerated, fluctuates during day/interview, depressed, euphoric, anxious, agitated.
Logical, reasonably to the point, clearly understandable, flows comfortably.
Autistic, thought block, circumlocution, confabulation, flight of ideas, loose associations, neologisms, perseveration, tangential thought, word salad.
Thought processes Form
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Area
Normal findings
Abnormal findings
Thought processes (continued) Credible, socially and culturally appropriate.
Delusions, themes - somatic, ritualistic, destructive, defensive.
Abstract thought
Capable of abstract thought, explains symbolic meaning of idiom correctly.
Concretizes, explains meaning of idiom concretely.
Insight, judgement
Understands realities of illness/health situation.
No/deficient insight into illness/ health situation.
Correct observation of surroundings.
Illusions.
Content
Cognitive processes
Perception
Hallucinations.
An example of a psychiatric report is given at the end of this chapter. Patient's physical condition A physical examination is performed by the doctor or nurse. Abnormalities are linked to the present psychiatric disorder and recorded on Axis III. Special examinations It is sometimes necessary to do one or more of the following special examinations on psychiatric patients: 1. Biochemical examinations 2. Chemical profile, for example: liver functions renal functions thyroid functions 3. Vitamin levels, for example, B12 4. Psychoendocrinological examination, for example: TRH stimulation test Dexamethasone suppression test 5. Electroencephalographic examination 6. Computer tomography of the brain 7. Psychometry 8. Neuropsychological evaluation: Wechsler
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Grassi Bender Gestalt 9. Personality evaluation: Rorschach TAT MMPI 10. Psychosocial background report 11. Occupational therapeutic evaluation The use of the DSM-IV-TR multiaxis system The development of the DSM-IV-TR was an attempt to improve as far as possible on the deficiencies of previous classification systems. The attempt was successful, as the system offers extensive and complete descriptions of the various diagnostic categories. The following descriptions are included: Essential features of the various disorders; Associated features, in other words, other characteristics that are usually also present; Diagnostic criteria, in other words, other essential and associated features that must be present before a diagnostic label can be attached to an individual; Differential diagnoses, in other words the grounds on which a specific disorder can be distinguished from others with which it may be confused. The DSM-IV-TR provides for the evaluation of psychiatric patients in terms of a five-axis system. Each axis measures the separate functioning dimension of a patient. This evaluation method is a comprehensive approach that promotes an effective treatment programme. The advantage of using the different axes is that they partially eliminate the confusion that exists between aetiological factors and the description of conduct. While Axes I and II are classifications of abnormal conduct, Axes III and IV are directed at aetiological factors. Axis V, on the other hand, offers the possibility of determining whether deterioration has occurred or whether normal functioning is being exhibited. Since previous classification systems made no provision for the classification of functioning level, the DSM-IV-TR is a considerable improvement in this regard. Patients are evaluated for each of the following: Axis I: Axis II:
Clinical disorders and the V-codes Mental Retardation and Personality Disorders
Axis III: General medical condition Axis IV: Psychosocial and environmental problems Axis V:
Global assessment of functioning
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Axis I Axis I includes the total classification of psychiatric disorders as well as the V-codes. Vcodes are conditions that cannot be attributed to a psychological disorder, but which are the focus of attention or treatment. When necessary, a multiple diagnosis can and must be made on Axis I so that a comprehensive description of a patient's present condition can be provided. It is possible, for instance, for a person to have both a psychoactive disorder and a mood disorder on Axis I. Axis II The separation of Axes I and II ensures that the possibility of a personality disorder will definitely be investigated during the assessment of adults. If the two axes are not separated, there is a tendency to pay more attention to the obvious psychiatric diagnosis, while the personality of the patient is not considered. As far as the assessment of children and adolescents is concerned, the separation of Axes I and II ensures that the possibility of disturbances in the development of cognitive, social and motor skills is investigated. Multiple diagnoses can and must be made on Axis II, as on Axis I. If no specific personality disorders are diagnosed on Axis II, specific personality traits or the use of coping mechanisms can be recorded. The main diagnosis of a patient is generally the Axis I diagnosis, which will therefore be the focus of treatment. If the Axis II diagnosis is the main diagnosis, the words 'main diagnosis' must be written on Axis II. Axis III Any current physical disorder or condition that is potentially relevant to the aetiology or treatment of the psychiatric disorder is recorded here. Multiple diagnoses can also be made on this axis. Sometimes the physical disorder is aetiological to the psychiatric disturbance (a neurological disorder associated with dementia), sometimes the physical disorder is important to the management of the psychiatric disorder (diabetes in children with conduct disorders) and sometimes this axis is used merely to record important associated physical symptoms (neurological symptoms). Axis IV Recorded on this axis are psychosocial stressors or multiple stressors that were present in the previous year and played a role in the: development of a psychiatric disorder(s); appearance of a previous psychiatric disorder; and exacerbation of an existing psychiatric disorder.
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The following types of psychosocial stressors are considered: 1. Conjugal stress (marital or non-marital), for example, engagement, marriage, separation, the death of a spouse, or discord. 2. Parenthood, for example, becoming a parent, friction with children or the illness of a child. 3. Other interpersonal problems, for example, problems with friends, family, neighbours or partners, a discordant relationship with the boss or the illness of a good friend. 4. Occupation (work, school or home), for example, unemployment, retirement or school problems. 5. Life circumstances, for example, a change of residence, a threat to personal security or immigration. 6. Legal aspects, for example, arrest, imprisonment, a lawsuit or a trial. 7. Development: Phases of the life cycle, for example, puberty, transition to adulthood or menopause. 8. Physical illnesses or injuries: A physical disease may be recorded on Axes III and IV. Diseases, accidents, surgery and abortion are recorded on Axis IV if the impact of the condition is of particular significance to the individual. 9. Other psychosocial stressors, for example, a natural disaster or a disaster caused by humans, persecution, unplanned pregnancy, out-of-wedlock pregnancy or rape. 10. Family matters (only applicable to children and adolescents), for example, a cold, hostile, intrusive, insulting, conflicting or confusingly inconsistent relationship between parents or with the child; a family member's physical or mental disorder; a lack of parental guidance; excessively harsh or inconsistent parental control; inadequate, excessive or confusing social or cognitive stimulation; an anomalous family situation; foster parents; institutional care; or the loss of nuclear family members. The specific stressor is recorded, as well as whether it should be regarded as a predominantly: acute event (present for fewer than six months); or enduring circumstance (present for longer than six months). The following factors are considered when the severity of the psychosocial stressor is rated: - the degree of change that the stressor is causing in the person's life; - the degree to which the person welcomes the stressor and has it under control; - the number of stressors. Axis V
The patient's psychological, social and work functioning at present and for the past year is recorded on this axis.
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Scale for the global evaluation of functioning Consider psychological, social and occupational functioning on a hypothetical continuum of mental health-psychiatric illness. Do not include deficient functioning due to physical or environmental restrictions. Code
90-81 Symptoms absent or minimal (for example, mild fear of examination), good functioning in all areas, interested and involved in wide range of activities, socially effective, generally satisfied with life, no more than ordinary problems or worries.
80-71 If present, symptoms are short-lived and expected responses to social stressors (for example, ability to concentrate after a family row) only a slight impairment of social occupational or school functioning (for example, temporary problems with school work). 70-6] Certain mild symptoms (for example, depression and mild insomnia) or problems with social occupational or school functioning (for example, occasional truancy) but, generally speaking, functions fairly well; maintains meaningful interpersonal relationships. 60-51 Moderate symptoms (for example, occasional blunted affect and panic attacks) or moderate problems regarding social, occupational or school functioning (for example, few friends or conflict with colleagues).
50-41 Severe symptoms (for example, thoughts of suicide, serious obsessive rituals) or any serious impairment of social, occupational or school functioning (for example, no friends or unable to keep job).
40-31 Some impairment of reality testing or communication (for example, speech sometimes illogical, obscure or inappropriate); severe impairment of various areas such as work or school, family relationships, judgement, thought or mood (for example, depressed person avoids friends, neglects family and is unable to work; child often assaults younger children, is defiant at home and fails at school).
30-21 Conduct considerably influenced by delusions or hallucinations or serious impairment of communication or judgement (for example, sometimes incoherent, behaves most
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inappropriately, preoccupied with suicide) OR inability to function in almost any area (for example, in bed all day or no work, home or friends).
20-11 Some danger of injuring self or others (for example, suicide attempts without clear expectation of death, often aggressive, manic excitement), OR does not succeed in maintaining minimum personal hygiene, OR extreme impairment of communication (for example, usually incoherent or mute).
10-1 Sustained danger of severely injuring self and others (for example, recurrent violence), OR sustained inability to maintain minimum personal hygiene, OR serious suicide attempts with clear expectation of death (Louw 1989: 31). 10.4 ASSESSMENT FOR A NURSING DIAGNOSIS A nursing diagnosis is differentiated from a medical diagnosis in that the first is illness driven while the second is needs driven. However, most nursing diagnoses are framed in deficit terms and this in itself represents a challenge for psychiatric nursing wishing to work more from a strengths related perspective. Ongoing assessment of the patient attending the psychiatric clinic The following outline may be used for organizing information in a psychiatric clinicbased assessment. Its advantages are that it takes about the same amount of time as the current method of symptom-medication assessment; focuses on medical and psychosocial issues; is largely an asset or strengths-based assessment but provides some of the same information required from a symptom-medication interview; provides an opportunity for patients to think about and to verbalize both the stressors and protectors operating in their lives and options for coping. 1. Current issues/concerns (stressors): Could occur in any one or more of the areas listed under protective factors; None of significance could be operating at the moment and the patient might simply be wishing to collect his/her medication. 2. Current symptom presentation: Prescience of symptoms on mental state examination; In the absence of symptoms, pejorative statements such as 'denies any symptoms' should be avoided because the statement suggests the person does have symptoms, but is saying he/she does not, or it could imply the patient is an unreliable source of personal data because he/she does not know when he/she is experiencing symptoms.
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3. Current personal and environmental protective factors: Psychiatric diagnosis and medication review; Medication efficacy; Symptom identification and management abilities; Social support network; Physical health status; Family relationships; Personal coping, activities of daily living, scholastic and vocational skills; Access to needed social welfare and other health resources, for example, disability grant; home affairs for identity documents; dentistry; family counselling; Process of consultation, referral, linking and monitoring patient's use of referral service initiated and sustained when necessary. 4. Statement of relationship between 1, 2 and the moderating effects of 3. 5. Statement of patient's need and nursing actions based on 4. Assessment of an inpatient The admission of a patient to a psychiatric unit marks the beginning of a period of intense assessment. All the members of the multiprofessional team do an assessment from the perspective of their profession, and the information is pooled in order to form a comprehensive picture of the patient. Within this framework the nurse's assessment covers mainly the following aspects: the pattern of providing for biological needs; the pattern of developing and maintaining relationships; the pattern of participating in work. The nurse can also help other members of the team with their assessments by taking note of patterns that are of particular importance to them. The clinical psychologist, for instance, will pay particular attention to psychodynamic patterns, while the occupational therapist will concentrate mainly on the way in which the patient spends work time and free time. Inpatient assessments are planned in such a way that they concentrate on the most important problems identified from the admission data. There are basically two approaches that may be adopted either individually or in combination: The patient's functioning may be assessed as a whole. A specific area of functioning may be assessed. Total assessment
This assessment is used to obtain a total picture of the patient's day or functioning. It may be carried out by means of either a comprehensive assessment instrument or periodic
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recordings. The Inpatient Evaluation Scale, which was developed in South Africa, is an example of a comprehensive assessment instrument (see appendix 1). This numerical scale has an interrater reliability of 0,7 and a test/retest reliability of 0,8. Operational validity was determined by evaluating patients before and after a therapeutic intervention. The instrument showed a significant improvement in the condition of these patients, which indicates operational validity. It covers four aspects of functioning - physical, social, orientation and psychopathological - and gives a numerical mark to describe the patient's level of functioning. Another method of total assessment is periodic recording. Periodic recording means that the nurse observes the patient at regular intervals and makes notes of what the patient does and of the context of behaviour. The example in Table 10.1 illustrates how clear a picture of behavioural and coping patterns a periodic recording schedule can give. The period of the schedule may vary from every 15 minutes to every three hours and may continue until a clear picture emerges. After completing a total assessment, the nurse may decide to investigate particular aspects in greater depth by means of specific assessment methods, or she may immediately proceed to make a nursing diagnosis. Table 10.1 Periodic recording schedule
Patient: Mr Simon Dlovu 10/7
11/7
Schedule: Hourly for 24 hours
15:00
Other patients resting
Sitting on bed talking to himself.
16:00
Tea time
Refuses to come to dining room, becomes verbally aggressive when I insist.
17:00
Supper
Takes food to corner of dining room, sits and eats on floor.
18:00
Sits alone on floor in passage
When I approach, he says: 'I am Mary's son.' Speaks incoherently, takes medication without trouble.
19:00
Comes to duty room
Complains of 'thousands of (ice on my back', becomes distressed because nurse does nothing, becomes aggressive, etomine is given.
20:00 06:00
Quiet in ward Rising bell
Quiet in bed. Refuses to get up, is left alone.
07:00
Breakfast
Comes to dining room of own accord, eats at table, talks to no one.
08:00
Medication round
Takes medication without trouble, is quiet.
09:00
Occupational therapy
Sits at table, does nothing, at times seems to be listening to something.
10:00
Mother visits
Sits quietly with mother, she talks.
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11/7
11:00
Tea time
Assaults another patient with mug, is isolated for 15 minutes.
12:00
Ward round
Tells white doctor: 'I have millions of white girlfriends.' Does not answer questions.
13:00
Lunch
Eats at table, takes medication.
(com)
Specific assessment Examples of this type of assessment are: the assessment of the sleep pattern of a patient who complains of an altered sleep pattern; the assessment of the intake of a patient with an eating habit problem; and the assessment of aggressive outbursts or any other episodic behavioural problems. This type of assessment is done by means of a specialized assessment instrument or by means of incident recording. The instrument in the box is an example of a specialized assessment instrument. It is detailed and is used only after a problem in this area has been identified, as it would be too time-consuming to use it on every patient. Sleep Problem Assessment Interview Background 1. How long have you had this problem? 2. What were your circumstances when the problem started? 3. Measures that have already been tried to solve the problem 4. Activities during the day 5. Activities in the evening 6. Medication 7. Do you have any idea what caused the problem? Sleep pattern 1. How many nights a week do you suffer from initial insomnia? How long does it take you to fall asleep? 2. How many nights a week do you suffer from intermittent insomnia? How often during the night does this happen? How often do you have difficulty in falling asleep again? Judge on a scale of 1 to 10 how difficult you find it to fall asleep again. 3. Judge on a scale of 1 to 10 how rested you feel in the morning. 4. How often do you feel tired during the day because you slept badly the previous night? 5. Specify how insomnia affects your daily life.
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Contextual factors 1. What time do you go to bed? 2. Do you wake up with or without an alarm and when? 3. Do you have your own bedroom or do you share a bedroom? 4. Do you sleep alone in bed or do you sleep with someone? 5. What are the noise and light levels in your surroundings at night? 6. Do you use your bed for other activities like studying, reading, watching TV or listening to music or the radio? 7. Do you sleep during the day? If so, where and how often? Cognitive-physiological problems 1. Do you have troublesome or recurrent thoughts? If so, specify what they are. 2. Do you have recurrent dreams or nightmares? 3. Do you experience somatic sensations like a rapid heartbeat, restless legs or muscular tension? Observations
Night
1. Bedtime 2. Periodic observations: s = sleep a = awake r = sleeping restlessly
09:00 10:00 11:00 12:00 01:00 02:00 03:00 04:00 05:00 06:00 07:00 08:00
1
2
3
4
5
6
7
Remarks
Incident recording means that a particular type of behaviour, which is the target of treatment, is identified and recorded every time that it occurs. The extent of the problem and the improvement of the condition can be accurately evaluated by establishing how often it occurs. In this way a record can be kept of the number of times that a patient asks for a painkiller or expresses suicidal thoughts. Observation is a very important aspect of the functions of psychiatric nurses in inpatient units. This task must be scientifically planned and accurately and thoroughly performed.
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Assessment of an outpatient In this case nurses see their patients for short periods only. Their own observations must therefore be supplemented by those of the family or caregivers. To begin with, a complete psychiatric assessment is done of every outpatient and a DSM-IV-TR diagnosis made, after which the nurse does a nursing assessment of each of the six lifestyle patterns. This cannot all be done during the first visit, neither can all the information be obtained from the patient alone. The assessment must therefore be spread over several visits and, if possible, a home visit must form part of the process. If the family or caregivers do not accompany the patient to the clinic and a home visit is impossible, a letter with a few important questions may be used to obtain information. A functional assessment instrument that effectively and easily covers lifestyle is the Functional Assessment Scale of the University of Natal (UNFAS) (see appendix 2). This instrument can be used along with the letter to the caregivers in order to obtain a complete picture, even if the family does not come to the clinic. 10,5 DOING A QUICK ASSESSMENT USING A TIME-EVENT CHART A time-event chart is a visual representation of the patient's illness pattern. In essence, it plots the signs and symptoms of the illness, and associated trigger events, over a period of time. In this way, it gives a longitudinal view of the person's relapse and recovery pattern. This chart can be used in a number of different situations and it can be adapted to suit the specific kind of information you and your client wish to clarify. It can be used to: 1. Plot the onset, duration and recovery periods of the illness for the purposes of a psychiatric diagnosis. The information might help to distinguish between the schizophrenia disorders and their subtypes. For example, the criteria for schizophrenia and schizophreniform are identical in all respects, except for the time period. It might also help to classify the longitudinal course of schizophrenia, which can only be done after at least one year has passed since the initial onset of the active-phase symptoms. 2. Plot specific troublesome symptoms that interfere with daily functioning. For example, a person who is troubled by persistent delusions might wish to monitor the symptom in terms of its onset, frequency, trigger and helping factors, on a weekly or daily basis. 3. Plot troublesome side effects associated with medication. For example, a person on lithium might be encouraged to monitor side effects in terms of their onset and relationship to such factors as exercise, salt intake in the diet and water consumption. It is an activity that the client and family can do together, at home. Clients and family members often have different perspectives on the illness. If they use different colours to complete the chart, differences and similarities can be highlighted, and both can be used as a basis for patient/family teaching. Time-event-symptom chart Jonathan's psychiatric history is given on the next page. This method makes it possible to summarize Jonathan's history on a single page which can then be looked over at a glance.
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One can see that the illness has been present for nine months; that most of the symptoms he presents with are active-phase symptoms which have been present for more than two weeks; that the stresses associated with the university seem sufficiently intense to have precipitated a psychotic episode and that the less stimulating environment of home seems to have helped to reduce the intensity of the symptoms for a while; that symptoms reemerged with greater intensity prior to his admission to hospital. The same chart could be used to map his recovery process until he returns home. Jonathan and his parents could be taught to use this method to monitor his recovery, and to detect early signs of relapse. Trigger events could also be used as the basis for teaching coping skills. Event
Time
Enrolled for mechanical engineering at the university. Academic demands stressful. Conflict with roommate.
January 2000
Above events persisted.
April 2000
Symptom
Odd beliefs - people looking at him strangely; suspicious of others, particularly roommate. Persecutory delusions - food being poisoned; authorities 'out to get him'. Academic performance deteriorated
Left university and returned home.
Admitted to hospital by parents
June 2000
Seemed 'calmer' to parents, but was somewhat socially withdrawn
August & September 2000
Self-care functioning deteriorated and social isolation increased. Persecutory delusion returned - food being poisoned and refused to eat
October & November 2000
Auditory hallucinations of a persecutory type; grandiose delusions with thought insertion; psychomotor restlessness.
End November 2000 (present)
Above symptoms present, along with thought blocking and loosening of associations. Loss of weight, appears pale and thin.
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Monitoring specific troublesome symptoms Event
Time
Symptom
Had a fight with father about not looking for a job.
15/2/2002 8:00
Felt anxious, started hearing funny sounds in the right ear; wandered around the house.
Went to buy the newspaper to look for work.
10:00
Felt people were looking strangely; couldn't turn the pages of the newspaper; sound in right ear got worse.
Went to bed and locked bedroom door.
11:00
Sounds became softer; felt a bit calmer.
Slept so couldn't take lunchtime dose of medication; woke up when mother came home and had tea with her.
11:3015:00
Felt calmer but a bit anxious; sound in ear hardly troublesome.
Father came home and apologized for shouting at me.
17:00
Felt a bit anxious but had a nice supper together.
This example shows that the person's troublesome symptom (auditory sound) seems to get worse in situations of conflict and where demands are placed on him to 'do something' constructive. The chart shows that the person does attempt to control the symptoms through withdrawal and quietness. This activity helps but it is not necessarily a long-term solution. The patient could be taught to deal with conflict, and both the parents and the patient could be taught how to communicate with each other in a more constructive way. Depending on time constraints, the nurse could do this herself, or refer the patient to a specialist psychiatric nurse. 10 6 NURSING DIAGNOSIS After the information has been collected, it is classified and interpreted, and the nurse prioritizes the patient's problems that fall within the scope of nursing practice. If there are important problems that fall outside this category, the nurse refers the patient to the appropriate team members or authorities. It is not good practice to identify long lists of problems, since they cannot all be addressed simultaneously and they fragment the attention of the nurse, the patient and the family. It is therefore preferable to work on two or three problems until they have been solved before embarking on a new set. A nursing diagnosis must not only indicate the lifestyle problem but must also identify a possible cause, as intervention depends to a large extent on the cause. The observable
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signs of the problem (or the indicators) must also be recorded to serve as a basis for evaluation. An example of a nursing diagnosis of a patient with residual schizophrenia who is being treated as an outpatient is given below. Absence of work behaviour Indicators: Causes:
Does no home chores, does not even make bed. Lacks motivation, is overprotected by mother.
Absence of community involvement Indicators: Causes:
Does not take out own library books, does no shopping, listens to church services on radio. Is overprotected by parents, institutionalization.
A nursing diagnosis determines not only nursing interventions but also future assessments. For example, if a patient arrives at the clinic with the nursing diagnosis set out above, special attention is given to these patterns during the interview and not to matters which, according to previous assessments, were not problematic. 10.7 GROUP ASSESSMENT
It may be necessary for a nurse to assess groups of people instead of individuals. In this section special attention is given to three ways in which this can be done. Genogram for family assessment A genogram is a diagrammatic, historical 'map' of three or more generations of a family. The preparation of a genogram commences during the first interview with the patient. Universally known symbols are used for the visual representation of facts about the family. The symbols may be viewed as a kind of shorthand understood by all professionals who use genograms as a means of data collection. They also give the patient and family a visual image of the information that they have already given and the information that is still missing. This method of gathering information enables the nurse to compose a visual image of the patient's development, genealogical relationships and present social interaction patterns. This method also affords the patient the opportunity of giving the nurse further information at a later stage about areas that have already been covered but on which the patient wishes to expand. Some of the symbols used to represent various people and their genealogical relationships are set out in Figure 10.1. The nurse 'draws' the history obtained from the patient and keeps the 'map' (visual representation) at hand to obtain more information or to work therapeutically with the patient.
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Masculine
Death
Feminine
Divorce
Marital relationship
Separation
Parent-child relationship
Twins (boys)
Relationship
Remote relationship
Adopted child
Intense relationship (over-involved)
Pregnancy Abortion
Relationship with conflict
Figure 10,1 Symbols for people and their relationships A genogram can be used as part of the family assessment. Ecochart An ecochart (see Figure 10.2) is a review of a nuclear family within the context of the world beyond the family, for example, residential area and community. It demonstrates the relationship of the family members with the community and systems outside the structural boundaries of the nuclear family. An ecochart is particularly useful to a nurse working with a family that has manifold problems. It also serves as a guide for co-operation and the consolidation of services for families. The use of an ecochart alerts a nurse to the possible isolation of a family. Sociogram If the members of any one group associate with one another for a period, they will at some stage show interaction patterns. Certain people associate with particular individuals and ignore others. Some people make a great deal of contact, while others make hardly any. A sociogram is a visual representation of the interaction among people. A sociogram can be drawn up by an observer merely by watching a group of people for a certain period. This is done with the use of the symbols shown in Figure 10.3. See Figure 10.4 for an example of a sociogram drawn up in this way.
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Consumer services
Cultural system
Police
Friends
Extended family
School system
Value ++
Neighbours
Social service
Housing system
Health system
Religion
Figure 10.2 An ecochart representing a family
Patient (add initials)
Busy with an activity
Standing
Staff member (add initials)
Sitting
Observer
Lying
Nurse
Pacing
Nursing assistant
Reading
Hallucination (if patient is obviously hallucinating)
Sleeping
Student nurse
Interacting
Friendly
Interacting for more than a minute
Neutral
Two-way communication
Hostile
Chair
Table
Visitor Figure 103 Symbols used in a sociogram
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Figure 10.4 Sociogram A sociogram is most useful both in identifying factors that hamper or prevent socialization and in demonstrating the interaction patterns of specific patients. 10,8 EXAMPLE OF A PSYCHIATRIC REPORT Psychiatric history 1. Identifying information Jonathan Simons Name: 22 Age: Gender: Male Single Marital status: Occupation: Unemployed Address: 5 Woodstock Road, Claremont, Durban 21 November 2000 Date of admission: Type of admission: Certification Previous admissions: First admission to a psychiatric hospital Religion: Non-practising Church of England 2. Main complaint
Patient admitted to the hospital with the chief complaint of 'the security police are out to get me'. Patient was extremely restless and showed evidence of heightened anxiety, auditory hallucinations and a disturbance in form of thought and content of thought.
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1. Loosening of associations: moves from one subject to another without completing his sentences. 2. Thought blocking: starts a sentence, stops midway and falls silent. 3. He believes that the 'security police are out to get me because I know all about the Star Wars programme and so they want to eliminate me because I am a threat to state security'. 4. He is convinced that the security police are putting thoughts of 'terrible destruction into my head and the radio sent me a message to be careful about putting food into my mouth ... that's how they work ... they poison people they don't like'. 5. He believes that the security police are trying to kill him because he was given the power to stop the Star Wars programme and he is the only person in the world who can do so. 6. Hears a single voice telling him to 'protect the world'. 3. History of present problem
Patient enrolled for a course in Mechanical Engineering at the university in January 2000 (11 months ago). He found the academic demands of the course stressful; he had difficulty in mastering the work and failed all tests and assignments. He disliked having to share a room and was irritated by his roommate who often borrowed his radio without asking. This was a constant source of stress for him, partly because he was unable to confront his roommate about it. He resorted to hiding his radio and eventually took it apart so 'he couldn't get to me any more'. Four months after the course started, that is, eight months ago (April 2000), the patient first noticed that 'something was going on ... I couldn't put my finger on it, but people seemed to be looking at me strangely'. He began to feel suspicious of other people, particularly his roommate, and became convinced that the hostel food was poisoned and that the authorities were 'out to get him' because he realized he knew the 'secret workings of Mechanics'. His academic performance deteriorated; he began missing lectures and refused to write any more tests because 'they wanted to suck my brains dry'. He left the university in June 2000 after three months and returned home. His parents reported that he 'seemed much calmer' for the first two months he was home, although his behaviour was a 'bit odd', for example, he would refuse to eat with the family or talk to his friends when they came to visit him. His social and self-care functioning deteriorated rapidly during August and September 2000 - he refused to wash or change his clothes and would sleep with a pile of dirty laundry near his bed. He began withdrawing from the family and spent the last month totally isolated in his room, writing a book on 'Mechanical Engineering and techniques for interplanetary espionage'. He would refuse to eat the food prepared by his mother, saying 'it's contaminated with poisons and evil things'. He would sneak down to the kitchen after the family had gone to bed and make his own sandwiches, which he would eat in his own room.
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In the two months before admission (that is, October and November 2000), he began hearing voices; he was convinced that the security police were trying to kill him; believed that he was vested with a power to stop the Star Wars programme; maintained that the security police were putting terrible thoughts into his head. The day before his admission he left the house in an agitated state, saying that he 'had to leave because they are coming to get me'. His parents were able to stop him and immediately took him to their family doctor who arranged for the patient to be certified and admitted. The parents are very concerned about him and are willing to participate fully in his treatment plan. 4. Previous illnesses Emotional or mental disorders Treated by a private psychologist in 1996 (4 years ago) for depression following the death of a close friend who was killed in a motor vehicle accident. Treatment lasted 6 months and was successful. Psychosomatic disorders: Nil Medical disorders No specific medical disorders. His sleeping pattern has changed in that he sleeps most of the day and 'works' at night. Personal hygiene and grooming are impaired. His mother reports that he has not washed or changed clothes for two weeks and refuses to allow her to change his bed linen. He eats sporadically, mainly sandwiches at night, and has lost 10 kg in the last 4 weeks. He appears thin and pale. He has no history of drug or alcohol use and does not take over-the-counter medications except for the odd headache tablet. Neurological disorders: Nil 5. Personal history Prenatal history Planned, normal pregnancy; 'difficult labour', forceps delivery for fetal distress. Mother reports 'baby was a bit blue but was fine a little later'. Early childhood No difficulties or problems were noted with feeding or toilet training. Normal physical development but patient reports that mother has told him that he was a 'shy, quiet child'. Mid-childhood Went to preschool at the age of four. He enjoyed preschool and had many friends. This changed when he went to a different primary school from that of the friends he had made at preschool. He found it difficult to make friends and would spend playtime alone. The older boys bullied him, for example, would steal his lunch-box. He began developing anxiety symptoms, for example, nightmares and nail-biting, and his performance at school deteriorated. After four months his mother moved him to the school where most of his friends were and his functioning improved, although he still describes himself as a 'shy, withdrawn child'.
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Late childhood Uneventful period; passed all standards satisfactorily and left school at the age of 18 after completing matric. He seems to have enjoyed school; he had a few close friends and managed the workload satisfactorily. No evidence of learning problems or emotional and physical problems, although he does say he thinks he had an 'inferiority complex, especially with girls'. He found girls intimidating and when his friends began dating girls, he felt left out. Psychosexual history He first learned about sex at the age of 10 when his unmarried 17-year-old cousin fell pregnant. His parent were horrified and lectured him about the 'evils of sex outside of marriage'. He began dating girls at the age of 16. He found dating very stressful because he didn't know what to say to girls and he and his date would sit in silence for almost the entire evening. After the third date, he stopped asking girls out and would spend his time with his friends. Religious background Family are non-practising members of the Church of England. Adulthood Patient worked for one and a half years as a petrol-pump attendant after he left school, before entering the army for national service in July. It was while he was doing his national service in a Maintenance Unit that he developed an interest in mechanical engineering and made the decision to study in this field. He had few friends during this time and describes the period as a lonely one. There was 'no one special, I was sort of a loner ... I did go out a few times with some friends from school but I liked to be on my own, listening to music'. He had no girlfriends since early dating in adolescence. A friend organized a blind date for him, but he found the experience stressful because he didn't know how to relate to the girl. He felt shy, awkward and embarrassed and decided to 'quit girls, they are more trouble than they are worth'. He fantasizes about falling in love and getting married. He spent two years in the army in the Maintenance Unit. Again, his pattern of interpersonal relationships was one of withdrawal and isolation.
6. Family history Jonathan is the only child in the family. His parents married in their late thirties and the mother was 40 years old when Jonathan was born. Both parents are physically healthy 60year-olds. Both are retired; his father managed a garage and worked as a motorcar mechanic and his mother was an insurance salesperson for a major insurance company. They are economically secure, provided they live carefully. He describes his mother as somewhat anxious, strict, moody and overinterested in him, for example, she wants to know exactly what he's doing and where he's going every day. This behaviour irritates him but he puts up with it because he believes she 'does it out of love'. He is ambivalent about his relationship
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with her. He describes them as close under certain circumstances, for example, when he is prepared to do what she tells him, and distant under other circumstances, for example when he wants to go out with friends or do something on his own. Jonathan describes his mother as supportive when he has a problem, but otherwise not very warm or demonstrative towards him. He describes his father as a quiet, shy, submissive man, difficult to get close to because of his intense involvement in his work. The family has little contact with the extended family and seem to live an insular life. This behaviour irritates him but he puts up with it because he believes she 'does it out of love'. He describes his relationship with her as warm and supportive. He describes his father as a quiet and shy man. He feels comfortable with his father and enjoys being with him. The family has little contact with the extended family and seem to live an insular life. 6.1 History of mental illness in the family
Jonathan believes his aunt (mother's sister) is a 'bit crazy'. He thinks she was hospitalized for a while in a psychiatric hospital for 'doing strange things', but the family are reluctant to discuss her. The aunt now lives in London. The mother is reluctant to talk about her and indicated that the subject was closed. Mental state examination 1. General appearance
Thin-looking young man, slightly stooped posture. Appears dishevelled and dirty; jeans and shirt torn and dirt-stained, shoes scuffed and laces missing. Appears anxious during interview, for example, exhibiting rapid respiration, rapid speech and verbalization of feelings of fear about being found by the security police if he stays in one place for too long. Restless and agitated with fleeting eye contact - he constantly shifted his eyes around the room, paced back and forth, looked out of the window and under the furniture for the duration of the interview. When asked what he was looking for, he said 'for the devices. I've got to be one step ahead of them all the time'. Attitude to examiner: Seemed suspicious, for example, constantly questioned why interviewer needed to know about his life and became evasive when specific topics such as his book were mentioned. 2. Affect Fluctuated during the interview, but predominantly inappropriate, for example, laughed when talking about the security police 'coming to get him' but objectively appeared anxious and frightened. 3. Perceptual disturbances Auditory hallucinations of a grandiose content: hears a single voice telling him to 'protect the world'. He assumes that this means by guarding his knowledge of interplanetary space wars. The voice has been present almost daily for the past two months and is driving him 'crazy'.
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4. Thought disturbances Form of thought: Generally well sequenced but in times of heightened anxiety evidence of: -
loosening of associations, for example, moves from one topic to the next before completing a sentence;
-
thought blocking, for example, starts a sentence and sometimes stops midway and becomes quiet.
Content of thought: Delusions. -
Grandiose delusions, for example, believes that he is the only one who can stop the space war because he has been 'infiltrated' with the power to do so.
-
Persecutory delusions, for example, believes that the security police are trying to eliminate him by poisoning his food, because of his knowledge of the Star Wars programme,
-
Thought insertion, for example, believes that the security police are putting thoughts of wanton destruction into his head.
Abstract thinking Thinking is concrete. He is unable to explain the symbolic meaning of the idiom 'a rolling stone gathers no moss' - says a stone that rolls obviously won't gather moss because it's moving all the time.
5. Orientation Difficult to test because he believes that it is 'irrelevant where I am, who I am or what time of day it is'. However, he mentioned in conversation that having to stay in a psychiatric hospital would be dangerous for him. This suggests he is oriented as to place. 6. Memory and concentration Long-term memory: Could recall information about his childhood, for example, was able to describe his experiences of preprimary and primary school. Short-term memory: Able to recall the events of the past few days, for example, events leading up to his admission. Immediate retention and recall: Impaired. Unable to concentrate for more than a minute and has to be brought back to the topic. 7. Judgement Impaired, for example, maintains that social rules such as wearing clothes in public are for the 'stupid' and have no relevance to him. 8. Insight Partial in that he recognizes something is wrong with him, but believes that his problems are being caused by the security police.
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Psychiatric diagnosis Axis I
Clinical disorder
Schizophrenia: subchronic type.
Axis II
Developmental and personality disturbances
Not usually assessed by nurse.
Axis III
General medical condition
Has lost 10 kg in the last month, otherwise no significant medical findings.
Axis IV
Psychosocial stressors
1. Chronic: Interpersonal problems - difficulty in developing and maintaining interpersonal relationships and in dealing with conflict. 2. Acute: Occupation - found the academic demands of the course stressful; failed all tests and assignments.
Axis V
Global assessment of level of functioning now and in the past year
30-21, that is, conduct considerably influenced by symptoms and inability to function in almost any area, for example, relationships, self-care.
Axis VI (Protective Factors)
No history of substance abuse. Supportive parents. Completed school education.
Nursing diagnosis Impaired reality testing Severe anxiety Increased motor activity Impaired ability to communicate
Evidence of perceptual and thought disturbances, impaired judgement, insight and concentration. Rapid speech, restlessness, verbalizes feelings of fear possibly related to experience of frightening symptoms. Restless, paces up and down, possibly related to experience of frightening symptoms. Suspicious and mistrustful of others; thought blocking, loosening of associations, perceptual disturbances make it difficult to relate meaningfully.
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CONCLUSION When we say that nursing demands a scientific approach, we mean that the actions of nurses must, as far as possible, be based on empirical data. Empirical data consists either of information gathered directly from patients or from their situations or research data. Scientific nurses therefore collect information from their patients, consider it in the light of theoretical knowledge and then decide what to do. This means that the assessment of patients is the basis of scientific practice. It is not a single stage at the beginning of the interaction between nurse and patient but is interwoven throughout the period of nursing care. Nurses make use of the information gathered by other team members and they in turn use the nurses' data. Both the patients and the people in their environment play an active role in assessment. The more skilled nurses become at the process of assessment, the more easily they are able to decide which aspects to assess and the degree of detail required for each aspect. A beginner's assessment naturally takes longer but need not, because of this, be less effective. WEB RESOURCES
www.allpsych.com/disorders/DSM.html This site gives you more information about each of the DSM-IV-TR diagnostic categories. (See reference below.) www.psychologynet.org/DSM.html Provides a shortened version of the DSM-IV-TR and then a reference book about the condition described in each section. http://www.elis.sk/psych/psyl99.htmtfCROSS This website gives you more information about research on different psychological tests. REFERENCES American Psychiatric Association. 1994. Quick reference to the Diagnostic Criteria from DSM-1V. Washington, DC: American Psychiatric Association Duhe, B D. 1989. Development and Testing of an Instrument for Functional Assessment of Psychiatric Outpatients, (unpublished MSocSc thesis, University of Natal) loudrey, R & Gough, J. 1999. Caring and curing revisited: student nurses' perceptions of nurses' and physicians' ethical stances. Journal of advanced nursing. Vol. 29, (5), p. 1154-1162 Kaplan, H I & Sadock, B ). 1988. Synopsis of Psychiatry. 5th ed. Baltimore: Williams & Wilkins Poggenpoel, M. 1996, Psychiatric nursing research based on nursing for the whole person theory. Curationis. Vol 19. No. 3, 60-62 Pratt, C W, Gill, K J, Barrett, N M & Roberts, M N. 1999. Psychiatric rehabilitation. Academic Press: San Diego Widdeshoven, G A M. 1999. Care, cure and interpersonal understanding. Journal of advanced nursing. Vol. 29, ( 5), p. 1163-1169
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Nursing Interventions LRUYS
Objectives After studying this chapter the learner should be able to: Describe the different nursing interventions applicable to mental health nursing and describe how each works. Implement all mental health nursing interventions appropriately and evaluate your own practice in this regard.
INTRODUCTION The approach followed in this textbook is to give major attention to the basic methods that the nurse uses in psychiatry or mental health. This range of methods, once mastered, can be applied to the nursing care of patients with various psychiatric disorders, or persons in other health areas, or to life generally. In many ways these methods are non-specific - that is, they are not applicable only in a psychiatric setting or only to one diagnostic group. The methods are then discussed, commencing with assessment methods, followed by intervention methods. The methods aimed at groups of consumers are dealt with first, and then the methods aimed at individuals. As the basic approach is similar, the reader will find the same themes recurring in all the different methods. For instance, the theme of empowering people through teaching is evident throughout the many references to teaching. The methods are not watertight compartments: they flow into each other, and one method is often used with one or two others. Ill FUNCTIONAL ASSESSMENT AND SKILLS TRAINING Objectives Define functional assessment, and list the steps in the process. Describe the steps and illustrate the process of teaching a skill to an individual patient.
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Doing a functional assessment is the first step in the process of rehabilitation, just as doing a mental health assessment is the first step in the treatment process. A functional assessment is done to develop an understanding of the client's functioning in the critical skills needed to be successful and satisfied in a particular environment (Cohen, Farkas & Cohen 1986). This definition emphasizes that a functional assessment of an individual is done in the context of his/her environment, and is not a general assessment of functioning - in other words, it measures the person's capabilities against the demands of the environment he/she is in. A functional assessment leads directly into skills teaching of the individual, which will therefore also be dealt with here. The process of functional assessment consists of the following steps: Listing critical skills; Describing skill use; Evaluating skill functioning; and Coaching the client. Step 1: Listing critical skills Listing critical skills means naming the most important skills which the client requires to be successful and satisfied in a particular environment. This consists of listing the requirements from the environment (phase 1), as defined by the client, others and documents. Then, in phase 2, it is decided which of these behaviours are important to the specific client based on his/her strengths and weaknesses with regard to the listed requirements. Listing critical skills focuses the evaluation of client functioning on the most important skills. It is not always obvious which skills are necessary in a particular setting. The first phase of identifying such skills is to focus on the explicit and implicit requirements by talking to people in the environment, with the client, and studying the situation. Inferring behavioural requirements Explicit requirements. This is client behaviour the environment openly demands, for example, written rules. Implicit requirements. This is behaviour which people in the environment expect of the client but do not openly demand, for example, his parents want him to join them for a while in the lounge after dinner and not simply go to his room. How to infer behavioural requirements: Gather information about explicit and implicit requirements. Eliminate non-essential requirements. State the essential requirements as behaviours.
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Guidelines for establishing essential requirements: Frequency. How often is it required? Consequences. How serious are the consequences of not meeting the requirement? Emotional intensity. How strongly do people feel about this? Recency. How recently has this been mentioned? Relevance. How likely is it that the patient will not meet this requirement? Example Lucy Boya lives with her mother in the home of her married brother. She often fights with her sister-in-law about housework, and her brother says that he will not put up with it any longer. Dudu, the sister-in-law, says that her mother-in-law cooks and looks after the clothes. She gets angry when Lucy does nothing, and everybody else must work. Behavioural requirement. Lucy must clean the home every day while the family is out. This includes the yard. Although the list of requirements maybe long, many of them might not be particularly significant to the specific client. The next phase is therefore to identify where the problems and strengths lie. How to specify personally important behaviours Summarize recent unsatisfactory experiences (who, what, when, where and why) Brainstorm with the client behaviour that could positively resolve the experiences, for example: - change your own behaviour - change the other person's behaviour (the requirement); - avoid the circumstance. List the behaviours that need to change in the client. Choose the most appropriate behaviour based on: - Impact. Will the behaviour have a lasting positive effect? - Realism. Can the client imagine him/herself performing the behaviour? Example Lucy says that she wants to be out of the house when the family gets home. She does not like the noise and the many people there at that time. Dudu wants her there then to help with the children. In the afternoon Lucy likes to visit her aunt, who lives alone; they watch TV together. In this case, Lucy can either change her behaviour (stay at home and help with the children), she can change Dudu's behaviour (negotiate with Dudu not to expect her to help with the children), or she can avoid the circumstances (move in with her aunt). Lucy would like to live with her aunt. However, her aunt's son, who is currently in prison, is difficult to live with and is expected back at home when he is discharged. In addition, Lucy likes to live with her family. The choice is made to negotiate with Dudu about her expectations.
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Step 2: Describing skill use Describing skill use means explaining the client's specific use of critical skills, which are needed in a particular environment. This consists of defining behaviour, describing the circumstances under which it should occur, and the frequency at which it should happen. A skill is evidenced in the masterful performance of a set of observable behaviours according to standards, for a purpose, in appropriate circumstances over time. There are three types of skills: Physical skills: requiring primarily bodily behaviours. Emotional skills: requiring primarily interpersonal behaviours. Intellectual skills: requiring primarily mental behaviours. Another classification of skills refers to their primacy: Generic skills. Abilities free of any particular context, for example, planning. Applied skills. Abilities tied to a particular context, for example, planning time usage. Define the behaviour that makes up the skill How to define behaviour: Describe the observable action represented by the verb in the skill name, for example: Skill: 'Explaining problems' Action represented by verb (explain) = clarifying the reason for Explain the meaning of the object of the verb in the skill name, for example: Skill: 'Explaining problems' Object of verb (problems) ~ difficulties State the completed behaviour, for example: Skill: 'Explaining problems' Completed behaviour = clarifying the reasons for difficulties Describe the circumstances under which the behaviour should occur Describe specific people, situations and places clearly. This is done by answering the questions 'when?', 'where?' and 'with whom?' Identify how often the behaviour should be displayed How to identify frequency: Choose a frequency unit, for example, number of times, length of time, number of people. Choose a specified period of time for measurement, for example, every morning, every week, monthly.
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Put it together to state the frequency unit: 'Speak to one stranger at the club every week.'
Example Clean the home. Sweep the floors and yard every morning. Wash the dishes in the sink every morning. Put away things that are lying around. Wipe all tables, bath and basin clean. Make beds in all rooms. This has to be done without prompting, after the family has left for school and work, but before they come back. Negotiate with Dudu. Discuss with Dudu the difficulties around the time the family gets back in order to arrive at a solution. This must be done when they all have time to sit and talk (over a weekend). Step 3: Evaluating skill functioning Evaluating skill functioning means measuring the highest level at which the client can use critical skills. There are three levels of skill functioning: 1. Spontaneous use. Performance of a skill at the required frequency in the described circumstances in a particular environment without prompting. 2. Prompted use. Performance of a skill in the described circumstances in a particular environment when asked to do so. 3. Role-play. Active demonstration of the skill in circumstances similar to the described circumstances. When evaluating skill functioning, the teacher often cannot be present to see how well the client performs the skill. But one also cannot simply guess whether or not the performance of the particular skill is on an acceptable level. It might therefore be necessary to design ways of evaluating skill use. Designing evaluation procedures Identify the components of skill functioning to be evaluated; that is, answer the question: What will be evaluated? Decide on the evaluation method; that is, answer the questions: How would the evaluation be done? Who will be involved? Set the times for evaluation; that is, answer the questions: How often will it be done? For how long will the evaluation go on? The evaluation procedures should include all levels of functioning, as well as a statement on the required performance. Designing evaluation instruments Choose an appropriate instrument and either write the instructions for use, or teach the evaluator how to use it. Family members could be asked to assist with evaluation of skill
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use, as long as the client agrees and does not see it as 'spying' by the family. If a client cannot read, symbols can be used, or use objects which are counted out of one bottle into another. For instance, in the example below, pictures of a broom, beds, and a cloth can be used for the different activities. When evaluating skill performance, it is important to answer the following questions: Does the client perform the required behaviour? Does the client perform the behaviour spontaneously, with prompting, or only in roleplay situations? Does the client perform the required behaviour at the required rate? Does the client perform the required behaviour in the appropriate circumstances? Example Spontaneous evaluation of Lucy's use of her home-cleaning skill: Skill: Cleaning the home. Skill use description: -
Sweeping rooms
-
Sweeping yard
-
Washing dishes
-
Putting things away
- Wiping surfaces -
Making beds.
Date
8 9 10 11 12 13 14
Circumstances: a.m. after family has left, before they return p.m.
Yes Yes Yes Yes Yes No: weekend No: weekend
Sweeps rooms
Sweeps Yard
Wash
Beds
Wipe
Put away
Y N N Y N N N
N N N N N N N
Y Y Y N Y Y Y
N N N N N N N
Y Y Y N Y Y Y
N N N N N N N
Step 4: Teaching the skill Teaching a patient a skill involves leading him/her through a systematic series of instructional activities resulting in the acquisition of a new skill. It consists of the following processes:
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Outlining the content of the lesson. Planning the lesson: - Review the patient's prior experience with the skill. - Give an example of the entire skill and clarify unfamiliar terms. - Teach the patient the new skill. - Provide opportunities for practice. Coaching the patient. Programming for skill use (Cohen et al. 1985). The first two steps of the process should be set out in the form of a lesson plan, as outlined in Figure 11.1. Examples are a very important part of teaching a skill. Look through the lesson content and identify each part of the lesson requiring examples. Then select and create the most appropriate examples and list them in the lesson plan. Example Skill: Conversing with strangers. Examples: An audio tape of a person striking up a conversation at a bus stop. A flip chart with a list of questions and a list of remarks that could be used to strike up such a conversation. Role-playing with a group of patients, with the helper striking up a conversation with them. Opportunities for practice also need careful planning and preparation. The patient should have adequate practice in order to become competent. This requires both performance and critique opportunities. Example Skill: Conversing with strangers. Opportunities for practice: Practice. 'Strike up a conversation with me. I will play the roll of a shop assistant in a grocery store. The shop is not busy. Remember to start with a positive comment.' Critique. Two audio-tape excerpts. -
Identify why the first conversation succeeded. Identify why the second one failed.
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Content outline Skill:
Definition:
Benefit:
Behaviours:
Condition:
Lesson plan:
Review questions:
Outline of entire skill:
Terms and their explanation:
Examples:
Opportunities for practice:
figure 11,1 A lesson plan outline
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Coaching a patient is an interactive process. The helper should encourage patient participation at every step by inviting comments and questions and by receiving input respectfully. Instructions should be clear. The patient's understanding should be checked before proceeding. Part of this process is also to teach the patient to critique his/her own performance accurately. This demonstrates an understanding of the skill and also lays the groundwork for improvement. The helper invites critique from the patient, but also models the behaviour by sharing the helper's perceptions with the patient. This should include sharing your feelings about the performance ('I am pleased with the way you have used positive comments'); describing specific behaviour ('You did not look at me, however, so I had difficulty in hearing you'); and suggesting improvements ('Perhaps you could start by making eye contact and smiling, and then make the comment'). If your critique differs from that of the patient, it is important to stipulate which section of the comments you disagree about and give behavioural observations to back up your opinion. Programming skill use is a step-by-step plan to assist the patient to use the skill in the appropriate frequency and setting. It consists of identifying barriers to skill use, developing a programme to overcome each barrier in successive steps, and supporting client action in various ways. Without this important last step of teaching, many skills that are displayed in the practice setting are never used in real-life situations. Common types of barriers are a lack of confidence, lack of knowledge, lack of planning (forethought) and lack of resources.
Example Skill: Conversing with strangers. Barriers: Confidence: 'I am afraid they will laugh at me.' Knowledge: 'I don't know anything about sport or anything.' Planning: 'When 1 am standing there, I cannot think of a comment to make.' Resources: 'I do not have the bus fare to go to a shopping area.' The helper and patient must develop a series of steps to address each barrier. These steps must be small enough to encourage mastery. The patient can also be encouraged to act by building in supports. These usually take the form of target times (timelines), rewards or a system of monitoring which can include the patient, the helper or family members.
Example: Skill programming schedule Skill: Conversing with strangers. Barrier: Does not prepare for striking up a conversation. Has no knowledge of current events to talk about.
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Programme:
Due dates
Steps
Monitoring
Rewards
Monday
Watch TV news, list topics for conversation
Show list to mother
Bus ticket
Tuesday
List starter comments
Report to helper
Ithuba ticket
11.2 GROUP THERAPY
Objectives Distinguish between social and therapeutic groups, as well as between different types of therapeutic groups. Describe the curative factors in group therapy. Demonstrate skill in the establishment, maintenance, goal achievement and termination of group therapy. Group therapy is a structured or semi-structured process of therapeutic intervention in which the behaviour and emotional responses of the individual members of a group towards one another and towards the group leader are used to improve the mental health and combat the mental illness of the group members. Participation in group therapy provides an experience in re-education. It is a learning and problem-solving process in which each individual is involved with his/her 'own self and the group is involved as a 'collective self. The aim is to manage the behaviour and emotional responses required for change in the individuals and in the group. Table 11.3 Main distinguishing attributes of social and therapeutic groups Social groups Organization Informal, professional, religious activities Dependent on needs or certain interests Membership Varies regarding number of people and objectives
Therapeutic groups
Goal-directed, educational, interventive, preventive Specific change in way of thinking
Limited to people experiencing emotional stress and difficulty in managing Limited to people requiring therapeutic intervention
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Composition Heterogeneous
Sometimes heterogeneous
Representative of cross-section of society
Selection based on specific factors such as age, gender, marital status, specific needs, presenting problems
Leadership Usually by election, appointment, consensus
Therapist is primary group leader Has specific leadership tasks
Not clearly defined
Implements and leads therapeutic process
Flexible Emphasizes therapeutic process
kkkkk Classification of groups There are a number of group classifications, such as open and closed groups, structured and unstructured groups, and heterogeneous and homogeneous groups. The classification that follows distinguishes groups according to method used. A few of these are discussed below. Didactic-inspirational groups This type of group emphasizes the educational experiences of its members and promotes intellectual and emotional changes while reflecting ethical, religious or societal values. Examples Alcoholics Anonymous Sex education Discharge planning Diet group Conversation groups: exploratory, intervening groups This type of group emphasizes the exploration and verbalization of its members' emotional and psychological problems within the context of their past and present relationships and their interpersonal relationships in the group. Examples Personal growth group (T group) Family therapy
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Psychodrama Intensive psychotherapy Marriage therapy Activity groups This type of group uses a particular activity as the structure around which the interaction of the group members is built, encouraging the development of ego strengths and control.
Examples Music therapy Play therapy Exercise group Reality orientation Curative factors Participation in group therapy has a therapeutic effect on group members, provided the following curative factors are present in the group experience: Hope. Observing how members progress and overcome their problems gives the other group members hope. Confidence in the therapeutic process is engendered and group members begin to believe that their condition will improve. Universality. Sharing experiences and finding that others respond positively lead to the discovery that problems, feelings and behaviour are not unique but are shared by others. This is part of the wider human experience and confirms that the group member is not an exception or 'different', which is a reassuring realization. Shared information. Group members often share important information because they come from similar backgrounds and have had similar problems. Altruism. An opportunity to help a fellow group member acts as an important stimulus to an ego that may feel worthless and useless. Interpersonal learning: Group members not only learn from one another's life experiences but also analyse their own feelings and behaviour in the group. Group cohesion. A feeling of belonging and empathy for other group members develops and the group becomes an important source of support. Socialization. Group members learn new, socially acceptable behavioural patterns. They receive frank feedback in a supportive environment about unacceptable behaviour and are encouraged to try new patterns. Ventilation. This encompasses active, verbal participation in the group process by means of self-disclosure and self-examination and leads to the release of negative feelings.
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Group leader's tasks Preparation Meticulous planning is required before a group is started. The following aspects should be covered. 1. Objectives The group leader decides on the objectives of the projected series of group sessions or single session. The clearer the formulation of the objectives, the easier the planning and evaluation. Objectives may be set for the group and for each individual member. 2. Selection of group members Decisions should be made about the selection criteria for inclusion in the group, the number of members to be included, whether it will be an open or closed group and where the members will be recruited. These decisions are taken in accordance with the needs of the patients, the objectives of the group and the rest of the therapeutic programme. 3. Selection of the type of group The next choice is the method to be followed in the group. Will it be a didactic group, an activity group or a conversation group? This decision is based on a comprehensive review of literature. 4. Consultation with the team The group leader is now ready to present the plan to the multiprofessional team. This is done to obtain referrals from the rest of the team and to ensure that the group is congruent with the total therapeutic plan. Logistic arrangements - where and when the group will meet - can also be finalized at this stage. 5. Preparation of the group members It is important to conduct an interview with each member chosen in which the objectives and process (method) are explained and any misconceptions about the group are clarified. Maintenance and goal achievement Once the group has been established, the group leader is responsible for its survival and the achievement of its objectives. The following aspects are important in this respect. 1. Creation of group cohesion It is essential to create group cohesion because the group will be of no use to anyone if the members do not attend the meetings. In order to build group cohesion the group leader should show respect, warmth and empathy to all the members and teach them to do the same by example. This is conducive to a safe and supportive environment. The group leader should also at all times, verbally and non-verbally, emphasize the importance of the group by, for instance, always arriving on time for the meetings. The feeling of hope that this brings about, and of a safe, warm environment are important elements in group cohesion.
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2. Creation of therapeutic group norms All groups should have rules by which they function. In an ideal group the group leader helps the members to formulate their own rules to reach their objectives. The group leader should not be the one to make and announce the rules. Rather, the group should discuss each problem as it occurs and then make a sound rule to cope with the issue. Below is an example of how a group leader can help a group to accept a group norm. Mrs X:
I know I should get help, but I'm afraid to discuss my problem with just anyone. The whole town will know in next to no time.
Group leader: Are you worried that some of these group members might discuss your business with others? Mrs X: I don't want to accuse anyone. I'm just a private person. Group leader: I think it's a very understandable problem. What do the rest of you think? After a discussion the group decides that no one may disclose to outsiders anything they hear in the group. There are a number of important group norms, which the group leader should instil in the group as soon as possible. The first is confidentiality, which was discussed in the example above. An equally important norm is that the group should not, as far as possible, be leader-dependent - the members should talk directly to one another, not through the group leader; they should decide for themselves what they want to talk about and they should give honest feedback to one another. A third important norm is that the members should talk as frankly as possible about their own experiences and, in the fourth place, they should receive self-disclosures with empathy; they should not be judgemental or aggressive. Building such norms is a sensitive matter that requires wisdom from the group leader. Without group norms the group will not be able to survive or function. 3. Creation of a focal point If a group is not helped to focus, the members may chat or work quite happily without ever achieving their objective. There are various ways of focusing a group. In an activity group the activity is usually the focal point, and all the group leader has to do is to help the members concentrate on a well-planned activity. In a didactic group there are generally clear learning objectives that the group leader can highlight. In a conversation group, however, it is more difficult to maintain a therapeutic focus. In such a case a here-and-now focus is a valuable aid: Elinda: 1 find it difficult to get on with women. I enjoy the company of men far more. Group leader: With which woman in this group do you have the most problems? After a discussion Elinda's perceptions of a specific female group member and the latter's response to her are analysed. This makes her problem far more concrete than the vague statement in the 'there-and-then' with which she began.
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4. Management of problem behaviour Group members often display behaviour that threatens the effectiveness or even the survival of the group. The group leader should recognize and cope effectively with such behaviour. Examples are a member who monopolizes the group, people who all talk at the same time or arrive late, a member who loses contact with reality or becomes aggressive. A general rule for managing problem behaviour is to direct the attention of the group to the behaviour and to help the members to set limits themselves for coping with it. A second strategy is for the group leader to use modelling to demonstrate how to cope with unacceptable behaviour. An example is to show the members how to respond when a patient describes hallucinations. In the third place, the group members are encouraged to describe and discuss their response to the incident. These three interventions should enable the group to cope with most types of problem behaviour. Termination Group members should be assisted to take leave of one another from the group experience. Members are often very dependent on the group and are resistant to termination. Feelings of anger, fear, loss and affection should be verbalized and the members should be encouraged to evaluate the entire group experience. The group leader should allow enough time for this phase. 11.3
MENTAL HEALTH EDUCATION
Objective Describe the objectives of mental health education and distinguish between different approaches to and methods of mental health education. Mental health education provides individuals, groups and families with knowledge of and insight into all aspects of the promotion of mental health and the prevention of mental illness. The broad aims of mental health education may be set out as follows: To enhance the understanding, knowledge and ability of individuals so that they are able to manage their daily problems more effectively. To enhance the understanding, knowledge and ability of the community so that it is able to manage the problem of mental illness effectively and in a responsible manner. Various approaches to mental health education Total population approach An attempt is made to provide the total population of a particular area with certain information through the mass media. The aim is to bring about a change in the entire community.
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Milestone approach Individuals are prepared by means of instruction for the maturation crises or the predictable situation crises that await them. They are assisted in finding alternative coping mechanisms and in mastering their feelings. Gatekeeper approach Professional and non-professional groups in a community that have a caring or protective function, such as teachers, community nurses, ministers and police, are taught certain skills. These individuals work with large numbers of people every day and can serve as 'gatekeepers', ensuring early detection and promoting better insight and a positive attitude in the community. Community or group approach A community per se or a group that belongs together geographically (such as factory workers) is the target group for mental health education. High-risk approach The focus is on individuals who run a high risk of succumbing to a particular mental illness. A special teaching programme is prepared for them. For instance, the South African Police has been identified as a high-risk group and a teaching programme on stress management has been compiled to help members cope more effectively with stress, thereby maintaining their mental health. Methods of primary mental health education Mental health education may be given to individuals, groups and communities. Individual tuition can be highly effective if it is given in an understandable form by means of, for instance, lectures, demonstrations, talks or even cassette tapes. Individual tuition has the advantage of being easily adaptable to the known needs of the client. Group tuition often takes the form of speeches, but this is, unfortunately, also the most ineffective method. Behavioural change seldom takes place if people are not given a chance to discuss a matter. If group discussions are used together with speeches, the members of the audience have the opportunity of supporting one another in accepting or rejecting the novelty. The community approach often emphasizes the use of the mass media. This approach is more effective when it includes both the high-risk and gatekeeper approaches as well as group tuition. The life skills approach to mental health education The teaching of life skills as a way of preventing mental illness has recently received much attention. Clinicians have found that enhancing people's competency leads to improved problem-solving ability, so that they can eliminate problems which would otherwise have made them ill. Of course, this technique is not only useful in terms of primary prevention:
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enhancing people's competency can also be part of treating them once disorders have already occurred (see 'Social skills teaching' which follows in section 11.4). However, as a prevention technique it is used in healthy people to enhance their ability to cope with the circumstances and problems of everyday life. Life skills include all those skills that make it possible for a person to maintain a healthy and well-balanced life. Such a person must be able to: identify and acknowledge present and potential difficulties; recognize the short-term and long-term consequences of his/her behaviour; control stress and negative feelings; solve problems; make and implement sound decisions; and affirm positive behaviour with self-praise and increased self-regard. Just think of the many people who come to social services in distress and observe how many of them have a deficiency in one or more of these areas. For example: a young girl comes to the clinic with the symptoms of depression. She tells the story of a series of sexual relations with boys in her school, in search of somebody 'who loves me'. She now has a small baby, and nobody to support her financially or emotionally. She is currently drinking a lot of alcohol, both to make her feel better and as a way of seeking a group of friends. Her health is not good and neither is that of the baby, who has been hospitalized for malnutrition. This example shows a series of decisions which are not leading to health and happiness, but they are probably the best this girl in her particular circumstances could have made. If she had had more life skills, she might have been able to see the problems more clearly, anticipated the consequences of her behaviour, made different plans for her life, and implemented them. This is the aim of life skills training. In response to the 'International Youth Year' in 1985, the National Council for Mental Health developed a life skills programme with the following eight modules: 1. A healthy lifestyle 2. Knowing yourself 3. Communication 4. Assertiveness 5. Goal-setting 6. Time management 7. Productive problem solving 8. Stress management This programme is aimed at the 15 to 24 year age group, but is also applicable to older people. It contains some 'theory' and exercises that a person can do by him/herself, or which can be done in a group. This is a good example of a programme which can be used widely for youth groups, in schools, at churches or in non-governmental organizations.
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Life skills can also be taught through the use of a wide range of games, which have been published. One example is a game called 'Stress Strategies' which is aimed at children aged 8 to 14 years. It is a board game in which players move their tokens around a board and get dealt four types of cards to which they have to react: Relaxation cards. These describe a good relaxation strategy, which the player has to implement immediately, for example: 'Open your mouth and yawn making a loud, yawning sound.' Stress cards. These describe a stressful situation; the player must describe how he/she will deal with the problem, for example: 'Your parents have said that they will take you to a movie this weekend. They get angry about something you do and decide not to take you.' Canyon cards. In this case the problems are bigger, and all players must find solutions together, for example: 'You have problems at home, at school, with friends. You feel your problems will never go away. What can you do?' Sharing cards. These cards give players practice in interpersonal sharing, for example: 'Tell one thing that makes you happy.' The player who reaches the goal first, wins. The game can take quite long, and children generally enjoy playing it (Stress Education Center, Libertyville, USA). Another life skills programme is that developed by Lewis for teaching potential abusers caring for under-five-year-olds how to care for themselves and the toddlers. This programme, called 'Positive caring for the under-fives' is offered to groups of six to eight carers, and consists of ten sessions, each taking about 90 minutes. Carers are encouraged to bring toddlers with them to the group, and they are taught how to play with the toddlers. The sessions cover the following topics: I am a special person Communicating how you feel Do you know how to listen? Does smacking work? Taming the little monster First-aid for children in distress Tools of the trade I'm big Enuffl It's OK - I can handle it! Last words: praise, reward, punishment and togetherness The programme has been tested in different populations in South Africa and has proved effective (Lewis 1995). A facilitator's guide, group handout and visual aids are part of the programme. The life skills approach to health education is very far removed from what is sometimes called the 'information only' approach. It does not just dish out information,
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hoping the person will change his/her behaviour; it focuses on developing skills that will lead to different lifestyles and different life trajectories. 114 SOCIAL SKILLS TEACHING Objectives Define 'social skills' and describe how to assess people's social skills. Describe the steps in the process of skills teaching, and work out a teaching programme for selected social skills. Social dysfunction is characteristic of many mental illnesses, especially schizophrenia (Morrison & Bellack, in Bellack 1984). This is particularly true of persons who have been treated over long periods of time by hospitalization. The person with a psychiatric disorder is often socially isolated, and a member of only the family network. To reintegrate the person in the social world, it is essential that social skills training be part of the treatment and rehabilitation programme. In assessing whether a patient has a skills deficit, the following questions are helpful: Does the patient make others feel uncomfortable? Is the patient able to initiate and maintain a conversation? Can he/she express feelings? Can he/she get others to respond positively? If the answer indicates a deficit, and the patient is on optimal treatment for the underlying mental problem, skills teaching is indicated. Skills teaching can be done on an individual or a group basis. Individual skills teaching flows out of a functional assessment, and has been dealt with under the heading 'Functional assessment and skills training' (see section 11.1 at the beginning of the chapter). Skills teaching in groups is a versatile intervention which can be used both in the rehabilitation process and in primary prevention. It is a structured process that makes use of a behavioural framework to teach social skills. Social skills are learned response components which together comprise a behavioural repertoire that the individual can use in social encounters. Skills are situationally specific, and behaviour which is totally appropriate in one situation, may be inappropriate in another. Those individuals who, as a result of faulty learning experiences or a mental illness, lack particular skills are said to have social skills deficits. These deficits can be identified and can be remedied by training. A social skill is made up of the following components, all of which should get attention in skills teaching: Expressive elements: speech content, paralingual elements such as pace, tone, and pitch; Non-verbal behaviour: eye contact, facial expression, body proximity/distance, body movements;
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Social perception: attention, recognizing cues; Interactive balance: response timing, turn taking (waiting your turn and giving others a chance, social reinforcement (reacting positively to the input of others). The basic steps in the process of skills teaching can be summarized as follows: Identify the skill to be learnt and describe it in behavioural terms. The description must be kept simple; if it is a complex skill, it might have to be broken down into smaller steps. The description of the skill is usually followed by a discussion of why the skill is important or useful. For example: Opening a conversation Identify essential components. Ensure that the components of the skill are clear. When skills teaching is done with psychiatric patients, it is also important to devote attention to the development of correct social perceptions. For instance, a patient needs to be able to read non-verbal cues in others accurately. For example: A conversation involves people talking together. People talk about everyday matters, such as what they have been doing, or what others have been doing. Model the skill. Skills can be modelled in different ways: by role-playing, or by playing a video or audio tape. Such modelling has to be prepared carefully, so that all the correct behaviours are reflected in the example. It is important to give more than one example and to reinforce the important components of the skill. If models are used, they are more effective if they resemble the group members in as many respects as possible, for example: age, gender, status and competence. Patients with more advanced skills therefore make very good models. Do not make the modelling session too long. One or two minutes are sufficient, and the leader should point out aspects of the performance which should be noted specifically. For example: One group leader demonstrates two or three conventional ways of starting a conversation with a patient or another professional, for example, a greeting and a question about a current event such as football results. The different ways of starting the conversation are listed on the board. Rehearse the skill. Each person in the group should get the opportunity to practise the skill in the group. The person is usually encouraged to choose a situation with which he/she is familiar and to role-play this situation. For example: The patient travels by bus to the workshop every day. She is encouraged to turn to the person sitting next to her in the group and start a conversation as though they are sharing a seat on the bus. She may use any of the ideas listed on the board. Give feedback. Feedback is given by describing and discussing the behaviour the person displayed during the role-play. Other group members are encouraged to identify what was correctly done, and what needs improvement. The role-play can be repeated immediately, or a section of it can be repeated. In order to give everyone a chance to practise, the leader might also move to the next person after the feedback.
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Negative feedback could be embarrassing, and the exercise should therefore be structured in such a way that failure is almost impossible. This is done by making the steps fit the skill level of the patients, and by prompting the patient in a friendly, matter-of-fact way. Sometimes the directions given to the patient can also be made so specific that failure is almost excluded, for example: 'Say to the salesperson, "No, I am not interested".' Feedback should always be given in a supportive manner, with clear suggestions for improvement. The feedback should also be quite specific and focus on not more than one or two aspects of the behaviour at one time. For example: Leader: What did you think of the conversation Sue started? Mary: Well, she looked friendly ... Precious: She talked too softly, I could not hear her. She should speak up a bit. Give homework. If participants only practise the skill in the group, they might never transfer the skill to the real-life situation where they need it. They are therefore given a homework task, which requires them to apply the skill in the appropriate environment. This should only follow reasonably successful rehearsals in the group. For example: The patients are asked to open a conversation with one person each day until the next session. In setting up a skills teaching group, the group leader should remember that the lower the functioning of the patients, the shorter the sessions should be. Short sessions of 30 to 45 minutes each are recommended for patients with serious and long-term illness. The group members should be reasonably homogeneous in terms of their social functioning. The optimal number of group members is about four to six members, but this can double with a co-leader. Pace the tempo of the group according to their reaction. They should not feel overwhelmed, but must also be kept interested. 11.5 PSYCHOEDUCATION Objectives Define psychoeducation and discuss its importance. Design and implement an appropriate psychoeducation programme for a patient and family. It has been recognized that patient teaching is an essential component of nursing care so much so that Peplau calls mental health nursing an educative and therapeutic process (Peplau 1952: 9). However, in the nursing literature much more is said about the therapeutic role than about the educative role. This is a pity, because teaching patients and their families about the condition from which the patient is suffering, its treatment and management, is one of the most empowering interventions the nurse can implement. Psychoeducation aimed at patients and their families has been shown to increase their ability to cope with the mental illness and to decrease the possibility of relapse. Sometimes
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this kind of education is given to an individual patient, often to groups of patients in inpatient settings, and sometimes to patients and their families together on an outpatient basis. Patients have tried to explain to professionals how important such teaching is to them. Frese (1993: 40), for instance, says that it is very difficult for a rational adult to accept that he/she is mentally ill: 'The nature of this disorder is that it affects the chemistry that controls your cognitive processes. It affects your belief system. It fools you into believing that what you are thinking or what you believe is true and correct.' To combat these beliefs, rational systematic teaching is necessary. He further explains that, to the patient in a psychotic state, the experiences feel mystic and religious. Such mystical experiences can be very seductive, making the patient feel special and powerful. Again, solid teaching can assist the patient back to reality.
Evidence-based Practice Interventions for helping patients to follow prescriptions for medications Typically, patients take less than half of prescribed medication. This review addresses interventions aimed at improving this. For short-term treatments, one of three interventions reported in three Radomized Controlled Trials (RCTs) showed an effect on both adherence and clinical outcome. Eighteen of 36 interventions for long-term treatments reported in 30 RCTs were associated with improvements in adherence, but only 16 interventions led to improvements in treatment outcomes. Almost all of the interventions that were effective for long-term care were complex, including combinations of more convenient care, information, reminders, self-monitoring, reinforcement, counselling, family therapy, and other forms of additional supervision or attention by a health care provider (physician, nurse, pharmacist or other). Even the most effective interventions did not lead to large improvements in adherence and treatment outcomes. Two studies showed that telling patients about adverse effects of treatment did not affect their adherence. Reviewers' conclusions: The full benefits of medications cannot be realized at currently achievable levels of adherence. Current methods of improving adherence for chronic health problems are mostly complex and not very effective. Innovations to assist patients to follow medication prescriptions are needed. Haynes, R B, McDonald, H, Garg, A X & Montague, P. Interventions for helping patients to follow prescriptions for medications (Cochrane Review). In: The Cochrane Library, Issue 2, 2003. Oxford: Update Software.
As is the case in any other teaching, it is important to prepare a teaching plan for psychoeducation, along the following lines:
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Objectives of teaching plan Increase the patient's and the family's understanding of the condition (for example, schizophrenia), the treatment (for example, medication) and management (for example, symptom management). Increase the understanding and co-operation between patient, family and service providers. Increase the control of the patient and family over the illness and its trajectory. Decrease the family's feelings of guilt and anxiety, and increase their self-confidence, leading to a more stable family life. Teaching methods Since the learners are usually adults, the principles of Knowles (1977) are useful in designing a learning package: Learning should be problem-oriented and meaningfully relevant, so that the learners feel they can use the information immediately. Learners should be actively involved in the learning process and their experiences should form an active part of the content. The teaching should therefore include audiovisual material, short presentations, and much discussion and question time. It should be recognized that patients will have a short attention span and will display some side effects, making it difficult for them to sit still for prolonged periods. Anxiety symptoms can also be expected and teachers should accept and allow such behaviour. The teacher should be a role model to both patients and their families, exhibiting a therapeutic way of dealing with problematic symptoms and behaviour in the group. In this way the process of teaching becomes part of the teaching. A warm, caring and structured environment should be part of every course. Course content The following sessions usually make up a full course in psychosocial education: Session 1: Participants introduce themselves. Explanation of terms used in psychiatry (this gives people a common language to use). Show a film depicting the most common disorder of the participants, and discuss. Session 2: The adapted DSM-IV-TR classification system is explained, together with the main diagnoses in the group and their diagnostic criteria. The patients and families are encouraged to share experiences of symptoms and diagnosis. Biological and stressvulnerability theories of causality are then discussed. Session 3: Anxiety, stress and ways of dealing with anxiety are explored. Participants are encouraged to identify their own level of anxiety and how it manifests. Families are encouraged to discuss the impact of the patient's illness on themselves, and ways of reducing anxiety are explored.
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Session 4: Hallucinations and delusions are explained. Participants are encouraged to share their own experiences with hallucinations and delusions, and how they interact with family members during such episodes. Session 5: Psychotropic medications and the concerns people have regarding their use are discussed. Brain anatomy and physiology are explained and audiovisual material illustrating the work of the drugs is presented. Drug categories, side effects and adverse effects are discussed. Session 6: Symptom management. This is described in section 11.9 later in this chapter. 11.6 MILIEU THERAPY
Objectives Describe the history and current practice of using the environment therapeutically. Discuss the principles of a therapeutic environment. Describe the conditions causing institutional neurosis and the effects of this syndrome. When asylums were instituted for the care of the mentally ill in earlier times, people like Turk believed that patients should be placed in an environment that would have a healing effect on them. He emphasized that they should be treated with respect in a pleasing environment with adequate diversions. One of the most important therapies was therefore the environment itself. The tremendous growth of these institutions eventually led to their losing their therapeutic features. There was serious overpopulation, too few staff, and standards were inadequate. The result was that, far from being therapeutic, they had a detrimental effect on the mental state of many patients. Social scientists investigated the situation in mental institutions and found that these environments caused a secondary illness in patients. They called it institutional neurosis and found that it was caused by the following factors: the loss of contact with the outside world; forced idleness; brutality, suppression and teasing; the authoritative attitude of the staff; the loss of friends, belongings and personal mementoes; the excessive use of medication; the unattractive, uncomfortable and unfriendly environment; the loss of opportunities outside the institution. Patients with institutional neurosis are apathetic, without initiative, disinterested and submissive. Self-care is poor and the patients show no interest in the future or in making practical plans. In the 1940s, an American psychiatrist, Maxwell Jones, created the term therapeutic communityto describe the changes that he brought about in the environment
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within psychiatric units. He viewed the entire experience of living and working in psychiatric units as a psychosocial learning experience, and he analysed it every day during ward meetings. The traditional pyramid of authority with the staff in an exalted position above the patients was flattened so that the behaviour and feelings of the staff also became part of the daily discussions, and patients could take part in decision-making about one another's treatment. A fair amount of success was achieved with this approach. Other hospitals used more general strategies to make the environment more therapeutic. Opendoor units were initiated, staff and patients of both sexes were accommodated in the same ward, contact with the outside world was improved and the physical environment of old wards was refurbished. The World Health Organization set the following standards for a therapeutic environment: The individuality of the patients should be upheld by, for instance, allowing them to wear their own clothes and make their own decisions. The humanity of the patients should be accepted by, for instance, ensuring privacy and giving them living standards equal to those of general patients. The fact that the patients possess a considerable degree of responsibility and initiative should be accepted. Activities and a proper workday are essential for all patients. Principles of a therapeutic environment All inpatient units and institutions in which large numbers of people live together, such as old-age homes, children's homes and halfway houses, should apply the principles for creating a therapeutic environment. Democratization of the treatment process The traditional power structure of the treatment environment was based on a strong hierarchy with the doctor at its head. The milieu therapy approach flattens the hierarchy, giving all the participants a voice in decision-making. Group discussions and meetings are used to ensure that everyone becomes a member of the therapeutic team. Patients share responsibility with the staff for their own treatment and that of other patients. The responsibility that they are given is coupled with authority. This approach succeeds only if the patients and their families are adequately informed about the patients' illness and treatment so that they are then able to take part in decisionmaking with the necessary insight. This intervention is based on the principle of respect for the humanity of the patient. Open communication An essential element of the democratization of the treatment process is the establishment of open communication channels between staff and patients, staff and staff, and patients and patients. Each person is considered to be important source of information and
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therapy and should therefore be fully informed and involved. Secrets are actively opposed. Group therapy, group discussions, and staff and ward meetings are freely used to achieve this goal. Information is limited to the extended therapeutic team, which includes other patients and families. Open communication channels and democracy within the therapeutic framework can be very threatening to the staff. These methods can succeed only if the staff are prepared to run the risk of accepting frank communication and to acknowledge their own faults. Positive attitude of the staff An emotional climate is created largely by the attitudes of the staff. Negative attitudes lead to anti-therapeutic behaviour such as rigidity, teasing, withdrawal and the formation of cliques. Karl Menniger was the pioneer of planned interaction patterns as the basis of therapeutic attitudes. He regarded the following as essential: Flexibility. Rules and rituals are viewed as a means to an end and not an end in themselves. Active friendliness. Staff take the initiative in interaction and show special interest in each patient. Passive friendliness. Patients take the initiative in interaction and the staff respond positively. Casualness. This is an element of informal interaction to establish a comfortable interaction pattern. Vigilance. This means constant observation of and sensitivity to change in the patients or situations. Friendly firmness. This entails a direct, clear approach indicating self-confidence, which, in turn, gives the patient confidence. Work-related activities In the early days of custodial care, patients were often forced to take part in occupational activities to the advantage of the institution. Some work did have some therapeutic value, but patients were not paid for their efforts. There was insufficient work in many wards and this led to idleness, boredom and emotional blunting. Milieu therapy programmes reinstated work-related activities as part of the therapeutic process. A number of factors contribute to the effectiveness of occupational therapy programmes. Firstly, patients should be able to choose what they would like to do. This enables them to participate in activities that they find meaningful. Secondly, there should be a variety of activities to enable patients to investigate various work-related areas with a view to possible employment at a later stage. Other types of therapy, such as art, dancing, music and educational therapy, are also used to develop social and expressive skills.
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Community and family involvement In the past institutions for the mentally ill were far removed from the community. The idea was to protect the community against disturbed patients. Patients could spend their whole lives in an institution without ever going beyond its gates. In the era of the therapeutic milieu attempts are made to keep patients in their normal environment as much as possible to enable them to continue with most of their usual activities while receiving treatment. Open visiting times are maintained to keep family and friends involved with the patients. Contact by letter and telephone is encouraged and home visits over weekends and holidays often take place. Patients are encouraged to use recreational and commercial services outside the institution and not to be dependent on the institution for all their free-time activities. The community is encouraged to become involved with the institution and its residents. Pleasant and safe physical facilities The physical facilities should be acceptable to the patients, their families and the community. Physical facilities in psychiatric hospitals often leave much to be desired. Important aspects that demand the attention of nurses are the following: adequate privacy; acceptable standards of hygiene; facilities for work, recreation, socialization, therapy and safety. The physical environment can promote or impede normal, healthy behaviour. For instance, a ward in which the radio blares forth all day may foster withdrawal in a sensitive patient. On the other hand, an attractive sitting room with chairs cosily arranged in groups encourages socialization. Two scales for evaluating the environment in an institution are given below:
Management practice scale (King)
This scale identifies four aspects of management practice and distinguishes between institutiondirected and resident-directed practices. 1. Rigidity of routine:
Rigid
1
2
3
4
5
Flexible
2. Block treatment:
Group
1
2
3
4
5
Individual
3. Social distance:
Segregation
1
2
3
4
5
Integration
4. Depersonalization:
Institution
1
2
3
4
5
Resident
TOTAL:
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1. Rigidity of routine Management practices are institution-oriented when they are rigid from day to day and from person to person, and when the staff do not take individual differences or unique circumstances into consideration. 2. Block treatment Management practices are institution-oriented when residents are treated as a group rather than as individuals and have to wait in line or large groups for most activities. 3. Social distance This aspect focuses on the extent of segregation or integration between staff and patients. 4. Depersonalization This aspect measures the extent to which patients are allowed personal belongings and privacy, and opportunities for initiative and freedom of expression. Normalization scale (Wolfensberger & Glenn
This scale measures the extent to which the lives of residents are kept 1. Community integration 1 2 3 4 5 Physical: Isolated 1 2 3 4 Social: Isolated 5 2. Age appropriate 1 2 3 4 5 Inappropriate Policy: Practice: Inappropriate 1 2 3 4 5 3. Culture appropriate
normal as possible. Integrated Integrated Appropriate Appropriate
Inappropriate
1
2
3
4
5
Appropriate
Practice: Inappropriate
1
2
3
4
5
Appropriate
1
2
3
4
5
Promotes
Physical: Unattractive, inconvenient
1
2
3
4
5
Attractive, convenient
Social:
1
2
3
4
5
Respect
Policy:
4. Programme develops residents
Restrictive 5. Quality of environment
Paternalism, disrespect
11.7 COUNSELLING
Objectives
Distinguish between a counselling and a social interview. Describe what antecedent and consequent support are, and how these can be shown or not shown.
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Describe the different stages of a counselling conversation. Define and describe constructive confrontation. Describe how conflict is handled in an interview. Counselling is helping a person to analyse interpersonal and intra-personal patterns in order to understand and improve them. It is an interpersonal process in which one person (the counsellor) facilitates the exploration of a feeling or situation which another person (the counsellee) is experiencing. Characteristics of a counselling interview A counselling interview has a few characteristics that distinguish it from ordinary social encounters: The counsellee usually already has a relationship of trust with the counsellor, since people seldom share their concerns with a person they do not know or trust. The topic is usually directly related to something the counsellee is currently experiencing, and is specific. The counsellee provides concrete information and observations. Vague discussions about the past or future rarely lead to change. A counselling interview can take place in any situation if the counsellor recognizes the need of the counsellee and structures the situation so that an in-depth conversation can take place. For instance, it can happen when the person comes for a scheduled clinic visit, or on a home visit, or it can happen between colleagues or friends in their homes or in the tearoom. To ensure that counselling opportunities will emerge, the nurse should build the antecedents of support into relationships; that is, he/she should make sure that his/her relationships with people are supportive. This will open the door to counselling should the person need it at a later stage. The elements of antecedent support are any action that builds the person's trust in the counsellor, congruence in the counsellor's behaviour over time, availability of the counsellor when the counsellee needs him/her, and acceptance of the person. Unless these elements are in place, the counsellee will probably not choose to talk to the counsellor. Once the counselling session has commenced, the counsellor should make sure that the elements of consequent support are in place, so that the counsellee will continue to feel supported and therefore be willing to explore the issues. Consequent support consists of listening carefully so as to understand the person's experiences, recognizing the feelings of the counsellee and giving accurate empathic responses as soon as these feelings are expressed. The counsellor has to show not only that he/she is concentrating on what is said, but also that he/she is beginning to understand; frequent responses will show such understanding. Sometimes it is comforting to touch a person who is expressing such suffering, but this will depend on the person and the context. There are some responses which are almost guaranteed to stop the counselling session, since they make the counsellee feel unsupported.
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These are the following: The cliche. A cliche is an automatic response of superficial reassurance, for instance: 'It will be OK', or 'I'm sure he did not mean that!' This kind of response is appropriate in a social conversation, since it gives the message that the time is not right for deep exploration. However, it is inappropriate in a counselling conversation, where superficiality will bring to an end the discussion of feelings and interpretations. The 'Band Aid' response. This is the 'quick fix' response, in which the counsellor reacts to the first mention of the problem by saying 'Why don't you do such and such?' Such a response makes the counsellee's problems look trivial, since the counsellor can solve them so easily! It conveys the message that the counsellee is not very bright or he/she would have thought of the obvious solution him/herself. In addition, since the problem has not yet been thoroughly explored in the conversation, the solution proposed by the counsellor will probably be a poor one, and the counsellee now has to point out that it is a bad idea. Many a counsellee will feel unable to do this, and will therefore just say, COK, I will try that', and leave, knowing full well that he/she will not or cannot carry out the proposed solution. The counsellee will be introduced to different options only later in the conversation, after a full exploration of the situation. The judge. This is the kind of response which tells the person that he/she is wrong to feel this way or to have done what he/she did. 'How could you do that!' or 'You should not feel like that!' are typical responses in this category. Once a counsellor has become a judge, it is difficult for the counsellee to feel confident that the counsellor respects his/her feelings. Stages in a counselling interview A successful counselling conversation moves through the following stages: The counsellee describes the situation and the feelings associated with it, while the counsellor responds in a supportive way. The counsellor deals with the feelings first, since the expression of feelings decreases anxiety, which allows improved problem solving later in the interview. The counsellor deals with feelings by encouraging their expression and description, usually by giving empathic responses. The counsellor then encourages a thorough exploration of the situation by focusing on different aspects. The counsellee should look again and again at what happened, how it happened, who was involved, what happened before and after, etc. The counsellor tries to help the counsellee to see and understand something not understood or seen before. Useful questions may be: Tf you were in her shoes, what would you have thought/done?' or 'Could there be another explanation?' or Ts there another way in which you could do it?' At this stage of the interview it is important to give positive feedback about the strengths the counsellee has shown, if this has not been done before. Concentrating
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only on the problem, and on what needs to change, often places a great burden on the counsellee. Focusing on what he/she did right, or what the strengths were, builds the person up for the challenges that lie ahead. For instance, the following could be said at this time: 'I am impressed that you did not blow your top, but that you are seeking a positive way of resolving the issue. That is a very mature way of handling the situation' or 'You really have survived enormous hardship. You are clearly a survivor, and that enduring strength is a wonderful part of your personality.' Once the feelings and the situation have been thoroughly explored, it may be appropriate to move into problem solving. The core problem should be distinguished from the peripheral issues, and the counsellee should also be encouraged to concentrate on one problem at a time. It is just not feasible to work on a whole series of problems at the same time: one moves mountains by breaking them up into molehills! The counsellee and counsellor then identify which strategies have been tried and they look for different ones that could still be tried. It is not useful to keep on repeating things that clearly have not worked in the past - this just repeats the failure. However, it might be useful to analyse why strategies which looked promising have failed, since that could assist with future planning. One should look at all the options or alternatives, even those which seem impossible. Investigate the implications of each alternative. Does it seem possible to the counsellee? If not, does he/she need additional skills which can be taught, or additional support which can be given? It is important to generate more than one alternative, since that gives the counsellee hope. If there seems to be only one option, imagine what he/she will feel like when that fails! The counsellee is then assisted to choose an alternative for implementation. Once the choice has been made, the counsellor supports the choice by giving additional reasons why it is a good choice. A plan is also generated to implement the alternative, and the implementation is encouraged through homework, assignments, planning rewards, etc. Counselling interviews with specific goals There are a few types of counselling interviews which have specific requirements because their goals are more targeted than those of the generally supportive, problem-solving interview. The constructive confrontation interview This kind of interview has many uses in the work setting, but, in terms therapeutic settings, it is used mainly in the process of getting a person who is abusing alcohol to take responsibility for getting help. Constructive confrontation is a planned intervention by the confronter (counsellor) where growth is facilitated through drawing attention to inconsistencies. It is always for the benefit of the person being confronted, and the hope is that he/she will thus obtain insight into the perceptions of others and that this will result in a better insight into the situation, which will lead to change.
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Confrontation is usually done by people who have the right to be involved. Every kind of relationship has certain inherent rights, and confrontation is based on these rights. For instance, an employer has the right to confront you on your use of alcohol if it impinges on your work performance. Family members have the right to confront a person if his/her behaviour affects their lives in terms of the home they share, or the love they feel for the person. Confrontation is based on inconsistencies: Inconsistencies between what the person says and what the person does: 'On the 15th of January you said you would go for help, but it is now the 11th of February and you have not done so.' Inconsistencies between theory and practice: 'You tell students to rub pressure parts with soap and water, but research has shown that friction increases the chances of pressure sores.' Inconsistencies between what you perceive and what the person says: 'You say that you are a poor communicator, but I have seen you being very effective in the women's group.' Before embarking on constructive confrontation, the participants prepare a detailed list of instances of such inconsistencies. The more detailed the list, the better. If at all possible, more than one person should be involved in the confrontation, so that the person cannot use the excuse that the particular person is 'against him/her'. If it is a family confronting a family member, it is often useful to have someone from the extended family taking part. Furthermore, an appropriate time for the confrontation should also be chosen, so that there is enough uninterrupted time and the person is in the right frame of mind to listen. If the confrontation concerns a person who abuses alcohol, he/she should obviously be sober at the time of the interview. The interview starts by the confronter asking the other person to listen without interruption. The confronter then assures the person of the good intention of the interview - it is aimed at helping, and it is based on concern, not vindictiveness. The verbal and nonverbal communication of the confronter(s) should confirm that this is the end of the road: something has to be done. The person is then told what the inconsistencies in his/her behaviour are. At least three to five examples should be given at this time. The person is not allowed to interrupt or defend during this presentation. The confronter states clearly what the consequences of the inconsistencies are and puts definite choices before the confrontee. For example: 'Thabo, we as a family care for you, but we can no longer live with your drinking. Last month vou did not give me any household money, and the children and I were hungry for weti-:-, We only had the vegetables out of our own garden to live on. Last week vou slapped Bongi in her face \vhile you were drunk, and she could not go to school for three days to hid-, the injury to her face. On Saturday you were looking for money in the house while you \ere drunk, and broke the bedroom door and the wardrobe. We feel that you have to go to SANCA for treatment on an outpatient basis. We cannot help vou to stop, and you cannot help yourself. If you do not go for treatment, the three of us will move in with my brother Vusi, and leave you.'
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Once all participants have taken part in the confrontation, the confrontee can say how he/she feels about it. Hopefully, the incidents mentioned in the confrontation will have been enough to make denial impossible. However, if the person still denies, more incidents should be mentioned. It is not wise to get into an argument about a specific incident, but rather to point to the many incidents proving the same thing. A confrontation interview has been successful if it creates movement and growth in the confrontee. The conflict resolution interview Conflict is not an uncommon occurrence in life. It often happens, between colleagues, between friends, between family members and between patients and helpers. It is important that conflict be dealt with in a way that allows for its resolution. If that is not done, conflict either goes underground, where it festers and undermines the relationship or organization, or it builds into an explosion which destroys it. The first stage in handling conflict is to recognize that it exists, and that it needs attention. Sometimes little flare-ups between people can be ignored and the tension will pass. At other times, because of the people involved and the intensity or duration of their differences, or because of the importance of the issue, what was once a minor problem becomes a more serious clash, and this must be addressed. The counsellor must explore the conflict with the people involved - this includes the values which play a role in the conflict, the needs and interests which people have, as well as the objectives towards which the different parties are working. Usually all the people involved in the conflict should be present for these discussions. If this is not done, individuals may be able to rally support outside the group after the meeting, and undermine the decision reached. Meeting with everybody decreases the chances of disinformation being spread, thus fuelling conflict, and increases the flow of correct information between all concerned. In this way different participants in the conflict are also prevented from manipulating facts and people. Once the situation has been explored, the alternatives are identified and the possible results of each are outlined: What will be lost, and what will gained? How will it fit with the rest of the organization, rules, people? Groups should not be allowed to minimize the loss and maximize the gains when it comes to their own preferences. The inputs of the other parties are important in this regard. The groups must then come to a decision, and stick to it. This is clearly not always an easy task. Breaking the possible solutions into steps, and using steps suggested by both parties, is often the most successful way of dealing with the situation. 11.8 CRISIS INTERVENTION Objectives Define and discuss crisis, and distinguish between the different types and phases of a crisis. Do a crisis assessment and intervene effectively on the basis of this assessment.
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Define debriefing and explain when it is used. Describe and illustrate the stages of debriefing. A crisis is a situation in which a person finds that the usual problem solving and decisionmaking methods are inadequate. It may also be a turning point in life. This implies that successful management of the crisis results in a return to the pre-crisis condition, with the person back in equilibrium or having grown psychologically and having improved his/her skills. Unsuccessful management of a crisis leaves a person feeling anxious and threatened and functioning less effectively than before. It is also important to remember that a crisis is not a pathological condition; it can happen to anyone at any stage of life. Tyhurst puts it as follows: 'Too often, with its emphasis upon symptomatic treatment, present-day psychiatry denies the patient the opportunity to benefit from his troubles by personal growth and development in relation to the problem.' All crises are self-restricting and therefore temporary. The emotional discomfort caused by a crisis drives the person to take action to decrease anxiety to an acceptable level as soon as possible. The estimated duration of a crisis is one to six weeks. This is why it should be emphasized that crisis intervention takes place in the short term and is aimed at the solution of the immediate problem. A solution is sought to transform the disturbed state into one of equilibrium. A crisis may have one of the following consequences: The individual returns to the pre-crisis state. This does not necessarily imply psychological growth, merely a return to the normal state. The individual not only returns to the pre-crisis state but grows as a result of the discovery of new resources and new problem-solving methods. Lifestyle functioning is better after the crisis than before. The individual diminishes unbearable stress by falling into neurotic or psychotic behavioural patterns by, for instance, becoming withdrawn, suspicious or depressed. Types of crises Most sources classify crises into two main groups: Situational crises and developmental crises, as described below. Situational crises These crises occur as a result of sudden events such as loss of employment or a disaster. These are also known as external crises. Situational crises can be further subdivided into anticipated, non-anticipated and victim crises, as shown in the table on the next page.
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Anticipated crisis
The individual experiences a crisis and is partly involved by participation
Nursery school, divorce, promotion
Non-anticipated crisis
This is an unexpected crisis. The individual is involved without having been able to predict the situation.
Death, prison, hospitalization
Victim crisis
This is a traumatic event that includes physical aggression and forced action by other individuals or the environment.
War, rape, murder, assault, an aircraft disaster, a tornado
Developmental crises These are internal crises and are associated with the normal development stages such as puberty, marriage and menopause. Phases in the development of a crisis One can identify the following four phases in the typical course of a crisis. An individual, confronted with a problem that is threatening, responds with increasing tension. The individual uses the usual problem-solving measures in an attempt to resolve the problem and restore emotional equilibrium. If the usual measures fail and the problem or threat continues, tension and distress increase and the individual feels ineffective. Functioning becomes disorganized and hit-or-miss methods are used to find a solution. If a solution continues to evade the individual, tension rises further and this is viewed as a stimulus to mobilize emergency and new problem-solving methods. The problem may be defined to conform with previous experiences or certain aspects may be negated. The individual may identify with the problem to such an extent that some of the objectives may be abandoned in the process because the individual believes that they are unattainable. The individual may, on the other hand, solve the problem and regain emotional equilibrium. If the individual cannot solve the problem, tension rises above 'breaking point' and personality disorganization follows. Hoff calls this the stage of active crisis: 'Tension and anxiety rise to an unbearable state' (1984: 54). Assessment of a crisis According to Aguilera the following aspects should be taken into account: Stressful events Stressful events are part of everyone's normal life, and they always have the potential of becoming a crisis. The stressful events that play a role in causing a crisis should always be identified. This enhances understanding of the crisis and is helpful in finding a solution.
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Human organism
Stressful
event
State of equilibrium
Stressful event
State of disequilibrium
Feels need to restore equilibrium
A BALANCING FACTORS PRESENT
B ONE OR MORE BALANCING FACTORS ABSENT
Realistic perception of event
Distorted Perception of event
Adequate situational support
Inadequate situational support
Adequate coping mechanisms
No coping mechanisms
Resolution of problem
Unresolved problem
Equilibrium regained
Disequilibrium Continues
No crisis
Crisis
Balancing factors
Figure 11,2 Results of the balancing factors in a stressful event (Aguilera & Messick 1982:65)
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Figure 11.3 Phases in the course of a crisis (Parad & Resnick, in Wilson & Kneisl 1988: 786)
Everyone who contends with the same stressful event does not necessarily experience it as a crisis. There are, however, certain general stressful events (such as a loss caused by death with consequent grief and deprivation) that create a crisis for almost everyone, albeit in various degrees of intensity. More than one stressful event is usually involved in a crisis. Severity of the crisis A further important task is to assess the severity of the crisis by observing the signs and symptoms (such as depression, anxiety, rage and disorganization) and the degree and duration of the crisis. The more severe the degree of the symptoms and the duration of the crisis, the greater the disorganization already present in the lifestyle and the more urgent the necessity of restoring balance. Perception of the events If the individual has a realistic perception of the events, it allows the recognition of the relationship between the events and the feeling of stress. Problem solving is then directed at the reduction of stress and successful resolution is probable. If the individual has a distorted perception of the events, it prevents the recognition of the relationship between the events and the feeling of stress. Efforts to solve the problem are unsuccessful and stress is therefore not reduced. Support systems Support systems are the people in the environment of the individual who are available and who can be depended on to help resolve the problem. These support systems are not only required in a crisis. Humans are social beings, dependent on others in their environment
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to appreciate their intrinsic and extrinsic values. Lack of such support when confronted with a stressful situation may lead to disequilibrium and possibly a crisis. Coping mechanisms One generally applies one's coping mechanisms when confronted with a problem. Some people think about the problem or discuss it with someone. Others cry or relieve their feelings by swearing, kicking a door or breaking something. Yet others are able to withdraw from the situation temporarily while they consider the problem. See 'Psychodynamic patterns', in section 2.2 of Chapter 2, which discusses the effective assessment of the coping mechanisms of an individual. Crisis intervention Crisis intervention may take place by means of an emergency line such as Lifeline or Childline or counselling by a member of a health service. Special crisis groups may also be established to which individuals or groups in crisis may be referred. Sometimes a natural social group experiences a crisis, in which case the people involved are viewed as a group. Examples are a family in the process of divorce, a group of people who work together and who lose a colleague through suicide, and a community after a natural disaster. Strategies for helping people cope with a crisis include the following: Listen actively and with empathy. Be direct and supportive and provide hope. Help the patient gradually to accept reality. Help the patient to acquire new coping mechanisms. Mobilize support systems. Help with decision-making and problem solving. Reinforce newly learned coping mechanisms. Do follow-up work. Debriefing after trauma Psychological debriefing is a form of crisis intervention used with groups of individuals who have experienced a stressful or tragic event. It can be used with a person who has unexpectedly lost a loved one, or with a person who was raped, or with a group of people who were involved in a natural disaster such as a flood. This kind of intervention should take place as soon as possible after the experience of the traumatic event. It is aimed at allowing the victims to express their impressions, reactions and feelings in order to reduce their tension. It also allows them to improve their understanding of what happened, and their reactions to it. They come to realize that their reactions are not unique or weird, and they can be helped to anticipate future feelings
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which may arise. Such debriefing plays an important role in preventing traumatic events from leading to crises and post-traumatic stress disorder. The best time to hold a debriefing session is 24 to 48 hours after the incident. Prior to that victims may still be emotionally 'numb', either from the shock of the incident or because their feelings are still being suppressed so that they can deal with the crisis. Twenty-four to 48 hours after the incident, emotions often surface in an intense form, and this is a good time to deal with them. The effectiveness of debriefing diminishes with the passage of time after the event, as the person builds up defences around the memories. Every effort should be made to conduct the debriefing within six weeks of the event. Debriefing goes through the following stages: The fact stage. Each person in the group is asked to describe briefly what happened to them during the incident. The sequence of events and how they came to be where they were are important elements of this description. The leader can ask a few questions which encourage factual cross-referencing, so that participants get an overall picture of the incident. The thought stage. Each person is encouraged to describe their first thoughts when the incident happened, and what they saw, heard, or felt. These sensory impressions form the basis of the intrusive images and thoughts which may become very disruptive in the post-impact phase. It would seem that verbalizing and confronting these memories decrease their power. Examples of such sensations are: 'The smell is what got me - like a braai', or 'The children's eyes were all open - they all seemed to stare at me', or 'The sound was like a piece of material tearing, just louder, much louder.' This phase also includes asking about what people did, and why. This often brings to light motivation to protect or help others. The reaction phase. Once thoughts and experiences have been verbalized, the participants are asked to describe their feelings. During this sharing of feelings, the normality of feelings is brought to light. Everyone should be allowed to share their feelings and no one should be interrupted or cut short. No feeling is unimportant or irrelevant. Participants are also encouraged to link their feelings with events earlier in their lives. Questioning participants about the worst part of the experience is important, because post-traumatic reactions are often built up around such events. Feelings of helplessness, frustration, fear or loneliness often surface. The leader should identify people who have suffered a lot, who appear silent or who have extreme symptoms, since they may need additional support later. The symptom phase. Participants are asked to describe their reactions in more detail. They should identify emotional, cognitive and physical symptoms experienced at the scene and afterwards. Familiar themes are an initial numbness, with feelings only surfacing a day after the event. Participants often have difficulty repeating behaviour involved in the event, for example, driving a car, or walking home after dark. They
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also sometimes find it difficult to accept that ordinary life events go on after this incident happened to them, and blame family and friends for continuing with their daily lives. It might be useful to include family and friends in the debriefing process, even if it is not done from the beginning. The preparatory and re-entry phase. In this phase the input of the group is summarized in a way that organizes the experience, and normalizes it. It is emphasized that reactions are understandable given the abnormal events. It is helpful to outline feelings which participants may experience in the near future, such as being anxious, feeling vulnerable, having difficulty sleeping or concentrating. Participants should be encouraged to seek further help if their symptoms do not decrease after about six weeks or even increase over time, or if they cannot function at work or at home. It is advisable that a follow-up meeting be planned for the whole group a few weeks later. This follows much the same format as the first meeting, but in less detail. 11.9 SYMPTOM MANAGEMENT Objectives Discuss the phenomenon of relapse and the factors related to it. Describe the process of symptom monitoring, and teach it to a patient and family. Identify and describe strategies to deal with symptoms. People who have one of the three conditions which are collectively called Neurobiological Disorders (NBD), namely schizophrenia, bipolar and major depression, have been found to relapse in most cases (80 %). This leads to rehospitalization, with the resultant cost and trauma. Relapse can be defined as a return of illness symptoms to the extent that they disrupt daily activities and/or require unscheduled inpatient or outpatient intervention. The following are some facts about relapse: Most patients who relapse show an increase in a particular set of symptoms at least two weeks before their contact with the health service, but many about six weeks before. These symptoms typically include: - interpersonal sensitivity; - depression; - anxiety; - somatic concerns; - paranoid ideation; - unusual thought content. Families and patients can be taught to identify these sets of symptoms about one month before relapse takes place, although a small minority only become conscious of the symptoms as late as four days before relapse. About 50 % of patients experience the same cluster of symptoms each time.
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If action is taken, mostly in terms of increasing medication and psychosocial support, the relapse can be prevented in the majority of cases (80 to 90 %) (O'Connor 1991). The process of symptom monitoring and management can be taught to patients and their families by the nurse or another mental health worker. The steps in symptom management are as follows: 1. Identify the trigger symptoms which are associated with the onset of illness in this particular patient. 2. When the trigger symptoms are present, identify factors which are related to relapse. 3. Develop problem-specific interventions. Identify trigger symptoms There are different ways in which this can be done. Professionals sometimes use standardized instruments, such as the Brief Psychiatric Rating Scale, to monitor symptoms at each clinic visit. The findings can then be used to assess the possibility of relapse. Another way of doing this is to go over with the patient and the family the sequence of symptom increase that preceded a recent relapse, so that warning signs can be identified for future monitoring. The goal is to identify 'marker' or 'trigger' symptoms which are always present when relapse is in progress, but which are not present at other times. For instance, one patient reported that he continually hears voices, but he knows that he is relapsing when a particular woman out of his past talks to him. Some patients can identify two levels of triggers: the first level consists of symptoms which occur almost weekly, and which they handle through self-regulatory strategies, while the second level occurs only when relapse is imminent and can be dealt with only by getting help. Patients and/or families are asked to monitor their symptoms over time by filling in a rating scale about every two weeks. The rating scale helps the patient and/or the family to assess both the presence and severity of symptoms, since some indicators of relapse are the presence of a specific symptom (for example, paranoia or the increased severity of a symptom that is always present (for example, the voices become too loud to ignore. It has been found that there is a good correspondence between the ratings of patients and that of their families. However, for patients not to see the family's involvement as intrusive, it is important that the process be discussed openly with both family and patient present, and that agreement be reached regarding what should be done when the 'triggers' are identified. The nurse should then use the completed rating scales to identify the specific symptom or degree of severity which reliably indicates that the patient is in danger of relapse. This decision is crucial. The indicator should be sensitive enough to point reliably to all episodes of threatened relapse in time for them to be prevented. It should not be too sensitive, so that minor fluctuations lead to increased medication.
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The patient and family can then be given a card with the trigger symptoms listed, and asked to check weekly and report to the clinic if any of the symptoms are present at the indicated level. Identify factors related to relapse Generally, relapse is caused by a range of factors, both internal and external to the patient. A summary of such factors is given in Table 11.4. It will be noticed that all of these factors describe situations of increased stress, or of decreased support. fable 11.4 Variables related to relapse Health
Poor nutrition Lack of sleep Fatigue Infection CNS drugs Lack of exercise
Environment
Hostile environment Housing difficulties Pressure to perform Change in life events Interpersonal crisis Loneliness
Attitudes/Behaviour
Low self-concept (poor me) Hopeless - lack of confidence Tm a failure' Lack of control Feeling overpowered by symptoms Poor social skills Poor medication use
In each case, the nurse counsels the patient and family to assist them in identifying which factors are playing a role in the increased symptoms. It is important that they identify the factors themselves, and that the nurse does not 'tell them what is wrong'. This increases their own ability to identify problems and improves their problem-solving ability. Identify problem-specific strategies Early intervention strategies are then necessary to avert the threatened relapse. Usually a temporary increase of medication is needed, coupled with psychosocial strategies to decrease stress and increase support. The following symptom management categories and strategies are positive promoters of health. They are action-oriented, and often involve others: Distraction: - Talking with a friend; - Listening to music; - Prayer; - Dancing; - Watching television; - Working; - Writing; - Going to a nature setting; - Going for a ride or a walk.
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Fighting back: - Positive self-talk; - Positive thinking; - Yelling at the voices; - Not paying attention to the thoughts; - Avoiding situations which increase symptoms. Help-seeking: - Going to the clinic/hospital/therapist; - Phoning a health care worker; - Seeking the support of a family member; - Contacting a support group. Attempts to feel better: - Eating; - Using medication; - Taking a bath or shower; - Hugging a pillow or stuffed animal; - Using relaxation techniques. The following techniques are not so positive, although they may help the patient to remain stable. They do not involve positive action and tend to be passive and reflect the attitude of 'there is nothing I can do'. Isolation: - Going to bed; - Staying at home. The last category of strategies is negative and should be discouraged at all times. They lead to instability, since the use of self-medication counteracts the positive effects of medication and interferes with positive symptom management. Escape-oriented: - Using alcohol; - Using illegal drugs, for example, dagga. The nurse and the patient and family, if necessary, work out what to do to decrease the symptoms. Many of the strategies are fully under the control of the patient, and he/she can implement them without assistance once he/she has been taught what to do. However, since decompensation has already started, patients often need support from family, friends and health care workers to implement positive strategies. The longer it takes to identify the potential relapse, the greater the need for support to turn the process around. The process of symptom management is an essential part of discharge preparation, but the patient may not be well enough by the time of discharge to take in the whole process. It might also not be possible to involve the family at that stage, since hospitalization often takes place far away from where the family lives. This task then falls to the primary health care nurse, who can take a few monthly sessions or a home visit to teach both the family
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and the patient the process of symptom management. This one strategy should make a significant contribution to decreasing relapse and rehospitalization. 11.10
CASE MANAGEMENT
Objectives Discuss the place of case management in a community health service. Define and describe this method. Distinguish between the different models of case management. Describe and illustrate the process of case management. Background During the last two decades, psychiatric patients have been systematically deinstitutionalized, so that today most of them are treated within the community most of the time. In order for patients and their families to receive adequate support while both treatment and rehabilitation take place out of institutions, the National Institute of Mental Health has identified the following 10 essential components for a community support system (CSS). 1. Identification of the target population, whether in hospitals or in the community, and outreach programmes offering appropriate services to those willing to participate. 2. Assistance in applying for entitlements. 3. Crisis stabilization services in the least constrictive setting possible, with hospitalization available when other options are insufficient. 4. Psychosocial rehabilitation services, including but not limited to: goal-directed rehabilitation evaluation; training in community living skills, in a natural setting whenever possible; opportunities to improve employability; appropriate living arrangements in an atmosphere that encourages improvement of functioning; opportunities to develop social skills, interests and leisure-time activities to provide a sense of participation and worth. 5. Supportive services of indefinite duration, including supportive living and working arrangements and other such services for as long as they are needed. 6. Medical and mental health care. 7. Backup support to families, friends and community members. 8. The involvement of concerned community members in planning and offering housing or working opportunities. 9. Protection of client rights, both in hospitals and in the community. 10. Case management to ensure continuous availability of appropriate forms of assistance.
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In these guidelines case management is clearly identified as one of the pillars of community mental health care. Its use is not exclusive to mental health services. It can be used for all clients with long-term conditions, for example, children in rural areas with chronic diseases, and also as an approach to primary health care (Fischer & Weisman 1988). It can also be used for both support and rehabilitation. Case management is an approach to long-term health care which addresses both the medical and the psychosocial needs of the patient. Case management comprises activities aimed at linking the service system to the consumer and at co-ordinating the various system components in order to achieve a successful outcome. It is essentially a problem-solving function to ensure continuity of service (Levine & Fleming 1987). Case management programmes vary considerably, but they all seem to share the following functions: Client identification and outreach; Individual or family assessment and reassessment; Service planning; Linking clients to services; Monitoring the use and provision of service; Advocating for service improvement (Goering, Wasylenki, Farkas, Lancee & Ballantyne 1988; Fisher & Weisman 1988). In a study of the activities of case workers in a particular programme it was found that their activities could be classified as: direct services, such as assessment, supplying medication, living skills training, crisis intervention; indirect services, such as case consultation, support system contact and travelling; and non-clinical services, such as community education, staff meetings and staff development. For full-time case managers, fewer than 40 cases is regarded as a light load, while more than 50 is regarded as too heavy a load. With too heavy a load the functions can no longer be carried out as they should (Levine & Fleming 1987). These are the three basic models for case management (Levine & Fleming 1987): The genemlist model. In this model one case manager is responsible for all case management functions. It has the advantage that it provides the client and family with a single person to whom they can relate, allows the helper to use a variety of skills, and provides for more staff autonomy and accountability. The specialist model. In this model each member of staff is responsible for a specialized aspect of case management. This is particularly appropriate for specialized services, which deal with severely disabled clients.
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The therapist-case manager model. In this model the case worker is also the therapist. This is the most appropriate model for the primary health care setting (Levine & Fleming 1987; Fisher & Weisman 1988). The helper must make sure that neither of the functions is neglected, since this is the danger of this model. What constitutes a 'case' can vary from one programme to the next. Although the primary patient will be the first responsibility of the professional helper, the 'case' will include the family and significant others when following a family approach. It is impossible to work with the individual separate from his/her social group in community settings. The case worker will also find families who have multiple problems, of which the identified patient is only one. In such instances the whole family becomes the 'case', since the problems and solutions are usually linked. Intagliata, Wilier and Egri (1986) also point out that the family can play a very important role in assisting the case worker in every phase of the process and should not be excluded as a resource. Case management is necessary because the health and welfare systems are so fragmented, rigid and user-unfriendly that it is extremely difficult for clients to benefit maximally from them. Furthermore, the provision of services is often so expensive that new services cannot continually be created every time a need is identified. It is essential that available services be utilized fully, and even be changed to address new needs. The effectiveness of case management has been evaluated mostly on an anecdotal basis (for example, the Rural Efforts to Assist Children at Home or REACH in Fisher & Weisman 1988). However, during a two-year follow-up of psychiatric patients, Goering et al. (1988) found that those on casework were less socially isolated, lived more independently, and functioned better occupationally than a control group. The process of case management Client identification and outreach This first step requires of the service staff that they identify the clients to be serviced by the case management programme. It might not be possible to give every client a case manager. In this case those clients who have the greatest need of the service must be identified. The clients who are in greatest need of the service might not come to the clinic/institution/service. Outreach to where the clients are, and marketing of the programme, are then necessary. Client assessment This assessment is not the same as that done for treatment. In this case the assessment is focused on long-term rehabilitation or support needs. The main aspects needing assessment are summarized in Table 11.5. Service planning Service planning involves devising detailed schemes for meeting clients' needs for assistance.
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This includes the following skills: clarifying priority areas for services needed; setting service goals; choosing service providers; formulating service plans, which include clear actions to be taken and time-frames for completion. Priority areas for services needed are identified by asking the patient and significant others to describe the major upsetting situations that they face with regard to the client, and also to look at the rehabilitation goals shared by all and the obstacles in the way of achieving these goals. It also helps to look at the assessment data of the client. From the data possible problem areas can be generated, which can then be systematically investigated until the final problem formulation is reached.
Example Major upsetting situation: When Sizwe thinks about getting a job, he feels worried because he may not find a regular indoor job with a great deal of independence. Possible problem areas:
Indoor jobs are not available. Sizwe experiences health problems since contracting pneumonia. Sizwe does not know what kind of job he wants. Final problem formulation: Sizwe would like to be a messenger for a company, but does not know how to find such a job. Problem formulations should be manageable, client-oriented, current, neutrally stated and easily understood. Setting service goals means that the aim of getting services is stated. When setting goals, one of three generic problem-solving strategies can be used to arrive at a goal: the problem can be eliminated, reduced or accepted. The most appropriate alternative should be identified and this is set as the goal.
Example Eliminate the problem. Sizwe is able to identify available messenger jobs. Reduce the problem. Sizwe contacts a labour bureau. Accept the problem. The case manager finds Sizwe a job. Choosing the service providers depends on identifying the type of service the client needs in order to reach the goals, and then finding the most appropriate agency in the area to provide this service. According to Cohen and Nemec (1979), there are six basic types of service, namely assessment, information, intervention, materials, placement and planning.
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Table
11.5 Necessary information for a comprehensive client assessment
Ability to perform activities of daily living Personal hygiene Nutrition Dress Cleaning Cooking Maintenance of personal space and possessions Health and medication management skills Use and understanding of psychotropic and/or other medication Ongoing medical treatment for physical illness Participation in routine health care, including regular checkups Vision, dental care, etc. Social supports and functioning Relationship and extent of involvement with family and significant others Ability to pursue leisure/recreational activities Social skills and relationships with friends and peer group involvement Financial resources Personal income Eligibility, need and/or established linkages with Social Services, food stamps, housing subsidies, etc. Money management skills Residential placements and history Current housing situation Desired or appropriate housing placement Prior housing history
Transportation Ability to use public or private transportation Transportation needs Prevocational/vocational skills Employment history Readiness for job training Vocational skills Service linkages History of hospitalization Experience with local mental health programmes Current linkages with mental health treatment systems (Portions of this assessment were adapted from Leavitt, S S. 1982. Case management: A remedy for problems of community care, in Case Management in Mental Health Services, ed. C Sanborn. New York: Haworth Press.)
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In order to choose the most appropriate agency, a list of criteria should be prepared by helper and client, and the different agencies should then be evaluated in terms of these criteria. Criteria should include: accessibility factors, such as scheduled times, affordable fees and transport; service-specific factors, such as the track record of the agency, philosophy, policies, etc; personal factors, such as no-smoking rules, gender and age mix of clients, etc. The agencies can be given marks in terms of each criterion so that the final decision is easier. A simple, useful scale is: +1 = desirable, 0 = acceptable, and -1 = undesirable. If the choice remains difficult, criteria can be weighed or other criteria can be added to force a choice. Formulating a service plan involves the preparation of a written plan of action for achieving the goals. The first step is to prioritize the goals so that the most urgent or important goals are dealt with first. The factors which are taken into account when prioritizing goals are the level of motivation of the client to achieve the goals, the ease with which these could be achieved, the urgency of the need and the level of support for achieving the goal that exists in the client's environment. Once the goals have been prioritized, a plan of action is drawn up for the first goal. This includes listing and allocating the responsibilities and stipulating the timelines for each. The format for a final service plan is given in Figure 11.4. Linking clients to services Linking the client to the service requires much more than referring the client to the service. It includes the marketing of the client to the service, dealing with barriers to service utilization by the client and negotiating with the service provider to overcome service provider barriers. Service does not only involve agencies like workshops or housing facilities but also includes entitlements such as disability grants or old-age pensions. Marketing the client to the service aims at securing the service provider's commitment to achieving the client's goals. This includes a presentation of the client's assets, addressing objections the agency might have to accepting the client, and developing a service agreement. A service agreement sets out the expectations of the service provider and the client and may also stipulate how progress will be monitored. There might be a whole series of barriers against use of the service, and these might exist either in the client or in the agency or both. The case manager must identify these timeously and then make realistic plans to remove the barriers. There might be emotional, knowledge, skill or resource barriers in either the client or the service. Programming for the removal of client barriers includes listing all the necessary steps, the timelines for each action and the rewards the client could be given on completion of each step. Skills teaching and support are included in this process. Support of actions includes the target dates set for the completion of each action, building in a system of rewards administered by the client, manager or others, and monitoring the progress towards achievement of the service link.
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Negotiation is used to address service barriers and overcome them to the satisfaction of all. When conflicting interests exist between clients and service providers, the three available methods for resolving these are merging the interests, compromise or mediation by a third party. It is important that the case manager uses patience and skill in this process, so that both the agency and the relationship are strengthened without the client suffering in the process. Monitoring the use and delivery of service The objectives of the monitoring function are to ensure that the client receives the expected services. If the client is not using this service, or the service is not that which was contracted, the case worker must address these issues. Monitoring does not involve only telephonic or mail contact, but should include onsite visits while the client is using the service. This allows for first-hand observation, which places the case manager in a stronger position as regards decision-making. Monitoring also includes the aspect of evaluating whether the goals set when the client was linked to that service have been achieved and when the service could be terminated. An added benefit is that it allows the case worker to build up a clearer idea of how the service functions, which is of benefit for future case management. Advocating for service improvements It is often not possible to link clients to services because the appropriate services do not exist. In such cases the case manager acts as advocate for a client group in order to improve the level of community services available to them. Advocating means that the manager uses various methods to urge the decision-makers to improve the quality and/or number of services provided for specific client groups. In deciding whether or not a service problem should be advocated, the following questions can be asked: Is there a need for an improvement in service in this area? How large a group of clients needs this improvement or will benefit? What are the chances that an advocacy programme on this issue will succeed? Can the benefit from this issue radiate to other areas or groups? Do you personally feel passionately about this issue? Service problems can be divided into: Quantity deficiencies: - lack of services (no services available); - service unavailable (service cannot accept new clients); - lack of access (service not accessible to clients due to policies or location); Quality deficiencies: - lack of resources in the service; - lack of effective programmes in the service.
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Figure 114 Monitoring the use and delivery of service
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Once the service problem has been clearly identified, it should be documented. Such documentation should include the facts and figures describing the problem, previous attempts at resolving the problem, the impact of the problem, the expected increase in the severity of the problem in the future and the potential implications of the problem. The following categories and questions have been suggested by Cohen and Nemec (1979) as a basis for documenting the problem. Descriptive facts What exists? What is needed? How long is the wait for services? How far do clients have to travel (hours/kilometres)? How many clients are rejected for services? Why are clients rejected for services? How many clients want/need to use the services? How many clients currently use the services? What is the percentage of clients currently using the services? What is the number of eligible clients denied services because of a lack of space during the last six months? How many other providers are there for these services? Previous attempts to solve the problems Have other people recognized the problem? Have there been earlier attempts to solve the problem? Who was involved in earlier problem-resolution attempts? How did they go about trying to solve the problem? What is currently being done or planned to solve the problem? Impact of the problem What is the impact of the problem on clients (for example, their satisfaction, treatment, rehabilitation)? What is the impact of the problem on the service providers? What is the impact on the family members or significant others? What is the impact on the general public? What is the impact on key decision-makers? Projected increase of the problem in the future How many clients will want/need the service in the future? How likely is it that the problem will be resolved on its own?
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Potential implications of the problem What other groups/individuals other than the service providers are affected by the problem? What are the conditions/situations created for other services as a result of the problem? How are other groups/individuals reacting to the conditions created for them by the problem? Having documented the problem, the case manager has to mobilize action groups, which are core groups of key people committed to solving the problems. These groups should not only include professionals; it is essential that the community at large and consumers of the services or potential services be involved from a very early stage. Having identified potential action group members, the case worker makes individual plans to involve the groups/individuals. This could be by means of a personal meeting, or a larger group could be brought together, or open invitations could be extended. The action group then plans the advocacy campaign. Planning a campaign involves the usual steps of setting an overall goal, setting objectives and designing action steps to be taken in order to reach the objectives. Advocacy activities include meetings, writing letters and proposals, building coalitions, demonstrations, petitions, media coverage and investigative research. 11.11 DEALING WITH AGGRESSION Objectives Differentiate between violence, aggression and acting out, and discuss their dynamics. Discuss factors influencing the potential for violence, and assess the potential in a patient situation. Describe and illustrate the process of handling violence. Discuss the use of seclusion and describe how this can be used in a safe way. Identify the correct medication to restrain a violent person chemically. It can be said without fear of contradiction that most people are afraid of the mentally ill because they believe that such people are dangerous. In the era of deinstitutionalization mental health workers have tried to disseminate information to allay that fear. Most studies done during the first half of this century show that mentally ill patients are less likely to commit violent acts than the general population as measured by either arrest or conviction rates (Richardson 1990). However, one must remember that most of these studies were done before deinstitutionalization became widespread. In the second half of the century the picture has changed and the mentally ill show consistently higher arrest rates and higher rates for violent crimes (Richardson 1990). One has to accept that violence forms part of mental health nursing, and one must therefore learn to cope with this aspect, both emotionally and physically. Denial is dangerous and under-preparedness can endanger the patient, the helper and the family.
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In this discussion the following definitions apply. Violence is any physical behaviour which results in injury to self or others or damage to property. It is part of a larger set of behaviours, including acting out and aggression. Acting out refers to an aggressive type of behaviour which does not include violence, such as verbal threats, cursing, breaking rules, leaving the hospital without permission or self-medicating. It is often seen in inpatients with personality disorders. Acting out relieves the patient's feelings of frustration or anger without his/her actually becoming violent. Aggression is a much more general term, referring to behaviour aimed at causing harm. This might only be verbal behaviour, such as an insult, or it might be physical behaviour, in which case it is called violence. Aggression is not always negative: Instrumental aggression refers to aggression that is used in competitive situations to achieve gain for the aggressor. This kind of aggression is not driven by anger, but by ambition or need. Causes of violence In this section aggression and violence are dealt with together, although it must be understood that not all aggression leads to violence. This discussion is also limited to aggression towards the environment and not aggression towards self. The dynamics of self-directed violence are discussed elsewhere. Frustration is one of the most pervasive causes of aggression. When a person is moving towards a goal and that movement is blocked by interference, the result is frustration. One reaction to frustration is aggression. This pattern is often seen in children, who lash out at parents when not given what they want. Aggression may also be an automatic defence mechanism when anxiety rises, as in the case of a perceived threat or attack. This kind of aggression can be called self-defence, but the threat may not always be real and the anxiety may be vastly exaggerated. Many psychiatric patients react with violence to threats that are part of their psychosis rather than an objective reality. Acting out behaviour is often the result of feelings of helplessness where a person feels that he/she has no control over what is happening to him/her. Decisions are made for the patient, or he/she is treated like a child or is not trusted. People who experience the world as hostile and negative, and negative events as the result of deliberate action by negative forces, may be more inclined to aggression as a form of revenge. Someone with a paranoid inclination may display this kind of vengeful aggression, which is based mostly on the perception of the patient and with little basis in reality. Acting out and violence are sometimes used by a patient who is unsure of people and the environment, in order to test their reliability. So as to ascertain whether limits set by staff/parents are adhered to, the patient/child will test these by exceeding the limits in order to ascertain whether the helpers/parents have the resolve, unity, energy and power to enforce them.
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Behaviourists have repeatedly shown that aggression can be aimed at achieving the attention and interaction a person does not otherwise achieve. They have shown that the negative attention that follows on an aggressive outburst can be experienced by the patient as better than no attention at all. Assessing the potential for violence It is not possible to predict violence in the long term, that is, to predict whether a particular patient will become violent in the future. However, it is quite possible to predict violence in the short term. It is essential that nurses be aware of the risk of violence presented by a specific patient at a specific time. The following factors increase the risk of violence and, should they be present, the patient should always be regarded as possessing a high risk for violence. Medical history Confusion Drug abuse, including dagga Alcohol abuse Brain injury Childhood history Abused as a child Antisocial family Adult history Recent violent fight Financial difficulties Frequent change of abode Conviction for a violent crime Sexual conflict The process of violence and handling violence Violence is not an isolated event, but is part of a process that involves both the patient and the staff. In this process the following escalating levels in the process can be identified: 1. Anxiety level There are signs of increased anxiety in the patient. The patient may look nervous or anxious and pace or move about restlessly. At this stage the recommended staff intervention is to be supportive and to promote verbalization of the feelings of anxiety or other feelings. Empathic responses and any other intervention which will reduce anxiety are appropriate.
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2. Challenge level At this stage there are clear signs of aggression. The patient challenges the staff and their authority. Verbal aggression is evident, the patient looks angry and acts offensively towards those around him/her. He/she is easily irritated and resists or refuses to follow directions. At this stage the appropriate staff intervention is directive limit-setting. The staff takes control in a situation where the patient is losing control, by firmly setting limits to behaviour. This should not be done in a threatening way but by showing concern and empathy. For example, if the patient is becoming too loud, the first step is to let him/her know why such behaviour must cease. A simple explanation of the fact that the noise is disturbing others is often enough to calm the patient down. If not, there is no need to threaten the patient into compliance. Instead, point out the fact that he/she can remain in the area if he/she quietens down. If not, he/she will have to be escorted out. In this way the patient feels that there is a choice, and the consequences are determined by his/her own choices. Limit-setting means that the boundaries for permissible behaviour are set out. Limits should be clear, concise and above all enforceable: 'You seem very angry and we cannot allow you to harm other people. Please come to the office so that we can talk about what made you angry.' It would seem that people need to have their basic needs met when in a crisis. It is therefore a good idea to offer a safe place, something to eat or drink, and acceptance. There are many tips about how to approach angry patients. These are summarized below. However, it is important to use your own knowledge of the patient, the other staff and the ward situation to de-escalate the crisis. The patient should usually be given five to ten minutes to calm down. If de-escalation does not occur, verbal intervention should be discontinued and physical intervention initiated. Posture A supportive posture means that the posture should speak of support and not of assault. Do not approach the patient from the front or behind. Stay a little to the side, with arms and hands relaxed and open. Space Do not crowd the patient, but do not stay so far away that a normal tone of voice is impossible. Do not touch the patient. Speaking
The voice should be low and calm, but clear. Do not use profanities and do not shout. Do not challenge the patient. Avoid the use of stop words such as 'Okay?' at the end of sentences. Use open-ended questions which are more specific, rather than direct questions: 'Do you feel that people have been unfair to you?' rather than 'What is the matter?'
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Safety Ensure that you have enough staff as backup before approaching the patient. Do not take the patient to a secluded area far away from help. Do not wear dangling earrings or other jewellery which may cause grave injury. Remove dangerous furniture or equipment from the environment. 3. Crisis level
During this phase there is a loss of control, and resultant physical violence on the part of the patient. The patient may be breaking windows or furniture, attacking staff or patients, or injuring him/herself. At this stage verbal intervention from staff is inadequate and non-violent physical intervention is necessary. The patient must be physically controlled by staff and either placed in seclusion or chemically restrained. Non-violent physical intervention is a safe, non-harmful behaviour management system designed to aid staff members by maintaining the best possible care for individuals who are agitated or out of control, even during their most violent moments. When physical restraint is essential, it is important that the staff ensure that they and others remain safe, while at the same time ensuring that the patient remains safe. Figures 11.5 to 11.12 on the following pages illustrate some non-violent self-defence and patientcontrol strategies - that is, avoiding a reaction to patient violence in the form of staff violence. These strategies should be practised by nurses and security staff so that they can be performed smoothly and efficiently. The principles behind the self-defence and patient control techniques are the following: Do the unexpected. For example, when the patient pulls your hair and he/she expects you to pull away, move your head quickly towards him/her. This kind of action unbalances the patient and often induces him/her to let go. Do it fast. This kind of strategy only works if it is done fast, since it often relies on unbalancing the patient. If it is done slowly, the person has time to adapt his/her stance. Use your whole body. In the patient-control techniques, for example, staff should place the entire length of their legs against those of the patient in order to improve control, rather than standing far away from him/her. Seclusion
Seclusion means the containment of a patient in a room or other enclosed area from which the patient has no way of egress (Angold 1989). This method of handling violence is as old as psychiatric care itself, but its use has decreased dramatically with the introduction of chemical restraint in the 1950s. The rates of use vary enormously between various units, with some units secluding 66 % of their patients at one time or another, while others seclude only 1,9 % (Angold 1989). This is not surprising, since units differ markedly in their patient populations.
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Figure 11.5 Two-handed hairpull release
Clasp the patient's hands and immobilize these against your head to prevent injury. Move your head towards the patient's body at a 45° angle. The grip of the hairpull is levered backwards, which reduces its strength. Move out of the way.
Figure 11.6 One-handed wrist-grab release
Use the laws of physics - momentum and leverage. Pull away from the weak link between thumb and fingers. Increase momentum and leverage by using both hands. Move out of the way.
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Figure 11.7 Front choke release Throw the arms straight up for momentum and leverage; this will also cause a distraction. Lean away from the patient so as to extend his/her arms, which weakens the hold. Your shoulders will supply leverage as you turn away from the hold. Move out of the way.
Figure 11.8 Bite release Lean into the bite and use a vibrating motion about the patient's upper lip to induce him/her to open his/her jaws. The vibrating motion causes a parasympathetic response. Use the minimum force necessary to effect a release. Avoid pulling away from the bite. Move out of the way.
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Figure 11.9 Interim control position This is a temporary control position. The staff member with the acting-out person should always maintain control of one of the arms (do not let go of the wrist) and move his/her (staff's) hand under the acting-out person's arm to possibly gain control of the acting-out person's free arm.
Figure 11,10 Transport technique Staff remove their hands from the patient's shoulders, move them under the patient's hands and clasp their own wrists. This forms a cross-grained grip which secures the patient. Remain close to the patient.
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Figure 11.11 Team control position Staff face in the same direction with the inside legs placed in front of the patient and outside hands holding the patient's wrists. Staff's inside hands form a C on the patient's shoulders.
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The leader does the talking and throws a blanket over the patient's head. Nurses 1 and 2 take firm hold of the patient's legs, while nurses 3 and 4 take hold of the arms.
Lift the patient and place him/her on his/her abdomen on the floor. Nurse 2 sits on the patient.
Figure 11.12 Controlling a person with a weapon (not a gun)
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Studies have shown that patients find seclusion degrading, dehumanizing, frightening and lonely. The Royal College of Nursing has issued guidelines for the use of seclusion (1979) which still form a useful basis for setting standards for this type of intervention: 1. Seclusion should take place in a safe environment where the patient cannot intentionally or accidentally harm him/herself. To further ensure safety, there should be a means of indirect observation, which means that nurses should be able to observe the patient without entering the room. This kind of indirect observation should take place at least every 15 minutes. 2. Not less than once every two hours a primary review should take place. This includes at least two nurses entering the seclusion area to carry out direct observation of the situation. This visit should include efforts to initiate the last stage of the violence process, namely tension reduction/communication. 3. Not less than once every four hours a secondary review should take place, which requires the presence of a medical officer. Where the patient needs to be secluded for a period of more than eight hours consecutively or for more than 12 hours intermittently over a period of 48 hours, a further review procedure should be instituted. At this review, independent reviewers should be present, that is, people who are not part of the usual treatment team. 4. The privacy of the patient should be respected and physical care ensured throughout the period of seclusion. It is recommended by experienced child mental health nurses that seclusion not be used at all with children. In the Mental Health Care Act Regulations (Act No 17 of 2002), section 39 deals with the use of seclusion. It stipulates that seclusion shall not be used for punishment, but only to contain severely disturbed behaviour, which is likely to cause harm to others and where other treatment techniques have failed. It is also stipulated that the patient shall be observed at least every 30 minutes, and a register shall be kept, signed by a medical practitioner, which documents the period of seclusion, and the reasons for seclusion. The head of the institution should receive these reports daily. Mechanical or chemical restraint Mechanical restraint (hand-cuffs, chains) should very seldom be necessary if chemical restraint is judiciously used. In the Mental Health Care Act Regulations (Act No 17 of 2002), article 38 deals with this form of restraint. It stipulates that it should only be used if chemical restraint is inadequate to ensure that the person does not harm self or others, or where it is done for a short period to administer the chemical restraint. According to Evans et al. (2002) between 3,4 % and 21 % (average 10 %) of acute care patients were subjected to some form of physical restraint during their period of hospitalization.
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Joanna Briggs Best Practice Guidelines Physical restraint Part 1: Use in acute and residential care facilities; Level II Restraint education with clinical consultation or restraint alone can safely reduce the use of physical restraint in the residential care setting, Evidence Based Practice Information Sheets for Health Professions 6 (3: 2002:6).
The most appropriate medication is probably diazepam 5 mg to 10 mg given slowly intravenously over two minutes. It is important to administer it slowly and carefully in order to prevent respiratory arrest. The form of restraint, time period and indications should be documented in a register, and the medical practitioner has to sign this register. If intravenous medication is impossible, haloperidol 5 mg to 10 mg, or chlorpromazine 25 mg can be given intramuscularly. 4. Tension reduction level In the aftermath of violence there is a reduction of tension in the patient, both physically and emotionally. The patient is often drained emotionally and physically. He/she may be quiet, remorseful and apologetic. He/she may also not remember everything that occurred before. He/she may be afraid, confused and/or ashamed. This is the start of regaining control. The appropriate staff response is to establish therapeutic rapport and communication with the patient. The nurse can assist the patient with gaining control by assisting with physical grooming, for example, combing mussed hair, offering a drink of water, etc. It is advisable also to discuss the events and the patient's feelings about them, opening the way for in-depth counselling at a later date. Nurses used to be the most common targets of patient violence in the old days of institutionalization. Today the focus is shifting, and families are the most vulnerable. Families have no access to seclusion rooms or injections in order to control the patient, and have to deal with aggression and violence from the patient over a long period. They need all the teaching and assistance the mental health service can provide. CONCLUSION The centrality of teaching and empowering the patient and his/her family in the interventions described in this chapter is evident. Skills teaching, mental health education, social skills teaching, psycho-education, and symptom management is built around this important function. Another central function is helping the patient and/or family deal with the mental health problems they have. This is the core of the group therapy, counselling, crisis intervention and case management strategies. Lastly there is the custodial function of the nurse, as seen in the milieu therapy and management of violence.
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These functions are interrelated, and together they form the rich fabric of mental health nursing. WEB RESOURCES www.crisisprevention.com/ The Crisis Prevention Institute gives very useful information on this site. There are, for instance, the following brochures one can order: 'How to stay safe during home visits', and 'The art of setting limits'. http://www.bartow.kl2.ga.us/psych/crisis/crisis.htm This is a very interesting site by the Georgia, USA school system, dealing with plans in this system for predictable crises, for example, a plan for how a school should deal with the death of a student or teacher, or a natural disaster. They also outline a suicide prevention plan. REFERENCES Aguilera, D C & Messick, J M. 1982. Crisis Intervention. St Louis: C V Mosby Co Angold, A. 1989. Seclusion. British Journal of Psychiatry 154, 437-444 Cohen, M, Farkas, M & Cohen, B. 1986a. Functional Assessment: Reference Handbook 6. Boston: Boston University Cohen, M, Farkas, M & Cohen, B. 1986b. Direct Skills Teaching: Reference Handbook 6. Boston: Boston University Evans, D et al. 2002. Physical Restraint in Acute and Residential Care, A systematic review. No 22. The Joanna Briggs Institute, Adelaide, Australia Fisher, K & Weisman, E (eds.) 1988. Case Management: Guiding Patients through the Health Care Maze. Chicago: Joint Commission on Accreditation of Health Care Organization Frese, F J. 1993. Twelve aspects of coping for persons with schizophrenia. Innovations & Research 2(3), 39-46 Intagliata, J, Wilier, B & Egri, G. 1986. Role of the family in case management of the mentally ill. Schizophrenia Bulletin 12(4), 699-707 Knowles, M S. 1977. The Modern Practice of Adult Education. New York: Associated Press Kreigh, H Z & Perko, J E. 1988. Psychiatric and Mental Health Nursing, a Commitment to Care and Concern. Reston, Virginia: Prentice-Hall Inc Morrison, R L & Bellack, A S. 1984. Social skills training. In Schizophrenia ed. A S Bellack. Orlando: Grune & Stratton, Inc O'Connor, F W. Symptom monitoring for relapse prevention in schizophrenia. Archives of Psychiatric Nursing V(4), 193-201 Peplau, H E. 1952. Interpersonal Relations in Nursing. New York: G P Putnam's Sons RCN Society of Psychiatric Nursing. 1979. Seclusion and Restraint in Hospitals and Units for the Mentally Disordered. London: The Royal College of Nursing of the United Kingdom
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Psychopathology & Nursing Interventions
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CHAPTER
TWELVE
Nursing the Patient with an Anxiety Disorder I MIDDLETON
Objectives After studying this chapter the learner should be able to: Describe the concept of anxiety from a cognitive-behavioural perspective and describe the multidimensional responses associated with anxiety. Explore the sources of the nurse's own feelings of anxiety in dealing with psychiatric patients and implement a plan for change. Apply the strategies in each phase of the scientific process of nursing to the care of anxious patients. Make a diagnosis of a panic disorder, post-traumatic stress disorder, and acute stress disorder, and treat in a primary health care setting. Refer patients with other anxiety disorders to a secondary health care service.
INTRODUCTION Many theorists have devoted a great deal of time and energy to unravelling the mysteries that surround anxiety. Developing a valid conceptualization of anxiety has been a goal of psychiatric endeavour since the advent of Freud's pioneering work. Since anxiety is considered to be at the very root of what it means to be human, this is not surprising. The idea that anxiety shapes and directs human behaviour has important implications for psychiatric or mental health nursing practice. These implications lie in the impact anxiety has on human functioning; the greater the anxiety, the greater the degree of disorganized functioning. To the extent that anxiety can be seen as the pulse of human behaviour, it can also be seen as one of the vital signals for mental health nursing.
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12,1
UNDERSTANDING ANXIETY
Anxiety is a universal human emotion. It is experienced by everyone in mild form at some time or another; in a more extreme form it leads to fears of impending death or catastrophe: 'It comes over me all at once. First of all it is like something pressing only on my eyes. My head gets so heavy, there's a dreadful buzzing and I feel so giddy that I almost fall over. Then there's something crushing my chest so I can't get my breath ... My throat's closed together as though I were going to choke ... I always think I'm going to die. I'm brave as a rule and go about everything by myself- into the cellar and all over the mountain. But on a day when this happens, I don't dare go anywhere ...' (Freud's description of Katerina in Barrow 1988).
Characteristics of anxiety Research studies in nursing diagnosis show that anxiety is most frequently cited as a diagnosis in a wide variety of practice settings (Whitley 1989). For the past 15 years, nurse researchers have attempted to develop a workable diagnosis of anxiety that has universal meaning for nurse practitioners. The extent of the research done in this area and the apparent lack of consensus as to what the critical defining characteristics of anxiety are, reflect the elusive nature of anxiety. Table 12.1 lists the characteristics identified in four nursing studies. Common to most definitions of anxiety are the following six characteristics: It is an emotional state characterized by the subjectively experienced quality of fear or a closely related emotion. The emotion is unpleasant. It is directed towards the future. Either there is no recognizable threat or the threat is, by reasonable standards, quite out of proportion to the emotion it seemingly evokes. There are subjective bodily discomforts during the period of anxiety. There are manifest bodily disturbances. Anxiety defined ' . . . a feeling of uneasiness and apprehension about some undefined threat. The threat is often physical with intimations of bodily harm or death, or psychological with threats to self-esteem and well-being. The feeling is diffuse and ineffable, and the indefinable nature of the feeling gives it its peculiarly unpleasant and intolerable quality' (Taylor et al. 1988).
Most definitions agree that anxiety occurs in response to a stimulus (event, experience, object, person) individuals perceive as threatening to their physical, social or psychological integrity. There is as yet little theoretical consensus about what constitutes a 'threat' and the nature of the relationship between the threat and the experience of anxiety. This is partly because anxiety can be observed and/or experienced in a number of dimensions - subjective, cognitive, behavioural, physiological - and these dimensions largely determine 'how' the problem is defined. For example, behavioural theorists believe
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Table 12.1 Characteristics of anxiety
Critical defining characteristics Nursing study
Anxiety Apprehension Worry Increased tension Fear of unspecified consequences Distress Fearfulness Scaredness Restlessness Focus on self Facial tension Extraneous movement Difficulty in cognitive functioning Rejected defining characteristics Regretfulness (Adapted from Whitley 1989)
that anxiety is a learned response to a painful stimulus. The focus of treatment is therefore on helping the person to learn adaptive behavioural responses to anxiety-provoking stimuli. Physiological theorists emphasize the biological basis of anxiety and describe four neuro-anatomical structures and three neuro-transmitter systems implicated in anxiety. Treatment in this instance is medical, for example, psychotropic medications with the emphasis on symptom control. Levels of anxiety Four levels of anxiety are generally observed. These are: Mild. Here, the ability to cope increases. Alertness is increased, and sensory input seems heightened, enabling the person to achieve and succeed in specific tasks, for example, study productively for an examination; complete an assignment on time.
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Moderate. At this level, the ability to perceive and to communicate is reduced and a sensation of increased nervousness and tension occurs. Some coping skills are still functional, and the person can follow directions. Therefore, with some help, the anxiety can be dealt with successfully. Severe. In this form, a person's perceptual field becomes quite narrow and focussed on the short term. The attention span is shortened and the ability to attend to other things is impaired. An accompanying physical discomfort may add to a sense of emotional discomfort. Panic. At this level, a person's ability to cope is severely impaired. Perception is distorted. There is a feeling of terror and thoughts may be unfocused, random, fleeting, and irrational. A person cannot function at this level for long. Understanding anxiety from a cognitive-behavioural perspective Although no one theory can comprehensively explain the phenomenon of anxiety, it is still useful to examine in detail a particular approach: a working knowledge of one approach is more useful to the practitioner than scanty knowledge of a variety of theories. This approach provides a useful framework for understanding and intervening in anxiety, because it closely parallels the principles of psychiatric/mental health nursing practice. A great deal of emphasis is placed on expressing concepts in descriptive, concrete terms; problem solving is an integral part of treatment; much of the treatment is based on the here-and-now and requires that the patient, where possible, be an active participant in the process of care. Cognitive model of anxiety This model attributes anxiety to a disorder of thinking. The central thesis of this approach is that the special meaning an individual attaches to an event will determine his/her emotional and behavioural response. The meaning is encased in a cognition, namely, a thought or image. In anxiety, the thinking of the anxious person is dominated by cognitions of danger to his/her personal domain. Threats to physical integrity include the possibility of physical harm, serious illness or environmental hazards. Threats to the psychosocial well-being of the person encompass anticipated loss of interpersonal support, anticipation of criticism, humiliation or desertion. In addition, the possibility of losing some important object (person, financial security, material possessions) is another common threat to the personal domain. The cognitive model describes three specific concepts to explain how this process operates in anxiety. This is known as the cognitive triad. The cognitive triad consists of three major cognitive patterns that influence the way in which patients view themselves, the future and life experiences. The first aspect of the triad centres on the patient's negative view of self. Anxious patients see themselves as vulnerable in the face of potentially harmful situations. Because of this, they believe that they do not possess the necessary resources to cope with
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untoward events and therefore live in a constant state of anticipation of physical and/or psychological harm. The second aspect of the triad involves the tendency of anxious patients consistently to misinterpret their ongoing experience in a threatening way. The third component of the cognitive triad consists of a fearful view of the future. Fear of the future generally revolves around the theme of suffering. This may be experienced in response to the anticipation of physical harm or to the anticipation of a painful emotional state resulting from psychosocial hurt. Fear of loss of control leading to feelings of humiliation, embarrassment and sadness is common. This may include fear of losing control of one's faculties, for instance, 'going crazy', not being able to function, or harming others. Fear of death is also common, especially in patients experiencing panic attacks. Dysfunctional rules or beliefs All people have, embedded in their self-concept, a set of general rules that guide behaviour and form the basis for specific interpretations. These rules are thought to arise from memories of early experiences that were never fully processed or accepted by the individual. Beliefs are an overcompensation for painful emotional memories. A person's emotional memory of being inferior to others may have a corresponding belief, such as 'I have to be loved at all times'. Since this is an impossibility, the overcompensating beliefs often create precisely the experience the person is trying to avoid, namely anxiety. Although the rules involved in anxiety are varied, they are generally concerned with the concept of danger and patients' assessment of their capacity for coping with it. Most revolve around themes of acceptance, competence, control, responsibility and the symptoms of anxiety themselves. Themes Acceptance
Examples of belief I am nothing unless I am loved. I always have to please others. Criticism means rejection. I should always like others.
Responsibility
I am responsible for what others feel or think when they are with me. If something goes wrong, it is my fault.
Competence
I must never make a mistake. If I make a mistake, I will fail. I cannot cope. I am not strong or capable. Strong people don't ask for help.
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Themes
Examples of belief
Control
I must be in control at all times. If I let someone get too close, they will control me. Any strange situation should be regarded as dangerous. My security and safety depend on anticipating and preparing myself at all times for any possible danger.
Symptoms of anxiety
I must be calm at all times. I am having a heart attack. I am dying/going mad.
When people encounter novel situations, their perception of the situation is coloured by past emotional experiences, namely, a belief system. In the case of anxiety, beliefs about one's vulnerability are activated at an unconscious level but manifest themselves at a conscious level in the form of negative, automatic thoughts. Beck (1976) describes these thoughts as automatic since they arise as if by reflex and are unsolicited by the person. Because these thoughts tend to spring to mind easily, people regard them as plausible and worthy of belief. Negative automatic thoughts of vulnerability or threats to personal domain are triggered by the person's perception of the situation as dangerous and, in turn, trigger the experience of anxiety. People about to enter a social situation might automatically think 'I'd better keep my mouth shut or people will think I'm stupid', or 'I will not be able to cope with this situation'. At the same time, pictorial images of looking foolish, saying the wrong thing and having people laughing at them may flash through their minds. Cognitive errors (faulty information processing) Negative thoughts are a product of errors in processing, through which perceptions and interpretations of experience are distorted. These include the following: Selective abstraction. A person who is concerned about social evaluation may conclude that he/she is socially boring because he/she notices one person in the group yawning. Stimulus generalization. The same person may hear other people in the room laughing and conclude that they are laughing at him/her because he/she is boring. Catastrophizing. The same person will dwell on the most negative extreme consequences imaginable, such as being alone for ever in the world because he/she is boring. Dichotomous thinking. On the basis of selective abstraction, stimulus generalization and catastrophizing, the person may classify all social situations as unsafe, rather than arrange them in gradations of safety.
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Early experiences of vulnerability
Formation of dysfunctional rules
Trigger stimulus
Assumptions of harm/danger activated
Danger-related automatic thoughts
Symptoms of anxiety
affective/subjective
physiological
cognitive
behavioural
Figure 12.1 The cognitive model of anxiety
In summary, the individual's interactions with self, others and the environment are guided by a set of dysfunctional rules that predispose the individual to misinterpret a wide range of situations and experiences in a threatening fashion. This process of faulty information processing gives rise to a stream of negative thoughts and images that set the anxiety response in motion. 12.2 THE ANXIETY RESPONSE Clinical anxiety can be experienced and/or observed in the cognitive, affective/subjective and behavioural dimensions. These responses are often interpreted as further sources of threat and this leads to an increase in the intensity of the anxiety experienced. The effects of anxiety are diffuse and uneven; although all aspects of lifestyle functioning are affected, the effects are unlikely to manifest uniformly in each dimension. A patient may, for example, show signs of cognitive disorganization, yet appear calm and controlled.
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Subjective responses associated with anxiety This refers to the patient's descriptions and interpretations of symptoms. Patients sometimes present with anxiety as their chief complaint. More commonly, they present a range of physiological symptoms, such as heart palpitations, and cognitive symptoms, such as not being able to concentrate, or a fear of dying. Typical terms used to describe the subjective experience of anxiety: Tense Shaky Worried Terrified Wound-up Highly strung Nervous
On edge Panicky Anxious Scared Jittery Apprehensive Fearful
Physiological responses associated with anxiety These responses are primarily mediated through the automatic nervous system. When the patient appraises a situation as dangerous, a number of physiological changes occur. These responses serve a useful function in the face of realistic dangers, because they help to prepare the person concerned for flight, fight or fainting. However, when the threat arises from a misperception, the responses activated are inappropriate for the situation. Instead of serving a useful function, they are often interpreted as further sources of danger. This sets up a series of vicious circles that tend to maintain and increase the intensity of the anxiety. System
Symptoms
Musculoskeletal
Pains and aches, twitchings, myoclonic jerks, grinding of teeth, unsteady voice, increased muscle tone, spasms, tremors, restlessness, wobbling legs, clumsiness
Sensory
Tinnitus, blurring of vision, hot and cold flushes, feelings of weakness, prickling sensations, flushed face, pale face, sweating, itching
Cardiovascular
Tachycardia, palpitations, pain in chest, throbbing of vessels, feeling faint, skipped beat
Respiratory
Pressure or constriction in chest, choking feeling, sighing
Gastrointestinal
Difficulty in swallowing, flatulence, abdominal pain, burning sensations, abdominal discomfort, nausea, vomiting, looseness of bowels, loss of weight, loss of appetite, constipation
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System
Symptoms
Genitourinary
Frequency of urination, amenorrhoea, menorrhagia, premature ejaculation, loss of libido
Autonomic
Dry mouth, flushing, pallor, tendency to sweat, giddiness, tension headache, raising of hair
Cognitive responses associated with anxiety This aspect has already been discussed in detail. In addition to the aspects already mentioned, a number of diffuse changes in cognitive functioning take place. Cognitive symptoms
Sensory-perceptual
Hazy, cloudy, foggy, dazed Objects seem blurred/distant Environment seems different/unreal Feeling of unreality Self-conscious Hypervigilant
Thought impairment
Can't recall important things Confused Unable to control thinking Difficulty in concentrating Distractibility Blocking Difficulty in reasoning Loss of objective/perspective
Content of thought
Cognitive distortion Fear of losing control Fear of not being able to cope Fear of physical injury/death Fear of going crazy Fear of negative evaluations Frightening visual images Repetitive fearful ideation Obsessive thoughts
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Behavioural responses associated with anxiety A number of coping strategies may be evident in the patient's behaviour. These represent the patient's conscious and unconscious attempts to manage the problem situation and to deal with the affective consequences of the problem, namely anxiety. Conscious coping behaviours
Problem-focused coping involves taking direct action to modify or eliminate the source of threat. This includes behaviour such as physical and interpersonal withdrawal, aggression and external blaming. Emotion-focused coping includes responses with the primary function of managing the affect aroused by stressful situations. Behaviour such as crying, eating or smoking more, the use of alcohol and drugs, excessive sleeping, immobility, hyperactivity, talking about the experience and seeking help are examples of this type of coping. Unconscious coping behaviours
These unconscious manoeuvres are discussed in some detail in Chapter 2. Although these mechanisms are useful in protecting the person from feelings of worthlessness and inadequacy, they can, if used in the extreme, limit the person's functioning in all lifestyle dimensions. 1 2 3 NORMAL AND PATHOLOGICAL ANXIETY It is often difficult to draw a line between normal and clinical anxiety. However, anxiety can be considered pathological if any one of the questions appearing below is answered in the affirmative. Furthermore, the levels of anxiety mentioned earlier might help to decide whether the anxiety is 'working for' or 'working against' the person. 1. Is the degree of anxiety out of proportion to the danger? 2. Is anxiety present in the absence of objective danger? 3. Has the person sought treatment for anxiety? 4. Does the person engage in self-destructive behaviour to control the anxiety? 5. Is the intensity/frequency/duration of the anxiety experience such that it interferes with adaptive functioning? Anxiety can also be defined as pathological if the responses associated with it meet the criteria for any one of the diagnostic categories outlined by the adapted DSM-IV-TR. 12,4 CLASSIFICATION OF ANXIETY DISORDERS: DSM-IV-TR The DSM-IV-TR describes a range of anxiety disorders. Of these, only panic disorders, post-traumatic stress disorder, acute stress disorder and generalized anxiety disorder are relatively common, with a prevalence of 3 % and over in the general population.
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Table
12,2 DSM-IV-TR classification and diagnostic criteria: Anxiety disorders
Specific phobia (formerly 'simple phobia') A. Obvious and persistent fear that is excessive or unreasonable, triggered by the presence or anticipation of a specific object or situation (e.g. flying, heights, animals, receiving an injection, seeing blood). B. Exposure to the phobic stimulus almost always triggers an immediate anxiety response, which may take the form of a panic attack and can be either situationally bound or predisposed. In children the anxiety may be expressed by crying, tantrums, freezing, or clinging. C. The person is aware that the fear is excessive or unreasonable. In children this feature may be absent. D. The phobic situation(s) is/are endured or avoided, but with intense anxiety or distress. E. The avoidance, anxious anticipation, or distress in the feared situation(s) interferes significantly with the person's activities of daily life such as normal routine, occupational (or academic) ability, or social activities or relationships, or there is marked distress about having the phobia. F. The duration is at least six months in individuals under age 18 years. Specify subtypes: Animal, Fear triggered by animals or insects and usually has a childhood onset. Natural environment The fear is triggered by things in the natural environment, such as storms, heights, or water and usually has a childhood onset. Blood-injection-injury. The fear is triggered by seeing blood or an injury or by receiving an injection or other invasive medical procedure. May run in families and is often characterized by a strong vasovagal response. Situational. The fear is triggered by a specific situation such as public transportation, tunnels, bridges, elevators, flying, driving, or enclosed spaces. This subtype has a bimodal age-at-onset distribution, with one peak in childhood and another peak in the mid-2Qs. Appears similar to panic disorder with agoraphobia in its characteristic sex ratios, familial aggregation pattern, and age at onset. Other types. The fear is triggered by other stimuli, e.g. fear or avoidance of situations that might lead to choking, vomiting, or contracting an illness; 'space' phobia (i.e. the individual is afraid of falling down if away from walls or other means of physical support); and children's fears of loud sounds or costumed characters.
Social phobia (Social anxiety disorder) A. A noticeable and unrelenting fear of one or more social or performance situations in which the person is exposed to unknown people or to possible examination by others. The person fears that his/her behaviour (e.g. showing anxiety symptoms) will be personally humiliating or embarrassing. In children the anxiety must occur in peer settings, not just in interactions with adults. There must be evidence of the ability for age-appropriate social relationships with familiar people.
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Obsessive-compulsive
disorder
A. Either obsessions or compulsions: Obsessions as defined by (1), (2), (3) and (4): 1. Recurrent and unrelenting thoughts, impulses, or images that are experienced as intrusive and inappropriate and that cause marked anxiety or distress. 2. The thoughts, impulses, or images are more than just excessive worry about real-life problems. 3. The person tries to ignore or suppress such thoughts, impulses, or images, or to counteract (neutralize) them with some other thought or action. 4. The person is aware that the obsessional thoughts, impulses or images are a product of his or her own mind (not imposed from without as in thought insertion). Compulsions as defined by (1) and (2): 1. Repetitive behaviours (e.g. hand-washing, ordering, checking) or mental acts (e.g. praying, counting, repeating words silently) that the individual feels driven to perform in response to an obsession, or in terms of specific rules that must be strictly applied. 2. The behaviours or mental acts are directed at preventing or reducing distress or preventing some dreaded event or situation. However, these behaviours or mental acts are either not linked in a sensible way with what they are intended to counteract or prevent or are clearly extreme. B. At some time during the course of the disorder, the person has recognized that the obsessions or compulsions are extreme or unreasonable. This does not apply to children. C. The obsessions or compulsions cause obvious distress, take time to accomplish (take more than one hour a day) or considerably interferes with the person's activities of daily living. D. If another Axis I disorder is present, the content of the obsessions or compulsions is not limited to it (e.g. preoccupation with food in the presence of an eating disorder; hair pulling in the presence of trichotillomania; concern with appearance in the presence of body dysmorphic disorder; preoccupation with drugs in the presence of a substance use disorder; preoccupation with having a serious illness in the presence of hypochondriasis; preoccupation with sexual urges or fantasies in the presence of a paraphilia; or guilty ruminations in the presence of major depressive disorder). E. The disturbance is not related to the direct physiological effects of a substance (e.g. a drug of abuse, a medication) or a general medical condition.
Post-traumatic stress disorder A. The person has been exposed to a traumatic event in which both of the following - event and response - were there: 1. The person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others; and 2. The person's response involved intense fear, helplessness, or horror. In children this may be shown instead by disorganized or agitated behaviour.
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B. The traumatic event is tirelessly re-experienced in one (or more) of the following ways: 1. Repeated and intrusive distressing memories of the event, including images, thoughts, or perceptions. In young children, repetitive play may occur in which themes or aspects of the trauma are expressed. 2. Repeated distressing dreams of the event. Note: In children there may be frightening dreams without recognizable content. 3. Acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those that occur on awakening or when intoxicated). In young children, trauma-specific re-enactment may occur. 4. Intense psychological distress at exposure to internal or external cues that stand for or resemble an aspect of the traumatic event. 5. Physiological reactivity on exposure to internal or external cues that stand for or are similar to an aspect of the traumatic event. C. On-going avoidance of stimuli linked with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by three (or more) of the following: 1. Efforts to avoid thoughts, feelings, or conversations linked with the trauma. 2. Efforts to avoid activities, places, or people that trigger memories of the trauma. 3. Inability to remember an important aspect of the trauma. 4. Obviously diminished interest or participation in significant activities. 5. Feeling of detachment or estrangement from others. 6. Restricted range of affect (e.g. unable to have loving feelings). 7. Sense of a foreshortened future (e.g. does not expect to have a career, marriage, children, or a normal lifespan). D. Persistent symptoms of increased arousal (not present before the trauma), as indicated by two (or more) of the following: 1. Difficulty falling or staying asleep. 2. Irritability or outbursts of anger. 3. Difficulty concentrating. 4. Hypervigilance. 5. Exaggerated startle response. E. Duration of the disturbance (symptoms in Criteria B, C, and D) is more than one month. F. The disturbance causes clinically significant distress or impairment in activities of daily living, e.g. social, occupational, or other important areas of functioning. Specify if: Acute: if duration of symptoms is less than three months Chronic: if duration of symptoms is three months or more
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Specify if: With delayed onset: if onset of symptoms is at least six months after the stressor. Acute stress disorder A. The person has been exposed to a traumatic event in which both of the following were present: 1. The person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others. 2. The person's response involved intense fear, helplessness, or horror. B. The individual has three (or more) of the following dissociative symptoms, either while experiencing or after experiencing the distressing event. 1. A subjective sense of numbing, detachment, or absence of emotional responsiveness. 2. A reduced awareness of his or her surroundings (e.g. 'being in a daze'). 3. Derealization. 4. Depersonalization. 5.
Dissociative amnesia (i.e. inability to remember an important aspect of the trauma).
C. The traumatic event is repeatedly re-experienced in at least one of the following ways: recurrent images, thoughts, dreams, illusions, flashback episodes, or a sense of reliving the experience, or distress on exposure to reminders of the traumatic event. D. Obvious avoidance of stimuli that trigger memories of the trauma (e.g. thoughts, feelings, conversations, activities, places, people). E.
Marked symptoms of anxiety or increased arousal (e.g. difficulty sleeping, irritability, poor concentration, hypen/igiiance, exaggerated startle response, motor restlessness).
F.
The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. The person's capacity to track some necessary task, such as obtaining needed assistance or mobilizing personal resources by telling family members about the traumatic experience.
G. The disturbance lasts for a minimum of two days and a maximum of four weeks and occurs within four weeks of the traumatic event. H. The disturbance is not due to the direct physiological effects of a substance (e.g. a drug of abuse, a medication) or a general medical condition, is not better accounted for by brief psychotic disorder, and is not merely an exacerbation of a pre-existing Axis I or Axis II disorder.
Generalized anxiety disorder (includes overanxious disorder of childhood) A. Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least six months, about a number of events or activities e.g. work or school performance. B. The person finds it hard to control the worry. C. The anxiety and worry are linked with three (or more) of the following six symptoms where some symptoms are present more days than not for the past six months. Only one item is required in children.
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1. 2. 3. 4. 5. 6.
Restlessness or feeling keyed up or on edge. Being easily fatigued. Difficulty concentrating or mind going blank, Irritability. Muscle tension. Sleep disturbance (difficulty falling or staying asleep, or restless unsatisfying sleep).
D. The focus of the anxiety and worry is not confined to anxiety, worry or a specific fear related to any of the other anxiety disorders such as panic attack, social phobia, obsessive-compulsive disorder, separation anxiety disorder, somatization disorder, or to hypochondriasis, and the anxiety and worry do not occur only during post-traumatic stress disorder.
Panic disorder Panic disorder, with or without a phobic component, affects about one out of every 75 people worldwide, with females having the condition twice as often as males. It may commence at any time during life, but occurs most often in the mid-teens and early adulthood. Causal theories include a biological basis, pointing to general hypersensitivity of the autonomic nervous system, or a defect in lactate metabolism. It has been shown that panic disorders run in families. Cognitive theorists blame persistent catastrophic interpretations of physiological responses, such as interpreting slight breathlessness and palpitations as an impending heart attack. Whatever the causes, panic disorder can seriously impair a person's functioning. A panic attack is a discrete period of intense fear or discomfort, in which four (or more) of the following symptoms develop abruptly and reach a peak within 10 minutes: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13.
palpitations, pounding heart, or accelerated heart rate sweating trembling or shaking sensations of shortness of breath or smothering feeling of choking chest pain or discomfort nausea or abdominal distress feeling dizzy, unsteady, lightheaded, or faint derealization (feelings of unreality) or depersonalization (being detached from oneself) fear of losing control or going crazy fear of dying paresthesias (numbness or tingling sensations) chills or hot flushes
Panic attacks may occur with other conditions, such as substance abuse, depression and other anxiety and personality disorders.
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It is important to realize that the symptoms of panic attacks can mimic serious physical disorders such as myocardial infarction, cardiac arrhythmias, hyperthyroidism and different types of epilepsy. If not properly diagnosed, panic disorders can therefore result in repeated unnecessary physical investigations and even treatment. To differentiate panic disorders from medical disorders, it is important to do a thorough physical evaluation. It is also important to explore the emotional component of the attack, since the patients often concentrate on only a few physical symptoms, and do not talk about their fears and symptoms of depression. Panic attacks may be triggered by large doses of caffeine, some cold medications and dagga. Panic disorders are eminently treatable conditions. The usual treatments are cognitivebehavioural, pharmacological or a combination of the two. The cognitive-behavioural therapy usually involves weekly sessions for eight to 12 weeks, and the patient should show improvement by the third week. Pharmacological treatment includes tricyclic or MAO antidepressants and high-potency benzodiazepines. Medication guidelines Imipramine 25 mg for three days, then increase the dose by 25 mg every three days. Slowly increasing the dose is important to reduce attrition. Tell the patient that you plan to increase the dose to 150 mg-300 mg, or until the panic attacks cease. Also warn the patient that the panic attacks will get worse before they get better. Some patients cannot tolerate imipramine, and one should then use Fluoxetine. The side effects of the tricyclic medication might cause as many as 35 % of patients to discontinue treatment before a therapeutic level is reached. However, the medication can be taken on a once-a-day basis, with a low risk of dependency and no dietary restrictions. When the panic attacks have been eliminated or reduced significantly, one can reduce the dose gradually, but it might be wise to keep the patient on a lower dose to prevent relapse. This is especially necessary if the panic disorder has been a recurring pattern. Phobic disorder A phobia may be defined as a persistent fear of an object or situation that is not, in fact, objectively dangerous. Such fear results in the strong desire to avoid phobic situations, even though the person is thus dominated by thoughts and images of danger connected with specific, avoidable situations and objects. Phobias are considered to be learnt fears, acquired through direct and indirect learning (for example, a child sees the intense fear and pain experienced by a person who has been bitten by a dog or a snake, or a friend or family member is killed in an air accident), as well as through the transmission of information and/or instructions (for example, a parent continually warns the child not to touch dogs because they are dangerous). Simple phobia revolves around a single feared object or situation, for example, fear of heights, snakes or the sight of blood. People with such phobias are generally free of symptoms unless they are in or anticipate entering a phobic situation. Animal phobias may develop gradually out of childhood fears, blood-injury phobias commonly begin
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in adolescence or in early adulthood and circumscribed fears, such as a fear of heights, seem to begin during late adulthood (forties). Social phobia centres on fear of unobservable events, such as negative evaluation, rejection by other people or criticism. They may be circumscribed, for example, fear of not being able to speak in public, of choking on food when eating in public, of not being able to urinate in a public toilet, of writing in public and of having a hand tremble. In these instances they resemble simple phobias; generally they are more diffuse, involving most social situations, for example, fear of saying foolish things or of not being able to answer questions while at a social gathering. These fears generally emerge around late adolescence, when issues of identity are most crucial. Agoraphobia is the fear of being in places or situations from which escape from the phobic stimulus might be difficult (or embarrassing) or in which help might not be available in the event of an emergency. This type of phobia involves a cluster of situations, of which the most common are fear of confined spaces (for example, supermarkets, hair salons and cinemas), of public transportation and of being far from home. These situations are then avoided. These people generally feel safest at home or in the company of a trusted person; the further they venture from home and safety, the more fearful they become. If escape from the phobic situation seems impossible, they may experience panic. The DSM-IV-TR identifies two kinds of agoraphobias: those with and those without panic attacks. It is not clear whether these are two separate disorders requiring different treatment, or more or less severe manifestations of the same thing. Agoraphobia seems to start either in late adolescence, when particularly women are expected to become more independent, or around the age of 30. Obsessive-compulsive disorder Obsessions are unwanted and intrusive thoughts, urges or impulses that are involuntary. They generally concern topics that are distasteful to the person and difficult to dismiss. Once the thought occurs, it is accompanied by anxiety or by feelings of discomfort and the urge to neutralize the thought. Neutralizing generally takes the form of overt and covert compulsive behaviour. Overt behaviour might include avoiding situations that trigger obsessional thoughts or performing a particular activity, for example, checking repeatedly that all the doors are locked for fear of being physically harmed. Covert behaviour involves changes in mental activity, such as thinking a different thought in response to the obsessional thought or thinking the same thought an even number of times in order to feel better. These behaviours are usually carried out in a stereotyped way or according to personally defined 'rules' or rituals. They are coupled with temporary relief from anxiety as well as with the belief that, if the behaviour is not carried out, the anxiety will increase. Anxiety relief thus reinforces compulsive behaviour. As obsessions persist and rituals become extensive, patients sometimes prevent obsessional thoughts from occurring by performing neutralizing behaviour. Someone may wash his/her hands 100 times a day to prevent the original obsessional thought of contamination by germs from occurring. The disorder usually manifests itself in adolescence or early adulthood.
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Content and example of obsession
Example of compulsive behaviour
Contamination (ideas of being harmed by contact with substances believed to be dangerous, for example, dirt, germs, urine, faeces, blood, radiation, poison) The hairdresser's comb has the AIDS virus on it.
Rings doctor; checks body for symptoms of AIDS; washes hands and hair; sterilizes all things that others may touch.
Physical violence to self or others by self or others I will harm my baby.
Won't be alone with the baby; seeks reassurance, hides knives, plastic bags.
Accidental harm (not due to contamination or physical violence, for example, accident, illness) I may have hit someone with my car.
Telephones hospitals, police; retraces route driven; checks car for marks.
Socially unacceptable behaviour (for example, shouting, swearing, losing control of behaviour) I am going to shout an obscenity.
Tries to 'control' behaviour; avoids social situations; asks others whether behaviour was acceptable in particular situation.
Sex (preoccupation with sexual organs, unacceptable sexual acts) I am going to commit rape.
Avoids being alone with women; tries to keep mind off sexual thoughts.
Religion (for example, blasphemous thoughts, religious doubts) I am going to offer my food to the devil.
Prays; seeks religious help/makes confession; offers other things to God.
Orderliness (things being in the right place, actions done in the right way, according to a particular pattern or number) If I don't clean my teeth in the right way, I'll have to do it again until I get it right.
Repeats action a 'good' number of times; repeats until it 'feels right'.
Nonsense (meaningless phrases, images, tunes, words, strings of numbers) Hears (in the head) the tune of a TV sports programme while reading.
Repeats action until managing to read the same passage without tune occurring.
(Adapted from Hawton, Salkovsis, Kirk & Clark
1989)
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Post-traumatic stress disorder (PTSD) Post-traumatic stress disorder occurs at all ages, although in children the disorder might present with generalized nightmares, and a feeling that they will not live to be adults. PTSD usually occurs within three months of the trauma occurring, but sometimes the onset is delayed. The main symptoms are usually re-experiencing, avoidance of stimuli associated with the trauma, and hyperarousal symptoms. It must be differentiated from adjustment disorder, where the trauma need not be extreme. The disorder is treated by the debriefing procedure described in Chapter 21, 'Understanding trauma'. Temazepam 10 mg twice a day can be prescribed for two weeks. If it is necessary, this period can be extended to one month, but no longer. Medication alone will not help and counselling is essential. Acute stress disorder (ASD) is similar to PTSD, but occurs within one month of the extreme traumatic stressor. Added to the three classic symptoms of PTSD, dissociative symptoms, such as feeling numb or detached, and even dissociative amnesia are present. Feelings of despair and hopelessness might also occur. The diagnosis is only made if the symptoms last longer than two days, and cause clinically significant distress or impairment. If it lasts beyond three months, the diagnosis is changed. The treatment of ASD is the same as that of PTSD. Generalized anxiety disorder Generalized anxiety disorder (together with social phobia) is one of the more common anxiety disorders. More than half the people suffering from this disorder have had high anxiety levels since childhood, when the anxiety often centred around school performance or catastrophic events such as nuclear war. It is not common in people older than 20.
12.5 WORKING WITH THE ANXIOUS PATIENT Working with anxious patients can be particularly stressful. This is partly because of the helplessness mental health care workers may experience in the face of the patient's obvious distress and discomfort, and partly because anxiety itself is communicated interpersonally. In addition to the anxiety-reducing techniques mentioned later in the chapter, there are a number of other strategies the nurse can use to maintain personal and professional efficiency when working with anxious patients. Recognizing one's own feelings of anxiety The first strategy centres on recognizing one's own anxiety and the thoughts, events and feelings that may be responsible for provoking it. Many students enter the clinical situation beset by a range of fears about their own competencies and resources for coping: 'What if I say something wrong?'; 'What if the patient doesn't like me?'; 'What if I get hurt or hurt the patient?'; 'Will I be able to cope with mentally ill patients?'. These responses are quite normal considering that one is entering a novel situation, and often not voluntarily.
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Research has shown that no amount of preparation for the clinical experience can allay anxiety in students. What can be of help is to explore the beliefs that give rise to these negative thoughts and to work actively to reframe them as reasonable statements of intent. The nursing socialization process is to some extent responsible for the beliefs that nurses develop about themselves. Explicit images of the responsible, independent practitioner abound in nursing. Yet, at the same time, nurses encounter a variety of covert messages in the educational and clinical settings that are inconsistent with the dominant belief about nursing. Ripsel and Motsei (1988) mention a number of influences to which nurses are subjected, for example: powerlessness in the hierarchy, which overtly disallows the taking of responsibility, of questioning and of speaking out for their rights; and the extent to which nurses have allowed and continue to allow nursing matters to be directed by medical personnel. The socialization process of women in our society also feeds the beliefs nurses hold about themselves. Again, images of women as intuitively caring yet in need of care themselves, as incompetent in a range of 'worldly' activities such as finance or public speaking, infiltrate the beliefs we develop about ourselves both as women and as professional nurses. The contradiction between the images of ourselves as nurses (responsible, independent practitioners but rendered powerless by the hierarchy and directed by the medical profession) and as women (incompetent and emotionally labile, passive, subordinate, 'winning' through manipulation) creates the opportunity for anxiety. Male nurses are also subject to a range of social and professional attitudes that may lead to the development of a belief system fraught with contradictions. Generally, nursing is regarded by society and by nurses themselves as a female profession but also with the contradictions that exist between male stereotypes (competent, strong, emotionally guarded, assertive, self-directing) and those stereotypes that characterize females (dependent, submissive, emotional and weak). Thus, the mismatch between what we think we should be thinking, feeling and doing and what we are actually thinking, feeling and doing often leads to the development of a belief system that is at best confusing and at worst the source of much anxiety and distress. Hence, when thoughts of incompetence arise, it is important to question their validity. Is it reasonable to expect that one should be able to cope with all situations all the time? Is it reasonable to expect that all people should like us all the time? Is it reasonable to expect that nurses should never make mistakes? Is it unreasonable to expect that nurses are capable of directing and controlling their own profession? You should work at challenging the thoughts that pop up and at restating them in ways that allow for your own humanness. Thoughts such as 'What if I do something to hurt the patient?' can be rationally restated as 'I will use what skill and knowledge I have at this point to care for patients.' With persistence and practice, nurses can contribute towards challenging the values and beliefs that cause anxiety and work towards developing a realistic belief system that enhances their natural abilities and talents.
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Approaching the highly anxious patient The second strategy involves developing a set of verbal, non-verbal and environmental manipulation skills that can be used in dealing with anxious patients, especially those with a high level of anxiety. Liehr (1999) found that a clinically significant increase in cardio-vascular arousal (heart rate and blood pressure) occurs in people who are listening as well as in people who are talking. She refers to this arousal as 'the hidden language of the heart' and suggests that mental health nurses develop an awareness of this 'language' because talking and listening are integral to mental health nursing. Therefore, in working with the anxious patient, the nurse should balance the extent to which both she and the patient talk and listen. All of the following strategies are examples of how the nurse can use 'the hidden language of the heart' to communicate with people who are feeling anxious. Verbal communications Communicate with the patient simply and directly, without being patronizing. Avoid lengthy, in-depth discussions with the extremely anxious patient since his/her ability to process information is likely to be impaired. Speak in a calm, even tone of voice. Avoid criticizing or making judgements about what the patient does to limit his/her anxiety, even if these coping behaviours are maladaptive, for instance, neutralizing behaviour or avoidance. If the patient is talking fast and breathlessly, suggest he/she slows down and draws a breath between words to decrease cardio-vascular arousal. Non-verbal communications Allow the patient sufficient body space; being too close to the patient can increase the anxiety response. Make sure that physical gestures convey an intention to help, not harm; move slowly towards the person and reach out with the palms of the hand up so that the gesture is not misinterpreted by the person as an attempt to 'attack'. When moving towards the patient, inform him/her verbally of what your actions mean, for example: T'm going to sit down on the bench with you for a few minutes.' Sometimes restless and panicky patients need reassurance about the availability of support and nurture; provide this by holding the patient gently while making verbal statements of the desire to help the patient feel in control, for example: 'I'm here to help you cope with the distress and tension you seem to be feeling.' Environmental manipulation Decrease environmental stimulation by limiting the patient's interactions with others; by monitoring the noise level in the ward/home/clinic and by intervening to decrease it, if possible.
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Identify and modify situations that provoke anxiety for the patient until he/she is able to participate in this process; for example, ask the family to visit or not to visit if this is a source of anxiety for the patient. Offer supportive physical measures, for example, a warm bath or shower, or massages if the patient is able to tolerate physical touch. Administer prescribed medications to provide relief of symptoms. 1 2 6 ASSESSING ANXIETY Assessment has three aims: 1. to determine the precise nature of the problem; 2. to define the goals of treatment; 3. to identify appropriate nursing interventions. Determining the precise nature of the problem involves identifying: what the problems are and which are most distressing to the patient; when the problems started and how they have developed over time; what behavioural, cognitive, physiological and affective responses are associated with the problems; in what situations and contexts the problems occur; what factors serve to maintain the problems; and what coping strategies and resources the person employs to manage the problems and their emotional consequences. The psychiatric history, mental state examination and patterns of lifestyle functioning are the basic assessment tools of the nurse. There is a variety of assessment strategies that can aid the systematic and accurate collecting of information. These include: the behavioural interview; self-monitoring; self-reporting (for example, questionnaires); information from others (for example, interviews with key individuals); direct observation of behaviour in clinical settings; and physiological measures. The behavioural interview Chapter 10 deals in detail with this method of assessment. A time-event chart can be used to plot the course of the problem. Variations in severity of the problem are recorded down one side of the time-line, and life changes or stressful events down the other side (see appendix 6 for an example of such a chart). Self-monitoring This can be used as an adjunct to behavioural interviewing. It is flexible and can be applied to a wide range of problems or symptoms. There are two stages in self-monitoring. The
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patient first has to recognize that the behaviour, thought, emotion or event has occurred and then has to record that it has happened. The behaviour to be monitored should be clearly defined; 'feels anxious' is too vague a concept to measure. Criteria that indicate that the person is anxious should rather be used. These criteria can include self-critical thoughts when in the company of others, palpitations, breathlessness, etc. Alternatively, self-monitoring can be used to help specify what the problems are. A number of aspects of the problem can be monitored: How often the target behaviour occurs (frequency). How long the target behaviour lasts (duration). The situation in which the target behaviour occurs (context). Emotions associated with the target behaviour. Thoughts associated with the target behaviour. Rating scales can be used to establish the intensity of the various aspects of the problem and the extent to which the patient believes his/her negative thoughts. A scale of 0 to 100 can be used, where 0 = the absence of emotion, sensation or belief, 50 - a moderate degree, and 100 = as strong as it could be. To ensure the relative accuracy of self-monitoring, the patient should be instructed to record the information as soon as it is noted and not to delay doing so until later. Example Ms B reported that she felt 'terrified' all the time. She was unable to be any more specific than this, so the nurse asked her to keep the following record for one day. The purpose of this exercise was to reinforce the need for concrete as opposed to global thinking, as well as to determine specific problem areas. From Ms B's log it seems that she feels most anxious in the company of others and is concerned about how other people perceive her. The same method could be used to clarify further in what specific social situations she feels anxious and with whom, and the nature and intensity of the anxiety response. Date &
Emotion
Situation
Negative thoughts
What is it? How bad is it? 0-100
Where were you, what were you doing at the time and with whom?
What were your thoughts? To what extent do you believe each of them? 0-100
Nervous: 80 Angry: 80
Lying awake in bed; patient next to me snored all night
I can't stand this: 80 I would have slept if I was at home alone: 50
time
22.8 07:00
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Date& time
Emotion
Situation
Negative thoughts
08:00
Flustered: 90 Racing heart: 60 Muddled thoughts: 70
Sitting with other patients in the lounge; ward sister came to speak to me
What have I done wrong?: 80 The patients don't like me, the ward sister has to talk to me: 90
09:00
Relaxed: 50 Lonely: 70
Sitting outside alone, knitting
If I avoid people, I feel better: 90 Other people are much happier without me around: 90
Note how the patient's self-rating gives an indication of her cognitive thought patterns. Ms B concludes that, because she is alone and feeling relaxed, her anxiety must have something to do with being with other people (selective abstraction). This cognitive error might prevent her from considering the possibility that other factors such as focusing on a distracting task (knitting) might also be partly responsible for her feeling relaxed. Self-report questionnaires There are many types of questionnaires that can be used as part of the baseline assessment, for example the Hamilton Anxiety Rating Scale, Stanford Panic Appraisal Inventory and Stanford Panic Diary Instructions (see appendix 7 for examples of such scales). Direct observation of behaviour The nurse can gather information about naturally occurring behaviours that indicate anxiety by using time sampling, interval recording and continuous recording methods. If a specific target behaviour is to be observed, that which is to be observed should be clearly defined. For example, if a patient deals with his/her fear of social ridicule by withdrawing, the focus of observation could be on trying to establish the frequency of the patient's interactions, how long they last and with whom he/she interacts. It is insufficient to state simply 'socially withdrawn'; it is the degree to which the patient isolates him/herself that determines what intervention strategies are appropriate. Physiological measures Physiological processes can be monitored indirectly. A patient can be asked to monitor the frequency, duration and contexts. Physiological symptoms such as sweating, headaches, nausea, respiration and blood pressure can be monitored regularly to determine the extent of physiological arousal and the extent to which intervention strategies have helped decrease physiological arousal. Sometimes, especially with patients
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who deny feeling anxious, yet obviously appear to be so, tangible evidence of physiological arousal can help them to develop an awareness of the possibility that they might be feeling anxious. Mrs W had a persistent tachycardia for two weeks. Objectively, she appeared anxious and was pacing restlessly. She denied any feelings of worry or fear, yet she constantly phoned home to find out how her children were. The nurse used these physiological processes to help Mrs W make the connection between physical arousal, worry about her children and anxiety. In one sense, knowing that physiological arousal is associated with anxiety enabled Mrs W to acknowledge her emotional feelings of distress. Analysing the data for the purpose of diagnosis The DSM-IV-TR multiaxial case formulation is a useful framework for organizing information. Once this has been done, relevant nursing diagnoses are formulated, which specify the nature and intensity of the problem, the frequency and duration of the verbal and non-verbal behaviours that describe the problem and the specific stressors associated with the problem.
Mrs W's nursing diagnosis: Moderate level of anxiety, possibly related to her concern about her children being alone at home and manifest in persistent tachycardia and increased psychomotor activity.
Common nursing diagnoses Anxiety RELATED TO threat to self-concept EVIDENCED BY feelings of unreality and insomnia. Panic RELATED TO being exposed to phobic stimulus (name the patient's phobic stimulus), EVIDENCED BY palpitations, fear of dying, fainting, trembling and shaking Defining the precise nature of the problem sets the stage for identifying treatment goals and intervention strategies. 12.7
INTERVENING
IN
ANXIETY
Intervention takes place within the context of the supportive, collaborative relationship initiated between the nurse and the patient in the assessment phase. The broad, interrelated goals of intervention are to: 1. help relieve the patient's immediate distress associated with anxiety; 2. help the patient to gain an understanding of his/her experience of anxiety; and 3. help the patient to identify and cope with the source of his/her anxiety.
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Cognitive-behavioural therapy (CBT) Cognitive-behavioural therapy (CBT) is based on the idea that a person's feelings and behaviours in any given situation are largely determined by his or her interpretations of and assumptions about the experience. For example, if a person experiences depression after a relationship break-up, it may not be the break-up itself that causes the depression reactions, but the person's interpretations of and assumptions about 'breaking up': being seen as weak for not being able to sort out the problems; being unable to cope alone; being unable to find another partner; being half a person without a partner. It is possible for a person who accepts the many reasons why the break-up was necessary, and wanted the break-up to happen, to still feel depressed. This is because the beliefs underlying the person's construction of 'break-up' have been automatically activated by it. The person's task would be to use his/her thoughts about why the break-up was necessary and why he/she wanted it to happen, to moderate and counterbalance these automatic thoughts. In doing so, he/she develops a new set of beliefs about 'self and break-up' and consequently, a moderated set of behavioural reactions. ABC of CBT
Lam and Gale (2002) offer a clear outline of Beck's (1976) ABC theory of emotional disturbance. It is useful here because it puts into practice 'understanding anxiety from a cognitve-behavioural perspective' and the cognitive-behavioural therapy (CBT) treatment strategies outlined in the section. Activating event
Belief system
Consequences (emotional and behavioural)
From this perspective, anxiety (and depression and other negative feelings and emotions) are a set of emotional and behavioural consequences (C). These are not caused by an activating event (A) but by the person's beliefs (B) about (A). In the previous example, the (A) is the break-up, the (C) are the depressive feelings and the (B) are the beliefs the person has about 'self and break -up'. In this example, it is the beliefs, triggered by the activating event, which lead to the specific emotional and behavioural responses. CBT aims to help people to change the way in which they construct their experiences. Lam and Gale (2000) provide a seven-step programme which can be used to teach people (and facilitators) how CBT works. Because a few of the steps overlap in practice, they have been trimmed here to four steps.
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Step 1 Introducing the philosophy of CBT In this step, the aim is to explore the patient's understanding of CBT and to describe what CBT is and what it aims to do. Many people do not know what this form of therapy is about, and many of those who do see it as a way of'thinking more positively'. The first substep would be to introduce the idea of CBT as a form of treatment to the patient. For example, Pete is a patient in the ward. He is almost ready to be discharged. His illness (schizophrenia) is stable and he is ready to return home, and then back to work. He is a quiet, shy person who becomes 'dumb-struck' in social situations. He has a few close friends but he prefers his own company to that of others. The ward's pre-discharge supper-dance is a few days away. All patients who are about to be discharged are expected to attend, if only for the supper part. Friends and family of patients who are about to be discharged have been invited and everyone, except Pete, is excited. The nurse notices this. Nurse: Pete, I notice that you put yourself down a lot; just now you said you were useless at dancing and were 'stupid' when you had to talk to other people. The other day I heard you saying pretty much the same thing about how boring other people think you are. (Picking up on a pattern in the way he constructs himself.) Pete:
Well, I am bit stupid, I always say silly things in front of other people, I feel like they are looking at me and thinking 'there goes that geek'.
Nurse: And when you think they are saying 'there goes that geek', what sort of feelings do you have about yourself? Pete:
I feel really bad ... but what can I do? It's a 'geek's' life.
Nurse: Do you think there is any connection between the things you say to yourself about yourself, like 'I'm a geek', and how you feel about yourself afterwards? (Introducing the idea of a connection between beliefs and consequences.) Pete:
Well, I am a geek, so I suppose I behave like a geek (laughs weakly at himself, but looks a bit sad).
Nurse: I would like to use a form of therapy called CBT with you. I think it might help because according to this approach, your feeling bad about yourself is caused not by the presence of other people, but by how you believe other people in social situations see you. This approach says our emotions are largely caused by our interpretations and assumptions about situations, rather than by the situation itself. (Introducing the therapy and its rationale.) Pete:
Okay... but they do see me like that... but if you want me to think more positively, I will try.
Nurse: CBT is not so much about 'thinking positively' as thinking clearly about how the thoughts we have about ourselves in specific situations influences the way in
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which we feel and behave in those situations. The idea is that changing how and what people think about an event leads to changes in emotional and behavioural responses. (Correcting misperceptions about CBT and reinforcing its rationale.) Step 2 Using an example to illustrate the ABC concept In this step, the nurse working with Pete would use a similar example to his own to explain the ABC concept. The purpose of using a similar rather than his own is three-fold: Firstly, using an example not quite as close to Pete's heart distances him emotionally from his own problem, thus providing him with a mirror which he can use to reflect upon his own difficulties while learning about the ABC concept. Step 3 The A-C connection This step points out that it is not the event itself that causes emotional and behavioural responses. This is an important step, because it seems plausible that A causes C and many people believe that without A, C wouldn't have occurred. The many-people technique (see below) helps people to understand that the activating event simply triggers off the belief system of the person whose interpretations and assumptions about A are largely responsible for C. Pete:
CBT is fine, but if I didn't have to go to the dance, I would be absolutely fine, I wouldn't be feeling so bad about myself. Nurse: That seems logical and it is one way of seeing things, but let's look at it in another way. Suppose 100 people were all going to the same dance. Would they all feel the same amount of anxiety and embarrassment as you? Pete: No, but then they are not me; it depends upon them, how can I tell? Nurse: So maybe it is not the dance that is causing you the embarrassment, but your assumptions and interpretations about what is expected of you at the dance? Pete: You have me there! Step 4 The B-C connection This step is divided into three parts: The first part involves identifying unhelpful beliefs (B) and the specific situations (A) in which they are triggered, the second involves modifying beliefs (B) and associated behaviours (C), the third involves testing automatic thoughts of threat (B) and developing helpful alternatives (B). A fourth part comes into play when action is taken to test negative thoughts and develop helpful alternatives. Strategies for this step are described and illustrated below. Specific cognitive-behaviour strategies in the B-C connection The following main treatment strategies are used in cognitive-behaviour therapy to help people to develop new constructions of themselves at specific points in the ABC model.
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Cognitive distraction techniques These strategies can be used for managing the consequnces (emotional and behavioural) in the ABC model of cognitive-behavioural therapy (CBT). In other words, for immediate symptom management and to help patients realize that they can exercise some measure of control over their anxiety. These strategies aim to shift the patient's awareness from their anxiety to neutral things beyond self. The choice of strategy depends on the patient's degree of distress and cognitive ability: a highly anxious patient with marked cognitive impairment would not be asked to participate in mental exercise; this would serve to increase his/her level of anxiety; absorbing physical exercise or activities would be more appropriate. The nurse should also ensure that these games are not perceived as competitive; this is in and of itself a potential source of danger for the person. The way in which the strategy works, and its potential benefits, should be explained to the patient. Focusing on an object The patient can be taught to focus his/her attention on a neutral object, such as a bowl of flowers, chair, carpet or piece of furniture and to describe it in as much detail as possible when he/she feels anxious. Pete was interested in woodwork. When he felt anxious, he focused his attention on a piece of furniture and asked himself a series of questions: 'What is it made of?' 'How big is it?' 'What colour is it?' 'What could it be used for?' This technique helped to reduce his level of anxiety in the situation and he was able to use his knowledge in conversation with others. Sensory awareness This involves teaching the patient to focus on his/her surroundings, using all the senses. In this instance, Pete learnt a series of cue questions to stimulate awareness: 'What can I see if I look around me?' 'What sounds can I hear?' 'What is the texture of this wood/leaf/ tree trunk?' Mental exercises Any absorbing mental activity can serve as a distraction from feelings of distress, for example, counting backwards from 50, doing jigsaw or crossword puzzles or playing general-knowledge games. Absorbing activities Physical activities can help to distract the patient and reduce physical tension associated with anxietv. Activities such as playing tennis, setting the table, table-tennis, swimming, :>risk walks, stretchir^ exercises, yoga exercises, arranging flowers, making beds or serving meals are useful
Visualization techniques rhvuipeiitie visuali/ation is similar to the process of 'refraining'. Refraining is based on ih 2 yrs persistent symptoms?
Yes
Major depressive disorder in partial
No Dysthymic disorder
Depression NOs (recurrent, brief, minor, mixed anxiety/depression)
Figure 13.1 Diagnosing mood disorders (Stuart 1994: 15)
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13.2
NURSING ASSESSMENT AND INTERVENTION
The patterns of lifestyle functioning will be used to describe the phenomenon of depression as it occurs within the individual, and the process of psychiatric nursing intervention. Examples of nursing diagnoses which could be used to give substance to the intervention process are given below. Common nursing diagnoses Potential for violence: Self-directed RELATED TO threats to self-concept EVIDENCED BY possession of destructive means, hostile, threatening verbalizations. Alternations in nutrition: Less than body requirements RELATED TO lack of appetite EVIDENCED BY loss of weight, lack of interest in food, palse conjunctiva and mucous membranes.
Psychodynamic patterns Cognitive patterns The following unhealthy cognitive patterns are most commonly found in depressed patients: Selective abstraction. Because of their negative mind-set, they pick out the negative in every situation and ignore the positive. Overgeneralization. From one negative aspect they then generalize to all situations and people all the time. Catastrophizing. Having generalized the negative freely, they conclude that the worst will happen. These thought patterns, if consistently used, most obviously lead to and maintain a feeling of depression. The nursing intervention for destructive cognitive patterns is as follows. 1. Identify the pattern. 2. Help the patient to become conscious of it, in other words to diagnose him/herself. 3. Teach the patient to test the truth of the belief or thought and to correct it: Selective abstraction: also to identify positive aspects. Overgeneralization: to confine a negative aspect to where it belongs. Catastrophizing: to identify different scenarios, not just the one that is most negative. The following transcript of a conversation between a nurse and a patient illustrates how these principles work. The reader is also referred to Chapter 12, 'Nursing the patient with an anxiety disorder'. Patient:
I went out shopping yesterday ... it was terrible ... the shopkeeper didn't notice me standing there and I had to wait while he served others who arrived at the
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counter after me ... he did apologize but it's the story of my life ... no one notices me or cares about me. Nurse:
It sounds as if how others see you is really important to you . . .(Reflecting feeling.) Can you give me an example of another situation where you also felt unnoticed? (Collecting information to identify the cognitive pattern.)
Patient:
Well, as I said, it's the story of my life ... but okay, yesterday this other patient promised to keep me a seat in front of the TV. I got there and she had forgotten. She offered to fetch me a chair but that's not the point.
Nurse:
From the two stories you've told me, it seems as if two things happen to you when you feel other people aren't noticing you. First, you think that it must mean that you are a totally worthless person all the time, and second, you forget to look at the positive part of each situation; for example, the shopkeeper apologized to you and the other patient offered to fetch you a chair. Does that sound familiar to you? (Summarizing, identifying cognitive patterns of overgeneralization and selective abstraction; checking this out with the patient.)
Patient:
A bit ... but still, that's what happens to me all the time. If people noticed me, I wouldn't feel so bad and then it wouldn't happen.
Nurse:
So if people noticed you, you wouldn't feel so bad ... let's look at it in another way and see what you think. I'd like you to think back to a time before you became depressed. How did you feel about yourself then? (Helping the person to see that faulty thoughts are the problem, not the situation itself.)
Patient:
It's so long ago ... I remember feeling good and strong, a few ups and downs, but mostly well.
Nurse:
Imagine yourself feeling good ... you're in the shop you were in yesterday and the shopkeeper serves people who came after you before he serves you. If you had to rate your feelings of worthlessness on a scale from 0 to 10, where 0 meant not feeling worthless at all and 10 meant feeling totally worthless, what rating would you give yourself? (Helping the person to see the relationship between thoughts, feelings and behaviour.)
Patient:
Maybe 1 or 2 at the most.
Nurse:
So what do you make of the idea that because you saw yourself as a strong, capable person, what happened in the shop didn't really bother you so much? (Pointing out the influence thoughts have on feelings and behaviour without 'lecturing' the patient.)
Patient:
Maybe it works like that ... but right now it's hard to even imagine feeling good ...
Nurse:
It sounds as if you're fed up with feeling bad all the time ... let's try to get a good idea of how things really are. What I'd like you to do is to keep a diary for the next week about the specific situations where you felt useless and worthless.
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(Helping the person to get a baseline for negative thinking and teaching the patient to 'diagnose' patterns and the relationship between patterns, feelings and behaviours.) Date: Situation (who was involved, what happened, who said what and did what):
Thoughts about myself:. How I felt and behaved: Patient:
Okay ... I probably won't be able to do it properly.
Nurse:
That's one of the good things about this exercise. There aren't any 'proper' ways of doing it.
The following meeting (after social niceties) Nurse:
How did your homework go?
Patient:
Well, I tried, but it's probably not much good.
Nurse:
Let's look at it together ... on Sunday you felt bad about yourself after the nurse forgot to call you for lunch ... the same on Monday and Tuesday when the social worker asked to postpone her appointment. I see that after each incident you felt 'awful' for the rest of the day.
Patient: Yes, well, more evidence that I'm a nobody. Nurse:
Let's think of a few other reasons why the nurse forgot to call you, and why the social worker had to postpone her appointments. (Helping the person to test the thought and correct it through learning more rational ways of interpreting the situation.)
Patient:
The nurse was busy, I'll admit that. She was working on her own and there was a new admission. The social worker was called away to some special meeting at head office, but still...
Nurse:
Okay, it seems that there are fairly good reasons why the nurse and the social worker behaved as they did, and that it's not just because you are so 'forgettable'. Maybe what's happening here is that you're forgetting about the more positive, realistic aspects of the situation and focusing on the negative. (Reinforcing the relationship between patterns, feelings and behaviours.)
Patient:
Maybe.
Nurse:
It takes time to change the way we think about things. Keep your diary for another week and add an extra column 'New ways of thinking, feeling and
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behaving'. (Teaching the person to find alternative and more rational ways of seeing things so that eventually new thought patterns become as entrenched as the old, thus leading to a change in the way the person feels about self and subsequently behaves.) Taking care of yourself when suffering from depression
Pace yourself. Do not expect to do all of the things you were able to do in the past. Set a schedule that is realistic for you. Remember that negative thinking (blaming yourself, feeling hopeless, expecting failure, and other such thoughts) is part of a depression. As the depression lifts, the negative thinking will go away. Avoid making major life decisions during a depression. If you must make a major decision about your life, ask someone you trust to help you. Avoid non-prescribed drugs and alcohol. Research has shown that drinking too much and using drugs can worsen a depression. It can also lower the effectiveness of antidepressants or cause dangerous side effects. Understand that it took time for the depression to develop and it will take time to go away. Keep all your appointments with health workers, whether you are feeling better or worse. Tell them how you are feeling and about all side effects. If you have concerns about your treatment, ask questions, talk to someone you trust, get in touch with a consumer group, ask for a second opinion. (US Department of Health and Human Services 1993) Coping mechanisms Coping mechanisms used by patients who are depressed are usually passive in character and often involve dependence behaviour and withdrawal. Withdrawal Definition Withdrawal is the physical and psychological removal of the self from an environment, thus resulting in detachment and isolation. This is not always a passive process but may be very active and strongly enforced by the patient. Withdrawn patients have retreated from both external and internal stimuli. Involvement with others and with their own feelings is seen as a source of overwhelming threat for which they do not have the resources to cope. Healthcare workers often think that they have 'failed' if, after one or two interactions, patients still don't seem willing to express their feelings and talk about their problems. The withdrawn patient is probably the most difficult person to deal with for the nurse who measures her own therapeutic ability against how much the patient talks and shares. 1. The greater the pressure and/or the absence of pressure on the withdrawn person to interact, the more likely he/she is to retreat physically and emotionally.
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Cathy is a severely withdrawn 24-year-old woman. She spends the larger part of each day sitting on the floor in her room facing the corner. She avoids eye contact with the staff and turns her head away when they enter the room. She refuses to eat in the dining room but will eat food if it is brought to her. Her only form of communication with others is through non-verbal gestures and even then these are designed to isolate herself from others. Nurse Zuma and Nurse Mkhize (on opposite shifts) are assigned to care for Cathy. Nurse Zuma enters the room, moves close to Cathy and puts her arm around her, saying: 'Hello, Cathy, I'm Nurse Zuma ... look at me ... look at me, please, I'd like to talk to you ... you'll feel better if you talk about what's bothering you.' Cathy turns away and curls up into a ball. At the same time she tries to shrug off Nurse Zuma's arm from her shoulder. Nurse Zuma hugs Cathy tighter and tries to turn her head to face her while saying: 'I can see you are upset about something ... I'm here to help you ... please talk to me.' Cathy tries to retreat further, her body becomes rigid and she buries her head in her lap. After a minute or so Nurse Zuma gets up and quietly leaves the room. Over the course of the day she repeats her approach to Cathy, who continues to resist her. Her entry in the Cardex reads as follows: 'Patient very withdrawn and reluctant to engage in any form of communication and becomes very anxious when approached, for example, shrinks away from contact, body tense. To continue trying to interact with Cathy.' The following day Nurse Mkhize approaches Cathy. She enters the room and squats down on the floor a good few metres from Cathy, saying: 'Hello, Cathy, I'm Nurse Mkhize ... (few moments of silence) ... I can see from the way you are sitting curled up in a ball that you'd really like to be by yourself. . (Few moments of silence.) That's okay ... I'd like to sit quietly with you for a few minutes ... (few moments of silence) ... (Cathy peeks at Nurse Mkhize from under one arm and then looks away. Her body relaxes slightly.) If you'd like to sit more comfortably, that's alright, I'm not coming any closer ... (Cathy shifts her position slightly but is still turned away from the nurse.) I've brought you a magazine I thought you might like to look at ... I'll leave it here for you ... I'm going back to the ward now, but I'll come back in an hour's time and sit with you for a short while.' Over the course of the day she makes regular contact with Cathy. Before her shift ends, she notices that the magazine has been moved and assumes that Cathy has looked at the front cover. Her entry in the Cardex reads as follows: 'Patient showing some non-verbal evidence of communication, for example, fleeting eye contact and relaxing of body posture. To continue programme of graded interaction based on her non-verbal responses.' 2. The more consistent and reinforcing the withdrawn person perceives the environment to be, the greater the likelihood of his/her engaging with the environment. Nurse Zuma and Nurse Mkhize discuss their approaches to Cathy and decide to be consistent in their approach, that is: Respect her need for physical distance and emotional and social privacy, while at the same time ensuring that she knows they are available to her.
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Adjust the demand for interaction according to her non-verbal behaviour, while at the same time following a programme of graded social involvement that starts with the least threatening social activities. Keep promises of returning to spend time with her. Keep her informed of what is happening in the ward - for example, new admissions, discharges and ward activities - without pressurizing her to participate. Discuss their approach with other team members, Cathy's family and other patients. Realistically reinforce Cathy's attempts to engage with the environment. Example of Cathy's programme of graded social activity
Day
Time
Activity
Monday
07H30
Put chair and table in Cathy's
Cathy moved the table to the corner
room, place her food on the
of the room and stood while eating her food.
table and invite her to eat at
Outcome
the table.
09H30
Put a radio (playing softly)
Volume on the radio was turned
on the table. Tell Cathy about
up slightly.
it and leave the room.
10H30
Talk with Cathy about how she
Just shrugged her shoulders.
feels about having the table in her room and hearing news about the outside world on the radio. Acknow edge any attempt at communication.
12H30
Place Cathy's food on the table and invite her to sit down and eat.
Ate at the table but got up immediately nurse entered the room.
14h30
Cathy's sister to visit for 10 minutes.
Withdrawn after the visit, sitting hunched up in the corner. Reduce visit to 5 minutes.
16h30
Nurse Zuma to spend 5 minutes with Cathy, in silence if necessary.
Seemed more relaxed, made eye contact with the nurse and 'grunted' in response to a question.
17HOO
Place Cathy's food on the table
Sat at the table, did not get up
and invite her to sit down and eat.
until the nurse asked her how she felt sitting at the table.
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Tuesday
07HOO
07h30 09h30
Invite Cathy to wash once the other patients have finished. Make it clear she will be alone in the bathroom. Nurse asks Cathy if she may join her at her table for after-breakfast coffee. Ask Cathy whether she would like the radio turned on and to indicate yes or no with a nod or shake of the head. Respect her decision and acknowledge her communication.
Thus nursing intervention for the withdrawn person focuses on: gradually increasing the demand for interaction, first at a physical level and later at an emotional and social level (the amount and type of demand at any given moment is determined by the patient's level of anxiety evident in verbal and non-verbal behaviour); providing an environment that is consistent and reliable in its demands on the patient and one that realistically reinforces the person's attempts to engage with it. Nursing intervention 1. Make contact or link with the patient. Therapeutic use of family or close friends may be helpful. 2. Establish and maintain a trusting relationship. Staff must be aware that this may be a lengthy process requiring patience and perseverance and that the patient may initially reject them. 3. Respect the patient's need for silence and inform the patient that the staff is always available when he/she has a need to communicate. 4. Touch may be used therapeutically by staff who feel comfortable with touch and according to the patient's reception of touch. 5. Maintain consistency regarding appointment times. 6. Give the patient positive feedback to both verbal and non-verbal responses. 7. Avoid comments like 'Seeing you aren't busy ...' to a colleague sitting with a withdrawn patient. 8. Gradually introduce the patient to other people and then explore feelings with regard to contact made with others. 9. Gradually introduce and involve the patient in lifestyle activities again. 10. Use friends and family as a link with the community.
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11. The depressed patient will often be told by family to 'pull yourself together'. This indicates the void between the family's perception of depression and the patient's feelings. The nurse can bridge this gap by inviting family and patient to a 'family session' where the focus is on insight development of depression for the patient and family alike. Inactivity People who are depressed are often plagued by thoughts such as Tm not doing anything', Til never get anything done', 'I can't do anything', 'Nothing I do is worthwhile', 'I should be able to do that anyway'. Such thoughts undermine the person's sense of mastery because they do not account for the fact that in depression the simplest of tasks requires tremendous effort. Because depressed people tend to think in global, negative ways about themselves, what they do and what they don't do, it is important to establish the 'hard facts'. Are they inactive, withdrawn, incapable of solving problems, beset by negative thoughts and unpleasant emotions all day and in every situation they encounter? Or are there in fact some situations in which they feel less withdrawn, more active and more capable? Helping depressed people to become more active involves the following. .1. Finding out what they do on an hour-by-hour basis over a specified period of time, and rating each activity out of 10 for how much they enjoyed it (pleasure) and the sense of achievement the task gave them (mastery). Because depressed people tend to have unrealistically high expectations of themselves, it is important to stress that they rate their sense of mastery in terms of how they felt at the time and not in terms of how well they think they should have performed the activity. Example of Cathy's self-monitoring record of her activities
07hOO-08hOO
08hOO-09hOO
Monday
Tuesday
Got out of bed (Pleasure 0, Mastery 5), got dressed (P1, M3),
Got out of bed (P1, M4), got dressed (P1, M5), had breakfast at
had breakfast at the table
the table in the room with
in the room (P3, M4).
Mrs King (patient) (PO, M6).
Sat at the table, looked at a
Went to have a bath (P4, M6).
magazine (P2, M5). Nurse came to
Nurse came to see me (P4, M5).
see me (P3, M5).
09hOO-10hOO
Mrs King brought me tea (P3, M4),
Asked Mrs King to have tea with
!istened to play on the radio (P4, M6).
me (P4, M7), took my cup back to the kitchen (P1,M8).
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10hOO-11hOO
Nurse came to see me, went to have a bath (P3, M7).
Walked down the corridor (P1, M8) but turned back when I saw all the other patients (PO, MO).
12hOO-13hOO
Had lunch with the nurse (P4, M6).
Mrs King and Nurse had lunch with me at the table (P4, M9).
13hOO-14hOO
Rested in bed (P8, M3).
Rested for half an hour (P6, M3) and then got up (M9) and listened to the radio (P7).
Note how Cathy's programme also reflects her increasing involvement in social activities which were a part of her graded social involvement programme worked out by the nurses. 2. Using the information from self-monitoring to plan a schedule of activities for each day in advance. The aim is to increase activity slowly and to optimize mastery and pleasure. The schedule of activities should be realistic, clearly spelled out and achievable. The amount of activity expected from the patient should be consistent with how he/she is feeling and the level of activity identified during the self-monitoring phase. A severely depressed person might be able to accomplish one activity in a day, whereas another might be able to accomplish more. From Cathy's self-monitoring chart it is clear that spending time with the nurse and Mrs King and listening to the radio gave her the greatest pleasure, while leaving her room gave her the greatest sense of mastery. Activity scheduling for Cathy would focus on providing similar activities - that is, socializing with a limited number of familiar people outside her room environment. The level of demand for social interaction outside her room would be graded, that is, broken down into small steps to maximize the chances of success on the task, thus increasing pleasure and mastery. This is known as a graded task assignment. A graded task assignment spells out the specific steps to be taken to achieve each task, as well as specific rewards for achieving each task. Rewards help to maximize pleasure and mastery, and reinforce activity. Rewards can be anything the patient regards as worthwhile. Pleasurable activities identified in the self-monitoring can be used as rewards. Rewards can, in and of themselves, increase the person's interaction with the environment, for example, watching TV. A graded task assignment can also be used to determine mastery and pleasure levels. The patient can be asked to rate each step achieved in terms of these two concepts. This gives important evaluation information about how successful the patient perceived the task assignment to be in improving activity levels.
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Example of Cathy's graded task assignment Goal: Within seven days Cathy should be able to spend 10 minutes a day outside her room with Mrs King and one other patient with whom she feels comfortable.
Day Monday
Small steps to achieve goal
Rewards
Identify the second patient with whom
Lunch in her room with Mrs King.
she would feel comfortable. List the patients she knows. Rate her feelings about each patient on a 'comfort' scale of 0-10. Select the patient by name. Tuesday
Invite Ms Harry and Mrs King to have
Cathy's sister to bring headphones
afternoon tea with Cathy in her room.
so that she can listen to the radio
Nurse will approach Ms Harry.
at night.
Cathy will approach Mrs King. Wednesday
Identify an area outside her room in
Hire a portable TV and watch two
which she would feel comfortable
hours of TV per day in her room.
spending time. Walk around the ward with Nurse while other patients are having lunch. Identify an area by name. Imagine being in that area and discuss feelings and thoughts about it. Invite Mrs King and Ms Harry to join Cathy for tea in her room. Thursday
Become familiar with the area. Spend five minutes sitting in the area
Ask sister to bring her tape recorder and five favourite music tapes.
with Nurse, listening to the radio while other patients are having morning tea. Discuss feelings and thoughts about being outside her room. Invite Mrs King and Ms Harry to watch TV with her in her room.
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Friday
Invite Mrs King to sit with her in the area for 10 minutes on Friday morning.
Increase TV watching time to three hours per day.
Invite Nurse and Mrs King to join her for afternoon tea in the area. Saturday
Invite Mrs King, Ms Harry and Nurse to join her for morning tea in the area.
Nurse brings a cake for tea.
Inactivity occurs in all spheres of life, for example, at home, at work, community involvement, in relationships with others. The strategies of monitoring, scheduling and grading task assignments can therefore be adapted to the specific situations in which the person is inactive. Patterns of fulfilling needs In order to fulfil the biological needs, the biological problems or changes need to be identified. Some of these changes affect the sleeping pattern, eating pattern, libido and energy levels. Insomnia Insomnia must be regarded as a 24-hour problem and may be divided into day-time and night-time complaints. It is important for staff and patient to work out a sleep-wake cycle in order to identify and understand the problem areas so as to initiate an adequate treatment programme. Figure 13.2 is an example of such a cycle. The clock and time spacing will vary according to the patient's lifestyle. Managing insomnia As is the case with inactivity, people with insomnia can learn to master the problem by developing and maintaining a structured sleep-wake schedule. The first activity involves self-monitoring the sleeping pattern by means of a sleep-wake diary which records the following for each night over a period of a week: 1. The time the person goes to sleep. 2. The time he/she awakens, how frequently and for how long. 3. The number of hours he/she sleeps on average per night. 4. Factors that might precipitate awakening and falling asleep, for example, bad dreams, noise, preoccupation with specific thoughts. 5. What he/she does when awake, for example, lies in bed, gets up and does the washing, etc.
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Figure 13,2 Patient's sleep-wake cycle
Developing a sleep-wake schedule Most people with insomnia have as their goal '8 hours' sleep a night'. For many this is unrealistic, as their diary will probably show. A structured programme is developed around actual sleep time. It is maintained for at least 3-5 weeks and, according to Coleman (1986), most people experience success in this time. Sleep time can be increased by 30-60 minutes as the person experiences success. 1. Get into bed five hours before he/she is due to wake up and set the alarm if he/she has one, for example, into bed at 24hOO and wake at OShOO. 2. Darken the room before sleep and open the curtains and turn on lights/light a candle at rising time. 3. If awake and relaxed during sleep time, stay in bed. 4. If awake and anxious during sleep time, do relaxation exercises and stay in bed. If anxiety persists, get out of bed. 5. If out of bed, do household tasks, for example, wash dishes, sweep floors (for men as well). Get into bed if feeling sleepy. Get up at the designated time even if he/she returned to bed only an hour before.
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6. Avoid caffeine (tea, coffee, some over-the-counter headache powders/tablets), alcohol and cigarettes (if possible) within five hours of scheduled bedtime. 7. Avoid exercise and spicy, heavy meals within two hours of bedtime. Exercise is not a key factor in improving sleep. 8. If plagued by worrying thoughts before bedtime, set aside a 20-minute 'worry time' after supper in which to worry as much as possible. Keep a 'worry' diary with possible solutions to the problems. When entering the sleep area, leave 'worries' (the diary as well) outside the door. 9. Continue to keep the sleep diary. If after two nights less than five hours' sleep is achieved, take a sleeping-pill 30 minutes before the scheduled bedtime. 10. Avoid naps during the day - rather do something else, for example, household or gardening tasks. The eating pattern may vary: some patients may have an increase in appetite, thus gaining excessive weight that may result in a lowered self-esteem. The changes occurring in this pattern may have a direct influence on the changes occurring in the other patterns, for example, social withdrawal may occur. Some patients may not have the desire to eat at all; for some even preparing a meal is an effort. This results in marked weight loss and the resultant deprivation of nutrients perpetuates the existing listlessness and fatigue. An assessment of the patient's premorbid participation in exercise is necessary in order to improve the quality of the patient's life. An exercise programme may then be initiated depending on the assessment. Use may be made of available environmental resources, for example, using stairs instead of the lift. Other biological needs should be treated symptomatically, for example, constipation. Medication: principles of antidepressant therapy The cornerstone of the management of depression is the prescription of an effective antidepressant administered in an adequate dose for a sufficient period of time. Antidepressant medication should always be tailored to the needs of individual patients, titrating the dose against clinical effect and side-effect profile. Treatment should be introduced with the lowest dose possible and gradually increased so as to reduce the severity of initial side effects. It is impossible to generalize about the duration. In many instances eight to twelve weeks will suffice, but in some cases antidepressants may be required for six months or more. It is not easy to decide when to withdraw treatment. For this reason gradual withdrawal is recommended so that, should symptoms re-emerge, the drug can be rapidly increased to former doses. About 5-10 % of depressions become chronic. These patients require regular follow-up and continuous antidepressant medication. Classification of antidepressants 1. Tricyclics 2. Newer tricyclics
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3. Tetracyclics 4. Selective serotonin re-uptake inhibitors 5. Monoamine oxidase inhibitors (MAOI) 6. Re-uptake inhibitors of monoamine oxidase A (RIMA) 1. Tricyclics Generic name
Trade name
Dosage/24 h
Advantages/disadvantages
Trimipramine
Surmontil
25-150 mg
Sedative
Amitriptyline
Tryptanol
25-150 mg
Sedative/dangerous in overdose
Imipramine
Tofranil
25-200 mg
Activating
Clomipramine
Anafranil
25-200 mg
Less sedative
2. Newer tricyclics General action These drugs work by inhibiting the re-uptake of monoamines (noradrenaline and serotonin) at the central monoaminergic synapses and alleviate depression after an initial latent period of 2-3 weeks. Administration With food to avoid gastrointestinal irritation. Missed dose: The next dose not to be doubled and not to be taken in the morning due to the nature of side effects. Patient monitoring Full blood count, especially in long-term therapy and in patients with a fever or sore throat Blood pressure and pulse Glaucoma test Liver and renal function tests Cardiac function Six-monthly dental examination Side effects Most due to anticholinergic action: Dry mouth (sugar-free gum may help) Blurred vision
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Sweating Dizziness, especially with change of position Palpitations Tiredness Constipation (helped by drinking fluids and eating foods with lots of fibre) Conditions or situations in which the use of these drugs is contraindicated 1. Acute phase of myocardial infarction 2. Pregnancy - especially first trimester 3. Breast-feeding 4. Alcoholism 5. Glaucoma, especially narrow-angle glaucoma 6. Concomitant use of MAO inhibitors (should have a 14-day dry-out period) 7. Epilepsy may be aggravated What could happen if this medication is stopped suddenly? Stopping the medication suddenly, or skipping a dose, is not dangerous, but can be very uncomfortable. It may feel like coming down with the flu - that is, with a headache, muscle aches, stomach ache and/or nausea. Behavioural problems, sadness, nervousness or sleep disturbances may occur. What else should I know about this medication? An accidental or purposeful overdose with these medicines is very dangerous, with the exception of lofepramine. Be sure to keep the medication under very close supervision. The medication may cause a dry mouth, which could increase the chance of cavities in the teeth. Regular tooth-brushing is important. The medication may cause sleepiness. If this occurs, it is important not to drive a car, ride a bicycle or use machinery. Combining the medication with alcohol or tranquillizers may cause severe sleepiness or even unconsciousness. 3. Tetracyclics These also work by inhibiting the re-uptake of monoamines (serotonin). Generic name
Trade name
Dosage/24 h
Advantages/disadvantages
Mianserin
Lantanon
10-60 mg nocte (start low, increase slowly)
Safe in overdose/cardiac conditions
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Action 1. Inhibits re-uptake of serotonin (SH7) 2. Very sedative initially, less after 7-10 days Advantages 1. Safer than tricyclics in overdose 2. Although not readily cardiotoxic, it can produce tachycardia and occasionally heart block 3, Safer in the elderly 4, No anticholinergic side effects 5,, Not epileptinogenic (except in overdose) Side effects Transient drowsiness in some patients for first 3—5 days Agranulocytosis in rare cases (usually reversible) Contraindication 1st trimester of pregnancy Patient monitoring Full blood count 4. SSRI (selective serotonin re-uptake inhibitors) General action These drugs work by selectively inhibiting the re-uptake of serotonin, alleviating depression and imparting some anti-anxiety effect. Fewer side effects than tricyclics.
Generic name
Trade name
Dosage/24 h
Advantages/disadvantages
Fluoxetine Paroxetine
Prozac Aropax
20-80 mg 20-80 mg
Slight anorexia, anti-anxiety No change in weight, stronger anti-anxiety
Nuisance side effects Nausea (sometimes associated with vomiting) Diarrhoea Tremors Dizziness
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Insomnia Excessive sweating Headaches General advantages 1. Fewer side effects than tricyclics 2. No weight gain 3. No conspicuous alteration of seizure threshold 4. Anticholinergic effects are not a problem 5. Much safer than tricyclics in overdose Contraindications 1. Concomitant use of MAO inhibitors, for example, Parnate 2. Prozac interacts with many other medications. Be sure that the doctor or nurse knows all the medications that are being taken or have been taken in the past several months. 5. Monoamine oxidase inhibitors (MAOI) Generic name
Trade name
Tranylcypromine Phenelzine
Parnate Nardil
These drugs act by inhibiting the MAO enzyme, thereby causing an increase in biogenic amines such as noradrenaline, dopamine and serotonin in the storage sites throughout the central nervous system. This increased availability of one or more of these agents is thought to be responsible for the antidepressant effects of the MAOIs. Side effects Dizziness Orthostatic hypotension Diarrhoea Swelling of feet and lower limbs Unusual excitement or nervousness Tachycardia Dark urine Headaches Skin rash Possible hepatitis
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Blurred vision Constipation Decreased libido Difficulty urinating Tiredness and weakness Trouble sleeping Precautions Pregnancy Paediatrics Breast-feeding Geriatrics Contraindications Cardiovascular disease or coronary insufficiency, including angina pectoris Cerebrovascular disease (advanced) Severe liver function impairment Severe renal function impairment Phaeochromocytoma Porphyria Use with care in suicidal patients Patient information Medic Alert to be carried Dose to be administered in the morning to avoid sleep disturbances Food and beverages to be avoided during treatment and for 14 days after completion of treatment (hypertensive crisis is the most serious adverse effect of MAOIs and may be produced when taken in conjunction with agents high in tyramine): - Alcohol (beer and Chianti wine) - Avocado - Broad beans - Cheese, especially cheddar - Chocolate - Cream and yoghurt - Meat or fish preserved through smoking or pickling - Yeast products, for example, Marmite - Figs Drugs to be avoided: - Tricyclic antidepressants (14 days should lapse after stopping tricyclics and before starting MAOIs)
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- Amphetamines - Narcotic analgesics - Sympathomimetics, for example, ephedrine, phenylpropanolamine (often in overthe-counter cold remedies) The traditional MAOIs have not been widely prescribed in recent years because of the doubts about their efficiency in severe depressive illness and the severe dietary restrictions that accompany their use. 6. RIMAs (re-uptake inhibitors of monoamine oxidase - MAO-A) This group selectively and reversibly inhibits the action of MAO-A enzyme only. Thus tyramine can still be metabolized by MAO-B. It therefore has none of the severe tyramine effects (severe rise in blood pressure with foods like cheese, broad beans, etc). Generic name
Trade name
Dosage/24 h
Modobemide
Aurorix
300-600 mg (in divided doses)
Advantages 1. Relatively short half-life in the blood 2. Well tolerated and gives rise to fewer side effects 3. No sedation Side effects Nausea Insomnia Restlessness Dry mouth Tiredness Headaches Medication guidelines For major depression and dysthymia, the following could be prescribed in a primary health care setting: Amitriptyline (Tryptanol): 50 mg-150 mg every evening. Start with 50 mg for two days, then increase the dose by 25-100 mg every second day. If there is an inadequate response after three weeks, increase the dose to 150 mg. The following patients may not be put on amitriptyline, because it is a tricyclic drug: Patients who have a closed glaucoma, prostatitis, a recent coronary infarct, or a conduction defect of the heart during the last six months, for example, arrhythmias.
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A good physical examination is therefore essential before the medication is used. In such cases a consultation or referral is necessary. Furthermore, tricyclic drugs can be used to commit suicide, so if the patient is actively suicidal, these drugs may not be appropriate, and the patient may need to be admitted. The treatment goes through three phases. 1. The acute phase lasts for six to 12 weeks, and the goal of this phase is remission of symptoms. 2. The continuation phase lasts three to nine months, and the goal of this phase is to prevent relapse. If the patient is symptom-free at the end of this period, and has returned to normal functioning, decrease the medication gradually until it is discontinued completely. 3. The maintenance phase, during which the goal is to prevent recurrence of depression in patients with prior episodes of depression. Maintenance therapy is especially important in persons who have suffered from severe, repeated, sudden and lifethreatening depressions. Maintenance therapy is often necessary in cases where the person is young (under 20 years of age), has a history of recurrence within one year after successful treatment, and a family history of major depression or bipolar disorder.
Essential Drug List (EDL): Hospital Major Depressive Disorder Amitriptyline, oral, 75 mg-150 mg/day, titrate up to 300 mg/day OR Imipramine, oral, 75 mg -150 mg/day OR Fluoxetine, oral, 20 mg-40 mg daily. Dysthymic Disorder Amitriptyline, oral, 75 mg-150 mg/day, titrate up to 300 mg/day OR Imipramine, oral, 75 mg-150 mg/day OR Fluoxetine, oral, 20 mg-40 mg daily. Essential Drug List: PHC Adults: Amitriptyline initial dose of 75 mg increases by 25 mg per day at 7-10 day intervals to a maximum of 150 mg. Consult if more than 150 mg is needed. Elderly: Initial daily dose of 25 mg per day increasing by 25 mg per day at 7-10 day intervals to a maximum of 100 mg. Treat for at least six months after symptoms have ceased in cases of first major depressive episode. Longer treatment is indicated after relapse, old age and complicated cases. CAUTION: Do not issue more than one week's supply of Amitriptyline to patients with suicidal ideation because if overdosed it has fatal toxic effect on the heart.
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Evidence-based Practice Amitriptyline versus other types of pharmacotherapy for depression Main results:
The estimate of the overall odds ratio for responders showed that more subjects responded to amitriptyline in comparison with the control antidepressant group (odds ratio 1,12 [95 % confidence interval 1,01 to 1,23] number needed to treat 50). When the efficacy analysis was stratified by drug class, no difference in outcome emerged between amitriptyline and either tricyclic or selective serotonin re-uptake inhibitor comparators. The dropout rate in patients taking amitriptyline and control agents was similar; however, the estimate of the proportion of patients who experienced side effects significantly favoured control agents in comparison with amitriptyline (odds ratio 0,63 to [95 % confidence interval 0,56 to 0,71]). When the tolerability analysis was stratified by drug class, the dropout rate in patients taking amitriptyline and the selective serotonin re-uptake inhibitors significantly favoured the latter (odds ratio 0,84 [95 % confidence interval 0,75 to 0,95] number needed to harm 40). When the responder analysis was stratified by study setting amitriptyline was more effective than control ADs in inpatients (odds ratio 1,22 [95 % confidence interval 1,04 to 1,42] number needed to treat 24), but not in outpatients (odds ratio 1,01 [95 % confidence interval 0,88,1 to 17] number needed to treat 200). Reviewers' conclusions: This present systematic review indicates that amitriptyline is at least as efficacious as other tricyclics or newer compounds. However, the burden of side effects in patients receiving it was greater. In comparison with the selective serotonin re-uptake inhibitors amitriptyline was less well tolerated, and although counterbalanced by a higher proportion of responders, the difference was not statistically significant. Guaiana G, Barbui C & Hotopf M. Amitriptyline versus other types of pharmacotherapy for depression (Cochrane Review). In: The Cochrane Library, Issue 2 2003. Oxford: Update Software.
Electroconvulsive therapy (ECT) Although electroconvulsive therapy is not used exclusively for depression, it is often used in its treatment. Under general anaesthetic of a barbiturate of very short duration and a muscle relaxant, a weak electrical current of 70 V to 130 V is applied by placing electrodes either unilaterally or bilaterally to the patient's temples for 0,1 to 1,0 seconds in order to produce a tonic or clonic seizure. Physiology Effectiveness is possibly due to the large catecholamine response.
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Indications 1. 2. 3. 4.
If there is no improvement in major depression after a full trial of antidepressants. If lithium carbonate fails to control the acute phase of manic bipolar disorder. In the stuporous or excited type of catatonic schizophrenia. In the emergency treatment of the actively suicidal patient whose life is in danger while waiting for antidepressants to work.
5. In the treatment of depressed patients whose medical condition does not allow the administration of antidepressants. Contraindications There are no absolute contraindications. Very high risk Increased intracranial pressure Recent myocardial infarction Moderate risk Severe osteoarthritis, osteoporosis or a recent fracture Cardiovascular disease Major infections, recent CVA, chronic respiratory difficulty or an acute peptic ulcer Number of treatments Each patient is assessed individually; thus the frequency and number of treatments vary. On average, however, six treatments are given on alternate days for the depressed patient. ECT myths Talbot (1986) discusses four ECT myths: Myth 1: ECT is a barbaric and archaic form of treatment The public is exposed to literature such as 'One Flew over the Cuckoo's Nest' and various films that depict ECT as a horrific treatment. Psychiatry and anaesthetics have made great progress in the sense that it is impossible for the patient to be a victim of such unmodified forms of ECT. Myth 2: ECT causes permanent memory loss. Memory loss is both retrograde and anterograde, especially for small details such as names. It usually begins after three to four treatments and then gradually subsides over the next few weeks or in occasional cases in two to three months. There maybe less memory loss if the temporal electrodes are placed unilaterally to the non-dominant hemisphere. However, it is said that bilateral ECT is more effective in the treatment of depression. Myth 3: ECT causes irreversible brain damage. Brain damage has not been conclusively disproved and should not be discounted as a myth. Studies on this vary. Webb
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(1984) in Sands, Roger, McCary, Bigler, Becker & Waller (1987: 28) concludes that ECT does not alter the permeability of the blood-brain barrier or cause detectable brain damage, yet Bregging (1985) in Sands et al. (1987: 28) found during human autopsies small, diffuse haemorrhages throughout the brain, glial scarring and cell death. Myth 4: ECT is less effective than other types of therapy. In psychiatric illness, efficacy is a subjective term. In many instances the time factor has to be seriously considered. When the therapist is racing against time for the patient's life, ECT has proved to be the most effective type of therapy. The patient is the best judge of the treatment's effectiveness. ECT is generally considered effective when the patient begins to socialize with others, is no longer preoccupied with suicidal thoughts and verbalizes a sense of well-being. Pretreatment preparation Assess attitudes to and values concerning ECT. Assist the patient and family to accept the treatment positively. Identify the patient's and, when available, the family's knowledge and beliefs about ECT. - Assess their response to the media. - Assess the factual information that the patient has of ECT. Directly intervene to alleviate fears and to reduce anxiety. - Identify fears. - Allow expression of feelings about the forthcoming procedure. - Be direct and open in correcting misconceptions and clarifying existing information. - Discuss the problems that the family sees as important. Use a positive approach to the treatment. - Avoid using words such as 'shocks' and other negative terms. - Talk about the treatment, emphasizing its therapeutic value. Teach the patient and, where indicated, the family about the treatments and what to expect. - Go through the procedure with the patient. - Provide an opportunity for repetition and clarification. - Make the patient aware of ECT side effects and how these will be managed: amnesia and confusion; headaches, muscle aches and nausea; dizziness. - Reassure the patient that members of the team will be with him/her during each of the treatments. - Allow the patient to discuss ECT with another patient who has undergone the treatment. - Evaluate the outcome of this teaching exercise by assessing the patient's and the family's attitudes and knowledge afterwards. Prepare the patient as for any other anaesthetic procedure. Obtain consent once the patient has been given the above information.
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Post-treatment care Amnesia - Orient the patient with regard to time, place and what has just occurred. - Be sensitive to this. - Reintroduce primary care-givers. - Repeat where necessary or provide the patient with aids to orient him/her. Enquire about a headache, as the patient may be confused about whom to ask for an analgesic. Headaches may vary from mild to severe. Resumption of normal activities - Reinforce the concept of ECT as a therapeutic method and not an incapacitating procedure soon after treatment. - Observe the patient initially for postural hypotension. Educate the patient and the family before discharge about the possibility of amnesia and how to deal with it. Evidence-based Practice Electroconvulsive therapy for the depressed elderly Main results:
Randomized evidence is sparse. Only three trials could be included and these covered: 1. the efficacy of real ECT versus simulated ECT (O'Leary et al. 1994); 2. the efficacy of unilateral versus bilateral ECT (Fraser 1980); 3. a comparison of the efficacy of ECT once a week with ECT three times weekly (Kellner 1992). All three trials had major methodological shortcomings. Reviewers' conclusions:
None of the objectives of this review could be adequately tested because of the lack of firm, randomized evidence. Given the specific problems in the treatment of depressed elderly, it is of importance to conduct a well-designed randomized controlled trial in which the efficacy of ECT is compared to one or more antidepressants. Van der Wurff F B, Stek M L, Hoogendijk W L & Beekman AT F. Electroconvulsive therapy for the depressed elderly (Cochrane Review). In: The Cochrane Library, Issue 2 2003. Oxford: Update Software.
Patterns of building and maintaining relationships The depressed patient may attach him/herself to many people in his/her search for help, often with either overt or covert suicidal threats due to his/her use of passive dependence as a coping mechanism. Relating in this way leads to a great deal of anxiety, helplessness and guilt in the other people and very little pleasure or fulfilment, with the result that they gradually withdraw from the patient.
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The patient may also use passive withdrawal as a coping mechanism - not contacting friends or family, never accepting invitations, not talking or sharing - thereby making it difficult for relationships to be maintained. Nursing intervention should: 1. identify the family and friendship network of the patient prior to the illness; 2. reactivate these contacts gradually; 3. teach the patient to identify the kinds of behaviour that scare people off and assist in behaviour and change; offer interpersonal skills training, if necessary; 4. teach family and friends how to cope with both dependency and withdrawal behaviour. Patterns of participation in group and community life Owing to the dependence/withdrawal coping patterns of the depressed patient, one may find that participation in recreational, religious and cultural groups has diminished, while involvement with groups that reinforce the sick role has increased. Most depressed patients seem unaware of the political climate; for them political issues are too far removed and not of importance to them, resulting in their withdrawal from political involvement. There is often an ambivalence in the patient's approach to religion. Some patients who are depressed tend to use religion as a support system - religious practices may increase, prayers may become more intense, with a fervent plea for their God to help them. On the other hand, there may be anger towards their God, accompanied by such statements as 'Where's God - doesn't He know I exist?' From here the patient may distance him/herself from God, making such statements as 'Even God doesn't want me any more'. This is an indication of the intensity of the patient's sense of hopelessness and impending doom. This is a very vulnerable period for the patient and his/her religious beliefs should be respected, without other religious influences being imposed on him/her. It is often necessary to arrange for sensitive spiritual counselling to be done by an appropriate person. Patients may find it very difficult to participate in group activities, which limits their resocialization and rehabilitation. Nursing intervention may include the following. 1. Identify the premorbid level of social involvement of the patient and the extent of his/her withdrawal. 2. Involve the patient in group therapy to prepare for re-entry to community life. Patterns of participation in work The patient's work becomes a means to an end and is often only of extrinsic value. The patient alienates him/herself from his/her product, his/her peers and ultimately
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him/herself. He/she often has a temporary blind spot that prevents him/her from recognizing him/herself as a capable, productive, confident and creative worker. The results are decreased work performance, participation and productivity and, perhaps, ultimately the loss of his/her job. The following aspects of work habits may become affected. Personal presentation
A decrease in punctuality and an unkempt appearance. Social presentation
Difficulty in accepting feedback, an increase in negativism and complaining and difficulty in relating to peers. Work competence
Impaired concentration and forgetfulness, a low frustration tolerance and an inability to organize and plan. Work tolerance
An inability to tolerate a full day's work and its stress and pressures, and difficulty in completing a job in the required time and producing quality work. The nurse can assist the patient in rehabilitation with regard to the work environment by making use of simulation techniques, such as role-playing a job interview. Referrals can be made for job sampling, job trials and job placement through other disciplines, such as that of a social worker or an occupational therapist. Patterns of utilizing free resources Patients who are depressed deny the availability of free resources or may have reasons for not using them, for example, distance or transportation. This pattern is strongly influenced by changes in other patterns, for example, the patient who is an insomniac may suffer from fatigue and lethargy, which reinforces social isolation and ultimately the use of free resources. As the patient improves, he/she becomes more inclined to use these, for example, the library, parks, museums, the beach, mountains and the church. Behavioural techniques can be very useful in ensuring that the free time of the depressed patient is not spent in ways that increase or maintain the depression. 1. Identify activities that the patient previously found enjoyable and interesting or that gave a sense of accomplishment. Also monitor the activities during which the patient feels least depressed and most depressed. 2. Schedule positive activities for the patient during low times, for example, a widow who feels very depressed in the evening and who enjoys talking to friends can be scheduled to make two phone calls to friends every evening. 3. Teach the patient to reward him/herself for every prescheduled task performed or take people from the social network to do the reinforcement. The widow in the above example could have a bubble bath after her two calls.
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13.3 SUICIDE Suicide is the extremity of a self-inclined, self-destructive act - whether it be a thought, an expression or an attempt - to take one's own life. The degree of lethality, the motive, the intent and the awareness of possible consequences vary. A profile of suicide in South Africa A 2002 report entitled 'A profile of suicide in South Africa: 1999' shows the incidence of suicide by province, race and gender, by age and province, by means and finally, by place and time. This is important data because it can be used as the basis for managing the initial home-based suicide crisis, for community-based mental health promotion projects, and suicide prevention projects. The data is summarised below. Suicide accounted for 7,7 % of all non-natural deaths in South Africa. Within this percentage: The rates for each province are, in order from highest to lowest: Northern Cape (13,4 %); Gauteng (10,8 %); Eastern Cape (9,9 %); KwaZulu-Natal (5,9 %) Western Cape (5,0 %). 79 % of the suicide victims were male and 38 % of this percentage were white males. 45,1 % were categorised as black, 37,1 % as white, 13,1 % as coloured and 4,6 % as Asian. On average, suicide victims were 36 years old, but 53 % of all victims were between the ages of 15 and 34 years old. 2 % of cases in Gauteng were under the age of 15 years and 15 % of cases in the Eastern Cape were over the age of 55 years. White suicide cases were an average of 42 years, Asian cases an average of 35,6 years, Coloured an average of 31,2 years and black an average of 30,8 years. Almost one-third of cases had taken alcohol at the time of their death. The two most common causes of suicide were by firearm and by hanging. There are some differences in method between provinces, gender and race: Method of
Common method
Most common
Common method
suicide
by gender
method by province
by race
Gauteng
Whites
Northen Cape
Asians
Eastern Cape
Blacks
Kwazulu-Natal Western Cape
Coloured Asians
Firearm
Hanging
Poisoning
Male
Female
36,8
22,8
37,1
10,6
21,4
27,5
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Method of suicide
Common method by gender Male
Female
Jumping
2,7
6,1
Gassing
6,7
6,0
Burning
U
9,4
Other
4,9
6,8
Most common method by province
Common method by race
Eastern Cape KwaZulu-Natal
KwaZulu-Natal (10% of all cases) Northern Cape
Black women
* More than 70 % of all suicides occur in private homes or in residential institutions such as hostels and old age homes. (Adapted from the February 2000 report 'A profile of suicide in South Africa: 1999', prepared for the Directorate of Health Systems & Epidemiology, National Department of Health, by Dr. M Peden for the Violence and Injury Surveillance Initiative and Participating Forensic Pathologists.)
Assessment of suicide Numerous scales are available to the nurse for the assessment of suicidal risk in a patient. These scales, however, serve as a guide only and should be used in a flexible way. Suicide seems to be a subject that people are reluctant to broach. Comments often heard are 'I might have given him the idea', or 'If he was suicidal he'd talk about it', or 'I'm scared to find out that he's suicidal because I wouldn't know how to cope'. It is important that these misconceptions be explored so that the patient's potential risk to himself/herself can be exposed.
'SAD CHILDREN' A suicide potential assessment scale (As adapted from Di Vasto, West & Cristy 1979) This tool can be used by the nurse in any situation in which the patient finds him/herself, for example, assessment of the suicide risk and as a plan for intervention. None of the items below should be seen in isolation; instead they should be seen contextually. S
Support systems Suicide potential is influenced by the absence of support for the patient. The patient is also sometimes relied on by others for support.
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A
Alcohol Alcohol acts as a depressant. Many suicide attempts are made when patients are intoxicated. Assault Rape, battered spouse, sexual abuse or social unrest increase the potential for suicide.
D
Depression Early recovery stages of depression increase the risk of another suicide attempt as energy and drive begin to return to the patient. Delusion A paranoid delusional system.
C
Communication The patient who communicates his/her intent of suicide provides the nurse with an awareness of his/her thinking and gives the nurse an opportunity for exploration. The nurse should also be alert to indirect communication of intent, for example, 'I won't see you again'. Changes in behaviour Writing a will, giving away prized possessions, cancelling social arrangements or taking out extra insurance policies.
H
Hostility Strong anger towards others felt by the patient may result in a suicide attempt as a means of punishing them.
History - Is there a history of previous suicide attempts? The more often the patient has attempted suicide, the greater the chances of eventual success. What methods have been used before? Patients with a history of high-lethal methods or patients who have changed the method from a low-lethal to a high-lethal method are at greater risk than those with a history of low-lethal methods. - Family attempts at suicide - a recurrence of suicide and attempted suicide in the family Hallucinations Command hallucinations, which consist of voices ordering the patient to kill him/herself I
Impulsiveness This depends on the personality and coping skills of the patient during a crisis. The impulsive person is a high suicide risk. Illness A chronic illness such as terminal cancer or being newly diagnosed with, for example, HIV.
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L
Lethality
Men tend to use more lethal methods to commit suicide, for example, hanging, shooting or jumping, than women. The nurse should assess the patient's awareness of the lethality of the plan to commit suicide and his/her desire to be rescued. D Demography
The following factors increase the risk of suicide: - Living alone - A recent divorce - Difficulties with a relationship - Unemployment - Financial difficulties - A recent criminal offence or trouble with the police - A woman (suicide is attempted more often but is usually sublethal) R
Reaction of the evaluator
The evaluator's subjective view may vary from feeling angry, indifferent or irritated. This is especially towards patients with Axis II traits or an Axis II diagnosis. They can be antisocial, borderline cases or histrionic. This subjective feeling by the evaluator could indicate that the patient is using the suicide threat to manipulate, which thus lessens the risk of suicide. Feeling empathy and a strong desire to care could indicate a higher risk of suicide. E
Events leading to the suicide attempt
The patient may experience significant lifestyle changes such as the loss or threatened loss of a significant other, examination failure, loss of a body part or loss of a job or accommodation. The greater the loss, the greater the potential for suicide. N
No hope
In extreme situations both nurse and patient may experience hopelessness.
Care of the suicidal patient A highly suicidal patient cannot be cared for at home, and should be hospitalized. The decision about whether hospitalization should occur is dependent on the patient's suicide risk, the level of supervision available at home, and the patient and family's wishes. However, the patient's safety should be the first consideration. The care of the suicidal patient will therefore be discussed as taking place in a hospital setting. Some health care professionals believe that an appropriate goal for psychiatric inpatient treatment is to maximize the chances of survival rather than to guarantee survival (Talseth, Lindseth, Jacobsson & Norberg 1999). This is an important point, since it is almost impossible to predict who will commit suicide, when and where. Good nursing care can often make the difference between life and death for suicidal patients. It is significant that all of these nursing actions can be described as therapeutic interpersonal
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skills, which are regarded by mental health nurses as the cornerstone of the nurse-patient relationship. Therefore, refer to the section on interpersonal skills in Chapter 9. Suicidal inpatients' perceptions of 'good' and 'bad' nursing care Nursing actions which suicidal patients find helpful
Nursing actions which suicidal patients find very unhelpful
Attending to the patient's basic needs: Touching and comforting the patient appropriately, e.g. touch to the hand. Walking and talking with the patient outside in the fresh air. Making sure the patient gets food or food
Overlooking patient's basic needs: Not telling patients when food is served or saving the patient's food. Allowing patients to lie awake in bed for
is saved for patient. Allowing the patient to have sufficient sleep and rest and not being nagged to
hours without trying to talk kindly to them. Not 'seeing' patients. Ignoring patient's needs for personal cleanliness.
get out of bed.
Helping the patient to attend to personal hygiene. Making time for patients: Seeking out the patients to find out how they are. Making sure the patient and nurse are not disturbed by others or the telephone when talking. Simply being with patients in quietness.
Not having time for patients: Being too busy to spend time with patients.
Listening to patients without prejudice: Showing unconditional positive warmth and respect for the patients needs and feelings. Trying to understand the patients experience from his/her point of view.
Listening to patients with prejudice: Focussing talk on medication and symptoms rather than on feelings and experience. Changing the subject when the patient raises his/her problems.
Not seeking out patients regularly to find out how they are. Nurses isolating themselves in the duty room or tea room for long periods of time.
Using guilt tactics, e.g. 'How can you think of killing yourself, what about your child/husband/ family?'; or religion, e.g. 'It is a sin to kill yourself, do you want to go to hell?' in an attempt to convince the patient that suicide is 'wrong'.
Being open to patients: Having a non-threatening, relaxed posture, appropriate eye contact, a calm voice.
Not being open to patients: Showing disinterest in body language and tone of voice. Allowing outside events, e.g. telephone, a friend passing by, to disturb the interaction.
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Suicidal inpatients' perceptions of 'good' and 'bad' nursing care Nursing actions which suicidal patients find helpful
Nursing actions which suicidal patients find very unhelpful
Accepting patients f e e l Allowing patients to cry and staying w i t h them, in silence, while they cry as m u c as they need t Allowing them to talk about s u i c feelings.
ying patients their feelings:
Communicating hope to p a t i e through the above quality interactions.
Asking patients to 'stop crying',
patronizing or belittling the patient's nce, e.g. 'Don't worry so much, your husband does still love you'; 'Now you must calm down and act like an adult'. unicating hopelessness to patients
through disinterest, isolating self from patients, listening with prejudice.
(Adapted from Mclaughlin, 1999;Talseth, Lindseth, Jacobsson & Norberg 1999.)
Preventing harm 1. Limit the opportunities for suicide. Remove potentially harmful items such as sharp instruments, cleaning agents, medication and electrical cords. Monitor the therapeutic environment regularly. Be aware of possible means of committing suicide such as large windows or macrame hangings. Be aware of articles brought into the unit by both patients and visitors. It should be remembered, however, that no unit is suicide-proof and that patients constantly test the environment. 2. In cases of extreme risk of suicide, immobilize the patient through, for example, sedation. 3. Develop ward policies and identify plans for the prevention of suicide. Maintain a 24-hour observation period, recording accurately and specifically the patient's behaviour, with particular attention to changes in mood, a raised energy level and a change in the ability to concentrate. Identify a time when the patient may be more motivated to commit suicide. Identify and plan times of low staff/patient ratio such as staff changes and night duty. At such times there is a need for special awareness of the patient's behavioural patterns. 4. Initiate positive intervention to decrease the risk of suicide. Negotiate a no-suicide contract (See Figure 13.3 below) with the patient to give staff the opportunity to assist the patient in a crisis. This may be possible if a good
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rapport can be established but is not appropriate in hallucinating or highly impulsive patients. Name: Date: I, the above, declare that no matter what happens I will not kill myself either accidentally or on purpose. (Set a time limit relevant to the situation.) Signature of patient: Witness (where possibIe): Figure 133 Example of a no-suicide contract • Staff attitudes should be therapeutic. - Avoid non-therapeutic responses such as indifference, sarcasm and hostility. - Avoid arguing with or confronting the patient about his/her decisions; rather opt for a therapeutic exploration of the outcome of the decisions. Recognize the seriousness of suicidal behaviour. Reassure the patient of staff availability at all times and establish a relationship of trust with the patient. Explore the patient's belief about life after death and how the patient would like to be remembered by family and significant others. Avoid being drawn into confidential alliances with the patient that you are asked not to share with other team members. Do, however, acknowledge the patient's distress. Reinforce positive responses and activities in the patient, such as grooming. Encourage the development of a positive self-concept, with mastery and control by the patient over his/her own life. Offer the patient intensive psychotherapy after the immediate crisis of attempted suicide, with particular emphasis on effective coping strategies. Encourage the patient to participate in activities. Care of the survivors of suicide The involvement of family or significant others may vary on a continuum from detachment to enmeshment. This may be influenced by various factors such as guilt, anger, denial, exhaustion following numerous previous attempts at suicide, and fear.
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It must be emphasized that, irrespective of the setting in which the patient is found, the care-giver must be available to the survivors of a suicide. Through the act of contact, they appeal for help. The immediate care offered may vary from supportive counselling to crisis intervention. The survivors may then be referred to an agency for counselling. The following areas may be explored: Acceptance of the suicide; Sharing feelings about the suicide and feelings preceding the suicide; Managing questions posed by friends and other community members about the suicide; Coping with grief (the intensity of the grief may vary, as may its cause, from the physical death of a significant other to the loss of a self-imposed expectation of the significant other). Psychological care for care-givers Common reactions experienced by caregivers are guilt, anger, self-blame, sadness, fear and feelings of professional failure. All or some of the above may be experienced and may be projected onto patients or colleagues. A support group meeting for staff should be held when staff availability allows. Staff then have the opportunity to discuss their personal feelings about a suicide and to explore them. This exercise can create group cohesiveness and a support system. It can also provide an opportunity for unit policies to be reviewed and updated, thus creating a learning experience from a suicide. Evidence-based Practice Psychosodal and pharmacological treatments for deliberate self-harm Main results:
A total of 23 trials were identified in which repetition of deliberate self-harm was reported as an outcome variable. The trials were classified into 11 categories. The summary odds ratio indicated a trend towards reduced repetition of deliberate self-harm for problem-solving therapy compared with standard aftercare (0,70; 0,45 to 1,11) and for provision of an emergency contact card in addition to standard care compared with standard aftercare alone (0,45; 0,19 to 1,07). The summary odds ratio for trials of intensive aftercare plus outreach compared with standard aftercare was 0,83 (0,61 to 1,14), and for antidepressant treatment compared with placebo was 0,83 (0,47 to 1,48). The remainder of the comparisons were in single small trials. Significant reduced rates of further self-harm were observed for depot flupenthixol versus placebo in multipl repeaters (0,09; 0,02 to 0,50), and for dialectical behaviour therapy versus standard aftercar (0,24; 0,06 to 0,93). Reviewers' conclusions: There still remains considerable uncertainty about which forms of psychosocial and physical treatments of self-harm patients are most effective, inclusion of insufficient numbers of patients
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in trials being the main limiting factor. There is a need for larger trials of treatments associated with trends towards reduced rates of repetition of deliberate self-harm. The results of small single trials, which have been associated with statistically significant reductions in repetition, must be interpreted with caution and it is desirable that such trials are also replicated. Hawton K, Townsend E, Arensman E, Gunnell D, Hazell P, House A, & Van Heeringen K. Psychosocial and pharmacological treatments for deliberate self-harm (Cochrane Review). In: The Cochrane Library, Issue 2 2003. Oxford: Update Software. 13.4 BIPOLAR DISORDERS Manic episodes According to the DSM-IV-TR, the 'essential features of a manic episode are a distinct period in which the predominant mood is either elevated, expansive or irritable and the disturbance is sufficiently severe to cause marked impairment in occupational functioning or usual social activities/relationships with others'. Appearance. Colourful and flamboyant with very high energy levels. Speech. Loud, rapid and rumbustious, with the use of puns. Pressure of speech and flight of ideas accompany this disorder. Mood. Labile and the patient is easily susceptible to distracting stimuli. Social judgement. The patient is intrusive, domineering and demanding. He/she is typically grandiose and very often sexually inappropriate - promiscuous and hypersexual. DSM-IV-TR diagnostic criteria: Manic episodes A manic syndrome is described as including A, B and C below. A. A distinct period of an abnormally and persistently elevated, expansive or irritable mood. B. A persistence of at least three of the following symptoms (four if the mood is only irritable): 1. Inflated self-esteem and grandiosity. 2. A decreased need for sleep, for example, the patient feels rested after only three hours of sleep. 3. The patient is more talkative than usual or experiences pressure to keep on talking. 4. Flight of ideas or a subjective experience that thoughts are racing. 5. The patient is easily distracted; in other words, his/her attention is too easily drawn to unimportant or irrelevant external stimuli. 6. Increase in goal-directed activities (either socially, at work or school, or sexually) or psychomotor agitation. 7. Excessive involvement in pleasurable activities that have a high potential for negative consequences, for example, the patient engages in unrestrained buying sprees, sexual indiscretions or foolish business investments.
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C. Mood disturbances sufficiently severe to cause marked impairment in occupational functioning or in normal social activities or relationships with others or to necessitate hospitalization to prevent harm to self or others. Hypomanic episodes The essential feature of a hypomanic episode is a distinct period in which the predominant mood is either elevated, expansive, or irritable and there are associated symptoms of the manic syndrome. By definition the disturbance is not severe enough to cause marked impairment in social or occupational functioning, or to require hospitalization (as required in the diagnosis of a manic episode). (DSM-IV-TR) Recognizing bipolar disorders Recognition of the disorder is essential for adequate treatment. The early signs of bipolar disorder may be hypomania - a state of high energy, excessive moodiness or irritability, and impulsive or reckless behaviour. Hypomania might feel good to the person who is experiencing it, and family and friends may be the first to recognize that the mood swings are abnormal. In the beginning, bipolar disorder may also present as drug or alcohol abuse or poor school or work performance. If untreated, it worsens into a full episode of mania or depression. The person might need a lot of encouragement from their social circle to seek help. 135.5 NURSING ASSESSMENT AND INTERVENTION
The patterns of lifestyle functioning will be used to describe the phenomena of mania and hypomania as these occur within the individual and the process of psychiatric nursing intervention. Examples of nursing diagnoses which could be used to give substance to the intervention process are given below. Common nursing diagnoses Sleep pattern disturbance RELATED TO excessive hyperactivity, agitation EVIDENCED BY numerous periods of wakefulness during the night; awake and up extremely early in the morning, exhibiting signs of restlessness. Sensory-perceptual alteration, RELATED TO biochemical alterations, EVIDENCED BY talking and laughing to self, rapid mood swings, bizarre thinking and irritability. Examples of nursing diagnoses which could be used: Psychodynamic patterns A patient's psychodynamic pattern features are strong evidence of high energy levels. This affects pattern maintenance, which in turn affects lifestyle functioning.
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Patterns of fulfilling biological needs Subjectively it seems as if the manic patient does not have the need to eat, sleep or rest, although it does seem as if he/she has an increased sexual need. The patient appears rested with a maximum of two to three hours of sleep. This need to be perpetually active can lead to serious complications like exhaustion and collapse. The decreased need to sit down to a meal can be overcome by making finger food, snacks, fruit and high-calorie drinks available to the patient, as these can be eaten while the patient is in motion. Personal hygiene requires supervision; the patient has to be instructed with regard to bathing and the use of toiletries, cosmetics and jewellery. Medication When a patient has a manic episode, he/she is first put on chlorpromazine until the acute phase is over, and then on lithium to prevent further attacks. Lithium Lithium is a naturally occurring salt that is available in several different forms, including lithium carbonate tablets or capsules. These drugs have a mood-regulating effect and are therefore used as the primary agent in the treatment of bipolar affective disorder - in the manic phase (usually in conjunction with an antipsychotic) and for maintenance therapy to help reduce the intensity and frequency of subsequent manic episodes. It can also be used as adjunctive treatment in major depression. Lithium preparations Generic name
Trade name
Form and strength
Lithium carbonate
Camcolit Lentolith
250 mg tablets 400 mg capsules
Patient monitoring 1. Before starting lithium Complete medical history and physical examination Laboratory determination of: full blood count urea and electrolytes thyroid function tests electrocardiogram (those with histories of heart disease) 2. After starting lithium This group of drugs has a narrow margin of safety because the therapeutic and toxic dosages are close together. One should therefore do regular lithium serum-level investigations which should be kept between 0,6-1,2 mmol/litre to determine whether
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the dosage is correct. These may be done once or twice a week at first and then every month or two after the dose is set. Blood should be drawn first thing in the morning, 10-14 hours after the last dose. 3. Dose The dose of lithium should be guided by the blood levels, since one cannot predict the blood level from the dose. Blood levels should be done every two weeks for the first three months of therapy, and every three months after that. Start the patient on the following doses and then increase or decrease according to blood levels: Lithium carbonate (Camcolit) 250 mg bd OR Lithium carbonate (Lentolith) 400 mg nocte. Increases and decreases should be done every few days, until the required blood level of 0,6-1,2 mmol/litre is achieved. 4. Administration With food to avoid gastrointestinal irritation. Drink plenty of fluids, especially in hot weather and when exercising. Because lithium works in competition with sodium at cellular level it is essential that the patient's diet contain enough NaCl (table salt), otherwise toxic symptoms develop on lower dosages of lithium. If a dose is missed, take as soon as possible unless it is within six hours of the next scheduled dose. Do not increase the next dose. 6. Side effects The side effects of lithium are increased if a person is dehydrated (not enough fluid). If side effects appear, try giving the person one or two glasses of water. The following side effects are common and frequently disappear after two weeks or so. If they are troublesome, lower the dose of lithium. Lithium should always be taken with food to decrease side effects. Carbonated soft drinks are high in caffeine and may make the side effects worse. Common side effects Weight gain Stomach ache Diarrhoea Nausea Vomiting Increased thirst Increased frequency of urination Fine hand tremor Tiredness, weakness, dizziness Headache
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Occasional side effects Low thyroid functioning or goitre (enlarged thyroid) Acne Skin rashes Hair loss Change in blood sugar Metallic taste in the mouth Irritability Uncommon but potentially serious side effects (stop the lithium and call the doctor) Seizures Confusion Signs that the lithium level may be too high (call the doctor immediately and do not give lithium for at least 24 hours) Vomiting or diarrhoea more than once Severe trembling Weakness Lack of co-ordination Extreme sleepiness or tiredness Severe dizziness Trouble speaking, slurred speech Serious toxic side effects (admit to a general hospital immediately) Irregular heartbeat Fainting Staggering Blurred vision Ringing or buzzing sound in the ears No urination Muscle twitches High fever Convulsions Unconsciousness 7. Precautions Some drugs increase lithium levels, for example, Indocid, Voltaren, Feldene and thiazide diuretics. Do not take more than the prescribed dose.
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Do not drink large amounts of coffee, tea or carbonated drinks because of their diuretic effect. Lithium should not be taken during pregnancy because it can cause birth defects. Essential Drug List: Hospital Bipolar I or Bipolar II (Hypomania) Disorders Maintenance therapy: Lithium, oral, 20 mg/kg/day in divided doses. Range: 500 mg/day-1 200 mg/day, keep plasma levels at 0,4-0,8 mmol/l. OR Carbamazepine, oral, 200 mg-600 mg 2-3 times daily OR Sodium valproate, oral, 200 mg-500 mg 3 times daily as a mood stabilizer. Manic episode: Haloperidol, IM or IV, 5 mg-10 mg once OR Lorazepam, IM or IV, 1 mg-2 mg once. Cydothymic Disorders Major depressive disorder: Amitriptyline, oral, 75 mg-150 mg/day, titrate up to 300 mg/day OR Imipramine, oral, 75 mg-150 mg/day OR Fluoxetine, oral, 20 mg-40 mg daily. Mood stabilizer: Lithium, oral, 20 mg/kg/day in divided doses. Range: 500-1 200 mg/day, keep plasma levels at 0,4-0,8 mmol/l OR Carbamazepine, oral, 200 mg-600 mg 2-3 times daily OR Sodium valproate, oral, 200 mg-500 mg 3 times daily as a mood stabilizer. Essential Drug List: PHC As for acute management of psychotic patients (including mania). See Chapter 14, 'Nursing the patient with Schizophrenia'. Evidence-based practice Lithium for maintenance treatment of mood disorders Nine studies were included in the review, reporting on 825 participants randomly allocated to lithium or placebo. Lithium was found to be more effective than placebo in preventing relapse in mood disorder overall, and in bipolar disorder. The most consistent effect was found in bipolar disorder (random effects odds ratio 0,29 [95 % Cl 0,09 to 0,93] ). In unipolar disorder, the direction of effect was in favour of lithium, but the result (when heterogeneity between studies was allowed for) d-d not reach statistical significance. Considerable heterogeneity was found between studies in eii groups of patients. The direction of effect was the same in all studies; no study found a negative effect for lithium. Reviewers' conclusions: This systematic review indicates that lithium is an efficacious maintenance treatment for bipolar disorder. In unipolar disorder the evidence of efficacy is less robust. This review does not cover
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the relative efficacy of lithium compared with other maintenance treatments, which is at present unclear. There is no definitive evidence from this review as to whether or not lithium has an antisuicidal effect. Burgess S, Geddes J, Hawton K, Townsend E, Jamison K & Goodwin G. Lithium for maintenance treatment of mood disorders (Cochrane Review). In: The Cochrane Library, Issue 2 2003. Oxford: Update Software. Patterns of building and maintaining relationships The manic patient can be either the 'happy' manic, who seems to be loved by all or the 'irritable' manic, who becomes annoyed easily and has a low frustration tolerance. Both situations create problems for the patient, as responses from the people around him/her may ultimately be negative. He/she is often intrusive and has poor social judgement. This can lead to his/her being physically, emotionally and sexually abused. Relationships become strained as people cannot keep up with the manic patient. This may be verbalized or he/she may be avoided. Family, friends and staff are usually exhausted by his/her talkativeness, mood changes and increased energy. He/she seems to be at the mercy of the stimuli in the environment and cannot help him/herself. He/she is hyperalert to everything that he/she sees, hears or touches - even a subdued environment seems to provide a challenge for the manic patient to 'liven' it up. The patient also manifests manipulative behaviour, which staff and family have to recognize. Effective limit-setting provides structure and minimizes manipulative behaviour. Everybody working with the patient, such as family and staff, therefore has to be aware of the problems and how they are to be handled. 1. Limits must be explained briefly to the patient (he/she should be included in the setting of these limits where possible). The consequences of not adhering to these limits must also be explained. 2. Consequences must be direct and simple and, if possible, must have a bearing on the limits. 3. If the patient exceeds the limits, the consequences must follow immediately. The rewards for adhering to the limits must be appropriate. 4. Consistency in setting limits is of the utmost importance, as mixed messages render the exercise a failure and prevent the patient from understanding and assuming responsibility for his/her behaviour. 5. Limit-setting must not be taken as an opportunity to be punitive towards the patient. 6. Unacceptable behaviour must be handled firmly in a non-judgemental manner, with no show of anger or disgust. 7. Feedback must be given with regard to unacceptable behaviour. Acceptance of the patient as a person must be reinforced. 8. Positive feedback must be given with regard to acceptable behaviour.
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Patterns of participation in group and community life The manic patient seems to have a need to take over in group settings: he/she often interrupts discussion and usually wants all the attention. While the patient may be regarded as 'funny', he/she may actually disrupt and stunt group progress. He/she may embarrass group members or ask very personal questions, or he/she may be manipulative. He/she is usually flamboyant and convincing and can embark on major projects like making large purchases of furniture and vehicles successfully. He/she tends to spend money indiscriminately and becomes extremely extravagant. The patient may also be viewed as the community clown due to his/her expansive mood, his/her constant change of clothes at short intervals and his/her over-familiarity. The patient relates briefly and superficially to religious and political issues and can be very disruptive in such settings. Patterns of participation in work The work environment may be extremely stimulating to the manic patient, which may result in severe distraction and poor concentration, which in turn may result in poor work output. The manic patient may also be either extremely irritable or extremely euphoric, thus creating difficulties with fellow workers and supervisors. This may be aggravated by the manic patient's need to be in control of a situation due to his/her grandiosity and expansive mood. The patient may also be a danger to him/herself and others because of his/her excessive energy, the need to try something different and the speed at which he/she performs tasks. Fellow workers may be irritated by him/her or be exhausted by his/her energy, mood, talkativeness and manipulativeness. The manic patient invariably affects all those around him/her at his/her place of work. In a ward situation, activities such as jogging, scrubbing or painting large areas - all large motor activities — may be suitable for a manic patient. Patterns of utilizing free resources The manic patient has difficulty in utilizing free resources effectively and appropriately, as his/her judgement is socially impaired. This results in the patient behaving in a socially unacceptable manner, thus causing embarrassment and disruption, for example, an energetic, loud and grandiose individual may cause great disturbance and disruption in a library or a church. The patient is therefore not capable of enjoying and utilizing free resources in a socially acceptable manner. He/she can start to use these resources therapeutically only when he/she has been exposed to treatment and even hospitalization. CONCLUSION It can be seen that nursing the patient who is afflicted with a mood disorder sets a challenging task. It provides an opportunity for the nurse, the patient and significant
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others to work together in order to restore the equilibrium of the patient's patterns and to develop constructive coping skills. It is demanding and can be mentally exhausting. You are going to need a good support system of your own and you are encouraged to be involved in activities that promote your own mental health. You will periodically need to re-examine your feelings and your management skills with regard to, on the one hand, hopelessness, despair, negativism, low energy levels and, on the other hand, exuberance and hyperactivity. WEB RESOURCES
www.schizophrenia.co.za/support.htm This is a South African site which deals with all mental disorders and not, as the name implies, only Schizophrenia. Links to local support groups are also provided. http://bipolar.about.com/cs/africa_asia/ This site provides information about bipolar disorders, a help line and a list of contacts for support groups in various parts of South Africa and the world. www.psychnet-uk.com More information about the bipolar mood disorders. http://human-nature.com/odmh/bipolar.html On-line directory of mental health, covering almost every imaginable issue to do with mental health and specifically, with the bipolar disorders. Links to everything! http://bipolar.meetup.com/members/index.jsp?localeld=898 This is a meet-up and information site for people with bipolar disorder from all over the world. REFERENCES American Psychiatric Association. 1994. Diagnostic and Statistical Manual of Mental Disorders, 4 ed. Washington: American Psychiatric Association Beck, A T. 1967. Depression: Causes and Treatment. Philadelphia: University of Pennsylvania Press Cook, S H. 1999. The self in self-awareness. Journal of advanced nursing, Vol. 29 (6), 1292-1299. Di Vasto, P, West, D A & Cristy, J E. 1979. A framework for the emergency evaluation of the suicidal patient. Journal of Psychiatric Nursing, 17 (6), 15-20 Dunne-Maxim, K. 1986. Survivors of suicide. Journal of Psychosocial Nursing and Mental Health Services, 24 (12) Fish, A M. 1988. A Description of a Psychiatric Outpatient Population at an Urban Hospital (unpublished BSocSc (Nurs) (Hons) thesis, University of Natal, Durban) Gillis, L S, Sandier, R, Jakoet, A & Elk, R. 1986. Guidelines in Psychiatry, 3 ed. Wetton: Juta & Co Ltd Gillis, L S et al. 1986. Admissions to a psychiatric hospital. South African Medical Journal, 70, 731-734 Hawton, K, Salkovis, P M, Kirk, J & Clark, D M (eds). 1989. Cognitive Behaviour Therapy for Psychiatric Problems. Oxford: Oxford University Press Kaplan, H I & Saddock, B J. 1988. Synopsis of Psychiatry. London: Williams & Williams
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McLaughlin, C. (1999). An exploration of psychiatric nurses and patient opinions regarding inpatient care for suicidal patients. Advanced Journal of Nursing, Vol. 29, No. 5, 1042-1051 Obejide, A O, Oyewunmi, L K & Ohaeri, J U. 1989. Psychiatry in Africa: An overview. American Journal of Psychiatry, 146 (6), 708-716 Stuart, G W. 1994. Detection and Treatment of Depression: A Nursing Perspective. Washington: American Nurses Association Shaw, C. 1999. A framework for the study of coping, illness behaviour and outcomes. Advanced Journal of Nursing, Vol. 29, (5), 1246-1255 Talbot, K. 1986. ECT. Exploring myths, examining attitudes. Journal of Psychosocial Nursing and Mental Health Services 24 (3), 6-11 Talseth, A G, Lindseth, L, Jacobsson, L J, & Norberg, A. 1999. The meaning of suicidal psychiatric in-patient experiences of being cared for by mental health nurses. Advanced Journal of Nursing, Vol. 29, No. 5, 1034-1041 Tomb, D A. 1988. Psychiatry for the House Officer, 3 ed. Baltimore: Williams & Wilkins US Department of Health and Human Services. 1993. Depression is a Treatable Illness: A Patient's Guide. Rockville: US Department of Health and Human Services Uys, J (ed). 1992. Psychological Counselling in the South African Context. Cape Town: Maskew Miller Longman
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CHAPTER
FOURTEEN
Nursing the Patient with Schizophrenia L R UYS
Objectives After studying this chapter the learner should be able to: Make a diagnosis of schizophrenia and prescribe the appropriate medication. Monitor the reaction to medication, and prescribe the appropriate medication for maintenance and for prevention of relapse. Differentiate between various types of schizophrenia and identify the manner in which the disorder interferes with the patient's lifestyle and functioning. Identify the nursing interventions that could help to solve the patient's problems. Implement scientifically justifiable nursing care that would enable the patient to function as independently as possible as a member of a family and of a community.
INTRODUCTION Schizophrenia is a term used to describe a group of complex, severe conditions that are the most chronic and disabling of the mental illnesses. The conditions are characterized by patients experiencing a different reality from that of the people around them. This break with reality is why it is called a 'psychotic' condition. The reality of these patients is distorted, changeable and often frightening. Their sensory perceptions may be distorted by hallucinations, of which auditory voices are the most common. Their thought processes are often confused so that they find it difficult to 'think straight' or to focus on or engage in problem solving. The thought content is often also abnormal, delusions being common. Emotional expression is usually very limited or inappropriate. The symptoms of these patients are sometimes divided into positive and negative symptoms. Positive symptoms are associated with acute episodes and include confusion, delusions and hallucinations. Negative symptoms are related to the chronic syndrome and include flatness of affect, social withdrawal and poverty of speech.
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Schizophrenia is a very important illness for a number of reasons. It attacks people in the prime of their lives and in most cases it is not possible to effect a total cure of the patient. The disease therefore has a long-term course. The disease also has a high incidence so that it forms a large portion of the work of psychiatric nurses. Approximately 1 % of the population develops schizophrenia during their lifetime. Men and women are affected equally, although men tend to become ill in their twenties, while women become ill in their thirties. In South Africa patients with a diagnosis of schizophrenia make up between 28 % and 44 % of psychiatric inpatients (Gillis, Sandier, Jakoet & Elk 1986) and between 20 % and 46 % of outpatients (Uys, Dlamini & Mabandla 1995). In a recent community survey in the Western Cape, Rumble et al. (1996) found a very high prevalence of psychotic disorders. They found that 8 % of the 27,1 % of the population found to have a mental disorder could be classified as suffering from a schizophrenic disorder. Schizophrenia is often confused with a 'split personality' by the lay public because the word 'schizophrenia' means split. The split of schizophrenia, however, refers to a split between the affect and the thoughts and behaviour of the patient, and not a split into multiple personalities. Multiple personality is a rare dissociative disorder. It is still not clear what causes schizophrenia, although it seems that genetic factors produce a vulnerability, with environmental factors precipitating the acute episodes of the disease. The environmental factors are stressors such as tension in the family or demands at work/school or social problems. Children of schizophrenic parents have a 10 % chance of developing schizophrenia, compared to the 1 % risk of persons in the general population. Schizophrenia is not a 'mental illness' in the sense that there is nothing physically wrong with the person and that 'it is all in the head'. There are indications that the neurotransmitters of schizophrenic patients are abnormal, and certain structural features of the brain also show abnormalities. The prognosis of schizophrenic patients has always been viewed with great pessimism. However, this may be unnecessary. When schizophrenic patients are treated - within the community as far as possible - with antipsychotic medication as well as psychosocial approaches, about half of them make a very good recovery within the first five years (Prudo & Blum 1987). This group functions well, and shows minimal residual symptoms. Even patients who do not function so well after five years seem to improve in the long term and show good functioning in their later years (Harding, Brooks, Ashikaga, Strauss & Breier 1987). Comprehensive community treatment and rehabilitation programmes therefore hold some hope for this group of patients. 14,1 DIAGNOSIS AND TREATMENT It has been noted in the literature that black patients are often inappropriately given a diagnosis of schizophrenia. This might relate to cultural beliefs which are misunderstood by Western health care workers, but it may also be the result of communication problems and the process of translation. It might also be related to inadequate attention being given to eliminating other conditions which mimic schizophrenia:
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Many physical diseases produce schizophrenia-like symptoms, for instance, vitamin B12 deficiency, neurosyphillis, pellagra, heavy metal poisoning, Wernicke-Korsakoff syndrome, frontal or lymbic neoplasmas or strokes, carotid endocarditis and temporal lobe epilepsy. A very thorough examination is therefore essential. Special care should be taken if there are unusual or rare symptoms. The psychosis could be drug-induced. Alcohol hallucinosis, hallucinogens, dagga psychosis and barbiturate withdrawal therefore have to be investigated and excluded. It can be quite difficult to distinguish between schizophrenia and mood disorder, especially bipolar disorder. Since the treatment of bipolar mood disorder can be very effective, it is essential to get the diagnosis right. The adapted DSM-IV-TR stipulates that a manic episode can be distinguished from paranoid schizophrenia, and depression from catatonic schizophrenia, by looking at three symptoms that are more frequent in the mood disorders than in the schizophrenias. These are a family history of mood disorders, good premorbid adjustment and previous mood disorders that cleared up completely. Should these be present, it is more likely that the patient has a mood disorder than schizophrenia. DSM-IV-TR classification and diagnostic criteria: Schizophrenia and related conditions
Schizophrenia A. Psychotic symptoms present during the active phase - either symptoms under 1, 2 or 3 for at least one month: 1. Two of the following: -
delusions
-
prominent hallucinations
-
incoherence or marked loosening of associations
-
catatonia
-
flat or grossly inappropriate affect
2. Bizarre delusions 3. Prominent hallucinations of a voice keeping a running commentary or two voices having a conversation B. Functional level markedly below the highest premorbid level. C. Related conditions and organic factors have been ruled out. D. Continuous sign of the disturbance for at least six months.
Types
Catatonic: Catatonic stupor, catatonic negativism, catatonic rigidity, catatonic excitement, catatonic posturing. Disorganized: Incoherence and marked loosening of associations or grossly disorganized behaviour, flat or grossly inappropriate affect.
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Paranoid: Preoccupation with one or more systematized delusions or with frequent auditory hallucinations on a single theme, without gross thought, affect or behaviour disorder. Undifferentiated: Prominent delusions, hallucinations, thought disorder or disorganized behaviour, but does not meet the criteria for one of the above types. Residual: Continuing evidence of the disturbance, without prominent psychotic symptoms. Brief reactive psychosis A. Presence of at least one of the following symptoms indicating impaired reality testing: - incoherence or marked loosening of associations - delusions - hallucinations - catatonic or disorganized behaviour B. Emotional turmoil C. The symptoms in A and B appeared shortly after and apparently in response to one or more major stressful events. D. Did not have a typical withdrawn premorbid personality, or prodromal symptoms of impending schizophrenia. Also not related to an organic factor or a mood disorder. E. The episode lasts from a few hours to one month, with full return to premorbid functioning. Schizophreniform disorder The condition looks like schizophrenia, but the episode lasts less than six months, without the criteria for Brief Reactive Psychosis being met. Schizoaffective disorder A. A disturbance during which, at some time, there is either a major depressive or a manic syndrome occurring at the same time as symptoms that meet the A criteria of schizophrenia. B. During an episode of the disturbance, there have been delusions or hallucinations for at least two weeks but no prominent mood symptoms. C. The duration of all the episodes of a mood syndrome have not been a minor aspect of a dominant schizophrenic disorder. Psychotic disorder due to ... (indicate the general medical disorder) The patient has prominent hallucinations or delusions, but also has a medical condition which may have caused these, for example epilepsy, CNS infections or endocrine conditions. This diagnosis is not given if the person has the delusions or hallucinations only during delirium, or when it is associated with dementia. Substance-induced psychotic disorder The patient has prominent hallucinations or delusions, but there is evidence that these developed during or shortly after intoxication or withdrawal from a substance. There can also be evidence
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that the substance use has played a role in causing the symptoms, which were not there before the substance use started. This diagnosis cannot be used if the psychotic symptoms persist over a month after withdrawal or intoxication. When working with patients who have schizophrenia, a distinction is made between positive and negative symptoms (see Table 14.1). Positive symptoms can usually be controlled by medication, but negative symptoms often do not respond to physical treatment.
Table 14,1 Frequency of symptoms Negative Symptoms
%
Affective flattening Unchanging facial expression Decreased spontaneous movements Paucity of expressive gestures Poor eye contact Affective non-responsivity Inappropriate affect Lack of vocal inflections
96 66 81 71 64 63 73
Alogia Poverty of speech Poverty of content of speech Blocking Increased response latency Poverty of speech Poverty of content of speech Blocking Increased response latency
53 51 23 31 53 51 23 31
Positive Symptoms
%
Hallucinations Auditory Voices commenting Voices conversing Somatic-tactile Olfactory Visual
75 58 57 20 6 49
Delusions Persecutory Jealous Guilt, sin Grandiose Religious Somatic Delusions of reference Delusions of being controlled Delusions of mind reading
Avolition-apathy
Thought broadcasting
Impaired grooming and hygiene
87
Thought insertion
Lack of persistence at work or school
95
Thought withdrawal
Physical anergia
82
81 4 26 39 31 28 49 46 48 23 31 27
Bizarre behaviour Anhedonia-asociality Few recreational interests/activities Little sexual interest/activity
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95
Clothing, appearance Social, sexual behaviour
69
Aggressive-agitated
20 33 27
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Negative Symptoms
%
Anhedonia-asociality Impaired intimacy/closeness Few relationships with friends/peers
84 96
Attention Social inattentiveness Inattentiveness during testing
78 64
Positive Symptoms
%
Bizarre behaviour Repetitive-stereotyped
28
Positive formal thought disorder Derailment Tangentiality incoherence Illogicality Circumstantiality Pressure of speech Distractible speech Clanging
45 50 23 23 35 24 23 3
Medication guidelines If the patient presents at the clinic in a very disturbed state, wild and aggressive, it might be necessary to control or prevent violence by giving an immediate intramuscular injection. The following agents may be used: Zuclopenthixol acetate 50 mg-100 mg, or Haloperidol 5 nig, or Chlorpromazine 50 mg-100 mg, or Etomine 80 mg-120 mg (this medication does nothing for the psychosis, and is therefore less effective in the long run than the other medications). The dosage depends on the severity of the condition, and also on the size and age of the patient. Haloperidol can be repeated after thirty minutes if the control is inadequate. The content of the ampoule can also be given orally in water if the patient is willing to take oral medication but not an injection; it is tasteless. Once a diagnosis of a psychosis has been made, the patient should be put on a neuroleptic. There are different options in this regard: Give the patient a stat dose of 300 mg orally or 150 mg IM of chlorpromazine (Largactil) at the clinic. Then observe the patient for about an hour to check for a drop in blood pressure.
OR Give the patient a stat dose of Fluphenazine (Modecate Acutum) 2,5 mg-5 mg IM, depending on the sedation required. This medication will settle the patient down, and the nurse can observe how the patient reacts to the medication.
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If the patient can be seen every second day for the next month, zuclopenthixol acetate (Clopixol Acuphase) 50 mg-100 mg IM can be given every 48 hours. This will mean that the patient does not have to take any medication at home, and will allow close supervision of the reaction to medication. If this is not possible, put the patient on 200 mg chlorpromazine in the mornings, and 300 mg in the evenings for two weeks, and then review the situation. Also take the patient's blood pressure again. If there is no response, increase the dosage to 300 mg in the mornings and 400 mg in the evenings for two weeks. At this time the family and patient have to be warned of the possibility of side effects. In the event of side effects, do the following: If the patient is still experiencing symptoms, add orphenadrine 100 mg bd for two weeks. Then discontinue and see whether side effects return. If the patient is not symptomatic, lower the dosage by at least 25 %, but preferably by 50 %.
After one month the situation has to be reviewed. If the symptoms have subsided, you can put the patient on a depot product. This is especially useful if there is a problem with the patient taking the prescribed oral medication: Fluphenazine deconoate (Modecate) 25 mg monthly, or Flupenthixol deconoate (Fluanxol) 20 mg monthly, or Zuclopenthixol (Clopixol) 100 mg-200 mg. It might be necessary to add oral chlorpromazine 100 mg-200 mg nocte to these preparations. If this is the first episode of a psychosis, the patient is kept on the stable dose for twelve months, and then it is reduced slowly. If such an episode has occurred two or more times, the patient is kept on a stable dose for four years before tapering off is done.
Essential Drug List (EDL) Emergency: Haloperidol, IM or IV, 5 mg-10 mg OR Lorazepam IM 1 mg-4 mg PLUS Zuclopenthixol IM 50-150 mg, which may be repeated if necessary after 2-3 days. Stabilization phase: Haloperidol, oral 1 mg-15 mg/day OR Chlorpromazine oral 75 mg-300 mg/day in divided doses. Maintenance: Fluphenazine deconoate IM 12,5 mg-100 mg every 3-4 weeks OR Flupentixol deconoate IM 20 mg-60 mg every 2-4 weeks. Extrapyramidal side effects: Biperiden, slow IV or IM, 2 mg repeated every 30 minutes if necessary up to a maximum of 4 doses daily.
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Primary Health Care (PHC) Acute management: Haloperidol and Lorazepam IM immediately and Lorazepam 2 mg-4 mg. PLUS Haloperidol 2 mg-5 mg, repeated at hourly intervals if required up to a maximum of 20 mg in 24 hours. After acute phase: Haloperidol orally 2 mg-20 mg per day in 2-3 divided doses (usually 4 mg-8 mg per day). Long-term: Haloperidol oral 2 mg-20 mg per day in 2-3 divided doses OR Fluphenazine deconoate IM 25 mg monthly.
142 FACILITATION OF A HEALTHY LIFESTYLE The appropriate type of nursing is determined by the degree of disorganization and disintegration of functioning exhibited by the patient. In the acute phase of the disease, all life patterns are disorganized, but in residual schizophrenia the greatest problems are selfcare patterns, work patterns and the use of free time. A treatment programme geared to encouraging patients to take maximum responsibility for their own health is developed in consultation with the patients, families and/or care-givers. Because schizophrenic patients need long-term care and rehabilitation while moving between many different agencies and services, it is recommended that the case management model of care be used for a large proportion of such patients. Case management is an approach rooted in social work and community health nursing. It is a community health care method in which one worker addresses all the needs of the longterm patient for assessment, planning, service arrangement and co-ordination, monitoring and treatment and reassessment. It has been shown that patients in a caseworker programme function significantly better than those patients in traditional programmes (Goering, Wasylenki, Farkas, Lancee & Ballantyne 1988). Common nursing diagnoses Potential for violence, self-directed or directed at others RELATED TO lack of trust, panic level anxiety, hallucinations of delusions EVIDENCED BY increased pacing, tense body posture, overt aggressive acts or threats. Social isolation RELATED TO lack of trust, hallucinations or delusions EVIDENCED BY social withdrawal, dull affect, preoccupation with own thoughts and meaningless actions. Ineffective individual coping RELATED TO personal vulnerability, inadequate support systems EVIDENCED BY inability to meet basic needs. Sensory-perceptual alternation: auditory/visual/tactile RELATED TO chemical imbalance EVIDENCED BY poor concentration, disordered thought, inappropriate responses.
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Alteration in thought processes RELATED TO chemical imbalance EVIDENCED BY distractibility, impaired and concrete thinking, abnormal content of speech. Impaired verbal communication RELATED TO impaired thinking and sensations EVIDENCED BY loose associations, neulogisms, nonsensical talk, echolalia. Self-care deficit RELATED TO regression, withdrawal into the self and perceptual and cognitive impairment EVIDENCED BY not eating, deficits in personal hygiene, poor grooming. Sleep pattern disturbances RELATED TO anxiety levels, delusions and hallucinations EVIDENCED BY restlessness, insomnia. (Townsend 1990)
Psychodynamic patterns Coping mechanisms Schizophrenic patients exhibit a wide variety of coping mechanisms. One of the most serious of these is withdrawal. Withdrawal occurs mainly in the passive form: patients avoid contact with others and contribute little to conversations. Sometimes, however, withdrawal becomes more active, for example, when word salad or bizarre behaviour is used to drive people away. Withdrawal in schizophrenic patients is probably the result of interaction between three factors: 1. The patient might have had limited social skills to begin with, so that he or she developed few relationships even before he/she became ill. This inability to establish close bonds with people might even have contributed to his/her becoming mentally ill. 2. During the process of treatment, the patient might have suffered long periods of hospitalization in units where social stimulation was limited, which caused withdrawal as a secondary symptom. Research has shown that a restrictive environment in which choice is severely limited, and one in which long periods during the day are spent doing nothing, has a very negative effect on the level of socialization of patients (Teasdale 1986). 3. Withdrawal is also a coping mechanism used by these patients to defend themselves against intrusive, critical and overstimulatory interaction. In situations where selfprotective withdrawal is not allowed, the symptoms of the patient might become more and more florid. Social withdrawal is one of the negative symptoms of schizophrenia, which is not effectively treated by medication, but needs psychosocial treatment approaches. In addressing withdrawal in schizophrenic patients, it is important that the problem be correctly identified. Withdrawn patients do not generally draw attention to themselves; they are quiet and unobtrusive. Unless nurses in large wards therefore make an effort to identify and approach them, they will simply fade into the background. What is more, a
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process of mutual withdrawal has been described in the literature. This concept describes the process of the patient's withdrawal as causing the nurse to feel rejected and inadequate so that she in turn withdraws from the patient. Her withdrawal strengthens the patient's feelings of rejection, and his/her withdrawal. To identify the withdrawn patient in an inpatient setting, Schwartz and Shockley (quoted by Golden & Bessant 1985) suggest that the ward sister should answer the following questions: When making a list of patients in the ward, which names are often left out? Which patients have the least informative nursing notes? Which patients can nurses remember the least about? Which patients do nurses move away from as quickly as possible? Which patients tend to isolate themselves? In an outpatient setting it is more difficult to identify the withdrawn patient. One useful technique is to assess the non-verbal behaviour of the patient in the interview setting, since this will give an indication of the level of social skills. Although the patient might be able to give an accurate indication of whether this is a problem in his/her life, the family should also be interviewed to round out the assessment. The treatment of withdrawal would probably need long-term strategies. Firstly, the treatment staff should establish a trusting relationship with the patient in which he/she is willing to become involved in therapy. Unless this trusting and personal relationship is established, it is doubtful whether the patient will be accessible to other treatment methods. The second treatment approach is to teach the patient the social skills needed to establish and maintain social relationships and to deal with intrusiveness. This is addressed in more detail in Chapter 11. Thirdly, the patient should be assisted to use the skills by placing him/her in groups and social settings where the skills can be practised and utilized. Cognitive patterns Hallucinations
A hallucination is a strongly perceived false perception that has a compulsive sense of reality although relevant and adequate stimuli for such a perception are lacking. The most common hallucinations in schizophrenic patients are auditory, although other kinds are also experienced. Hallucinations are one of the most significant problems of both acute and chronic schizophrenic patients. Hallucinations are a distressing experience in themselves, but they also depress social functioning and may underpin delusions. There are two significant theories about the development of auditory hallucinations: 1. The physical theory is that auditory hallucinations represent subvocal speech and movement of the vocal muscles originating in the non-dominant cerebral hemisphere and that the dominant hemisphere perceives this verbal activity as alien, due to the primary disassociation between the two hemispheres in schizophrenia. In other words,
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the voice that the patient hears is his/her own subvocal voice, stimulated by the nondominant hemisphere. The interventions based on this theory include strategies to curb covert vocalization, such as keeping the mouth open or asking the patient to name things in the immediate environment when the voices start, and strategies to limit the hearing of subvocal activity, such as wearing an earplug. All these strategies have proved successful in decreasing the hearing of voices. 2. The social theory postulates that hallucinations replace relationships the individual once had with real objects or people. In this theory five phases are identified in the development of auditory hallucinations: (i)
In a situation of increased stress, the person thinks of a person who might be helpful (either a recalled or a fantasized person), and the anxiety decreases.
(ii)
The stress and the adaptive reaction recur and the person starts to set up situations in which it is easier to 'think about' the helping person. Anxiety is felt about whether the 'helping person' will always be available.
(iii)
The person spends more time in the autistic reverie and loses touch with reality. Inappropriate behaviour occurs, resulting in shame and increased anxiety.
(iv)
Others try to intervene, which increases anxiety and reliance on the 'helping person'. The person becomes incapacitated due to the loss of contact with external reality, and this leads to further embarrassment and shame. The patient may be hospitalized, leading to a further loss of contact with familiar persons and objects. The voice might become negative, accusatory or derogatory at this stage. The hallucinations are more real than reality and the patient is constantly in a state of high anxiety. The patient makes promises and compromises with the voices in order to keep them available and supportive. The patient accepts the voices as part of his/her life.
(v)
Interventions based on this theory include keeping the patient occupied and limiting time alone, increasing social skills and social support, and improving the self-image of the patient. The two theories and the strategies based on them are not mutually exclusive, and can be creatively combined to assist patients with this symptom of the disease. Specific nursing care for hallucinations Diminish the reality of the hallucinations. — Touch the patient. - Make eye contact. - Maintain an open posture. - Speak in a calm tone of voice. - Do not argue about the hallucinations. - Show scepticism about the hallucinations, for example: 'I don't see them.' - Use direct responses, for example: 'Look at me; don't pay attention to the voices.'
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- In cases of auditory hallucinations, your voice should dominate the hallucinations. - Investigate the patient's present interests, activities and emotions. — Involve the patient in ward activities such as walks or any other constructive activities individually or in groups. - Encourage the patient to drive away the voices. - Identify the subjects that distress the patient and avoid them. Limit free and unstructured time. - Set up a day programme. - Involve the patient in activities. - Provide regular physical activities that require the use of the large muscles and demand concentration. i Involve the patient in concrete reality. - Discuss everyday subjects. - Ask simple questions. - Give concrete instructions. - Discourage discussion of hallucinations. Reduce anxiety. — Encourage acknowledgement of feelings of being threatened. - Encourage discussion of emotions and anxiety. - Explain possible causes of hallucinations, for example, loneliness or anxiety. - Enhance the patient's ability to test reality by encouraging questions. - Teach the patient alternative coping mechanisms for more appropriate management of identified reasons for hallucinations. — Set reasonable expectations for the patient. - Gradually increase the patient's responsibilities in relation to the level of anxiety. Block auditory hallucinations. — Teach patients to whistle or sing when they hear voices. - Determine whether hallucinations harm others or the patient and, if so, provide protection. - Identify and evaluate the content of hallucinations and hospitalize if necessary. Promote understanding and management of hallucinations by the family. - Explain the causes of and the behaviour that may be expected with hallucinations. - Encourage family members to discuss their emotions about the patient's hallucinations. Specific nursing care for delusions Reduce the reality of the delusions. - Avoid all efforts to convince patients that their views are wrong or unreal. - Say only that you do not share their views. - Focus on facts and reality. - Encourage the discussion of present feelings. - Change the subject and give reasons for doing so.
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Reduce anxiety. - Avoid situations that cause conflict with delusions. - Avoid situations of condemnation and ridicule of delusions. - Give concrete, frank explanations for changes in treatment and environment to enable patients to interpret change realistically. - Always act consistently. - Keep promises. - Introduce only one anxiety-producing situation at a time to enable patients to remain in control. - Involve patients in single activities at first. - Encourage the use of healthy coping mechanisms for anxiety. Prevent the exacerbation of delusions. - Correct wrong interpretations. - Support doubts that the patient may express. - Talk about actual events and subjects. - Investigate possible reasons for false, fixed beliefs. - Encourage the patient to identify behaviour that relates to delusions. - Set fixed times for the discussion of a delusion. - Establish whether or not the patient is speaking the truth. - Encourage the patient to identify and express emotions. Promote a positive self-image. — Assure patients that they are accepted. - Always respect patients as people. - Involve patients in activities. - Give positive feedback about activities or interpersonal responses. - Encourage the setting of realistic goals. Maintain the patient's physical health. In the event of a delusion of suspicion or a delusion that the food is contaminated: - Use disposable crockery and cutlery. - Allow food to be sent from home. - Allow patients to open containers such as milk cartons themselves. - Serve food with skin or peels that patients can remove themselves. - Serve the other patients first and let them start eating. - Allow patients to serve themselves. - Suggest that patients will enjoy the meal. - Avoid tube feeding, as this may be experienced as aggression. Promote understanding and management of delusions by family members. - Information: The negative response of other people is of little importance, however realistic it may be. A negative response does not help to improve the situation. Always express acceptance of the patient and show that you care. - Give emotional support.
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-
Set realistic expectations for the patient. Set definite limits of conduct by making quite clear what behaviour is acceptable and what is unacceptable. - Explain possible causes of the problem. - Support: Give family members emotional support by affording them the opportunity to express their experiences in relation to the patient.
Thought disorders The schizophrenic patient's thoughts are disorganized and distorted. This makes communication very difficult and may lead to nurses avoiding conversation or giving superficial answers. It is important to remember that the patient may be desperately trying to make sense of his/her thoughts, or he/she may be clear as to what he/she is thinking, but find it impossible to communicate clearly. Since social isolation is such a problem for these patients, the nurse should make every effort to facilitate communication. Here are a few indications of thought disorders and how they should be handled in conversation: Vagueness. It may be difficult to follow the patient's conversation because the patient uses global pronouns, such as 'they', 'we' or 'you', without making it clear to whom he/she is referring. The nurse needs to clarify by questioning exactly who the patient is referring to. This can also be useful with generalizations ('everything is going wrong') and global adjectives ('I am a mess'). Circumstantiality. The patient may overarticulate details and take a long time to get to the point. In order to make sure that you have understood him/her correctly, you can restate the actual message briefly and validate with the patient whether this is what he/she meant. This will also assist the patient to focus and clarify his/her thinking. Loose associations, incoherence, tangentiality. Sometimes the thoughts of the patient are so muddled that they become very difficult to understand, or you may understand them up to a point, but then lose the thread. In such cases it is important to stop the patient politely and admit that you are finding it difficult to understand. Restate what you have understood and ask for clarification about the rest. Sometimes it might be wise to redirect the patient to something concrete, rather than follow him/her into an increasingly frustrating conversation. Delusions, autistic thinking, magical thinking. In this case it is not a problem understanding the patient, but the content of the thoughts does not follow the usual logic or is based on false beliefs. It is important to seek to understand the real message of the communication, which may be camouflaged in a delusion or magical thinking. 'I am Caesar' may mean 'I am important', or 'I was betrayed by a friend' or a range of other things. Try to reflect the meaning of the communication, rather than argue about the form in which it is expressed.
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Pattern for meeting biological needs Self-care Diminished drive, flat affect and disturbances of thought are reasons why patients have difficulty in accepting responsibility for self-care. They should be supported in their efforts to improve their personal appearance and nurses should help them with their personal grooming and ensure that they dress neatly and appropriately. They should gradually be encouraged to accept responsibility for personal grooming. Nurses should spend time with these patients but should allow them to do what they can for themselves. Behaviour therapy techniques such as a token economy system, activity scheduling and shaping may be used to good effect. Mobility should be encouraged by means of, for example, a regular exercise programme or a daily four-kilometre walk. Such a programme should provide for an average of eight hours' sleep a night to ensure that patients spend their days effectively. Eating problems due to illusions or delusions are discussed below. A ccommoda tion Accommodation is often a problem because patients cannot always be placed with their families. If accommodation means only somewhere to stay, patients are inclined to wander socially and geographically. The accommodation should be of such a nature that the occupants have the opportunity to be kept busy, to become interested in finding stimulating jobs (for profit, if possible), to keep in social contact with people in their community and to develop new interests. Placements that contribute to the adjustment of patients include halfway houses, day and weekend hospitals to avoid full-time hospitalization and hostels with single accommodation. Placements not recommended are cheap hostels and boarding houses, since these provide circumstances that are unfavourable for optimum functioning. Patients should not be placed in circumstances that are worse than those in the hospital. Illness behaviour Schizophrenia is a serious diagnosis and one that has to be explained in detail to the patient. Just as in the case of diabetes, the management of this long-term illness is mainly in the hands of the patient, and unless he/she understands both the disease and the treatment, rehabilitation cannot be successful. A significant amount of teaching therefore has to be done when the diagnosis has been made and the patient has recovered to the level where he/she can understand the teaching. Schizophrenia is a long-term illness, characterized by episodes of relapse. When patients relapse, they first go through a period of non-psychotic symptoms and then through a period of psychotic symptoms. In one study it was found that 63 % of schizophrenic patients had insight into impending relapse and that these patients were less likely to be hospitalized than those who did not have insight (Heinrich, Cohen & Carpenter in McCandless-Glimcher, McKnight, Hamera, Smith, Peterson & Plumlee 1986). Patients
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should therefore also be taught to monitor their own symptoms to detect a threatening relapse, and also what they should do in such a case. The most common non-psychotic signs of impending relapse are nervousness/tenseness, trouble sleeping (either too much or too little), greater than usual fatigue and a lack of energy, depression, difficulty in thinking or concentrating, less activity than usual, an inability to get going and irritability. These early signs may differ from one patient to the next, and every patient should be encouraged to identify his/her own early signs. Major tranquillizers Long-term medication is an integral part of the treatment of schizophrenic patients and the maintenance of this therapy is an important function of the nurse. The group of sedatives with marked antipsychotic effects is known as 'major tranquillizers', and is also called neuroleptics or antipsychotic medication. Principles of neuroleptic treatment 1. Start with low dose and increase gradually. 2. Avoid polypharmacy and do not chop and change. 3. Wean slowly from a drug. 4. Use smaller doses in older people. 5. Less frequent dosages (twice/once daily) increase compliance. How do these medicines help? They are all dopamine receptor blockers and are used to treat psychoses such as schizophrenia and mania. They can reduce episodes of hallucinations and delusions, and help the patient to be less upset and agitated. They can improve the ability to think clearly. Sometimes they may be used to reduce aggression or severe behaviour problems in young people with conduct disorder, mental retardation or autism. Patient monitoring Regular appointments are essential to ensure compliance, to be sure that the medicine is working and is still needed, to check weight and to watch for side effects. Regular blood pressure checks initially. The use of clozapine requires regular blood tests to watch for a decrease in blood cells. What side effects can this medicine have? Any medication may have side effects, including allergy to the medicine. Please talk to the doctor if you suspect that the medicine is causing a problem. Common side effects - not usually serious Dry mouth (sugar-free gum may help).
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Sleepiness or tiredness (warn against activities such as driving or working with machinery). Constipation (encourage dietary fibre and drinking fluids). Mild difficulty urinating. Blurred vision (mechanical apparatus to be avoided). Dizziness (stand up slowly from sitting or lying down, especially first thing in the morning). Weight gain (introduce weight-control measures, for example, avoiding sweets, cakes, etc). In the case of clozapine, increased salivation. Occasional side effects - may be distressing to adolescents Decreased sexual interest or ability. Changes in menstrual periods; increase in bust size (boys and girls). Emotional side effects Sadness, nervousness, clinginess. Tabale 14.2 Major tranquillizers Generic name
Trade name
Examples of drugs in general use Chlorpromazine
Dosage
Action
Dosage/24 h Largactil
75-600 mg
Sedative
Thioridazine
Melleril
75-400 mg
Sedative
Trifluoperazine
Stelazine
3-50 mg
Mild sedation
Haloperidol
Serenace
2-40 mg
Mild sedation
Clothiapine
Etomine
80-200 mg
Marked sedation
Ciozapine
Leponex
25-300 mg
Very marked sedation
Long-acting preparations
Dosage/2-4-weekly
Fluphenazine deconoate
Modecate
25-75 mg
Mild sedation
Flupentixoi deconoate
Fluanxol
20-40 mg
Activating
Zuclopenthixol
Clopixol
1 00-200 mg
Decreases aggression
Fluphenazine HCL
Modecate acutum
Inj 2,5 mg/ml 8 h
Zuclopenthixol acetate
Clopixol acuphase
Inj 100 mg/2 ml 24-72 h
Short-acting preparations
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Serious side effects Parkinsonism-type syndrome - Akinesia (slow, robot-like movements). - Rigidity (shuffling gait and tremors of the tongue and mouth). Akathisia - Restless movements of hands or feet, or rocking movements. -
Inability to sit still. This can be treated by adjusting (reducing) the dose or with anti-Parkinsonism agents, for example, biperiden (2 mg-8 mg/24 h), or orphenadrine (200 mg-400 mg/24 h).
Acute dystonic reaction Spasms of the large muscles at the neck, back and eyes may occur within the first 24-48 hours of commencement of treatment. Treated with an anti-Parkinsonism drug given intravenously (slowly). Tardive dyskinesia - Usually not before six months of onset. - Abnormal involuntary, irregular movements of body parts. - The longer patients take the medication, the greater the possibility of this complication. - Reduce or discontinue medication. Neuroleptic malignant syndrome — Life-threatening complication. - Hyperpyrexia, perspiration, increased pulse rate and blood pressure, muscle rigidity, dystonia and mutism. - Immediately discontinue medication. — Treat symptomatically. - Reduce temperature. Warning to patients 1. Medicines make skin sensitive to sunburn; use sunscreen and/or protective clothing when outside. 2. Medicines make many people sleepy; if this occurs, do not drive a car, ride a bicycle or operate heavy machinery. 3. No alcohol is to be used with neuroleptics. 4. The drugs may not be changed without approval of a doctor or nurse, especially as regards stopping or increasing the dosage.
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Joanna Briggs Best Practice Guidelines For subjects suffering from schizophrenia, the following evidence has been found: Individual Cognitive Behaviour Therapy can be effective in improving overall mental state and global functioning (level I evidence) Interactive Behavioural Training is not effective at improving social functioning (level II evidence). Longer term Group Psychotherapy or Modular Skills Training can be effective at improving overall psychological symptoms (level II evidence). Modular Skills Training is effective at improving living skills (level III). Group Psychoeducational Training is not effective for improving medication compliance (level II evidence). The use of Activity Groups can be effective at improving social interaction (level II evidence). Group Psychotherapy is ineffective at producing lasting improvement in subjects presenting with polydipsia (level II evidence), Best Practice 3 (4): 1-6, 1999
Building and maintaining relationships Patients with long-term psychotic disorders lack social skills and this is a limiting factor in their rehabilitation. They have difficulty initiating conversations and are incapable of forming and maintaining friendships. These skills need to be mastered, since they form the basis for interpersonal relationships in the work situation. The family Most psychiatric patients in South Africa live with their families, either the family of origin or the nuclear family. Hospitalization time has been dramatically reduced during the last two decades, so that even the schizophrenic patient spends more time in the community than in the hospital. The most important milieu for the treatment and rehabilitation of these patients is therefore the family. If a close family member is diagnosed as having schizophrenia and this involves having to care for that person in the long term, it places an enormous objective and subjective burden on the family. An objective burden involves problems such as financial hardship and the disruption of family functioning, while a subjective burden refers to the psychological distress engendered by the disease, such as the stigma attached to mental illness. Families often experience mental health professionals as blaming, critical and unsympathetic instead of supportive. Studies have shown that the inclusion of the family in the treatment process, mainly through psychoeducation, greatly decreases the relapse of patients - in some studies from 50 % to 9 % (Keith 1990). One of the most important functions of the nurse is therefore to enlist the family in a positive clinical alliance.
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Evidence-based Practice Family intervention for schizophrenia Family intervention may decrease the frequency of relapse (one year OR 0,57 Cl 0,4-0,8, NNT 6,5 d 4-14). The trend over time of this main finding is towards the null and some small but negative studies may not have been identified by the search. Family intervention may decrease hospitalization and encourage compliance with medication but data are few and equivocal. Family intervention does not obviously affect the tendency of individuals/families to drop out of care. It may improve general social impairment and the levels of expressed emotion within the family. This review provides no data to suggest that family intervention either prevents or promotes suicide. Reviewers' conclusions: Clinicians, researchers, policy makers and recipients of care cannot be confident of the effects of family intervention from the findings of this review. Further data from already completed trials could greatly inform practice and more trials are justified as long as their participants, interventions and outcomes are generalizable to routine care. Pharoah F M, Mari J J & Streiner D. Family intervention for schizophrenia (Cochrane Review). In: The Cochrane Library, Issue 2, 2003. Oxford: Update Software. The family as a group plays an important role in the functioning of a patient. Every member should be encouraged to take co-responsibility for the patient's rehabilitation and must therefore be fully involved. This prevents uninformed family members from sabotaging efforts. This does not, however, exempt the patient from responsibility in this regard. Researchers have identified two types of families. Members of families with high expressed emotion are verbally and non-verbally very critical in their communication with patients. They do not believe that they are ill and expect them to take responsibility for their conduct and circumstances. At the same time they are overprotective by giving unsolicited advice, taking decisions for patients or not allowing them to carry out activities on their own. Despite all this, the underlying message conveyed is that patients cannot function independently. The result is that patients have little privacy, which is reduced even further because these families plan their activities around the patient. Much of the suffering of these families or care-givers is due to overinvolvement with patients and/or exaggerated self-sacrifice. The rehabilitation of patients who are placed with this type of family is poor. Families with low expressed emotion believe that the illness is caused by factors beyond the control of the patient and he/she is not expected to behave normally. These families allow patients a measure of social freedom and expect them to take responsibility for their own decisions and health. The approach of such families may be summarized as one of benevolent neglect, and schizophrenic patients who are discharged to them do very well.
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Nursing care of the family Give information
Information relieves the anxiety of both patients and their families or care-givers. It gives them hope and, in general, more control of the situation. Information that must be given includes the symptoms; possible causes; the course of the disorder; the prognosis; treatment that may be given, for example group therapy, behavioural therapy, medication (the type of medication, the aim/dosage, side effects, contraindications and follow-up); guidelines for the effective management of patients; community resources in the family's area, for example, day centres, support groups, social clubs for handicapped people; and the latest research findings about the illness and treatment. The information must be conveyed in understandable terms in order for the family to apply it meaningfully. Give emotional support Family members must be given a structured opportunity to air their feelings, for example, in the form of a support group. Feelings they may experience include being trapped; powerlessness; failure; a feeling of physical, emotional and social abuse, and frustration due to failure to make contact with the patient. These feelings may be caused by the patient's unpredictability and socially unacceptable behaviour and the family's inability to make and maintain contact with the patient. All this contributes to tension, and the family must learn to cope with it effectively. The family members must define the relationship between the patient's behaviour, their experiences, their coping mechanisms and the effect of their coping mechanisms. They must be given the opportunity to investigate, implement and evaluate new coping mechanisms. The family must be continually supported. The longer patients are psychotic or ill, the greater the impact of their stay on the people with whom they live, and the older the caregivers, the greater the impact on their quality of life. There are parent support groups in various centres in the country. Some of these are YANA in Pretoria and Cape Support for Mental Health in Rondebosch, Cape Town. Three support groups in Johannesburg have formed a liaison committee, FAFOFS (Friends and Family of Schizophrenics). Both the patient's children and other children in the family should be informed in comprehensible terms of the reasons for the patient's behaviour. Discussion groups should be held with the children to explore their feelings and practise coping mechanisms. Teachers should be informed of the situation to enable them to support the children. Teasing at school about the 'mad' family needs to be identified as early as possible, as it may lead to the development of behavioural problems. Teachers can play a supportive role in such instances. Children should know to whom they can go if the patient's conduct frightens them and they should be encouraged to discuss their fear with someone. Parents who suffer from schizophrenia should be supported and counselled concerning the management of their children.
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Teach problem-solving techniques Problem-solving techniques can be used in all family situations, not only in those involving the patient. Every family member shares responsibility for the success of the planned solution. If the solution does not succeed, everyone - not only one person - bears the responsibility. The family can apply this method without the aid of a therapist. Teach behaviour modification principles The effective use of behaviour modification principles by the family and patient to strengthen appropriate behaviour and unlearn inappropriate behaviour gives them concrete guidelines for action. The patient and family will be calmer as a result of the concrete structure. These principles promote communication. In the first place, messages are more clearly formulated. Secondly, implementation encourages positive behaviour, for example, giving patients positive feedback if they are well groomed. Thirdly, the principles help to set limits. Patients know exactly what is expected of them and what they can expect of others. The family must be prepared for conflict and tension if patients refuse to act within the set limits. Care should be taken to ensure that the family members, including the patients, cope effectively with the tension. In the fourth place, the principles are applied to negotiate a contract which binds all the family members to reaching the objectives. Lastly, the timeout technique is very useful for managing tense situations. Both the patient and the family may apply the technique, but care must be taken that it is not used to avoid tense situations. Reduce face-to-face contact Findings have shown that psychotic patients who spend more than 35 hours per week in the company of their families run a greater risk of relapse. Although families should spend time together, both patient and family should be given opportunities to go out on their own. They should all be encouraged to have interests that they enjoy independently of the family. This is a problem for patients, as they lack interests and communication skills and are often short of money. This is an area in which support groups for outpatients, churches and social clubs can make an important contribution to the rehabilitation of schizophrenic patients. Participation in group and community life The community is uninformed about schizophrenia. This hampers the rehabilitation of these patients and consequently their integration into the community. Organizations that patients and their families may join are church groups and social clubs with specific interests such as stamp collecting and birdwatching. If possible, schizophrenic patients should be allowed normal use of community services such as libraries, sports facilities, other recreational facilities and health services by means of a systematic integration programme.
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In some cases, however, additional specific support services are required for these patients and their families. Community services that may be used by patients and their families are outpatient services, home visits by the community psychiatric staff, and family therapy units; crisis volunteers who maintain contact with patients through outpatient services can give patients limited social support and can inform the nurse if they identify a problem. Helpful hints for families
Talking is difficult Families may find it difficult to talk to the patient. Encourage them to try in short, simple sentences, and to be patient in trying to understand what the patient says. Including the patient in activities Invite the patient, but do not feel bad if he/she declines. What to do about drowsiness because of medication Try to encourage a long sleep at night, but no naps during the day. Also, report drowsiness to nurse, since a reduction of medication, or taking it at night, may help. Also try to prevent boredom. Should the patient be pushed to meet expectations? It is not acceptable for the patient to rule the house with his/her illness by threatening or withdrawing. So, the family needs to bargain with the patient for compliance, and encourage activity. It would be best to start by encouraging passive activities, such as listening to the radio, eating or watching television. Then more active involvement could be gently encouraged. Bargaining, such as 'I will pay for your cigarettes if you will go and buy some milk', may be useful at times. The patient who lives at home should understand that he/she has to accommodate the wishes of others in the home, and make some contribution to living together. The patient is still an adult Although the person has a serious illness, he/she is still an adult with adult needs, such as sexual and independence needs, and the rights of an adult. In the final instance the family cannot take responsibility for the choices of the person. (Seeman, Thornton & Plummer 1989)
Evidence-based Practice: Day hospital treatment Main findings:
Nine trials (involving 1 568 people) showed that day hospital treatment was feasible for 23 % of those currently admitted to inpatient care. People in day hospitals showed more rapid improvement in mental state (n=407, Chi-square 9,66, p=0,002) but not in social functioning (n=295,
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Chi-squares 0,006, p=0,941). Four of the five trials found that day hospitals were cheaper than hospital treatment. Reviewer's conclusions: There was evidence from one trial suggesting that day treatment programmes were superior to continuing outpatient care in terms of improving psychiatric symptoms. There was no evidence that day treatment programmes were better or worse than outpatient care on any other clinical or social outcome variable, or on costs. Marshall M, Crowther R, Almaraz-Serrano A M & Tyrer P. Day hospital versus out-patient care for psychiatric disorders (Cochrane Review). In: The Cochrane Library, Issue 2, 2003. Oxford: Update Software. Work patterns Investigations have shown that schizophrenic patients who work are hospitalized less frequently than those who do not work. A job can therefore contribute to more effective functioning. Schizophrenic patients usually have a poor work record due to their lack of drive, limited interpersonal and social relationships, lack of job experience and almost complete lack of job specialization. The establishment of job rehabilitation programmes that include the teaching of work behaviour is often necessary. It may also be necessary to create special job opportunities in the form of sheltered workshops. The problem is that this type of work offers little stimulation because there is so little variety - it is usually simple and repetitive. Contracts are hard to come by and the remuneration is generally too poor to meet the needs of the patients. Furthermore, these facilities are not within reach of everyone, as there are only a few in the country, each of which can accommodate only a limited number of people. If every firm or organization were obliged to employ a number of people with disabilities, the private sector would also make its contribution in this regard. One reason for the private sector's not making a larger contribution, however, is that, the weaker the economy, the fewer the available job opportunities. Another reason is the ignorance of the general public concerning the disease. The function of the nurse regarding the work rehabilitation of patients is to see to it that the following aspects are built into the rehabilitation programme: self-care, opportunities for socializing, punctuality, self-discipline, accurate performance of activities, planning of own activities and the completion of tasks. This may be done individually or in groups. The nurse should also assist in finding gainful employment for patients by means of appropriate referrals to services. Utilizing free time Patients must be assisted in planning their activities and time economically for a day or a week, as they often require help in this regard. The positive use of free time is an important
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activity in the gradual development of a healthy lifestyle. Patients should be helped to develop a positive pattern for spending their free time because they lack drive and interest in their surroundings. Watching television is a common free time activity of schizophrenic patients. The problem is that they spend hours watching without taking in anything. This is a passive activity that can contribute to withdrawal and deterioration. It should therefore be restricted and supplemented with more social and active behaviour. This means that activities on the inpatient day programme need to provide for the learning of alternative skills that patients must be able to use after discharge. Examples of such activities include leather-work and pewter-work, tatting, cane-work and organized sports activities. Bus tours, visits to places of interest, formal dances and visits to the cinema and other places of entertainment can be arranged for inpatients. Funds are a limiting factor in the rehabilitation of these patients. Most receive disability grants and, if they have no other income, a large proportion (two thirds) of the grants may be subtracted for board and lodging and other services. This limits their ability to take part in community activities. They often require assistance in spending their money judiciously in order to meet their personal needs.
14.3 DUAL DIAGNOSIS Although the term dual diagnosis can refer to any two psychiatric diagnoses occurring in the same patient at the same time, it is normally used to refer to schizophrenic patients who also have a problem with substance abuse. In the USA it is estimated that about 60 % of schizophrenic patients also have a substance abuse problem (Dixon, Haas, Weiden, Sweeney & Frances 1990). In the general psychiatric population 72 % of patients were found to abuse some substance, but only 46 % of these patients were identified as having a substance abuse problem by the psychiatric team (Ananth, Vandewater, Kamal, Brodsky, Gamal & Miller 1989). Dual diagnosis is therefore a common but underdiagnosed problem. There are five different ways of explaining why psychiatric patients are substance abusers. 1. Aetiological model This model states that the abuse of substances causes the mental breakdown. This model is substantiated by findings such as that the relative risk of schizophrenia is six times higher in high dagga consumers than in non-users (Anderson, Andreasson, Engstrom, Allebeck & Rydeberg, in Dixon et al. 1990). Aggregate data from a series of epidemiological studies have shown that schizophrenia occurs four times as frequently in alcoholics as in non-alcoholics (Drake 1990). 2. Dopamine dysfunction model This theory, which is largely theoretical and without direct factual evidence, postulates that the dopamine dysfunction which is involved in schizophrenia is also involved in substance abuse and therefore causes both conditions. 3. Socializing effects model In this model the idea is that the substance abuse helps isolated, socially inadequate people cope with a social group and helps them to socialize. The problem is that about
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50 % of substance-abusing patients report that they use dagga or alcohol when alone. This would argue against the socializing theory. 4. Self-medicating model There are many indications that substance-abusing schizophrenic patients treat problems like depression, negative symptoms and the extrapyramidal side effects of neuroleptic medication by taking alcohol or dagga. There is a significant consensus amongst drugabusing patients that self-medication is the reason for their substance abuse. 5. Independence model This model states that the reasons for substance abuse in psychiatric patients are similar to those in the general population and that the two conditions develop independently in the same person. The majority of reports in the literature indicate that substance abuse causes an acute worsening of the symptoms of schizophrenia, but in a minority of patients some calming effects were observed. Dagga would seem to cause more delusional and hallucinatory activity and heavy dagga use increases symptomatology generally. Alcohol increases assaultiveness, disruptive behaviour, poor self-care and homelessness. The treatment of schizophrenia is complicated by substance abuse since it increases hospitalization, overutilization and underutilization of services and non-compliance with prescribed drug treatment. Patients with dual diagnoses are difficult to treat for a whole range of reasons, for example: the problem of dual diagnosis is not recognized and the patient is treated for either the one or the other problem only; caregivers have negative and hopeless feelings about them; medication is either underused or overused for treatment. The following treatment guideline may be useful with this population of patients: A detailed, individualized assessment of current and past substance abuse should be made in all schizophrenic patients. If substance abuse is found, the patient should be placed in a treatment programme which addresses the co-morbidity and not just one aspect of it. It might be better for these patients to be handled in the psychiatric units of general hospitals where a combination of detoxification and psychiatric treatment is possible. Institutional treatment should be done in a safe, supportive environment, which is drug-free. Random urine or blood screening tests or breath analysers should be used routinely in the treatment programme. This is important to ensure that patients undergo treatment in a sober state and also to improve the staff's understanding of changes in behaviour. Treatment strategies from both psychiatric and substance-abuse specialities should be adapted to fit patients with a dual diagnosis. For example, while total abstinence might
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be a goal of an outpatient treatment programme, it cannot be a prerequisite for entering or remaining in the programme. Mentally ill abusers tend to relapse more often than non-abusers and may take longer to achieve abstinence. Early in the treatment process there should be enough structured activities to fill the void left by abstinence, but the patient should not be overstimulated, since this could exacerbate the psychiatric condition. Although dual diagnosis patients should be encouraged to take part in Alcoholics Anonymous (AA) activities, it should be recognized that participation could make them very uncomfortable due to their paranoid ideation or withdrawal, or other schizophrenic symptoms. In the same way constructive confrontation, which is the cornerstone of treating substance abusers, must be used carefully with patients who also suffer from schizophrenia. The stress of gentle confrontation may be all that they can stand. Psychoeducational strategies, which include teaching the patients both about the illnesses they have and their treatment, should form a large part of the treatment. Skill teaching is also important, since the lack of skills plays a role in both schizophrenia and substance abuse. Medication should be used with great care. Neuroleptics are essential to treat the schizophrenia, but the side effects and the 'snowed' effect of these medications may lead patients to self-medicate by means of alcohol or dagga. The lowest effective dose should therefore be used, so that negative side effects are limited as far as possible. Anti-Parkinsonism drugs can be very useful in treating these side effects, thus preventing self-medication, but they can be abused in their own right. It may be necessary to conduct careful individual clinical trials to establish whether a particular patient does better with or without these drugs. To prevent the discontinuation of neuroleptic drugs when the patient is on dagga or alcohol, it might be better to use depot-type administration. Depot neuroleptics are administered intramuscularly once a month, and this supplies a basic blood level that is not dependent on the patient's taking tablets regularly. However, it is more difficult to get precise clinical results with this method, so using a depot base with added oral neuroleptics is probably the best solution. These patients need long-term, comprehensive rehabilitation programmes in the community, in which there is understanding for the severity of the problems. Staff and patients alike need to set reachable goals and not become depressed at recurrent relapses. Since these patients probably form a large proportion of the patients with recurrent psychiatric hospitalizations, they deserve the attention of psychiatric nurses in order to deal with them effectively. CONCLUSION Nurses deliver scientific nursing care as members of the multidisciplinary team on an inpatient and outpatient basis to patients and their families.
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Sound knowledge of the causes of the disorders that hamper the functioning of psychotic patients, their consequences for the patients, the influence of the behaviour of patients on other people, nursing interventions, treatment possibilities by other team members and available facilities are the basis on which treatment in general should be planned and implemented. The aim of treatment is for patients to be able to function as independently as possible within their personal capabilities as members of families and of the community. WEB RESOURCES
www.psychguides.com This website provides expert treatment guidelines for psychiatric conditions. Most of these have been published in reputable professional journals as well. The treatment guideline for schizophrenia is available, and there is also a guide for patients and families. www.mentalhealth.com/book/p40-scO 1 .html This website provides information on different mental health topics. The specific area in this address refers to a book Schizophrenia: a handbook for families that can be accessed on this site. If you go to the home page of this site, you can also access the 'Transcultural Psychiatry Newsletter' www.nsfoundation.org This is the website of the Schizophrenia Foundation of the USA. It has very useful resources, especially the list of available videos. The site also leads you to the website of the Schizophrenia Anonymous at sanonymous.org/ - this organization invites consumers to join self-help groups based on the 6-step programme. www.docguide.com This is a commercial website. On the home page, go to 'Select a channel' at the top right of the page and select a topic. 'Schizophrenia' as a topic will lead you to very useful recent journal abstracts. REFERENCES American Psychiatric Association. 1987. Diagnostic and Statistical Manual of Mental Disorders, 3 ed (rev). Washington, DC: American Psychiatric Association Ananth, J, Vandewater, S, Kamal, M, Brodsky, A, Gamal, R & Miller, M. 1989. Missed diagnosis of substance abuse in psychiatric patients. Hospital and Community Psychiatry, 40(3), 297-299 Dixon, L, Haas, G, Weiden, P, Sweeney, J & Frances, A. 1990. Acute effects of drug abuse in schizophrenic patients: Clinical observations and patients' self-reports. Schizophrenia Bulletin, 16(1), 69-79 Drake, R E. 1990. Diagnosis of alcohol use disorders in schizophrenia. Schizophrenia Bulletin, 16(1), 57-67 Gillis, L S, Sandier, R, Jakoet, A & Elk, R. 1986. Admissions to a psychiatric hospital: South African Medical Journal, 70, 731-734
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Goering, P N, Wasylenki, O A, Farkas, M, Lancee, W J & Ballantyne, R. 1988. What difference does case management make? Hospital and Community Psychiatry, 39(3), 272-276 Golden, M & Bessant, A. 1985. Social withdrawal. Nursing 2nd Series, 1029-1032 Harding, C M, Brooks, G W, Ashikaga, T, Strauss, J S & Breier, A. 1987. The Vermont longitudinal study of persons with severe mental illness II: Long-term outcome of subjects who retrospectively met DSM III criteria for schizophrenia. American Journal of Psychiatry, 144(6), 727-735 Keith, S J. 1990. Schizophrenia: Public Perceptions, Private Reality. Keynote address: Sixth Rosalynn Carter Symposium McCandless-Glimcher, L, McKnight, S, Hamera, G, Smith, B L, Peterson, K A, Plumlee, A A. 1986. Use of symptoms by schizophrenics to monitor and regulate their illness. Hospital and Community Psychiatry, 37(9), 929-933 Prudo, R & Blum, H M.I987. Five-year outcome and prognosis in schizophrenia: A report from the London Field Research Centre of the International Pilot Study of Schizophrenia. British Journal of Psychiatry, 150, 345-354 Rumble S, Swartz, L, Parry, C & Zwarenstein M. 1996. Prevalence of psychiatric morbidity in the adult population of a rural South African village. Psychological Medicine, 26: 997-1007. Seeman, M V, Thornton, I F & Plummer, E. 1989. Schizophrenia: Returning Home. Richmond Hill: Merrell Dow Pharmaceuticals Teasdale, K. 1986. The withdrawn schizophrenic. Nursing Times, 5 Feb, 32-34 Test, M A. 1989. Substance use in young adults with schizophrenic disorders. Schizophrenic Bulletin, 15(3), 465-475 Townsend M C. ] 990. Nursing diagnoses in Psychiatric Nursing. Philadelphia: F A Davis Uys, L R, Dlamini, N K & Mabandla, A P. 1995. A profile of selected psychiatric out-patients in South Africa. Curationis, 18(1), 22-25
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FIFTEEN
Nursing the Patient with a Substance-related Disorder L R UYS 0 ADEJUMO
Objectives After studying the chapter the learner should be able to: Explain the following concepts while giving health education on substance related disorders: -
Abuse
-
Addiction
-
Substance dependence
-
Withdrawal
-
Intoxication
-
Detoxification
-
Alcoholism
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Acute alcohol poisoning
-
Alcohol withdrawal
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Normalization pressure
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Employer assistance programme.
Assess responses associated with the more common dependence-producing substances. Participate in the implementation of primary and secondary prevention of alcoholism. Do a complete assessment of a patient with alcohol withdrawal. Develop a plan of nursing care of a patient with alcohol withdrawal. Function as a member of the health team in the treatment and care of substance-dependent people. Give appropriate comprehensive education, instruction and counselling to alcoholics and their families about the disorder.
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INTRODUCTION Tobacco, alcohol and illicit drug use pose a significant threat to the health, social and economic fabric of families and all communities. People use a host of substances for various purposes; to celebrate achievements, to entertain guests, to restore health, to reduce pain, to reduce anxiety, to increase energy, to create a feeling of euphoria, to induce sleep, and to enhance alertness. Alcohol consumption is a feature of every community of today, including communities where alcohol use was formerly tabooed (WHO 2001). Based upon unofficial estimates of the United Nations Drug Control Programme (UNDCP), the annual global rate of illicit drug consumption is likely to be in the range of 3,3 to 4,1 % of the total population (WHO 2000). In a recent study amongst young people in the Northern Province of South Africa, Peltzer and Cherian (1999) found that the substances used were alcohol (38 %), tobacco (25 %), cannabis (12 %), amphetamines (10 %), tranquilizers or sedatives (8 %), sniffed or inhaled substances (8 %) and cocaine (7 %). According to the DSM-IV-TR (APA 2000) classification, substance-related disorders comprise two groups: the substance-use disorders (dependence and abuse) and substance-induced disorders (intoxication, withdrawal, delirium, dementia, amnesia, psychosis, mood disorder, anxiety disorder, sexual dysfunction, and sleep disorders). This chapter deals with four of the conditions which are specific to use or abuse of substances: dependence, abuse, intoxication and withdrawal (other conditions are dealt with elsewhere in this book). Commonly used substances A wide variety of substances are available legally and illegally. The substances can be administered by any means or by any route into the body, bringing about impairment of mood, altered level of perception and impairment of brain function. Those in common use and associated street names are summarized in Table 15.1
Table
15.1 Classification of the more common substances in use
Substance
Legal status
Amphetamines
Street name Uppers, speed
Dexedrine
Prohibited
Dexies
Benzedrine
Prohibited
Bennies
Drynamil
Prohibited
Purple hearts
Appetite suppressors Obex
Prescription, schedule 7
O's, obies, yellows
Nobese
Over the counter
Nobies
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Substance
Legal status
Street name
Appetite suppressors (continued) Redupon Minobese Cocaine Ephedrine Adrenaline Nicotine Alcohol
Over the counter Prescription, schedule 5 Coca leaves and cocaine powder, prohibited Scheduled for use in local anaesthetics Over the counter Prescription, schedule 4 Freely available Available to individuals over 18 years
Coke, snow, crack Uppers
Speed Ciggies, snuff, loose Juice, dop, booze, spirits
Narcotics (a) Non-synthetic Opium Heroin Morphine Codeine (b) Synthetic Pethidine Wellconal Physeptone (Methadone)
Prohibited substance Prohibited substance Prescription, schedule 7 Over the counter
O's, oupa Berries, horse Morph, Miss Emma
Prescription, schedule 7 Prescription, schedule 7 Prescription, schedule 7
Petts Pinks, welkies
Prescription, schedule 6 Prescription, schedule 6
Red devils, sleepers, candy
Hypnotics (a) Barbiturates Seconal Vesperax
(b) Non-barbiturates Prohibited in South Africa Mandrax
Vees Mandies, buttons, originals, whites
Sedatives Diazepam Oxazepam Lorazepam, etc.
Prescription, schedule 5
Painkillers (non-narcotics) AP Codis Prescription, over the counter Paracetamol Beserol Syndol Grandpa powders, etc.
Tronks
Downers
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Substance
Legal status
Street name
Inhalants (Industrial and household substances) Benzine
Found in freely available commercial product Commercial products
Petrol Glue Turpentine, etc.
Sniff
Thinners
Anaesthetics Nitrous oxide
Used as anaesthetic in surgery
Laughing gas Thinners
Prohibited
Joint, grass, zol, 'boom', weed, pipe, dope, ganja
Prohibited
Add, California sunshine,
Ether, etc.
Hallucinogens Dagga (cannabis, marijuana) LSD
(lysergic acid,
smarties, black panther,
diethyiamide)
white lightning
Phencyclidine
Scheduled for veterinary use only
Angel dust, PCP, peace pill
Prohibited
Ecstacy
(PCP) Methylene dioxymethamphetamine (MDMA)
Substance dependence This occurs when a substance becomes an integral part of an individual's life and it is becoming increasingly difficult for the individual to do without it. Dependence on a substance may be physical or psychological or both. The development of physical dependence is evidenced by the phenomenon of tolerance and individual's need to continue the use of the substance in order to prevent unpleasant effects characteristic of the withdrawal syndrome associated with that particular substance (Bratter & Forrest 1985). Psychological dependence, on the other hand, occurs when the use of a substance is perceived by the user to be necessary to maintain optimal state of personal well-being, interpersonal relations, or skill performance (Bratter & Forrest 1985).
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DSM IV-TR diagnostic criteria: Substance dependence
A maladaptive pattern of substance use evidenced by three or more of the following occurring in the same 12-month period. Usually leads to a clinically significant impairment or distress. 1. Tolerance, as shown by either of the following: (a) A need for obviously increased amounts of the substance to achieve intoxication or the wanted effect. (b) Obviously decreased effect with on-going use of the same amount of the substance. 2. Withdrawal, as shown by either of the following: (a) The characteristic withdrawal syndrome for the substance. (b) The same (or similar) substance is taken to relieve or avoid withdrawal symptoms. 3. The substance is often taken in bigger amounts or over longer periods than was intended. 4. There is a history of persistent wish or unsuccessful effort to reduce or control the use of the substance. 5. A great deal of time is spent in activities necessary to get, use or to recover from the substance and its effects. 6. Important social, occupational or recreational activities are given up or reduced because of substance use. 7. The substance use is continued despite knowledge of having persistent or recurrent physical or psychological problems related to the use. (APA 2000) The following factors may be present in a substance-dependent person: Emotional stress associated with a feeling of wretchedness and helplessness experienced as anxiety, tension, depression, loneliness, boredom; Inability to express intense feelings of rage in a socially acceptable manner - substances offer a measure of control and lessen the patient's anger (Duncan 1965: 25); Inability to resolve conflict - substances provide short-term relief from the associated discomfort; Feelings of happiness and satisfaction, resulting in improved social interaction; Distortion of perception and sensation (especially with regard to space and time). The degree of distortion depends on the strength of the substance dosage. Larger doses give rise to the following aberrations: Impaired judgement or memory; Distortion of emotional responses; Irritation and confusion. The following phenomena are associated with chronic use: Lowering of sensory thresholds, especially to optic and acoustic stimuli, resulting in more intense appreciation of art and music;
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Hallucinations, illusions and delusions, usually of the paranoid type, presenting with aggression, antisocial behaviour, anxiety and sleep pattern disturbances; Fragmentation of thoughts; Euphoria; Enhanced self-confidence; Anxiety bordering on panic. There is a relationship between substance dependence and a number of sociodemographic and psychological variables. Substances are taken to escape from personal and psychological problems, and conformation to social values and norms is resisted. This leads to reduced involvement in conventional activities. It would seem that substance-dependent individuals try, because of their distrust in expectations of the future, to prevent potentially stressful situations in community, love and job circumstances. These people avoid problem situations and acceptance of responsibility, with the result that they experience intense social maladjustment. This in turn impedes social initiative and involvement even more. Substance abuse In this case the person shows a maladaptive pattern of substance use resulting in a clinically significant impairment or distress within a period of 12 months, as manifested by one or more of the following: 1. Failure to fulfil major role obligations at work, school or home. 2. Recurrent substance-related legal problems, for example, arrests for substance-related disorders, or possession of illegal substances. 3. Substance use in situations which are physically hazardous, for example, drinking and driving. 4. Recurrent social or interpersonal problems, for example, arguments and physical fights as consequences of intoxication. However, the condition does not include the development of tolerance to the substance, withdrawal or compulsive use. Table 15.2 indicates the conditions associated with substances in DSM-IV-TR (APA 2000). Substance intoxication This is a reversible and substance-specific syndrome which follows recent ingestion of (or exposure to) the substance. It may cause severe maladaptive behaviour or psychological changes that result from the effect of the substance on the Central Nervous System (CNS), for example, belligerence, mood swing, cognitive impairment and impairment of occupational functioning.
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Table 15.2 Diagnoses associated with class of substances (• indicates that the category is recognized in DSM-IV-TR)
Dependence
Abuse
Intoxication
Withdrawal
Alcohol Amphetamines Caffeine Cannabis Cocaine Hallucinogens Inhalants Nicotine Opioid Phencydidine Sedatives, hypnotics or anxiolytics Polysubstance Others (American Psychiatric Association 2000)
Substance withdrawal This is also a substance-specific syndrome following the cessation or reduction of ingestion after heavy and prolonged use. It may cause significant distress or impairment. Please note that different substances may produce similar or identical syndromes. Possible nursing diagnoses Potential for injury RELATED TO intoxication or withdrawal EVIDENCED BY disorientation, poor judgement, unstable vital signs, seizures, etc. Potential for self-directed or other-directed violence RELATED TO intoxication, withdrawal, depression EVIDENCED BY history of suicide attempts or violence, anger, disturbed behaviour. Alternation in nutrition: less than body requirements RELATED TO drinking instead of eating, poor appetite, no money for food, malabsorption of food EVIDENCED BY loss of weight, pale mucous membranes. Ineffective individual coping RELATED TO inadequate support systems, unrealistic perceptions, poor social learning EVIDENCED BY low self-esteem, inability to meet role expectations, inability to meet basic needs.
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Knowledge deficit (re effects of substance abuse) RELATED TO lack of exposure to learning, lack of interest in learning EVIDENCED BY statements of misconceptions, requests for information, verbalization of this problem. (Townsend 1990:77-88) 15.1
ALCOHOL-RELATED DISORDERS
The global status report on alcohol (WHO 2001) indicates that while alcohol consumption is declining in most of the developed countries, it is found to be rising in many of the developing countries and the countries of Central and Eastern Europe. Production of various forms of alcohol for domestic consumption is widespread and decentralized in many countries increasing the incidence of alcoholism (or alcohol dependence, chronic alcoholism or problem drinking) in many developing countries. This trend has serious consequences for alcoholics, their families and the community. There is sufficient evidence to indicate that alcohol poses significant threat to the health of the millions of users across the globe. Among alcoholics the death rate is two to four times higher than among the general public. In a 1992 hospital study in South Africa, 57 % of the patients presenting with burns showed signs of alcohol dependence, while alcohol was present in 62,9 % of homicide victims (WHO 2001:101). In the United States of America, 50 % of all road accident deaths are the result of alcohol usage and, in four Western countries, 10 % to 15 % of hospitalized patients suffer from alcohol-related disorders and more than 40 % of the health budget is spent on these disorders (WHO 1990). Suicide attempts are also common among alcoholics: 25 % to 40 % of male and 3 % to 12 % of female alcoholics have attempted suicide (Glatt 1972: 87). According to Parry and Bennets (1998), alcohol related problems are very common in South Africa, especially in men, young people of all races, workers in specific occupations and inhabitants of peri-urban townships and informal settlements. The occupations especially hard hit is migrant mine workers (over 40 %) and male farm workers in the Western Cape (over 65 %). In general the rate of high-risk drinking in women is 5 % to 17 %, while in men in the high-risk areas it is 25 % to 30 %. The majority of alcohol consumed is in the form of beer. The impact of high-risk drinking behaviour on South African society is immense. The same authors estimate that 7 % of drivers and 13 % of pedestrians in a random survey had alcohol levels of greater than 0,08 g/ml, which is the legal limit for driving. Between 25 % and 50% of medical-surgical patients in general hospitals abuse or depend on alcohol, and between 50 % and 60 % of psychiatric inpatients have an alcohol problem (De Miranda & Wilson 2001). The high prevalence of alcohol problems in South Africa is related to a large number of societal factors. The colonial and apartheid history with its manipulation of social interaction, social structures and access to alcohol played a role. So did the 'dop' system of compensation with alcohol for farm workers in the Western Cape, and rapid urbanization and industrialization.
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DSM-IV-TR classification: Alcohol-related disorders Intoxication: Symptoms following recent indulgence of alcohol, such as disinhibition, impaired judgement, slurred speech, incoordination, unsteady gait, flushed face. Uncomplicated alcohol withdrawal: Symptoms following cessation of prolonged drinking, such as tremors, nausea or vomiting, malaise or weakness, autonomic hyperactivity, anxiety, transient hallucinations or illusions, irritability. Alcohol withdrawal delirium: Delirium complicating withdrawal from alcohol. Alcohol withdrawal with perceptual disturbances: Vivid persistent hallucinations developing shortly after cessation of or reduction in heavy alcohol intake, without delirium. Alcohol-induced persistent amnesic disorder: Demonstrable evidence of impairment in both short-term and long-term memory following prolonged, heavy ingestion of alcohol. Alcohol-induced persistent dementia: Dementia following prolonged, heavy ingestion of alcohol and persisting for at least three weeks after cessation of alcohol ingestion. (American Psychiatric Association 2000) vSimilar conditions exist for other substances. Alcohol dependence There are as many definitions of alcoholism as there are writers on the subject. The Expert Committee on Mental Health of the WHO defines alcoholics as excessive drinkers whose dependence on alcohol has reached such proportions that it is evident in psychological aberrations or interferes with their physical and mental health, interpersonal relationships and smooth social and economic functioning. 'Excessive' drinking means the consumption of more than 150 ml whisky, 937 ml wine or 3 000 ml beer per day (WHO 1990). Forrest (1975) identifies four essential features of alcoholics: They drink compulsively and therefore without restraint. They have usually been drinking for a long time (chronically). They drink until they are intoxicated. Their drinking pattern has, without exception, a negative influence on their interpersonal functioning. Two disorders that are part of the course of alcoholism are acute alcohol poisoning (intoxication) and the alcohol withdrawal syndrome (known as delirium tremens or DTs in its acute form). Nurses must be able not only to identify alcoholics but also to notice signs of poisoning or the withdrawal syndrome. Jellinek has set out the general steps in the development of an alcoholic as follows (Mueller 1974): Pre-alcoholic phase. Episodic and later constant drinking in response to stress. Alcohol tolerance increases.
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Prodromal (Early Alcoholic) phase. Blackouts, secret drinking and a preoccupation with alcohol. Drinks are swallowed rapidly; the person has guilt feelings about drinking and refuses to discuss the problem. Crucial phase. Loss of control over drinking ('one drink is too many and a bottle is not enough'). The behaviour is rationalized; paranoid and aggressive behaviour is evinced and the person is always remorseful. Repeated attempts are made to control drinking and more and more problems are experienced with the family and employer. Self-pity becomes evident and interest in other things, including food, begins to diminish. The person becomes unreasonably vengeful, jealously protective of liquor, suffers from tremors and begins to take a 'pick-me-up' in the morning. Chronic phase. The individual is in a protracted state of poisoning and deteriorates physically and morally. Thought is impaired, and the person suffers from indefinable anxiety and is obsessed with alcohol. Prevention Primary prevention There are a number of approaches to primary prevention, which Kissin and Begleiter (1976) summarize as follows: Normative manipulation The percentage of alcoholics is low in societies that denounce moderate drinking, condemn excessive drinking and in which there is broad agreement on these norms; the norms may therefore be encouraged in a particular society to prevent alcoholism. Plant stresses that there should be definite criteria for what is considered to be 'excessive' drinking and suggests that four episodes of intoxication per year should be considered a criterion of excessive drinking (Kissin & Begleiter 1976: 522). Integrated drinking Integrated drinking means that the consumption of alcohol in the community is subordinated to other activities, especially family, religious and recreation activities, rather than an organizing principle of social activity. In country and groups with few alcohol problems, the consumption of liquor may be commonplace but it is merely one aspect of a more important activity. In Italy, for example, liquor is a necessary part of meals and Jewish people drink liquor as part of their religious observance. The French, on the other hand, structure social events around the intake of alcohol, which results in a higher incidence of alcoholism. As part of primary prevention, the consumption of alcohol should be encouraged in situations of restraint, that is, where it is restricted by coincidental activities. Level of mental health and social conditions Apart from the specific approaches mentioned above, there are also indirect measures, that
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is, anything aimed at enhancing the general level of mental health and improving social conditions. These include measures such as enhancing the quality of family life, helping people to cope more effectively with crises and alleviating poverty and deprivation. Price control and distribution Various authors have proved indisputably that the lower the price of liquor, the higher the average intake per person and the greater the proportionate increase in the number of deaths from cirrhosis of the liver (see Figure 15.1). This gave rise to the idea that increasing the price of liquor would prevent alcoholism. However, many authors believe that this would mean only that moderate or social drinkers would drink less, while alcoholics would drink as much as before. Others believe that price increases would lead only to the large-scale production of illicit liquor, since prices would have to be almost trebled to make a significant difference to the consumption of alcohol. It would seem therefore that price control on its own would create new problems, as was the case during prohibition in the United States in the 1920s. Evidence-based practice Primary prevention for alcohol misuse in young people Main findings:
Twenty of the 56 studies included showed evidence of ineffectiveness. No firm conclusions about the effectiveness of prevention interventions in the short-term and medium-term were possible. Over the longer-term, the Strengthening Families Program (SFP) showed promise as an effective prevention intervention. The Number Needed to Treat (NNT) for the SFP over four years for three alcohol initiation behaviours (alcohol use, alcohol use without permission and first drunkenness) was nine (for all three behaviours). One study also highlighted the potential value of culturally focused skills training over the longer-term (NNT=17 over 3 1 /2 years for 4+ drinks in the last week). Reviewers' conclusions: 1. Research into important outcome variables needs to be undertaken. 2. Methodology of evaluations needs to be improved. 3. The Strengthening Families Programme (SFP) needs to be evaluated on a larger scale and in different settings. 4. Culturally-focused interventions require further development and rigorous evaluation. 5. An international register of alcohol and drug misuse prevention interventions should be established and criteria agreed for rating prevention intervention in terms of safety, efficacy and effectiveness. Foxcroft D R, Ireland D, Lister-Sharp D J, Lowe, G & Breen R. Primary prevention for alcohol misuse in young people (Cochrane Review). In The Cochrane Library, Issue 2, 2003. Oxford: Update Software.
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Figure 15,1 Alcohol consumption, the relative price of liquor and deaths from liver cirrhosis in the province of Ontario, Canada, 1928-1967 (WHO 1975: 150)
During the First World War the sale of liquor in the United Kingdom was limited to between 1 IhOO and 15hOO and again from 17h30 to 22h30. This led to a dramatic decrease in arrests for drunkenness and deaths from liver cirrhosis. The exact cause of these decreases is not clear, but the control of sales could definitely be viewed as a measure of primary prevention. Much has already been done to implement the above approaches, but in many cases the results have been evaluated poorly or not at all. The methods used include the following: Total population education In the United States, large programmes have been launched, particularly against drunken driving, with a singular lack of results. Although the public remembered the slogan ('If you drink, don't drive; if you drive, don't drink'), this had no influence on the target behaviour (Kissin & Begleiter 1976: 538). Some governments have tried to encourage the drinking of beer and wine, also without success. Some authors suggest that liquor advertisements be prohibited, since they stress themes such as sex, power and social mobility instead of integrated drinking. The WHO points out that, although advertisements make liquor more socially acceptable, people drink even when there are no advertisements. Cigarette advertisements have been banned in the United Kingdom, but this has made no noticeable difference to the prevalence of smoking.
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Milestone education In this context the milestone approach means preparing children for their first drink. Although studies show that parents have the greatest influence on the alcohol consumption of their children, peer groups and the school as a socializing institution can be used for education in this regard. High-school children were first used as a target group, but it gradually became clear that teaching should begin earlier. An epidemiological study in the United States showed that 50 % of all Grade 10 pupils drink while driving or as passengers in cars (Bragg 1976: 11). It has also been found that children have already mastered the concept of alcohol and know the smell and behavioural manifestations of inebriation by the age of eight years. It is generally accepted that small-group discussions constitute the best teaching method (Williams, as cited by Kissin & Begleiter 1976: 556). It is probably better for someone other than teachers to do this teaching - not only because they have no knowledge of group methods but also because children who will probably develop an alcohol problem usually have a poor relationship with their teachers. Educating groups at risk The only significant group at risk in the primary prevention context is the children of alcoholic parents. In this case, the teaching method also constitutes small-group discussions and ages vary from primary to high school. Secondary prevention Only one aspect of secondary prevention is discussed here, and that is early detection. Treatment is discussed separately. The early detection and treatment of alcoholics is very difficult because they use denial as a defence mechanism, and the fact that they are alcoholics cannot be 'proved' to them. Identification of alcoholics at an early stage Alcoholism develops slowly and alcoholics themselves cope with it by means of denial. The people close to them, for example, a spouse, friends, colleagues and supervisors, go through various stages of recognizing the problem. First stage Supervisors are vaguely aware of impaired performance but do not regard it as serious enough to be regarded as abnormal. Employees make sure that their abnormal behaviour is integrated in their work behaviour. The spouse and friends are vaguely concerned. Signs: Light hand tremors; More nervous and tense; Hangovers at work; Avoidance of supervisor and co-workers;
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Drinking in the mornings before going to work; Leaving their post every now and again; Unusual excuses for absence from work; Displaying deteriorating quality of work; Mood changes after lunch; Bloodshot eyes. Second stage This is the stage of 'blocked consciousness'. The supervisor becomes increasingly aware that the problem behaviour is associated with alcohol, but is prevented by various factors from designating it as abnormal, for example, the status of the employee or the consequences that confrontation might hold for the supervisor. The spouse is aware of the problem, but hides it for the sake of appearances, the children or holding down a job. Signs: Displaying increasing absenteeism and poor quality of work; Can no longer conceal hangovers; Sporadic work performance with 'good days' having to compensate for 'bad days'; Aggressiveness during bouts of intoxication. Third stage This is the 'see-saw' stage during which supervisors are increasingly forced to describe the deviant behaviour as abnormal, while the blocking factors ('when he works he does a fantastic job') time and again affect the decision to act. The spouse threatens to leave but the alcoholics are 'always so penitent when sober'. Signs: Drinking at lunch; Marked personality change after lunch; Speaking loudly; Hands tremble obviously; More supervision required due to unpredictable work behaviour; Negative influence on work group; Children evince problems; Spouse is despondent and often depressed. Fourth stage The supervisor decides to acknowledge the problem. The pressure of the deviant behaviour causes alienation from co-workers and they lose their empathy. The family often breaks up.
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Signs: Drinking while on duty; More frequent absences due to physical disorders; Flushed face and bloodshot eyes. There is often a strong tendency in the work situation not to do anything about the problem. This is known as normalization pressure and consists of the following: The tendency to maintain the homeostasis of the group. The identification of a group member as a deviant draws attention away from the purpose of the group and necessitates all kinds of activities the group would rather avoid: 'We are here to work. Leave him alone.' The value of poor workers insofar as they make other workers appear better. The absence and poor performance of alcoholics make them the worst workers in the group, which means that the rest can all compare themselves favourably. Poor workers serving as scapegoats. The deviant member gives the group an excuse for any failing that may exist, which is acceptable both to them and to outsiders. The fear of boomerang labelling. Group members may be afraid that if they label alcoholics as deviants, they may be pointing out their weak points or may be branded 'persecutors'. The fear of being held accountable for the problem. Group members may, for various reasons, fear that they will be held accountable for the development of the problem if they point it out as a problem. There is a risk that the alcoholic may play the game of 'look what you have made me do'. The exploitation of affected workers. As previously described, co-workers may give alcoholics enough rope to hang themselves if they compete with them for scarce rewards. A dubious definition of the problem. Even professionals differ in their views of what constitutes a drinking problem and what does not. Employers often have a stereotyped idea that alcoholics are unkempt tramps and indignantly deny that they have any alcoholics in their service. Strong norms regarding privacy. There is a strong set of norms in our society that stresses individualism, privacy and non-interference in the business of others. The drinking problem is consequently viewed as the alcoholic's own business, which may not be mentioned or discussed. Therapeutic treatment in a general hospital Many alcoholics come into contact with the general health service without anything being done about their basic problem - alcoholism. The following recommendations could be incorporated into nursing interventions:
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Talk to these patients about their drinking problem Heinemann and Estes (1976) identified the following responses as being characteristic of such patients: 'There's been a period of four years now that I haven't known what was wrong with me. If they had told me it (seizures and blackouts) was due to alcohol, it would have relieved my mind so much.' 'I believe both doctors and nurses could have stressed alcoholism while I was in the hospital. But they don't do it. They more or less concentrate on your ailments other than your alcoholism' (Heinemann & Estes 1976: 36). Heinemann and Estes suggest that nurses should tell patients that they are glad that their physical condition is improving, but that they think they should talk about their drinking problem. If patients are not willing to talk about it, their decision should be respected, but an opportunity should be sought later to raise the subject again. If patients are willing to talk about it, they should be asked to describe it from their point of view. Do they think it is a problem or is it a solution to their problem? It should be ascertained whether there is any aspect of the problem that worries them and this should be used as a therapeutic starting point. During conversations the danger signs of alcoholism should be mentioned, for example, more than four episodes of intoxication per year, drinking alone, the need for a 'pick-me-up', drinking more than one's friends, the need for liquor to cope with stress, and drinking more than one wants to drink. Hearing about these signs can sow doubt and undermine denial. The physical aspects of alcoholism should be stressed, for example, by comparing them with those of diabetes. This emphasizes both the reality of the disease and the necessity for treatment. It should be explained that the compulsion usually develops slowly, with the result that one does not become aware of it until the condition is far advanced. The difficulty of accepting the possibility that one is an alcoholic should be spoken about frankly. Such constructive confrontation should take place after a solid relationship has been built up with the patient. Denial should be counteracted, but preferably without using the words 'alcoholic' and 'addiction', as these may be unacceptable. Respect for the patient should always be conveyed, but at the same time it should be clearly indicated that alcoholism is regarded as a serious disease that will not go away by being ignored. Help patients to plan a constructive programme to obtain assistance Alcoholics should be helped to plan a constructive programme for obtaining assistance and they also require assistance with the implementation of the first steps to set it in motion. No two patients are alike. Alcoholics Anonymous may be the appropriate (and acceptable) recourse for one, a rehabilitation centre for a second, while the best choice for a third may be a psychologist or a psychiatrist. Nurses should be able to give their
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patients hope, as alcoholics often have a long history of failure. They should not, however, oversimplify the rehabilitation process, as this could foster the idea that they really do not understand. They should give realistic information about the various treatment programmes and should help their patients with their first steps in that direction. Medication guidelines When a patient arrives at a clinic in a state of substance or alcohol intoxication or delirium, it might be necessary to control the disturbed behaviour with medication. Give the patient a stat dose of diazepam 10 mg IM. This can be repeated after 30 minutes if the response is inadequate. If the patient is not too difficult, and is willing to take oral medication, 10 mg oral diazepam can be given. When a diagnosis of alcohol dependence is made and the patient wishes to be detoxified, this can be done on an outpatient basis if there is adequate family support. This may, however, not be feasible in cases of severe dependence over a very long time, or where return to the clinic or hospital in case of complications is not possible or too difficult. Also, if there is a history of delirium tremens or convulsions, the patient should be admitted for detoxification. If home detoxification is undertaken, the family should be told to make the patient take lots of fluid (3 I per day or more), and to bring the patient back if he/she has convulsions or becomes delirious. The patient usually presents in a state of sympathetic nervous system hyperarousal, with a rapid pulse, tremors, nausea, sweating and a raised blood pressure. Prescribe: Vitamin B complex, and diazepam 10 mg twice a day. The role of nurses in treatment Approach to patients Nurses who work with alcoholics should realize that feelings of superiority and domination have no place in the care of these patients. Alcoholics already have very poor self-esteem and the attitude of their nurses can make a major contribution to their regaining their self-respect. In a study of alcoholics in American prisons, Chavigny found that something as simple as being addressed as Mr So-and-so by only one member of the staff over a period of four months resulted in a significant change in the behaviour of 95 % of the respondents (Chavigny 1976: 638-639). Care should nevertheless be taken not to be overly sympathetic or accepting, thereby bolstering the pathology. In this regard it would be useful to know, recognize and manage the three games that alcoholics play. These games were identified by Steiner (1971) and are based on the transactional analysis theme: T'm no good, you're okay (ha ha).' In all three games, alcoholics place themselves in a position in which their behaviour is obviously
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objectionable and allow those who disapprove to appear innocent and virtuous. A close look at the situation reveals that it is structured in such a way that the others are not as innocent as they appear and that they appear stupid and foolish as well. 'You're okay (ha ha)' therefore actually means 'You're not okay.' Drunk and proud (D and P) Theme: 'You re good, I'm bad (try and stop me).' Alcoholics who play this game do anything while they are drunk and apologize very remorsefully afterwards. Virtuous people can then either forgive them (and be seen to be playing the role of Patsy) or reject the apologies (and be seen to be playing the role of Persecutor, since the 'poor' alcoholics are so sorry). Alcoholics can laugh at those who play Patsy because they are so foolish. They can also laugh at those who play Persecutor because they are so hateful and hard and not at all virtuous. D-and-P players seldom drink at home and their work seldom suffers. They are inclined to play the same game with the staff when they receive therapy. This game should be explained to all patients and staff. If patients should try to use it, nurses only have to say: 'My name is not Patsy' or something similar. They have found that patients immediately know what the nurses are talking about and that manipulative behaviour decreases significantly. Lush Theme: 'I'm crazy (depressed), you can make me better (cure me) (ha ha).' This game arises from sexual deprivation and is played mainly by middle-aged married, suburban housewives or by downtrodden, hard-working, white-collar employees. It is played with partners who are unable or find it very difficult to give strokes (positive regard). The patients' intoxication serves as an excuse for the partners' inadequacies while the partners act as Persecutor. Because of their guilt feelings, the partners easily change to the role of Rescuer. The players are usually alcoholics and their spouses (Persecutor or Rescuer) and a professional (Rescuer or Patsy). Lush players are basically making a plea for strokes but, since they cannot obtain them under ordinary circumstances, are satisfied with the strokes they receive when they are rescued. They usually drink at home. A short summary of this game is: Alcoholic:
I can't control my drinking.
Partner:
I'll try and help you to control yourself. (Rescuer) You're lying. (Persecutor) I know what you mean. Have another drink. (Patsy)
Nurses can avoid the role of Persecutor by strictly limiting interactions with these patients by referring them to therapeutic facilities. They can avoid the Patsy role by remaining sceptical about the verbal declarations of alcoholics, which are refuted by evidence, for instance: 'I'll never drink again.'
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Wino Theme: 7'ra sick (try to prevent it), you're well (ha ha).' Wino players have a self-destructive life script, and the game continues until they have destroyed themselves. They obtain strokes by making themselves physically ill. In these circumstances other people, known as Connections, assist them, even if this means sending them to prison. Connections do not really forgive alcoholics, but neither do they persecute them - they merely see to it that they obtain security. Because alcoholics argue that it is wrong for them to receive assistance only when they are dangerously ill, they really regard Connections as guilty and therefore not okay, hence the 'ha ha'. Connections are not people who are close to alcoholics; they are policemen, the staff of the emergency department or the soup kitchen of the Salvation Army. In order to avoid the role of Connection, assistance in the form of medication and food should be given with discretion, without too much sympathy being shown. The game can be interrupted if the alcoholic is in an institution where basic physical essentials are provided and there is a desire to stop drinking. Assessment of alcoholics
A nursing history can be taken in one or more sessions, depending on the patient's condition. If the problem is understood and accepted to be an alcohol-related one, the drinking history can be taken as a starting point, but if it is not acknowledged, the history must begin with related problems. Heinemann and Estes (1976: 787-788) constructed and tested the nursing history form set out below. The questions with asterisks refer to emergencies and threatened withdrawal syndrome.
Nursing history form for patients with alcohol problems Demographic data Date: Place of interview: Patient's name: Ethnic group: Age: Sex: Place of birth: Occupation: Education level: 1.
Why did you come to this institution/organization?
2.
In what way would you most like to be helped right now?
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Drinking history 3. How old were you when you began drinking alcohol regularly? 4. How long have you had problems with alcohol? 5. How often do you drink alcoholic beverages? 6. What types of liquor do you drink? 7. How much of each alcoholic beverage do you drink? 8. When did you have your last drink?* 9. When did your last drinking bout begin?* 10. What did you drink during your last drinking bout?* 11. How much alcohol did you consume each day during your last drinking bout?* 12. Has your drinking caused problems in any of the following areas? With your spouse At work With your children With your friends 13. Have you ever been injured as a result of drinking? Yes No Fighting Road accident Accidental falls Other reasons 14. Have you ever been arrested as a result of drinking? Yes No On what charge? Driving under the influence Fighting Other (specify) 15. Have you ever been in prison as a result of drinking? Yes No 16. What previous treatment have you had for alcohol problems?
Date Place Symptoms relating to the gastrointestinal system 17. What did you eat during your last drinking bout?* 18. What is your normal eating pattern: When drinking?
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19. 20. 21. 22.
23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. 34. 35. 36.
37. 38. 39. 40. 41. 42.
When not drinking? Have there been recent changes in your appetite? Has your weight changed recently? Are you on a special diet? What fluids, other than alcohol, do you drink? Coffee Tea Water Milk Fruit juice Do you often have mouth or throat irritations? Do you have stomach ache? Are you bothered by heartburn or flatulence?* Are you nauseous?* Do you vomit or gag without bringing up anything?* Have you ever vomited blood? If so, when?* Have you ever had gastric ulcers or other stomach problems? How often and for what reason do you take aspirin? What medication do you take for stomach ache? Do you suffer from pain in your abdomen? Do you suffer from diarrhoea or constipation? Do you have piles? Have you ever had blood in your stools? Have you noticed a change of colour in your stools? Clay-coloured Black Bright red What problems have you experienced in the past with your bowels? What medication do you take for abdominal pain? Have you ever had pancreatic problems?* Has your skin or the whites of your eyes ever turned yellow?* Have you ever had problems with your liver?* Do you have diabetes? If so, what medication do you take?
Symptoms relating to the neurological system 43. Have you noticed how much more alcohol it takes to obtain the effect you desire? If so, describe the change. 44. What reactions do you have when you stop drinking? Tremors Hear or see things
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45. 46. 47. 48. 49. 50. 51. 52.
53. 54. 55.
Other convulsions DTs Have you ever taken medication for the convulsions? Have you ever had periods of loss of memory after a drinking bout? Have you ever experienced tingling, pain or numbness in your hands or feet? Do you ever have muscle pains in your arms or legs? Do you have any trouble keeping your balance? Do you have any problems with your vision?* Do you have problems with sleeping? How many hours a night do you usually sleep? When you drink When you don't drink Do you feel rested after a night's sleep? What do you do if you are unable to sleep? Have you noticed any change recently in your sex life? If so, describe the change.
Symptoms relating to the cardiovascular and pulmonary systems 56. Do you have heart trouble? If so, describe the trouble. 57. Do your hands and feet swell? 58. Are you often short of breath? 59. Do you have chest pains? 60. Do you take any medicine for heart disease? 61. Have you ever had pneumonia? 62. Have you ever had tuberculosis (consumption)? 63.NDo you often get infections (for instance, colds, boils or sores that do not heal easily)? 64. Do you have a persistent (chronic) cough? If so, describe the cough. 65. Have you ever coughed up blood or phlegm? 66. Describe any other lung problems that you might have. 67. Do you smoke? If so, how many a day? Psychosocial status 68. What is your marital status? 69. With whom do you live? 70. Does this person use alcohol regularly? Yes No 71. To whom do you feel closest? 72. Do your neighbours, family and/or friends use alcohol regularly? Yes No
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73. How many children do you have? 74. How often do you see your children? 75. Describe your home: Type (for example, house, flat or room) Cooking facilities Number of stairs Availability and type of transport 76. Have you ever had mental or emotional problems? Depression Suicide attempts Loneliness Nervousness (anxiety) Other 77. Are you currently involved in a counselling programme? 78. Are you currently taking medication for a psychiatric problem? If so, describe the medication. 79. Are you affiliated to a religious group? 80. What is your present employment status? 81. Do you have any specific occupational skills? 82. If you have a job, how does this period of treatment affect it? 83. If you are unemployed, what is your present source of income? 84. What are your hobbies or special interests? 85. How do you spend a typical day at home? Drug-taking 86. What medication do you take that you have not yet mentioned? Prescribed drugs Over-the-counter drugs Drugs obtained on the street 87. What is your usual manner of taking medication? As prescribed More than prescribed Less than prescribed 88. Are you allergic to any medication?* Final questions 89. How do you plan to control your drinking when you are discharged? 90. Would you like to make any further remarks? 91. Would you like to ask any questions? (* Refers to emergencies and threatened withdrawal syndrome)
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This interview schedule includes the most important problem areas of alcoholics, that is, drinking habits, symptoms of damage-prone systems and psychosocial status. Alcoholics often give less than accurate histories, especially about their drinking, so it is useful to confirm this aspect by interviewing family or friends. Patients may also be examined for signs of physical damage. The CAGE Questionnaire A very simple tool that can be used to screen for alcoholism is the CAGE questionnaire. Mersy (2003) observed that CAGE questionnaire performs well as screening tool for substance abuse. It consists of four questions from which the acronym C A G E is extracted. The questions focus on Cutting down, Annoyance by criticism, Guilty feeling, and Eye-openers. Have you ever felt you ought to Cut down on your drinking? Have people Annoyed you by criticizing your drinking? Have you ever felt Guilty about your drinking? Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover (Eye-opener)? Scoring: Two 'yes' answers indicate probable alcoholism (Ewing, 1984:1905) A fairly accurate history of drinking is important, as it enables the nurse to anticipate the nature and degree of withdrawal symptoms and to evaluate the chronicity of the alcoholism. All the other questions relate to specific complications of alcoholism. It has been found, for instance, that alcohol prevents the type of sleep that is necessary for rest that is REM (rapid eye movement) sleep. REM sleep deprivation results in poor concentration and memory, and causes anxiety, fatigue and irritability. Information about these aspects is consequently necessary, not only for planning nursing interventions but also for planning patient education. Enquiry into the use of medication is also important, as some substances are incompatible with alcohol, for example, some oral hypoglycaemic substances. The action of some substances, such as the anticoagulant Warfarin, is impaired by alcohol, while others, such as aspirin, can cause serious damage if taken with alcohol. Another reason why nurses should know what medication patients are taking is that withdrawal symptoms may occur if certain drugs are suddenly discontinued. The action of some substances, such as psychotropic drugs, is enhanced by alcohol. Nursing care during acute intoxication and withdrawal Acute intoxication Breath that smells of liquor together with a drunken appearance do not necessarily imply intoxication. A thorough examination is always required to eliminate other causes of the signs and symptoms. This is particularly important in patients who are subsiding into a coma.
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Patients who are in a coma due to too much alcohol are always in danger of dying of circulatory collapse or depressed respiration. Medical assistance should be sought in such cases and aspiration should be prevented by nursing the patients on their side with the head slightly higher than the body. An airway may be required. Vital signs should be monitored and respiratory secretions suctioned if necessary. Alcohol metabolism takes place at a constant rate and no medication or substance can speed it up. The rate is, however, higher in alcoholics. Remedies such as cold showers, strong black coffee, forced activity or vomiting evidently contribute nothing to sobriety. Withdrawal Knott and Beard (1970) divide withdrawal symptoms and signs into four categories: Stage 1: Psychomotor restlessness, loss of appetite, insomnia and hyperactivity of the autonomic nervous system. Stage 2: Hallucinations - generally of hearing and sight and often terrifying in nature - and partial amnesia. Stage 3: Delusions, disorientation and delirium, followed by total amnesia. Stage 4: Epileptiform activity (rum fits). The nursing care of such patients includes the following: 1. Keeping the patient as calm as possible Patients with pending true DTs should be on bed rest. Mechanical restraints in the form of ankle and wrist shackles and cot sides are often necessary until the sedatives begin to take effect. Some authors recommend that the room be slightly darkened to enable the patient to sleep, but the disadvantage is that this exacerbates hallucinations (McNichol 1970: 57). Procedures should be planned in such a way that these patients are disturbed as little as possible while asleep to avoid startling them and making them uncontrollable all over again. This is the reason why an intravenous infusion is often set up to avoid having to wake the patient to take fluids. An in-dwelling catheter may also be passed to obviate the necessity of disturbing the patient for urine specimens. Insomnia may be a problem after the acute phase, but narcotics must be administered with great circumspection as addiction is a distinct possibility. The patient's fearfulness should not be disregarded, and even the simplest procedure must be properly explained. 2. Keeping the patient well hydrated Most people who have been drinking for a long time are dehydrated. In addition, patients suffering from the withdrawal syndrome perspire profusely and are very agitated; both conditions cause further dehydration. The oral fluid intake of patients with mild to moderate withdrawal is increased: at least 180 ml milk is given every half hour until 1 440 ml has been taken, followed by fluids ad lib. If patients with threatened or true DTs can keep to this regimen, they are kept on it, but nausea often precludes oral fluid intake. In such cases fluids are given intravenously, with milk, fruit juice and other fluids administered orally ad lib.
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An accurate record of fluid intake and output must be kept. Output must be checked at least four-hourly or hourly if it is low. 3. Checking vital signs and symptoms to prevent complications Hypertension is a common, but not inevitable, sign of imminent DTs. Both systolic and diastolic pressure rise and this is particularly dangerous in patients who are already hypertensive. Hypotension occurs if sufficiently-high doses of sedatives are given in the treatment of DTs. Hypotension and a raised pulse rate can also be indications of internal haemorrhage, for example, from oesophageal varices. Patients with DTs often have a subnormal temperature unless an infection somewhere in the body complicates the condition. Hyperthermia is a very serious prognostic sign and demands immediate intervention to lower the temperature. Vital signs are consequently taken every hour for 12 hours, two-hourly thereafter for another 12 hours and as often as dictated by the patient's condition after that. Another important observation is to test the urine for albumin every four hours, since this may give an indication of renal function. Nurses should also be mindful of signs and symptoms of pending hepatic coma or bleeding oesophageal varices. These two disorders are complications of liver cirrhosis, which is common in alcoholics (refer to texts on medical and surgical nursing for nursing care). 4. Keeping the patient well nourished Most alcoholics suffer from malnutrition and they are put onto a normal, balanced diet as soon as the acute phase is over. A low fat diet, rich in proteins and carbohydrates, is sometimes prescribed, especially for people who cannot tolerate fatty foods. Patients with gastritis sometimes require a soft, bland diet. 5. Observing side effects and toxic effects These patients are on many forms of medication and should be observed for side effects and toxic effects. 6. Treating convulsions Convulsions (rum fits), which sometimes occur, are managed in the same way as ordinary epileptic fits and the same preventive measures are taken for the patient's safety. Patient education Most alcoholics are surprisingly uninformed about the influence of their drinking on their health and about factors that influence their drinking habits. Structured patient teaching consequently often forms part of treatment programmes, especially for inpatients, and this function is often delegated to nurses. The broad outlines of such a teaching programme are as follows: What is alcoholism? A number of authors emphasize that the concept that alcoholism is a disease is most acceptable to patients, since it allows them to retain a modicum of self-respect and
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self-confidence. However, the therapeutic philosophy of the institution will dictate the approach of the nurses, since the illness concept does not, for example, fit in with the transactional-analysis approach. Physical consequences of alcohol abuse The effect of alcohol on general health, and particularly on the following systems, must be pointed out: Gastrointestinal system; Cardiovascular system; Liver and pancreas; Nervous system (see Figure 15.2). Information should be made more comprehensible by the use of diagrams and photographs, and should be supported by statistical data. Dietary habits Alcoholics usually follow very poor diets, which may even exacerbate their drinking problem. A breakfast of only bread and coffee and a lunch of starch may lead to fatigue by mid-morning or mid-afternoon, and this increases chances of drinking. Alcoholics often eat a lot of sweets to cope with their anxiety and this leads to a sharp rise in blood sugar. When the blood sugar declines sharply again, they generally feel weak and tremulous, which once again increases their chances of drinking. Coffee often has a detrimental effect on alcoholics - it increases tremors and impedes sleep. This and other information should be given to patients without demands being made that they change their eating habits. It should be remembered that these patients have already given up alcohol, and they may become rebellious if too many demands are made. The desired habits (a balanced diet and eating habits) must be emphasized, rather than the undesirable ones. Sleeping habits Sleep disturbances should be discussed in detail. Information should be given about the effect of alcohol on sleep, and about measures to improve sleep. Promotion and maintenance of general health The importance of an annual general medical examination, including chest X-rays, needs to be stressed. The effects of alcohol on the body must be given special emphasis. Assisting the family of the alcoholic The stages through which alcoholics and their families pass are summarized as follows by Joan Jackson (Meiring 1970: 187-188; Burton 1970: 173). 1. At first all the members of the family cope with the drinking problem by pretending that it is not a problem (denial). Tension increases and emotional security diminishes,
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Figure 15.2 Physical effects of alcohol abuse (Adapted from Cole 1990)
but they try to give the impression that they are a 'normal' family and that there is nothing wrong. 2. As the frequency and level of the drinking bouts increase, the pretence becomes impossible and the family members concentrate their efforts on hiding the problem. All the family members reduce their social activities. This leads to isolation and introversion and their lives become alcoholic-centred. Home remedies to resolve the problem are used repeatedly. The alcoholic tries very hard to hide the supply of
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liquor, while the family colludes in efforts to find and destroy it. The efforts of the family to persuade the alcoholic to stop drinking vary from sentimental requests to quarrels. 3. The intrapsychic conflicts of each member of the family become apparent during this stage. The alcoholic feels guilty because he/she repeatedly disappoints the family. The spouse feels guilty because of accusations that he/she is causing the alcoholic's drinking problem. The children feel guilty for various reasons, for example, because they feel disloyal or because they think that their behaviour causes the drinking. Hostility, frustration, quarrelling and fear are common in this stage. 4. In the fourth stage the family members stop their fight against alcoholism in an effort to retain a measure of individual inner stability. Although they do not experience the problem themselves, they tolerate it without trying to hide it any longer. The spouse now has the confidence to seek help. This stage may be reached as long as nine years after the commencement of the problem (Krimmel, in Bourne & Fox 1973: 365). The family no longer functions as a unit. If a combined effort is needed, however, role interchange takes place. The alcoholic's role in the family is assumed by the spouse and the alcoholic is no longer involved in planning and decision-making. Counselling for the spouse The spouse needs to be counselled in order to prevent complete disintegration of the family. It also helps to teach the family not to encourage the drinking habits of the alcoholic. Estes (1974) divides this type of counselling into stages: Early phase During this stage, the aim and procedure of the counselling are defined and the spouse is given the opportunity to unburden him/herself while information about alcoholism is given all the time. The goal is clearly defined as an opportunity for the spouse to learn to know him/herself better. No other results are promised. The spouse often hopes that the counselling will by some miraculous means make the alcoholic stop drinking. In fact, however, the alcoholic has to practise self-control to remain sober. This fact must be frankly and clearly stated, even if it takes some time before the spouse truly accepts it. The spouse is encouraged to air feelings of guilt, rage and frustration. At the same time the spouse is helped to describe important incidents in daily life in minute detail. At first these descriptions are used merely to formulate thoughts, feelings and behaviour, but they are used later to seek alternatives. The counsellor counteracts any tendency to a negative self-image from the beginning. This is done by asking questions that extract positive and realistic self-appraisals. The relationship between the nurse and the spouse can, of itself, lead to greater selfconfidence and a feeling of worth.
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After the initial unburdening, a didactic process is commenced in order to establish the idea of alcoholism as a disease. Misconceptions about alcoholism (associated with denial) are thoroughly and systematically eliminated. The spouse must learn what alcoholism is and must be able to recognise physical manifestations in the alcoholic. The spouse must also learn to recognize the alcoholic's usual defence mechanisms, for example, denial, and rationalization, as disease symptoms and not as shameless lies, meanness or laziness. This insight enables the spouse to be less judgemental. Middle phase The middle phase commences when the spouse is able to examine problem areas in his/her own life frankly and consistently. The spouse acts purposefully and is emotionally willing to work at him/herself and his/her situation. The aim of this phase is to identify, examine and, where necessary, change the way in which the spouse copes with his/her problems. Oxford and Guthrie (as quoted by Estes 1974: 1254) have identified five distinct and persistent types of coping behaviour, namely withdrawal within the marriage, protection, attack, safeguarding of family interests and acting out. The spouse is often unaware of his/her conduct and should be helped to gain insight into his/her own behaviour. After the type of conduct has been identified, its effect on the marriage relationship, the development of the children, the drinking behaviour and the spouse's own personality are examined. This is a lengthy process and eventually certain behaviour patterns are modified and others completely eliminated. Krimmel (Bourne & Fox 1973: 306) emphasizes that the spouse should be encouraged to follow a creative approach. By this he means that the non-alcoholic family members should stop playing roles complementary to the role of the alcoholic. (In terms of transactional analysis or TA, this would mean that they should stop playing the roles of Patsy or Persecutor.) The non-alcoholics should release the alcoholic emotionally and should completely stop trying to control his/her drinking or protecting him/her from its consequences. Final phase The final stage commences when it becomes clear that the spouse has more self-respect and has a better understanding of alcoholism. The spouse is able to make good decisions after considering the alternatives and sticks to them even if they are resisted or questioned. The spouse looks better and is calmer and more relaxed. The spouse is also more meticulous about grooming. The aim of this phase is to help the spouse to plan the future realistically, after which counselling is terminated. The spouse may decide to confront the alcoholic regarding the need for treatment in this stage. The spouse should be well prepared for this confrontation, so that he/she does not make idle threats or play the role of Patsy or Persecutor. If the alcoholic agrees to accept help, the spouse could put him/her in immediate touch with appropriate sources. The spouse should, however, leave as much initiative as possible to the alcoholic him/herself.
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The spouse should also know what to do if the alcoholic does not agree to accept assistance, as such a decision would require reconsideration of the situation. The spouse also considers alternatives such as divorce or separation during this stage. The spouse often requires spiritual help for this decision and may be advised to discuss it with a minister, pastor or priest. At the end of the counselling, the spouse may be referred to an Al-Anon group for further support. Al-Anon family groups Al-Anon groups are similar to Alcoholics Anonymous but members are the spouses of alcoholics. They originated in the United States in 1945 and by 1974 there were 6 500 registered groups throughout the world. Groups began meeting in South Africa in 1953 and by 1974 there were 56 of them in the country. Alateen groups, specially intended for the children of alcoholics, were first established in South Africa in 1970. Al-Anon groups meet regularly (usually weekly), generally in the form of discussion groups. Members share their experiences openly with peers who have been through the same trauma. The 'Twelve Steps' of Alcoholics Anonymous are used in a modified form to enable non-alcoholics to understand that they cannot make alcoholics stop drinking but that they can improve their own and their children's lives with the help of a Higher Power. Members have very high opinions of the groups and professionals recommend them in cases where long-term counselling is impossible. They may also be of great value in conjunction with or after counselling. Al-Anon groups may be contacted through local AA branches. Employee assistance programme (EAR) The highest incidence of alcoholism occurs in people between the ages of 35 and 45 years when most adults are active in their occupations. A study by VIok in 1974 revealed that 2 % of coloured workers in the Republic of South Africa had obvious drinking problems. He also found that alcoholics who were in rehabilitation centres in 1974 reported that they already had problems with their job behaviour at an average age of 33,3 years, but that they did not come tor treatment before an average age of 43,5 years. Contrary to the popular believe that alcoholics are neglected tramps, more than half of this group were still gainfully emploved when they submitted to treatment. Employment organizations offer both an opportunity for the early identification of problem drinkers and good reasons for constructive intervention. The following factors make this situation eminently suitable for early intervention. Alcohol dependence impairs occupational functioning from an early stage of a worker's drinking hl-tory. Winslow (Bourne & Fox 1973: 363) undertook one of the most definitive studies \ d of the financial burdens imposed by alcoholics on industry. He studied four aspects: the cost of diminished productivity; interpersonal friction; absenteeism; and health and accident problems. As regards health and accidents, it should
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be noted that alcoholics do not have more accidents while at work - according to some authors this can be attributed to higher concentration because of an awareness of the problem - but they do have more accidents while off duty and they are often ill, for example, with colds, lung problems and gastritis. Vlok found that alcoholics cost their employers twice as much as other workers do, and their insurance companies three times as much. The relationship between employer and employee offers valid grounds for interference by the employer with regard to a poor performance record. The employer has the 'right' to try to do something about the drinking behaviour, whereas very few other people in an alcoholic's life have this right. Factors in the work role of an alcoholic may contribute to or trigger alcohol abuse. These factors can be identified and changed if a preventive programme is applied in the work situation. According to Roman and Trice (in Kissin & Begleiter 1976: 457), the risk factors may be summarized as follows: Absence of dear goals. Jobs that are new in an organization or one-of-a-kind present problems of performance evaluation for both the employer and the employee. Freedom to set work hours. This disengages a worker from involvement with informal groups. This involvement is an important source of social control. 'Field' roles. Employees who travel and have more contact with people outside the organization also experience social isolation, little supervision and the absence of peer group control. There is often a great deal of stress, since the job entails regular contact with strangers on their home ground and a great deal of free time in the evening. Exploitative relationships. In many organizations, competition among certain employees is so strong that some of them benefit from the faults of an alcoholic and may exploit this to get to the top. Addiction to work. In the language of transactional analysis (TA), these people collect coupons for overtime which they later exchange for a session of excessive drinking. Since it has been 'earned', others tolerate it without intervening. Occupational obsolescence. This is a modern phenomenon that is becoming more common. The skills and knowledge of certain people become outdated due to the rapid changes and progress in science and technology. Since they usually occupy middle or top positions, they are seldom retrenched, but are rather moved out of the mainstream of the organization. This leads to drinking problems while the deterioration in their occupational behaviour goes unnoticed. Job mobility. Some occupations entail working in situations in which norms with regard to drinking show sharp differences. Heavy drinking is often commonplace in field construction and overseas briefs, although there is social control, which prevents adverse effects. On-the-job drinking. Lunch-time drinking in particular is also a risk factor. If a drink with a client is an accepted part of the job role, the risk is so much greater.
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Another reason why preventive programmes in the work situation are so important is that confronting problem drinkers with their poor job record can precipitate a crisis, which may serve as a motivation for treatment. Employee assistance programmes address alcoholism and other forms of dependence, as well as emotional and social problems. These programmes follow the steps set out below: Employers should have a clear understanding of the true nature of alcoholism. Employers should set out their policy regarding alcoholism clearly and honestly. Recommended policy is that alcoholism be regarded as a disease that can be treated in recognized treatment centres. Employees should have assurance that there will be no discrimination against them in any way if they agree to treatment. Employers should check whether their medical aid provides for the treatment of alcoholism. If not, they should do everything in their power to have it included in the benefits. Supervisors at all levels should be instructed about the problem of alcoholism, its symptoms and signs and its management. Role-play and the methods of instruction should be used to give them practice in the process of constructive confrontation. Supervisors should not confront alcoholics with their alcoholism or symptoms, but rather with the deterioration of their occupational functioning. In order to do this, they should keep complete data on: - individual quality and quantity of production or a sales record; - absenteeism; - late arrival for work; - going off duty early; - an illness record, with diagnoses; and - accidents on and off duty. This data is given to the manager, who should call in such employees and confront them with their poor work record. They should be told that they probably require treatment as it seems that they have a health problem that impairs their occupational functioning. It should be clearly stated that their job will be in jeopardy if their performance does not improve. The policy of constructive confrontation should receive equal emphasis at all levels of the organization. Employees who ask for assistance should be referred to an outside organization by the liaison officer of the secondary prevention programme, who may be a personnel officer or an industrial nurse. Those who refuse help should be given a set number of'chances'. Each time that their job performance deteriorates further, or after a specified period of sustained poor performance, they should again be confronted with the choice of assistance or discharge. They should be discharged after the specified number of chances. The same procedure should be followed with treated alcoholics who relapse. Relapse is not viewed as an irreversible disaster.
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15.2 OTHER COMMON DEPENDENCE-PRODUCING SUBSTANCES Up to the early 1990s so-called 'hard drugs' (heroin and cocaine) were a very small problem in South Africa. This changed rapidly during the 1990s and into the new century. A combination of methaqualone (mandrax) and marijuana ('white pipe') remain very common, but heroin, cocaine and crack cocaine, and 'recreational drugs' such as ecstacy (3,4-methylenedioxymethamphetamine) are gaining ground fast (Wilson & De Miranda 2001). Dagga (Cannabis or marijuana) Dagga is the substance most used by young people in South Africa. It is obtained from the dried flowers and leaves of the Cannabis sativa plant. The active intoxicating ingredient in dagga is 9-delta-tetrahydrocannabinol (THC) and it acts in conjunction with other chemical compounds called cannabinoids. Dagga can be taken in the form of cakes, hash oil and tea, but it is generally smoked in cigarettes or pipes. Dagga is used mainly for the relief of anxiety and tension, for its pleasurable and euphoric effects, and to escape from reality. The signs and symptoms caused by the use of this substance are set out in Table 15.3. Although many people believe that dagga is not a harmful substance, long-term use has the following adverse effects: Dagga damages the respiratory system, which may lead to bronchitis, lung damage and a higher risk of lung cancer. It has a negative effect on the body's immune system. Dagga harms the foetus of a pregnant woman who uses it. It affects the sex hormones by: -
suppressing ovulation in young women, resulting in infertility; and
— delaying sexual development in young men (De Miranda 1987: 43). The effects of dagga intoxication and consequently the associated symptoms are the following: People experience extreme happiness or euphoria, with giggling and laughing. Others become quiet and introspective, thinking about and discussing what they think are wonderful topics, but they are actually talking/thinking nonsense. Loss of short-term memory. Hunger, especially a craving for sweet foods, and thirst. Reddened eyes. Slower reaction time and perception. Hallucinating while taking dagga is a sign of overdosage, while 'bad trips' in the form of acute anxiety or psychosis also occur. With long-term use people develop an
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'amotivational syndrome', in which they lose interest in most activities, drop out of social, occupational and other circles, and do very little. The Marijuana Anonymous group suggest a dagga smoker ask the following questions to decide whether he or she has a abuse problem: Twelve Questions 1. Has smoking pot stopped being fun? 2. Do you ever get high alone? 3. Is it hard for you to imagine a life without marijuana? 4. Do you find that your friends are determined by your marijuana use? 5. Do you smoke marijuana to avoid dealing with your problems? 6. Do you smoke pot to cope with your feelings? 7. Does your marijuana use let you live in a privately defined world? 8. Have you ever failed to keep promises you made about cutting down or controlling your dope smoking? 9. Has your use of marijuana caused problems with memory, concentration, or motivation? 10. When your stash is nearly empty, do you feel anxious or worried about how to get more? 11. Do you plan your life around your marijuana use? 12. Have friends or relatives ever complained that your pot smoking is damaging your relationship with them? (http://www.marijuana-anonymous.org/Pages/12quest.html)
Mandrax The active ingredient in Mandrax is the synthetic chemical methaqualone. Mandrax causes physical addiction, which soon leads to tolerance. This substance is forbidden in South Africa. It is usually taken by mouth in tablet form, but in southern Africa it is generally smoked with dagga, a method practically unique to this part of the world. Mandrax is used mainly for the relief of insomnia and anxiety. It causes strong physiological dependence, and the physical effects include impaired functioning of the respiratory and circulatory systems. Many users of the substance die of an overdose or in accidents, the latter due to the fact that Mandrax reduces vigilance and causes mental apathy. Inhalants (industrial and household substances) This heterogeneous group of substances can cause general suppression of the central nervous system. It includes glue, benzene, petrol, nail polish remover, naphtha, fluorocarbons, turpentine and paint thinners. These substances belong to the groups of chemicals known as volatile hydrocarbons and volatile fluorocarbons. Inhalants are used for the euphoric sensation that they induce within 15 to 45 minutes. They are freely available, cheap and legal, and easily hidden. They are used to alter the state of
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consciousness and cause sensation of light-headedness and disorientation. They are inhaled from plastic bags or directly from cloths, tissues or handkerchiefs (Madden 1979: 186). This form of addiction occurs mainly among young children who cannot afford more expensive substances. Inhalants can engender strong psychological and physiological dependence and can cause serious physical damage. They damage the central and peripheral nervous systems, kidneys, liver and mucous membrane of the airways. They can also result in death from asphyxiation as they cause spasm of the larynx. Cardiac failure may also occur. Table153 Symptoms associated with common dependence-producing substances Physiological signs
Psychological signs
and symptoms
Withdrawal symptoms
Dagga (Cannabis or Marijuana) Fine tremors
Euphoria
Restlessness
Slight reduction in temperature
Feelings of relaxation and
Aggression
Decreased muscle strength and
drowsiness
Insomnia
balance
Increased libido
Lack of self-control
Decreased motor coordination
Distorted perception of
Moodiness
Dry mouth
time, distance and control
Irritability
Bloodshot eyes Nausea and headache Nystagmus
Uncontrollable laughter Loss of contact with reality Disintegration of body
Listlessness Nausea
Slight hypotension
image
Headache
Elevated respiratory rate Tachycardia
Somatosensory disturbance Depersonalization
Loss of appetite
Disorientation Anxiety that may lead to panic Paranoid delusions sometimes occur At behavioural level, conduct may vary between drowsiness and hyperactivity Chronic use may cause fluctuations of conduct and mood Feeling of irritation and aggressive outbursts General inadequacy
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Physiological signs
Psychological signs and symptoms
Withdrawal symptoms
Dagga (Cannabis or Marijuana) (continued) Impaired occupational functioning and capacity for work Possible internalization of an apathetic and unmotivated way of life Mandrax Drowsiness Retarded thought processes Dull, thick-headed feeling Noticeable loss of weight Emaciation
Feelings of relaxation and unreality Improved social interaction Absence of sexual inhibitions Lack of concentration Retarded thought Poor judgement General emotional instability
Insomnia Nervousness Anxiety Nausea and vomiting Abdominal cramps Hallucinations Convulsions
Inhalants Sensory - Light sensitivity - Eye irritation - Diplopia - Buzzing of the ears Respiratory - Sneezing - Sinus discharge - Cough Gastrointestinal - Nausea - Vomiting - Diarrhoea - Poor appetite Ataxia Chest pain Abnormal heart rhythm Muscle and joint pains Pallor Lethargy
Forgetfulness Inability to think logically and dearly Disorientation Ataxia Visual and tactile hallucinations Aggressive outbursts Decreased inhibitions Floating sensation Incorrect perceptions or illusions Amnesia Behavioural disturbances
Hallucination Depression Anxiety Impaired intellectual functioning Delirium
Headache Muscle spasms Gastric distress Aggressive outbursts Sensation of cold
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Psychological signs and symptoms
Physiological signs
Withdrawal symptoms
Inhalants (continued) Tremors Thirst Drowsiness Rash round the nose and mouth Amphetamines and Cocaine Hyperactivity Increased vigour Stereotypical behaviour Hallucinations
Euphoria Gregariousness Interpersonal sensitivity Tension Talkativeness Grandiosity Impaired judgement
Withdrawal starts within 24 hours, and peaks within 2-4 days. Fatigue Depression Nightmares Insomnia Headaches Sweating Muscle cramps Craving
Hallucinogens Sympathomimetic, so intoxication leads to: Tachycardia Hypertension Sweating Dilated pupils Hyper-reflexia Pyrexia
Anxiety or depression Ideas of reference Impaired judgement Perceptual abnormalities
Craving Hangover after ecstacy use Insomnia Fatigue Drowsiness Loss of balance Headaches
Opioids Flushing, orgasmic sensation Drowsiness, lethargy Constricted pupils Respiratory depression Hypotension Bradicardia Hypothermia Impaired concentraiton and memory Slurred speech
Euphoria and contentment Long-term use leads to personality changes, mood swings.
Withdrawal starts within 10-48 hours, mild to severe. Lacrimation Sweating Yawning Piloerection Hypertension Tachycardia
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Physiological signs
Psychological signs and symptoms
Withdrawal symptoms
Opioids (continued) Long-term use leads to lowered sex drive and appetite, constipation and weight loss
Hot and cold sweats Muscle and joint pain Nausea and vomiting
Cocaine and Amphetamines These drugs are used recreationally and lead to feelings of euphoria. People intoxicated with cocaine can have a variable heart rate and/or blood pressure, dilated pupils, perspiration or chills, nausea or vomiting, weight loss, psychomotor agitation or retardation, muscular weakness, respiratory depression, chest pain, confusion, seizures, dyskinesias, dystonias or coma. In terms of psychological indicators, one can also see aggression, wildly irrational behaviour, which is called 'cocaine agitated delirium'. The behaviour should be controlled as described in Chapter 11, 'The process of violence and handling violence'. During the withdrawal of these drugs, the following medication can be used for five to seven days: diazepam 5 mg-10 mg three times a day haloperidol 2 mg-5 mg three times daily methylphenidate 10 mg three times a day and reduced gradually. (Wilson & De Miranda 2001) Hallucinogens Most of the hallucinogens are synthetically made and used for their effect on moods. MDMA or ecstacy is the most common drug of this kind in South Africa; it is used especially by young people at 'raves'. Heavy users may spend hours each day using or recovering from an episode of use. During acute intoxication or withdrawal, one needs do little more than keep the person safe, and make sure he/she does not become dehydrated or over-heated. Diazepan can be used to calm the person if she or he is very restless. Opioids Dipipanone HCL (Wellconal), Pethidine HCL and heroin are the main opioids used in South Africa. While these drugs are very good for pain control, abusers usually use them for the euphoric feelings they induce. Due to their easy access to such drugs, health care professionals are amongst the most common abusers of these substances. These drugs are extremely addictive, and although few people are involved in their abuse, the costs to such
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people, their families and communities are very high. The substances can be taken orally, smoked or administered by injection. The drugs lead to tolerance, so that the person needs higher and higher doses to satisfy the craving. A person who wants to stop needs to be supported with methadone 5 mg-10 mg at the first signs of withdrawal. This can be increased if the withdrawal symptoms are more severe. The dose should be repeated every 12 hours, until the symptoms subside. The dose should then be cut systematically every day (Wilson & De Miranda 2001). There is no statutory provision in South Africa for long-term methadone substitution for opioids, as is the practice in the USA and Europe. 153 TREATMENT OF SUBSTANCE-DEPENDENT PEOPLE The treatment of substance-dependent individuals is a complex problem, since psychological, social and medical aspects must be taken into account. The following aspects emphasize the importance of active treatment: The social costs of treatment programmes; The harm that dependent individuals do to themselves. People who are substance-dependent are often members of subcultures that are poorly integrated with the broader community and often reject social norms. This makes it difficult to involve them in treatment. The aim of treatment is not so much an immediate cure as gradual improvement of the behaviour. To this end realistic but simple and limited objectives which patients will accept as being within reach, should be set. Treatment depends on factors such as the abilities of the individual, the duration of the dependence, the type of substance used, available treatment facilities, the objectives of the dependent person and the presence of physical and psychological complications. Bothwell (1998) describes as follows the process of motivational counselling which needs to be implemented with patients with an addiction: Step one: Consider reasons for stopping. Without being authoritarian or blaming, give reasons for thinking the substance use is a problem and suggest that the person think about it. If the person agrees to consider stopping, support his/her reasons. Step two: Discuss barriers preventing the patient from stopping and find solutions to these. The patient may fear the withdrawal symptoms, or losing friends who are still using the substance. Stopping may lead to boredom or pressure from friends. Discuss these and find solutions. Step three: See the patient again. Make sure that the person follows through with plans, and give support and encouragement.
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The short-term objectives of treatment are the initiation and support of uncomplicated withdrawal or detoxification of the substance, as well as treatment of any physical complications that may be present. Detoxification may be facilitated by blocking the dependence-producing appetite by means of chemical agents such as methadone or narcotic antagonist. Criminal activity, such as theft to obtain money for the substances, should be stopped from the outset. As soon as withdrawal is completed, patients are involved in a therapeutic programme that covers the physical, psychological and social aspects of functioning. The will to avoid the substance and not to try to obtain it is reinforced in every possible way. New, healthy behaviour patterns are established and reinforced at the same time. During treatment, attempts are made to break the pathological structure of substance dependence. This means that patients should be removed from their substance-centred culture and, if appropriate, also from their pathological family structure. This helps to reduce their negative effects. Guidelines for a less substance-centred way of life should be given in this phase. One of the most important factors in the management of substance-dependent patients is the reduction of anxiety and confusion about their own value systems. Problem areas in the management of these patients consequently centre on their dependence on a lifestyle of substance dependence, which affords them a constant source of excitement, challenge and adventure, while authority, responsibility and emotional pain are suppressed. This is why the attainment of independence and confidence is stressed. Patients also have to be freed of their overwhelming anxiety in order to establish a more adaptable lifestyle (Gibbens, Israel, Kalant, Popham, Schmidt & Smart 1974: 283-284). Tertiary prevention emphasizes the functions and contributions of social support systems. The most important contributions of a social network at emotional support, task-oriented aid and communication that focuses on evaluation and expectations, particularly the establishment of a sense of belonging. Support groups, whether they be the family, friends or members of the community, therefore have the task of rendering assistance in order that patients may learn to cope more effectively with their environment. Their assistance enables patients to assess problem areas, plan and implement problem-solving methods, and evaluate the results with the aid of feedback information. CONCLUSION Alcohol and substance dependence constitute a tremendous problem in South African society. Because of the interweaving of these problems with other socio-economic and political problems, prevention and treatment are more problematic. This needs to be addressed on a broad front by society itself. The key position of nurses in the health services and their wide distribution in the community demand that they play a cardinal role in the fight against this debilitating disorder.
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WEB RESOURCES
www.addictions.org/recoveryworks/ This website not only directs you to specific sites for different addictions, it also offers resources to assist a person in recovering from a range of addictions, including drugs and alcohol. www.niaaa.nih.gov/ This is the website of the National Institutes of Alcohol Abuse and Alcoholism, which is the major research organization of the USA government. It is a very useful site, with answers to frequently asked questions, data bases on this topic, and publications. It also has a Graphics Gallery, where you can access all kinds of illustrations for talks and lectures. One such a diagram is the ecological model of drinking behaviour, which is very useful for teaching. www.ecstacy.org and www.aromadome.com/ecstacy.html Both sites give a lot of information about the use of ecstacy. The second one is especially user friendly and gives useful tips for people using this drug at raves. The following three sites represent some of the consumer websites in this area: www.alcoholic-anonymous.org www.na.org Narcotics Anonymous www.ca.org Cocaine Anonymous REFERENCES American Psychiatric Association. 2000. Diagnostic and Statistical Manual of Mental Disorders (4th ed.), Text Revision. Washington, DC: American Psychiatric Association Bourne, P G & Fox, R. 1973. Alcoholism. Progress in Research and Treatment. New York: Academic Press Bothwell R. 1998. Alcohol and other substance abuse problems. In Bauman S E (ed) Psychiatry and primary health care. Kenwyn: luta. 215-240 Bratter, T E, & Forrest G G. 1985. Alcoholism and substance abuse. New York: The Free Press Bragg, T L. 1976. Teenage alcohol abuse. Journal of Psychiatric Nursing and Mental Health Services, 14(12), 10-18 Burton, G. 1970. An alcoholic in the family. In Psychiatric Nursing, ed D Mereness, Vol 2, 2nd ed. Dubuque: C Brown Co Chavigny, K. 1976. Self-esteem for the alcoholic: An epidemiologic approach Nursing Outlook, 24(19), 636-639 Cole, D. 1990. Identifying the alcohol misuser. Nursing Times, 86(16), 58-59 De Miranda, S & Wilson, D. 2001. Alcohol-related disorders, pp 180-195. In Robertson B, Allwood, C & Gagiano, C (eds) Textbook of psychiatry for Southern Africa. Oxford: Oxford University Press. Duncan, T L. 1965. Understanding and Helping the Narcotic Addict. Philadelphia: Prentice-Hall Estes, N }. 1974. Counselling the wife of an alcoholic spouse. American Journal of Nursing, 74(7), 1251-1255
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Ewing, ) A. 1984. Detecting alcoholism: The CAGE questionnaire. JAMA: the Journal of the American Medical Association, 252(14), 1905-1907 Forrest, G G. 1975. The Diagnosis and Treatment of Alcoholism. Springfield: Charles C Thomas Freed, L F. 1970. The social aspects of the alcohol problem. Rehabilitation in South Africa, 18(3), 96-98 Gibbens, R }, Israel, Y, Kalant, H, Popham, R E, Schmidt, W & Smart, R G. 1971. Research Advances in Alcohol and Drug Problems. New York: John Wiley & Sons Glatt, M M & Marks, J. 1982. The Dependence Phenomenon. London: MTD Press Heinemann, E & Estes, N. 1976. Assessing alcoholic patients. American journal of Nursing, 76(5), 785-789 Kissin, B & Begleiter, H (eds). 1976. Social aspects of alcoholism. The Biology of Alcoholism, Vol 4. New York: Plenum Press Knott, D H & Beard, J H. 1970. Diagnosis and therapy of acute withdrawal from alcohol. Current Psychiatric Therapies, 10, 143-152 Louw, E. 1974. Alcoholism and the employer - a positive policy. Rehabilitation in South Africa, 18(3), 75-79 Mersy, DJ. 2003. Recognition of alcohol and substance abuse. American Family Physician, 67(7), 1529-1532 Meiring, P J. 1970. Die rol van gesinsterapie in die rehabilitasie van die alkoholis. Rehabilitasie in Suid-Afrika, 14(4), 185-188 Mueller, J F. 1974. Treatment for the alcoholic: Cursing or nursing. American Journal of Nursing, 74(2), 245-247 Parry, C D H & Bennets, A L. 1998. Alcohol Policy and Public Health in South Africa. Cape Town: Oxford University Press Peltzer, K, Cherlan, V 1 & Cherlan, L. 1999. Substance use among urban secondary school pupils in the Northern Province, SA. SA Journal of Child and Adolescent Mental Health, 11(1): 49-55 Skinner, H A. 1982. The drug abuse screening test. Journal of Addiction Behaviour, 7(4), 363-371 Steiner, C. 1971. Games Alcoholics Play. New York: Grove Press Inc Wilson, D & De Miranda, S. 2001 Other substance-related disorders, pp 196-217. In Robertson B, Allwood, C & Gagiano, C (eds) Textbook of psychiatry for Southern Africa. Oxford: Oxford University Press World Health Organization. 1990. Management of Drinking Problems. Copenhagen: WHO World Health Organization. 2000. Substance Dependence website: Introduction. WHO, Department of Mental Health and Substance Dependence. Geneva: WHO World Health Organization. 2001. Global Status Report on Alcohol. Geneva: WHO
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CHAPTER SIXTEEN
Nursing the Patient with a Cognitive Disorder L MIDDLETON LRUYS
Objectives After studying this chapter the learner should be able to: Distinguish between delirium, dementia and pseudodementia. Apply the scientific process of nursing to the care of patients suffering from acute and chronic cognitive disorders, including those associated with HIV/Aids. Utilize the process of coping to assist the person with epilepsy to adjust to the condition. Describe the impact of the HIV/Aids pandemic on mental health of the population.
INTRODUCTION For many health care professionals an aura of pessimism surrounds the term cognitive disorders. This aura has as much to do with the fact that some of the commonly encountered syndromes are, in medical terms, incurable, as it does with the myths and stereotypes associated with these syndromes. An example of a stereotype is: 'people with cognitive disorders are unresponsive to the environment and therefore do not benefit from therapeutic intervention'. People with non-progressive brain damage are capable of relearning a variety of skills such as visual-spatial relationships, motor skills, attention, memory and reading. Although little is seen in the recovery of function in progressive conditions such as dementia, it has been shown that demented patients are capable of showing a beneficial response to environmental manipulation. Hence, although it is not possible to alter the course of the patient's condition, it is possible to alter the environment in which the person with a progressive cognitive disorder lives. The most common cognitive disorders are delirium and dementia. They are classified in the adapted DSM-IV-TR as mental disorders because they involve deterioration in
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mental, behavioural and emotional functioning. However, the underlying cause is almost always physical and may be due to a disease as in the case of dementia due to HIV illness, the effect of a drug or substance as in delirium related to substance abuse, or head trauma. This chapter focuses on three issues within the area of the cognitive disorders. The first issue is that of delirium and dementia as they occur in the elderly population. Delirium related to substance abuse is addressed in Chapter 15. The second issue concerns the psychosocial needs of the person with epilepsy. Although the DSM-IV-TR does not classify epilepsy as a cognitive disorder, it is a neurological one and a common dual psychiatric diagnosis among psychiatric patients. The third issue focuses attention on HIV/Aids. HIV/Aids is a current and critical health issue and will therefore, as in the DSM-IV-TR, be addressed within the scope of this chapter. 16.1UNDERSTANDING COGNITIVE DISORDERS Cognitive disorders are clusters of psychological and behavioural problems that are directly traceable to permanent or transient brain dysfunction. The hallmark of a cognitive disorder is cognitive impairment. The individual's capacity to interact meaningfully with the environment and his/her capacity for self-awareness is therefore drastically altered. The most common cognitive disorders are delirium and dementia. The major features of these brain syndromes are listed in Table 16.1. Not all symptoms occur in all disorders; there is considerable variety in symptom pattern. Causes of cognitive disorders Brain-tissue dysfunction can stem from a variety of causes and people of all ages are vulnerable to cognitive disorders. Table 16.2 outlines some of the causes, using a mnemonic, MEND A MIND. Although these syndromes are organically based, the form the syndrome takes depends in part on psychosocial factors. Table16,1 Major features of cognitive disorders Impaired orientation Particularly for time: public time markers (year, month, date) cued time (time of day, season of year) personal time (subjective experience of the passage of time) Also for place and person: Unfamiliar surroundings are mistaken for familiar ones and vice versa This may become more pronounced in twilight and as the night progresses Sufferers become unsure of whom they are, to the extent that self-identity may be lost
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Impaired memory and recall Particularly for recent events, but also for remote ones: Forgetful, absent-minded May invent stories (confabulation) to fill in the gaps Unable to perform basic self-care activities Impaired intellectual functioning Comprehension, recall, production of speech, abstract reasoning, general information and the ability to learn new tasks are reduced. Impaired judgement The person loses the ability to make appropriate decisions and to plan, for example, what to have for lunch and when to keep clothes on and take them off, Emotional dysfunction Emotional liability: strong emotion in the absence of stimuli that may shift suddenly and excessively without warning from sadness and crying to euphoria and laughter, or the emotion may be inappropriate to the situation Emotional blunting: a general lack of responsiveness and the presence of apathy and indifference Sensory and perceptual impairment Hallucinations, illusions Delusions usually of a paranoid nature, often related to beliefs about being threatened and mistreated. They often reflect underlying feelings of fear, hopelessness, loneliness and abandonment. Impaired vision, hearing and sensory deprivation in the form of monotonous environment or an environment that makes demands the person is unable to cope with, all contribute to the development of confusion. (Adapted from Bootzin & Acocella 1988, Kaplan & Sadock 1988, and Sahakian 1986)
Example Mrs K and Mrs J moved in with their respective daughters because their increasing forgetfulness and absent-mindedness had begun to worry them. Mrs K's daughter was determined that Mrs K should fit in with the family and its routines, for example, meal times and not eating in front of the TV. Since Mrs K's own routine had been somewhat different; she had great difficulty in adjusting, especially as she would often forget her new routine. As a result, she became increasingly confused and disoriented. The more demanding the daughter was, the more confused Mrs K became and the less able she was to interact meaningfully with the environment. Mrs J's daughter, on the other hand, structured a routine for her mother that was similar to the one she had followed at home. The daughter arranged with the family that each member would spend some time with Mrs J at least three times a week doing jigsaw puzzles or helping her with her knitting. Since her routine was familiar to her and no overt
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expectations were placed on her with which she could not cope, Mrs J was able to interact meaningfully with the environment most of the time. If demands from the environment are beyond the person's ability to cope, disorganized behaviour will be accelerated and maladaptive behaviour is more likely to occur; lack of stimulation in the form of a monotonous environment can lead to increasing confusion and disorientation in the person. Table 16.2
Causation of cognitive disorders
Cause
Examples
M Metabolic and endocrine disorders
Hepatic disease, uremic encephalopathy, porphyria, thyroid dysfunction, adrenal dysfunction, WernickeKorsakoff syndrome
E
Tonic, clonic, tonic-donic, focal seizures, psychic seizures
Electrical (convulsive) disorders
N Neoplasma and tumours
Astrocytoma, medulioblastoma, meningiorna
D Degenerative diseases that lead to deterioration of the brain and possible genetic influence
Alzheimer's disease, Parkinson's disease, Huntington's chorea, Aids
A Arterial diseases and multiple, small or large cerebral infarcts with occlusion of small terminal arteries reducing blood supply to the brain
Arteriosclerosis, vascular, circulatory or valvular disease, emboli
M Mechanical diseases, where the physical structure of the brain is affected
Head trauma, subdural haematoma, concussion, and contusion
I
Urinary tract, viral diseases, bronchopneumonia, meningitis, tuberculosis, neurosyphilis
Infections
N Nutritional deficiencies
Lack of protein, deficiencies in vitamin C and the B vitamins, fluid and electrolyte imbalances
D Drugtoxicity
Alcohol, barbiturates, opiates, cannabis, caffeine, cocaine, amphetamines, petrol, glue, paint removers, solvents, aerosols, heavy metals (lead, mercury, arsenic)
Classification of cognitive disorders Of primary importance when working with people with cognitive disorders is the need to make a distinction between the two types, namely progressive and non-progressive. This is because the needs, treatment goals, interventions and expectations of some degree of
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recovery, are different. Failure to make the distinction may account for some of the pessimism nurses feel when their interventions seem to have little impact on the patient's functioning. Cognitive disorders may be classified as acute (temporary, reversible and nonprogressive) or chronic (permanent, irreversible and/or progressive). Delirium is the syndrome usually associated with acute disorders and dementia with chronic disorders.
DSM-IV-TR diagnostic criteria: Cognitive disorders Delirium A Disturbance of consciousness, which reduces ability to focus, sustain or shift attention. B. A change in cognition (such as memory deficit, disorientation, language disturbance) or the development of a perceptual disturbance that is not better accounted for by a pre-existing, established, or evolving dementia. C. The disturbance develops over a short period of time (usually hours to days) and tends to fluctuate during the course of the day. D. There is evidence from the history, physical examination, or laboratory findings that the disturbance is caused by the direct physiological consequences of a general medical condition. The kinds of delirium are: Delirium due to a medical condition, substance intoxication, substance withdrawal and to multiple aetiologies. Dement/a A. The development of multiple cognitive deficits manifested by both: 1. Memory impairment (impaired ability to learn new information or recall previously learned information); 2. One or more of the following cognitive disturbances: Aphasia (language impairment); Apraxia (impaired ability to carry out motor activities despite intact motor functions); Agnosia (failure to recognize or identify objects despite intact sensory function); Disturbance in executive functioning (i.e. planning, organizing, sequencing, abstracting). B. The cognitive deficits (A.1 or 2) cause significant impairment in social or occupational functioning and a decline from previous levels of functioning. C. The deficits do not occur exclusively during the course of a delirium. D. The disturbance is not better accounted for by another Axis I disorder (e.g., Major Depressive Disorder, Schizophrenia). In dementia of the Alzheimer's type, the onset of symptoms is gradual and cannot be attributed to a CNS or systemic condition or substance-related condition. In vascular dementia there are focal neurological signs and symptoms or laboratory evidence of cerebrovascular disease.
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In dementia due to other general medical conditions, such as HIV disease, head trauma or Parkinson's disease, there is evidence of these conditions causing the dementia. In substance-induced persisting dementia there is evidence that the dementia is related to the persisting effects of substance abuse.
Dementia, delirium and pseudodementia in the elderly population The elderly are particularly vulnerable to delirium and dementia. Because cognitive changes in the elderly are considered by many health workers and family members to be part of the normal process of ageing, they are often overlooked. This is especially dangerous in the case of delirium because, if left untreated, death may result. The death rate for delirium varies from 10 % to 30 % (Potocnik, in Meiring 1990).
Dement/a Potocnik (in Meiring 1990: 134) defines dementia as '... a syndrome consisting of extensive brain disease impairing memory, personality and intellect in an alert patient. The impairment must be sufficiently severe to interfere with the individual's occupation or social functioning.' The incidence of dementia rises progressively with age and varies from 3 % for 60-year-olds to as much as 40-50 % in 90-year-olds. Up to 15 % of the elderly in medical wards and up to 50 % of the elderly in retirement homes are demented. There are many types of dementia, each of which is named according to the underlying disease state. For example, dementia of the Alzheimer's type and dementia related to HIV. Senile dementia is a term probably associated with the dementia of the Alzheimer's type. Delirium Delirium is a synonym for acute brain failure (ABF):'... an acute, reversible, temporary disorder producing reduced awareness of or contact with the surroundings, an inability to attend to any given task or conversation and disorientation with memory impairment' (Potocnik, in Meiring 1990: 142; Mcabe 1990). It is a common concurrent of illness, especially with the older patient. The incidence of delirium increases in proportion to the increase in the elderly population. Delirium is commonly seen in medical and surgical wards and in institutions. Approximately 10 % to 15 % of elderly surgical patients become delirious post-operatively and between 30 % and 50 % of elderly people admitted to hospital are likely to become delirious at some point during hospitalization. Delirium in the elderly may be associated with longer hospital stays. Improper management of delirium maybe partly responsible for increases in the length of stay. Table 16.3 outlines the major clinical differences between delirium and dementia.
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Table 163 Differences between delirium and dementia Delirium Onset
Acute
Dementia Usually insidious; if acute, preceded by coma or delirium
Course
Fluctuating
Deterioration
Duration
Usually less than one month
At least one month, usually longer
Prognosis
Reversible
Irreversible
Orientation
Faulty, at least for a time; tendency
May be correct in mild cases;
to mistake unfamiliar for familiar
absent in severe cases
place, person Thinking
Disorganized, incoherent, rambling
Impoverished
Memory
Recent impaired
Recent and remote impaired
Usually disturbed, hard to direct
May be intact
Attention
or sustain Awareness
Always reduced, tends to fluctuate
Usually intact
during the day (generally drowsy) and to be worse at night (psychotic, unmanageable) Alertness
Increased or decreased
Normal or decreased
Perception
Misperception (illusions, visual
Often absent, but may occur in
hallucinations) and paranoid delusions
severe cases
Always disrupted
Normal for particular age;
Sleep-waking cycle
disrupted as the disease progresses
(Adapted from Kaplan £iSadock, 1988:1 91 ; McCabe 1990)
Pseudodementia is a term used to describe a syndrome of cognitive and memory impairment that mimics the manifestations of dementia but is in fact associated with depression. It is important that nurses be able to differentiate between the two because misdiagnosis can lead to mismanagement and, consequently, to unwarranted hospitalization. The DSM-IV-TR does not specifically classify this as a condition but makes it very clear that the clinician must rule out depression before making the diagnosis of dementia.
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Table 16.4 Dementia and pseudodementia Dementia
Pseudodementia
Onset
Intellectual deficits antedate depression
Depressive symptoms antedate cognitive deficits
Presentation of symptoms
Patient minimizes or denies cognitive deficits, tries to conceal them by circumstantiality, perseverance, and changing topic of conversation
Patient complains vocally of memory impairment and poor intellectual performance, exaggerates and dwells on these deficits
Appearance and behaviour
Often neglected, sloppy; manner facetious or apathetic and indifferent; catastrophic reaction may be evoked; emotional expression often labile and superficial
Facial expression sad, worried; manner retarded or agitated, never facetious or euphoric; bemoans or ridicules own impaired performance but not true catastrophic reaction
Response to questions
Often evasive, angry or sarcastic when pressed for answers or tries hard to answer correctly but just misses
Often slow 'I don't know' type of answer
Intellectual performance
Usually globally impaired and consistently poor
Often confined to memory impairment; inconsistent; if globally impaired, it is because patient refuses to make effort
(From Kaplan et al. 1988:194)
1 6 2 PATTERNS OF LIFESTYLE FUNCTIONING ASSOCIATED WITH COGNITIVE DISORDERS One of the important functions of cognition is reality testing. Cognitive processes enable people to interact purposively with themselves and with the environment. Because cognitive impairment is a feature of cognitive disorders, the behaviours associated with these disorders reflect a drastic alteration in the person's self-image and ability to interact meaningfully with the environment. Cognitive deterioration gradually erodes the person's ability to perform the basic activities of daily living, interferes with recall of personal memories and experiences to the extent that the past, which defines who and what we are, maybe lost. The present becomes a foreign place; familiar faces, places and personal objects become strange and unfamiliar. Personfamily interactions become strained as the family battles to adjust to the loss of a significant relationship and to the increasing need to provide supervision for the person. Exhaustion, demoralization and the degree of strain experienced by family caregivers have been cited as common reasons for referral to hospital services (Morris, Morris & Britton 1989).
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Psychodynamic patterns Self-knowledge and self-esteem Self-knowledge and self-esteem are gradually eroded as the disease progresses. This occurs because of the person's awareness of his/her growing inability to function efficiently and because of the way in which the disease process itself develops. Thus disorientation, memory loss, impaired judgement, impaired communication patterns and alterations in affect and personality all combine to reduce the person's ability to interact meaningfully with self and the environment. The latter represents two very important sources of selfknowledge and self-esteem. Impairment of the ability to retain and recall information is the most prominent symptom of dementia. In the initial stages, the person may be absent-minded and forgetful but may spend a great deal of time reminiscing about events and experiences of the past. As the disease progresses, memory loss extends to the remote past; familiar faces and places are mistaken for the unfamiliar, important memories and experiences are lost and the world becomes an alien place. As time disorientation increases, the ability to assimilate, retain and use cues in the environment is lost, for example, getting up in the middle of the night to go shopping. Disorientation with regard to place and person, as in the case of Alzheimer's disease, may become so extensive that the identity of the person concerned is eventually obliterated. Patterns of communication become impaired to the extent that the person is no longer able to interact meaningfully with others or to communicate needs. Use of language, which we take for granted, is gradually undermined. Aphasia (the inability to express oneself), apraxia (the inability to understand the meaning of things and inability to perform certain movements by virtue of motor impairment), palilalia (the pathological repetition of words or phrases) and paraphasia (the misuse of spoken words or word combinations) may develop. Comprehension of messages is also impaired: Mrs C is told repeatedly by the nurse that the television set is broken but she remains seated, waiting expectantly for the programme to start. Personality changes accompanying dementia include one or more of the following: emotional lability; impaired impulse control; suspiciousness as perception of the external and internal environments becomes increasingly distorted; lack of social tact, judgement, discretion and reliability; apathy or euphoria; and lack of inhibition. In some cases premorbid personality traits are accentuated. For example, a previously outgoing and sociable person might become withdrawn and paranoid. These personality changes have an impact on the people around the person. Family members may become irritable, frustrated and angry with the person even though they may realize that these changes are organically based. These changes often serve to further alienate the person from potential sources of support, thus leading to a further decrease in self-esteem. Thought patterns In the initial stages of the disease, some or all of the cognitive patterns mentioned in Chapter 2 may be present. Generally, those patterns characteristic of the person's thinking
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before the onset of the disease becomes accentuated. As the disease progresses, thinking becomes impoverished. In more severe cases, the person may become mute. Coping behaviours Defence mechanisms As the person becomes aware of the reduced ability to interact with the environment, feelings of hopelessness, worthlessness and frustration increase. The person may attempt to defend him/herself against the pain and distress associated with the growing realization of these losses. Denial of impairment, compensation for deficits, regression, rationalization, somatization and hypochondriasis in the form of preoccupation with symptoms such as dry mouth and gastric upsets, and overt aggression in response to demands from the environment, may be evident in daily behaviour. As the disease progresses, these defences crumble and the person might engage in more primitive defences, as seen in rigid, negativistic behaviours. These people are particularly vulnerable to depression and anxiety and the associated complications such as suicidal thoughts and changes in vegetative functions. Cognitive appraisal and coping behaviours The ability to interpret (appraise) environmental cues and the value of objects is lost (judgement). Faulty appraisal results in inappropriate social behaviours such as shoplifting, going to town in a dressing gown, and exhibitionism. Promiscuity as a coping behaviour has been noted in young dementing adults. Because some patients have difficulty in differentiating between what is worth keeping and what is not, hoarding of seemingly meaningless objects such as teaspoons, or saving everything that comes into their possession, may also be observed. This behaviour may also indicate a need to create a stable point of reference in the face of declining losses. In addition, confabulation, changing the subject and pretending not to hear may also be noticed as the person attempts to compensate for the deficits. Wandering behaviour, which is a common outcome of disorientation and memory loss, is described as a means of coping with stress and anxiety, as a means of relieving feelings of loneliness, separation and frustration, as a means of communication, as a means of self-stimulation to relieve boredom, as a desire to travel in search of new experiences or discover old ones, and as a symptom of paradoxical agitation caused by psychotropic medications. One nursing research study compared the movement and social behaviour of eight wanderers and eight non-wanderers. The result showed that wanderers were more likely to have a diagnosis of cognitive disorder, had greater impairment of memory and orientation and tended to be less sociable than nonwanderers (Fopma-Loy 1988). Wandering behaviour is not always random and is to some degree under external, environmental control. One study mapped the patterns of wandering of three institutionalized wanderers. The results showed that these people developed consistent patterns of travel and would rest at points of interest, stimulation or potential
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reinforcement, such as an untended food tray, around other people, near windows with views outside and in areas of high activity like the nurses' station and/or tearoom (FopmaLoy 1988). Patterns of fulfilling biological needs The usual patterns here are invariably altered. The degree of disruption determines the amount of supervision necessary. Agitation, which is defined as 'inappropriate verbal, vocal or motor activity not explained by apparent needs or by confusion' (Curl 1989), can be manifested through wandering, inability to sit still, short attention span, picking at clothing, dressing and undressing, and constant hand movements. It is common in patients with dementia but is also seen in delirious patients. The person's sleep-waking cycle is generally normal for that particular age, in contrast to the pattern found in delirious patients who are generally drowsy during the day and unmanageable at night. However, as disorientation increases and the person loses a sense of cued time, the normal sleep-waking cycle may be disrupted and restlessness and confusion may be noted as twilight approaches. In the case of patients with a reversal of the day/night rhythm, chlorpromazine 25 mg-50 mg daily can be prescribed. As the disease progresses and self-care abilities are reduced, supervision in respect of eating, drinking and elimination is necessary. Poor appetite during the day is often noted and sphincter control is often reduced. Personal hygiene and dress may appear slovenly and disorganized, yet the same person may be compulsively ordered in other aspects, for example, arranging ornaments on the dresser in a particular way. Patterns of building and maintaining relationships Increasing cognitive impairment interferes drastically with this pattern of functioning. Significant people are not recognized and conversational abilities are reduced because of short-term memory loss and the loss of the ability to acquire new information. In the initial stages of dementia, memories of events and experiences before the onset of memory loss are easily recalled and the person might spend great deal of time reminiscing and describing these events in detail. This behaviour can isolate the person from others but, if understood within the context of the disease, it can be used to establish some contact with the person. Social isolation and withdrawal are common behaviours as the person confronts the losses associated with the disease. Caregivers' response to these behaviours depends to a large extent on their understanding of the disease process and their coping abilities. Harvis and Rabins (1989) report that at least two thirds of demented individuals are cared for in their homes. Care-giving can be very stressful and can lead to psychological and physical ill health in some family caregivers. One study shows that families caring for people with Alzheimer's disease in the home experience more stress symptoms, a more negative affect balance and less satisfaction with life than controls in the same age group.
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The stress of increased physical work because of the person's condition, sleepless nights, constant vigilance, social isolation, frustration and intra-family conflict can lead to family strain. One possible and frequently reported outcome of family strain is abuse of the elderly. Tentative statistics for elderly abuse show that at least one in ten elderly people experience maltreatment. Maltreatment may take the form of passive and active neglect, emotional anguish, financial abuse, material deprivation, deliberate neglect or benign neglect. The tragedy is that the elderly rarely report acts of abuse and neglect for fear of not being believed, fear of reprisal, fear of getting their children into trouble and fear of abandonment in an institution. Table 16.5 outlines the behaviours in the elderly that are associated with high risk for abuse, as well as the characteristics of those persons more likely to engage in maltreatment. A meshing of these profiles in the family can precipitate a crisis or series of crises in the abuser, which, in turn, can lead to the phenomenon of abuse. Table 16,5
Risk profile for abuse of the elderly
High-risk people (abused)
Female Physically and/or cognitively impaired Dependent but maintains authoritarian role with adult child Exhibits problematic behaviour; wandering, incontinence, night-time shouting High-risk profile (abuser) Family member (daughter is usual caregiver) Ill-prepared or reluctant to provide care Ineffective coping patterns Life in disarray Alcohol or drug abuse Marital conflict Lack of communication skills (Adapted from Hirst & Miller 1986)
Professional caregivers are also vulnerable to the stressors experienced by family caregivers. A common coping behaviour reported in nurses caring for the cognitively impaired is distancing and interpersonal withdrawal. These behaviours, although understandable, further serve to alienate the caregiver from much-needed interpersonal contact and support and can lead to increasing disorientation and confusion in the impaired person. Patterns of participation in group and community life As with all the other patterns of functioning, these patterns are also impaired if the disease is progressive. Requests to the person to join in certain activities might be met with
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aggression and hostility. Although these people appear to be, and in many instances are, solitary, one research study showed that when the chairs in the communal lounge were moved away from the wall and arranged into small groups of six or seven, demented people were more likely to interact with each other (Fopma-Loy 1988). Patterns of participation in work and of utilizing free resources As the cognitive impairment progresses, the person's ability to handle money, organize his/her time constructively and engage in meaningful, work-related activities is diminished. 16,3 WORKING WITH THE ORGANICALLY IMPAIRED PERSON Working with the organically impaired person can be extremely challenging for the nurse, both professionally and personally. Many of the behaviours associated with cognitive disorders result in distancing by caregivers; slovenliness, hostility, belligerence, slowness to respond or refusal to comply with requests may generate feelings of frustration and anger in caregivers. It can also be depressing for nurses to be caring and committed, only to find their patients deteriorating. Caregivers may be aware that there are no 'cures' and that the patient's functioning will deteriorate over time. This knowledge does little to protect the caregiver against feelings of hopelessness and impotence that might emerge as the patient deteriorates, despite every nursing effort. Behaviours such as emotional and physical withdrawal, avoidance and benign neglect are some of the ways in which nurses deal with their own feelings of helplessness, impotence and frustration. Although psychosocial nursing interventions might not reverse the process of dementia, it has been demonstrated that they can do much to minimize the maladaptive responses associated with cognitive disorders. Approaching the management of the person from the perspective of maintaining quality of life might help to reduce the nurse's sense of helplessness as well as some of the problematic responses associated with these disorders. Nurse-patient relationship One of the defining characteristics of mental health nursing is that it is an interpersonal process. One might question the validity of this characteristic when dealing with people with progressive brain syndromes because of their impaired communication abilities. The use of appropriate communication skills based on the principle of unconditional positive regard makes it possible for the nurse to enter and understand the world of dementia and delirium. Treating the patient as if he/she were not impaired conveys an attitude of normality to the patient. These communication principles form the basis for effective assessment, planning and intervention. Verbal communication Get the person's attention before speaking.
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Address the person by name and identify yourself by name each time that you interact with the patient. Messages should be clear, concise and unhurried. Because pronouns are often misunderstood, use short noun sentences that convey one idea at a time: 'Mrs X, it is time for lunch' is clearer than 'Mrs, I want you to walk to lunch with me.' Questions that require yes/no answers are more appropriate than open-ended questions. When making requests of the person, present the steps of the task one at time. Allow the patient ample time to respond to statements and requests. If the question or statement needs to be restated, exact repetition should be used. If the patient does not understand the request or statement after it has been repeated a few times, rephrase the content or change the subject to decrease frustration. Do not increase voice tone unless the person has a hearing problem, because it can be interpreted by the person as an aggressive overture. Non-verbal communication Non-verbal and verbal communication should be congruent so that the person's confusion is minimized. Allow the patient ample time to respond to statements and requests. Non-verbal gestures should be clear and unhurried; they can be used to enhance verbal communication and to cue appropriate responses from the patient, for example, pointing at the cup while asking the patient to pick it up. Physical stroking, hugging, patting and holding are valuable means of conveying caring and establishing contact.
Table 16,8 Mini mental-state examination Orientation 1. What is the: year? season? month? day? date? 2. Where are we: country? province?
Score point 1 1 1 1 1 1 1
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town or city? hospital? ward?
1 1 1
Registration 3. Name three objects, taking one second to say each. Then ask the patient to repeat all three after you have said them. Give one point for each correct answer. Rehearse the answers until the patient learns all three. Attention and calculation 4. Serial sevens. Give one point for each correct answer. Stop after five answers. Alternate: spell WORLD backwards (or 'HERFS' for Afrikaans-speaking patients). Recall 5. Ask for the names of the three objects learned in question 3. Give one point for each correct answer. Language 6.
Point to a pencil and a watch. Have the patient name them as you point.
7.
Let the patient follow a three-stage command: 'Take this paper in your right hand. Fold the paper in half. Put the paper on the floor.'
8.
Let the patient repeat 'No ifs, ands or buts'
9.
Let the patient read and obey the following: 'Close your eyes.' (Write the instruction in large letters.)
10.
Let the patient write a sentence of his or her choice. (The sentence should contain a subject and an object, and should make sense. Ignore spelling errors when scoring.)
11.
Let the patient copy the design printed below, (Give one point if all sides and angles are preserved and if the intersecting sides form a diamond shape.)
Date: TOTAL: 30 (Meiring 1990:136)
Assessment This process of assessment is not specific to the needs of the elderly population and can be used with people of all ages who may be suffering from dementia, for example, HIVrelated dementia. Since nursing assessment and intervention are primarily concerned with the patient's and the family's response to illness, assessment in this case focuses on: Differentiating between delirium and dementia; Identifying the underlying cause of the condition (HIV, Delirium toxicity and so on);
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Identifying the patient's current level of lifestyle functioning; Identifying the extent of the impact of the cognitive disorder on the family and/or caregivers; and Identifying to what extent factors in the environment influence the patient's response to the cognitive disorder. The psychiatric history, mental state examination and assessment of patterns of functioning are the basic assessment tools of the nurse. One particularly useful instrument which can be used as an adjunct to the mental state examination is the mini mental-state examination. Mini-mental-state examination
This examination (See Table 16.6) is particularly useful in distinguishing dementia from pseudodementia. Depressed patients usually attain a normal score. A score of below 24 for literate patients and below 20 for non-literate patients is indicative of dementia. Delirious patients rarely complete the test, largely because of attention difficulties. There is no time limit for completing the test. Patterns of lifestyle functioning
A number of specific questions concerning the patient's response to the cognitive disorder (see Table 16.7), how the family is coping (see Table 16.8), and the impact of the environment on the patient (see Table 16.9) can be asked as part of the assessment of patterns of lifestyle functioning. Table 18,7 Patient's response to the cognitive disorder 1. What coping behaviour is the patient using to defend against awareness of increasing impairment? 2. Is the patient becoming isolated and withdrawing from others? 3. Does the patient display emotional changes or increasing disorganization at certain times or in specific situations? 4. Is inappropriate behaviour brought about by specific situations, requests or communications? 5. Does the patient avoid situations that would expose the loss of intellectual functioning? 6. Do the patient's deficits require protection from self-injury? 7. Are the caregivers flexible, supportive and sensitive to the patient's needs? 8. Are eating, elimination, hygiene, dressing and sleeping problems developing or worsening? 9. What is the nature of the patient's sleep-waking cycle? 10. Are the patient's judgement and decision-making abilities becoming less reliable? 11. Is there behavioural evidence that delirium is worsening? 12. Is there evidence suggesting a toxic reaction to medication? 13. Is the patient using negativistic behaviour when requested to perform a specific task? 14. Does the patient wander and, if so, is this a problem? To who is wandering a problem? How serious is the problem?
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15.
What needs might any wandering behaviour be communicating?
16. 17.
Is the patient agitated? What degree of supervision does the patient require?
(Adapted from Haber, Hoskins, Leach & Sideleau 1987; Harvis and Rabins 1989; Curl 1989) Table 16.8 Family coping 1. 2.
Is the family involved in the care of the patient or is there hostility and rejection? What was the nature of the relationship between the caregiver and the patient before the onset
3. 4. 5.
of the disease? Have all family members accepted the diagnosis? Are some denying the diagnosis and, if so, how is this affecting interaction with the patient? Is only one member responsible for the care or is the responsibility shared?
6. Does the care-giving person feel burdened and unable to obtain relief? 7. Does the patient require constant supervision? 8. How is the patient's condition affecting the family financially and/or socially? 9. Are those members not directly involved in the care supportive of those who are? 10. Are family members able to talk about their feelings, fears and fantasies? 11. Does the behaviour of family members aggravate or minimize the patient's coping? 12. What coping behaviours - namely, problem-focused and/or emotion-focused - does the family use and to what degree are these behaviours effective? 13. How do family members feel about the eventual institutionalization of the patient? 14. Have they discussed this and who is to make the decision? 15. Is the caregiver able to have time free from supervising the patient? 16. Is there potential or actual abuse related to patient-care exhaustion? (Adapted from Haber et al. 1987; Morris et al. 1989; Harvis & Rabins 1989; Gilhooly & Whittick 1989) Table 16.9
Environment
1.
Is there safe, adequate space in which the patient can wander about?
2. 3.
Are any actions which are intended to manage the wandering actually intensifying the behaviour? Are other environmental factors such as weather and seasonal changes related to an increase in wandering behaviour?
4.
Is there an adequate number of staff members and/or family caregivers to allow for unhurried assistance to the patient and for supervision of daily activities?
5. 6.
Are clocks and calendars visible to help the patient maintain time orientation? Are the various rooms, for example, dining room, bathroom and bedrooms, clearly signed to help the patient maintain space orientation?
7.
Are the caregivers (including staff) knowledgeable about how the brain dysfunction affects behaviour, and does the ward programme reflect this understanding? Do opportunities arise for the patients to be informed about community and current events?
8.
(Adapted from Fopma-Loy 1988; Haber et al. 1987; Farran & Keane-Hagerty 1989)
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In addition to observation and interviewing, a number of strategies may be used to ensure that a thorough assessment of patterns of lifestyle functioning is done. These include: Behavioural mapping of wandering behaviour; Time-sampling recording, interval recording and continuous recording to identify the frequency of target behaviours, for example, withdrawal, agitation, wandering, confusion, aggression and factors (environmental, interpersonal) that might precipitate, reinforce or reduce these behaviours; and Rating scales for depression and anxiety (see Chapters 12 and 13 on anxiety and mood disorders). Behavioural mapping of wandering behaviour This involves monitoring the patient's wandering behaviour for a specific period of time, for instance three 40-minute periods over two days. Where the patient goes, the route travelled, the nature of the 'spots' rested at and factors precipitating wandering should all be noted. For example, one of Mrs G's maps might read: Name: Mrs G Date: 10.5.20 . . Factors precipitating wandering (weather changes, time of day, ward activities, recent losses, reaction to medication) Time 07:45
Sitting alone in the lounge; staff involved in bathing the patients; radio not working; warm, sunny morning.
Time 08:00-08:15
Route Left the dining room, walked through the lounge, out of the front door, across the lawn and slowly past the new ward construction site.
Stood at the fence watching the workers until they left for tea.
08:15-08:20 08:20-08:30 08:30-08:40
Rest points
Left the construction site, walked slowly down to the main gate. Stood watching the security guards checking in the cars; brought back to the ward by staff.
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An analysis of Mrs G's wandering maps might show that she was in search of stimulation; some form of activity was happening at each of the rest points. This information can then be used to plan appropriate intervention. Time-sampling recording, interval recording and continuous recording These methods can be used to determine the frequency, duration and intensity of target behaviours as well as factors that precipitate, reinforce or inhibit them (see Chapter 10, on psychiatric assessment). For example, the nurse noticed that Mr J seemed to become more aggressive when people were around him. Because this observation is too vague a basis for scientific care, she noted his behaviour every hour for ten hours, using time-sampling recording. The entries for four hours are as follows: Name: Mr J Date: 10.5.20.. Time 08:00
Behaviour Spat at Mrs S.
Location Lounge
Possible reason Mrs S knocked him with her elbow as she passed.
09:00
Quiet
Bedroom
10:00
Struck Mr G with walking-stick.
Dining room
Mr G was shouting loudly.
11:00
Kicked Nurse H on shin.
Bathroom
Nurse H was tugging at his belt buckle while he was trying to undo his shirt buttons.
This record shows that Mr J tends towards physical aggression rather than verbal aggression, and that this behaviour seems to occur when he feels his bodily space is being encroached upon. It is also possible that he interpreted the behaviour of others as aggressive and responded accordingly. Again, these findings serve as the basis for appropriate intervention. These techniques can be used as part of the initial assessment, to provide further clarification of problem behaviours identified in the nursing diagnoses, to monitor progress during intervention and to evaluate the effectiveness of nursing interventions. Analysing the data for the purpose of diagnosis The information is analysed and nursing diagnoses relating to the person and family are formulated. It is crucial that dementia be distinguished from delirium. Some examples of nursing diagnoses are given in Table 16.10.
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Common nursing diagnoses Potential for Injury: trauma RELATED TO disorientation and confusion EVIDENCED BY frequent shuffling of feet and falling. Disturbance in self-concept RELATED TO loss of independent functioning and ineffective verbal communication EVIDENCED BY excessive crying alternating with expressions of anger, refusal to participate in self-care activities and withdraws into social isolation. Table 1610 Nursing diagnoses Diagnosis
Information
Delirium
Manifested in night-time psychotic behaviour, drowsiness during the day and difficulty in directing or sustaining attention, possibly related to urinary tract infection.
Dementia
Manifested in impoverished thinking, impaired short-term and long-term memory and confabulation, possibly related to brain-tissue dysfunction.
Wandering
Manifested in prolonged absences from the ward, possibly related to the need for stimulation.
Aggressive outbursts
Manifested in hitting out and verbal swearing, possibly related to growing awareness of deficits and/or accentuation of pre-morbid traits and/or loss of privacy.
Daughter feeling exhausted and burdened
Manifested in physical neglect of the patient, possibly related to the patient's need for 24-hour supervision.
Goal-setting Because there is a difference between reversible and irreversible cognitive disorders, realistic goal-setting is an important part of the intervention process. Two principles guide the process of goal-setting. Firstly, it should be guided by the patient's level of functioning and the course the disease is likely to take. When a cognitive disorder is reversible, nursing goals and interventions are concerned with helping the patient to respond adaptively to the temporary deficits, supporting medical treatment of underlying pathophysiology and reassuring the patient that a return to health is a realistic expectation. When a cognitive disorder is irreversible, nursing goals and interventions are geared towards minimizing the psychiatric and physical complications that can accompany these disorders, relieving treatable symptoms of the disorder and creating an environment in which the individual can live as long, productive, and comfortable a life as is possible. Nurses sometimes become despondent when treatment goals are not achieved. One of the reasons for this is that they fail to take the progressive nature of the disease into account when setting goals.
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Example Nurse G set the following goal for Mr S, an elderly gentleman with the diagnosis of dementia: 'To improve orientation to reality'. Nurse K, on the other hand, set Mr S's treatment goal within the context of his behaviour and the disease process: 'To maintain orientation by increasing the availability of environmental supports as disorientation increases'. Nurse G became more and more despondent as her efforts to achieve the goal were frustrated. Nurse K was able to maintain a more optimistic perspective of herself as caregiver because her intentions were guided by a realistic frame of reference. A second but equally important aspect of realistic goal-setting is to include criteria that reflect the notion of the patient functioning at maximum potential. For example, a goal such as 'patient will make an effort to bath without supervision' allows the patient to achieve some degree of independent functioning but, at the same time, acknowledges that, given the circumstances, supervision might be necessary. Thus, goal-setting involves finding a balance between realism, hopeful expectancy and quality of life. 16.4
INTERVENING IN COGNITIVE DISORDERS
It has been shown that the environment can be manipulated to bring about positive changes in the cognitively impaired person's functioning. The term sheltered freedom is used to describe an environment that is supportive of the person's emotional, social, physical and cognitive abilities and deficits. Environmental manipulation is based on the principle of normalization. Intervention is concerned with creating as normal an environment as possible, based on the following notions (Redfern 1986): Patients are consistently encouraged to engage with reality. The environment compensates for gaps in patient functioning. Meaningful therapeutic activities and stimulation encourage optimal functioning. Activities take place in small groups. Patients are encouraged to exercise some degree of personal control within the context of their particular disability. Patient interaction and mutual help are encouraged. Appropriate behaviour is consistently reinforced. Ward staff are actively involved with patients and demonstrate attitudes of respect and acceptance in their verbal and non-verbal communications with patients. Environmental manipulation Because the intensity of the person's deficits and abilities fluctuates, the environment should be flexible enough to accommodate this, and stable enough to provide the person with a sense of consistency and continuity. This can be achieved in the following way.
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By establishing an unhurried and consistent daily schedule. Meal times, medication administration, therapeutic activities, rest times, bath times, etc, should take place at the same time each day. By allowing patients sufficient time to complete the various activities. It is vitally important that the ward programme matches the patient's needs and abilities rather than, as is often the case, requiring the patient to 'slot' into the ward programme. A rigid ward routine encourages dependency on the part of the patient because the pressure to ensure that activities are completed by a specific time generally results in the staff'doing for' patients. By ensuring that, where possible, the same staff members care for the same group of patients and that staff changes are reduced to a minimum, for example, a six-monthly rotation as opposed to a monthly rotation. Manipulating the physical environment to decrease wandering behaviour The physical environment can be modified to promote social interaction and reality engagement and to decrease wandering behaviour. Lounge chairs arranged in small groups of six or seven are more conducive to social interaction than chairs arranged in lines around the walls of a room. Sommer and Ross (in Holden 1982) found that social interaction among geriatric patients almost doubled after the room had been rearranged. Similarly, patients are more likely to interact with each other at meal times if the dining room is arranged to cater for small groups. Because wanderers are easily distracted by anything that is perceived as a barrier, access routes leading to unsafe or undesirable areas, for example, stairways, can be camouflaged with room dividers or screens. Placing chairs in areas of high activity, for example, outside the duty room and next to the front door, offers self-stimulating wanderers the distraction they might be seeking. In addition, an activity barrel filled with plastic objects - for example, large spoons, Tupperware containers and plastic toys - might also help to engage the attention of wanderers. Improper lighting in the form of sharp contrasts of shadow and light and night-time shadows contributes to increased disorientation and confusion. Improper lighting has also been associated with an increase in the probability of the patient's experiencing hallucinations and illusions. It has been suggested that proper lighting, for example, night-lights and lit corners, can promote normal sleep-waking patterns as well as reduce nocturnal confusion associated with delirium. Excessive background noise can increase feelings of tension and thus contribute to agitation, wandering and confusion. Noise, for example, a radio left playing in an unoccupied room and staff summoning patients from a distance, should be kept to a minimum where possible.
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Wide open spaces and lengthy corridors are not 'user-friendly' and may inhibit exploratory behaviour and mobility because of the lack of stable furniture to cling to. Although it is difficult to intervene at a structural level, furniture strategically placed may help to encourage mobility and exploratory behaviour. An enclosed outdoor area in which patients are able to wander safely is useful. The hazards associated with being outdoors should be taken into account; for example, suntan lotions, hats and umbrellas to prevent sunburn, and the provision of some shelter are necessary. Evidence-based practice Subjective barriers to prevent wandering of cognitively impaired people No randomized controlled or controlled trials were found. The other experimental studies that we identified were unsatisfactory. In all studies, outcomes were measured only in terms of wandering frequency rather than more broadly in terms of quality of life, resource use, anxiety and distress; no studies included patients with delirium; no studies were based in patients' homes. Reviewers' conclusions: There is no evidence that subjective barriers prevent wandering in cognitively impaired people. Price J D, Hermans D G & Grimley Evans J. Subjective barriers to prevent wandering of cognitively impaired people (Cochrane Review). In: The Cochrane Library, Issue 2 2003. Oxford: Update Software.
Environmental supports or aids Environmental supports refer to those devices that can be used to promote and maintain orientation to reality. Spatial orientation can be increased by the use of signs, arrows and colour-coded routes. Rooms should be labelled clearly according to their function, in other words, Lounge, Bedroom, Dining Room, Toilets and Bathroom. For those patients who are unable to comprehend language, pictures indicating the function of the room can be used. Coloured arrows along the walls, pointing the way to the various rooms, are also helpful. Coloured lines along the floors can be used to the same effect. Visible clocks with numerical dials, calendars, maps and pictures of places, boards with clearly written information about the day, month and weather and pictures of the current season help to increase orientation. It is not sufficient simply for them to be visible: patients must be encouraged to look at them and to comment on them as frequently as possible each day. Prosthetic devices in the form of glasses, hearing aids, walking rings or sticks can be used to compensate for sensory and motor deficits. Other devices, such as non-slip
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mats for plates, thick-handled utensils for eating and Velcro fasteners to replace buttons are useful when motor deficits interfere with eating and dressing skills. Psychosocial environment Intervention at this level focuses on manipulating the social and interpersonal atmosphere of the ward to support, maintain and enhance appropriate lifestyle functioning. Obviously, the quality of the physical environment will influence, to some degree, the quality of the psychosocial environment. However, if the quality of the physical environment is greater than the quality of the psychosocial environment, the therapeutic value of the environment as a whole is reduced. Staff attitudes are an important aspect of the psychosocial environment because they can influence positively and/or negatively the quality of care the patients receive. The impact of staff attitudes on patient well-being is perhaps best illustrated by the concept 'self-fulfilling prophecy'. This says that if people are treated in a certain way, they will respond accordingly. Caregivers may contribute to increasing dementia in several ways. Firstly, treating the patient as 'senile' encourages disorganized thinking and behaviour. Secondly, the assumption that progressive cognitive deterioration by definition implies an inevitable worsening of the condition leads to the belief that a stimulating environment is of no real value. Consequently, deterioration of the patient is expected and ascribed to a worsening of the condition without the impact of the environment being considered. Thirdly, treating the patients as incapable of making limited choices, of independent functioning and of some degree of awareness of the environment fosters dependency in patients and contributes to a loss of self-esteem. For example, behaviour such as talking about a patient as if he/she were not there because 'they won't understand', leaving the toilet door open because 'he/she doesn't know what is going on anyway', giving patients nicknames they have not chosen themselves or calling all patients 'darling/dearie/love', serves to reinforce the loss of dignity and self-esteem the patient might already be mourning. Attitudes that allow the person individuality as an adult, dignity, self-respect, choice and independence foster desirable patient behaviours. Psychosocial interventions include the following: Maintaining the physical well-being of the patient; Reality orientation; Reminiscence therapy; Validation therapy; Behaviour modification; Remotivation therapy; The use of physical restraints; Intervening within the family situation.
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Maintaining the physical well-being of the patient This aspect will be mentioned briefly because it is assumed that the learner is competent at intervening at this level. Patterns of nutrition, elimination, mobility, sleep, rest and hygiene can be maintained in the following ways: By ensuring adequate hydration and nutrition in the form of nourishing drinks and light, -well-balanced diets. Patients are often given 'sloppy' food because it is assumed that, even though they may have their own teeth or dentures, they are incapable of chewing and digesting firm foods. In addition 'sloppy' food is often given because patients take less time to swallow than to chew their food. The implications of this for the emotional and physical well-being of patients need to be seriously considered. By preventing constipation by increasing the amount of fibre in the diet, regular toileting, exercise and, if necessary, the use of mild laxatives.. By employing stimulating day-time activities (patients are often allowed to doze all day in chairs and then spend at least ten hours a night in bed) thus reducing day-time doziness and the need for night sedation, which in itself might contribute to nocturnal confusion and disorientation. Regular 'nap periods' built into the daily programme might help to restore energy for activities. By reinforcing the importance of personal cleanliness, grooming and dressing in the overall well-being of the person. Patients who appear dishevelled or who are dressed in an odd assortment of clothes are less likely to be treated with dignity and respect than those who are appropriately dressed. Dean (in Adams 1987: 42) investigated the clothing of elderly patients in hospital. He reported that'... to be fully dressed is good for morale, helps to maintain dignity, independence and status, delays institutionalization and in mental illness helps to mitigate disturbance and to provide resistance to deterioration'. Self-help in daily bathing and grooming should be encouraged and patients should be allowed to select their own clothing. By monitoring the physical health of the person carefully. Because urinary tract infection is one of the most common causes of delirium in the elderly, regular urine-testing is advocated. Self-care activities are not chores to be got out of the way so that the 'real' programme can start. They represent opportunities for remotivation, reality orientation, validation and retraining and are an integral part of the psychosocial environment. Reality orientation (RO) Reality orientation (RO) is a basic communication approach that aims to increase awareness of time, place and person. Helping patients to experience success and to protect them from undue exposure to their growing deficits are the major aims of RO. The less patients are exposed to their growing deficits, the more intact their self-esteem will be.
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Twenty-four-hour informal RO Twenty-four-hour RO is a 'continual process whereby staff present current information to the person in every interaction, reminding the patient of time, place and person and providing a commentary on events' (Holden & Woods 1982:51). Manipulation of the physical environment and the provision of environmental supports are important components of 24-hour RO. Every interaction with the patient is an opportunity for RO. Routine activities such as waking the patients, serving meals and helping them to the bathroom are invaluable opportunities for RO. It is important that information be presented in an interactional style so that the patient is given an opportunity to respond. In addition, RO information should also be linked to concrete experiences that have meaning for the patient. Telling the patient each time you pass him/her where he/she is, what the time is and who you are is of no value because patients with impaired cognition have difficulty in interpreting the meaning of abstract concepts. Example Nurse:
Mrs Nel, it is three o'clock in the afternoon. Would you like some tea? (Orientation to time, place and person; information is presented in a short, single-noun sentence; questioning to elicit a response; pause to allow sufficient time for a response.)
Patient:
Isn't it nearly supper time?
Nurse:
Are you hungry? (Validation, in other words, finding the meaning behind disorientation.)
Patient:
Sort of.
Nurse:
Tea time is at three o'clock (pointing to the clock). There are biscuits for tea. Supper time is at six o'clock ... that is three hours from now (showing where three o'clock is in relation to six o'clock). (Verbal and visual prompting; drawing a relationship between the abstract concept time and a concrete activity.)
Guidelines for 24-hour RO
Remind the person:
who he/she is; where he/she is; what time of day it is; and what is happening in his/her surroundings.
Do not: ask orientation questions of the patient.
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Aids: Use simple, short sentences. Use repetition. Encourage response. Use clear visual, tactile, sensory prompts. Use past experiences as a bridge to the present. Provide a commentary on events as they happen. Use concrete questioning. Encourage humour. Responding appropriately to confused, rambling talk is another important aspect of orientation. Responses that protect the patient from exposure to his/her deficits while at the same time helping him/her maintain a link with reality are desirable. There are a number of ways to achieve this, depending on the person's level of distress and disorientation. Tactfully correct the patient so that corrections can be accepted without loss of dignity. For example 'I am Sue Reed; perhaps I look like your daughter Sally?' If the patient is distressed and agitated, ignore the content of rambling talk and distract the patient by changing the topic or moving the patient's focus to something in the surroundings, for example, flowers or pictures. Focus on the underlying feeling behind the statement. For example: Mrs P, a retired school teacher, told Nurse F that she had to leave because she was due to hand out her students' test papers. Instead of correcting Mrs P with reality-based information, Nurse F focused on the underlying message: 'That must have been a good time of life when you were a school teacher and busy all the time.' Indirectly, Nurse F reorientated Mrs P to the present by referring to the past and recognized her need to feel productive and useful. Helping the patient to succeed involves protecting him/her from exposure to deficits by asking concrete, simple questions the patient will be able to answer, by creating opportunities for patients to respond, by using verbal and visual prompts and by acknowledging the relevant aspects of rambling, disoriented talk and behaviour. Structured RO sessions These can be used as an adjunct to informal RO. They provide the opportunity for intensive stimulation, guidance and retraining. As with 24-hour RO, the basic aim is to help the person to experience success, to know what is happening and to communicate. Group sessions are generally held on a daily basis for between 30 minutes and an hour. They should be scheduled at times when patients are least likely to be fatigued, for example, in the early morning or after naps. In many respects, structured RO sessions are similar to remotivation groups. The significant difference is that reality orientation information (time, place and person) is emphasized in the first phase of remotivation, namely when establishing a climate of acceptance.
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Therefore, reality orientation can be seen as one of the many topics for remotivation. The principles of RO sessions should be integrated with the principles of remotivation. The setting should be as informal and as pleasant as possible. Many authors suggest that a special room be set aside for RO sessions. In most instances this is not possible. However, a small corner of a room can be screened off and decorated with plants, colourful pictures and so on, to simulate a comfortable, homely environment. Group size depends on the patients' level of functioning. As a general rule, the numbers should be restricted to two or three patients, but the size of the group could be increased for mildly disorientated people. Naming members by name, using large name tags and shaking hands establishes physical and personal contact among members. Equipment includes a large, portable weatherboard with a collection of smaller slot-in pieces on which names of the days and months, and comments and pictures about the weather, are written. For those patients who can still write, personal diaries in which they can copy down the information can be handed out. Prompts to stimulate recall and the various senses can also be used to reinforce verbal information. This may include fresh fruit, flowers, food (sweet, sour, cold, hot or savoury), maps of places, picture cards illustrating occupations, pets, places, cars, birds or real-life models and songs appropriate to the situation. The possibilities are endless. Helping the patient to succeed involves protection from exposure to his/her deficits by asking concrete, simple questions that the patient will be able to answer, by creating opportunities for the patient to respond, by using verbal and visual prompts and by acknowledging the relevant aspects of rambling, disoriented talk and behaviour. Reminiscence and life-review therapy Reminiscing is the process of remembering one's past, either verbally or internally; it is memory that has been filtered through time and altered by one's life experiences. Reminiscing in the elderly is often regarded as a sign of impending senility and many caregivers tend to discourage it in favour of reality orientation. However, reminiscing about past events and experiences has adaptive value. Remembering past achievements contributes to the maintenance of a person's self-image and self-esteem. In addition, it creates opportunities for that person to resolve painful conflicts and memories and to integrate these into his/her self-concept. On the other hand, it also has potentially destructive aspects, especially if it leads to feelings of despair over the past or is used to avoid life's realities. Reminiscing is commonly seen in the early phases of dementia. As the person's shortterm memory fades, he/she begins to live more in the past and often recounts in great detail stories and happenings from the past. A great deal of important information can be gleaned about the person by listening to him/her reminisce. Previous coping mechanisms, hobbies, interests, etc, can be identified. Because memories from the past are filtered
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through the patient's current state of feeling, the nurse is able to assess the patient's current mood and to intervene appropriately. Understanding who the person was in the past can clarify otherwise confusing statements and behaviour. For example, knowing that a patient was an avid science fiction reader might help to explain why he/she refers to the duty room as the control room. Reminiscence therapy involves the following: Setting aside time to listen attentively to past memories; Encouraging reminiscence by introducing tangible reminders of the past, for example, photograph albums, old letters and music from the period; Acknowledging and reinforcing the person's past achievements and successes and, where possible, distracting him/her from focusing on painful memories — this is especially important because reduced ability to process new information limits the development of self-insight; Encouraging patients to share their memories in a group setting to promote interpersonal contact. Evidence-based Practice Reminiscence therapy for dementia
Two trials are included in the review, but only one trial with 15 participants had extractable data. The results were statistically non-significant for both cognition and behaviour. Reviewers' conclusions: No firm conclusions could be reached regarding the effectiveness of reminiscence therapy for dementia. The review highlighted the urgent need for more systematic research in the area. SpectorA, Orrell M, Davies S & Woods RT. Reminiscence therapy for dementia (Cochrane Review). In: The Cochrane Library, Issue 2 2003. Oxford: Update Software.
Validation therapy Validation assumes that the behaviour and speech of the person suffering from dementia have an underlying 'meaning'. The person's thinking and behaviour are primarily concerned with re-experiencing past enjoyments or emotions, or with attempting to resolve past conflicts and problems. Focusing on the feelings and experiences behind the seemingly nonsensical behaviour therefore brings to light the issues the patient may be grappling with. By talking with patients on their terms and on the subjects that they raise and choose to discuss, the nurse can help them to resolve past conflicts and to integrate these indirectly into their self-concept.
Example Nurse:
Are you filling your purse with paper?
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Patient:
No, no, no ...
Nurse:
Is this (touching the purse) very important, very precious?
Patient:
(Nods, continues to fold tissues carefully before stuffing the purse.)
Nurse:
You need to fill it up, to put everything where it belongs, to feel better?
Patient:
Yes, yes, very much ... (she used to stuff envelopes for a bookkeeping firm).
Note that this process of resolution is aided by the nurse focusing on feelings and not by confrontation, problem solving or insight-promoting therapy. Bleathman (1988) suggests that this form of therapy might be more useful in dealing with people suffering from dementia than reality orientation. She argues that the loss of skills necessary for independent living is so absolute that RO information is valueless. She poses the question 'Why should the patient care if it is Friday or Tuesday?' However, all the interventions mentioned thus far have their place and, if correctly used, can complement each other. Evidence-based practice Validation therapy for dementia Reviewers' conclusions: There is insufficient evidence from randomized trials to make any conclusion about the efficacy of validation therapy for people with dementia or cognitive impairment, although observational studies suggest there may be some positive effects. There is a clear need for well-designed, randomized controlled trials of validation therapy for dementia. Neal M & Briggs M. Validation therapy for dementia (Cochrane Review). In: The Cochrane Library, Issue 2 2003. Oxford: Update Software.
Behaviour modification There is evidence to suggest that people with cognitive disorders are capable of learning, given the right environmental conditions. These studies show that the use of positive reinforcements is effective in increasing the frequency of desirable behaviours such as independent eating skills, mobility, social and verbal interaction, participation in activities and continence (Holden & Woods 1982). A number of questions need to be asked in order to provide sufficient information to serve as the basis for a behaviour modification plan. Firstly, behaviours to be modified must be carefully defined. Continuous, interval and time-sampling recording can help to define the behaviour in terms of how frequently it occurs, the situation in which it occurs, events that precipitate it and, finally, what follows as a result. Secondly, the person's assets, abilities, interests and likes and dislikes must be
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identified because these are potential sources of positive reinforcers. Finally, inconsistencies in the person's behaviour should be noted. Inconsistencies refer to behaviour that occurs in some situations and not in others. For example, Nurse X reports that Mr L is able to dress himself, whereas Nurse Y says he cannot. Noting inconsistencies is especially important because it provides further clues to the best way to help the person and to the person's capacity for change. The behaviour modification plan consists of a set of goals or target behaviours, together with a set of procedures to achieve the target behaviours. The target behaviours should be specific enough to measure and should relate to the problem. Reward and modelling are the basic methods that can be used to bring about change. Reward If a particular consequence follows immediately after a behaviour, the person is more likely to repeat that behaviour when he/she next encounters a similar situation. Positive reinforcers include consumable reinforcers (food or drink); activity reinforcers (things the person likes to do, for example, hobbies, crafts, pouring the tea, watching TV, listening to the radio, walking or wandering); possessional reinforcers (things the person likes to possess, for example, perfume or a hairbrush; social reinforcers (verbal and physical stimulation, for example, verbal praise, hugging or touching). Reward should follow immediately after the desired behaviour has occurred. This is especially important when dealing with confused people, because they tend to forget quickly and the impact of the reinforcement is then lost. The environment can also be adapted to increase the probability that the behaviour will occur so that it can be rewarded. Example Nurse T noticed that Mr B became verbally aggressive when he was surrounded by large groups of people but was socially appropriate when in the company of smaller groups. She rearranged the lounge environment by placing the chairs in circles of four. Although the same number of people were involved, arranging the lounge in this way created an atmosphere of intimacy and privacy. Manipulating the environment in this way increased the probability that desirable behaviour would occur. Mr B was rewarded with attention from the staff each time he sat in the lounge without becoming aggressive. Over time, the circle in which he was sitting was enlarged by one chair each week until he was able to sit among a group of ten people without becoming aggressive. Russian (in Fopma-Loy 1988) describes how spatial orientation in patients was improved by the use of positive reinforcement. Patients were trained to follow coloured arrows (stimuli) to find their rooms. When they returned to their rooms, they were given preferred reinforcements such as food or TV. Modelling Modelling is a procedure whereby the desired behaviour is demonstrated to the patient in order to prompt him/her to perform that behaviour. Modelling is generally accompanied
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by a verbal description of the behaviour being performed. The behaviour to be modelled should be broken down into small steps, sequenced from the simple to the complex. Reinforcement should be given immediately when the person imitates an aspect of the modelled behaviour. Example Mrs B had forgotten how to make her bed. Nurse D broke the task down into small steps. First she demonstrated how to pull up the bottom sheet, explaining in simple sentences what she was doing. Then she asked Mrs B to pull up the bottom sheet in the same way. Immediately Mrs B attempted to straighten the sheet, she was rewarded with verbal praise. This continued until the entire bed was made. After two weeks of daily modelling and reinforcement, Mrs B was able to make her own bed with only verbal instructions to guide her. After another two weeks, she was able to complete the task with minimal instructions being given. Nurse I) was careful to give instructions immediately when she noticed Mrs B becoming frustrated in order to protect Mrs B from undue exposure to her defects and to ensure that she experienced success in performing the task. Behaviour modification techniques need to be adapted to maximize the possibility that learning will take place. The patient should not be allowed to become frustrated and rewards should never be withheld. Each time a reward is given, the reason for it should be explained to the person. The environment should constantly be monitored to ensure that it is aiding learning and not inhibiting it. Remotivation therapy Remotivation therapy aims to stimulate patients into thinking about and discussing topics associated with the real world. It can stimulate interest in the environment, increase communication skills and help patients to learn or relearn a wide variety of skills. It is essentially a group-based intervention, but the principles can be used to intervene at an individual level. Group remotivation has the advantage that self-esteem can be increased by means of belonging to a group, as well as by means of participation in offering answers, learning new knowledge and gaining skills. The philosophy behind remotivation is fun, success, involvement and sharing. Topics for remotivations are numerous, for example, reality orientation, washing hair, grooming, modes of transport and food. The phases of remotivation are the following. Establishing a climate of acceptance Here, the nurse attempts to establish an atmosphere of friendly rapport with and among the patients. This is achieved by introducing the patients to each other by name or by asking them to introduce themselves. Quiet patients are encouraged to participate, but if they choose not to, the nurse maintains friendly contact with the person through the use of non-verbal communications, such as smiling or eye contact. The nurse conveys a sense of enthusiasm, optimism and interest in the patients by commenting briefly on positive aspects of, for example, their appearance.
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Creating a bridge to reality This phase is a natural continuation of the first. The topic to be discussed can be introduced using a variety of approaches. Since the aim is to encourage the group to focus its attention on events outside themselves, approaches that stimulate the entire group to think about the topic are appropriate. The 'bounce' question is a short, thought-provoking type of question that is designed to lead from a general to a specific topic. Asking the entire group to name different types of garden plants might elicit the topic for discussion, for example, flowers. Visual aids, such as having a bowl of flowers on the table, may also stimulate participation. Poems, newspaper articles or a piece of music related to the topic can be introduced to stimulate further discussion. Sharing the world we live in Concrete questions such as why, when, where, how and what with regard to the topic are asked to stimulate further discussion. Patients are constantly reinforced when they participate. Visual aids may also be used to stimulate responses. Appreciating the world of work The aim here is to relate the topic under discussion to an occupation or hobby in the real world. Similar questioning skills are used. If reality orientation is the topic of the group, the importance of time in relation to work can be discussed, for example, being late for work and length of working hours. This helps to develop a subjective sense of the passage of time in patients. Again, visual aids may be introduced to help with the connection between abstract ideas and concrete reality. Creating a climate of acceptance All participants are thanked warmly for their involvement in the group and for their contributions. Patients should be thanked individually and praised for some aspect of their participation. The important themes are summarized and a date for the next meeting is set. Specific remotivation techniques include the following: talking to the whole group; redirecting questions to the group: 'Sally wants to know the name of the flowers on the table; can anyone tell her?'; acknowledging contributions as and when they are made; using a series of direct questions that move from the general to the specific: 'What season is it?' (Summer) 'Right! What month is it?' (December)'Good! What special holiday comes this month?' (Christmas) 'Well done!'; using repetition; summarizing is another form of repetition that helps to establish relationships between ideas and to set learning;
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using movement in the form of eye contact, turning towards members and leaning forward and clear, slow gestures can help to sustain attention because interest is maintained; using visual aids that are large, clear, colourful and uncluttered. Physical restraint The use of physical restraints is a controversial issue. In some instances it may become necessary, but it should be avoided if possible because it can aggravate the delirious elderly and cause untold physical problems such as abrasions and pressure sores. Rosen and DiGiacomo (in Strome 1988) list five specific instances when physical restraint might become necessary: violent behaviour that cannot be controlled adequately by interpersonal techniques or medication; severe agitation in a person whose condition precludes the use of medication; impending exhaustion or cardiovascular collapse due to hyperactivity; severely regressed behaviour, for example, faecal smearing; patient request. If a patient is to be restrained, restraints should be applied in such a way that the person's dignity and self-esteem remain intact. When using restraints, the following principles should be adhered to: Patients should be restrained in an upright position. Restrained patients should be placed in a position where staff are able to observe them and in an environment that is therapeutic. Patients should be ambulated and toileted two-hourly and on demand. Restraints should be made of soft, non-abrasive material. Restrained patients should be included in therapeutic activities where possible, or staff should ensure that they spend frequent, short periods sitting and talking quietly with the patient. Restraints should be removed immediately when the behaviour decreases and should never be used as a preventive measure. Patients should be positively reinforced for desirable behaviour. Restraints should not be used to punish patients for undesirable behaviour. All environmental and psychosocial intervention strategies aim to stimulate different aspects of the cognitively impaired person. Research has shown that, in the absence of stimulation, people rely on their recent memory to maintain orientation and clarity of thought. Because memory loss is a feature of cognitive disorders, sensory deprivation in the form of a monotonous environment or an absence of therapeutic activities can increase confusion and wandering behaviour in the organically impaired person.
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It has been found that increased stimulation by way of therapeutic activities leads to an increase in appropriate behaviour among a group of patients with dementia. These gains were lost when the programme was halted for two weeks. This study highlights the importance of stimulation as a guiding principle when intervening with the cognitively impaired person. 16,5
INTERVENING WITHIN THE FAMILY SITUATION
In working with the family, the aim is to assist the family to continue in its role for as long as possible. From the caregiver's perspective a cognitive disorder can be regarded as a chronic illness. Because there are no cures for the condition, the emphasis of family intervention lies in helping the patient to adapt to the various demands associated with the condition by developing effective coping behaviours. There is a clear relationship between caregiver burden and patient behaviours. For example, when patients are accusatory, violent, and delusional or exhibiting catastrophic reactions, 80 % of their families reported excess burden in care giving. Caregivers also need to be taught how to monitor and manage patient behaviours. The available literature on coping points out that emotion-focused coping strategies such as wishful thinking impede the adaptation process because, unlike acute illnesses, the problems are not going to go away. In dealing with chronic illness active, concrete, problem-focused coping skills are needed. Therefore, the most useful framework for family intervention is the problem-solving method. This method has the added advantage that, if used correctly, it can help the family gain a sense of mastery and control in the face of an otherwise unpredictable condition. A positive nurse-family relationship is central to the well-being of the family caring for a demented person at home. Hertzberg and Ekman (2000) suggest that nurses talk about 'we' and not 'us and them' to facilitate this process. Acknowledging family distress and exploring feelings associated with the condition. These include sadness related to the loss of a significant relationship, feelings of anger and resentment towards the person, guilt about having these feelings, denial of the condition, feelings of helplessness in the face of the person's declining abilities. Asking family members to narrate, in their own words, aspects of the person's lifehistory they wish the staff to know about. Making uninterrupted time to sit with family members and to talk about issues of concern, changes in treatment and so on. Identifying and exploring problem areas and establishing how the family copes with the person and his/her behaviours. Reinforcing positive coping strategies. Exploring the extent of the family's knowledge about the condition and providing necessary and desired information. Involving the family in the care process and in decisions relating to care.
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Helping the family to find alternate ways of coping with the patient and any problem behaviour, as well as with the family's own level of distress. A simple method of behaviour analysis the family can use to understand problem behaviour is the ABC method of analysis. A refers to the activating event, that is, to what happened just before the onset of the problem behaviour, B refers to the behaviour itself, and C to the consequences of the behaviour, that is, the responses of people within the environment to the behaviour. It may be that specific activating events precipitate specific behaviours which, in turn, elicit specific responses from people which themselves become activating events, and so on. Other helpful interventions: - Teaching the family stress management skills. - Devising time away from care-giving. - Reallocating physical and emotional care-giving tasks among family members for periods of time. - Providing simple activities for the person that create immediate pleasure, reestablish connections with family members, provide meaningful tasks and enable friendships. Examples include re-viewing family photographs, playing simple, home-made rhythm instruments, doing puzzles made out of old family photographs. - Developing environmental manipulation skills. - Facilitating psychosocial support meetings. - Eliciting outside help where necessary, for example, community nurses. Intervening with families can be done with individual families or by arranging for a number of families to meet together as a group. The latter approach is especially useful because families can share their problems as well as any successes and obtain support from other families in the same position. There are no simple techniques for dealing with the complex issue of abuse. A diagnosis of abuse is made on objective facts and not on personal feelings. Both the abused and the abuser are in need of help, support and counselling. Short-term management may involve providing both parties with immediate relief from stress by removing the elderly person from the home for a short while. Individual counselling with the abuser focuses on helping the family member to explore personal feelings about the aged adult, what factors are especially disturbing, how the response is triggered and what other mechanisms are available for dealing with stress. The abused elderly person in turn needs a supportive environment in which to regain self-esteem and the ability to trust. 16.5 PSYCHOPHARMACOLOGY In general, pharmacological treatment is symptomatic. Table 16.11 shows the different types of medication used in treating various conditions. The elderly are particularly responsive to pharmacological agents because old age causes alterations in receptor sensitivity and homeostatic mechanisms. The elderly therefore require smaller doses and/or longer intervals between doses.
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Oversedation (snowing) is not uncommon and contributes to increasing confusion, agitation and disorientation. Medication should therefore be prescribed judiciously and nurses should monitor the effects of medication and report these carefully. Table 16.11 Recommended medication Behaviour
Medication
Anxiety
Smalt doses of a benzodiazepine
Insomnia
Short-acting benzodiazepine (Triazolam)
Depression
Tricyclic antidepressants
Psychotic symptoms and potentially harmful behaviour, e.g. aggression, wandering and restlessness
Antipsychotic agents, e.g. haloperidol for daytime control and thioridazine at night
Essential Drug List (EDL) Delirium with acute confusion and aggression Acute delirium: Haloperidol, IV, 2,5 mg once; Lorazepam, IM or IV, 1 mg-2 mg once. PHC and emergency: Diazepam, IV, 10-20 mg for immediate sedative or hypnotic effect. Do not administer at a rate over 5 mg/minute. Monitor for respiratory depression. OR Lorazepam, IM, 2 mg-4 mg - if no response, THEN Haloperidol, IV, 5 mg-10 mg slowly OR Haloperidol, IM, 2 mg-5 mg hourly; Referral to hospital as soon as possible.
Evidence-based Practice Haloperidol for agitation in dementia Main results: The five included trials led to the following results: There was no significant improvement in agitation among haloperidol-treated patients, compared with controls. Aggression decreased among patients with agitated dementia treated with haloperidol; other aspects of agitation were not affected significantly in treated patients, compared with controls. Although two studies showed increased dropouts due to adverse effects among haloperidol patients, there was no significant difference in dropout rates, comparing all haloperidol-treated patients with controls. Reviewers' conclusions: 1. Evidence suggests that haloperidol was useful in the control of aggression, but was associated with increased side effects; there was no evidence to support the routine use of this drug for
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other manifestations of agitated dementia. Similar dropout rates among haloperidol and placebo-treated patients suggested that poorly controlled symptoms, or other factors, may be important in causing treatment discontinuation. 2. The present study confirmed that haloperidol should not be used routinely to treat patients with agitated dementia. Treatment of agitated dementia with haloperidol should be individualized and patients should be monitored for side effects of therapy. Lonergan E, Luxenberg J & Colford J. Haloperidol for agitation in dementia (Cochrane Review). In: The Cochrane Library, Issue 2 2003. Oxford: Update Software.
167 EPILEPSY AND COPING: PRINCIPLES FOR PSYCHOSOCIAL NURSING INTERVENTION It is assumed that the general nursing student has a thorough knowledge of the different types of epilepsy and of the associated nursing and medical treatments. This section focuses on assisting the patient to manage the psychosocial implications the condition may have. Although reference is made to the patient, this method of intervention can be used to intervene at a family level as well. Ruth Corbell, a busy mother and community worker, knew her life had changed when she suffered an epileptic seizure last year. She writes: I was a coward for not writing this a year ago, and seeing the full horror in print. I did not want to leave writing about it till the time when I could say 'the first few months were dreadful' or, 'I've got used to it now, it doesn't bother me'. I realize that my emotions are as strong as ever. They well up at a chance remark, a minor difficulty, a frustrated whim. Somehow, the idea of me and epilepsy just don't fit.
Ruth's statement illustrates two of the most important and yet two of the least understood characteristics of epilepsy. The first is that epilepsy as a chronic illness involves adjustment, not cure. The second is that adjustment involves successfully negotiating a change in self-image to accommodate this new aspect of self. This process of adjustment is often a difficult and painful one. What does nursing have to offer the person engaged in this process? Underlying the process of adjustment is coping. Coping has been variously defined, but within the context of nursing coping refers to the behaviours people use to control, master or resolve problems and their negative emotional consequences. Nursing is concerned with a variety of health-related behaviours observed in ill and well people. The actual health problem is the focus of medicine, whereas a person's response to the problem is the focus of nursing assessment, diagnosis and treatment. Because nursing has effective coping as its aim, it would be useful to place the psychosocial nursing management of the person with epilepsy within the context of a coping model. This model is shown in Figure 16.1.
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Principles for psychosocial nursing intervention
Epilepsy and coping
LEVEL 1
Beliefs about self; severity of condition and degree of seizure control; attitudes of others
Explore belief systems
LEVEL 2
Positive-negative appraisal
Explore threatening situations
LEVEL 3
Emotion-focused coping responses
Explore relationship between beliefs, appraisal of situations and behaviour LEVEL 4
Minimization, denial, anger, withdrawal, dependency
Examine positive and negative consequences of coping behaviours
LEVEL 5
Develop effective coping behaviours
Emotion-focused expressing negative emotions acknowledging strengths developing positive belief system
Problem-focused information-seeking support-seeking other direct actions
POSITIVE SELF-CONCEPT
Figure 16,1 Epilepsy and coping: strategies for psychosocial nursing intervention
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Cognitive appraisal Studies in the area of epilepsy and coping show that the way in which people perceive their condition and options for coping is the most significant factor in adjustment. People with epilepsy tend to view themselves and their condition as unacceptable to themselves and to others and are thus less likely to seek support. This negative appraisal is influenced by a number of factors. Firstly, people are more likely to evaluate their condition as threatening if they have tonic-clonic seizures, if their seizures are poorly controlled, if they experience unpleasant side effects from medication and if they have previously experienced rejection as a result of their condition. Secondly, the attitudes of others significantly influence the appraisal process. Negative attitudes towards people with epilepsy have decreased over the last 30 years, but they still exist. One study in this area showed that, of the 602 people interviewed, over two thirds believed that people with epilepsy are abnormal and more than one third associated epilepsy with violent crime and believed that the person should not go out without an escort. Prejudicial attitudes also exist in the area of employment. In general, underemployment and unemployment are high in people with epilepsy. The figures differ, but one study cites it as high as 34 %. Several investigators have identified difficulties encountered by people with epilepsy in finding and maintaining employment. For example, one study shows that 15 % of people lost their jobs because of seizures. Another shows that 50 % of people with epilepsy experienced difficulty finding work, while 42 % reported limited opportunities for career advancement because of their seizures. Family reactions vary and range from overprotection to scapegoating and rejection. A comparison study of epileptic and diabetic families showed that epileptic families perceived themselves to be less close and that the person with epilepsy was less involved in family interaction and activities. Considering the wide range of personal and social implications epilepsy has for patients, it is hardly surprising that they tend to evaluate themselves, their condition and their life events in a negative light, some more and some less. Coping behaviours The second step in the coping process focuses on the actual behaviour people use to manage the stressful appraisal. Depending on their function, they can be classified as emotion-focused or problem-focused strategies. Studies in the area of chronic illness and coping show that chronically ill people tend to use more emotion-focused strategies to cope with the anxiety they experience as they negotiate the adjustment process. For example, when Ruth was first diagnosed, she was afraid: afraid of hurting herself, afraid of dying during a seizure, afraid of what others would think of her, and afraid of losing her job. To deal with the emotional consequences of the problem, she began minimizing the true nature of the condition by referring to her seizures as faints resulting from bad migraines. She also continued to drive and forgot to
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take her medication or to keep her appointments at the local clinic. These behaviours can be interpreted as a denial of the condition. It was only after she was banned from driving that she began developing an awareness of the reality of the situation. She became resentful of the condition for causing her pain, embarrassment and inconvenience. She also began blaming society in general for its attitude towards people with epilepsy: if society were more receptive to the condition, she would be able to accept it more easily. Unpredictability in respect of epilepsy was a great source of fear to her. She began isolating herself at home and became more and more dependent on the family for comfort, support and reassurance. Denial, minimization, resentment, blaming and isolation are some of the emotionfocused coping responses people with epilepsy might demonstrate as they become involved in the process of adjustment. Psychosocial nursing management In terms of the coping model and the focus of nursing, these responses or illness behaviours may be called maladaptive if they interrupt, retard or halt the adjustment process. The challenge facing nurses is to assist the individual to accept the condition as an aspect of self and to develop coping responses and resources that enhance rather than inhibit self-image. If the coping model is reviewed from a nursing management perspective, a number of intervention strategies emerge, all of which are interrelated and based on the premise that the way in which someone thinks about an event influences his/her behaviour and emotions. Level 1: Exploring the person's belief system The starting point would be, within the context of a supportive counselling relationship, to work with the person to explore the beliefs he/she may have about self, the condition and its implications for his/her lifestyle. At this level, health education about the condition, medication and its side effects, the precipitating factors and injury precautions might be sufficient to correct beliefs based on lack of knowledge. One nursing study shows that the most important factor in medication compliance is information about the condition. Ruth described how, because she was not fully informed about her seizure condition and the role of medication in controlling her seizures, she would take her medication at irregular intervals or only when she remembered. On the basis of inadequate health teaching, she developed the belief that, as long as she took her medication at some time, seizure control would be achieved for that day. This belief led to a lowering in her seizure threshold. Another faulty belief that people hold is that mental and physical strain precipitate seizures. For many people this can lead to unnecessary passivity and a restricted way of life. Contrary to this popular belief, it has been shown that moderate amounts of physical and mental activity have the tendency to reduce epileptiform activity and seizure frequency.
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Because the person's perception of the condition is influenced by the social context, it might also be necessary to explore some of the positive as well as the negative beliefs that he/she might come up against. Asking the patient to make a list of all personally held beliefs about self and the condition is a useful strategy because the person is forced to clarify and make abstract ideas concrete. At this stage, the idea of being a PRO for people with epilepsy rather than a victim of prejudicial attitudes might be introduced. This level leads to the second level of intervention, where the person is assisted to identify events and situations he/she finds threatening, as well as situations in which he/she feels competent. Level 2: Identifying threatening situations People with a negative self-image tend to label all situations as threatening. This labelling does not always have its roots in reality and the person needs to learn to differentiate between situations that are in reality threatening and those that are not. Here, the person might be asked to make a list of situations in which he/she feels competent and of those in which he/she feels threatened. Ruth was anxious about going back to work because she believed her colleagues would avoid her and be unsupportive. In reality, her colleagues had been visiting her regularly and had clearly stated that they missed having her at work. As Ruth came to realize that her beliefs about her work environment were products of her own thinking, her anxiety began to diminish and she was able to consider returning to work. Level 3: Exploring the relationship between beliefs, appraisal of situations and behaviour The third level of intervention is to assist the person to understand that beliefs influence the appraisal of situations and, consequently, behaviour. A useful strategy would be to ask the person concerned to match the beliefs with the identified situations and then, next to each pair, to list the ways he/she behaves and the feelings he/she has in each situation. Ruth compiled the list shown below. Ruth was able to recognize that the beliefs she held about herself in various situations influenced her behaviour. Beliefs
Situations
Feelings, behaviours
Worthless
Work
Inferior, avoiding going back
Exercise causes fits
Playing with children
Anxious, finding excuses not to play with them, feeling guilty
Social outcast
Social events
Inferior, resentful, angry, blame others, avoiding social situations, e.g. going to the shop
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Again, to reinforce the idea of epilepsy as only one aspect of self, it would be important for the person to focus on the positive as well as on the negative. Ruth believed she was a social outcast. This led to her interpreting all situations involving other people as threatening, and consequently she isolated herself at home. At the same time, Ruth saw herself as a caring mother and wife. Highlighting this aspect of herself helped to increase her sense of self-worth. Level 4: Examining the positive and negative consequences of coping As the person begins to develop an understanding of how he/she responds emotionally and behaviourally to events, the fourth level of intervention is introduced. At this point, the nurse should explore with the person the positive and negative consequences of the coping responses. Just as people with negative self-concepts tend to interpret all situations as threatening, they also tend to evaluate their coping behaviours as ineffective. Again, this evaluation needs to be carefully challenged. Not all coping behaviours are ineffective. Coping is a shifting process and is, to some extent, situationally determined. Minimization might be a useful response in a situation involving strangers. On the other hand, if the person constantly uses minimization, some of the negative consequences could be medication non-compliance, leading to increased seizure frequency, which could in turn lead to further isolation. Sometimes people with epilepsy express a great deal of resentment and anger at having to take medication regularly, eat sensibly, monitor their seizures and be aware of factors that precipitate seizures because it means having to make lifestyle adjustments. In this case, the nurse could point out the positive consequences of these coping behaviours, such as seizure control and increased mastery of the condition. Level 5: Developing effective coping behaviours The goal of this level of intervention is for the person to develop and strengthen effective emotion-focused and problem-focused coping responses. Developing the ability to engage actively in the problem-solving process is particularly important since the aim is to facilitate a sense of mastery and control. Depending on the area of need, this would involve health education around a variety of alternate emotion and problem-focused coping behaviours. Emotion-focused strategies These may include learning to express negative emotions appropriately, to acknowledge the positive aspects of self and to develop a positive belief system. Ruth learned the positive self-statements each time she felt anxious in situations involving other people. She would say to herself, over and over, 'My seizures are only one part of me. There are other parts to me; I am a good mother, a competent worker and I like talking to people.' With continued practice, these positive beliefs became a part of her self-image and she was able to put her epilepsy into perspective.
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Problem-focused strategies These may include information-seeking strategies such as learning more about the condition, precipitating factors, medication and its side effects, legal restrictions on driving, and alternative transport services, such as bus routes, and possible safety precautions. Other strategies may include seeking support from social agencies, family and friends, learning how to tell relevant people about what to do and what not to do in the event of a seizure, and learning how to monitor seizures in terms of frequency and precipitating events and how to report this information in the course of clinic visits. Learning strategies such as relaxation training to deal with feelings of anxiety, assertiveness skills and ways of developing a realistic exercise plan can also prove useful. Ruth started to keep a seizure calendar. She would record the seizure type and frequency and any side effects she felt from her medication. When she attended the clinic, she was able to report her findings concisely. Being able to participate in her treatment in this way gave her a sense of control over the condition. Epilepsy and coping: Conclusion Too much emphasis has been placed on an individual's seizure and deficiencies rather than on strengths, abilities and overall capacity. This approach needs to be remedied if the person is to negotiate a successful change in self-image to accommodate epilepsy as only one aspect of him/herself. Placing the psychosocial management of the person concerned within the context of a coping model is one way of correcting this approach, since coping by definition implies mastery and control. Evidence-based Practice Specialist epilepsy nurses for treating epilepsy As yet, there is no convincing evidence that specialist epilepsy nurses improve outcomes for people with epilepsy overall. Important outcomes (for example, seizure frequency, psychosocial functioning, knowledge of epilepsy, general health status, work days lost, depression and anxiety scores) show no significant improvement. There is evidence that newly diagnosed patients whose knowledge about epilepsy is poor may improve their epilepsy knowledge scores after nurse intervention.
Reviewers' conclusions: It is clearly plausible that specialist epilepsy nurses could improve quality in epilepsy care. However, there is as yet little evidence to support this assumption as the present research base is small. Further research is needed to investigate the effectiveness of specialist epilepsy nurses before such recommendations can be made. Bradley P & Lindsay B. Specialist epilepsy nurses for treating epilepsy (Cochrane Review). In: The Cochrane Library, Issue 2 2003.
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168 HIV/AIDS AND MENTAL HEALTH The current level of 19,94 % of the adult population with HIV/Aids in South Africa makes it one of the most important contributors to morbidity and mortality in the country (UNAIDS 2000). It impacts on mental health care in two ways: firstly because of the emotional shock of a terminal diagnosis dealt to people living with HIV/Aids and their families, and secondly because of the psychiatric syndromes associated with this infection. The emotional shock of a terminal diagnosis is what keeps many people from going for Voluntary Counselling and Testing (VCT). However, the diagnosis cannot always be avoided, and shock, denial, anger, blaming, anxiety and depression often result from being told the diagnosis. These responses are normal, but the individual and family needs support from the nurse during the acute stress period. Often the diagnosis has not yet been disclosed to anyone else; this means the health professional is the only person who can support the individual. This support includes listening, recognizing and accepting the range of feelings expressed, giving information, assisting with decisions about whether to disclose and to whom, and assisting in identifying and accessing resources and other sources of support. According to Shephard (in Kirton 2003) people move from the initial shock after the diagnosis through a transitional phase to acceptance. One should not put a time limit on post-test counselling. Individuals and families vary enormously in terms of dealing with the diagnosis, and support should be available for as long as they need it. See the section on Crisis Intervention in Chapter 11 on this aspect. The following mental illnesses are associated with HIV/Aids: Depression: Rates of major depressive disorder amongst asymptomatic HIV-infected people range between 2 % and 11%, and amongst symptomatic HIV-infected people between 4 % and 18 % (Morrison et al. 2002). Anxiety disorders: It is estimated that between 2 % and 40 % of HIV-infected people have an anxiety disorder (American Psychiatric Association 2002). HIV-related encephalopathy occurs in 20 % to 30 % of persons with advanced Aids (Brew 1999). It consists of a complex of neurological conditions including HIV-related dementia, sub-acute encephalitis, HIV-related cognitive and motor dysfunction. It is also called Aids dementia complex. It begins slowly but increases progressively until the person is almost vegetative. HIV-related dementia (HAD): Between 70 % and 80 % of patients develop some cognitive impairment during Aids, but the severity varies (Wilson et al. 2002). Delirium: This is the most common neuropsychiatric complication in hospitalized Aids patients in the USA (Shephard & Dole, in Kirton 2002). Delirium may be caused by an underlying infection, electrolyte abnormality, or toxicity of prescribed or abused drugs. The mortality rate in cases of delirium is high and if the cause is treatable, it should be addressed urgently. The care of patients with depression and anxiety is not significantly different because the conditions are associated with HIV/Aids. Pharmacotherapy is indicated, but tolerance for
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tricyclic antidepressants may be high, while the side effects of the SSRIs, which include loss of appetite and diarrhoea, can be problematic. Many SSRIs also interact with antiretroviral therapy, and complicates the choice further. Table 16.12 Presentation of neurological conditions associated with HIV/Aids Condition
Presentation
HIV-related Encephalopathy
Early: Forgetfulness, motor slowing, poor finger movement. Later: Flattened affect, inability to perform routine mental tasks, obvious motor dysfunction, global dementia, paraparesis, incontinence.
HIV-related Dementia
Same as later stages of HIV-related Encephalopathy. Also difficulty in recall and problem-solving
Delirium
Marked fluctuation in symptoms, worse at night, prominent visual hallucinations, disorientation and altered level of consciousness. Abnormal movements may occur.
The objectives of care of patients with the neuropsychiatric syndromes are the same as those outlined in section 16.4, 'Intervening in cognitive disorders', and following on from the summary in Table 16.12, are as follows: Maintain a safe environment for the patient; Prevent complications from the neurological symptoms; Maintain vital functions; Provide support for family and caregivers; Assist with meeting self-care needs (hygiene, intake, elimination). Common nursing diagnoses Alterations in maintaining self-care RELATED TO nervous system dysfunction EVIDENCED BY psychomotor dysfunction, dementia, delirium. Potential seizures, paresis, weakness, disorders of movement RELATED TO nervous system dysfunction. Potential impairment of reasoning, perception, memory, language, problem solving, consciousness RELATED TO nervous system dysfunction. Potential emotional lability, personality changes RELATED TO nervous system dysfunction. Potential fever, headache, nausea and vomiting, stiff neck RELATED TO central nervous system (CNS) opportunistic infections. (Pratt 1995)
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The nurse should make sure that the underlying causes of delirium or dementia are addressed and eliminated, if possible. This includes metabolic abnormalities, sepsis, hypoxemia, anaemia, central nervous system (CNS) infections and malignancies, ARV, and illicit drug use. Once this has been done, the patient needs good basic nursing care. If this is given at home, the primary caregivers have to be educated and supported to ensure they know what to do and how to do it. This demands that the nurse make an assessment of the caregivers' resources and understanding, and that they are assisted in the care they have to give. CONCLUSION Working with cognitively impaired people offers a unique challenge to the nurse. Many nurses regard this area of involvement as time wasted since, in many instances, biopsychosocial deterioration is inevitable. However, considering that quality of life is the basic ethos of nursing, working with cognitively impaired people provides the nurse with a unique opportunity to practise this philosophy. WEB RESOURCES
http://alzheimers.meetup.com/members/857 This site allows you to make contact with other people and families (in South Africa and elsewhere in the world) who are finding ways of coping with many of the difficult life decisions presented by Alzheimer's disease. It also provides links to other information sites. http://www.mentalhealth.com/dis/p20-or05.html This mental health site provides up-to-date information on all aspects of organic mental conditions - including assessment, diagnosis, treatment, family management and links to other sites dealing with mental conditions and their treatment. http://www.goafrica.co.za/southafrica/society/health.html This is a South African site providing information on a range of health-related issues such as epilepsy, HIV, anxiety and depression, diabetes and so on. It also links to support groups for each of these areas of health. REFERENCES American Psychiatric Association. 2002 HIV and anxiety. Office on HIV Psychiatry-Anxiety. Retrieved from the www.psych.org/aids/modules/anxietyon Batt, L S. 1989. Managing delirium. Journal of Psychosocial Nursing, 27 (5), 22-25 Bjornaes, H. 1988. Consequences of severe epilepsy: Psychosocial aspects. Epilepsia, 29 (5), 28-33 Bleathman, C & Morton, I. 1988. Does it matter whether it is Tuesday or Friday? Nursing Times, 84 (6), 27 Brew B J. 1999. AIDS dementia complex. Neurologic Clinics, 17, 861-881 Caris-Verhallen, W M C M, Kerkstra, A & Bensing, J M. 1999. Non-verbal behaviour in nurseelderly patient communication. Journal of Advanced Nursing, Vol. 29 (4), 808-818
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Chiu, L, Tang, K Y, Liu, Y H, Shyu, W C & Chang, T P. 1999. Comparison between family-based care and nursing home care for dementia. Journal of Advanced Nursing, Vol 29 (4), 1005-1012 Clarke, C L. 1999. Family care-giving for people with dementia: some implications for policy and professional practice. Journal of Advanced Nursing, Vol. 29 (3), 712-720 Curl, A. 1989. Agitation and the older adult. Journal of Psychosocial Nursing, 27 (12), 12-14 Ellis, 1 M. 1999. Nursing care of older people: a personal construct theory perspective. Journal of Advanced Nursing, Vol. 29 ( 1 ) , 160-168 Floyd, M, Chaplin, J, Espir, M & Kurtz, Z. 1988. The management of epilepsy at work. International Journal of Rehabilitation and Research, 11 (1), 3-10 Fopma-Loy, J. 1988. Wandering: Causes, consequences and care. Journal of Psychosocial Nursing, 26 (5), 8-18 Graham, O, Naveau, I & Cummings, C. 1989. A model for ambulatory care of patients with epilepsy and other neurological disorders. Journal of Neuro-science Nursing, 21 (2), 108-112 Hutchinson, S A & Marshall, M. 2000. Responses of family caregivers and family members with Alzheimers disease to an activity kit - an ethnographic study. Journal of Advanced Nursing, Vol 31 (1), p. 44-50 Hertzberg, A & Ekman, S L. 2000. 'We, not them and us?'. Views on the relationship and interactions between staff and relatives of older people permanently living in nursing homes. Journal of Advanced Nursing, Vol 31 (3), 614-622 Kaplan, H I & Sadock, B J. 1988. Synopsis of Psychiatry (5 ed). Baltimore: Williams & Wilkins Kellet, U M. 1999. Transition in care: family carers' experience of nursing home placement. Journal of Advanced Nursing, Vol 29 (6), 1474-1481 Kirton C (Ed). 2003. ANAC's core curriculum for HIV/AIDS nursing (2 ed). Thousand Oaks: Sage Publ Lee, E^ T F, Chan, M C, Tarn, E P Y & Yeung, W S K. 1999. Use of physical restraints on elderly patients: an exploratory study of the perception of nurses in Hong Kong. Advanced Journal of Nursing. Vol. 2 9 ( 1 ) , 153-159 Levin, R, Banks, S & Berg, B. 1988. Psychosocial dimensions of epilepsy: A review of the literature. Epilepsia,29 (6), 805-816 Meiring, P de V 1990. Textbook of geriatric medicine. Cape Town: Juta & Co, Ltd Morrison M F et al. 2002. Depressive and anxiety disorders in women with HIV infection. American Journal of Psychiatry, 159 (5), 789-796 Pratt, R. 1995. HIV & AIDS: A strategy for nursing care (4 ed). London: Edward Arnold Resnick, B. 1999. Motivation to perform activities of daily living in the institutionalised older adult: can a leopard change its spots? Journal of Advanced Nursing, Vol. 29 (4), 792-799 Rundqvist, E M & Severinsson, E J. 1999. Caring relationships with patients suffering from dementia - an interview study. Journal of Advanced Nursing, Vol. 29 (4), 800-807 Rodney, V. 2000. Nurses' stress associated with aggression in people with dementia: its relationship to hardiness, cognitive appraisal and coping. Journal of Advanced Nursing, Vol 31 (1), 172-180 Shaw, C. 1999. A framework for the study of coping, illness behaviour and outcomes. Journal of Advanced Nursing, Vol 29 (5), 1246-1255 UNAIDS. 2000. AIDS in Africa, Country by country. Geneva: UNAIDS Webster, A & Mawer, G E. 1989. Seizure frequency and major life events in epilepsy. Epilepsia, 30 (2), 157-162 Wilson, D, Naidoo, S, Bekker, L, Cotton, M & Maartens, G. 2002. Handbook of HIV Medicine. Oxford: Oxford LJniversity Press
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CHAPTER SEVENTEEN
Nursing Care of Persons with Intellectual Disabilities L R UYS
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After studying this chapter the learner should be able to: Analyse the concept of intellectual disability and models of approach in the care of the person with an intellectual disability. Differentiate the most common disorders associated with intellectual disability. Assess level of functioning of the person with an intellectual disability utilizing an appropriate and relevant assessment tool. Compile and implement stimulation and skill-teaching programmes in the cognitive, social, occupational, and motor areas of development. Provide relevant information to parents and family with regard to caring for a person with an intellectual disability. Promote the prevention of learning disabilities at primary, secondary and tertiary levels by compiling mental health education and rehabilitation programmes for target population groups. Assess the impact of intellectual disability on the family and provide therapeutic interventions to assist family.
INTRODUCTION Nurses have been involved in the care of people with intellectual disability for many years. The attitude of the community to these people has varied over the years, ranging from disregard, and even rejection, to positive involvement. The last 50 years have seen tremendous progress in the care of people with intellectual disability. The greatest breakthrough was probably the general acceptance of a
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developmental perspective in this regard. A task group of the National Institute For Child Health and Human Development put it this way: The major empirical finding has been that in the majority of domains of infant behavior little relationship has been found between assessments or diagnosis in the first year of life and assessments later in childhood. The major theoretical achievement has been the explanation for the lack of these relationships. A developmental approach has emerged that recognizes that child progress is a product of both the capacities of the child and the experiences of the child' (1986: 2).
This approach is based on the assumption that no diagnostic label can forecast what a child will or will not be able to do. The emphasis is therefore on the development of capabilities and not on the making of forecasts. There are some problems with the terminology used in this area of psychiatry. Persons who have the disability feel that the term 'mental retardation' is stigmatizing and derogatory. However, this remains the correct terminology in terms of the DSM-IVTR classification system. Some people prefer the term 'mental handicap', which is not correct in terms of the WHO definitions of impairment, disability and handicap. In this system, handicap refers to the social barriers, rather than to the 'real' disability. In the UK the term 'learning disability' is now generally used, but causes confusion in terms of 'learning disabilities' as defined by the DSM-111-TR. In South Africa's Mental Health Care Act of 2002 the term used is 'intellectual disability', hence the decision to use it in this chapter, except when referring specifically to the diagnostic system. Intellectual disability is a term that best describes the problem and is correct in terms of the WHO classification. Similarly, in terms of anti-stigma language usage, one should not equate the person with the condition. Therefore, one should not talk of 'mentally retarded people', but of 'people with mental retardation'. This approach is followed in this chapter. The views of consumers are expressed below. Who we are is as much about how others see us as it is about our physical beings. We can eat right, exercise, and believe in ourselves all we want, but if no one ever notices it won't last for long. So what does it mean to be 'a person with mental retardation?' Does it say something about a person that is meaningful and relevant? Does it tell people something about that person that is valuable, helpful, or essential? When asked, most self-advocates with mental retardation will make it clear that the label 'mentally retarded1 is stigmatizing and limiting. If the label comes before the person then a large part of who that person is has already been defined. Despite clear indications from self-advocacy groups that the words mental retardation should be 'retired', support professionals and agencies that oversee support systems struggle with how to provide the necessary assistance to people who need it, without defining who is eligible (i.e., creating a label). By its very nature service provision hangs onto labels in order to know where to best put resources. The dilemma of dropping all labels and still accurately describing who can receive supports through State agencies is not solved. But
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there is a clear mandate from the people who receive these services and supports that people - not labels - always come first.' (Hewitt & O'Neill 998, 1)
The legislative position of people with an intellectual disability still needs further clarification and development, as outlined by Wigton et al. in 1997. Little has changed since that time, and the Integrated National Disability Strategy and the Constitution is still the mainstay of the policy in this area. 17.1 PREVENTION Primary prevention In a study by Molteno and Lachman (1996) in Cape Town, it was found that 45 % of intellectual disability was caused by prenatal factors, 17 % by perinatal factors and 9 % by postnatal factors. The most obvious way in which nurses can be involved in the primary prevention of intellectual disability is by ensuring good antenatal and maternity services. In South Africa these are a serious problem however. The South African Nursing Association identified the obstetrical services in the country as a serous problem area in 1986, and prenatal and mortality rates support this diagnosis. This means that birth injuries may be expected to remain an important cause of intellectual disability in this country. Another serious problem causing intellectual disability in many children is Foetal Alcohol Syndrome, which affects a very large number of babies in areas of South Africa (Molteno 1998). Another important preventive measure is genetic counselling to prevent genetic abnormalities. The most common abnormalities causing intellectual disability in South Africa are Down's syndrome and 'Fragile X'. Prevention is, however, not easy. Mabaso (1989) found that black parents would not consent to a therapeutic abortion even if a serious congenital abnormality were to be diagnosed prenataly. Early genetic counselling aimed at the prevention of high-risk pregnancies would probably not achieve much greater acceptability. Only long-term strategies, such as the improvement of the socioeconomic status of families and improved literacy, would make genetic counselling a more successful strategy for the overwhelming majority of the population. Secondary prevention The early detection of intellectual disability in order to commence stimulation and learning programmes as soon as possible after birth could play an important role in optimizing the capabilities of all children. This type of programme originated in the United States of America in the 1970s and spread rapidly. Early detection means the early identification of groups at risk because of developmental delays. The diagnosis only indicates a risk and focuses attention on the need for stimulation and learning, and should not be seen as a forecast of future capabilities. The programme usually includes comprehensive teaching and counselling of the parents. There is evidence that such programmes limit the educational, motor, sensory, language and social handicaps of these children.
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The establishment of programmes for early detection, stimulation and learning in South Africa is hampered by the following factors: There are few psychiatric nurses in primary health services throughout the country who could launch this type of programme. Alternative staff, such as primary school teachers and clinical psychologists, are just as scarce, if not more so. A large proportion of the population is illiterate and very poor, and home environments in such circumstances do not facilitate the early recognition of developmental delays. Specialized services for children with a developmental disability - and even for other children — are not generally available in large parts of the country.
Evidence-based Practice Iron therapy for improving psychomotor development and cognitive function in children under the age of three with Iron Deficiency Anaemia No evidence that this intervention is effective, although there is clinical improvement. Martino, S, Logan, S & Gilbert, R. 2001. Iron therapy for improving psychomotor development and cognitive function in children under the age of three with Iron Deficiency Anaemia. Cochrane Review www.cochrane.com, accessed June 2003.
Tertiary prevention This means that adequate, goal-directed programmes and services should be available for the optimum development of all identified people with an intellectual disability throughout their lives. This is an ideal that has not yet been remotely realized. Considering the fact that the population is made up of about 41 million people and according to the statistics about 1 % of the population can be expected to have mild or moderate developmental disability, the enormous need for services is evident. The policy of 'mainstreaming' or inclusion in typical classrooms might go a long way to addressing the need. Inclusion is the educational process by which all learners, with or without disabilities, are educated together with sufficient support, in age-appropriate, regular education programmes in their neighbourhood schools. Support is often provided in a 'push-in' (inciass aid), or 'pull-out' (visits to a resource room) basis. This approach became the rule rather than the exception in the USA in the late 1970s, when the Education for All Handicapped Children Act made educational provision for all children in the 'least restrictive environment a right (Rynders & Low 2003). in a recent national studv in the USA the majority of teachers who participated in the nationwide study, commissioned by the National Down Syndrome Society (NDSS), reported that entire classes benefit from working with a learner with Down's syndrome.
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Almost all teachers who responded found inclusion enjoyable, with some calling it the single most interesting and rewarding experience of their careers. Overall, both parents and teachers find current inclusive practices successful, but there is room for improvement. The study found that more appropriate teacher preparation and more time for conferences between teachers, therapists, parents and support personnel would be beneficial to all involved. Factors directly affecting the success of an inclusive experience, as measured by both parents and teachers, include a match of teacher personality and style to the skills of a learner. Teachers who are flexible, willing to modify classroom materials, and who utilize hands-on learning tools, are the bests catalysts for achievement. Those parents whose children with Down's syndrome had friends in class rated the inclusion experience the most successful and reported great benefits in the areas of communication, self-esteem and independence. Teacher preparation is important for success, but surprisingly, formal training from the school district does not appear to be relevant (NDSS 2003). This approach to rehabilitation and social integration of people with an intellectual disability is the direction in which the future lies. 17.2
INTELLECTUAL DISABILITY
The term 'mental retardation' refers to significant sub-average intellectual functioning associated with concurrent impairments in adaptive behaviour manifested during the developmental period (Molteno & Westaway, in Robertson, Allwood & Gagiano 2001: 345). The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) defines mental retardation according to the following four subtypes reflecting the degree of intellectual impairment: mild mental retardation; moderate mental handicap; severe mental handicap; and profound mental handicap. Persons with mental retardation or an intellectual disability comprise 2 % to 4 % of the population and, of this group, most have mild retardation, approximately 20 % have moderate retardation and 5 % have severe or profound retardation. A figure of 4 per 1 000 of the population is used for the planning of services for learning disabled persons. This condition is often associated with others, such as epilepsy, cerebral palsy, sensory impairment and behavioural problems. The population with an intellectual disability has the same wide variety of characteristics as people with a normal IQ, and the person with an intellectual limitation has his/her own preferences just as others do. It is therefore important to treat every person with an intellectual limitation as an individual and without prejudice. People with such a limitation sometimes have a limited range of emotions, and lack personality traits such as self-control and perseverance due to their intellectual disability. They find it
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difficult to grasp abstract concepts and they have a limited understanding of the choices that may be put before them. They usually have less drive, energy and motivation than people with a normal IQ, although such traits vary enormously even in the 'normal' population. A limited intellect impairs normal development. This in turn makes this group more vulnerable to personal and emotional problems such as poor self-esteem, acting-out behaviour and excessive attachment. Because of their cognitive and affective limitations they are unable to give adequate meaning to the realities surrounding them and it is almost impossible for them to interpret abstract reality. They have a fragmented perception of their world and often miss the meaning of complete experiences. Table 17.1 Development features of subtypes of people with intellectual disability Degree of mental retardation
Preschool age: 0-5 years
School age: 6-20 years
Adult: 21 years and over
Mild: IQ 50-55 to about 70
Can develop social and communication skills; minimal impairment in sensormotor areas; often not distinguishable from normal children
Can master academic skills; often taught in special classes in normal schools; can be guided into social adjustment
Can usually master vocational skills well enough to be self supporting, but require guidance and support when under unusual social or economic stress; open job market; are in unskilled or semi-skilled employment
Moderate: IQ 35-40 to 50-55
Can talk and learn to communicate; poor self-awareness; fair motor development but reach milestones later; profit from training in self-help procedures by means of early detection and stimulation and learning programmes; placement in day centres from the age of three years
Profit from training in social and occupational therapeutic skills; can learn to travel alone in familiar places; trained in training centres
May be self-supporting and able to do sheltered employment in special workshops; require supervision and guidance when under moderate social or economic stress
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Degree of mental retardation
Preschool age: 0-5 years
School age: 6-20 years
Severe: IQ 20-25 to 35-40
Poor motor development; speech minimal; profit little from training in selfhelp procedures; few or no communication skills; early detection, stimulation and learning programmes
Can talk or learn to
May contribute partially to
communicate; can be
self-care under full-time
Profound: IQ below
20 or 25
Minimal capacity for sensor-motor functioning; require total physical care
Adult: 21 years and over
trained in elementary
supervision; can develop
hygiene skills; profit from
self-protection skills to a
systematic habit training
minimally useful level in a
in stimulation centres
controlled environment; spend their lives in stimulation centres
Limited motor development; may respond to minimal or limited training in self-care; admission to care facilities often necessary
Limited motor and speech development; may develop very limited selfhelp skills; require total care for life
(Adapted from Kaplan & Sadock 1985)
173 ASSESSMENT In keeping with the developmental approach, assessment focuses on function and development and not on the DSM-IV-TR diagnosis. A complete assessment of a person with an intellectual disability includes more than the assessment of the individual. It also includes an assessment of the parents or caregivers and the environment. The Washington guide for promoting development in the young child (Barnard & Erickson 1976) offers a framework for developmental assessment. The developmental stages and chronological age are compared, offering guidelines for the support of parents. This instrument is included as an example (Table 17.2). Table 17,2 Washington guide for the evaluation of the development of young children Motor skills
Eating skills
Play
1-3 months Head erect briefly when prone Head erect and bobbing when supported in sitting position
Sucking reflex Rooting reflex Swallows strained food
Quietens when picked up Regards face of others
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Motor skills 1-3 months (continued) Follows object through all planes Palmar grasp Moro reflex 4-8 months Sits with minimal support and stable head and back Sits alone steadily Plays with hands which are usually open Grasps rattle or bottle with both hands Picks up small objects, for example a cube Transfers toys from one hand to other Neck-righting reflex 9-12 months Rises to sitting position Creeps or crawls, maybe backwards at first Pulls self to standing position Stands alone Cruises Uses index finger to poke Parachute reflex Landau reflex
13-18 months Walks several steps without support Balanced when walking Walks upstairs with help and crawls downstairs Turns pages of book
Eating skills
Play
Co-ordinates sucking, swallowing and breathing
Uses tongue in moving food in mouth Hand to mouth motions Recognizes bottle on sight Gums or mouths solid foods Feeds self cracker
Plays with own body Distinguishes strangers from family Seeks out objects Grasps, holds and manipulates objects Repeats enjoyable activities Bands toys or objects together
Holds own bottle Drinks from cup or glass with assistance Finger-feeds Begins to hold spoon
Puts objects in containers and takes out Explores objects in hand Plays interactive games (peek-a-boo) Holds toys out to others without letting go Makes an effort to get hold of toys which are out of reach
Holds cup and handle with digital grasp Lifts cup and drinks well Begins to use spoon, may turn bowl down before reaching mouth Difficult in inserting spoon into mouth May refuse food
Plays alone, may play near others Has preferred toys Enjoys walking activities, pulling toys Throws and picks up objects, throws again Imitates, for example reading newspaper, sweeping
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Motor skills 19-30 months Runs Walks up and down stairs one at a time (not alternating feet) Imitates vertical strokes Imitates building tower of four or more blocks Throws ball overhand Jumps in place Rides tricycle
Eating skills
Play
Drinks without spilling
Parallel play, not
Holds small glass in one hand
interactive but plays alongside another child
Inserts spoon in mouth correctly Distinguishes between food and inedible material Plays with food
Uses both large and small toys Rough-and-tumble play Play periods longer than before, interested in manipulative and constructive toys Enjoys rhymes and singing (TV programmes)
31-48 months Walks downstairs, alternating feet Hops on one foot Swings and climbs Balances on one foot for 10 seconds Copies circle Copies cross Draws person with three parts
49-52 months Balances well Skips and jumps Can heel-toe walk Copies square Catches bounced ball
Pours well from jug Serves self at table with little spilling Rarely needs assistance Interested in setting table
Feeds self well Sociable and talkative during meal
In playing with others, begins to interact, shares toys and takes turns Dramatizes and expresses imagination in play Combines playthings, more use of constructive materials Prefers two or more children to play with, may have a special friend
Dramatic play and interested in going on excursions Fond of cutting and pasting, creative materials Completes most activities
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Language
Toilet training
Dressing and undressing
1-3 months Smiles when socially stimulated Has facial, vocal and generalized bodily responses to faces Makes prelanguage vocalizations that consist of cooing, throaty sounds, for example 'goo' Makes 'pleasure' sounds Crying can be differentiated from discomfort, pain and hunger sounds 4-8 months Eyes locate source of sounds Responds to 'hi there' by looking up at face across and in front Turns head to locate sound at 90-degree angle from head Laughs aloud when stimulated Produces vowel sounds and chained syllables, for example baa, goo-goo and didi Makes 'talking sounds' in response to others talking Vocalizes to toys Babbles to produce consonant sounds 9-12 months Ceases activity when name is pronounced or 'no no' is said Gives toys on request when accompanied by facial and bodily gestures
Begins to show regular patterns in bladder and bowel elimination Has one to two stools daily
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Language
Toilet training
Dressing and undressing
9-12 months (continued) Attends to simple commands Imitates definite speech sounds such as tongue-clicking,
Interval of dryness does not exceed one to two hours
lip-smacking or coughing Uses two words that are specific for parents, for example 'mama' and 'dada' 13-18 months Attends to person speaking
Will have bowel movement
Finds 'the baby' in picture
if put on toilet at
when requested
approximate time
Removes socks, hat and
Indicates wants by gestures
Indicates wet pants
shoes
Co-operates in dressing by extending arm or leg
Looks towards family members
Can unzip zips
or pets when named
Tries to put shoes on
Uses three words other than mama and dada to denote specific objects 19-30 months Points to one named body part
Anticipates need to
Can undress
Follows two or three verbal directions not accompanied by gestures
eliminate Same word for both
Can remove shoes if laces are untied
functions
Helps dress
Combines two different
Daytime control
Tries to unbutton
words, for example 'play ball', 'want cookies'
(occasional accident)
Pulls on simple clothes
Names objects in picture Refers to self by pronoun
Requires assistance (reminding, dressing and wiping)
rather than by name 31-36 months Attends longer to stories
Takes responsibility for
and TV programmes
toilet if clothes are simple
is more skilled
Demonstrates understanding of two prepositions by carrying
Continues to verbalize
Tries to fasten shoes,
need to go, apt to hold
usually incorrectly
out two commands, one at a
out too long
Does not know back
time, for example 'Put the block under the chair'
May have occasional accident
from front
Interested in dressing and
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Language 31-36 months (continued) Follows commands asking for two objects or two actions Demonstrates understanding of concepts of big and little Gives first name and surname Names what has been drawn after scribbling Tells you what sex on request Repeats few rhymes or songs Tells what action is going on in picture
Toilet training
Dressing and undressing
Needs help with wiping
Washes and dries hands, brushes teeth Buttons
General independence
Dresses and undresses with care except for tying shoes and buckling belts May learn to tie shoes Combs hair with assistance
38-48 months Expresses appropriate responses when asked if tired, cold or hungry Tells stories Common expression: 'I don't know1 Repeats sentences composed of 12 to 13 syllables Masters phonetic sounds of p, k, g, v, tf, d, z, Ir, hw, j, kw, I, e, w, qe and o 49-52 months Points to 1 cent, 5 cents or 10 cents on request Carries out command containing three parts Counts three objects, pointing to each in turn Defines simple words, for example hat and ball Asks questions Can identify or name four colours
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17.4 SUPPORT OF THE PARENTS OF CHILDREN WITH AN INTELLECTUAL DISABILITY Effect of a member of the family having an intellectual disability The gravity of the problems experienced with a family member who has an intellectual disability depends on the degree of disability, the concomitant emotional and physical impairment and the values, interests and circumstances of the rest of the family. Parenthood is a challenge and is viewed as an enriching and uplifting experience. Consequently, the birth of a child with a disability is extremely disillusioning. The hopes and expectations that the parents have for the child are shattered and they have to make tremendous adjustments. The most common responses of families with a member who is intellectually disabled are the following: denial, apathy, shock and tension; anger, bitterness and rejection; bargaining and going from service to service; depression, sadness, grieving, despair and guilt; acceptance and planning. Even after initial acceptance, such families find that raising a child with an intellectual disability is far more complicated than raising a normal child. Among the factors that cause additional pressure in the life of the family are the following: the specific disability of the child; slow development; the necessity of making special arrangements for the child's physical care, training and comradeship; the family's expectations of the future. These problems easily cause disequilibrium in the family. Financial problems are also common. Methods of supporting the parents of a child with an intellectual disability Professionals who work with the parents of children with intellectual disabilities should be knowledgeable about the medical, social, educational and behavioural aspects of the disability. They should also be well informed about available agencies and services, as well as about written information and aids that are useful in the home. Essential attributes demanded of these professionals include sensitivity to the needs of the families, and a great deal of patience and skill in solving short-term family problems. Barnard and Erickson (1976: 44-47) discuss the following guidelines for supporting the parents of children with an intellectual disability: Help the parents to learn how to plan for the optimum development of their child's capabilities.
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Encourage communication with both parents; it is important to communicate with them as a couple and not as individuals. Encourage them always to share their problems with each other. Offer them meaningful information. Talk about the future and encourage a positive outlook. A sense of hopelessness about their child's chances of improving is very discouraging and results in a negative attitude. Provide opportunities for meeting other parents in a similar position for the purpose of sharing their experiences and needs. Assist in establishing community facilities to support parents with children with an intellectual disability in their educational task. These include schools, day centres and therapy centres. Support them for the periods of stress they experience while their child is growing up. Among the most effective sources of support are parent groups, such as the Down's Association, which offers support, information and services to members. Parents with similar problems readily accept one another because they understand one another's problems and can talk about them. Parents find a sympathetic ear for their anxiety and stress in these groups, as well as support to work through and cope rationally with their problems. The support of the parents of children with an intellectual disability is a long-term undertaking, as these children may always be dependent on some level of support. Support is required to enable them to fulfill their role as a permanent unit in a functioning family and to prevent family dysfunction and disintegration. Support with regard to specific aspects Discipline The parents of a child with an intellectual disability often have difficulty in disciplining the child because of their response to the child's condition. The child's condition. These children do not learn as easily as normal children do because of their limited intellectual capacity. They require stronger, more organized and more repeated stimuli than their brothers and sisters. When they realize that normal discipline is unsuccessful, parents may begin to believe that these children are incapable of learning the desired behaviours, instead of understanding that they merely need more help. Response of the parents. Overprotection is often one of the responses of parents to a child's disability. They do not want to be strict, as they are afraid that this will be construed as rejection or cruelty and they feel sorry for the child. This, together with the belief that the child has too little understanding to profit from discipline in any case, results in a lack of discipline.
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Intervention is essential. People with an intellectual disability are not readily accepted in the community at the best of times and to be further handicapped by unacceptable behaviour is an almost certain recipe for rejection. The future of such children therefore depends on successful discipline. The following interventions are necessary: 1. Help the parents to discuss their own feelings about the problem. Work through feelings of guilt or pity and correct misconceptions about the child's capabilities. 2. Identify problem behaviour and help the parents to plan and implement a consistent response. It is often necessary to acquaint parents with techniques such as time out, as these are seldom used with normal children. Time out means that the child is removed from a situation for up to five minutes so that undesirable conduct is not reinforced by attention. It may be necessary to equip a special room in the house for this purpose. It may also be necessary for parents to use a particular technique, for example, ignoring a temper tantrum, by means of role play. 3. Ensure adequate support for discipline. The parents must support each other, and others in the immediate circle must understand and support the disc spline. Older brothers and sisters, grandparents, domestic helpers and play-group leaders should all be involved to ensure consistent discipline. Sexuality The past two decades have seen a greater acceptance of sexuality in South African society. At the same time the developmental approach to mental handicap has led to a more positive view of the potential of these people to lead normal lives. Their sexuality therefore presents special challenges with regard to their care. Sexuality is not limited to sexual intercourse, homosexuality, or masturbation. It is defined as the quality of being sexual and is one way in the individual expresses his or her personality. This can be seen in the person's choice of clothing, use of cosmetics and hairstyles, interaction in social settings and use of leisure time. Health workers can be encouraging and in the first instance promote healthy sexuality by assisting the mentally handicapped person to look as attractive as possible. This can be achieved by attending to personal hygiene and grooming, by encouraging the choice of appropriate clothing and by teaching acceptable social skills. Opportunities for males and females to interact socially in an age-appropriate manner should be encouraged. A few guidelines should be kept in mind in this respect: Sexuality is part of every person's being. It is not possible to encourage the development of a strong and healthy self-image in people who have an intellectual disability if their sexuality is denied. They must be helped to know and accept themselves as men and women. The sexual drives and needs of people with an intellectual disability seldom differ from those of normal people. They enjoy sex and view marriage in a very positive light, and some would like to have children. They are seldom hypersexual or asexual.
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Acceptable sexual conduct and morality needs to be learned by people with an intellectual disability from an early age. The denial or avoidance of this aspect of life leaves these people very vulnerable in the adult world. There are many myths, fears and beliefs in the wider community and among those involved in the care of people with an intellectual disability that impede healthy learning and development in this respect. Some of these problems are the following: The community denies the dignity of people with an intellectual disability and therefore has an aversion to associating highly regarded human behaviour, such as sexual intimacy and motherhood, with them. Remarks such as 'It's not right' or 'They don't understand' are typical of this view. Parents and caregivers are afraid that girls with an intellectual disability will be vulnerable to sexual exploitation and unwanted pregnancies. They fear that boys and girls will express their sexual curiosity and drives in an unacceptable manner and that this could lead to rejection and even prosecution. This fear often results in the denial of sexual maturity, for instance, by dressing adults with an intellectual disability like children, or by teaching them that all sexual behaviour is wrong. Professionals are often unwilling to make provision for normal sexual activities within the services for which they are responsible, as they are afraid of rousing the ire of families or the community. An extramarital sexual relationship or even a pregnancy could result in serious accusations against the service. Most institutions still do not provide married quarters and this exacerbates the problem for the staff. Some people question the ability of people with an intellectual disability to accept the responsibility of parenthood and believe that sterilization should be enforced. It is important to examine this argument thoroughly and from an ethical viewpoint. Few research findings are available, but those that exist show that mentally handicapped parents have 50 % fewer children than normal parents and that the intelligence of most of their children is within normal limits. It is not easy to find answers to this aspect of the lives of people with an intellectual disability. However, it is important to broach the subject with the parents early in the life of such children, and to help them to sort out their own feelings in this regard. In this way it will be possible to help the children to experience this enriching aspect of human life in a positive way. Schooling By the age of six years children with an intellectual disability also have to enter the school system. At this stage parents have to decide whether to place the child in a special school or not; many opt for integration into a mainstream school. It is very useful to have a thorough assessment done by an agency experienced in this field. To identify such agencies, contact a parent support group in the area, since they usually have the most experience. If parents decide on integration, the most appropriate school needs to be
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identified. Not all schools and/or teachers are equally 'disability-friendly', and some who might be very willing, have class sizes that makes it more difficult to cope. All these factors need to be taken into account when making a choice. Once a decision has been made, the child and parent need careful preparation for entry into the school. This might mean, for example, that the parents initially accompany the child, and then gradually reduce time with the child at school. If the child is in a mainstream school, Henderson (2001) makes the point that it might be necessary during adolescence for parents to organize social events where the child can interact with others with the same disability. The after-school programmes strive to build community and foster interdependence among young people who can become a peer group for each other. The activities emphasize communication skills, group affinity, decision-making, personal empowerment, self-help, financial responsibility, opportunities for service and recreation, lifetime fitness, outdoor adventure, creative movement, and the arts. Each group has 6-12 participants and meets roughly once a week for an hour and a half for a duration of nine months, following the academic calendar. In addition, the groups plan and take field trips or go on outdoor adventures together several times each year. 17.5 STIMULATION OF DEVELOPMENT Home stimulation programmes are based on the assumption that children with an intellectual disability develop better in stable, loving families than in institutions. The reasons for this are that sustained attention, a familiar environment and a consistent model exhibiting the same opinions, gestures and attitudes day after day are an advantage. Parents should be encouraged to act as teachers to their child with an intellectual disability for the following reasons: Parents are powerful agents of reinforcement. Parents know their children better than anyone else and usually devote more time to them. The effectiveness of interventions can be enhanced if parents use the skills they have learned. Teaching children at home reduces expense. Parents experience satisfaction by contributing to the development of their children. A home stimulation programme can be described as one in which parents are taught how to stimulate and teach a child who is living with an intellectual disability. A home stimulation programme consists of the steps outlined in Figure 17.1 and is based on the following components: Early stimulation of all senses; Teaching self-care.
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Early stimulation of senses Infants and toddlers with an intellectual disability require more repeated and stronger stimulation for development. Their environment should therefore be more stimulating than that of normal children - and this is seldom the case in institutions. Ideas for stimulating infants up to the age of three years are given in Table 17.3. Teaching self-care Observation and assessment form the first link in the chain of skills development. Teaching a skill merely because it is the next skill on a checklist - regardless of its relevance to the individual's life - is frustrating and useless to the person with an intellectual disability. For example, a child may be taught to tie shoelaces and is then given slip-on shoes to wear.
Assessment of child, parents and environment
Planning of priorities,
Follow-up
stimulation and teaching
Counselling and instruction of parents
Figure 17.1 Home stimulation cycle: assessment of child, parents and environment
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Table 17,3 Development stimulation chart Age in months
Communication and sound
Smell and touch
Vision
Gross motor skills
Fine motor skills
Feeding
0
Call child by name. Use full sentences and words; do not use baby talk. Tell child what you are doing; name objects you use. Parents must co-operate in . every way. Leave child with baby-sitter once in a while. Sing to child. Play radio softly near crib for short periods. Introduce child to sound of running water, musical toys, household utensils, whistling, rattles.
Hug, hold kiss, .stroke. Rub with different textures, for example cotton, silk, feathers, sandpaper, wood, thread. Introduce to odour of fruit, vegetables, :cereals, perfume, ;spices. Rub down vigorously with towel after bath. Feed and change from both sides.
Move crib around in room. Move child round to windows. Hang a single-object mobile 22 cm from eyes. Use bright sheets, pillowcases, clothes.
Exercise arms and legs in bath (passively if .' necessary). Place prone on hard surface.
Objects with different textures.
Make meals relaxed and pleasant. Give bottle and teach to suck and swallow.
1
Stitch bells to bracelets and shoes with dental floss. Encourage smiles and laughter.
Change mobile weekly. Use mittens in bright colours. Move objects in air in circle and arc for eyes to follow.
Help to sit up on mat on floor. Stimulate to raise head. Use infant seat. Place in sitting position for short periods.
Bring hands together round bottle. Show bright colours and objects for eyes to follow.
Feed cereals and strained food.
Toilet training
Age in months
Communication and sound
Smell and touch
Vision
2
Gross motor skills
Fine motor skills
Feeding
Supply good variety of tastes. ; Feed fruit.
Take outside, weather permitting. Roll over and over. Tilt in all directions. Swing in blanket. Bounce on bed.
Feed vegetables
3 4
Speak loudly, softly, Introduce hot, in high pitch, in a cold, hard, soft. low pitch, whisper. ; Bring into kitchen Reinforce sound when cooking. with facial expression and posture. ;
5
Clap child's hands. Play peek-a-boo. Repeat child's own sounds. Play finger and toe games. Start scrapbook with one object. Parent to name pictures in book.
Teach how to finger foods.
Hang multiple object mobile , 30-37 cm from eyes. Still change weekly.:
Allow to stretch for objects out of , reach.
; Rock prone back I and forth on beach : ; ball. Support in sitting position. . Allow to sit alone. ' Allow to sit on low ; stool in front of' table. Parent to play rough-andtumble games. Let swim if possible.
Give objects to hold in hands (to grasp and let go). Allow to reach for small objects.
For supper, feed egg yolk, meat (foods containing iron). Feed more coarse foods. Offer cup.
Toilet training
Age in Communication Smell and touch months and sound
Vision
Gross motor skills
6
Reward all language attempts. Give toys that make noise to hold.
Play mirror games. Fasten balloons to wrist and feet.
Allow to play with belly board.
7i
Play hide-andseek. Allow to stay with family during meals.
Alternate toy collection. Divide toys in 2-3 groups. Change groups every 2-3 weeks.
Allow to ride on parents' shoulders. Allow to play with blocks, aeroplanes.
8
Play hide-andseek (with parents and toys). Stay with parents during meals. Introduce to animal sounds.
9
Smell and touch trees, shrubs, flowers, grass, etc.
Fine motor skills
Feeding
Toilet training
Allow finger foods, for example crackers, cereals, toast. Encourage to dip fingers in food and bring to mouth. Allow to bang on blocks, saucepans, lids. Use kitchen utensils as toys.
Show outdoor Hang mirror above objects in motion, cot. Use Jolly for example cars, Jumper. Support lawn-mowers, feet. Allow to aeroplanes. Change , crawl on various toy collection. ! surfaces, for Divide toys into example floor. 2-3 groups. Teach to kneel. Play dropping and throwing games.
Allow to play with rag dolls, pack things in and out of boxes (aids visual coordination). Play water games.
Feed tactile foods. Try to get child to eat with spoon. Use bowl instead of plate. Often offer cup.
Check regularity of bowel actions. Put on potty when elimination is expected. Praise for success., ignore failure. Use correct terms for body functions. Use same words every time child goes to potty.
Age in months
Communication and sound
10
12
Name toys with single words. Name and point to body parts. Let child point to pictures.
14
Allow to play with toy telephone, listen to real telephone. Read simple stories. Help to follow simple commands.
Smell and touch
Vision
Allow exploration within boundaries of safety.
Hang notice board in child's room instead of pictures. Change pictures on board often. Use large, single pictures with objects.
Gross motor skills
Fine motor skills Wants to know what everything does. Allow to slash, stir, pour; feed self, drink from cup. Take off bottles one at a time.
Allow to play in sandpit with spades, buckets, cars. Teach to transport objects.
Encourage to return affection.
Encourage to touch textured pictures.
Feeding
Allow to push and pull toys. Give opportunity to help in house. Provide swing in garden. Help to climb up stairs. Allow to undress. Ask to fetch and carry. Encourage walking, holding onto shirt-tail, walking on various surfaces, for example grass, mattress, walk backwards, do somersaults.
Help to brush teeth.
Encourage to open, close, explore functions. Allow to play with crayons, build towers with blocks.
Toilet training
Age in months
Communication and sound
16
20
Teach to say please and thank you. Play blowing games. Teach to use plural, combine two words, play with others, name desired object, name object in picture.
Smell and touch
Vision
Gross motor skills
Fine motor skills
Teach to balance on one foot. Play jumping games. Imitate pets. Allow to play with tricycle, in paddling pool with supervision.
Teach to trace, finger-paint, put on shoes (without fastening), wash and dry hands.
Walk on stepping stones.
Feeding
Toilet training
Check on regularity of avoiding urine: 1. Fairly regular times. 2. Holds urine for hours. 3. Bothered by wet nappy. Keep written record of voiding for 2-3 weeks. Sit on potty when voiding is expected. Praise for success, ignore failure. Gradually teach neatness and table manners. Do not try to teach rapidly. Teach to drink through a straw.
Age in months
Communication and sound
24
Simple how and why of daily activities. Allow to play with puppets. Imitate other people, animals, objects.
30
Teach basic colours, opposites, to share, to fill in words in stories, name and address.
36 (From Godfrey 1975:60-61)
Smell and touch
Vision
Gross motor skills Teach to dress with help, without help.
Teach concept of shapes. Let play with form box. Teach names of colours. Teach concepts like under, in, on top.
Fine motor skills Teach long, short, i big, small, to trace ; circle, to build \ bridge with blocks.
; Play walking games \ Allow to play with I on well-marked I busy board, clay. ; route. Play followmy-leader. Let play i with large ! cardboard box.
Teach to set table.
j Feeding
Teach to brush ! teeth without I help.
! Make dental I appointment.
Toilet training
MENTAL HEALTH NURSING - A SOUTH AFRICAN PERSPECTIVE
There are a number of principles to remember when teaching anything to a person with an intellectual disability: Create a therapeutic environment conducive to learning. Ensure basic needs, such as toileting, are attended to first, before commencing teaching. Develop a trusting relationship, so that the person is comfortable with the teacher. The learning process should be fun. Ensure involvement of the individual, family, parents, other care-team members and significant others. Teach a skill that is one step above competence or at level of competence. Ensure continuity of teaching programme in a specific direction, so that gains are not lost. All teaching should be a building-on process, moving from simple to complex tasks. Establish a baseline (measurement of what the person can do before any intervention to change). Routine, reward and repetition are important in teaching the person with an intellectual disability. Break task into simple steps (task analysis). Talk to the person when teaching. Chaining is a technique used to teach a number of behaviours which, when linked together, form a complete skill, for example, 'feeding/eating with a spoon'. The task is broken into small steps which can be taught to the individual. The procedure of teaching a skill from the beginning to the end is termed forward chaining or progressive chaining This technique is not often used with the mentally handicapped as it can make learning difficult. Backward chaining refers to first teaching the person to complete the last step of the chain, and then working backwards. This is more successful, since the reward can be given immediately after completion of the task. The following are the most important aspects of self-care: motor skills, which eventually enable the child to walk and without which independence is impossible; feeding skills; dressing and undressing; and toilet training. Motor skills Children's early motor skills develop in the following sequence. Children can: 1. Lift their heads when lying prone. 2. A. Lift their heads with the weight on the elbows. B. Keep their heads in line when pulled into a sitting position.
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3. 4.
Lift their heads with the weight on their hands (and arms straight). A. Lean forward when sitting. B. Roll over from prone to supine. 5. A. Creep on the floor in the prone position. B. Crawl on arms and legs. C. Crawl contralaterally. 6. Stand with support. 7. Pull themselves into a standing position. 8. Stand without support. 9. A. Walk with support. B. Walk without support. 10. Balance and maintenance posture. - Do static balancing stunts. - Do balancing beam activities. - Do tumbling and gymnastics. - Play games requiring balance. - Go through an obstacle course. 11. Undertake locomotion. - Execute basic motor skills such as walking, running, hopping, skipping, jumping and landing. - Play games of touch. - Play relay games. - Do stunts. - Repeat rhythms. - Participate in play that entails movement. - Go through an obstacle course. Teaching step 1: Control of the head - lifting the head when prone
1. Place the child prone on a firm surface such as a carpet. 2. Stimulate the child to lift his/her head by calling the child's name or shaking a rattle in such a position that the child has to lift his/her head to identify the origin of the sound.
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Give plenty of reinforcement (smile, kiss and become excited) for every attempt to lift the head. 3. Kneel on the floor behind the child. Hold the child's head in your hands and lift it so that the child can focus on an object 30 cm in front of his/her eyes. The object must be directly in front of the child. Hold the child's head in this position for 15 to 30 seconds before lowering it. Allow the child some rest before repeating. Repeat the exercise three times a day (lift the head five times during each exercise session) to strengthen the child's neck muscles. 4. As soon as the child can lift his/her head and hold it upright for one minute, he/she is ready for the next step. Teaching step 2: Lifting the head with the weight on the elbows
A. 1. Place the child prone on the floor. 2. Place a blanket or rolled towel under the child's chest in such a way that the child's elbows and forearms rest on the floor. The roll strengthens the neck muscles and also those of the trunk and shoulders. 3. With much of the child's weight now on the elbows, place a toy nearby in such a position that the child can see, grasp and move it. The child may also enjoy looking in a mirror. 4. Engage in play, call the child's name, hang an object in front of and above the child's head, ring bells, anything to make the child lift his/her head. 5. Reinforce this behaviour by singing, clapping your hands and kissing the child. Gradually demand more from the child before showing that you are satisfied. 6. Place the child on the floor without the rolled blanket under his/her chest. Exert slight pressure on the sacrum; this stimulates the spine to straighten and lift the head. B. When the child has mastered the steps above, attention must be given to opening fists, as this is a prerequisite for placing weight on the hands. The following steps lead towards the child's opening his/her fists.
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1. Hold the child on your lap or place him/her prone on the floor and carefully massage a closed fist. Massage away from the knuckles until the hand begins to relax. Open the hand and let it rest on a smooth surface for a few moments. 2. While bathing the child, follow the same procedure in the water. Warm water is relaxing and the child's hand will open more readily. 3. Every day place a face cloth or small toy in each hand for 20 to 30 minutes. Roll up a face cloth (or other absorbent material) and place it in the child' hand in such a way that the thumb is pushed out straight. If necessary, use masking tape or sticking plaster to ensure that the hand stays in this position. 4. Every time you pick up the child, place your middle and index fingers in the child's fist to encourage a more open hand position. Carefully pull the child up into a sitting position to take him/her into your arms. Put your arms out and encourage the child to imitate you. Initially accept any attempt at an open-hand technique, but gradually demand more before you show your satisfaction. 5. Place your thumbs in the child's hands and bring both arms to the mid-line position, or bring the child's hands (with your thumbs inside them) to his/her eyes and play peek-a-boo. Always show your pleasure at all attempts to do what you wish, in this case opening the hands. C. When the child's hands are open most of the time, the arm and upper trunk muscles must be strengthened before the child is able to place his/her weight on the arms. The following procedures strengthen these muscles and help the neck to remain stable while the child is pulled to a sitting position. 1. Take hold of the child's upper arms and elbows and slowly pull him/her to a sitting position. Now bring your hands to the child's chin and use them to gently lift the head to a normal position. Initially repeat this procedure five times twice a day, but gradually increase as the child's strength increases. Also shift your support to the child's elbows and then to his/her hands. 2. Place the child on your lap facing you. Lift the child's arms above his/her head and slightly away from the body. The child will be inclined to lift his/her head. 3. Place the child on your lap facing away from you. Bring his/her hands together directly in front. It is more fun if you allow the child to clap his/her hands or place an interesting object between his/her hands. 4. Place the child on your lap facing you. Lift the child's outstretched arms (with the elbows straight) to shoulder height and move them slightly backwards. 5. Inflate a large inflatable plastic ball to about three-quarters of its full size and let the child lie on the ball. Sit in front of the child and hold his/her arms out to the sides like wings. Carefully rock the ball and the child forwards, backwards and sideways. Be prepared for initial signs of fear such as crying. Gently encourage the child to overcome this fear and enjoy the experience. 6. Hug the child and suddenly release your firm grip.
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7. Swing the child in a blanket and play rough-and-tumble; the other parent can be of great help in this regard. Continue with these procedures until the child holds his/her head steady when pulled into a sitting position.
Teaching step 3: Placing weight on the hands A. 1. Place the child prone on the floor. 2. Place a rolled blanket under the child's chest. The roll must be large enough to keep the child's elbows off the floor. (Make a large roll like this: use masking tape to attach two 1 kg-sized coffee tins to each other lengthways and covering the roll with foam rubber.) 3. Place the child's hands flat on the floor and in front. 4. Place toys with colourful designs in front of the child, and encourage him/her to place weight on his/her hands. Shake a rattle or other noisy toy above and slightly behind the child's head so that he/she has to use his/her hands as support to look at it. 5. Place the child prone on the floor with a cloth under his/her chest. Kneel over the child and use the cloth to lift his/her trunk until the arms are straight and the hands rest on the floor (crawling position). Gradually allow the child to take more weight on his/her hands. 6. Play the 'aeroplane' game with the child to improve the parachute reflex. This reflex usually appears at 12 months and must develop before the child can walk. Hold the child in the air (face down) and make a swooping motion down to a firm surface without touching the surface. Note whether the child puts out his/her arms as though to stop (this is the parachute reflex). Initially work at getting the child to put out his/her arms - this may take a few weeks. As soon as this has been achieved, allow the
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hands to touch the surface when playing. Also gradually allow more weight to be placed on the hands. The ideal position aimed at in this step is shown below.
B. Preparing to sit 1. Tut the child in an infant's chair for 30 minutes a day. Adjust the chair in such a way that the child advances from a reclining to sitting position over a period of weeks. Take the child from room to room in this position, while you talk to the child and allow him/her to watch you at work. 2. *Place the child prone on the floor for at least 15 minutes a day. 3. The child must develop a sense of balance, as this is essential for sitting. Let the child sit on the floor. Kneel in front of the child and gently rock him/her to and fro. Watch whether the child tries to stop by stretching his/her arms out to the sides. It may be necessary for you to do this for the child at first. (This exercise may initially require two people - one to move the child's arms and one to rock him/her.) These activities should be part of the daily routine of all infants from the age of two weeks. 4. Place the child on his/her back and allow him/her to touch and play with his/her toes. This strengthens the muscles of the lower trunk and will also help the child to become aware of his/her legs and feet. The latter is important for the development of self-image and for standing and walking. 5. Let the child sit on the floor with his/her legs wide apart, knees bent and hands on the feet. Support the child in this position for a few minutes, taking care not to let the child fall over. 6. When the child can sit reasonably well but still requires support, place him/her in a Jolly Jumper for short periods. Ensure that the feet are firmly on the floor. If the Jolly
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Jumper is too high, place a cardboard box underneath it. Encourage the child to bounce up and down by pushing with his/her feet. Initially set the example by pushing the seat down. Smile and give praise for every bounce. Gradually decrease your help but continue giving praise. Continue with these procedures until the child can sit as shown here.
Teaching step 4: Rolling over This is an important preparatory step to mobility. A. Supine to prone 1. Place the child on the floor on his/her right side. Move the left leg over the right, and encourage the child to roll over onto his/her abdomen. It may be necessary to roll the child over at first, but your assistance should gradually be diminished. As soon as the child can turn from his/her side to his/her abdomen, place the child on his/her back, place your hands in the hollow of the back and encourage the child to roll over. Make sure that the head is turned in the direction he/she is to roll, as this will help a great deal. 2. Repeat the procedure with the child placed on his/her left side. In both cases a rattle can be used to give the child something to work towards.
B. Prone to supine 1. Place the child prone on the floor and kneel alongside him/her. Lift one arm, bend it at the elbow and let the palm press down flat on the floor. Place the other arm underneath, making sure that the child's head is turned in the direction of the bent arm. Encourage the child to use the arm which has its hand pressing on the floor to help him/her turn over onto his/her back. It will probably be necessary to show the child what you want by placing one of your hands on the flat hand and your other
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hand under the child's back in order to roll him/her over. Say 'Push yourself over' while doing this so that the child knows what you expect. Let the child roll to both sides.
2. This exercise is best done with the child wearing only a vest and nappy. Allow the child to roll over on various surfaces, such as the carpet, the floor tiles, grass, paper and a blanket. Teaching step 5: Crawling A. The child should crawl with the abdomen on the floor (start this simultaneously with step 3 B). I. Place the child prone on the floor with a favourite toy in front of him/her, but just out of reach. Kneel behind the child and encourage him/her to move forward. Initially two people may be required, one to kneel behind the child and one in front. Both must move the child's arms and legs in opposing motions, that is, left arm forward, then right leg, then right arm, then left leg. Encourage the child to move forward and talk all the time so that he/she knows what you want. Praise every little success. B. Start the exercises for crawling on all fours when the child can do 3 B and 5 A fairly well. 1. Place the child prone on the floor. Place a cloth under the child's chest, kneel and pull up the cloth until the child is on his/her hands and knees. Retain this position for a few minutes and then rock the child back and forth. Talk all the time, saying what it is you want. Gradually decrease your help. Practise until the child can rock to and fro on his/her hands and knees without support. 2. Place the coffee tin roll of step 3 under the child's waist so that his/her knees reach the floor in a normal crawling position. Note: the tin rolls better if it is covered with plastic material. C. As soon as the child can carry his/her own weight in the crawling position or can remain in this position with the support of the tin roll, contralateral crawling can commence. 1. Do this activity with the child in the crawling position and with two people helping (one behind and one in front). Move the child's arms and legs in a contralateral pattern, that is, right arm and then left leg, then left arm, then right leg. When moving
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the child's leg forward, first press gently against the foot. This pressure will later be sufficient to induce the child to move the leg forward. Always explain what you want and break the activity down into small sections. 2. As soon as the child is fairly skilled at moving his/her arms forward, the person in front may leave. Place a favourite toy in front of the child, but out of reach, and encourage him/her to move towards it. At this stage it will generally still be neces-~ sary to move the legs. 3. If the child has no particular interest in toys, a favourite food may be used instead. Initially this food can serve as reward for each small success but use it together with a social reward (praise, a kiss or a hug). The child will soon discover the advantages of crawling, and then the artificial reward (food) can be withdrawn. Teaching step 6: Standing with support 1. Place the child on a plastic ball that has been three-quarters inflated. Carefully rock the ball back and forth so that the child is forced to balance with his/her arms and legs. Take hold of the child's hands and lift them above his/her head so that the feet reach the ground and the body is partially supported by the ball. Bring the hands down to the ball so that the child gets the feeling of support. A second person holds the child by the knees and ensures that the feet are resting firmly on the floor. Initially hold the child in this position for a few seconds and later for a few minutes. 2. Place the child on the floor in a crawling position. Kneel behind the child - close enough for your knees to support the child's lower legs. Place a cloth around the child's waist and pull on it carefully to bring the child to a kneeling position. 3. Place a large blanket roll on the floor and let the child sit on it. Support the child to prevent his/her falling.
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4. Place the child in a Jolly Jumper so that his/her feet rest flat on the floor. Encourage the child to jump. 5. Sit on a chair. Let the child sit in front of you with his/her back against your lower legs. Place a cloth around his/her chest and pull him/her upright.
Note: Do not hold the child by the arms or hands, as he/she must use these to balance him/herself. Teaching step 7: Pulling the child up into a standing position 1. Kneel next to the sitting child. Move one arm (with the elbow straight) slightly behind the child's body and place an open palm on the floor. Encourage the child to rest the wrist partly on that arm. 2. While in this position, encourage the child to reach out with the other hand. This may be done by offering a toy or something to eat. Praise attempts at reaching out. 3. When the child has learned to reach out with the unoccupied hand, guide this hand to a firm support, for example, the armrest of a chair, and encourage the child to pull him/ herself up. Say 'Pull up' and help the child upright at first. Decrease your help but continue to praise. 4. When the child is in his/her cot, show him/her how to reach up with a free hand and grasp the bars of the cot. Tie a favourite toy or 'busy board' to the bars, initially at knee height and later at standing height. 5. When the child begins to pull him/herself up, fix a small mirror (20 cm x 25 cm) to the backrest of a chair just above the seat.
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Allow the child to stand upright to look in the mirror. Place the child in front of the chair in a sitting position and encourage and help him/her to pull him/herself up so as to stand and look in the mirror. Teaching step 8: Standing without support 1. Stand with the child in a standing position in front of you, with the child's back resting against your legs. 2. With the child in this position, place a cloth around his/her chest. Hold cloth close to the child's body and move away slightly. Give praise for slightest attempt at standing alone. As the child becomes steadier on his/her feet, continue using the cloth but hold it further away from the child's body, as illustrated in (b) below. Gradually reduce your support over the next few sessions and later remove the cloth. By this time the child should be able to stand alone for a few seconds. 3. Let the child stand facing you while you sit. Place your hands at the child's sides. Let go for short periods but give support when necessary. Allow the child to lean forward against your legs for support if necessary. A toy in your lap may help the child relax and make him/her more willing to stand.
4. Let the child stand facing away from you and repeat step 3. Give the child a toy to hold to help him/her relax and make him/her more willing to stand. Note: Never support the child with his/her arms outstretched and his/her hands in yours. The child needs support near the waist and arms should be free to balance. Teaching step 9: Walking with help and then without A. 1. When the child has learned to stand using furniture as support, kneel and move the child's leg to the side at the knee (side-step). Place a toy just out of reach and encourage the child to step sideways to reach it. Say'Step' when you move the child's leg sideways. 2. Place the child in a standing position. Stand in front of the child and gently pull him/her forward by his/her hands. If the child does not take a step, a second person
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may be required to kneel behind the child and move his/her legs forward in a walking movement. Even if you started the movement, show enthusiasm for the child's attempts, no matter how small. The assistance of the person behind the child should be gradually decreased. 3. Stand behind the child and give support with your legs when he/she leans back. Take the child's hands and gently push-kick forward. B. 1. When the child takes steps with support, two people are required for the following exercise: support the child from behind with a cloth tied around his/her chest. The second person stands in front and offers an object in such a way that the child must take two steps in order to reach the object. Show your approval if this is done. Gradually hold the toy (or something to eat) further away and grasp the cloth further and further from the child's body. Verbally encourage the child to walk. Practise until the child can walk unaided. Feeding skills
Feeding skills develop in the following sequence. 1. Sucking and swallowing are co-ordinated and the child sucks fluid from a bottle. 2. The child puts his/her hands around a bottle and holds it. 3. The child learns to eat with a spoon; is fed. 4. The child is ready to start finger-feeding when he/she puts his/her hands or toys into his/her mouth. This may involve two separate activities. - The child dips a finger into strained food and licks the finger. - The child takes solid food, for example, a piece of bread, in his/her hand and puts it in his/her mouth. 5. The child drinks from a glass. 6. The child feeds him/herself with a spoon. This develops in the following sequence: - The child bangs the spoon when he/she gets hold of it. - The child holds the caregiver's wrist when he/she feeds him/her. - The child holds the spoon while the caregiver guides his/her hand to his/her mouth. - The child holds the spoon, with the caregiver's hand on his/her arm for guidance. - The child holds the spoon while the caregiver observes and encourages. - The child fee us him/herself with very little supervision, 7. The child drink rhrough a straw. Teaching steps 1 and 2: Strong and co-ordinated sucking and holding a bottle r\.
The child is first taught to suck if he/she is still unable to suck rrom a bottle. 1. Dip a clean, hemmed linen cloth in milk and allow the child to suck it. Very little sucking is necessarv to ensure a pleasant result for the child, and this encourages, the child to trv again.
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2. When the child is sucking fairly strongly, pour part of the feed into a bottle with a teat with an enlarged hole. Chill the teat in ice and dip it in a sugar solution. Place it between the child's lips and at the same time let the child smell some ammonia, vinegar or clove oil. This technique combines all the stimuli required for sucking. B. The child is then taught strong and co-ordinated sucking from a bottle. 1. Hold the child in your arms or let the child recline in an infant's seat. 2. Use a bottle with a teat with a hole just large enough to let through about 12 drops a minute when the bottle is held upside-down. 3. If the child's mouth does not open when the bottle is brought near, tap the child's lips lightly with the teat or gently press the child's cheeks together to force the lips apart. It may sometimes be necessary to pull the child's chin down firmly but gently to open the mouth. 4. When the teat is in the child's mouth, put your fingers round the lips and gently stretch them outwards. This usually causes the lips to move in the opposite direction, thus pouting around the teat. 5. Place your fingers under the child's chin and over the upper lip and move the jaw up and down to initiate sucking. It may be necessary to move the jaw up and down occasionally to remind the child to continue sucking. Continuous upward pressure on the lower jaw also encourages a stronger sucking reflex. 6. Occasionally pull lightly at the bottle while the child is sucking to encourage stronger sucking. 7. Begin holding the child's hands around the bottle at every feed, even if the child does little or nothing to help. C. Some children dribble a lot and cannot close their mouths properly. To encourage better lip control and to reduce dribbling, the following may be done: 1. Massage the area around the mouth with your index finger as follows: - Place your finger horizontally, parallel to the mouth above the upper lip, directly under the nose. Massage the area above the upper lip with downward strokes of the finger. Use firm pressure but do not massage the lip.
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Place your finger on the area lateral to the corner of the child's mouth and rub with rapid strokes to the corner of the mouth. Repeat on the other side.
Place your finger horizontally to the mouth on the chin beneath the lower lip and massage this area.
- Massaging must be done at least once a day or before every feed. 2. If the skin above the upper lip is short because of an undershot jaw, it must be stretched before the lips can close properly. In this case perform step (a) more regularly. 3. If the child dribbles, the aim is to develop subcortical, automatic control. If the child concentrates all day on whether or not dribbling occurs, this impedes functioning. If the child dribbles, push up the lower jaw and maintain the pressure until the child swallows, without comment. Teaching step 3: Learning to eat with spoon and to be fed
A. Infants should start eating solids by the age of three months (for example, cereals with iron, strained vegetables and fruit). 1. Be absolutely consistent in your feeding routine in order to facilitate learning. The slightest deviation in the order in which you put on the bib, place the child in the chair, etc., is upsetting. Make sure that at least one other person in the household knows the feeding routine in order to relieve the caregiver once in a while. 2. Feed the child in a high chair. Support his/her feet. Begin by offering solid food once a day when the child is hungriest and make the food more or less the consistency of a milk pudding. 3. Sit directly in front of the child with your thumb on his/her chin, your middle finger under the chin and your index finger alongside the jaw. Use your thumb to open the
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child's mouth and your index finger to close it. Open and close the mouth a few times before offering food.
4.
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6. 7. 8. 9. 10. 11.
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While the child's mouth is open, put a very small amount of food on the tip of a teaspoon and bring the spoon near enough to touch both lips. Do not give food while the child's neck is stretched backwards. This can be stopped by gently patting the child's chest with the back of the hand. Open the child's mouth (not too wide) and place the spoon on the middle of the tongue. Gently press the spoon to the tongue for a few seconds until the child's lips begin to close. Verbally encourage the child to close his/her mouth and/or use manual manipulation. Pull the spoon out straight without scraping it against the upper teeth, the upper lip must learn to take food from the spoon. Close the child's mouth with your middle finger as soon as the spoon has been removed and keep it closed until the child has swallowed. If swallowing is slow, gently stroke the throat towards the chest and say 'swallow'. Do not continue with a feeding attempt for longer than half an hour. Stop and try again at the next feed or the following day. Gradually reduce your assistance; withdraw help with the middle finger last of all. Give small portions; rather offer second helpings. Do not force the child to eat to satisfy you, as this may lead to emotional problems and teaches poor habits such as overeating. If the child refuses all food and you are sure that he/she is physically healthy, do not force the food. You can remove the food after a thorough attempt and offer only small amounts of water until the next meal. Missing a few meals will cause no harm. If the child gags on or vomits the food, make sure that there are only small amounts of food in his/her mouth at a time and that the child swallows before the next mouthful. Try smaller feeds five or six times a day in the case of a child who vomits. Do not give fluids with meals. If the child vomits, clean up and immediately give a smaller amount more slowly.
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B. The child is taught to inhibit strong tongue-thrusting. 1. The tongue step procedure is followed twice a day as follows: - With the tip of the child's tongue behind the lower teeth, put the bowl of a teaspoon on the tip of his/her tongue and push it down.
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Place it a little further back and push down again. Continue until the child gags. Open the mouth quickly by means of upward pressure under the chin to encourage swallowing. 2. Teach the child to imitate a yawn and to do so throughout the day. This pushes the tongue down. Teaching step 4: Finger-feeding A. The first step is to teach the child to chew. 1. Help the child to achieve better control of his/her tongue by placing something sticky, such as peanut butter, on the tip of the tongue and lips. Place grapenuts, pieces of cake or raisins on and under the tongue or between cheek and gums. This teaches the tongue to move food around in the mouth. 2. Place something that makes a crackling sound under a large molar. If you are afraid that the child might choke, use a long piece of food that you hold onto (a carrot stick, finger of bread or piece of tough biltong). If choking is not a problem, try a piece of water biscuit, hard sweet, potato crisp or apple. 3. Close the child's mouth. 4. Place your hand on the child's jaw and move it up and down in a chew movement. Say 'Chew' and demonstrate. 5. If the child refuses to swallow, gently massage the throat upwards or downwards, or place upward pressure under the jaw with the back of two fingers. 6. Make sure that the child's mouth is closed when swallowing. 7. Gradually make the child's food more bulky: add small pieces of bread or toast and leave a few lumps in mashed potato and other foods. B. The second step is to teach the child to finger-feed. 1. When you serve the food, give the child a chance to lick some of it from his/her forefinger. Put the finger in the food and allow the child to lick it. This may sound
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messy but it teaches the child plate-to-mouth movement. Offer finger-feeding when the child is hungry. 2. Put the child in the high chair, put on a large feeder and spread newspaper on the floor. Place pieces of buttered bread, fruit or cheese directly on the tray of the high chair. Encourage the child to grasp and eat them. Do not worry about a little mess, as long as the child gradually learns to eat with his/her hands. C. The child is taught lip and jaw control. Once the child starts eating, these techniques will not be willingly accepted. Follow the following brush-and-ice procedure once a day very consistently for a few months. 1. Brush the area around the mouth as shown in the diagram without brushing the lips. Repeat about 10 times.
2. Brush under the lower jaw with upward strokes.
3. Brush the throat area under the chin with upward strokes.
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4. Take an ice cube in your hand (protecting your hand by covering it with a paper towel or face cloth). Rub the ice cube seven times around the outer edge of the lips as illustrated below. Do not rub the lips. Periodically dab the mouth area as you work to prevent dripping.
5. Rub the throat area as described in step 3 above. Dab regularly. 6. Hold the ice cube in the hollow above the breastbone for five seconds and dab as soon as you remove the ice. Teaching step 5: Drinking from a glass A. The child should learn to drink from a glass with help at about five to six months. 1. Use the normal jaw control grip or stand behind the child and hold his/her chin from the back. Keep a feeder under the chin. 2. Use a small plastic tumbler without handles. Pour a little of the child's favourite drink into it - only a teaspoonful at first. From now on the child must drink this fluid only from this glass. 3. Place the rim of the glass between the child's lips (not against the teeth, as this stimulates a child to bite) and pour in a little of the fluid. Do not remove the glass because the child must learn to take a few sips in succession. Tip the glass very slightly and apply a little pressure under the jaw to encourage swallowing. 4. If the child refuses to swallow, gently stroke up and down the throat area or show the child how you swallow and say 'Swallow'. 5. Rest after two or three sips and gradually increase the volume of fluid in the glass. B.
Teach the child to drink independently. 1. Use the same glass and fluid. 2. Stand behind the child, place your hands over the child's hands around the glass and help the child to bring it to his/her mouth. 3. Let the child practise with an empty glass between meals. 4. Take the child off the bottle as soon as he/she can drink well from the glass. Gradually decrease bottle feeds; first omit the meal-time bottles and last of all those at bedtime.
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Teaching step 6: Eating independently with a spoon 1. Make the child comfortable with his/her feet and back well supported and put on a feeder that covers the child up to the waist. 2. Place the feeding bowl in front of the child and fix it to the table with plasticine. Start with fairly thick food that will not fall off the spoon. 3. Sit comfortably next to the child so that you can see his/her arm and head movements. 4. Draw the child's attention to the spoon by using it to tap the food bowl and by saying: 'Look at the spoon' and/or turning the child's head in that direction. Give plenty of verbal approval if the child takes the spoon. If not, place your hand over the child's hand and bring it to the bowl. 5. Help the child scoop up the food and bring it to his/her mouth. Do not allow fingerfeeding at this stage and do not go passively through the movements if the child does not look at the spoon or bowl. The child will learn nothing if he/she does not watch what is being done. 6. Gradually decrease your assistance; first place your hand over the child's wrist, then on his/her elbow and eventually remove your hand altogether. 7. Remember to praise the child lavishly for these attempts and not to help for too long, as this makes the child lazy. Try feeding every other mouthful, making a game of it, then every third mouthful, and so on. The child will probably require most assistance in scooping up the food. 8. Avoid all behaviour that interrupts the spoon-to-bowl, bowl-to-mouth sequence, for example, by keeping other children out of the room. 9. Do not be concerned about eating neatly at first; table manners can be learnt later. Teaching step 7: Drinking through a straw This is a very important activity because the sucking movement gives the mouth and tongue muscles essential exercise. 1. Use a plastic straw. Dip it into a favourite drink and put your finger over the opening to keep the fluid, which has been drawn up into the straw, in place. Hold the straw in the child's mouth and let the fluid run into it. Repeat a few times until the child begins to associate the drink with the straw. Do not allow the child to obtain the fluid in any other way. 2. Hold your side of the straw a little lower so that the child has to suck a little to obtain the fluid. 3. Place the straw in a plastic bottle with the top cut off just enough to admit the straw. Encourage the child to suck, and help by squeezing the bottle. Demonstrate the sucking movement and encourage the child to put only his/her lips, not his/her teeth, around the straw. Use your hand to help close the child's mouth around the straw. 4. Give plenty of praise for sucking and gradually withdraw your assistance. 5. Eventually offer all drinks with a straw and gradually thicken the fluids to force the child to suck more strongly. Children with cerebral palsy must continue to drink through a straw at least twice a day.
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Dressing and undressing Undressing is taught first, as it is easier than dressing. The sequence is not important and the child does not need to be able to distinguish between the inside and outside of garments. As is the case with other tasks, it is important to divide the activity into very small steps. Chaining is the usual method used to teach dressing and undressing. This means that the child starts by performing only the last part of an activity. For instance, pull down the child's pants until both legs are halfway over his/her feet and then allow the child to pull them off the rest of the way. Gradually allow the child to pull the pants down further and further. Place your hand over the child's hand if necessary to show him/her how it is done. Praise every attempt lavishly. Dress the child in simple, loose-fitting clothes during the training period. A front zip may initially be easier to undo than buttons. Show the child how to fasten and undo buttons by starting with large ones and gradually decreasing the size. To help put the correct shoe on the correct foot, mark the heel of one with a dab of paint. People with an intellectual disability often find dressing a very difficult skill to learn. Besides breaking up the process into small steps, the child can be further assisted by keeping to a very strict sequence, for example, by always laying out the clothes on a chair and doing so in the same order. The child should always stand facing the chair and should put on the garments in the same way and in the sequence in which they have been laid out. Chaining is once again the teaching method of choice. An easy way of teaching a child how to put on shirts, jerseys and jackets follows: 1. Hang the shirt over the back of the chair. 2. Let the child sit on the chair. 3. Make the child look right and put one arm into the sleeve. 4. Make the child look left and put the other arm into the sleeve. 5. Let the child lift the shirt over the back of the chair and put it on by pulling both arms forward. The child requires about twenty minutes at a time to learn to dress and undress. This exercise should also be included in playtime, for example, dressing and undressing dolls, fastening and undoing buttons and threading shoelaces. Toilet training Toilet habits cannot be taught before the child can walk. The ability to walk demonstrates that the spinal pathways are myelinated as far as the level of the bowel and bladder sphincters and that the child is physiologically capable of sphincter control. A. Preparations for teaching toilet habits 1. Keep the following record for three or four days: Times wet or soiled 9.30 soiled Child's response tearful
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Your response Intake
cleaned immediately porridge and milk hour before
Keep the record in a convenient place, for example, pasted to the bathroom door. 2. If the child urinates more than once an hour, take him/her for a medical examination to exclude the possibility of a physical problem. 3. Baseline data should not be gathered if the child is ill or if the fluid intake pattern is temporarily disturbed. 4. Toilet habits can be taught if the child: - can hold urine for about two hours and has one or two stools a day; - can walk (except if the child has a physical handicap); - shows signs of being aware of elimination, for instance, changing facial expression, becoming quiet, pulling at clothes, making other sounds, crossing legs and being irritable; - can feed him/herself; - is not ill. 5. Make sure that the child wears clothes that are easy to handle, such as pants with elastic. 6. The bathroom must be convenient for the child. Leave the door open and put a footstool next to the toilet so that the child can reach it. If a potty is used, it must be kept in the bathroom. 7. Flushing may frighten the child; initially avoid this while the child is in the bathroom. 8. Toilet-training must commence when social interruptions are at their minimum, for example, when there are no visitors. 9. Determine what reinforcers you are going to use, for example, smile, touch, verbal praise or food (such as raisins). 10. Always dry the child immediately to make him/her used to being dry; being wet then becomes unpleasant. B. Teaching toilet habits 1. Study the record you have kept and use it to determine the most likely time that the child will eliminate. This is usually after a meal, exercise or long nap. These are the times that the child should be taken to the toilet as a regular routine. 2. Lead the child to the bathroom, take down his/her pants and put him/her on the toilet. 3. Stay and keep the child's attention to the task at hand. If the child has done nothing after five or ten minutes, take him/her off the toilet. It is important not to punish or scold or even to change your facial expression if the child does nothing or wets his/her pants between visits to the toilet. 4. If the child does eliminate, reinforce (reward) him/her with food or praise. 5. Take the child off the toilet, pull up his/her pants and wash his/her hands. 6. Watch for signs that the child is beginning to indicate needs and take him/her to the toilet immediately.
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7. Gradually allow the child to pull down his/her pants, climb on to the toilet, wipe and wash his/her hands. In the end you will only be required to stand by. Never forget to give a reward. 17.6 INSTITUTIONAL CARE A single principle that could be of great help to nurses in judging and planning a department or institution for people with intellectual disability is the normalization principle. This principle originated in Sweden but has since become accepted throughout the world. It means that the existence of people with intellectual disabilities should be as normal as possible. In fact the normalization principle implies normalization of the total environment, of activities, attitudes and atmosphere surrounding the mentally subnormal to such a degree that life in the open community will have become understandable to them. The application of the normalization principle will 'not make the subnormal normal', but will make life conditions of the mentally subnormal normal as far as possible, bearing in mind the degree of handicap, competence and maturity, as well as the need for training activities and availability of services. (Gunzburg 1973: 30)
The normalization principle comprises the following: Normal rhythm for every day This means that patients get up at a normal time, dress and go to work (regardless of the type of work). They eat under normal circumstances, that is, relaxed and sociably at a family table. They do not go to bed earlier than normal people and allowance is made for their personal rhythm. Example: Bedtime is regulated and laid down by a 'lights out' order; or largely left to the discretion of the patients. Normal rhythm for every week Normal people live in one place, work somewhere else and relax in other places. Patients with an intellectual disability should be able to choose their recreation and should, as far as possible, make use of facilities outside the institution as soon as possible. Working hours should be normal. Example: Sundays follow the same pattern as other days; or patients may sleep in on Sundays if they wish. Normal rhythm for every year The recreation, food, clothes, etc., of normal people change with the seasons, but seasonal changes usually have little impact on people with intellectual disability. In addition, normal people generally have an annual holiday, which includes physical and psychological rest and a change of environment. Days of personal significance are also commemorated.
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Example: No distinction is made between winter and summer underwear and clothes except for the addition of jerseys and/or coats in winter; or different underwear and clothes for summer and winter. Normal life cycle The environment of normal people changes as they grow older, for example, toddlers have warmth and continual stimulation and encouragement, schoolchildren have educational institutions with all the necessary facilities, adults have job opportunities and social events, and the elderly have a more restful but familiar environment. All these facilities and opportunities should also be available to people with intellectual disabilities. Normal respect for the choicest wishes and wants of individuals People with an intellectual disability should be consulted as much as possible about rules, routines and events in their own environment. They should have their own personal belongings. Example: Personal belongings in lockers are regularly inspected by staff to prevent the accumulation of rubbish; or considered private and clearing out is done by discussion and persuasion. Normal heterosexual world To normalize the lives of institutionalized people with intellectual disability and to prepare them for heterosexual society, the two sexes must mix as much as possible within the constraints of normal control. Sex education must be given as part of the education programme. Normal economic standards People with an intellectual disability must be considered for normal financial benefits such as old-age pensions and minimum wages. Even though most of the money is spent on board and lodging, a portion should be available as pocket money. Normal standards for physical facilities Normal standards of living, working and recreational facilities in the community should also hold good for people with intellectual disability. The size of living quarters should correspond with those in the community, the underlying principle being that the longer the tenure, the smaller they should be. The standard of decoration and furniture should also be the same. Example: Staff use separate toilet facilities; or staff use the same toilet facilities as patients/residents. If the normalization principle were to be implemented in the total organization for those with an intellectual disability, it would have far-reaching consequences for them, for health workers, for parents and for the community. Various modalities for promoting socialization and preventing institutional neurosis can be used in institutions where people with intellectual disabilities live permanently.
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Group activity therapy Activity groups develop self-respect as well as social and interpersonal skills. They offer individuals living with an intellectual disability an opportunity to develop a feeling of acceptance and an outlet for aggressive impulses. Group activity therapy may comprise the following: action games, volley-ball, clay modelling, story-telling, role-play, finger-painting, excursions, starch work, care of pets and plants, gardening and needlework. These activities strengthen the interests and attention span of a person with an intellectual disability to ensure pleasure, fulfillment and personal development. Play or games Play is one of the most effective ways of learning, according to Marzollo (1984). Play is a natural way in which people with intellectual disability can learn to concentrate and use their imagination. They can also use play to test new ideas and adult behaviour. Play also develops their thinking and teaches them a measure of control over their world. The body is developed by means of play. Play promotes social adjustment and offers a safe means of giving vent to frustrations. Play means far more than mere amusement or a pastime. Important aspects during play activities: Nurses must begin with something that the patient can already do and gradually build on this; success stimulates the learning process. The play of people with individual learning styles is adapted to their needs. Nurses must create effective learning opportunities. This means that the right activity must be introduced at the right time, with a specific aim, at each individual's level of functioning. Games equipment must be easily manageable, simple and strong. The patients should not be frustrated by equipment that constantly breaks or is too complicated to master. Music therapy Music therapy is defined as the systematic use of music (rhythmic, melodic and harmonious) in a therapeutic environment to bring about behavioural change. Music provides pleasure to most people, whether or not they are handicapped. Music provides an atmosphere of unity and group identity - it communicates without words. Music should be adapted to the category of disability, for example: Passive music (listening): The profoundly intellectually disabled person show signs of pleasure such as smiling, clapping hands and relaxation at hearing music. Active music (dancing, percussion band, singing, exercising to music): This promotes coordination, balance and rhythm in people with mild and moderate intellectual disability.
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17.7 MANAGEMENT OF PROBLEM BEHAVIOUR The most common problem behaviours among institutionalized patients with intellectual disability are hyperactivity, aggression, absconding and self-mutilation. These types of behaviour occur fairly regularly among about a quarter of all institutionalized patients with intellectual disability (Amam & Singh 1983). Pharmacological treatment Antipsychotic medication: Reduces stereotype behaviour, for example, selfstimulation. Reduces effectiveness of behaviour therapy programmes. Chlorpromazine reduces inappropriate behaviour. Anticonvulsive medication: Has no positive effect on problem behaviour. Stimulants: Have no positive effect. Anxiolytic drugs: Probably have no positive effect and may exacerbate the situation. Behavioural problems and low impulse control can be treated by giving fluphenazine deconoate (Modecate) 25 mg monthly. The patient should be seen again after one week, to assess whether sedation is too severe. Evidence-based Practice Antipsychotic medication for challenging behaviour in people with intellectual disability Only eight randomized controlled trials could be included in the analyses. These provided no evidence of whether antipsychotic medication helps or harms adults with intellectual disability and challenging behaviour.
Reviewers' conclusions: There are limited data on this important issue and more research is urgently needed. Brylewski, J & Duggan, L. Antipsychotic medication for challenging behaviour in people with learning disability (Cochrane Review). In: The Cochrane Library, Issue 2, 2003. Oxford: Update Software.
Probably the only approach that offers hope for these problems is behavioural therapy, which combines unlearning problem behaviour and learning adjusted behaviour. 17.8 THE ADULT PERSON WITH AN INTELLECTUAL DISABILITY The adult status of a person with an intellectual disability is greatly dependent on learning and development during the childhood years and whether the person has other disabilities or problems, such as epilepsy or blindness. It should be possible for the majority of people
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with an IQ of 35 and above to be relatively independent as adults. In such cases, all the principles of psychosocial rehabilitation come into play. Goldberg (2000) suggests that people with an intellectual disability should be prepared for the world of work throughout their lives: Elementary school age Introduce the concept of work into everyday activities. Learners should become familiar with all types of careers. Develop self-care and daily living skills and routines. Focused development of human relationships and good social skills at home and school. Explore the available vocational opportunities at the upper grade levels and beyond. Make the child a productive part of the household, introduce chores and an allowance. Primary school age Begin career exploration, watch movies, read books, go to work with adults, etc. Support the teacher's efforts to provide job training as part of the school programme. Gather information about the type of education programme options, such as inclusion, vocational, combination, etc. At home, parents can also help their children explore careers by getting them to do chores around the house, volunteer in the community and participate in community service projects. Age 14 to 16 years Parents should participate in a transition programme for parents, which assists them in planning for their children after school. Ensure that vocational training is built into the educational programme in which the child is placed. Explore recreation and leisure interests. Find out how funding sources (for example, skills development levies and learnerships) and financial assistance programmes (for example, disability grants) may benefit the child. Develop independent living skills. Age 17 to 18 years Find and hold a part-time job in school or in the community. Discuss how long learner will attend high school - the required number of years or until age 21.
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Obtain information about future planning. Enrol in vocational education classes. Establish a graduation date. Investigate guardianship procedures and determine what is in the best interest of the child. Schedule a vocational evaluation to better assist in determining the child's interest and setting a vocational goal. Attend a job fair. Age 19 to 21 years Introduce budgeting and the real cost of living 'on your own'. Find suitable employment, which means, amongst others, employment that offers the desired work hours and salary. Housing and work are major issues, since the person should not only be safe but happy and have adequate resources for life. In the USA and the UK, supported employment has become the technique of choice. This means that employment is found for the person in the open labour market, and the person is supported to enable him/her to learn and maintain the job. This approach works well for persons with an intellectual disability, since they are reliable and consistent workers. In the UK, 4 800 people with learning disabilities are employed through such programmes (Jenkins 2002). However, the same author cautions against over-emphasizing employment for this group. He points out that the demands of employers might be too onerous for the person with a disability, and conditions at work might influence their health negatively. They might also be worse off financially if the social support system (disability grants, etc.) is not geared to encouraging employment. Group homes seem to be the approach of choice for adults who might otherwise find total independence - that is, financially, physically and emotionally - impossible. Such homes can accommodate a small number of individuals with different strengths and weaknesses. Pooling their resources might make them more able to cope, and living together makes it easier to provide them with social support on a cost-effective basis. Very few such homes are currently available and there is much room for growth in this sector. The South African Down's Association has been providing training in Supported Employment to a core group of parents and professionals over the last two years, and it will be interesting to see whether they manage to implement this modality more widely in South Africa. CONCLUSION The limitations in lifestyle functioning of people with an intellectual disability make stimulation, support, motivation and love imperative for their development into more independent individuals. The effective assessment of and planning for such patients will result in the implementation of appropriate interventions to optimize their functioning.
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WEB RESOURCES http://www.thearc.org This website of the Association for Retarded Citizens of the USA has a range of very useful resources for consumers and their caregivers. http://www.acf.hhs.go/programs/pcmr This website belongs to the US Department of Health and Human Services, but more particularly to the President's Committee on Mental Retardation. The most valuable resource on this site is the series of books, With a little help from my friends, which can also be accessed online. http://www.nichy.org This site allows access to information provided by the National Information Center for Children and Youth with Disabilities. Intellectual disability is one of the topics addressed and the information is up to date and relevant. http://ndss.org This is the website of the National Down's Syndrome Society and is a wonderful resource for parents and professionals. It provides basic information, emerging research, and chat rooms. REFERENCES Amam, M G & Singh, N N. 1983. Pharmacological intervention. In Handbook on Mental Retardation, eds J L Matson & J H Mullik. New York: Plenum Press Barnard, I E & Erickson, M L. 1976. Teaching Children with Developmental Problems. A Family Care Approach (2 ed). St Louis: The C V Mosby Co Barnard, K E & Powell, M L. 1972. Teaching the Mentally Retarded Child. A Family Care Approach. St Louis: The C V Mosby Co Godfrey, A & Eddington, C. 1971. Motor Skills and Feeding Skills. Pamphlets of the Department of Social Services, Salt Lake City, Utah Godfrey, A B. 1985. Sensory motor stimulation for slow-to-develop children. American Journal of Nursing, 7'5 ( 1 ) , 60-61 Goldberg A M. 2000. Transition Timeline 2000 Conference Compendium http://\\ r ww.ndss.org/content.cfm?fuseaction=InfoResSchEduArticle&article=225. Accessed luly 2003 Gunzburg, H C (ed). 1973. Advances in the Care of the Mentally Handicapped. London: Bailliere Tindall Henderson N. 2001. Being in Sync with Teens and Young Adults: A Guide to Relationships. National Down's Syndrome Society (NDDS) Compendium http://www.ndss. org/content.cfm?fuseaction=InfoResSchEduArticle&article= 166. Accessed July 2003 Hewitt, A & CVNell, S. 1998. Speaking up - Speaking out. US Department of Health and Human Services, http://www.acf.hhs.go/programs/pcmr/. Accessed June 2003 Molteno, C & Wetawav, ]. Mental handicap (intellectual disability). In Robertson, B, Allwood, C & Gagiano, C. 2001. Textbook of psychiatry for Southern Africa. Oxford: Oxford University Press
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Molteno, C. The patient and the family affected by mental handicap. In Bauman S E. 1998. Psychiatry and Primary Health Care. Kenwyn: Juta & Co Molteno, C & Lachman, P. 1996. The aetiology of learning disability in preschool children with special reference to preventability. Anals of Tropical Paediatrics, 16: 141-148 Mabaso, M S. 1989. An Evaluation of Total Health Care Given to Black Babies with Profound Congenital Defects Based on the Perceptions of Parents/Care Takers and Health Care Teams (unpublished MSocSc thesis, University of Natal, Durban) National Down Syndrome Society. 2003. National study finds inclusive education rewarding for all involved http://www.ndss.org/content.cfm?fuseaction=InfoResSchEduArticle&article= 166 Accessed July 2003 National Institute for Child Health and Human Development. 1986. Early Diagnosis and Intervention Subcommittee Report. Washington Rynders, J E & Low, M L. 2003. 'Adrift' in the educational mainstream: The need to structure communicative interactions between students with Down Syndrome and their nondisabled peers. Down Syndrome Quarterly http://www.denison.edu/ Accessed July 2003 Wigton, A, Adnams, C & King, M S. 1997. Child mental handicap: related policies in the new South Africa. SA Journal of Child and Adolescent Mental Health, 9 (1), 44-56.
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CHAPTER EIGHTEEN
Mental Health Nursing of Children and Adolescents L VAN RHYN L MIDDLETON
Objectives After studying this chapter the learner should be able to: Know the classification of the psychiatric disorders of infancy, childhood and adolescence. Assess the mental health and functioning of children, adolescents and their families. Implement certain guidelines for nursing interventions for children with depression, enuresis, encopresis, and conduct disorders, and for adolescents with anorexia nervosa.
INTRODUCTION A recent study of new cases presenting at two child psychiatry clinics (at four locations) in Johannesburg shows that the three most common problems for which boys were referred were behaviour disorder, attention-deficit hyperactivity disorder (ADHD) and learning disorder (Vogel and Holford 1999). For girls, the three most common causes for referral were behaviour disorder, learning disorder and mood/anxiety disorder. South Africa has an acute shortage of mental health personnel. The Committee of Inquiry into Child Mental Health Care Services investigated the provision of staff for specialized mental health services. The professional councils, with the exception of the South African Nursing Council, do not indicate specific sub-specialities, which means that it is impossible to pinpoint the number of specialists involved in child psychiatry. Only ten advanced mental health nurses have specialized in this field. Mental health nurses generally have limited exposure to child psychiatry during their basic training. The South African Nursing Council has introduced an advanced diploma in child psychiatry, but specialized training for this diploma is at present offered in only two centres. The number of nurses involved in the care of children with psychiatric
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problems is therefore limited, with the result that the training of nurses in this speciality leaves much to be desired. The implications of these shortages are serious; nurses must be capable of playing an active role in this respect. In a recent study by Rudd and McMaster in Zimbabwe (1996), it was found that while 49,6 % of children attending a Primary Health Clinic in that country had a mental health problem according to the Reporting Questionnaire for Children (RQC), the nurses in the clinic only identified 1,5 % of cases. All of the children presented with physical complaints, and nurses showed a very narrow organic orientation, which did not allow them to identify mental health problems. 18,1
MENTAL HEALTH DISORDERS IN CHILDREN AND ADOLESCENTS
To date no reliable epidemiological research regarding child psychiatric disorders has been undertaken in South Africa. However, estimates from a number of studies carried out in the sub-Saharan region suggest that 10 %-24 % of children under the age of 15 suffer from mental health problems (Acuda 1993). Cohen (1994) believes that the prevalence rate increases with severe psychosocial disadvantage. A study conducted in Kenya in the early 1980s shows that the most frequently occurring disorders are of the psychoneurotic type (for example, anxiety), followed by depression, conduct disorder and substance abuse, attention-deficit hyperactivity disorder and, finally, childhood psychosis (Acuda 1993). Acuda (1993) suggests that a similar pattern prevails in other developing countries. The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) describes a wide range of disorders that are usually first diagnosed in infancy, childhood or adolescence. These include: Mental retardation; Learning disorders; Motor skills disorders; Pervasive developmental disorders; Attention-deficit and disruptive behaviour disorders; Feeding and eating disorders of early infancy and childhood; Tic disorders; Elimination disorders; Other disorders of infancy, childhood and adolescence. The DSM-IV-TR also points out that any of the disorders associated with adults may also apply to children if they present with the symptoms characteristic of that disorder, for example, a major depressive episode or a manic episode. Nurses are not usually directly involved in the treatment of disorders such as communication and learning disorders. However, it is important that nurses be able to recognize the essential features of these disorders. The defining characteristics and diagnostic criteria for each of these disorders can be found in the DSM-IV-TR.
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Learning disorders These disorders are diagnosed when the child's 'achievement on individually administered, standardized tests in reading, mathematics or written expression is substantially below that expected for age, schooling and level of intelligence' (American Psychiatric Association 1994: 46). Green and Green (1995) studied the relationship between perceived scholastic underachievement and four school systems previously operating in South Africa, namely those of the Department of Education and Culture (DEC, that is, controlled by the then House of Representatives), private schools (P), the Cape Education Department (CED) and the Department of Education and Training (DET). There was a distribution of 173 student teachers between these four school systems. Their task was to identify a learner who was thought to be underachieving and then to describe the nature of the problem and its background. Observation, consultation with full-time staff members and learner records were used to identify the underachieving learners. The results of this study showed that a wide range of reasons is associated with underachievement. Some of these reasons include intrapersonal factors (for example, loss of motivation); interpersonal factors (for example, family under-involvement or overinvolvement); and contextual factors (for example, poverty and transport). The highest number of reasons for underachievement were found in DET schools (158), closely followed by CED schools (154), DEC schools (97) and, finally, private schools (26). The most common reasons for underachievement in the DET schools were related to socio-economic factors, while intrapersonal factors were found to be most common in the other three systems. This suggests that students in the DET system suffered from a wider range of debilitating factors than students in other school systems. The implication of this study is that the diagnosis of a learning disorder should be considered in the context of the child's socio-economic and educational background. Pervasive developmental disorders These are a group of psychiatric conditions in which expected social skills, language development and age-appropriate behaviours either do not develop appropriately or are lost in early childhood. In general, these disorders affect multiple areas of development, are manifested early in life, and cause persistent dysfunction. Examples include autistic disorder, childhood disintegrative disorder and Asperger's disorder. Children with such disorders should be referred for specialist treatment. Attention-deficit and disruptive behaviour disorders Attention-deficit hyperactivity disorder (ADHD) Although there are no exact statistics on the prevalence of this disorder (ADHD), it is fairly common in practice.
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Aetiology The causes of ADHD are not known. The suggested contributing factors include prenatal toxic exposures, prematurity and prenatal mechanical insult to the foetal nervous system. Food additives, colourings, preservatives and sugar have also been suggested as possible causes of hyperactive behaviour. No scientific evidence indicates that these factors cause ADHD. There is evidence of a genetic basis for the disorder. Siblings of hyperactive children have about twice the risk of having the disorder as children in the general population. When ADHD coexists with conduct disorder in the child, alcohol-use disorders and antisocial personality disorders are more common in the parents than in the general population. Minimal, subtle and subclinical brain damage may be responsible for the genesis of ADHD. Soft neurological signs are frequent. No clear-cut evidence implicates a single neurotransmitter in the development of ADHD, but many neurotransmitters may be involved in the process. The human brain normally undergoes major growth spurts at several ages. Some children have a maturational delay in the growth sequence and then manifest with symptoms of ADHD that appear to be temporary. Some children with ADHD have abnormal electroencephalograph (EEC) patterns. Children in institutions are frequently overactive and have poor attention spans. These signs result from prolonged emotional deprivation and they disappear when deprivational factors are removed, such as through adoption or placement in a foster home. Stressful psychic events, a disruption of the family equilibrium and other anxiety-induced factors contribute to the onset and perpetuation of ADHD. Predisposing factors may include the child's temperament, genetic-familial factors and the demands of society to adhere to a routinized way of behaving and performing. Socio-economic status does not seem to be a predisposing factor. (Intervention follows on page 550.) DSM-IV-TR diagnostic criteria: ADHD A. Either 1 or 2: 1. Inattention: Six (or more) of the following symptoms of inattention have persisted for at least six months to a degree that is maladaptive and inconsistent with developmental level: (a) Often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities. (b) Often has difficulty sustaining attention in tasks or play activities. (c) Often does not seem to listen when spoken to directly. (d) Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behaviour or failure to understand instructions).
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(e) (f) (g) (h) (i) 2.
Often has difficulties organizing tasks and activities. Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework). Often loses things necessary for tasks or activities (for example, school assignments, pencils, books, or tools). Is often easily distracted by extraneous stimuli, Is often forgetful in daily activities.
Hyperactivity-impulsivity: Six (or more) of the following symptoms of hyperactivityimpulsivity have persisted for at least six months to a degree that is maladaptive and inconsistent with developmental level: Hyperactivity
(a) (b)
Often fidgets with hands or feet or squirms in seat. Often leaves seat in classroom or in other situations in which remaining seated is expected. (c) Often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness). (d) Often has difficulty playing quietly or engaging in leisure activities quietly. (e) Is often 'on the go' or often acts as if 'driven by a motor'. (f) Often talks excessively. Impulsivity
(g) (h) (i)
Often blurts out answers to questions before the questions have been completed, Often has difficulty awaiting turn. Often interrupts or intrudes on others (for example, butts into conversations or games).
B. Some hyperactive-impulsive or inattentive symptoms that caused impairment were present before age seven years. C. Some impairment from the symptoms is present in two or more settings (for example, at school [or work] and at home). D. There must be clear evidence of clinically significant impairment in social, academic, or occupational functioning. E. The symptoms do not occur exclusively during the course of a pervasive developmental disorder, schizophrenia, or other psychotic disorder, and are not better accounted for by another mental disorder (for example, mood disorder, anxiety disorder, dissociative disorder, or a personality disorder). Code based on type: Attention-deficit/hyperactivity disorder, combined type: if both criteria A1 and A2 are met for the past six months.
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Attention-defidt/hyperactivity disorder, predominantly inattentive type: if criterion A1 is met but criterion A2 is not met for the past six months. Attention-defidt/hyperactivity disorder, predominantly hyperactive-impulsive type: if criterion A2 is met but criterion A1 is not met for the past six months. Coding note: for individuals (especially adolescents and adults) who currently have symptoms that no longer meet full criteria, 'in partial remission' should be specified. (American Psychiatric Association 1994)
Oppositional defiant disorder Aetiology Oppositional behaviour is normal at certain developmental stages, for example, the 'terrible twos' and adolescence. Pathology begins when that developmental phase persists abnormally, authority figures overreact or Oppositional behaviour recurs considerably more frequently than in children of the same mental age. Children may have constitutional or temperamental predispositions to strong will, strong preferences or great assertiveness. If power or control is an issue for the parents or if they exercise authority for their own needs, a struggle can ensue that sets the stage for the development of Oppositional defiant disorder. In late childhood environmental trauma, illness or chronic incapacity such as intellectual disability may trigger oppositionalism as a defence against helplessness, anxiety and loss of self-esteem. Classic psychoanalytic theory implicates unresolved conflicts that developed during the anal period. Behaviourists have suggested that oppositionalism is a reinforced, learned behaviour through which the child exerts control over authority figures - for example, by having a temper tantrum when some undesired act is requested, the child coerces the parents to withdraw their request. In addition, increased parental attention - for example, long discussions about the behaviour - may reinforce the behaviour. (See Intervention, page 550.)
DSM-IV-TR diagnostic criteria: Oppositional defiant disorder A. A pattern of negativistic, hostile and defiant behaviour lasting at least six months during which four or more of the following are present: (a) Often loses temper. (b) Often argues with adults. (c) Often actively defies or refuses to comply with adults' requests or rules. (d) Often deliberately annoys people. (e) Often blames others for his or her mistakes or misbehaviour. (f) Is often touchy or easily annoyed by others.
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(g) Is often angry and resentful. (h) Is often spiteful or vindictive. Note: Consider a criterion met only if the behaviour occurs more frequently than is typically observed in individuals of comparable age and developmental level. B. The disturbance in behaviour causes significant impairment in social, academic or occupational functioning. C. The behaviours do not occur exclusively during the course of a psychotic or mood disorder. D. Criteria are not met for conduct disorder and, if the individual is age 18 years or older, criteria are not met for antisocial personality disorder. (American Psychiatric Association 1994)
Conduct disorder Aetiology Some parental attitudes and faulty child-rearing practices influence the development of children's maladaptive behaviours. Chaotic home conditions are associated with conduct disorder. Broken homes per se are not causatively significant; it is the strife between the parents that contributes to conduct disorder. Parental psychopathology, child abuse and negligence often contribute to this disorder. Sociopathy, alcohol dependence, psychosis and substance abuse in the parents are associated with conduct disorder in their children. Psychodynamic hypotheses suggest that children with conduct disorder unconsciously act out their parent's antisocial wishes. Current theories suggest that socio-economically deprived children, unable to achieve status and obtain material goods through legitimate routes, are forced to resort to socially unacceptable means to reach those goals and that such behaviour is normal and acceptable under circumstances of socio-economic deprivation, as the children are adhering to the values of their own subculture. Conduct disorder and ADHD often coexist. Studies indicate decreased noradrenergic functioning. Blood serotonin is increased. Children who are exposed to violence for long periods, especially those who endure physically abusive treatment, often behave in aggressive ways. ADHD, central nervous system (CNS) dysfunction or damage and early extremes of temperament can predispose a child to conduct disorder. Diagnostic criteria DSM-IV-TR diagnostic criteria: Conduct disorder A repetitive and persistent pattern of behaviour in which either the basic rights of others or major age-appropriate societal norms or rules are violated, as manifested by the presence of three (or more) of the following criteria in the past 12 months, with at least one criterion present in the past six months:
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Aggression to people and animals 1. Often bullies, threatens, or intimidates others. 2. Often initiates physical fights. 3. Has used a weapon that can cause serious physical harm to others (for example, a bat, brick, broken bottle, knife, gun). 4. Has been physically cruel to people. 5. Has been physically cruel to animals. 6. Has stolen while confronting a victim (for example, mugging, purse snatching, extortion, armed robbery). 7. Has forced someone into sexual activity. Destruction of property 1. Has deliberately engaged in fire setting with the intention of causing serious damage. 2 Has deliberately destroyed others' property (other than by fire setting). Deceitfulness or theft 1. Has broken into someone else's house, building, or car. 2. Often lies to obtain goods or favours or to avoid obligations (that is, 'cons' others). 3. Has stolen items of non-trivial value without confronting a victim (for example, shoplifting, but without breaking and entering; forgery). Serious violations of rules 1. Often stays out at night despite parental prohibitions, beginning before age 13 years. 2. Has run away from home overnight at least twice while living in parental or parental surrogate home (or once without returning for a lengthy period). 3. Often truant from school, beginning before age 13 years. B. The disturbance in behaviour causes clinically significant impairment in social, academic, or occupational functioning. C. If the individual is age 18 years or older, criteria are not met for antisocial personality disorder. Specify type based on age of onset: Childhood-onset type: Onset of at least one criterion characteristic of conduct disorder prior to age 10 years. Adolescent-onset type: Absence of any criteria characteristic of conduct disorder prior to age 10 years. Specify severity: Mild: Few if any conduct problems in excess of those required to make the diagnosis and conduct problems cause only minor harm to others.
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Moderate: Number of conduct problems and effect on others intermediate between 'mild' and 'severe'. Severe: Many conduct problems in excess of those required to make the diagnosis or conduct problems cause considerable harm to others. (American Psychiatric Association 1994)
Common nursing diagnoses Potential for violence directed at self, others or property RELATED TO neurological disorders, mild intellectual disability, unresolved grief related to real or perceived loss, frustration with regard to interpersonal relationships, poor coping skills EVIDENCED BY history of such violence, body language, threats. Impaired social interaction RELATED TO neurological disorders, mild intellectual disability, poor role models, dysfunctional family system EVIDENCED BY discomfort in social situations, acting out, lack of success in social situations. Anxiety (moderate to severe) RELATED TO situational and maturational crises, unmet needs, poor coping mechanisms EVIDENCED BY restlessness, insomnia, fears, difficulty in concentrating. (Townsend 1990)
Evidence-based Practice Family and parenting interventions in children and adolescents aged 10-17 with conduct disorder and delinquency At follow up, family and parenting interventions significantly reduced the time spent by juvenile delinquents in institutions (WMD 51,34 days, 95 % Cl 72,52 to 30,16). There was also a significant reduction in the risk of a juvenile delinquent being re-arrested (RR 0,66, 95 % Cl 0,44 to 0,98) and in their rate of subsequent arrests at 1-3 years (SMD -0,56, 95 % Cl -1,100 to - 0,03). For both of these outcomes there was substantial heterogeneity in the results suggesting a need for caution in interpretation. At present there is insufficient evidence that family and parenting interventions reduce the risk of being incarcerated (RR=0,50, 95 % Cl 0,20 to 1,21). No significant difference was found for psychosocial outcomes such as family functioning, and child/adolescent behaviour. Reviewers' conclusions: The evidence suggests that family and parenting interventions for juvenile delinquents and their families have beneficial effects on reducing time spent in institutions. This is of obvious benefit to the participant and his/her family and may result in a cost saving for society. These interventions
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may also reduce rates of subsequent arrest but at present these results need to be interpreted with caution due to the heterogeneity of the results. Woolfenden S R, Williams K & Peat J. Family and parenting interventions in children and adolescents with conduct disorder and delinquency aged 10-17 (Cochrane Review). In: The Cochrane Library, Issue 2, 2003. Oxford: Update Software.
Intervention ADHD, disruptive behaviour and conduct disorders Milder forms of these conditions should be addressed by working with parents/care-takers to assist them in the therapeutic handling of the children. Parent-teaching programmes such as Systematic Training in Effective Parenting (STEP) can assist parents to be consistent and use behaviour modification approaches to handling the children's behaviour. In more serious conditions much more robust approaches are needed, and even then prognosis is often poor. Firstly co-morbid disorders in the family should be addressed to reduce the level of stress and dysfunction in the family. This could mean treatment for substance abuse or another psychiatric condition for parents, or family therapy to assist the family in dealing with interpersonal conflict. Secondly, a network approach to dealing with the behaviour of the child is indicated. This means that all those adults working with the child should meet to decide on a coherent approach. This ensures that they do not undermine each other's efforts, or allow the child to manipulate conflict between them. Teachers, parents, social workers, adult siblings and other interested adults should be included. The plan the group draws up should be based on behaviour modification principles, but aversive conditioning should be limited, and firm, consistent limit setting within a warm and caring environment used as far as possible. Lastly, medication should be considered. Stimulants such as methylphenidate is the drug of choice and improve the symptoms in 75 % of children (Robertson 1996).
Evidence-based Practice 'Scared Straight' and other juvenile awareness programmes for preventing juvenile delinquency Analysis shows the intervention to be more harmful than doing nothing. The programme effect, whether assuming a fixed or random effects model, was almost identical and negative in direction, regardless of the meta-analytic strategy. Reviewers' conclusions: We conclude that programmes such as 'Scared Straight' are likely to have a harmful effect and increase delinquency relative to doing nothing at all to the same youths. Given these results,
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agencies that permit such programmes must rigorously evaluate them not only to ensure that they are doing what they purport to do (prevent crime), but that at the very least they do not cause more harm than good. Petrosino A, Turpin-Petrosino C & Buehler J. 'Scared Straight' and other juvenile awareness programs for preventing juvenile delinquency (Cochrane Review). In: The Cochrane Library, Issue 2, 2003. Oxford: Update Software.
Elimination disorders Enuresis Aetiology Mental disorders are present in only about 20 % of enuretic children and are most common in enuretic girls, in children with symptoms during the day and the night, and in children who maintain the symptoms into older childhood. Difficulties in the child's neuromuscular and cognitive development, socioemotional factors and toilet training may delay urinary continence. In a longitudinal study of child development, those children who were enuretic were about twice as likely to have concomitant developmental delays as were dry children. Although there may be a genetic basis for enuresis, much can be accounted for by tolerance for enuresis in those families. A child with enuresis has a functionally small bladder so that the child feels an urge to void with little urine in the bladder. Some studies report that bed-wetting occurs because the bladder is full and there is an absence of the high levels of a night-time antidiuretic hormone. Those factors allow for a higher than usual urine output. Enuresis does not appear to be related to a specific stage of sleep or time of the night. Little evidence indicates that enuretic children sleep more soundly than do other children. Psychosocial stressors appear to precipitate some cases of enuresis. In young children the disorder has been particularly associated with the birth of a sibling, the start of school, hospitalization between the ages of two and four, the break-up of a family because of divorce or death, and a move to a new environment. Diagnostic criteria DSM-IV-TR diagnostic criteria: Enuresis A. Repeated voiding of urine into bed or clothes (whether involuntary or intentional). B. The behaviour is clinically significant as manifested by either a frequency of twice a week for at least three consecutive months or the presence of clinically significant distress or impairment in social, academic (occupational), or other important areas of functioning. C. Chronological age is at least five years (or equivalent developmental level).
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D. The behaviour is not due to the direct physiological effect of a substance (for example, a diuretic) or a general medical condition (for example, diabetes, spina bifida, a seizure disorder). Specify type
Nocturnal only Diurnal only Nocturnal and diurnal (American Psychiatric Association 1994)
Intervention An assessment must be made; the family is the logical source of information about toilet training and the prevalence of enuresis. Information about the age at which toilet training was commenced and the technique used supplies clues regarding the family's expectations and the effectiveness of their toilet-training methods. Record keeping is helpful in determining a baseline; following the child's progress may itself be a reinforcer. Appropriate toilet training with parental reinforcement can be helpful. Look out for stressors that may cause the behaviour. One of the therapeutic objectives of the nurse is to help the family to re-establish physical and psychological security and to offer this to the child. Methods which may prove effective are to leave a night-light on, to allow the child to sleep with a favourite toy, to restrict fluids in the evening and to take the child to the toilet regularly. Behaviour therapy can also be successfully implemented. Nocturnal enuresis often clears up spontaneously if it is ignored. Children are rewarded after passing urine in the toilet. Fluids are encouraged to provide a reason for frequent reinforcement. Star charts are particularly helpful. Children are taught a structured procedure for elimination, that is, to go to the toilet, remove clothes, void, maintain hygiene and dress again. They are also rewarded for periods of keeping dry. Accidents are not punished and no special attention is paid to them. Another conditioning technique is the enuresis alarm, which consists of a urinesensitive pillow connected to an alarm system. As soon as the pillow becomes wet, the alarm goes off because the urine acts as an electrolyte and completes an electric circuit. This wakes the child, which means that he or she must get up, pass urine, change pyjamas and bed linen and reset the alarm. The child is taught by this means to inhibit urination in order to avoid the unpleasant experience. Dryness results in more than 50 % of cases. Difficulties may include child and family non-compliance, improper use of the apparatus, and relapse. Bladder (interval) training is another technique that may be attempted. Children with nocturnal enuresis pass very little urine during the day and it is possible that they have not yet learned to interpret the sensation of a full bladder. A few days are chosen during which there
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is no pressure and no interruptions and large amounts of fluids (about 400 ml) are given every half hour. The child is encouraged to try and lengthen the intervals between urination. Every time the sensation to void is experienced, the urine must be held back a little longer. Nurses must realize that parents are often very anxious and must be reassured and supported. The child must be taught to pay particular attention to hygiene, as unpleasant odours may lead to teasing and rejection by peers. The nurse must support the child without being judgemental. Drugs should rarely be used to treat enuresis and then only as a last resort in intractable cases causing socio-emotional difficulties for the child. Tofranil has been used successfully, but the success does not often last: tolerance often develops after six weeks of therapy. Encopresis Aetiology
The lack of appropriate toilet training or inadequate training may delay the child's attainment of continence. Evidence indicates that encopretic children suffer from lifelong ineffective sphincter control. A power struggle between the parent and the child over issues of autonomy and control can cause the disorder. Such battles frequently cause behavioural problems. Psychiatric difficulties may be present. Encopresis may be associated with neuro-developmental problems, including easy distractibility, short attention span, low frustration tolerance, hyperactivity and poor coordination. Encopresis may also be precipitated by life events, such as the birth of a sibling or a move to a new home. Occasionally, the child has a special fear of using the toilet. Encopresis sometimes appears to be a regression after such stresses as a parental separation or the start of school. Many encopretic children retain faeces and become constipated either voluntarily or secondarily to painful defecation. The resulting chronic rectal distension from large, hard faecal masses may cause loss of tone in the rectal wall and desensitization to pressure. Many children become unaware of the need to defecate and overflow encopresis occurs, usually with relatively small amounts of liquid or soft stool leaking out. It is not as common as enuresis. Diagnostic criteria DSM-IV-TR diagnostic criteria: Encopresis A, Repeated passage of faeces into inappropriate places (for example, clothing or floor) whether involuntary or intentional. B, At least one such event a month for at least three months. C. Chronological age of at least four years (or equivalent developmental level). D. The behaviour s not due exclusively to the direct physiological effects of a substance (for example, laxatives) or a general medical condition, except through a mechanism involving constipation,
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Code as follows: With constipation and overflow incontinence Without constipation and overflow incontinence (American Psychiatric Association 1994)
Intervention One first has to distinguish between encopresis with constipation and overflow incontinence and encopresis as a result of anxiety or inability to control the bowel. Retention encopresis is generally treated with laxatives, stool softeners and enemas until the bowel is empty, after which routine elimination is taught. Nurses must be sensitive and supportive and show empathy when using these measures, as both the symptom and the treatment are concerned with the same part of the body. Behaviour therapy and star charts can be used. The nurse must ensure that the child feels secure by reducing anxiety during toilet training and by teaching the parents to foster this security by ensuring that toilet behaviour is a desirable and rewarding experience for the child. The child's feelings of anxiety and guilt about the encopresis are best managed by making use of play. Relatively structured play allows the child to express concerns and serves as a non-threatening way of sharing feelings with others. Win the child's confidence to address the emotional subject of elimination. School nurses can support children by ensuring privacy for regular changing of soiled clothes to avoid teasing and rejection by peers. Learning bladder and bowel control is an important step in enabling children to take part in normal daily life. Family tension regarding the symptom must be reduced and a non-punitive atmosphere must be created. Psychotherapy is useful for easing family tension, for treating encopretic children's reactions to their symptoms (such as low self-esteem and social isolation), for addressing the psychodynamic causes present in those children who have bowel control but continue to deposit their faeces in inappropriate places, and for treating those cases of encopresis after a long period of faecal continence that are reactions to psychological stressors. Separation anxiety disorder Although there is no epidemiological evidence regarding the prevalence of separation anxiety disorder, it is frequently diagnosed in children. Internationally the prevalence is estimated at 3 %-4 % of all school-age children. Aetiology Young children, immature and dependent on a mothering figure, are particularly prone to anxiety related to separation. The disorder occurs when the child has a disproportionate fear of mother-loss.
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The character structure pattern in many children with separation anxiety disorder includes conscientiousness, eagerness to please and a tendency towards conformity. Families tend to be close-knit and the children often seem to be spoiled or the objects of parental over-concern. External life stresses often coincide with the development of the disorder. The death of a relative, illness in the child, a change in the child's environment or a new school are frequently noted in the histories of these children. Phobic anxiety may be communicated from parents to children by direct modelling. Some parents appear to teach their children to be anxious by overprotecting them from expected dangers or by exaggerating the dangers. There is a genetic basis for separation anxiety disorder. Parents who have panic disorder with agoraphobia appear to have an increased risk of having a child with this disorder. Separation anxiety disorder and depression in children overlap. Diagnostic criteria DSM IV-TR diagnostic criteria: Separation anxiety disorder A. Developmental^ inappropriate and excessive anxiety concerning separation from home or from those to whom the individual is attached, as evidenced by three (or more) of the following: 1.
Recurrent excessive distress when separation from home or major attachment figures occurs or is anticipated.
2.
Persistent and excessive worry about losing, or about possible harm befalling, major attachment figures.
3.
Persistent and excessive worry that an untoward event will lead to separation from a major attachment figure (for example, getting lost or being kidnapped).
4.
Persistent reluctance or refusal to go to school or elsewhere because of fear of separation.
5.
Persistently and excessively fearful or reluctant to be alone or without major attachment figures at home or without significant adults in other settings.
6.
Persistent reluctance or refusal to go to sleep without being near a major attachment figure or to sleep away from home.
7. 8.
Repeated nightmares involving the theme of separation. Repeated complaints of physical symptoms (such as headaches, stomach aches, nausea, or vomiting) when separation from major attachment figures occurs or is anticipated.
B. The duration of the disturbance is at least four weeks. C. The onset is before age 18 years. D. The disturbance causes clinically significant distress or impairment in social, academic (occupational), or other important areas of functioning.
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E. The disturbance does not occur exclusively during the course of a pervasive developmental disorder, schizophrenia, or other psychotic disorder and, in adolescents and adults, is not better accounted for by panic disorder with agoraphobia. Specify type
Early onset: if onset occurs before age six years (American Psychiatric Association 1994)
Major depressive disorder A South African study has indicated that 8 % of children under 12 and 20 % of children older than 12, who are seen at child guidance clinics, are depressed. Aetiology Children's moods are especially vulnerable to the influences of severe social stressors such as chronic family discord, abuse and neglect, and academic failure. Learning problems and underachievement can cause depression in a child. There is a genetic basis for major depressive disorder - it tends to cluster in the same families. Having one depressed parent probably doubles the risk for the offspring. Having both parents depressed probably quadruples the risk of a child's having a mood disorder before age 18 when compared with the risk for children with two unaffected parents. Boys whose fathers died before they were 13 years old are more likely than are controls to have depression. Prepubertal children in an episode of a major depressive disorder secrete significantly more growth hormone during sleep than do normal children. Hypoglycaemia is suggested in some studies as a cause of depression in children. Separation or loss. The loss may be real (for example, parental divorce) or symbolic. Hospitalization A South African study was conducted among black children during hospitalization for orthopaedic procedures. A big correlation between hospitalization and depressive symptomalogy was found. According to a recent review, at least 20 % of children admitted into hospital display some degree of behavioural or emotional disturbance. In hospital, children are separated from parents, siblings, peers and familiar environments. This separation deprives them of the psychological and social support necessary for adaptation to the strange surroundings and events, and sometimes also to pain and discomfort. It has been suggested that surgery, in particular, poses a significant risk for the child. Maternal separation often elicits depressive-like symptoms.
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It is probable that illness and hospitalization have different meanings for and impacts on children from different cultural and social groups. An increased risk of problem behaviours in response to hospitalization has been found to be associated with coming from a deprived and disadvantaged home. The difficult circumstances of many black South African children may have a negative effect on their experience of hospitalization. For example, socio-economic conditions, as well as long distances from urban health services, make it difficult for parents to pay regular visits to their children in hospital. The ability of parents to visit their children has been found in some studies to influence the child's experience of hospitalization. Children may also have problems understanding the language that is being spoken to them in hospitals. Often the food in hospitals is unfamiliar to them. These factors contribute to the child's anxiety. Diagnostic criteria Except for the two differences indicated in the table below, the same diagnostic criteria for this disorder are used for both children and adults. DSM-IV-TR diagnostic criteria: Major depressive disorder A. Five (or more) of the following symptoms have been present during the same two-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure. Note: Do not include symptoms that are clearly due to a general medical condition, or moodincongruent delusions or hallucinations. 1. Depressed mood most of the day, nearly every day, as indicated by either subjective report (for example, feels sad or empty) or observation made by others (for example, appears tearful). Note: In children and adolescents can be irritable mood. 2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated either by subjective account or observation made by others). 3. Significant weight loss when not dieting or weight gain (for example, a change of more than 5 % of body weight in a month), or decrease or increase in appetite nearly every day. Note: In children, consider failure to make expected weight gains. 4. Insomnia or hypersomnia nearly every day. 5. Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down). 6. Fatigue or loss of energy nearly every day. 7. Feelings of worthlessness or excessive or inappropriate guilt (which maybe delusional) nearly every day (not merely self-reproach or guilt about being sick). 8. Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others).
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9.
B. C. D. E.
Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide. The symptoms do not meet criteria for a mixed episode. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. The symptoms are not due to the direct physiological effects of a substance (for example, a drug of abuse, a medication) or a general medical condition (for example, hypothyroidism). The symptoms are not better accounted for by bereavement, that is, after the loss of a loved one; the symptoms persist for longer than two months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation.
(American Psychiatric Association 1994)
Additional features of depression Somatic complaints like abdominal pain, headaches and dizziness; Social withdrawal and sad appearance; Mood-congruent auditory hallucinations; A poor self-esteem; Anhedonia and ambivalence; Severe psychomotor retardation; A sense of hopelessness, loneliness and boredom; Declining academic performance; Aggressive behaviour and violent outbursts; Enuresis; Failure to thrive; Bad dreams; Children have fewer problems with sleep and appetite than do depressed adults. There may be a loss of appetite in depressed children, but sleeping problems are rare; Negativistic behaviour; Feelings of restlessness, grouchiness, sulkiness and a reluctance to co-operate in family ventures; Inattention to personal appearance; Increased emotionality; Sensitivity to rejection in love relationships; Poor peer relationships; Poor concentration, slowed-down thinking, lack of interest and motivation, and fatigue;
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Delusions which centre on themes of guilt, physical disease, death, nihilism, deserved punishment, personal inadequacy and sometimes persecution; Description of feelings as follows: sad, empty, low, down, blue, very unhappy, crying, or having a bad feeling inside that is there most of the time; Depression in a child may be misdiagnosed as a learning disorder. Intervention To prevent this disorder as a result of hospitalization, all efforts to reduce anxiety in hospitalized children should be made, for example, parents should be allowed to stay with their children, play activities to support the child emotionally should be implemented, procedures should be explained. The child must be prepared regarding the consequences of certain nursing and medical interventions. For example, when a child has to go to the theatre, dolls can be used to explain this to the child beforehand. When a depressed child is suicidal, a safe environment should be created. Family counselling and education, as well as individual counselling of the child, have to be structured and directed. The child can be taught social and problem-solving skills. Group therapy for children and adolescents with chronic mood disorders function best when integrated with a variety of individuals from other diagnostic realms. Medication (antidepressants) is often used and therapeutic and side effects should be monitored. Post-traumatic stress disorder (PTSD) Aetiology The most common stressors for PTSD in children are violence, rape, physical and sexual abuse. Although there are no reliable epidemiological statistics available for the sexual abuse of children, it is commonly diagnosed. Nurses in child psychiatric units in South Africa report that approximately 60 %—70 % of girls seen in these units have been sexually abused. Sexual abuse is not a psychiatric diagnosis but it causes severe emotional distress in children. Sexual abuse will not be discussed in this chapter, but in the bibliography there are some references applicable to the management of these children. Diagnostic criteria DSM-IV-TR diagnostic criteria: PTSD A. The person has been exposed to a traumatic event in which both of the following were present: 1. The person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others. 2. The person's response involved intense fear, helplessness, or horror. Note: In children, this may be expressed instead by disorganized or agitated behaviour.
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B. The traumatic event is persistently re-experienced in one (or more) of the following ways: 1. Recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions. Note: In young children, repetitive play may occur in which themes or aspects of the trauma are expressed. 2. Recurrent distressing dreams of the event. Note: In children there may be frightening dreams without recognizable content. 3. Acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociated flashback episodes, including those that occur upon awakening or when intoxicated). Note: In young children, traumaspecific re-enactment may occur. 4. Intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event. 5. Physiologic reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event. C. Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by three (or more) of the following: 1. Efforts to avoid thoughts, feelings, or conversations associated with the trauma. 2. Efforts to avoid activities, places, or people that arouse recollections of the trauma. 3. Inability to recall an important aspect of the trauma. 4. Markedly diminished interest or participation in significant activities. 5. Feeling of detachment or estrangement from others. 6. Restricted range of affect (for example, unable to have loving feelings). 7.
Sense of a foreshortened future (for example, does not expect to have a career, marriage, children, or a normal lifespan).
D. Persistent symptoms of increased arousal (not present before the trauma), as indicated by two (or more) of the following: 1.
Difficulty falling or staying asleep.
2.
Irritability or outbursts of anger.
3.
Difficulty concentrating.
4.
Hypervigilance.
5.
Exaggerated startle response.
E.
Duration of the disturbance (symptoms in criteria B, C, and D) is more than one month.
F.
The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
Specify if:
Acute: If duration of symptoms is less than three months. Chronic: If duration of symptoms is three months or more. With delayed onset: Onset of symptoms at least six months after the stressor. (American Psychiatric Association 1994)
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Intervention The nurse should refer the patient to a psychologist. However, if no psychologist is available, the following approaches can be used: Encourage desensitization by allowing the child to speak about the incident in a supportive environment, or to express feelings through drawing or playing. Help the child to assert himself or herself in threatening situations by teaching assertiveness skills. Building self-confidence can help the child to cope with the aftermath of trauma. Eating disorders In the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association (DSM-IV-TR classification), Anorexia nervosa and bulimia nervosa have been placed in a category of their own. Both rarely begin before puberty and are more common in women than men. Diagnostic criteria DSM-IV-TR diagnostic criteria: Anorexia nervosa A. Refusal to maintain body weight at or above a minimally normal weight for age and height (for example, weight loss leading to maintenance of body weight less than 85 % of that expected; or failure to make expected weight gain during period of growth, leading to body weight less than 85 % of that expected). B. Intense fear of gaining weight or becoming fat, even though underweight. C. Disturbance in the way in which one's body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or denial of the seriousness of the current low body weight. D. In post menarcheal females, amenorrhoea, that is, the absence of at least three consecutive menstrual cycles, (A woman is considered to have amenorrhoea if her periods occur only following hormone administration, for example, oestrogen.) Specify type:
Restricting type: During the current episode of anorexia nervosa, the person has not regularly engaged in binge-eating or purging behaviour (that is, self-induced vomiting or the misuse of laxatives, diuretics or enemas). Binge-eating/purging type: During the current episode of anorexia nervosa the person has regularly engaged in binge-eating or purging behaviour (that is, self-induced vomiting or the misuse of laxatives, diuretics or enemas).
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DSM IV-TR diagnostic criteria: Bulimia nervosa A. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following: 1. Eating, in a discrete period of time (for example, within any 2-hour period), an amount of food that is definitely larger than most people would eat during a similar period of time and under similar circumstances. 2. A sense of lack of control over eating during the episode (for example, a feeling that one cannot stop eating or control what or how much one is eating). B. Recurrent inappropriate compensatory behaviour in order to prevent weight gain, such as selfinduced vomiting; misuse of laxatives, diuretics, enemas, or other medications; fasting; or excessive exercise. C. The binge eating and inappropriate compensatory behaviours both occur, on average, at least twice a week for three months. D. Self-evaluation is unduly influenced by body shape and weight. E. The disturbance does not occur exclusively during episodes of anorexia nervosa. Specify type: Purging type: During the current episode of bulimia nervosa, the person has regularly engaged in self-induced vomiting or the misuse of laxatives, diuretics or enemas. Nonpurging type: During the current episode of bulimia nervosa, the person has used other inappropriate compensatory behaviours, such as fasting or excessive exercise, but has not regularly engaged in self-induced vomiting or the misuse of laxatives, diuretics or enemas. (American Psychiatric Association 1994)
Common nursing diagnoses Alternation in nutrition; less than body requirements RELATED TO altered perception of body, control issues EVIDENCED BY refusal to eat, loss of 15 % of body weight, amenorrhea, abuse of laxatives. Disturbance in self-concept RELATED TO unrealistic expectations, retarded ego development, threat to interpersonal security EVIDENCED BY not taking responsibility for self-care, selfdestructive behaviour, negative comments about self.
Intervention Treatment entails, firstly, obtaining the patient's co-operation; secondly, the recovery of normal weight; and thirdly, the treatment of concomitant family pathology and personality problems. Nurses are involved mainly in the first two aspects of treatment.
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A hospitalized behaviour therapy programme, which affords environmental structure, is generally required to recover normal weight. Nursing objectives, actions and the rationale for each 1. Build up a relationship of trust, avoiding conflict with the patient. Assign a primary nurse to the patient, since this provides security. Maintain a non-judgemental attitude and do not show any signs of approval or disapproval. Do not punish the patient. These patients often have difficulties with control, approval and guilt. Non-judgemental nursing decreases the possibility of a power struggle. Be aware of your own feelings and discuss them with colleagues. 2. Encourage weight increase and intake of food. Establish a contract with which patient concurs. Treatment goals are set and the patient experiences feelings of control and responsibility. At first, do not allow the patient to eat with the other patients, who often reinforce the pathological eating pattern by focusing on it. Provide structure and set limits for meals. Always tell the patient when it is time to eat, offer food and state the time limit of the meal. Be consistent. The patient knows what is expected if definite limits are set. Consistency reduces manipulating behaviour. Do not coax or threaten the patient to eat. Do not focus attention on eating. Withdraw attention if the patient refuses to eat. Remove food at the end of the meal without discussing the issue. Secondary gain by fasting is minimalized. Problems of control (especially about eating) must not be reinforced. Supervise the patient during and after meals (for 90 minutes at first, gradually decreasing the time). Do not allow the patient to use the bathroom for at least 30 minutes after a meal. The patient may vomit or do away with hidden food. Provide a pleasant, relaxed atmosphere without distractions. Encourage relaxation techniques, rest and quiet before and after meals. Meals can cause a great deal of stress due to anxiety and guilt about eating habits. Attention is focused on emotional issues and not on food per se. The patients must learn independent eating habits. Encourage the patient to discuss feelings with the primary nurse after meals. Direct attention away from food and eating behaviours. Rather encourage the patient to focus on emotional problems. Gradually increase choices regarding type of food, meals, etc. Grant and restrict privileges according to gain and loss of weight. Work through feelings if there is weight loss. Administer hyperalimentation or tube-feeding if the patient is critically malnourished, since the illness can be fatal.
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3. Improve physical health and safeguard the patient against complications and malnutrition. Monitor vital signs, intake and output, since the patient's physical health is the top priority and the patient may provide inaccurate information in this regard. Provide a diet rich in fibre and fluids, which prevents constipation. Discourage the use of purgatives since the patient may abuse them to control weight. Weigh the patient daily or weekly at a specified time after the bladder has been emptied. Always maintain the same circumstances (clothes, scales) when weighing the patient and do so with a neutral attitude - showing neither approval nor disapproval. Consistency is necessary for accurate comparisons. The patient may hide weights in clothes. Weight loss or gain is not a criterion for failure or success. A neutral attitude helps to separate emotional problems from eating behaviours. Observe all physical activities (some may be covert), in the bed or shower. Structure and limit physical exercise. Do not forbid all physical exercise. The patient may exercise excessively in an effort to control weight, but complete lack of exercise may severely increase anxiety. Help the patient with personal grooming. Hair, nails and skin are often in poor condition due to the nutritional state. Vomiting causes dental caries. Watch room temperature, since patients are apt to feel cold as a result of reduced fat and subcutaneous tissue. Direct attention away from food and eating behaviours. Rather encourage the patient to focus on emotional problems. 4. Encourage healthy eating habits. Gradually reduce limits to meals and snacks. Gradually allow the patient to control food intake, and choice and preparation of food. The patients must develop independent eating habits. Give positive feedback about healthy eating. Positive support reinforces target behaviour. Be aware of your own role in modelling healthy behaviour. The nurse is the role model. Assess the patient's knowledge of weight and nutrition. If necessary, instruct in factual and unemotional terms. The patient may have misconceptions about nutrition and weight. Limit the duration and frequency of instruction. Emotional 'investment' in food and eating must be reduced. Do not discuss subjects directly related to food and eating. Rather focus on emotional issues.
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5. Improve the patient's self-image and social skills, and reduce regressive behaviour. Do not confine the patient to his/her room as part of restriction of privileges, since social isolation may be part of the disturbed behaviour. Expect behaviour consistent with age. The patient may look younger than her true age and would like to be treated like a child to avoid independence. Encourage schoolwork during hospitalization, since it is part of the normal routine of adolescents. Focus on the patient's positive traits and strengths to improve self-image. Allow therapeutic groups and role-play so that the patient can share feelings and test new behaviours in a non-threatening environment. 6. Reduce the patient's associations between food and stress and develop coping mechanisms unrelated to food. Allow food and snacks only at specified times. Do not discuss emotional problems at these times. Allow patients to ventilate feelings at other times. Patients must learn to separate emotional issues from eating behaviours. Observe the patient's perceptions and response to stress. Encourage contact during periods of stress. The patient may be unaware of his/her own responses to stress and must be taught to cope with stressful situations. Identify resources and activities in the patient's environment (for example, hobbies) that can reduce stress and anxiety. The patient learns new skills to deal with stress. Encourage the patient to express feelings concerning family, independence, social skills, sexuality and control. These are often problem areas for patients with anorexia nervosa. Tic disorders A tic is a sudden, rapid, recurrent, non-rhythmic, stereotyped motor movement or vocalization. It is experienced as irresistible, but it can be suppressed for variable lengths of time. It may increase during stress, and lessen when the person is absorbed in something. Tourette's syndrome (TS), is a tic disorder that occurs more in boys and is genetically linked. The child has one or more vocal ticks, and multiple motor tics. It is often related to obsessive-compulsive disorder, hyperactivity and other problems. A tic disorder is treated by medication similar to that used for ADHD. Olivier and De Lange (1999) found that adolescents with Tourette's syndrome have a significantly poorer selfconcept that those who do not, and proposed a wide range of interventions, from individual to community-focused, in order to prevent mental health problems later in life. Poor mother-infant interaction When nurses observe a mother with her infant, they sometimes identify problems in the relationship. The mother might look unresponsive to the infant, might not make eye
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contact with the infant or play with him/her. In return, the infant might avoid eye contact with the mother, resist cuddling or playing. Berg (2002) describes an intervention which consists of role modelling for the mothers three basic behaviours that well mothers spontaneously show in their interaction with their infants: Rhythmic verbal and non-verbal behaviour, that is, repeating phrases, sounds, and bodily movements when holding the baby. Making the infant a person, by talking to the infant by name, talking about his/her place in the extended family and reciting clan names. Identification with the baby's feelings, such as hunger, anger or discomfort. If a nurse therefore identifies a mother-child relationship that is not warm and caring, she should take the baby on her own lap, talk to it and play with it, using rhythmic phrases and movements. She should talk to the baby as a person, even though it may be very young, praising it for its characteristics and its position in the family. If the infant expresses feelings such as tiredness or discomfort, she should name these feelings empathetically and respond appropriately. Berg contends that such role modelling communicates to the mother that her infant is an important, thinking, feeling person, and separate from her. It also confirms for the infant, small as he or she is, that she/he is heard and appreciated. It is a non-prescriptive intervention, which has been shown anecdotally to make a difference in the mother's subsequent behaviour. Schizophrenia Schizophrenia in children is very rare - it is more common in adolescents. Other psychotic disorders are also rare and are frequently associated with substance-related disorders. Obsessive-compulsive (OCD) and generalized anxiety disorders (GAD) According to nurses practising child psychiatry in South Africa, obsessive-compulsive and generalized anxiety disorders are frequently diagnosed in children. The same diagnostic criteria are used for both children and adults. 182 THE ASSESSMENT OF CHILDREN WITH MENTAL HEALTH DISORDERS A comprehensive evaluation of a child includes clinical interviews with the parents, the child and the family. Clinical interviews allow for the most flexibility in understanding the evolution of problems over time and in establishing the role of environmental stressors. Sources often disagree about a variety of symptoms and behaviours during a comprehensive assessment of a child. When faced with contradictory information, the nurse must realize that those differences may reflect an accurate picture of the child's presentation in different settings.
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interviewing the child Holford and Smith (1992) outline four general reasons for interviewing children. These are: to make a psychiatric diagnosis, such as depression; to get information about physical or sexual abuse; to encourage children to talk about their understanding of traumatic events which they may have witnessed or in which they may have been involved; to get the child's perspective on why he/she has been brought for an interview and how he/she understands his/her present problems. Babich (1982) lists five objectives for the assessment of the mental health of children: 1. Determine in which areas and to what extent the child differs from other children of the same age group. 2. Determine the chronicity of the problem. 3. Identify the areas of strength of the child and the family from the viewpoint of the family and the nurse. 4. Formulate hypotheses about previous and current contributing factors, and the interaction among the factors. 5. Plan priorities for intervention. (Babich 1982:24) The success of an interview with a child depends on prior preparation. Children are an excellent source of information about their own symptomatology, but they often have difficulty with the chronology of symptoms; they are sometimes unwilling to talk about behaviours that have got them into trouble; and they may have difficulty in verbally expressing their feelings and experiences. Information from the family, the school and any community agencies involved may help to explain the reasons for the referral and to plan the process and content of the interview. The process of the child interview A number of factors may influence the process of the interview. These include the developmental abilities of the child, factors within the interviewer, factors within the child and, finally, the way in which the interviewer interacts with the child. The developmental abilities of the child The order in which these clinical interviews take place is influenced to some extent by the developmental age of the child. For example, Holford and Smith (1992) believe that adolescents should be interviewed before their parents. One of the major developmental tasks of the adolescent is to establish his/her own identity as a person, separate from those of the parents. It is therefore important for the adolescent to feel that the interviewer's impressions of him/her have not been biased in any way by prior in-depth contact with the parents. On the other hand, interviews with infants and young children usually begin with the parents present, since very young children may be frightened by the interview situation.
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Having the parents present also provides an opportunity for the nurse to assess the parentchild interaction. Nevertheless, Holford and Smith (1992) believe that at some point in the interview process the child should be seen without the parents present. They cite two major reasons for this: 1. The child might not feel free to talk openly for fear of eliciting a critical or undermining response from the parent/s. 2. The child might minimize his/her problems and anxieties through fear of the parents' response, or to protect the parents. Knowing the developmental norms associated with the age of the child to be interviewed helps the nurse to match the content and process of the interview with the child's developmental abilities. For example, fear of imaginary dangers such as ghosts or monsters is a feature of children in the two to five-year-old age group. The nurse could use this knowledge as a basis for enquiring about the nature of any fears the child might have: Nurse: 'Do you see monsters? What do the monsters want to do to you?' The level of confidentiality in a child assessment is correlated with the age of the child that is, just about all specific information is shared with the parents of a very young child and more privacy is reasonable with an adolescent. School-age and older children may be told that if the nurse becomes concerned that they are a danger to themselves or to others, that information will have to be shared with other adults. However, the nurse must determine whether a child is safe in his/her environment and make clinical judgements about whether the child is a victim of abuse or neglect. Factors within the interviewer Many people may feel the need to rescue the child from the situation or problem that he/she is facing. In instances where the professional's attempt to engage with the child elicits negative or angry responses from the child, the professional may become angry and/or demoralized. Holford and Smith (1992) identify four factors within the interviewer that may interfere with the process of the interview. These are: 1. Overidentification with the child because of the way the interviewer was treated as a child; 2. The interviewer may experience the emotional residue of old conflicts in response to certain behaviours in the child; 3. Racial, religious and political prejudices within the interviewer may influence his/her interactions with the child; 4. The interviewer may feel threatened by sexually attractive children and adolescents and concentrate more than is necessary on sexual aspects of development, or ignore these aspects altogether. The interviewer may also overidentify with the parents' struggles with the child, because of his/her own experiences as a parent.
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Factors within the child Children are first and foremost members of a family system, which provides them with a sense of identity. Because of this children are often ambivalent about sharing their problems and feelings, even if the problem involves them and other members of the family. They may feel ashamed to talk about things that they have been punished for doing. They may feel guilty about disclosing a family secret such as parental conflict but, at the same time, they want the behaviour to stop. Children sometimes feel responsible for family problems, particularly sexual abuse. Professionals are often confused about why a child who initially claimed that he/she was a victim of sexual abuse later withdraws his/her statement. This is because the consequences of the claim may be far worse for the child than the abuse itself (for example, the loss of a family member such as the father; fear of being harmed by an avenging family member; economic hardship for the rest of the family through loss of a breadwinner; feeling responsible and guilty for sending a loved one to jail). An adolescent may approach an interview with apprehension or outright hostility, but open up when the nurse is neither punitive nor judgemental. Nurses must be aware of their own responses to an adolescent's behaviour (countertransference), so as to remain therapeutic, even in the face of a defiant, angry, or difficult adolescent. Nurses should set appropriate limits and should postpone or discontinue the interview if they feel threatened or if patients become destructive to property or to themselves. The interview should always include an exploration of suicidal thoughts, assaultive behaviour, psychotic phenomena, substance use, and sexual relationships. Once rapport has been established, many adolescents appreciate the opportunity to tell their side of the story and may reveal things that have not been disclosed to anyone else. Guidelines to facilitate the process of the interview The following guidelines could facilitate interaction with children of any age: 1. A child may find offices or clinics very intimidating. A short walk may ease the tension and allow the child to see you as a non-threatening, friendly person. 2. Conduct the interview in a spirit of fun, exploration and enthusiasm. Be friendly and relaxed. Avoid a serious, rushed and super-professional attitude - it is quite all right to sit on the floor with the child. Show interest, give feedback and reassurance, and do not express either positive or negative judgements about what the child says. 3. Use action-oriented tools. Play materials are used for young children and a game is played, or something is made in the case of older children. Examples of toys in an interview room include paper, pencils, paint, a writing board, plasticine, a sandpit, cars, dolls, puppets, storybooks, building blocks and various games, for example, card and board games. 4. Allow the child to take the lead. The self-concept and developmental functioning of children are reflected in their perception of life events. Do not offer suggestions, answers or solutions to problems unless they fit the child's explanation. However, it is essential to guide a child who cannot take the lead.
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5. There are two levels to all communication: the process and the content. Look and listen carefully. The conduct of children is just as important as what they say, and all observations are relevant data. For example, the response of a child to your touch may be an indication of his/her ability to relate to adults. 6. Direct questions can be very threatening. Children respond more easily to examples and fantasy, and speak more readily about other children than about themselves. The following are examples of questions that could be asked: 'Tell me about good (bad) mothers and fathers you have seen on television or whom you have read about in storybooks. Do you know someone like that?' or 'If trees could talk, what would they say to you?' 7. Use the child's language and frame of reference when following up themes that have touched a chord ('I wonder what makes him do that?'). 8. Take the child's side and show empathy in times of stress. Give feedback in a manner that will not be viewed as judgemental or as criticism. A monologue works well when sensitive areas such as the child's problem behaviour are being discussed. Tell a story and watch carefully for non-verbal responses. 9. Do not limit the assessment to one session. Additional contact adds validity to a database (Babich 1982: 60). The content of the child interview Holford and Smith (1992) have formulated the guidelines set out in Table 18.1 regarding the content of the child interview. Table 18,1 Child Psychiatric Interview (CPI) Child Psychiatric Interview (CPI) The Child Psychiatric Interview is intended as a guide to interviewing children. It is not a checklist and it is not intended to be all-inclusive. Where specific information is required, for example, with abused, depressed, psychotic or autistic children, reference to more specialized interviews is indicated.
A. Introduction and interviewing 1. 2.
Escort child to and from waiting room. Welcome child and set at ease.
3. 4.
Initially with younger child, use play and observation, then move into verbal communication. Reassure that confidence will not be betrayed unless the information has to be revealed, such as in a report for court, in which case an explanation to the child is necessary. Discuss reason for referral. What do you call this place? Do you know why children come here? Useful materials: drawing materials, construction toys (e.g. Lego, blocks) and family of dolls.
5. 6.
As far as possible the rest of the room should be free of toys or other distracting objects.
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B. General questions This includes general topics and conversation about recent events and activities. (a) What he/she likes doing on weekends. (b) What television he/she watches. (c) What his/her hobbies/interests are and what games are played. (d) Ambitions and aspirations. What he/she would like to be when grown up. (e) Three wishes. (f) Island companion. (g) Free drawing - e.g. ask the child to draw whatever he/she likes and to tell a story about the drawing on completion. C. Structure and specific questions (a) School: e.g. How are you getting on there? Any homework? Who helps? What do you like best and least? Why? Likes or dislikes the teacher - specify. Likes or dislikes subjects specify. Likes or dislikes activities - specify. (b) Peers: e.g. Do you have one special friend? Enquire about teasing, bullying or anxieties. Specify peer contacts and child's popularity or isolation. Do you ever feel lonely? (c) Appetite: Do you like eating? Enquire about eating patterns. Enquire about weight loss or gain. (d) Sleep: e.g. Some kids do not like getting up in the morning. How about you? What about going to sleep at night? Enquire about sleep problems. (e) Dreams: e.g. Everyone dreams; what do you dream about? Do you have bad, nasty, scary, etc., dreams? How often? Do you wake up? Who comes to comfort you? (f) Worries: e.g. Most people worry about something. What kinds of things do you worry about? Does thinking about unpleasant or nasty things ever stop you from getting to sleep? Do you every get nasty/unhappy/worrying thoughts? What is your biggest worry? (g) Depression: Do you ever cry? Do you feel really unhappy sometimes? Do you sometimes feel sad for no reason? (h) Fears: e.g. Many children have things they are afraid of, such as snakes or spiders. Enquire about fears of shadows, dark, ghosts, cats, dogs, etc. Are these fears in the past, or present? What do you do when you meet whatever things you are afraid of? Are you afraid of things happening to you or your family? What kind of things? (i) Anger: e.g. Everyone gets angry sometimes - what gets you angry? What do you do when you are angry? Do you get into fights sometimes? Do you like fighting? Are they 'friendly' or 'real' fights? Who do you fight with? How often? What makes you stop being angry? (j) Home: e.g. Who lives there? What is father's/mother's work? Do you have your own bedroom? Who do you get on best with? Do you have any brothers or sisters? We all have fights with siblings - do you fight often? Are they real or friendly fights? (k) By now the presenting problem should have been dealt with - if not, it should be actively dealt with at this stage. Enquire about frequency, severity and duration of problem/s. Ask for examples, for instance in the case of sexual abuse, enquire in which room or house the abuse occurred, who was present, how often it occurred and where the parent was.
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Mental Status Examination This section of the interview is generally obtained through observation of the patient during the specific questioning period. A. General appearance Note the child's general physical appearance, body posture, dress and grooming. Does he or she appear neglected? Does he or she appear small/large for age? Note facial expression. Also note waiting room behaviour, separation and reunion. B. Interview reaction Note the child's general reaction to interviewer. The following factors may be noted: Eye contact; Preoccupation with anxiety, or depressive lapses; Reserve or expansiveness; Selfconfidence and esteem; Spontaneous remarks; Rapport with interviewer, i.e. capacity to engage; Response to interviewer: friendly, open, teasing, hostile, negativistic, shy, sullen, ingratiating, precocious or familiar; Co-operation and compliance. C. Cognition Note the child's: Level of general information; Attention span; Distractibility; Persistence; Impulsivity; Curiosity; Memory. Note general impression of intellectual level. D. Motor reaction Note the child's: Hyperactivity; Fidgetiness; Muscle tension; Co-ordination - Fine/Gross; Clumsiness; Tics; Involuntary movements. E. Affect Specify whether the child appears: Sad; Tearful; Depressed; Sullen; Withdrawn; Anxious; Hostile; Angry; Negative; Oppositional. Note whether there is any: Oddness/Flatness/lncongruity; Guilt feelings; Suicidal thinking. Also note the child's emotional expressiveness and range.
F. Speech Note if any of the following are present: Stammer/Stutter; Lisp; Articulatory defects; Indistinct expression; Aphasia. Also note comprehension and use of language.
G. Thought content Note whether there is any impairment of cognition manifested in the following: Inappropriate behaviour or speech; irrelevant answers to questions; Repeated words or phrases; Tendency to drift away from topic; Lack of coherence; Delusions or false beliefs; Illogical thought patterns; Irrational or strange behaviours; Hallucinations - sight, sound, touch, taste or hearing; Mood swings; Lack of insight; Bizarre behaviours. H. Summary (a) Diagnosis - preliminary. (b) Formulation - Hypothesis of relation of disorder to presenting problem and current or antecedent events (From Holford, L E & Smith, C. 1992. The child psychiatric interview [CPI]. Southern African Journal of Child and Adolescent Psychiatry, A (2) 35-41)
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Obviously, most children will be unable to give an account of their own developmental history; part of the family interview will thus be used to obtain this information. Interviewing the family A family interview may involve a number of interviews, each with a different constellation of family members. A family interview is important because the symptoms with which children present are often a reflection of the functioning of their families. Sometimes an interview with the entire family, including the parents' other children, can be enlightening. The purpose is to observe the attitudes of the parents toward the patient and the affective responses of the children to their parents. The nurse's job is to maintain a non-threatening atmosphere in which each member of the family may speak freely without feeling that the nurse is taking sides with any particular member. The nurse must validate each family member's feelings in the setting, because a lack of communication within the family often contributes to their problems. The parents may be interviewed together, without other family members present. Here, the objectives would be to get a chronological account of the child's growth and development, the parents' perspective on family dynamics, their marital history, their beliefs about the cause and nature of the child's problems, and their expectations of professional intervention. Family assessment An example of a family assessment follows.
Family assessment Name Record the name of the index patient and the names of all the other family members present. Indicate reasons for the absence of significant members. Orientation Orient the family by clarifying what each member expects of the interview and what each hopes to get out of it. Give feedback by explaining what you, the therapist, plan and hope to achieve with the interview, and explain why the whole family must be present. Presenting problems Each individual member of the family describes the problem or problems that brought the family for assessment. Record the problems, their duration and possible precipitating factors.
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Family functioning Problem solving The ability of the family to solve instrumental and affective problems at a level that maintains effective family functioning. Communication The way in which information is transmitted within the family: Instrumental (goal-directed, task-directed and without emotion) Affective (emotion-laden and person-directed) Direct or indirect Clear or masked Roles in the family Who does what? Are the roles complementary? Is there mutual acceptance of roles? What constitutes the mother role, father role and child role? Affective responsiveness How freely are negative and positive emotions shown? Who shows them? To whom are they shown? Affective involvement The degree to which the family as a whole takes an interest in and respects the interests and activities of individual members. Behaviour control The pattern that the family adopts for coping with three types of situations: Physically dangerous situations, for example, a child playing with fire. Meeting and expressing psychobiological needs, for example, reaching adolescence and entering into relationships with the opposite sex. Interpersonal socializing behaviour - within and outside the family, for example, joining new groups. There are four styles of behaviour control, namely rigid, flexible, laissez-faire and chaotic. Identify the one used by the family.
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Parent assessment Parent assessment Physical health Personality Psychiatric disorders - current emotional condition - history of previous disorders - duration - treatment Alcohol/ substance abuse - quantities - duration - effects Violence - towards spouse, peers or children Marital relationship Previous marriages: - father - mother Marital status: - father - mother Courting and marriage Relationship (including sexual) Social circumstances Circle of friends, use of free time, community involvement Families of origin Paternal/maternal families (including step-grandparents) Age
Education Occupation Religion Physical health
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Personality Psychiatric disorders Alcohol/substance abuse Violence (criminal record) Marital relationship Parent-child relationship Siblings Familial illnesses This assessment may take longer than one session. A genogram can be compiled on completion of the assessment. The family is referred to a psychotherapist for family therapy if there are serious problems. Individual assessment This is based on information about the child obtained from parents/care-givers.
Development history This may be taken in the presence of the whole or part of the family. Number of pregnancies and abortions Age difference between index child and previous child/pregnancy. Pregnancy Planned Conceived out of wedlock (be very tactful in obtaining this information if it is not volunteered spontaneously) Physical health Emotional health Significant events (this refers to emotionally significant events during pregnancy and includes the death of a parent and desertion by the father of the child) Birth Labour Delivery - full term
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Normal vertex delivery Forceps delivery Breech delivery Caesarean section delivery - birth weight - sex preference - postpartum Mother: any physical or psychological problems Child: first six weeks after birth, for example, prolonged incubation Early development Mother and child relationship Feeding Sleeping Crying Restlessness/irritability Role of father Milestones Motor activities - sitting - crawling - standing - walking Language - babbling - using words - constructing sentences - comprehending Bladder control - day - night Bowel control Physical health Illnesses Seizures
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Operations Injuries Hospitalizations Separations Details about periods of separation during early childhood Age of child Length of separation Nature of alternative care Reaction of child Facilities for care If the mother is absent or works School history Schools attended by the child and reasons for changing schools Scholastic ability Adjustment Refer to the child's conduct and general and social adjustment with peers and teachers. Request permission to obtain a report from the school.
Interests and activities Self-help The child's ability to perform age-appropriate self-help activities. Physical health and functioning Eating Sleeping Seeing Hearing Bladder and bowel control Sexual behaviour and knowledge Psychophysiological symptoms Record any problems in the areas mentioned. (Red Cross War Memorial Children's Hospital, Psychiatric Outpatient Unit, Cape Town)
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Children's drawings Having children draw pictures of themselves and of their family provides important assessment data. When asked to draw a picture of themselves and their family, children project specific fears, anxieties and concerns. In addition to viewing drawings within the child's developmental context, it is important to ask the child about the drawings, because artwork can easily be misinterpreted. Although the child's drawings are a rich source of assessment data, they need to be examined within the context of other assessment data for verification. The child's drawings of human figures provide an index of the child's body image. Drawings of a three to four-year-old child usually depict large heads and eyes, with arms and legs as appendages of the head. Gradually the trunk appears, with arms and legs as stick appendages. The child's overemphasis or omissions of body parts gives clues to the child's body image. Excessively large hands may indicate aggression, small arms and hands withdrawal and denial. Clearly defined body boundaries indicate a balance of body parts of the person on the drawing paper and are signs of a positive body image. Children's drawings rarely include genitals. When the child draws genitals or stylized sexual figures, the nurse must realize that the child's drawing may be in response to rape, trauma or sexual abuse. Often children draw what they cannot say. Principles for evaluating the behaviour of children 1. Behaviour should be evaluated in terms of standard development characteristics and age-appropriate competencies. 2. Behaviour should be gauged against the background of the developmental problems of a specific stage that could make children vulnerable to stress and anxiety, for example, loss and separation situations such as divorce and death may be viewed by children as punishment or desertion because of egocentric thoughts. Such misunderstandings can cause serious emotional problems. 3. The unique patterns of children must be considered. For example, a child who appears to be aloof and shy may have a good friend. Such conduct should not be summarily dubbed as disturbed. 4. Children may function poorly in one or two areas while performing well in others. A problem must be identified when the balance is disturbed. (Babich 1982:26) If special investigations are available and the nurse deems them necessary when assessing a child, the child may be referred. Special investigations include psychometry, audiometry, neurological investigations and occupational therapy evaluation. 18,3 MANAGING EMOTIONALLY AND BEHAVIOURALLY DISTURBED CHILDREN Milne (1995) outlines ten basic strategies that can be used to manage emotionally and behaviourally disturbed children. She points out that each of these strategies should be
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adapted to take the child's unique difficulties into account. Management also involves cooperation between the parents, health professionals and teachers, because home and school are major aspects of the child's life. Communication principles Be consistent and firm, but gentle. Give clear and simple instructions, repeat these three to four times if necessary, and maintain eye contact while doing so. Instructions or information should be exact, without qualifiers. Break down the information into small, easily assimilated sections. Give one task at a time and, if necessary, break it down into small, achievable steps. Help the child to perform/complete a task instead of criticizing him/her for failing to attempt it. Overt and implied pressure can increase the child's anxiety and resistance to the intervention. Fantasy control Children may retreat into fantasy when they feel threatened or if they are left alone. If this happens: Gently remind the child where he/she is, who you are, etc. Do not join in with the child's fantasy or wait for him/her to finish the theme. Structure The child's inner world may be chaotic and, because of this, he/she may perceive the real world as a dangerous and strange place. It is therefore important to create some kind of order for the child. External rules and limit setting can help. Establish and maintain a predictable environment. Maintain regular routines of eating, sleeping, playing and discipline. Maintain a calm and simple environment to promote attention and subsequent learning. For example, the child should sit as near as possible to the teacher to reduce the possibility of being distracted by other children. Create a positive environment in which the child's needs, abilities and self-esteem can be nurtured. Tell the child about any changes to the environment before they are made, including what they are, when they will happen and where they will happen. Limit setting This helps to provide structure and, consequently, helps the child to feel safe because of the boundaries that are provided. Children may have difficulty with understanding the need for limits. Avoid lectures; simply state the rules and back them up. Use as few words
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as possible and keep instructions simple, focusing on one thing at a time. The goal is for the child to develop self-control and, with it, self-respect. Behaviour control and physical restraint When children become increasingly anxious, their behaviour may become increasingly chaotic. When this happens, the following procedures may be beneficial: Physical containment with gentle and persistent reminders of reality may be necessary. For example, holding children gently while softly reminding them where they are, who they are and what is happening is far more anxiety-reducing than shouting or slapping a child. Milne (1994) suggests that, if the child bolts, it is better to run with the child in as calm a manner as possible, rather than to chase him/her. If the child feels that he/she is being chased, fears about the possibility of being harmed will be reinforced. Ask the child what he/she thinks. This will make him/her feel safer. If possible, implement the measures suggested by the child. This may help to increase the child's self-esteem and problem-solving skills. Occupational therapy Children with communication disorders may need speech therapy, those with motor skill disorders may need physiotherapy, and those with learning disorders may need some form of remedial education. However, these facilities are not always available; if they are, a referral should be made. Occupational therapy is helpful for many children as it provides opportunities for learning new skills, developing co-ordination, and is a form of constructive distraction. Medication Medication can be a very valuable tool. Central nervous system stimulants (such as Ritalin, Dexedrine and Cylert) and antidepressants (such as Tofranil) are frequently prescribed for children with ADHD. These medications increase the ability to concentrate and, to some degree, decrease impulsive behaviours and activity levels. Ritalin should be stopped immediately if it does not seem to be working. It can have harmful effects in a psychotic child. Thioridazine may help to reduce anxiety, improve sleep and decrease the tendency to lapse into psychosis. If the child is depressed, an antidepressant may be helpful. Some have anti-anxiety properties, which may also be useful. Sometimes depressed children present with hyperactivity which may resolve with antidepressant medications. Haldol, Lithium and Tegretol can be very useful in reducing aggression and aggressive behaviour.
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Special schools As is the case with other complementary therapies, special schools are not readily available to the majority of the population of this country. Individual therapy Individual therapy is useful but, again, is not always available. Family involvement Family involvement is important at all levels of intervention. The family needs to know about the disorder, as well as to work on the issues within the family and within the marital relationship that may be contributing to the child's behaviour and individual members' distress. The following may prove advantageous: education about the disorder, medical treatments and symptom management techniques; techniques to manage tension in the home, for example, communication and conflict resolution skills; parenting skills; methods and styles of discipline; family therapy or couple counselling may be useful in dealing with marital and family issues; support groups may be helpful for parents and the other children in the family. Parents often feel frustrated because they have worked so hard and yet their child continues to have problems. Communicating with other parents struggling with similar problems can help to relieve the burden that family members may experience. CONCLUSION The vast majority of children in South Africa are exposed to environmental conditions which are known to be detrimental to mental health, namely social disadvantage and family stress. Most of these at-risk children are black children. Social disadvantages include poverty, malnutrition, disease, lack of educational opportunities and inaccessible health and welfare facilities. Probably the most important factor in the causation of childhood mental health problems is the exposure of young children in the intimacy of family life to damaged parents. Two other major circumstances contribute to social disadvantage and family stress within the South African context. The first is the structural violence inherent in our society. The second circumstance is associated with developments in southern Africa generally, namely urbanization, the breakdown of traditional ways of life, including the extended family system, the abuse of alcohol by the young, as well as their unguarded sexual activity.
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Current psychiatric services for children in South Africa include the following: child and family units; child guidance clinics; the private sector; psychiatric community services; consultation services and information centres. The drawbacks of these services are that they are geographically poorly distributed and concentrated mainly in the cities. The bottleneck that prevents the development of child psychiatric services is situated at the administrative and not at the legislative level. The organization of existing services is such that children and their parents go from one specialist (educational, health and social work) to another in search of expert advice. The valuable time of experts, who are in short supply, is thus taken up unnecessarily. Furthermore, the available services of the health, social and educational authorities are not sufficiently co-ordinated. Other problems include the following. Information about available services and problems regarding psychiatric disorders in children is not sufficiently available and accessible. The essential services of a co-ordinated professional team are not available in all cases. Services cannot be effectively extended before the required staff has been trained, yet there is a shortage of training facilities. There are no co-ordinated figures regarding the extent of psychiatric disorders in children in South Africa. Existing statistics are not collected in a simple manner and a comprehensive view therefore cannot be obtained. White health care professionals have failed to learn African languages. It seems that a monumental task awaits us if we are to provide for the mental health needs of children. WEB RESOURCES www.aacap.org This is the website of the American Association for Child and Adolescent Psychiatry. Go to Publications where you will find the very useful 'Facts for Families', which provides fact sheets about a long list of conditions and which you can print and give to parents. www.priory.com This is the home page for the Priory Online Journals, and there is a Child and Adolescent Online journal which you can access here. The articles cover a wide range of child and adolescent mental health issues.
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REFERENCES Acuda, S W. 1993. Broadening the perspectives in child and adolescent mental health care. Opening address at the 9th annual national congress of the SA Association for Child and Adolescent Psychiatry and Allied Professions. Southern African Journal of Child and Adolescent Psychiatry, 5 (2), 54-56 American Psychiatric Association. 1994. Diagnostic and statistical manual of mental disorders (4th ed.), Washington, DC: American Psychiatric Association Babich, K S (ed). 1982. Assessing the Mental Health of Children. Colorado: Western Interstate Commission for Higher Education Berg, A. 2002. Talking with infants: a bridge to cross-cultural intervention. SA Journal of Child and Adolescent Mental Health, 14(11), 5-14 Cohen, D J. 1994. News from the International Association for Child and Adolescent Psychiatry and Allied Professions. Southern African Journal of Child and Adolescent Psychiatry, 6 (1), 35-36 Green, D D & Green, L. 1995. Perceived reasons for high school underachievement in four historically separate South African school systems. Southern African Journal of Child and Adolescent Psychiatry, 7(1), 19-30 Holford, L E & Smith, C. 1992. The child psychiatric interview (CPI). Southern African Journal of Child and Adolescent Psychiatry, 4 (2), 35-41 Milne, M. 1995. The management of children with so-called borderline disorders of childhood: Experiences at the therapeutic learning centre. Southern African Journal of Child and Adolescent Psychiatry, 7 (2), 94-99 Olivier, M A J & De Lange. 1999. The self-concept of the adolescent suffering from Tourette's Syndrome part 2: recommendations for management. SA Journal of Child and Adolescent Mental Health, 11 (1): 1999 Rangaka, M, Rose, C & Richter, L 1993. Depressive symptomatology in hospitalized children. Curationis, 16 (2), 40-44 Red Cross War Memorial Children's Hospital, Psychiatric Outpatient Unit. Diagnostic Assessment of the Child and Family Robertson, B. 1996. Handbook of child psychiatry for Primary Care. Cape Town: Oxford University Press Rudd, C & McMaster, J. 1996. Childhood mental health problems in Primary Health Care in a developing country: Some factors influencing detection by PHC nursing staff. SA Journal of Child and Adolescent Mental Health, 8(1), 2-12 Schultz, J M & Dark, S L. 1986. Manual of Psychiatric Nursing Care Plans (2 ed). Boston: Little, Brown & Co Vogel, W & Holford, L. 1999. Child psychiatry: an audit of presenting problems and diagnoses at two clinics in 1997. SA Journal of Child and Adolescent Mental Health, 11 (1), 38-48
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Nursing Forensic Psychiatric Patients LRUYS
Objectives After studying this chapter the learner should be able to: Understand the concepts 'fitness to stand trial' and 'criminal responsibility'. Distinguish between different types of forensic psychiatric patients. Describe and discuss the role of the psychiatric nurse in the observation unit and the security unit. Discuss the problems in the forensic psychiatric system.
INTRODUCTION The word 'forensic' means pertaining to the law or the courts of law. Forensic psychiatry refers primarily to dealings with mentally ill offenders, but other aspects of contact between the psychiatric/mental health system and the justice system are also included. The recognition that the justice system cannot deal with crimes committed by those suffering from a mental disorder in the same way as it deals with crimes committed by other lawbreakers, is not new (Dorrell 1991). Perhaps the famous Pinel, wTho loosened the chains of the criminally insane and transferred them to care facilities, can be regarded as the first health worker to act on this belief (Kat 1991); today it is incorporated into the penal codes of most countries (\Vhitehead 1982; Sakuta 1991; Gacengeci 1986; Matate 1988). Criminal law involves the punishment of crimes by the authorities. A crime consists of two elements: actus reus: a wrongful physical act or omission; and niens rea: a guilt}' mental state. With regard to the mentally ill person, it is his/her mens rea that is usually questioned.
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191 HISTORICAL BACKGROUND Ancient law held people responsible for what they did, virtually without exception. The Code of Hammurabi is a good example: insanity is not mentioned at all (Kruger 1980). In Roman law it was recognized that children and the insane (the furiosus) could not be held liable for murder. This was also accepted in Roman-Dutch law, the Constitutio Criminalis Caroli of 1532 stating that sanity is a prerequisite for punishment (Kruger 1980). There are many indications that it was informally accepted that insanity exempted a person from punishment under English law (Walker 1968). The system of King's Pardon, by which an insane person found guilty of murder would automatically be brought before the monarch for pardoning, was in effect until the time of Queen Victoria. When she ascended the throne at the age of 18, the system was changed so that the death sentence in such cases would be recorded, but not pronounced by the judge. In 1843 Danile M'Naghten was tried in England for shooting Drummond, the secretary of the Prime Minister, Sir Robert Peel, thinking that he was the Prime Minister himself. He was found to be suffering from paranoia, and the criteria established during this case, which became known as the M'Naghten Rules, read as follows: To establish a defence on the ground of insanity, it must be clearly proved that, at the time of the committing of the act, the accused was labouring under such a defect of reason, from disease of the mind, as not to know the nature and quality of the act he was doing, or, if he did know it, that he did not know he was doing what was wrong. (Archbold in Kruger 1980: 172).
In South Africa, the first concession to the mentally ill in criminal law was the 'special verdict' instituted in 1891. This meant that the person was found guilty as charged, but declared to have been insane at the time of committing the crime. The court then had the discretion to order detention in any suitable place. In 1953, a case against Koortz led to the equivalent of the M'Naghten Rules being formulated for South Africa. It read: A person is not punishable for conduct which would in ordinary circumstances have been criminal if, at the time, through disease of the mind or mental defect (a) he was prevented from knowing the nature and quality of the conduct, or that it was wrong; or (b) he was the subject of an irresistible impulse which prevented him from controlling such conduct. (Kruger 1980: 156).
In 1967, after the assassination of Prime Minister H F Verwoerd in Parliament by a mentally ill man, the Rumpff Commission of Inquiry into Criminal Responsibility of Mentally Disordered Persons and Related Matters recommended a new formulation, which was incorporated into the Criminal Procedure Act of 1977. Section 78 of this Act reads: A person who commits an act which constitutes an offence and who at the time of such commission suffers from a mental illness or mental defect which makes him incapable (a) of appreciating the wrongfulness of his act; or (b) of acting in accordance with an appreciation of the wrongfulness of his act, shall not be criminally responsible for such an act.
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19.2
CURRENT LEGAL PROVISIONS IN SOUTH AFRICA
Fitness to stand trial The fitness of the accused to stand trial may be questioned at any time during the criminal proceedings, either by the accused, the defence, the prosecution or the court. Fitness to stand trial refers to the question of whether or not the person's mental state allows him or her to understand the proceedings well enough to make a proper defence. If this question is raised, the following may happen: If the court has no doubt on the matter, the case may be withdrawn. This often happens in the case of minor infringements of the law. If the court is unsure of the fitness of the accused to stand trial, the accused can be admitted to a psychiatric hospital for a period of observation of 30 days at a time. The motion can be denied by the court if the allegation of unfitness to stand trail is inadequately motivated. If the patient who is admitted for observation is accused of an offence for which the death penalty could be imposed, three psychiatrists may be involved in the decision, namely the superintendent of the psychiatric hospital, a state-appointed psychiatrist and one appointed by the defence. In South Africa psychiatric nurses are at present sometimes involved in the decision about an accused's fitness to stand trial because of the shortage of psychiatrists and beds in observation units. The observers must make a psychiatric diagnosis and answer the following questions: Does the accused know what the charge involves? Does the accused know what it means to be tried in a court of law? Does the accused understand the proceedings in court? Does the accused understand that the court must decide on his/her guilt or innocence with regard to a specific charge? It must be remembered that a person might be mentally ill and still understand the proceedings well enough to stand trial. Fitness to stand trial is not the same as certifiability. If the accused is found to be unfit to stand trial, the charge may be withdrawn, or he/she can be declared a state patient under section 77 (6) of the Criminal Procedure Act. This provision of the South African Criminal Procedure Act (which is similar to the English Act), has been criticized because it does not allow the facts of the case to be fully investigated. A person in the same circumstances as Demetrio Tsafendas, who was accused of murdering Dr Verwoerd, could be found unfit to stand trial and declared a state patient, which then means that the murder would never be investigated in an open court. This may prejudice the patient, because he/she will be considered a state patient involved in a serious crime for the rest of his/her life, without his/her guilt ever having been established. If he/she was not implicated in the crime, it is unfair to make him/her a state patient as opposed to treating him/her under the provisions of the Mental Health Act (Kruger 1980).
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Criminal responsibility In South Africa the question of whether or not an accused can be held responsible for a criminal act or omission on the grounds of insanity can be raised by the defence or the prosecution, and evidence may be lead in this regard. The judge makes the final decision. If the defence raises the issue, it forms part of a plea of not-guilty. The South African, American and German definitions of criminal responsibility are very similar. They combine the right-wrong criterion (unable to appreciate the wrongfulness of the act) with the ability to conform to the requirements of the law (unable to act in accordance with such an appreciation). The following aspects of criminal responsibility in the South African context should be kept in mind: The definition of mental illness or mental defect in the Criminal Procedure Act is not the same as that in the Mental Health Act. For example, psychopathic disorders are included in the latter, while these are specifically excluded from the Criminal Procedure Act. Alcoholism as such does not lead to non-responsibility unless it incorporates a mental illness. However, it may be taken into account during sentencing. Emotional distress or stress in itself is not acceptable as a defence on the grounds of insanity. Witchcraft or the belief in witchcraft is not regarded as a mental illness. The result of a hearing to establish responsibility can be one of the following. The patient may be found not responsible and declared a state patient under section 78 (6) of the Criminal Procedure Act. In this case he/she can be kept in a psychiatric hospital for an undetermined time. The patient may be found not responsible and acquitted. An example of this is a case in which an offence was committed as the person awoke from a nightmare. He was found not responsible and acquitted. The person may be found to have diminished responsibility, in which case this fact can be used as extenuating circumstance. The person may be found responsible, and the trial and sentencing proceeds. The new Mental Health Care Act has addressed much of the criticism levelled against the old Act in terms of not sufficiently safe-guarding the rights of the accused. Some of the criticisms and the changes in this regard are as follows: 1. State patients have no right of appeal to anybody to enquire why they are still being detained. In terms of section 20 of the Mental Health Act patients may apply for an enquiry into the grounds for their continued detention. This is not possible in the case of state patients. In 1956 a full bench of the Supreme Court ruled against such an enquiry in
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the case of Khan v the Commissioner oj'Mental Health, and in 1978 a decision that the court cannot be involved was made in the case of Jurgens v the Attorney-General. In the United Kingdom a patient detained in a similar manner can apply for a review of the case by a Mental Health Review Tribunal, although the tribunal can only make a recommendation and not order a release (Whitehead 1982). Anybody, including the patient, a spouse or associate or a 'person authorized to act on behalf of a State patient' may apply for discharge of the patient according to article 47 of the Act. In essence, that protects the rights of the person in the same way as an appeal would have done. 2. In the case of a state patient the curator ad litem and the prosecutor are the same person. Patients admitted under the Mental Health Act have a curator ad litem from a different system than the one which detains them, in the form of the Attorney-General of the area. In the case of a state patient, however, the Attorney-General is both his/her prosecutor and curator - an untenable position. In the new Act, section 4(b) states that the Judge must specifically consider whether a conflict of interest exists, and appoint another legal practitioner to act on behalf of the patient in such a case. 3. The detention order of the State patient amounts to an indefinite sentence, the length of which is dependent on extremely subjective criteria. Although Kruger (1980) is at pains to point out that a declaration as state patient does not amount to punishment of a guilty person and that there can therefore not be a direct relationship between the offence and the 'measure' of detaining the state patient, it is clear that the length of detention is often based on the characteristics of the crime and not on the condition of the state patient (Henning 1983). In this way the psychiatric treatment system has been co-opted into the service of the Department of Correctional Services, serving as agents of social control rather than as agents of therapy (Stone, in Webster, Ben-Aron & Hucker 1985). In the United Kingdom the detention of a patient under similar conditions may be for a specific time only, after which he/she reverts to the conditions laid down by the Mental Health Act, or it may be indefinite. The release of a state patient is often dependent on a prediction about whether the patient is still potentially dangerous. The problem in this regard is that all research has shown that there is currently no reliable way of predicting how dangerous a person will be in future (Stone & Greenland, in Webster et al. 1985; Coleman 1984). The prediction therefore becomes a guessing game. The professionals are overcautious since there is no penalty for conservatism, while the penalty for a wrongful discharge is high (Zabow 1989). The indefmiteness of the sentence of the patients causes enormous suffering to them and their families. Coleman (1984) graphically describes the despair caused by the repeated application for release, the hopeful waiting, and the disappointment at refusal. He believes that even a long sentence, but a specific one, is easier to bear than the recurrent disappointment of an indefinite sentence.
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Question
Report
Triability (s 77 CPA)
Observation (s 79(2) CPA, Report) (s 79(4)(c) CPA)
Result of enquiry
Status of patient
Triable (s 77(5) CPA)
Offence
CASE PROCEEDS IN ORDINARY WAY Serious violence offence (s 29(5) MHA)
Non-triable (s 77(6) CPA)
Observation (s 79(2) CPA Report) (s 78(6) CPA
CPA = Criminal Procedure Act
Guilty Not guilty (ss 78(1 ) & (6): Not proved that accused committed an act which constitutes an offence)
Non-serious violence offence (s 29(5) MHA) Diminished responsibility (s 78(7) CPA)
Attorn eyqeneral
Minister of Health (s 29 (MHA)
.';MK#
Not guilty by reason of mental illness (s 78(6) CPA)
Hospital
Judge
SPD {detained in to^pffil or jail si§2{2)
Criminal responsibility
Discharge procedure
Hospital Board (s 29(4A) MHA)
SENTENCE, TAKING INTO ACCOUNT MENTAL CONDITION ACCUSED FOUND NOT GUILTY AND DISCHARGED
MHA - Mental Health Act
Figure 19,1 Process for the discharge of a State patient Coleman (1984) also refers to the effect of this system on the treatment process, by pointing out that when the length of hospitalization depends so much on the good opinion of the staff, it might be difficult for patients to share negative thoughts and
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reelings in therapy. Since anything that they say may be used against them, they say only the acceptable. Although this problem is not directly addressed in the new Act, the new procedures in the Act might in reality address this issue. 19.3 SERVICES PROVIDED FOR A MENTALLY ILL OFFENDER
Provision for a mentally ill offender varies from one country to the next. One of the important factors which determines the form that the services take is the state's policy regarding which sector should render the service. In the United Kingdom it is stated government policy to divert such people from the criminal justice system into the health or social services systems as far as possible (Wool 1991). In accordance with this policy the United Kingdom has established a network of 13 regional security units, which provide medium security and have a total of 650 beds, and also three special hospitals which provide maximum security and have 1 700 beds at present (Wood 1991). In contrast, mentally ill offenders in Japan are cared for in prison hospitals within the justice system (Sakuta 1991). Crime rates in Japan are significantly lower than those in Western countries, and this may be why the prison services there are better able to deal with mentally ill offenders. In the USA, persons awaiting trial are kept in 'jail' and criminals already sentenced in 'prison'. From these facilities persons can be referred to special security hospitals in the prison service (or back). If necessary, the special security hospital can refer the person to a civil mental hospital. Mentally ill offenders in the USA therefore usually find their way into the health system, either to a special security hospital, or to a civil mental hospital. In South Africa mentally ill offenders are dealt with in psychiatric hospitals, although they can be held in prison or in prison hospitals. In most psychiatric hospitals there are special units for these patients, where medium to low security is available (security unit). In one hospital a maximum-security unit exists (built specifically for this purpose). 19.4 CLASSIFICATION OF FORENSIC PSYCHIATRIC PATIENTS
Classification according to legal status Steadman and Cocozza (1974) provide the following classification of patients in forensic psychiatric units according to their legal status: Mentally ill inmates. According to the authors, this group made up 40 % of the patients in forensic units. The offenders were arrested, convicted and sentenced. While serving time in prison, they became mentally ill and were transferred to a psychiatric hospital. In South Africa legal provision is made for these patients in Chapter 4 of the Mental Health Act. Defendants incompetent to stand trial. In the USA these patients make up 40 % of forensic psychiatric patients. In South Africa they are called state patients.
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Not guilty by reason of insanity. Also called state patients in South Africa, this group makes up about 4 % of the forensic patients in the USA. Dangerous mentally ill. This group is quite different from the previous three. In this case patients were civilly committed to a psychiatric hospital, but because of their behaviour and condition they are deemed dangerous and are therefore held in a highsecurity unit. Classification according to type of problem From the literature it would seem that the following types of patients can be expected in forensic units: Inadequate functioning. This group needs greater supervision because of poor intellectual functioning, inadequate social skills and other handicaps. They may be inclined to clash repeatedly with the law, and even in the institution find it difficult to keep to rules and routines. They need long-term supervision. Personality disorders.This group has specific personality disorders, especially antisocial and borderline personalities, and needs a therapeutic community-type treatment setting. In this kind of setting the patient can explore and acknowledge his/her pattern of behaviour, understand the motives underlying it, and modify his/her behaviour in the longer term. Seriously violent. The outstanding characteristic of this group is its propensity for serious violence. After studying the violence of forensic psychiatric patients, Greenland (in Webster et al. 1985) comes to the conclusion that there are four different types of violent behaviour. The implications of this and other studies should be used to design programmes specifically for this group of patients. Substance abuse. Substance abuse plays a very important role in a large proportion of forensic psychiatric cases. This means that the treatment programmes should address the problem directly and indirectly. 19,5
THE NURSE IN THE OBSERVATION UNIT
Persons are sent for observation either before or during their trial, to establish their fitness to stand trial or their criminal responsibility, or (during their prison term) to establish whether they are mentally ill and need treatment. In some hospitals the observation and security patients are in one unit. Nurses might also sometimes be asked to undertake observation in a prison setting. The objectives of an observation unit are to: prevent the escape of an accused or sentenced person; observe the inmate systematically in order to establish his/her psychiatric condition, and identify inmates who are malingering; protect the human rights of the inmates; ensure the safety of the staff and inmates.
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From these objectives it is clear that the staff in this case do not have a treatment function. They only have diagnostic and custodial functions. This might be difficult for the staff, and is probably not the kind of setting that every nurse will be interested in working in. It should be noted that article 46-3 of the Mental Health Care Act states that if the person is ill to such a degree that there is a danger to self or others, treatment should commence immediately. In order to prevent the escape of these inmates, it is important that this kind of unit should provide for maximum security. The Mental Health Care Act makes provision for patients who cannot be contained in an ordinary mental hospital to be transferred to a Maximum Security Unit (article 22-1). The Act also makes provision for such a transfer to be assisted by the police (article 27). Systematic observation is dependent on the nurses having a clear understanding of the following: Why the inmate has been sent for observation. Is it to establish his/her fitness to stand trial or criminal responsibility, or is only the mental illness of the prisoner at issue? What are the alleged crime and the possible psychiatric diagnoses? Unless the nurses are aware of the issues involved, their observations cannot be planned systematically. The nurse should revise his/her knowledge of the psychiatric diagnoses involved and make sure that he/she knows what the critical points are. In an observation unit, nurses should report on the mental status of every inmate every day. During the day nurses gather data on every aspect of the mental status examination, such as attention, concentration, mood and intelligence, and record this in their daily report at the end of each day. Any incidents that occur could also be slotted in under the appropriate heading of the mental status examination. Special opportunities for observation can be created, so that all aspects are observed in different situations. For example, attention, concentration, memory and intelligence can be observed during an interview with the nurse, but also while playing board games or completing ward tasks. The inmate may also be sent to another facility, such as a hospital, for special tests, but not for a period longer than eight hours (MHCA article 47-4). The regulations for the Mental Health Care Act sets out as follows the information the Court will require from the mental health system: 1. A review of the medical and psychiatric history. 2. Clinical findings during the time of observation. 3. A summary of the relevant facts and circumstances of the offence as supplied by the prosecutor. 4. The estimated (where possible psychologically assessed) intelligence level of such a person. 5. The psychiatric diagnosis (if any). 6. An assessment of whether the person can co-operate in his or her own defence.
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7. An assessment of whether the person at the time of the offence would have been disturbed to the extent that from a psychiatric point of view he or she was not responsible for his or her acts. 8. An assessment of the type of treatment (if any) considered to be fairest to such a person and safest for the community. It is also important to have orientation groups in observation units in which inmates are oriented to the legal process that has brought them to the unit, and the implication of the findings of that process. According to the Mental Health Care Act, the inmate has to be informed that a mental status report will be submitted by a mental health practitioner to a court of law, and that he or she is under no obligation to divulge information (article 46[1]). Criminals sometimes think that they will get away with a lighter sentence if they are found to be insane. This may be true in the case of crimes carrying the death penalty, but in most other cases state patients are incarcerated a great deal longer than prisoners serving specific prison sentences. Giving appropriate information about the legal system might help real psychiatric patients to understand their situation, and might convince malingerers to come clean. 19.6
THE NURSE IN THE SECURITY UNIT
Patients in security units remain in hospital for between five and nine years on average (Wood 1991). This means that these units are long-term treatment and rehabilitation units. Steadman and Cocozza (1974) state that three general themes run through the research literature about these units: detention, lack of treatment and a strong psychiatric conservatism as regards the release of these patients. It is probably a good idea to group these patients according to the classification given under the heading 'Classification according to type of problem' on page 592, or in terms of time in custody (orientation and treatment group for the newly admitted, rehabilitation group for the middle group, and discharge preparation group for those close to discharge). In general the objectives of these units are to: treat the patient for his/her psychiatric condition and achieve remission as soon as possible; decrease the potential for future violence; improve the chances of successful reintegration into society; monitor the condition of the patient and propose leave of absence and discharge appropriately. To achieve the first of these objectives, the programme in the forensic unit does not have to be much different from that in an ordinary admission unit. The patients are probably acutely ill and the usual physical and psychosocial treatment methods would be used. However, in the orientation of these patients, the reality of the legal conditions under
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which they have been admitted must be included. In ordinary circumstances patients know that when they are better, they will be discharged. In this case it is not that simple, especially if the crime involved serious violence. From the outset they have to understand the length of the average stay in the unit, and that their discharge depends on some assurance of the safety of the community. They should understand the chain of decision-making involved in discharge, and that their stay will probably be a long one. Another aspect that needs special attention is substance abuse, since it plays a role in so many of these cases. To decrease the potential for future violence, this aspect must be addressed directly in the treatment programme. Greenland (in Webster et al. 1985) gives the following typology of violent offenders, based on extensive research: Chronic antisocial (state patients 35 %; prisoners 60 %): These people are habitually aggressive, prone to assault and 'undercontrolled'. Alcoholism plays a part and they are chronically socially maladapted. Psychotic episode (state patients 56 %; prisoners 36 %): The violence is usually associated with an acute psychotic episode with a marked delusional system and/or loss of contact with reality. They are often caught in what they experience as an unbearable situation, with extreme emotional tension. Episodic situational violence (state patients 6 %; prisoners 4 %): This type of violence is usually the result of recurrent manic-depressive illness, organic brain dysfunction or cyclical alcoholism, resulting in rage states. Extended suicide (state patients 21 %; prisoners nil): This group consists mainly of females who killed for altruistic reasons as a form of extended suicide. Depression and previous help-seeking behaviour are usually present. Greenland makes the point that the urge to kill is episodic in nature and never a permanent state, and that it is very often accompanied by an urge to prevent the killing, leading to behaviour such as contacting professionals with other complaints, drinking to obliterate the urge or even ensuring an arrest on a minor charge. In order to deal with aggression and violence in a therapeutic programme, a very detailed history of each patient's violence should be taken. The situational, social, victimizational and cultural aspects should be fully explored. The team should endeavour to obtain a full history of all violence, and not only the incident that led to the admission. Furthermore, collaboration of the patient's account of the violence should be obtained from family, friends, court records and any other available source so that the extent, intensity and situational factors can be accurately identified (Dietz, in Webster et al. 1985). Nurses should also keep detailed records of all incidents of aggression in the ward, so that the patient's progress can be evaluated. Treatment approaches include the following: Individual counselling to obtain a full violence history and to explore the patient's perception of the violence. Group therapy which focuses on an exploration of feelings and appropriate expression, as well as teaching mature coping mechanisms, including problem solving.
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Dutton (in Webster et al. 1985) shows that husbands who assault their wives display a very poor ability to identify their own feelings and express these appropriately. The use of anger-diaries and teaching them alternative ways of satisfying their power motivation is advocated. Family therapy and/or marital therapy in the case of sexual violence in the family, in which feelings about the crime, the disclosure of the crime and the aftermath of the criminal proceedings are explored. The patterns of interaction in families of origin and the present family are also explored. Group therapy in the case of all sexual crimes, in which sexuality is explored, appropriate sexual behaviour and communication in intimate relationships are taught and feelings explored. Since children are often involved in sexual crimes, the sexuality of children is described, and patients are assisted to identify appropriate parental responses and good parenting behaviour in general. The sexual crimes are discussed. This includes dealing with the denial and rationalization displayed by the sex offenders, helping them to understand the impact of their behaviour on others and helping them to accept responsibility for their behaviour. To reach the objective of successful reintegration into society, it is important that social and other role relationships should be maintained during the hospitalization. If these were broken down during the court proceedings, they should be re-established as soon as possible. This might be a fairly difficult task. In a survey of state patients in one South African psychiatric hospital, it was found that 36 % had no contact with their families, and no way of contacting them (Ngubane & Uys 1994). The usual route for making contact with families is to use the services of social workers in outlying districts. If this does not work, one could try community nurses. This aspect of care should improve once psychiatric care is integrated with the primary health care system. Once families have been contacted, they should be fully involved in assessing the patient and in treatment and rehabilitation. Another way in which this objective can be reached is to improve the life and job skills of patients. This may include teaching them life skills such as parenting, assertiveness and better use of recreational time, as well as job-related skills such as literacy, training in bricklaying, carpentry or roofing. According to the Mental Health Care Act (article 50), the Department of Education is responsible for the establishment of educational programmes of learners in the compulsory age group or those entitled to basic adult education programmes. The Department of Correctional Services maintains an extensive training system, and forensic psychiatric patients could be incorporated into this system. This would mean that a state patient applies for a specific training course, and is then transferred to the prison for the duration of that course. It is important that state patients not be allowed to sit around doing nothing for the five to nine years they have to stay in a psychiatric hospital. This will lead to institutional neurosis at worst, and very poor work habits at best. The last objective refers to the discharge decision, and is one of the most difficult problems in this kind of work. It has already been pointed out that the discharge of
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forensic patients accused of serious violent crimes is problematic. Perhaps one of the most important ways of improving discharge rates is a scientifically based and progressive treatment programme. If it can be shown that the patient has received all possible treatment and has completed the treatment successfully, this should form some rational basis for discharge. However, the prediction of future violence will always come into the decision and should be addressed directly. Dietz (in Webster et al. 1985) gives a list of what he calls first-rank predictor variables. The presence of one of the criteria is enough to predict that violence will be repeated. These variables are: 1. One murder with mutilation of the corpse. 2. One murder with vampirism or cannibalism. 3. One murder with antemortem sexual sadism. 4. One contract murder. 5. One sniper murder of a stranger. 6. One abduction with torture of the victim. 7. Three forcible rapes of strangers. 8. One arson episode with sexual arousal. 9. Two arson episodes for profit. 10. One kidnapping for ransom. 11. One bombing of an occupied building. 12. Two bombings of motor vehicles. 13. One forcible rape with torture of the victim. 14. Two episodes in which a child under 12 was forcibly raped or tortured. 15. One instance of insertion of the penis in a body orifice of an infant. 16. Three batteries of an individual child under 12. 17. Three batteries of a spouse within one year. 18. Three or more felonious assaults within one year with escalating degrees of violence. 19. Two unprovoked attacks with a lethal weapon on strangers. 20. Five violent offences of any kind. 21. Threats to kill another named person uttered three or more times, at least two of which included no display of anger, and extending over a period of at least three months. 22. Preoccupation with a casual acquaintance or stranger lasting more than three months with at least one attempt at direct communication with the other person and at least one potentially injurious action directed at the other person or a surrogate, or association, effigy or symbol of the other person.
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23. A plan to commit an intolerable crime that the person says he/she fully intends to carry out, and a history of any violent felony. 24. Delusional beliefs not acknowledged as such by the person that, if true, would justify an intolerable crime; a history of violent felony and a history of stopping medication against medical advice. Dietz furthermore lists second-order and third-order variables, but since the second-order variables usually refer to crimes during the past year, and the third-order variables refer to demographic characteristics such as 'male' and 'age 16 to 24', they are of very little help in the discharge decision. Dietz's work would therefore seem to identify only those patients with whom special care should be taken before discharge. There simply are no clear criteria to indicate who will murder or rape again. The creative use of the leave of absence option may assist the team in making the discharge decision. This means giving the patient leave to visit specified family or friends, or even spend a trial period in a halfway house. During this period responsible persons in that situation could observe the patient, and report back to the team on his/her behaviour and adjustment. The decision to discharge forensic psychiatric patients is made easier if comprehensive community services such as halfway homes, accessible clinics, staff who do regular home visits, a crisis service and day-hospitals are available. Since all these services are vary scarce in South Africa, it can be expected that hospitalization would be longer than in other Western countries. CONCLUSION Two systems meet in the forensic unit, namely the judicial system and the health system. This complicates the work of the team, since it is not always a comfortable mix. The judicial system is set up to punish and rehabilitate criminals; the health system is set up to treat and rehabilitate patients. While the judicial system deals mainly with the safety of the community, the health system deals mainly with the safety of the patient. In the judicial system criminals have limited choice and control, while in the health system the aim is to give them maximum choice and control. In the judicial system the relationship between workers and criminals is adversarial, in the health system it is a helping relationship. In forensic psychiatry these systems overlap, with resultant grey areas, and a confusion of roles and philosophies. Nurses who specialize in this area of psychiatric nursing should understand their dual role and develop a unit-philosophy to accommodate this duality. Clarity on these issues will greatly assist unit staff to find fulfilment in this very interesting and challenging area of specialization. WEB RESOURCES
www.priory.com/forpsy.html This is the website of a Priory Medical Journal Online, dedicated to forensic psychiatry. Full text articles can be accessed.
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REFERENCES Dorrell, S. 1991. Crime and mental illness. Journal of the Royal Society of Health, June, 114-117 Coleman, L. 1984. The Reign of Error. Psychiatry, Authority and Law. Boston: Beacon Press Criminal Procedure Act 51 of 1977, as amended Gacengeci, D M. 1986. A retrospective study of police and court referrals to a forensic psychiatric clinic. East African Medical Journal, 63 (3), 159-162 Henning, P H. Beleid ten opsigte van die ontslag van presidentspasiente. Tydskrifvir Regswetenskap, 8 (2), 132-142 Kat, C F A M. 1991. Planning and the mental health system. Medicine and Law, 305-310 Kruger, A. 1980. Mental Health Law in South Africa. Durban: Butterworth Matete, F G. 1988. Crime and mental illness: a retrospective study of a cohort of court referrals to a provincial psychiatric clinic in Kenya. East African Medical Journal, 65 (10), 664-669 Mental Health Care Act, Act No. 17 of 2002 Ngubane, V G & Uys, L R. 1994. Social Support Networks for Black Psychiatric Inpatients. Curationis 17 (2), 6-9 Sakuta, T. 1991. Prison Psychiatry in Japan. Medicine and law, 10, 275-284 Steadman, H J & Cocozza, J J. 1974. Careers of the Criminally Insane. Lexington: Lexington Books Walker, N. 1968. Crime and Insanity in England. Edinburgh: Oxford University Press Webster, C D, Ben-Aron, M H & Hucker, S J. 1985. Dangerousness: Probability and Prediction, Psychiatry and Public Policy. Cambridge: Cambridge University Press Whitehead, T. 1982. Mental Illness and the Law. Oxford: Basil Blackwell Wool, R. 1991. The present and future handling of the mentally disturbed offender. Journal of the Royal Society for Health, part I (October), 203-205; part II (December), 248-251 Zabow, T. 1989. Psychiatric evidence in extenuation: Assessment and testimony in homicide defendants. Medicine and Law, 8, 631-639
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CHAPTER TWENTY
Nursing the Patient with a Personality Disorder D HOOK
Objectives After studying this chapter the learner should be able to: Develop an understanding of the common characteristics and defence mechanisms of people with personality disorders. Use a transactional analysis model to assist with understanding the psychodynamics involved in personality disorders, as well as to direct rededsion. Diagnose common personality disorders, using DSM-IV-TR criteria.
Maintain long-term therapeutic relationships with people suffering from various personality disorders. Use various therapeutic modalities in the care of persons with personality disorders, for example, group therapy, skills teaching.
INTRODUCTION How much personal pain are you, as a mental health nurse, willing to experience? Are you able to deal with feeling helpless, threatened, abused, confused, incompetent, frustrated and furious, and see the process through? Working with people who have personality disorders can be one of the most challenging areas of mental health nursing. The mental health nurse must have the inner strength to experience some of the above-mentioned feelings in order to penetrate the protective armour of the patient with a personality disorder. These feelings will be further exacerbated if the mental health nurse feels solely responsible for the successful treatment of the patient.
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At the outset, two guiding therapeutic principles can be proposed which might assist in the treatment of patients with personality disorders. First, whether working in the community or in a hospital setting, make full use of a team approach, otherwise you will want to give up, you will feel emotionally drained, you will get angry, and you will suffer burnout. Ensure that you have the necessary supervision and support, and work together with other members of the team to help you disentangle yourself from your patients. Second, when caring for a person with a personality disorder, your responsibility lies simply in endeavouring to implement your own interactions with the patient, not an entire treatment programme. Discard the old adage 'Don't just sit there, do something', and replace it with 'Don't just do something, stay there!' So, instead of feeling responsible for curing the patient, which you often cannot do, just be there as a constant source of support. We have all made use of labels such as 'He/she is so PDd'. Such a label, however, sanctions the 'need to avoid'. Maybe some of these labels serve to hide our own pathology, since it is not an uncommon experience to see part of oneself in patients with personality disorders. Instead of 'avoiding', this identification with the person can be used to expand empathy within oneself - that is, as a private resource rather than as a 'denial'. We need to be careful not to be dismissive of the person with a personality disorder, since beneath the patient's armour is often a person who is depressed and anxious. The mental health nurse's task, then, is to understand those with personality disorders, rather than to judge or condemn them and, consequently, to avoid them. 20 1 UNDERSTANDING THE PERSON WITH A PERSONALITY DISORDER People with personality disorders are not easy to understand. In contrast with a neurotic person who is often aware of his/her problem and more willing to adapt through changing the self, the person with a personality disorder is more likely to deny his/her problems. Such people are also more likely to refuse psychiatric help and to blame the external environment for their problems; they expect the environment, rather than the self, to change. The external environment here would include the family, the therapist, the hospital psychiatric team and the mental health nurse. What, then, does the mental health nurse need to know about patients with personality disorders in order to facilitate an understanding and assessment of them and to create a sense of anticipation and readiness when working with them? Firstly, the mental health nurse must have knowledge of the characteristics common to persons with personality disorders. Secondly, a knowledge of the broad classification of personality disorders in terms of the DSM-IV-TR is essential. Thirdly, a knowledge of some of the defences used by patients with personality disorders is required.
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Finally, the mental health nurse must be aware of the natural countertransference reactions, which may arise in staff who deal with patients suffering from personality disorders. Four common characteristics of all personality disorders A longstanding, inflexible, and maladaptive response to stress, recognizable by adolescence or before, which continues throughout adulthood. A pervasive disability in the areas of working and loving. Personality disorders almost always occur in response to a social context. Some clinicians refer to a person with a personality disorder as being a 'social psychotic'. This is because they consistently fail to see themselves as others see them (failure to test reality) and they lack empathy with other people. On the continuum of mental health, however, personality disorders fall between neurosis and psychosis. The capacity to irritate and annoy others, which is linked to the previous characteristic. Classification of personality disorders The DSM-IV-TR groups the personality disorders into three clusters: Cluster A includes the paranoid, schizoid and schizotypal personality disorders. People with these disorders often appear odd and eccentric. Cluster B includes the histrionic, narcissistic, antisocial and borderline personality disorders. People with these disorders often appear dramatic and erratic. Cluster C includes the avoidant, dependent, obsessive-compulsive and passiveaggressive personality disorders. People with these disorders often appear anxious and fearful. In order to be categorized according to one or more of the above personality disorders, the patient must exhibit traits/symptoms which can be defined in terms of specified criteria outlined in DSM-IV-TR. The specific criteria are discussed later under the management of each disorder. A specific personality pattern becomes a personality disorder when a trait/symptom is of sufficient severity to have a life of its own and to cause subjective distress or impairment of adaptive functioning. Defence mechanisms used by patients with personality disorders In order to help patients with personality disorders, the mental health nurse must understand their defences and their underlying fears, so as to be in a state of readiness. Although a patient with a personality disorder will exhibit a predominant defence, most patients will use several defences. Consequently, the management of defences will be dealt with globally, rather than under each specific disorder.
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Important factors to be taken into account when dealing with defence mechanisms: The predominant defence used by the patient is observable through interactions with the patient, either on an individual basis or in a group setting, and is exhibited by or can be inferred from their behaviour. However maladaptive the defence, it represents unconscious efforts on the part of the patient to heal him/herself, rather than an intention to be difficult. The patient with a personality disorder uses defences so as to escape feeling anxious and depressed; if the defence is confronted, this will result in anger in the patient. The main reason why patients with personality disorders are reluctant to change their behaviour is that this will involve giving up their defence and thus increase their anxiety and depression. Early recognition of the predominant defence used by the patient enables the mental health nurse to respect the underlying fear and to anticipate its use by the patient in future interactions. Instead of removing the patient's mask and tearing down his/her defences, the mental health nurse must respect and work with or around the defence. Be aware of your own feelings when interacting with these patients, as your feelings provide a valuable source of information regarding the defences used by the patient.
Table 20,1 Some defence mechanisms used by patients with personality disorders which may result in negative feelings in staff Defence
Fear within patient
Response of mental health nurse
Fantasy
Antisocial behaviour of person rests on a fear of intimacy or closeness.
Could feel rejected by the antisocial behaviour and insist on a reciprocal response. The therapist should rather respect the fear and maintain a quiet, reassuring approach which acknowledges the fear of closeness and gradually 'thaws' the patient's frozen inner self.
Person seeks inner comfort by creating an imaginary life or people in his/her mind. Behaviour
Person appears aloof, unsociable; often used by schizoid personality disorder.
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Defence Projective identification Person unconsciously projects a self into therapist. The therapist identifies with the projected self unconsciously, feels bullied into complying with the projected role; used by borderline, narcissistic, paranoid and schizoid personality disorders.
Fear within patient
Response of mental health nurse
Undoes past trauma
Could react in accordance with projected
by externalizing those
self of patient and abuse patient.
parts of the internal
Instead be aware of feelings evoked
self which 'cannot
by patient in self. What is being re-
be owned' onto
enacted here? What is the patient trying
others.
to make you into at that moment? The mental health nurse acts as a repository for the projected parts of patient and consciously separates this from him/herself. Therefore: feel, think, hold or contain, then react.
Isolation/distancing
Fear of losing
Could feel bored or frustrated with
Intensified self-restraint; over-
control; fear of
patient's need for self-control or
formal social behaviour when
intimacy.
rejected by patient's distancing.
stressed; commonly used by
Rather than engaging in a power
the obsessive-compulsive
struggle, allow such patients to
personality disorder and
control their care.
schizoid personality disorder.
Projection
Fear of trusting
Defensiveness and argument should be
Attributing one's own
others.
avoided by the mental health nurse. Instead, be honest and acknowledge the patient's feelings in accordance
unacceptable motives/feelings or characteristics to others in the form of fault-finding; often
with his/her perception of the situation.
found in the paranoid
You don't have to agree with the
personality disorder.
patient's feelings of injustice or with his/her perception of the situation; empathize with his/her feelings and try to perceive the situation as he/she does.
Splitting Viewing oneself or others as all
Fear that the bad-
Conflict between staff as a team,
good or all bad, without inte-
ness within or
assume polarized positions in staff discussions about the patient.
grating positive and negative
without will destroy
qualities into the evaluation;
the good; hence the
Rather see the splitting as projected
thus idealizing some people
need to keep it
fragments of the patient's psyche; the
whilst devaluing others. Often
separate and apart.
patient then has a better chance of
used especially by the borderline personality and by narcissistic, paranoid and schizoid
integrating good and bad. Staff need to understand this and remain a cohesive team.
personalities.
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Defence
Fear within patient
Response of mental health nurse
Passive aggression Involves turning anger against the self which takes the form of failing, procrastinating, self-demeaning behaviour, as well as self-destructive behaviour, e.g. cutting, burning; commonly used by passive-aggressive and borderline personality disorders.
Fear of own anger, which is seen as omnipotent, or to alleviate anxiety.
Anger in the staff who feel personally assaulted and who can react by humiliating the patient about his/her foolish, irrational behaviour. Rather increase the patient's conscious awareness of his/her angry feelings and get him/her to talk about the anger, rather than acting it out.
Staff reactions It is clear from the above that the treatment of patients with personality disorders is a complex issue, since it involves: a person who often does not seek help; someone who blames others for his/her discomfort and who often is not willing to take responsibility for his/her own problems and thus implement change; someone who has a longstanding maladaptive pattern of behaviour, causing impaired functioning of the self as well as distress to others; someone who uses defences that can lead to a merging of personal boundaries between patient and staff, impairing the staff's ability to make sound professional judgements about the patient; a patient who often directs his/her angry, wounding and demanding statements at the therapist/staff. Negative staff feelings and reactions to the above behaviour are natural and normal and include getting angry with the patient, feeling defensive, wishing to control the patient, losing the ability to concentrate or to think rationally, feeling helpless, frustrated and impotent. However, the mental health nurse must learn to accept that it is normal to experience such feelings and must be trained not to act on them. Only by anticipating and understanding these feelings will the mental health nurse be able to retain his/her own sense of self and create enough distance from the patient to maintain a therapeutic role. Support and supervision from the team also aid this process. 20.2 USING A TRANSACTIONAL ANALYSIS MODEL WHEN TREATING PATIENTS WITH PERSONALITY DISORDERS The nature of the support required by the patient with a personality disorder in a hospital or in a community setting depends on the severity of the patient's symptoms and on
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his/her support systems. The severity of symptoms can vary considerably. At one end of the spectrum is the patient displaying just one specific trait; at the other end, the mental health nurse may have to deal with someone whose personality is severely disordered, as is often the case in patients with borderline, antisocial personality disorder. Severe symptoms occur less frequently in patients with narcissistic, schizoid and paranoid disorders. Support involves both passive and active strategies on the part of the mental health nurse. The patient with a severe personality disorder paradoxically often requires very little active support. Such a patient needs the nurse to act as a 'repository' for the patient's projected feelings, thus integrating the good and bad in him/herself with the outside world. In such a case the mental health nurse will have to take care not to relinquish his/her therapeutic role as a result of the powerful negative feelings which these patients often evoke in caregivers. On the other hand, the patient whose personality is less severely disordered needs a great deal of active support and intervention. In such a case the aim is to 'reconstruct' the patient's personality; the mental health nurse may work in conjunction with a psychologist in this regard. There are numerous conflicting viewpoints regarding the nature and treatment of patients with personality disorders. Most theorists agree that each person is a conglomerate of mutually influencing thoughts, feelings and behaviour, some of which are maladaptive and have a reciprocal effect on the interpersonal environment.
Thoughts
Feeling;
Environmental reaction
Maldaptive behaviour
Person (indirectly observable as in the mind)
Person (directly observable)
Figure 20.1 Psychodynamics of personality disorders (From Carson & Butcher 1992: 633)
The transactional analysis model is an approach that is eminently logical and based on concepts that are user-friendly and easy for patients to understand. It thus serves to empower patients and can be taught and applied in the treatment of any personality disorder. Another method which is often considered the only effective approach in the treatment of the more severely disordered patient (that is, in the treatment of borderline personality disorder and sometimes the narcissistic personality disorder) is the psychoanalytic theory of object relations. This approach is outlined briefly in the
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discussion of strategies employed in the treatment of the borderline and narcissistic personality disorders and the 'container' function of the mental health nurse. It is also dealt with in relation to the paranoid, schizoid, antisocial, narcissistic and borderline personality disorders. The transactional analysis model This model was initially devised by Eric Berne and has been further developed by other personality theorists in their work on redecision therapy, and by Paul Ware in his theory of personality adaptations. Transactional analysis is based on the premise that the personality has three functional parts - identified as the Parent (P), Adult (A) and Child (C) ego states - which make up the whole person. These ego states are characterized by systems of feelings accompanied by an identifiable set of behaviour patterns: The parent ego state is divided into a nurturing (NP) element and a critical element. This ego state contains moral and value judgements introjected from outside sources, mainly the individual's parents. The nurturing parent (NP) is that part of the self that has the potential to be: - caring; - loving; - encouraging; - guiding; - supportive; - listening to; - protective; - affectionate; - and to allow feelings within the self and in others in terms of all the above.
Nurturing
Critical
(NP)
(CP)
Parent
The critical parent (CP) is that part of the self that has the potential to: - be critical; - be a strict disciplinarian; - be questioning; - be comparing; - have high expectations;
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- display little affection; - be uncomfortable with feelings; and - to use words such as should, must, will, can't, won't with the self and others in terms of all the above. The adult ego state (A) is that part of the self that is the objective evaluator of reality, and has the potential to: be logical; be rational; be responsible; process information about the world and people in it; check out input; be decisive; be assertive; express feelings felt by the child ego state; be compromising in conflict situations.
ADULT (A)
The child ego state, in contrast with the other ego states, consists of the inner impulses and feeling states of the self. Like the parent ego state it is also divided into two parts, namely the adapted child (AC) and the free child (FC): The adapted child (AC) is that part of the self which consists of a set of feelings and behaviours developed in response to parental demands and the demands of reality and is further divided into two parts: - Rebellious child (RC): that part of the adapted child self that can: be impulsive; be blaming; act out feelings, for example, have a tantrum or sulk, abuse alcohol; be reckless; be demanding in response to critical parental messages from others or the self; - Conforming child (CC): that part of the adapted child self that: is shy;
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pleasing; withdrawn; gives in; bottles up feelings in response to critical parental messages from others or the self.
CHILD Adapted child (AC)
Free child (FC)
RC CC
Natural/free child (FC) is that part of the self which is the spontaneous expression of the individual and has the capacity to: - be creative; - have fun; - be expressive; - be intimate; - be energetic; - be original; - feel the feeling; - be decisive and aware of choices. Development of the three ego states The child is born to parents with all three ego states. The mother has the responsibility for taking care of her helpless newborn and functions initially in a normal symbiosis with the infant. When the baby cries, the mother must think for it, figure out what is wrong and solve its problems. If its biological and emotional needs are met, the child grows both physically and emotionally and, in the process, learns to think. However, this initial thinking is primitive and intuitive rather than careful, objective or sequential. As the child continues to grow, it also learns how to take care of others and, in doing so, learns to take care of itself. Much of learning how to think, as well as how to take care of others and the self, is a natural outgrowth of the child's relationship with his/her parents and other important adult figures in his/her life. If the child's needs have been met, he/she will grow normally, symbiotic dependencies will no longer exist, and the child will gradually become autonomous through introjection of the three ego states. This model can be used to analyse and explain to patients both their intrapersonal and their interpersonal problems. This model recognizes the power within each person to identify and solve his/her own problems; it is thus empowering since control is handed to the patient.
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Analysis of intrapersonal problems These ego states are present in each person to a greater or a lesser degree and develop within an interpersonal context in response to both parental messages and messages from reality introjected by the child. An example of an intrapersonal problem is the case of an individual who often feels anxious, useless and worthless through having constantly introjected critical messages from his/her parents, resulting in a permanent feeling of inadequacy. A person with an unhealthy egogram (illustrated below) has introjected a huge CP (critical parent) from his/her parent/s and, even in the parents' absence, carries on where they left off, being hard on him/herself, thus hooking his/her own AC (adapted child). This results in the individual's behaving in a maladaptive way. Such a person needs to develop a more gentle, nurturing parenting of him/herself. This will enable his/her free child to feel the feelings which have been bottled up or acted out, so that the adult part can give the feelings a Voice' in his/her relationships with others.
Unhealthy egogram (relationship with self)
CP
NP
Big critical parent which hooks own AC Small NP Adult contaminated by huge CP and AC
Adult
AC
Healthy egogram
FC
Big adapted child Small free child
NP
CP
Mult
AC;
FC
Big nurturing parent
Uncontaminated adult
Big free child
Figure20.2 Egograms of differing ego states Analysis of interpersonal problems These ego states can also be used to explain to patients their interpersonal or transactional problems. Three basic transactional patterns are recognized: complementary, crossed and ulterior. Complementary transactions Complementary transactions involve a parallel communication between two ego states. One way in which this pattern can be problematic is when a transactional pattern occurs between a critical position in one person and a rebellious or conforming position, identified as AC (adapted child), in another.
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NP
CP
NP
A
Af
CP
A
Ff
Party 1
AC
i FC •, (R
Party 2
Figure203 Problematic complementary transaction Example Party 1:
You must stop drinking; you behave like a moron when you are drunk.
Party 2: Stuff you (as he opens another beer). It's your fault that I drink.
P
P
A
A
C
C
Party 1
Party 2
figure 20.4 A healthier complementary transaction Example Party 1: I feel hurt when you drink because it feels like you don't care for me or the children. I've decided that if you decide to carry on with this, I will not stay in this relationship. (Adult)
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Party 2: (hesitates) ... Oh, I realize that I've been quite irresponsible and it's probably difficult for you to respect me when I'm drunk. I have decided to stop drinking and will need a lot of support from you whilst I get treatment. (Adult) Crossed transactions Crossed transactions involve a non-parallel communication between ego states. This can become problematic if the receiving party actively projects a critical element onto the sender of a non-critical message.
NP
CP
NP
A
A
AC
CP
FC
Sender
4C
Ff
Receiving oartv (e.g. paranoid personality disorder)
Figure 20.5 Crossed transactions Example Sender:
I feel frustrated when you constantly question me because it feels like you don't trust me. (Adult)
Receiver:
Well, it's your fault, you always let me down and you probably arrived late because you are having an affair with Eric. (RC [rebellious child] blaming, suspicious; projects a critical element onto the sender of a non-critical message.)
Ulterior transactions Ulterior transactions involve three or four ego states between parties when communicating double-bind messages. Hidden messages could be non-verbal and could be incongruent with the verbal message; this can be problematic. The patient can be made aware of the hidden message behind the direct message in his/her transactions.
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P
P
X (verbal)
A
RC
A
Not X (non-verbal)
Party 1
C
Party 2
Figure 20,8 Ulterior transactions Example 'You are important to me', whilst fiddling with the TV (for example, passive-aggressive personality disorder). Other related concepts Injunctions: Parental messages internalized by the child part of the self, which can be positive or negative in content. Examples of negative injunctions: 'don't feel' 'don't think' 'don't be close' 'don't be weak'. Scripts: Opinions the child forms about him/herself and the world through internalized parental messages. 'You are worthless; others are more important than you.' Rackets: Bad feelings most frequently felt by the person, often related to negative injunctions received and decisions made by the child part of the self. Games: Behaviour pattern which reinforces the bad feelings and is used to support the racket. Existential position: Belief about self and others which the person forms at the end of the game. Application of above concepts A person might often experience the bad feelings (racket) associated with depression; this could be related to the injunction (parental message) of'don't feel'. The person then plays the game of holding on to his/her feelings in his/her here-and-now relationships. This
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leaves him/her feeling more depressed, which reinforces his/her existential position: 'I'm not important; others are more important.'
Racket (Depression)
Injunction
Game
(Don't feel)
Existential position
I'm not important
Others are important
(Holding onto feelings in here-andnow relationship)
Figure 20.7 An example of the dynamics of depression Redecision therapy The Gouldings have expanded on the transactional analysis model. They are best known for their view of the child as an imaginative decision-maker who reacts innovatively to injunctive family messages and learns to use emotions as tools in interpersonal strategies. The child is viewed as: capable of making choices in arriving at creative decisions as to how he/she will be in order to feel secure and loved in his/her unique family environment. Example The child decides either to: act out (RC)
conform (CC) be spontaneous (FC) use his/her adult reasoning any of which may gain him/her attention from his/her parents (positively reinforced).
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The Gouldings recognize that the child's immaturity and lack of experience limit the range of choices, but still emphasize that the child's decision comprises a genuine element of choice. This idea is used with patients who as adults typically feel that they have no choice; they are helped when they see that even as children they had choices. The injunction-decision-racket complex is the Goulding way of summarizing the outcomes of the child's inventiveness and choice. These carry-over products of childhood mislearnings appear in adult life in the form of 'personal myths'; although they may have been functional in the unique childhood setting, they create problems for the adult, and thus become the focus of intervention. The idea that we are free to choose and have a responsibility to make conscious, informed choices becomes a powerful influence for change (humanistic existential philosophy). In brief, then, the process of redecision involves the patient's doing something, so that he or she can enter the Free Child (FC) ego state. This may entail, for example, regressing to early childhood and re-experiencing the feelings, the scene, the words, the action involved in an initial, early decision and then, while still reliving the experience, changing the decision. In essence, the overall aim of the therapist is to: Replace parent Educate adult Deconfuse child, so that the person can be Energetic Creative Intuitive Sensual Intimate Original Now! Redecision therapy involves three steps which are illustrated by the flow chart in Figure 20.8. The process of redecision therapy begins with the therapist using the identified racket and belief that the patient has about self and others as a stimulus to evoke an early scene in which the same feelings and beliefs were experienced by the patient. The patient is then invited to re-experience the early scene. The therapist gets the client to take the parts of the significant others in the scene him/herself and listens to the injunctions (messages) given and the decisions made in response. The patient is invited to experience the power and satisfaction of the early decision, which moves the patient from an adapted child (AC) position to a free child (FC) position. The patient stays with the early decision until a redecision emerges spontaneously.
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Contracting
Impasse clarification 'unstick' the stuck ego states
Rededsion
Statement of problem
Contracting for desired change
Here therapists identifies:
1. rackets 2. games used to support rackets 3. belief about self and others at the end of the game
Lreprogramme 2. educate S.deconfuse
emotional working through
parent ego state adult ego state child ego state
early experiences
enabling a redecision in the child ego state
behaviour change
Figure20.8 Flow chart of redecision therapy
The redecision results in new behaviour, which needs practice in order to become comfortable to the patient. The therapist operates from specific ego states (his/her own) so as to develop specific ego states in the patient (see tables 20.2 and 20.3). Patients with personality disorders often feel vulnerable in an individual setting and even more so in a group setting. As a result, they often react strongly to any show of vulnerability and to the risk-taking required for a redecision to emerge. Paul Ware's information on personality adaptations and doors for intervention is extremely useful when using redecision therapy to facilitate change in patients with personality disorders. The personality types and the intervention approaches applicable to each type are presented in the conceptual framework of six personality adaptations and doors to therapy.
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Table 20.2 Therapist's ego state Nurturing Parent
Patient's ego state Natural Child
Protection of the patient, emphasizing his/her own personal power and responsibility and giving him/her permission to feel/think or behave as he/she does now and did then.
Enables the patient: to trust and feel safe to feel the therapist is on his/her side to take risks and re-experience early scene to redecide.
Reinforce new behaviour.
Patient feels comfortable with new behaviour.
Exhibit healthy behaviour.
Models healthy behaviour.
Create a nurturing environment for change in group setting (specific norms).
Person has a stage to redecide.
Table20.3 Therapist's ego state Adult
Separating myth from reality in terms of old decisions made by the patient as a child which assisted survival for the child then, but which are now outdated. Script diagrams drawn to illustrate what child ego state experienced.
Patient's ego state Adult
Educate patient's adult ego state. Deconfuse child ego state.
Provides adult ego state reinforcement of what child state experiences.
The six personality adaptations are the hysterical, obsessive-compulsive, schizoid, antisocial, passive-aggressive and paranoid, each of which requires different approaches when making contact (the open door) with the patient. Those to avoid (the trap door) and the ongoing direction tor change (the target door) are also described. Other types listed in DSM-IV-TR do not seem to have clear personality adaptations. Since each personality type has its own pattern, therapists must recognize and understand the area in which each patient invests the most energy (open door) - be it primarily in feelings, thoughts or behaviour - and make initial contact with this area. The schizotypal borderline, narcissistic, dependent and avoidant personality disorders will be dealt with separately.
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Table20.4 Personality adaptation therapy and doors for intervention Doors
Adaptations (Open door) Contact door
Target door
Trap door
Schizoid (Cluster A)
Behaviour
Chinking
Feeling
Antisocial (Cluster B)
Behaviour
Feeling
Thinking
Paranoid (Cluster A)
Thinking
Feeling
Behaviour
Histrionic (Cluster B)
Feeling
Thinking
Behaviour
Obsessive-compulsive (Cluster C)
Thinking
Feeling
Behaviour
Passive-aggressive (Cluster C)
Behaviour
Feeling
Thinking
20.3 WORKING WITH PATIENTS WITH SPECIFIC PERSONALITY DISORDERS CLUSTER APERSONTTDIS The essential feature common to all three cluster A personality disorders is their tendency to be odd and eccentric. Schizoid personality disorder DSM-IV-TR diagnostic criteria: Schizoid personality disorder A. A pervasive pattern of detachment from social relationships and a restricted range of expression of emotions in interpersonal settings, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following: Neither desires nor enjoys close relationships, including being part of a family. Almost always chooses solitary activities. Has little, if any, interest in having sexual experiences with another person. Takes pleasure in few, if any, activities. Lacks close friends or confidants other than first-degree relatives. Appears indifferent to the praise or criticism of others. Shows emotional coldness, detachment, or flattened affectivity. B. Does not occur exclusively during the course of schizophrenia, a mood disorder with psychotic features, another psychotic disorder, or a pervasive developmental disorder and is not due to the direct physiological effects of a general medical condition.
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Note: If criteria are met prior to the onset of schizophrenia, add 'premorbid', for example, 'Schizoid personality disorder (premorbid)'.
Tsble20,5 Understanding the patient with a schizoid personality disorder in terms of a transactional analysis model Adaptation
Schizoid
Characteristics
Withdrawn Passivity Daydreaming Avoidance Detachment
Description
Shy Overly sensitive Eccentric
Drivers
Be strong Try hard Please others
Injunctions
Don't make it Don't belong
Don't enjoy Don't be sane Don't grow up Don't feel (love, sex, joy) Don't think
Contact door
Behaviour
Target door
Thinking
Trap door
Feeling
CP
NP
A
FC
AC
Figure 20,9 Egogram of the schizoid patient
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Application by example A schizoid patient had been hospitalized following an overdose attempt because he could not hold down a job. When he made contact with other people on the job, he became withdrawn, frozen up and nervous. Instead of working, part of him would rather sit down and listen to a radio, just sleep, get up and go back to bed. His shyness, withdrawal, detachment and living in his own world were evidence of his withdrawn passivity. The be strong driver was evident in the client's lack of emotion. The injunctions don't feel and don't enjoy were also clearly evident. Don't grow up and don't think injunctions were apparent from his helplessness and refusal to take responsibility for himself. Since the patient's energy level was so low, the therapist had to devote a great deal of energy to the patient's withdrawn passivity, his open door of behaviour, thus entering his world. As therapy progressed, the therapist invited him to his target door of thinking, forcing him to move from a passive to an active state, thus making him aware of choices he had made - getting him to own his passive behaviour. Core psychodynamic problem The person with a schizoid personality disorder has an underlying fear of closeness since he/she fears not only devouring others with his/her neediness but also that others might smother or consume him/her with their neediness. This is because as an ...
infant
consequently, all relationships experienced
he/she initially perceived mother as rejecting
withdraws from world
but neediness grows
becomes insatiable
feels that own greed devours mother
leaving infant alone again
as dangerous
to be avoided
but needed
socially isolated alone and empty person
and
emotionally constricted
but safe, with no risks
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Defences used: Fantasy - to comfort self. Distancing - push others away so as to avoid feeling insatiable or feeling devoured by others; - others feel rejected. Splitting - keep good and bad parts of self and others apart because of fear that badness will destroy/devour goodness. Protective identification - world becomes rejecting towards patient as mother did, leaving person alone. Therapeutic principles Major goal. Establish positive view of social interaction and personal closeness and reduce negative views of social isolation (educate adult, replace parent). Identified problems. Poor social skills (behaviour), evidenced by social isolation and emotional constriction; impact on others related to fear of closeness, resulting in feelings of emptiness and aloneness. The use of individual therapy and group therapy are discussed below. Individual therapy 1. The initial goal is to motivate the patient to see the need to change his/her behaviour (contact area), as he/she may feel afraid to do this. Explore the advantages and disadvantages of his/her social withdrawal for self and the effect of his/her behaviour on others. Gradually the patient begins to take responsibility for his/her withdrawn passivity (behaviour) and perceives the need for change. 2. Educate patient on basic patterns of human interaction = target area of thinking. These patients typically show little understanding of interpersonal relationships and may have quite poor social skills, since they have not managed either to observe or to experience such skills. During sessions with the patient, the therapist may use opportunities to point out the patient's characteristic interaction pattern and can provide feedback to the patient regarding his/her impact on others. Practise the newly learnt social skills in which the patient was previously deficient to test the patient's new understandings and skills, both when interacting with the patient and during his/her free time. 3. Recognize that change in a schizoid patient is a slow, painstaking process and that the therapist needs to take a few, small steps at a time and exercise extraordinary patience. Adopt a permissive, accepting attitude towards the patient's silence.
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4. Monitor your own feelings when working with the schizoid patient, as this provides a valuable source of information about the patient (that is, his/her own inner world defences). If feeling frustrated and rejected by the patient, and desiring to give up on him/her, attempt to understand these feelings rather than to act on them. (The patient is probably using the defences of distancing and protective identification, and needs more nurturing.) In this way you act as a repository for the patient's projections, which helps him/her to integrate the good and bad aspects of him/herself, which becomes evident in the risks later taken by the patient through increasing trust in him/herself and others. Group therapy 1. Schizoid patients are prime candidates for group therapy, since group therapy is oriented towards helping patients with socialization, which is precisely the area in which schizoid patients are most deficient. It is also a setting in which new parenting can take place, both by the therapists and by other group members (NP). Such patients can benefit a great deal simply from having regular exposure to others. As they begin to feel accepted and to find that their fears are not realized, they gradually become more comfortable with people (reinforces patient's FC). 2. Dealing with problems that arise in the group therapy of schizoid patients: Other patients may resent having to 'spill their guts' while the schizoid patient remains silent; this can result in 'ganging up' to force the schizoid patient to talk (other patients CP or RC). Here the therapist must support (NP) the schizoid patient and help other members to accept that the patient needs to be silent. Other patients may ignore a withdrawn schizoid patient and treat the person as if he/she were not present. Here the therapist's task is to get other members to give feedback to the patient regarding the effect of his/her behaviour on others (only once enough trust has been established in the group). The therapist can also bring the patient into the group by pointing out how a pattern that takes place outside the group is now repeating itself inside the group. Point out gently how withdrawn and unreceptive the patient is in the group (address patient's Adult). It is important to prepare the patient emotionally prior to group therapy, since his/her anxiety will be increased at the very idea of the therapy. Explore the patient's fantasies about what he/she fears will happen in the group (patient's FC).
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A combination of individual therapy followed by group therapy is ideal for many schizoid patients in order to increase their positive views of social interaction. Schizotypal personality disorder DSM-IV-TR diagnostic criteria: Schizotypal personality disorder A. A pervasive pattern of social and interpersonal deficits marked by acute discomfort with, and reduced capacity for, close relationships, as well as by cognitive or perceptual distortions and eccentricities of behaviour, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following: 1. Ideas of reference (excluding delusions of reference). 2. Odd beliefs or magical thinking that influence behaviour and are inconsistent with subcultural norms (for example, superstitiousness, belief in clairvoyance, telepathy, or 'sixth sense'; in children and adolescents, bizarre fantasies or preoccupations). 3. Unusual perceptual experiences, including bodily illusions. 4. Odd thinking and speech (for example, vague, circumstantial, metaphorical, overelaborate or stereotyped). 5. Suspiciousness or paranoid ideation. 6. Inappropriate or constricted affect. 7. Behaviour or appearance that is odd, eccentric, or peculiar. 8. Lack of close friends or confidants other than first-degree relatives. 9. Excessive social anxiety that does not diminish with familiarity and tends to be associated with paranoid fears rather than negative judgements about self. B. Does not occur exclusively during the course of schizophrenia, a mood disorder with psychotic features, another psychotic disorder, or a pervasive developmental disorder. Note: If criteria are met prior to the onset of schizophrenia, add 'premorbid', for example, 'Schizotypal personality disorder (premorbid)'.
At the one end of the continuum, Schizotypal patients are much the same as schizoid patients in terms of their social isolation (except for a few more oddities of behaviour and communication). At the other end of the continuum, there are those Schizotypal patients who are closer to schizophrenia and are prone to brief psychotic episodes. Understanding the Schizotypal patient in terms of a transactional analysis model Refer to Table 20.5 regarding the schizoid patient, as this table also applies to the schizotypal patient. Specific injunctions for the Schizotypal patient include don't be sane and don't belong, resulting in the often bizarre behaviour characteristic of the patient with a schizotypal personality disorder.
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Therapeutic principles 1. The principles of individual and group therapy, previously outlined in the management of the patient with a schizoid personality disorder, also apply to the patient suffering from a schizotypal personality disorder. 2. A careful assessment must be made of the patient's ego functioning in terms of his/her reality testing and judgement. Those schizotypal patients with better ego functioning will obviously progress better than those with profoundly disturbed ego functioning. 3. More disturbed schizotypal patients may need support with their ability to test reality and with their judgement. 4. Social skills training and re-education will help to reduce their bizarre behaviour. 5. Antipsychotic medication, such as Fluanxol or Clopixol Acuphase, may be prescribed to reduce the magical thinking which causes bizarre behaviour. Individual therapy may be the preferred modality for treating such a patient if his/her behaviour is too bizarre, since the patient might become a scapegoat in group therapy because he/she is simply too different from other members. Paranoid personality disorder DSM-IV-TR diagnostic criteria: Paranoid personality disorder A. A pervasive distrust and suspiciousness of others such that their motives are interpreted as malevolent, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following: 1. Suspects, without sufficient basis, that others are exploiting, harming or deceiving him or her. 2. Is preoccupied with unjustified doubts about the loyalty or trustworthiness of friends or associates. 3. Is reluctant to confide in others because of unwarranted fear that the information will be used maliciously against him or her. 4. Reads hidden demeaning or threatening meanings into benign remarks or events. 5. Persistently bears grudges, that is, is unforgiving of insults, injuries, or slights. 6. Perceives attacks on his or her character or reputation that are not apparent to others and is quick to react angrily or to counterattack. 7. Has recurrent suspicions, without justification, regarding fidelity of spouse or sexual partner. B. Does not occur exclusively during the course of schizophrenia, a mood disorder with psychotic features, or another psychotic disorder and is not due to the direct physiological effects of a general medical condition. Note: If criteria are met prior to the onset of schizophrenia, add 'premorbid', for example, 'Paranoid personality disorder (premorbid)'.
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Table 20.6 Understanding the patient with a paranoid personality disorder in terms of a transactional analysis model Adaptation
Paranoid
Characteristics
Rigidity of thought Grandiosity Projection
Description
Hypersensitive Suspiciou! Jealous Envious
Drivers
Be strong Be perfect
Injunctions
Don't be a child Don't be dose Don't feel Don't enjoy Don't trust
Contact door
Thinking
Target door
Feeling
Trap door
Behaviour
Patients with paranoid personality disorders are characterized by grandiosity and rigidity, especially in their thinking patterns. Their grandiosity, reflected in unrealistic expectations of themselves (be perfect) is a cover-up for deep-seated feelings of insecurity and inadequacy. Paranoids project strongly what they think and feel onto others, and are very accusatory. They operate in a move-in and move-out pattern, making contact with someone one day and then pulling away the next. Very early in life they received messages (injunctions) of dont trust, dont be a child, don't feel, dont be dose and dont enjoy. Their open door is in thinking, which they can do carefully and accurately because of their hypersensitive perception. Their target door or access door is feeling and their trap door is behaviour. If their behaviour is attacked, they become more suspicious and delusional and begin to project in order to blame others. Application of the transactional analysis model by example A highly sensitive and perceptive young paranoid patient had been admitted to the unit following the loss of his brother. The following interview illustrates how the therapist (X)
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moved from a thinking to a feeling level in a very gentle and supportive way. The patient seemed very guarded at first, sitting quietly, investing considerable energy in thinking. The first step taken by the therapist (X) was to invite him to share his thinking aloud and to share the negative feelings he was experiencing, so that these could be dealt with. As the therapist stroked the patient for his clear thinking regarding how this loss of his brother had affected his life, the co-therapist intervened expertly when he said 'I imagine you have a lot of feelings about the loss of your brother' and broke through his be strong and don't feel drivers. As he began to cry and look at the therapist, the therapist moved in and made contact with him on a feeling level. Although hesitant and hard on himself, he became more accessible to feeling. His don't be close injunction was evident in his fear of closeness and positive feelings. He needed to be weaned into positive feeling and continually reassured that caring about somebody and being close, although scary, would not be destructive. Core psychodynamic problem Good-enough parenting in infancy enables the infant to integrate simultaneously both good and bad aspects in the world and within the self (depressive position). In the paranoid personality disorder, parenting during childhood has involved a predominance of unsatisfying experiences (bad); this results in the need to keep good and bad feelings towards the world and within the self separate to survive emotionally (splitting). The badness within is projected into outside figures (which themselves became persecuting) to reduce the internal tension between good and bad introjects (paranoid-schizoid position). Defences used thus include splitting, projection and projective identification. The patient's experience of others is discontinuous; no relationship is perceived as enduring over time. Instead, the patient has only the perception of the moment. Low self-esteem, feelings of inferiority, and feelings of weakness underlie the patient's external mask of rigidity and his/her need for perfection. Therapeutic principles Major goal. To shift the patient's perception of the origin of his/her problems from an external source (world and others) to an internal one (the self). Instead of faultfinding or blaming, the person moves towards owning his/her own critical projections. Identified problems. Difficulty in trusting others related to frustration with early figures and a predominance of unsatisfying experiences; evidenced by low self-esteem, suspiciousness, a tendency to be guarded and to find fault with others. Individual therapy is the preferred initial modality of treatment because of the patient's mistrust of others. Here the mental health nurse may work in conjunction with a psychologist to achieve the major goal. Working with the person on an individual basis 1. Build a therapeutic alliance. This process is extremely difficult because of the patient's
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difficulty in trusting anyone and because of the patient's tendency to attack or blame others, including the therapist (projection, projective identification). The mental health nurse must be willing to act as a 'repository' for feelings of hatred, badness, impotence and despair, instead of reacting defensively to attacks from the patient. Instead of challenging the patient's thinking or construction of events, get more detail from the patient (contact area). Secondly, empathize with the patient's feelings and perceptions of the situation (target area). For example, 'I can see why you might be angry with me if you thought I was criticizing you. Frankly, I don't have any critical thoughts towards you.' Openness is important when endeavouring to build a relationship of trust with a paranoid patient. 2. Help the patient to identify gaps in his/her knowledge about reality so as to establish a creative doubt about his/her perceptions of the world. The person with a paranoid personality disorder presents with a faulty perception of the world. The mental health nurse must communicate tactfully with the patient in order to expose his/her pattern of thinking. Questions must be worded carefully and neutrally so as not to challenge the patient's view of the world. For example, 'Did your friend say that she hates you?' When the patient responds negatively to the question, the therapist can comment matter of factly about the patient's limited knowledge of the friend's feelings. As the patient becomes more expansive, the therapist can begin to identify the patient's feelings (target door) and help the patient to distinguish between emotions and reality. Violence can be a real threat when working with paranoid patients because of their 3. constant perception of attack from the world. The following principles are important in this regard: Do everything possible to help the patient to save face (nurture, empathize with patient's feelings while the relationship of trust is developing). Avoid arousing further suspicion (openness, consistency). Help the patient to maintain a sense of control (communicate respect of his/her autonomy in order to reduce anxiety). Encourage the patient to talk about, rather than to act out his/her anger (explore consequences of becoming violent). Give the patient plenty of breathing space (in terms of seating arrangements). Maintain your own feelings when working with the paranoid patient. - If you feel afraid, avoid situations that might jeopardize your safety, especially if the patient has been physically aggressive in the past. - Recognize your own potential to be destructive and aggressive, instead of seeing these feelings as typical only of such patients.
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CLUSTERB PERSONALITY DISTODER
The essential feature common to all four Cluster B disorders is the tendency to be dramatic and erratic. The histrionic personality disorder DSM-IV-TR diagnostic criteria: The histrionic personality disorder A pervasive pattern of excessive emotionality and attention seeking, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following: 1. Is uncomfortable in situations in which he or she is not the centre of attention. 2. Interaction with others is often characterized by inappropriate sexually seductive or provocative behaviour. 3. Displays rapidly shifting and shallow expression of emotions. 4. Consistently uses physical appearance to draw attention to self. 5. Has a style of speech that is excessively impressionistic and lacking in detail. 6. Shows self-dramatization, theatricality, and exaggerated expression of emotion. 7. Is suggestible, that is, easily influenced by others or circumstances. 8. Considers relationships to be more intimate than they actually are.
Table 20.7 Understanding the person with a histrionic personality disorder in terms of a transactional analysis mode Adaptation
Hysterical
Characteristics
Excitability Emotional instability Overreactivity Dramatic attention-seeking Seductive
Description
Immature Self-centred Vain Dependent
Drivers
Please me Trv hard Hurry up
Injunctions
Don t grow up Don t be important Don t think
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Contact door
Feeling
Target door
Fhinking
Trap door
Behaviour
CP
NP
A
FC
AC
figure20.10 Egogram: active dependent stylele People wim nistnonic personalities invest tneir energy ror me most part in teeiing. iney present with excitability, emotional instability and overreactivity. They are often referred to as attention-seeking and dramatic, with immature and self-centred behaviour. Although they are exciting to be with, relationships with these people can be difficult. They attach themselves to others, get close, become dependent and invite conflict within the person they are dependent on. Their number one driver is please me or please others, and the messages often come from the parent of the same sex. In order to make contact with such a person and invite him/her to change, the therapist must first communicate and connect with him/her at a feeling level, which is the level at which his/her energy is invested (open door). The patient can then be invited to change through his/her target door (that is, his/her thinking processes); the therapist must be careful to relate to the patient from an equal rather than a one-up position. The trap door to be avoided is the patient's behaviour, which usually occurs at an unconscious level. Application by example During an interview with a young female histrionic patient, the interviewer was struck by how attractive, cute and emotionally energetic the patient was. As she leaned towards the interviewer, the interviewer made emotional contact by encountering her playfully at a feeling level. The interviewer later commented on her thinking, upon which the patient made a significant statement: all she needed to do was to think and that was what she needed time and space to do. This statement was reinforced and anchored by the therapist's leaning over and touching her arm. Continuing to talk, the patient clearly showed her please me driver by using phrases like 'You know', T think so'. Several times her hurry up driver was interrupted by the therapist's inviting her to think clearly. She expressed anger towards the enmeshed relationships she had with her
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mother, which was stroked by the therapist when she intervened by telling the patient that the way to get well was to grow up, think and become separate. Core psychodynamic problem Relative maternal deprivation during the oral stage, and difficulty resolving the oedipal situation are at the core of the pathology of the person with a histrionic personality disorder. The lack of maternal nurturance leads to the seeking of gratification from the father. One of the basic beliefs of the histrionic person seems to be 'I am inadequate and unable to handle life on my own, so I'll have to rely on others to take care of me!' In contrast with the dependent person, who gets taken care of by emphasizing his/her helplessness and by assuming a passive role, the histrionic person takes the initiative by actively seeking attention and approval from others in a child-like manner. The thinking style of such a person is characteristically global, impressionistic, vivid and interesting, but lacking detail and focus. His/her knee-jerk emotionality is exaggerated, labile and intense and is accompanied by attention-seeking behaviour. This collectively serves to keep the person from getting in touch with any genuine feeling states, and is used to manipulate others into taking care of him/her. Defences used: Denial, repression, idealization, splitting Generalization Emotionality Therapeutic principles Major goal. To develop the patient's (adult) sense of competence and self-reliance, through refining his/her thinking processes and helping him/her to feel more deeply, thus enabling the person to communicate his/her needs more assertively. Identified problems. Inability to rely on self for care or approval related to relatively early maternal deprivation; evidenced by emotionally dramatic, attention-seeking behaviour, a need for approval from others and impressionistic, global thinking, resulting in problems in relationships with others. Working with the person with a histrionic personality disorder on an individual basis 1. Establish a therapeutic alliance, focusing on specific target problems and goals. The person with HPD readily becomes attached to the therapist because of his/her underlying dependency and fantasy of being rescued. The use of collaboration and guided discovery (by means of questioning) is very important here; this enables the patient to arrive at his/her own solutions to facilitate his/her own self-reliance. By being empathic, first communicate through the open door of feeling. In this way the patient will feel understood and will be able to identify and reflect on his/her deeper feelings - a process which the patient usually guards against.
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Help the patient to focus his/her attention on one issue at a time; this will prevent both the patient and the therapist from getting lost in all the dramatics of the patient's experiences. It is important to set firm limits to demands in order to prevent the person from trying to manipulate the situation. Limits must be clear, concrete and immediate (for example, a time limit for individual therapy). 2. Establish the need for detail or specifics with regard to thinking and feeling states. Make the patient aware of his/her vagueness of perception and superficial impressionistic feeling; explain the consequences of this in terms of his/her ability to rely on self. Help the patient to reflect specifically on events/feeling states instead of reporting globally and dramatically on these in a superficial and distant manner. As the patient reflects on and attends in detail to his/her internal and external world, he/she will be able to see the connections between specific thoughts/ideas and specific feelings. Reinforce the person's competence and attention to specifics rather than his/her more commonly reinforced emotionality and manipulation. During individual therapy help the patient to develop assertiveness skills - that is, open, honest, direct and specific communication of his/her feelings, thoughts and needs. If patient sees the benefit of being more specific and assertive during individual therapy, he/she may also learn that being assertive and engaging in active problem solving can pay off more than manipulation and emotional upheaval in the real world. In this way, instead of perceiving the self as a victim of others, these persons learn to rely more on the self as an agent who is competent and in active interaction with the environment. Group therapy Persons with histrionic personality disorder are prime candidates for group therapy. This is because the group as a whole can: provide a source of nurturing that these patients believe they missed during childhood; provide feedback to individual patients regarding their cognitive style - that is, how they tend to distort their view of self and others by omitting details from interactional patterns; provide opportunities to exercise their assertiveness and see positive consequences for themselves. Potential problems that might arise in the group are displays of emotionality, demands to be the centre of attention, blaming, appearing to be stuck and pressure from patients to be rescued. The principles outlined under individual therapy can be used here.
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When working with the histrionic patient in both individual and group therapy the underlying principle is to empower the person by: educating his/her adult ego state; and increasing his/her capacity to tolerate the deeper feelings contained within the free child. This can initially be achieved through the therapist's nurturance and later through the group's nurturance and the person's own nurturing parent capacity. The antisocial personality disorder DSM-IV-TR diagnostic criteria: The antisocial personality disorder A. There is a pervasive pattern of disregard for and violation of the rights of others occurring since age 15 years, as indicated by three (or more) of the following: 1. Failure to conform to social norms with respect to lawful behaviours as indicated by irepeatedly performing acts that are grounds for arrest. 2. Deceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal profit or pleasure. 3. Impulsivity or failure to plan ahead. 4. Irritability and aggressiveness, as indicated by repeated physical fights or assaults. 5. Reckless disregard for safety of self or others. 6. Consistent irresponsibility, as indicated by repeated failure to sustain consistent work behaviour or honour financial obligations. 7. Lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another. B. The individual is at least 18 years old. C. There is evidence of conduct disorder with onset before the age of 15 years. D. The occurrence of antisocial behaviour is not exclusively during the course of schizophrenia or a manic episode. Table 20.8 Understanding the person with an antisocial personality disorder in terms of a transactional analysis model Adaptation
Antisocial
Characteristics
Conflict with society Low frustration tolerance Need for excitement and drama Seductive
Description
Selfishness Callousness Irresponsibility
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Drivers
Be strong Please others
Injunctions
Don't make it Don't be dose Don't be a child Don't feel
Contact door
3ehaviour
Taraet doo
Feeling
Trap door
Thinking
CP
NP
A
FC
AC
Figure20,11 Egogram: active independent style Antisocials have a low frustration tolerance and experience problems with rules and regulations, which often leads to their being in trouble with the law. They search for excitement and drama because getting in touch with feelings requires so much effort. Their number one driver is be strong, this enabling them to cope with their early emotional deprivation. Their number two driver is please others because, if they are able to do this, they can get others to do what they want. Their injunctions are don't be a child and don't feel (particularly fear or sadness). A don't make it message is also part of their script, and, regardless of how clever they are, they always get caught. Don't stay dose is also an injunction for antisocials because, although they connect quickly with others, relationships do not last. The main open door of antisocials is their active aggressive behaviour towards self or others. The therapist starts by confronting this behaviour and then moves to their target door of feeling. Their trap door is their thinking and this should be avoided because of their insincerity and quick and clever ability to outsmart the therapists. Application by example A 20-year-old antisocial male admitted to the unit with a history of physical violence involving his fiancee, appeared quite illiterate on interview but both pleasant and charming. The therapist started by confronting the patient's aggressive behaviour and
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explained the potential consequences of his acting out his angry feelings. The patient's be strong driver became apparent when he revealed in an emotionless manner how, as a child, he was physically and emotionally abused by his father. The therapist intervened here when she reflected on how powerless and afraid he must have felt, and for a while saw the sadness in his eyes. However, he moved quickly away from his feelings into the defence of toughness that he had learnt to build around himself in order to survive. The therapist again confronted his be strong driver, this time commenting on how his decision to be tough as a child helped him to cope whilst he was helpless, but how as an adult he was now better able to protect himself and work through his pain and anger by talking about it, thus letting it go. Core psychodynamic problem Biological factors and problems in the infant-mother relationship can on their own or together contribute to the aetiology and pathogenesis of antisocial personality disorders. Biological factors In a number of studies it has been found that various biological factors, for example genetic, hormonal and neurochemical, as well as organicity and autonomic hyperactivity, can contribute towards antisocial personality disorder. These biological factors may in turn contribute to early problems in the infant-mother relationship, making the infant difficult to soothe and comfort and thus interfering with the normal attachment process. Infant-mother relationship Antisocial patients often have a history of childhood neglect or abuse by parental figures. Regardless of whether the responsibility rests with the infant, the mother or both, antisocials clearly have not achieved the developmental task of object constancy. Object constancy is the progressive developmental process occurring during the first three years of life during which the child develops an evocative memory, the capacity consistently to distinguish self from others and the ability to integrate good and bad representations of the same person. In the first year object constancy is limited to an attachment to a beloved person based on the infant's capacity to recognize this figure and miss the person when he/she is absent, but without the capacity to evoke an internalized image unless the person is physically present. During the second year object constancy implies a more enduring mental image of the beloved figure (that is, evocative memory), capable of being remembered when the beloved is absent or when an internalized need state is present and the figure is perceived as the ideal object to comfort the infant. This object permanence occurs around the age of 18 months.
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Finally, around the third year of life, object constancy in the child involves more advanced mental representations which integrate the good and bad or loved and hated aspects of the person. Two prerequisites for developing object constancy would include biological integrity and good enough parenting for the child. Lack of basic trust, combined with the absence of loving experiences with a maternal figure, prevents object constancy in the antisocial person. Instead of being a soothing introject, the ideal object becomes an aggressive introject, and the parent is experienced as a stranger who cannot be trusted and who harbours hatred towards the infant. This situation arises from real experiences of parental cruelty and neglect. Object permanence reaches a stalemate before the completion of separation/ individuation. Instead, two processes coexist: one is characterized by a severe detachment from all relationships and from feelings, while the other is an object-relatedness characterized by sadistic attempts to bond with others through the exercise of power and destructiveness (grandiose sense of self). The child thus does not move into a depressive position where it can integrate good and bad aspects of the same person, neither does it experience the depressive anxieties or the guilt stemming from concern that his/her actions can hurt others (also characteristic of the depressive position). Implications for the true antisocial person 1. The true antisocial person does not see people as separate individuals with feelings of their own - that is, there is no capacity for empathy, but instead a grandiose sense of self based on the need to exercise power. 2. He/she does not usually experience anxiety, depression or guilt. 3. Suicide attempts tend to grow out of narcissistic rage rather than out of genuine hopelessness and a wish to die; there is a rageful resentment at the world for not conforming to the person's wishes, accompanied by feelings of boredom and emptiness. 4. Inability to internalize results in a massive failure of superego development, that is, the conscience. The only value system is the exercise of aggressive power with a lack of remorse following antisocial behaviour. When confronted with his/her antisocial behaviour, the true antisocial person often responds by being self-righteous, stating that the victim deserved what they got. Defences used: Denial Dissociation from feelings Displacement Splitting Projective identification - of his/her aggressive introject into others
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Therapeutic principles Major goal. To help the patient to accept responsibility for his/her antisocial behaviour in the here and now. Identified problems. Exercise of power and destructiveness in his/her relationships with others, related to childhood neglect/abuse; this is evidenced by aggressive acts, impulsivity, lack of remorse, and failure to have empathy for others. Working with the person with an antisocial personality disorder These action-oriented individuals will never get in touch with their feelings as long as they have the outlet of behaviour to discharge their impulses. It is only when they are immobilized in an inpatient setting that they might get in touch with feelings of anxiety and depression. However, the antisocial's disruptive behaviour may interfere with other patients' treatment and disrupt the milieu in the unit. The decision to hospitalize the person must consequently be carefully considered. Objective criteria must be used as predictors of the possible response to treatment (Gabbard 1990: 410). General principles: management within the inpatient setting 1. The treatment of a person with antisocial personality disorder will be enhanced if the other patients have a similar pathology. This is because the programme relies heavily on group confrontation by peers. In addition, other antisocials are familiar with con-artist strategies and, if the patient is confronted regularly enough, these might be neutralized. 2. A setting with a tight structure and clear and rigidly enforced rules, where the consequences for rule-breaking are clearly spelt out, will help the antisocial person to think before he/she acts. 3. Staff members must monitor their own countertransference reactions, both as individuals and in a group context. Three common staff reactions are disbelief, collusion and condemnation. Disbelief may surface as denial that the patient is really that bad, and may cause staff members to deny the presence of psychopathic features; instead, the person may be viewed as depressed or misunderstood. Collusion occurs when the patient is able to corrupt or exploit one or more staff members. Through simulated fearfulness, remorse or sadness, antisocial patients manipulate clinicians into empathizing with them; which may cause splitting because other clinicians may regard the same response in the patient as a performance, rather than as a real feeling state. Condemnation occurs when caregivers state that the antisocial patient is untreatable after listening to his/her history. If this stems from intensive contact with the patient, it can be seen as a projective identification with the aggressive introject of the patient.
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Other common reactions include feelings of helplessness in the face of a treatmentresistant patient, a desire to destroy the patient which grows out of anger, and feelings of invalidity and loss of identity. Fear of assault by the patient may cause staff to avoid implementing the firm structure that the patient needs. 4. Continual focus on the patient's faulty thought processes is a major aspect of his/her treatment. The staff must point out repeatedly how the person fails to anticipate the consequences of his/her behaviour. 5. All interventions are based on the here and now because exploring past trauma is often long-term and useless. Working with the antisocial person on an individual basis 1. The mental health nurse must be stable, persistent, incorruptible and sure of herself in order to prevent manipulation. 2. Repeated confrontation of the patient's denial and minimization of his/her antisocial behaviour helps the patient to accept responsibility for his/her actions. 3. The mental health nurse must help the patient to connect actions with feelings so that his/her needs can be fulfilled through being assertive. 4. Confront here-and-now behaviour instead of exploring past trauma. 5. Monitor your own countertransference feelings in order to remain objective. 6. Avoid having excessive expectations of improvement. Unconscious envy of the therapist's positive qualities often leads to a repetitive cycle of deception. This results in a feeling of triumph in the patient but also prevents a meaningful relationship with the therapist from developing and leaves the patient feeling empty. In some cases the use of empathy can be collusive and even hypocritical, especially if the antisocial behaviour is shocking. Rather than remaining neutral, the therapist can simply comment on how shocked he/she is and respond appropriately. Narcissistic personality disorder DSM-IV-diagnostic criteria: Narcissistic personality disorder A pervasive pattern of grandiosity (in fantasy or behaviour), need for admiration, and lack of empathy, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following: 1. Has a grandiose sense of self-importance (for example, exaggerates achievements and talents, expects to be recognized as superior without commensurate achievements). 2 Is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love. 3. Believes that he or she is 'special' and unique and can only be understood by, or should associate with, other special or high-status people (or institutions).
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4. Requires excessive admiration. 5. Has a sense of entitlement, that is, unreasonable expectations of especially favourable treatment or automatic compliance with his or her expectations. 6. Is interpersonally exploitative, that is, takes advantage of others to achieve his or her own ends. 7. Lacks empathy, that is, is unwilling to recognize or identify with the feelings and needs of others. 8. Is often envious of others or believes that others are envious of him or her. 9. Shows arrogant, haughty behaviours or attitudes.
Table 20.9 Understanding the person with a narcissistic personality disorder in terms of a transactional analysis model Injunctions
Don't feel Don't be close
Drivers
Be strong
Beliefs
Self: I'm in a class of my own Others: People are there to be trampled on Life: Life is a contest already won
Behaviour
Ignores others' rights
Stroking
Takes positive strokes; self-strokes
Life position
I'm okay, you're not okay
CP
NP
A
FC
AC
Figure 20.12 Egogram: active independent style Core psychodynamic problem in terms of an object relations approach Behaviour characteristics These people tend to be extremely self-centred, often needing praise and constant recognition in order to feel momentarily good about themselves, and are unable to feel a
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sense of their own worth or value. In their relationships they tend to be exploitative and insensitive to the needs of others. They may expect special privileges from those around them without giving anything in return, yet feel easily humiliated or shamed and respond with rage at what they perceive to be criticism or failure of people to react in the way they wish. Some may alternate between letting people see their vulnerabilities and an aloof distancing, while others maintain an arrogant exterior. Many can elaborate active fantasies about magnificent success in love, sex, beauty, wealth or power. Defences used: Primitive Idealization/devaluation Splitting Projective identification Kohut versus Kernberg's understanding of the narcissistic personality disorder
The nature of the narcissistic personality disorder remains a controversial issue, revolving mainly around the models of Kohut and Kernberg.
fable 20,10 Differences between the models of Kohut and Kernberg Kohut
Kernberg
1. Based theory on outpatients who functioned quite well but whose self-esteem was vulnerable to slights.
1. Based theory on a mixture of in- and outpatients who were mostly primitive,, arrogant with a haughty grandiosity.
2. Differentiates narcissistic from borderline states.
2. Defines narcissistic personality as similar to borderline personality, but usually having better ego functioning in terms of anxiety tolerance, impulse control and reality testing.
3. Emphasis is on internalization of mission functions - no definition of internal object relations.
3. Defines primitive defences and object relations typical of borderline personality.
4. Defines archaic normal self as one that is developmental^ arrested.
4. Defines self as a highly pathological structure composed of the fusion of the ideal self, ideal object and real self.
5. Accepts idealization at face value as a normal developmental phase.
5. Views idealization as a defence against rage, envy.
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Kohut's emphasis is on the internalization of missing functions, as indicated in Figure 20.13.
As an infant
empathic parental failures such as
Now, as an adult
constant and crucial need for self-objects
1. lack of validation or admiration of child's phase-appropriate exhibitionism 2. absence of a model worthy of idealization 3. absence of a feeling of oneness with the parent (self-objects)
someone who performs a necessary function for person, while being experienced as part of him/her
to help him/her regulate his/her self-esteem and feel complete
Consequently, when in therapy
because of patient's tenuous self-cohesion empathic failures may result -fragmentation and anger in the person which is secondary to the narcissism
Figure 20.13 Kohut's model of narcissistic personality disorder Kernberg's emphasis is on the narcissistic person's need for self-sufficiency and pathological internal object relations which allow the patient to feel self-sufficient (see Figure 20.14).
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self and object images that are good
object images that are bad Person with borderline personality organization
unable to
synthesize
the core of his/her splitting, projective identification and idealization cannot feel ambivalence, ie simultaneous love and hate for the important persons in his/her life
has pathological fusion of aspects of his/her: ideal self real self ideal objects
i.e. combines everything he/she wants from an ideal other person and all he/she grandiosely wants for himself/herself with aspects of his/her real self Different from borderline personality
narcissist consequently, person has within himself/herself everything he/she needs from others and therefore is totally selfsufficient
does not have to acknowledge, therefore: separate existence of other person (no empathy) feelings of helplessness, envy, rage about that person
Figure 20,14 Kernberg's model of narcissistic personality disorder
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Working with the narcissistic person on an individual basis using the models of Kohut and Kernberg For Kohut empathy is the cornerstone of the treatment of the person with narcissistic personality disorder. The mental health nurse must: actively soothe the person through the use of empathy and try to immerse self in the patient's internal world (supportive); reflect on the patient's yearning to be soothed; empathize with patient's need for affirmation, for idealization, or for being like the therapist (self-object transferences); avoid comments that might be viewed as harshly critical and focus rather on the positive side of the person's experience, that is, their progress; and help the patient to identify and seek out appropriate self-objects - instead of overvaluing separation and autonomy. Kernberg's approach is more confrontational than that of Kohut. Once an alliance has been established, the traits of greed and demandingness must be confronted and examined from the point of view of their impact on others. The mental health nurse must: focus in particular on the patient's envy and how it prevents him/her from receiving or acknowledging help. For example, the person might dismiss the therapist's comments as being ridiculous or meaningless to avoid painful feelings of envy (after the patient receives something positive from his/her therapist, as it reinforces the patient's feelings of inferiority); » help the patient to develop a concern for others through the experience of guilt, for example: 'I wonder if your wife often feels that her needs are not important or feels excluded from your pain?' (self-sufficiency); act as a 'repository' for the patient's rage, idealization, devaluation and splitting, and projected aspects of him/herself. The mental health nurse must be aware of his/her own negative feelings and use this awareness to identify the defence used by the patient. Empathically point out what the patient is 'trying to turn you into'. This facilitates the integration of good and bad aspects of self and others. Common negative feelings Idealization. The therapist may enjoy the glow of warmth and love to such an extent as to collude with the patient's wish to exclude hatred and anger from the relationship. Boredom. Because of the patient's self-sufficiency, the therapist may have to tolerate a sense of being used as a sounding board. Dismissal. Where the patient fails to see the therapist as a separate person with separate thoughts and feelings (projective identification); the patient excludes the therapist as he/she was once excluded by his/her own parents.
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The therapist may experience a feeling of impotence in response to the intense devaluation by the patient. Group therapy Table 20.11 Problem areas and advantages of group therapy for narcissistic personality disorder Problem areas
Advantages
The person might...
The person might...
resent the fact that other people take some of the therapist's time and attention.
enjoy having a captive audience.
view group therapy as a situation in which his/her specialness is overlooked.
have to confront and accept the fact that others have needs and that he/she cannot be the centre of attention at all times.
make observations about other people's problems but deny his/her own.
benefit from feedback from others about the impact of his/her behaviour on others.
be scape-goated by the group because of his/her intense neediness.
benefit from active support from the therapist who can help the others to empathize with the person's need to be recognized and admired.
Borderline personality disorder DSM-IV-TR diagnostic criteria: Borderline personality disorder A pervasive pattern of instability of interpersonal relationships, self-image and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following: 1. Frantic efforts to avoid real or imagined abandonment. Note: Do not include suicidal or self-mutilating behaviour covered in criterion 5. 2. A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation. 3. Identity disturbance: markedly and persistently unstable self-image or sense of self. 4. Impulsivity in at least two areas that are potentially self-damaging (for example, spending, sex, substance abuse, reckless driving, binge eating). Note: Do not include suicidal or self-mutilating behaviour covered in criterion 5. 5. Recurrent suicidal behaviour, gestures, or threats, or self-mutilating behaviour.
O
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6. Affective instability due to a marked reactivity of mood (for example, intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days). 7. Chronic feelings of emptiness. 8. Inappropriate, intense anger or difficulty controlling anger (for example, frequent displays of temper, constant anger, recurrent physical fights). 9. Transient, stress-related paranoid ideation or severe dissociative symptoms.
Understanding and working with persons with borderline personality disorder (BPD) continues to be one of the biggest challenges both for the novice and the experienced mental health nurse. Firstly, this is because BPD pervasively influences regulation of affect, sense of self, cognitive processes, impulse control and interpersonal relationships. Secondly, intense transference-countertransference develops between the person and the mental health nurse. Theoretical perspectives surrounding BPD are discussed first, followed by the nursing treatment and implications of caring for people with BPD. Core psychodynamic problem In an attempt to define the nature of borderline personality disorder, two different perspectives are discussed, namely: failure to achieve object constancy; the role of biological factors. Failure to achieve object constancy Refer to the section on object constancy under the antisocial personality disorder. This section outlines the three prerequisites of object constancy, namely evocative memory, the capacity consistently to distinguish self from others, and the ability to integrate good and bad representations of the same person. By the age of three most children will have object constancy reinforced to such a degree that they can embrace a whole object view of the mother and self. This is not true of borderline-prone individuals. Instead of internalizing a whole, soothing internal image of their mother that comforts them in times of her physical absence, people suffering from borderline personality disorder have a predominance of negative introjects which contribute to their intolerance for separation and aloneness. They are convinced that the overwhelming 'badness' will destroy any 'goodness' in themselves or in others; they thus unconsciously keep themselves separate via the defence of splitting. Some therapists relate this failure to achieve object constancy to a constitutional excess of aggression in the child, or to maternal problems with parenting, or even to a combination of both.
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Current research findings have shown that many people diagnosed with BPD were abused either physically or sexually in early childhood (Paris, in Greene & Ugarriza 1995). The role of biological factors One biological theory postulates that BPD is the result of either acquired or developmental organic brain dysfunction. Causes of the organic brain dysfunction include trauma, epilepsy and attention-deficit hyperactivity disorder. Dysfunctions may occur in the limbic system or frontal lobe, resulting in self-mutilation, impulsiveness and affective disinhibition. Transient psychotic symptoms may be the result of increased dopamine action. Irritability and impulsiveness may be related to a decrease in serotonin activity. Defences used: Splitting Projective identification Idealization and devaluing Denial Working with the person with borderline personality disorder in a hospital setting Major goals - Increase the patient's tolerance of his/her anxiety and anger without impulsively acting it out. - Help the patient (long term) to integrate good and bad aspects in him/herself and others. - Establish a soothing-holding introject within the patient so that he/she can tolerate separations from significant others. Identified problems — Intense anger evidenced by extreme mood swings, self-damaging acts, acting out, argumentativeness and overreaction; this is related to the patient's intolerably bad self-image which is projected intensely onto others who remind him/her of parental figures (transference). - Intense anxiety evidenced by clingy controlling and manipulative behaviour and splitting related to separation, individuation conflict faced earlier in life, and fear that the badness within will destroy goodness. Therapeutic principles 1. Establishing a holding, stable treatment environment. Because of the chaotic nature of the borderline patient's life, stability must be imposed from external sources/settings.
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2.
3.
4.
5.
Rogers (as cited in Greene & Ugarriza 1995) has advocated the use of motion, therapeutic touch, meditation, music and humour to pattern the environment and create symphonic interaction. Here the nurse sends back soothing wave patterns and does not react to the countertransference that the client has evoked. Contract to see the patient daily for a specified time. Often, however, short frequent contacts help the patient to internalize a holding, soothing introject more effectively. Steadiness, persistence, firmness and a capacity for flexibility are important in tuning in to the patient's internal state. The principle healing factors are non-interpretative; being a stable repository for the projected aspects of the patient's psyche is more therapeutic and helps to integrate the good and bad aspects within the patient's self and others. Containment of the patient's anger. Action is the language of the BPD - the person might feel that action is the only option to achieve relief from the intensity of his/her feeling states. Establish a connection between feelings and actions by helping the patient to identify feeling states when confronted with acting-out behaviour. Limit-setting of those behaviours that threaten the safety of the clinical staff or the patient (aggressive outbursts, suicidal gestures). The consequences of acting out need to be clearly spelt out to the patient in a nonpunitive manner. The team must decide on consequences and limits for acting-out behaviour, and ensure that these consequences are implemented if the patient acts out; for example, if the patient is a threat to his/her own or others' safety, he/she might need containment in another hospital which is more secure (certification). Maintaining a here-and-now focus. Focus on the spaces in which the patient finds him/herself now and how these spaces change. Empower the patient by getting him/her to take responsibility for asking for individual time outside contracted time. Monitoring of negative staff feelings. Containing the projected parts of the patient and reflecting on the nature of these projections will help the nurse to diagnose the internal world of the patient. If splitting between staff has occurred and different staff members hold fixed, polarized views of the patient, this must be discussed in team discussion and ward handovers. Neither staff member is right or wrong; rather, each of them is identifying legitimate aspects of the patient's world. Ongoing attention to one's own feelings prevents countertransference acting out. Being able to share with the team the strong feelings evoked by the patient provides essential data about the patient's internal world and prevents acting out by staff.
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It is important to adopt a mental attitude of free-floating responsiveness that allows for spontaneous (although attenuated) reactions to the provocations of the patient. The therapist needs to be sincere and genuine in dealings with borderline patients. For example, 'I really don't feel I can work with you effectively if you continue to shout at me. I think that it's important for you to work on controlling your anger so that you can express it to me without screaming', expresses the therapist's own humanness. Each staff member must project a well-defined self in order to work therapeutically with patients suffering from borderline personality disorders; this is because of the defences used by such patients as well as their need to fuse with others. Progress with patients suffering from borderline disorders is often slow, intense and difficult to measure, and repeated admissions might be required during periods of crisis. Long-term studies have shown that by middle age most persons with BPD have recovered from acute symptoms and no longer meet the diagnostic criteria for this disorder. 6. Medication Lithium can be used to decrease instability and impulsive behaviour. Carbamazepine can also stabilize the patient's mood. Fluanxol is often used to stabilize the mood and to reduce impulsivity; it is antipsychotic. 7. With regard to the risk of suicide in patients suffering from this disorder, refer to the article by M H Stone entitled 'Paradoxes in the management of suicidality of BPD' (Stone 1993:255-272). 8. For management of self-destructive behaviour in an open, inpatient setting, see Psychosocial Nursing, February 1996, 34 (2), 38-42. CLUSTER C PERSONALITY DISORDERS
Patients suffering from these disorders often appear anxious and fearful. Avoidant personality disorder DSM-IV-TR diagnostic criteria: Avoidant personality disorder A pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following: 1. Avoids occupational activities that involve significant interpersonal contact, because of fears of criticism, disapproval, or rejection. 2. Is unwilling to get involved with people unless certain of being liked.
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3. 4. 5. 6. 7.
Shows restraint within intimate relationships because of the fear of being shamed or ridiculed. Is preoccupied with being criticized or rejected in social situations. Is inhibited in new interpersonal situations because of feelings of inadequacy. Views self as socially inept, personally unappealing, or inferior to others. Is unusually reluctant to take personal risks or to engage in any new activities because they may prove embarrassing.
Table 20.12 Understanding the person with an avoidant personality disorder in terms of a transactional analysis model Injunctions
Don't need
Driver
Be perfect
Life position
I'm not okay, you're not okay
Beliefs
Self: I'm nothing Others: Others see through and reject me Life: Life is a risk, so run away
Behaviour
Withdraws, belittles self
Reinforcing memory
People ignore or reject
Stroking
Hankers after strokes but cannot ask for them
CP
NP
A
FC
AC
Figure 20,15 Egogram: avoidant personality Avoidant persons have an active, detached style of relating in terms of which they dare not allow themselves to need others for fear of humiliation or rejection; however, unlike schizoid people, they long for close interpersonal relationships. Core psychodynamic problem People can be avoidant for a number of reasons; however, the main reason is to defend against feelings of embarrassment, humiliation, rejection and failure (= shame related to early developmental experiences).
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Person
avoid social situations
to prevent vulnerable or inadequate aspects of self from being exposed
which cause shame
ashamed of various aspects of self
sees self as weak unable to compete physically or mentally defective messy/disgusting exhibitionistic
Working with the person with avoidant personality disorder Main goal. Help the person to develop a greater trust in self and others and to move into a life position of Tm okay, You're okay', in order to take more of the risks associated with day-to-day living. Identified problems. Active detachment and avoidant behaviour related to fear of shame and humiliation, evidenced by avoidance of specific social situations, symptoms of anxiety, low self-worth, depression, suppressed anger. Therapeutic principles These include both supportive and expressive elements used by the mental health nurse. 1. The use of empathic appreciation of the embarrassment and humiliation associated with the feared social situation will increase the patient's trust in the therapist and engender a sense of feeling soothed and comforted (nurturing parent of therapist). 2. Exploring the underlying causes of shame related to early decisions made about the self, and to early developmental experiences will enable the patient to redecide now as an adult. 3. Helping the person to see the value of actively seeking out the feared situation will enable him/her to: desensitize self; and increase self-worth, trust in self and in others. 4. Encourage the person to take risks in confronting and seeking out the feared situation, instead of a defensive posture of withdrawal.
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5. Help the patient to express feelings of anger which are often suppressed and connected to the shame experience. 6. Group therapy is of great value to avoidant persons as it provides them with: an opportunity to expose themselves to the potentially feared social situations; an opportunity to receive feedback from others regarding other people's perception of them; exposure to others' fears and inadequacies, thus allowing them to be human and not perfect; an opportunity to be nurtured. Dependent personality disorder DSM-IV-TR diagnostic criteria: Dependent personality disorder A pervasive and excessive need to be taken care of that leads to submissive and clinging behaviour and fears of separation, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following: 1. Has difficulty making everyday decisions without an excessive amount of advice and reassurance from others. 2. Needs others to assume responsibility for most major areas of his or her life. 3. Has difficulty expressing disagreement with others because of fear of loss of support or approval. Note: Do not include realistic fears of retribution. 4. Has difficulty initiating projects or doing things on his or her own (because of a lack of selfconfidence in judgement or abilities rather than a lack of motivation or energy). 5. Goes to excessive lengths to obtain nurturance and support from others, to the point of volunteering to do things that are unpleasant. 6. Feels uncomfortable or helpless when alone because of exaggerated fears of being unable to care for himself or herself. 7. Urgently seeks another relationship as a source of care and support when a close relationship ends. 8. Is unrealistically preoccupied with fears of being left to take care of himself or herself.
Table 20,13 Understanding the person with a dependent personality disorder in terms of a transactional analysis model Injunctions
Don't grow up Don't think Don't be important
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Drivers
Please me/others
Life position
I'm not okay, you're okay
Beliefs
Self: I'm unimportant and incompetent Others: Others are important and competent
Behaviour
Maximizes failures, minimizes successes
Reinforcing memory
People help out
Figure 20,18 Egogram: dependent personality
People with dependent personality styles include both the histrionic and dependent personality disorders. Both assume an 'I'm not okay, you're okay' position which accounts for their reliance on others for satisfaction of their needs. However, the dependent is more passive and the histrionic more active in the search for need satisfaction. Both have similar drivers and injunctions. Core psychodynamic problem A pervasive pattern of parental reinforcement for dependency throughout all phases of development is common amongst dependent people. Dependent clinging may also mask aggression. Past traumatic separations from significant others can also result in dependent behaviour. Working with the person with dependent personality disorder Main goal. Promote independent thinking and caring for self and independent action in the person; that is, develop the patient's individual adult and nurturing parent. Identified problems. Reliance on others in major areas of their life related to past reinforcement of dependent behaviour, previous traumatic separations; evidenced by helplessness, getting others to tell them what to do.
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Therapeutic principles 1. Help the patient to take responsibility for his/her own decisions/thoughts/actions. This is difficult as the patient often presents with feelings of helplessness and pressures the therapist to fix these feelings. The patient does this by getting the therapist to tell him/her what to do and by making the therapist collude in his/her avoidance of decision-making and assertive behaviour. Discuss the above with the patient and emphasize what the patient stands to lose by sitting around and waiting for others to solve his/her problems. Show how this type of behaviour impacts on others (draining). Mobilize the patient's adult ego state. 2. Explore anxieties about separation and loss related to past experiences. 3. Positively reinforce the patient's independent thinking and decision-making abilities. 4. Within a group context, encourage feedback from others regarding the effect of this dependency on others. Explain to others, who might attempt to rescue the person, what losses the dependent person could suffer as a result. 5. Adhere strictly to the time limits for each therapy session to remove the fantasy of the never-ending availability of nurturing figures; this may result in frustration in the patient. Passive-aggressive personality disorder DSM-IV-TR diagnostic criteria: Passive-aggressive personality disorder A pervasive pattern of passive resistance to demands for adequate social and occupational performance, beginning by early adulthood and present in a variety of contexts, as indicated by at least five of the following: 1. Procrastinates, that is, puts off things that need to be done so that deadlines are not met. 2. Becomes sulky, irritable, or argumentative when asked to do something he or she does not want to do. 3. Seems to work deliberately slowly or to do a bad job on tasks that he or she really does not want to do. 4. Protests, without justification, that others make unreasonable demands on him or her. 5. Avoids obligations by claiming to have 'forgotten'. 6. Believes that he or she is doing a much better job than others think he or she is doing. 7. Resents useful suggestions from others concerning how he or she could be more productive. 8. Obstructs the efforts of others by failing to do his or her share of the work. 9. Unreasonably criticizes or scorns people in positions of authority.
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Table 20,14 Understanding the person with a passive-aggressive personality disorder in terms of a transactional analysis model Adaptation
Passive-thinking aggression
Characteristics
Aggressive personality Resentment
Description
Obstructive Stubborn
Drivers
Try hard Be strong
Injunctions
Don't feel Don't be dose Don't enjoy Don't make it
Contact door
Behaviour
Target door
Feeling
Trap door
Thinking
People suffering from the passive-aggressive personality disorder are angry and resentful towards the world, obstructive, pouting and stubborn. Others feel resentful, as well as a sense of being 'sucked in'. They are overly dependent in relationships with others, in spite of their fighting and complaining. Their drivers are try hard, struggle, make things difficult. Their injunctions are be tough, dont let anybody know that you are hurting inside. They are often very lonely underneath because of the double messages they give out and their sucking in and pushing out which leaves others angry and confused. One of the secrets of dealing with this kind of personality is to hang in with them and to repeatedly connect gently with them at a feeling level. Core psychodynamic problem Power struggles during the anal phase of development, as well as exaggerated parental authority, may contribute to passive-aggressive behaviour. Defences used: Denial Projective identification (of their anger to others) Working with the person with passive-aggressive behaviour Major goal. Help the patient to own his/her angry feelings.
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Identified problems. Difficulty in getting along with others which relates to their pattern of provoking anger in others; evidenced by power struggles, double messages, denial of anger. Therapeutic principles 1. Help the patient to gain insight into his/her own anger. If the patient provokes anger in you, use these negative feelings constructively. For example: 'I get the feeling that you're trying to make me angry with you. Do you have any thoughts about why you would want to do that?' If the patient denies his/her anger, point out specific aspects of his/her behaviour that evoke anger in others. Apply the above observations to other relationships in the patient's current life. 2. Explore the reasons for the patient's denying all forms of anger: 'What is so scary for you about being angry?' 3. Help the patient to develop assertiveness skills to express his/her anger. 4. Mobilize the patient's anger to help him/her move towards, rather than stay stuck in, his/her passivity and striving to be taken care of and stay little. Obsessive-compulsive personality disorder DSM-IV-TR diagnostic criteria: Obsessive-compulsive personality disorder A pervasive pattern of preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness and efficiency, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following: 1. Is preoccupied with details, rules, lists, order, organization, or schedules to the extent that the major point of the activity is lost. 2. Shows perfectionism that interferes with task completion (for example, is unable to complete a project because his or her own overly strict standards are not met). 3. Is excessively devoted to work and productivity to the exclusion of leisure activities and friendships (not accounted for by obvious economic necessity). 4. Is overconscientious, scrupulous, and inflexible about matters of morality, ethics or values (not accounted for by cultural or religious identification). 5. Is unable to discard worn-out or worthless objects even when they have no sentimental value. 6. Is reluctant to delegate tasks or to work with others unless they submit exactly to his or her way of doing things. 7. Adopts a miserly spending style toward both self and others; money is viewed as something to be hoarded for future catastrophes. 8. Shows rigidity and stubbornness.
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Table 20,15 Understanding the person with an obsessive-compulsive personality disorder in terms of a transactional analysis model Adaptation
:
Obsessive-compulsive
Characteristics
:
Conformity Conscientiousness
Description
Drivers
Tense Perfectionist Overly inhibited \ Overly conscientious Overly dutiful ;
Injunctions i
Be strong Be perfect Don't be a child Don't feel (joy and sex) Don't be close Don't enjoy
Contact door
Thinking
Target door
Feeling
Trap door
:
Behaviour
Perfectionistic, bright and organized, people suffering from obsessive-compulsive disorder devote their energy largely to thinking (their open door). The therapist could first stroke them with something like, 'Gosh, I'm really impressed with the clarity of your thinking. As you were thinking that, what were you feeling?' Moving repeatedly from thinking to feeling and finally to enjoying pleasurable feelings is the main goal of treatment. Core psychodynamic problem These patients often reveal strong unfulfilled dependent yearnings and a reservoir of rage directed at the parents for not being more emotionally available. Freud conceptualized their excessive orderliness as a reaction formation against an underlying wish to engage in anal messiness, related to power struggles with maternal figures around toilet training. Their difficulty in expressing aggression is thus related to the latter. Their quest for perfection, which is driven by a punitive and hypertrophied superego, is related to their belief that, if they can reach a stage of flawlessness, they will receive the parental approval and esteem that they missed as children.
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Defences used: Isolation of affect Intellectualization Reaction formation Undoing Displacement Working with the person with obsessive-compulsive personality disorder Major goal. Modify the patient's superego (critical parent), thus helping the patient to accept his/her humanness. Identified problems. Perfectionistic tendencies and preoccupation with control and order related to early power struggles and lack of emotional availability from parents; evidenced by self-doubt, rigid thinking style, difficulty with dependency and his/her own anger, and a quest for perfection. Therapeutic principles 1. Empathize with the patient's fear of loss of control when seeking help in order to establish trust. Work at a pace which the patient finds comfortable. 2. Cut through the smoke screen of words and focus on the person's feelings. The patient's wish to transcend feelings of anger and dependency is doomed to failure and must be accepted as part of being human. 3. The use of a non-judgemental, stable neutrality over time helps the patient to discover that his/her perception of the therapist as critical is related to past relationships. Help the patient to recognize his/her own critical projections onto others. Periodically confront the unrealistic expectations that the patient has about him/herself. The therapist's acceptance of the patient helps him/her to gain increasing selfacceptance. 4. Help the patient to identify his/her anger and encourage its expression in order to remove fantasies of its destructiveness. Look out for expressions of disguised anger in the relationship using your own countertransference, and reflect on this. 5. Group therapy is useful in that the patient gets the opportunity to: experience others' vulnerabilities; get feedback from others regarding his/her rigidity, preoccupation with detail (might accept this feedback without the same power struggle that accompanies feedback from the therapist); see that others are not nearly as critical as he/she is him/herself.
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6. Monitor negative staff feelings, and use this information to give feedback to the patient on the impact of his/her behaviour on others. Staff members may feel bored as the patient rambles on about seemingly irrelevant minute details. (What feelings is patient defending against?) The patient may attempt to recreate a power struggle, for example, as experienced with mother; avoid engaging in power struggles and rather use an approach which empowers the patient and recognizes his/her own capacity to decide for him/herself. CONCLUSION This chapter emphasizes two important principles to be taken into account when working with and trying to understand people with personality disorders. In the first place, the mental health nurse must recognize that behind the specific Axis II DSM-IV-TR diagnosis there is a person struggling to adapt (albeit unsuccessfully). Secondly, the two approaches used, namely the transactional analysis model and the object relations theory, both recognize the power within each person to heal him/herself. The mental health nurse thus empowers the patient by being constant and sincere and by using his/her valuable intuitive 'gut feel' to help the patient to take responsibility for making healthier decisions about him/herself, others and the world. In conclusion, we highlight two critical areas which must not be neglected when working with people with personality disorders. The first of these is the need to support and educate the patient's family, which arises from the fact that the family may experience considerable distress in their day-to-day dealings with a person suffering from such a disorder. Secondly, there is the need to make greater use of group therapy in the management of such patients. The author works in a clinic which runs three group sessions daily, using a transactional analysis/object relations approach, for patients in crisis; these sessions often include people with personality disorders. Although responsibility for change rests ultimately with the patient, two therapists are present to provide the necessary support and, in addition, the other patients provide the patient with valuable feedback regarding aspects of his/her behaviour, which could facilitate insight and change. WEB RESOURCES
www.mhsanctuary.com/borderline/ This is the Sanctuary site for Borderline Personality Disorder. It has many resources, but most impressive is the specialist chat-rooms, such as one for teens and another for Christians. www.itsa-net.org This is the site of the International Transactional Analysis Association. Those interested in getting a better understanding of this therapy approach can access articles, research and training opportunities on this site.
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REFERENCES Carson, R C & Butcher, J N. 1992. Abnormal Psychology and Modern Life (9 ed.) New York: Harper Collins Publishers Gabbard, G O. 1990. Psychodynamic Psychiatry in Clinical Practice. Washington: American Psychiatric Press Gabbard, G O. 1991. The therapeutic relationship in psychiatric hospital treatment. Bulletin of the Menninger Clinic, 56, 4-19 Greene, H & Ugarriza, D N. 1995. Borderline personality disorder: History, theory, and nursing intervention. Journal of Psychosocial Nursing, 33, 26-30 Stone, M H. 1993. Paradoxes in the management of suicidality of BPD. American Journal of Psychotherapy, 47 (2), 255-272 Ware, P. 1983. Personality adaptations (doors to therapy). Transactional Analysis Journal, 13 (1), January, 11-19
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CHAPTER TWENTY-ONE
People who have experienced trauma B MEINTJES
Contributing Editor: B J KILLIAN
O hipftiiipc £vs'|\*vs.a¥'w*> After studying this chapter the learner should be able to: Understand the use of the term 'trauma'. Understand a normal post-traumatic stress response. Develop skills to assist people and families affected by trauma. Develop skills to assist people with other trauma-related responses, such as anger, guilt and loss. Develop specialized skills for assisting survivors of particular traumatic experiences such as domestic violence and rape. Develop skills for working with children, families and communities affected by trauma.
INTRODUCTION These experiences were not meant to break us. They were given to us in order that we might be strengthened. It is the same boiling water that hardens an egg and softens a carrot. (Mrs Mthembu, Bhambayi)
These words were spoken by a woman, from the informal settlement of Bhambayi, who survived many traumatic experiences. She died recently, but we still have her powerful words of hope. Hamber (2000) describes the 'culture of violence' in South Africa, meaning that as a society we accept and even endorse violence as an acceptable and legitimate means of resolving problems and achieving goals. This culture of violence is a problem for all people living in the country. Van der Merwe and Dawes (2000) showed that young people who were exposed to violence displayed more aggression and lacked self-
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regulation. Another study of Grade 10 learners from a community with high rates of violence indicated that on average each adolescent had experienced 3,5 traumatic incidents, ranging from witnessing violence on the street, being robbed or mugged, to seeing family members injured, beaten, or killed (Seedat et al. 2000). These investigators found that many of the learners displayed symptoms of post-traumatic stress disorder (PTSD). In the course of its work with survivors of different kinds of violence, the Sinani/KwaZulu-Natal Programme for Survivors of Violence has made the journey towards healing with many survivors of trauma. Many people, even nurses, ask whether this is not a depressing world to move in, but the stories heard at centres such as Sinani are deeply touching and inspiring. Trying to assist a person whose life has been shattered by a traumatic event can be painful and difficult, but to see the same person emerging on the other side is a remarkable process and, as attested to by the staff at these centres, very rewarding. This chapter deviates slightly from others in the book, since it leans on the actual words spoken by trauma survivors, fitting in with the overall aim of trauma intervention, which can be described as allowing for, and indeed encouraging, the expression of feelings about a traumatic experience. 21.1 UNDERSTANDING TRAUMA After this happened to me I felt like I was carrying a heavy water container on my head all the time. (Trauma survivor)
Defining traumatic experiences There are many experiences that are negative and painful to go through. Some painful experiences that people survive include: Poverty Unemployment Divorce Loss of loved ones Illness
Disability
Being neglected by one's parents
Physical abuse*
Domestic violence*
Verbal abuse
Neglect
Being humiliated
Rape*
Attack*
Armed robbery*
Motor vehicle accidents* Loss of one's home
Loss of possessions Floods* (^Traumatic events)
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While all of these experiences are painful, not all of them may be called traumatic. Traumatic experiences are sudden and shocking, they involve danger and intense feelings of fear, helplessness or horror. I thought this is the end of me - I will never see my children again. (Trauma survivor)
Traumatic experiences involve: a sense of danger and a threat to one's life; intense feelings of fear, helplessness and/or horror. While all the experiences listed above would be stressful, the ones marked with an asterisk would be considered traumatic experiences by most people. It is the person's experience of the event that leads us to call some events traumatic. If the person believed that he or she was in extreme danger, and if the person felt intense fear, helplessness or horror, then the event would be called traumatic. For example, it would be traumatic if a person's home was burnt down during violence and he or she had to flee the situation. The distinction between traumatic and painful events is made in reference to the specialized ways of assisting the person's recovery, not to undermine the pain experienced by people who have gone through these events. Types of traumatic experiences It is sometimes useful to classify the trauma a person has experienced in order to facilitate decisions about how best to help the trauma survivor. Single traumatic experience. This is usually a once-off trauma, involving someone unknown to the person. For example, someone who has led a relatively peaceful life and then has to be rescued from a very serious car accident. Multiple trauma. We use this term when the same person has been exposed to several traumatic experiences. For example, someone may have survived several car accidents, or a car accident and an armed robbery. Continuous trauma. This term is used when the person is still living in a situation of ongoing danger. For example, during the political violence of the liberation struggle many South Africans lived in continuing danger for several years. Police who work in dangerous situations every day is another example. Complex trauma. Complex trauma is when the traumatic experiences happen within a particular relationship, for example, domestic violence, where one partner physically abuses the other. A hostage situation may also be called complex trauma, because a relationship usually develops between hostages and perpetrators over time, leading to people adapting their behaviour according to the requirements of the perpetrators. This leads to a situation in which people betray themselves in their efforts to comply with the demands of the perpetrators in order to avoid further problems.
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Impact of trauma on the individual Violence leaves you broken on the inside - like a cloth torn in shreds. (Trauma survivor) Because traumatic experiences are frightening and shocking, almost all people are affected for some time afterwards. Figure 21.1 shows how most people are affected after a traumatic event.
Having strong memories of the event Seeing, hearing or smelling things linked to the trauma Nightmares Sleeping problems Alertness, being 'jumpy' Substance abuse Talking about the event
a lot Sexual problems Body pains, headaches Concentration problems
Sadness, crying Anger and depression Wanting to take revenge Eating problems Avoiding things associated with the trauma Feeling hopeless Refusing to talk about the trauma Feeling guilty Not trusting others Isolating oneself
Figure 21.1 Normal post-traumatic response Normal post-traumatic stress response Figure 21.1 shows the normal reactions of a person to trauma. It is important to understand that these responses are completely normal following a traumatic event; almost all survivors of trauma have these reactions. This is called normal post-traumatic stress response, which can be described as a normal response to an abnormal event. In fact, it is even more worrying if a person does not show any of these normal reactions. Trauma survivors have these responses because intense trauma becomes 'stuck' in our bodies and minds. It is as if the trauma has become indelibly imprinted on the person. As one trauma survivor expressed it: 'Every day, all day long, I just keep seeing what happened.' When trauma is intensely frightening and painful, the person tends to respond in two ways: avoidance; and re-experiencing.
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Avoidance One response is to try to avoid what happened. The person tries not to think about the experience and avoids places and things associated with the event; the person refuses to talk about aspects that were particularly awful, and may use substances such as alcohol or medicines to block out feelings and memories. Some people even develop loss of some of the senses, such as loss of hearing, or the inability to talk. They avoid the trauma because to think about the event is like 'going back and experiencing it again', which is frightening and painful. Re-experiencing At the same time, because the event did happen, it is part of the memory and tends to keep coming back into the person's mind. This is when the person experiences nightmares and/or flashbacks, or thinks about the event even when he or she is trying not to. It is as if the memory keeps resurfacing to haunt the person. The tendency to both avoid the trauma and, at other times, to re-experience it is normal. It is called the approach-avoidance conflict. Most trauma survivors swing between these two responses for some time after the traumatic event. Post-traumatic Stress Disorder (PTSD) Post-traumatic Stress Disorder (PTSD) is a term developed by psychologists for a severe trauma reaction. However, it should only be used if it is necessary for professional purposes, because the term 'disorder' implies some type of illness. We know that almost all people respond to trauma with the reactions discussed on page 662; if someone responds in any of these ways, he or she certainly does not have a disorder. The term PTSD should only be used if the symptoms (as described) are: many, including avoidance, re-experiencing and increased arousal (anxiety); severe enough to interfere with the person's normal living; present for a long time after the trauma (at least one month, if not longer). Unless a mental health nurse needs the term PTSD for specific reasons (that is, to signify a disorder or illness), generally he or she should avoid it and rather speak of a normal posttraumatic stress response. An ex-combatant expresses the importance of normalizing these reactions as follows: 'This is not madness - some people may confuse it with madness, but we are still able to think rationally, and have strong feelings.' A member of the South African Police Services said, T think we forget how much the exposure to continuous danger affects us. We feel isolated and cut off from society. It is nice to be reminded that our reactions are normal. 1
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Evidence-based Practice Psychological debriefing for preventing post-traumatic stress disorder Single session individual debriefing did not reduce psychological distress nor prevent the onset of post-traumatic stress disorder (PTSD). Those who received the intervention showed no significant short-term (3-5 months) decrease in the risk of PTSD (odds ratio 1,22 [95 % Cl 0,60 to 2,46]). At one year one trial reported that there was a significantly increased risk of PTSD in those receiving debriefing (odds ratio 2,88 [1,11 to 7,53]) odds ratio 95 %). There was also no evidence that debriefing reduced general psychological morbidity, depression or anxiety. Reviewers' conclusions: :
There is no current evidence that psychological debriefing is a useful treatment for the prevention of post-traumatic stress disorder after traumatic incidents. Compulsory debriefing of victims of trauma should cease. Rose, S, Bisson, J & Wessely, S. Psychological debriefing for preventing post-traumatic stress disorder (PTSD) (Cochrane Review). In: The Cochrane Library, Issue 2, 2003. Oxford: Update Software.
Unusual trauma responses Sometimes the traumatic experience can worsen another type of underlying problem. For example, the person may have an underlying psychotic process, which is made worse by the trauma. These are not necessarily normal responses to the trauma, but may be underlying problems that would need separate specialized treatment. The following signs may indicate an underlying problem that should be treated professionally: Hallucinations: Hearing, seeing or feeling things that are not really there, but which are not flashbacks; Delusions: False beliefs about oneself or the world; Severe depression; Mania: Periods of hyperactivity, overspending, extreme happiness etc; Suicidal tendencies. Variations in trauma responses A trauma survivor should not compare his or her trauma with someone else's, or say that it was not as bad as that experienced by another person. All traumas are frightening and affect people. However, there are some factors which tend to make the impact of trauma last longer, and which affect the way in which someone may be helped. Factors believed to worsen the impact of trauma are: the length of time the person was exposed to the danger; the number of times the person was exposed to the danger; the age of the person when the event(s) took place (children may be affected more, particularly if they were very young at the time of the traumatic experience);
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whether the person perpetrating the violence was known to the survivor or not. (Betrayal by someone known to the person tends to make the impact worse than if it were done by a stranger.) Impact on family and friends The impact of trauma extends beyond the individual who was directly involved in the event. When something bad happens, our family, friends, neighbourhoods, communities and even society at large may be affected. This is illustrated by the words of the mother of a rape survivor who described the impact of this event on her own thinking: T know I should be more worried about my daughter, but it feels like her being raped has affected me even more than her. All my dreams for her are shattered.' The wife of a trauma survivor described the impact on the family as follows: 'Since the armed robbery, he has changed. He just sits and does not want to talk. He shouts at us for nothing. The children are learning to stay out of his way.'
figure 21,2 The impact of trauma (Adapted from Bronfenbrenner)
Many survivors of trauma report difficulties with their close relationships following the trauma. Naturally, the person's response to trauma, including fear, mistrust, irritability, withdrawal or dependence will have an impact on family and friends. The survivor of the trauma may feel let down or betrayed by the family, or may feel hurt by the way in which the family responded to the trauma. The survivor tends to become very sensitive towards other people. Some prefer not to tell their loved ones what has happened to them, for fear of upsetting the family unnecessarily.
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The family and friends of a trauma survivor are also likely to go through some type of traumatic stress response, including feelings of horror and fear. They may also feel helpless to assist the person who was involved in the trauma. Family and friends may feel guilty about what happened, or angry and blaming towards the survivor. Ways to assist families to be helpful towards survivors of trauma is discussed later in the chapter. When a family has been involved in a trauma together, this may complicate their feelings towards one another. For example, they may blame one another for what happened. Children may feel devastated at seeing their parents helpless and unable to protect them from the event. All of those involved are likely to experience intense guilt that they did not manage to save or help their family members. Impact on the community When an individual is involved in a traumatic experience, it is likely to affect his or her immediate community. People in the community may themselves experience a posttraumatic stress response, especially if the event happened in their area or in a place often visited by community members. Often members of the community don't know how to express feelings such as sympathy or empathy and become awkward towards the survivor. One rape survivor said: 'What made me most upset was the way my neighbours stared at me. I could see them talking about me, and they avoided me afterwards.' Trauma survivors are often very sensitive to changes in behaviour from community members. They usually prefer people to acknowledge what has happened to them, and then to be treated as normally as possible. One young girl said: 'I did a talk in class about what happened, and this helped me to get it out. Then I asked if everyone could treat me normally, and not treat me as special or different. This made me feel better.' The impact of trauma on a close community, such as a school community, should not be underestimated; children, educators and parents should be given a chance to express their concerns about the event. In a situation where a whole community has been affected by trauma - for example, by political violence or a natural disaster such as a flood - there are likely to be long-term effects on relationships within the community. This is particularly true when there was no clear enemy and people in the community ended up 'betraying one another'. For example, the high crime rate may make people suspicious and mistrusting of everyone they encounter. Mistrust can be a major issue that becomes an underlying problem in many relationships. Community members may also tend to group and label one another, further dividing the community. They may have difficulties in resolving small conflicts, which then grow into bigger conflicts. People may have little tolerance of one another and quickly jump to conclusions. If there is a sense of betrayal, it creates enormous anger in people towards one another. One young woman who survived political violence, said: T know my neighbours could hear me screaming, but no-one did anything to help.' Most communities affected by violence develop secondary problems, such as increased crime, domestic violence, sexual abuse and sexually transmitted diseases. Left untended, this often becomes a cycle of violence, illustrated in Figure 21.3
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Figure 21,3 The cycle of violence Shaik describes the cycle of violence, emphasizing that exposure to violence leads to extreme helplessness, fear and anger. If these feelings, in particular anger, are repressed, one of three things may happen: Firstly, the anger may grow inside the person and turn into hatred and a desire for revenge. This is common where a person's dignity has been damaged, and in cases where close family members have been attacked or killed. This reaction continues the cycle of violence. Secondly, the anger may be taken out (displaced) onto others, for example, in the form of domestic violence or sexual violence. Thirdly, we know that repressed anger may cause depression. And so the person may become depressed, more withdrawn and even self-blaming. There are theories that go on to say that this person may then become a further target of violence and be repeatedly revictimized. A journey to peace is possible, however. If a person's fear, helplessness and anger are expressed and contained in a safe relationship, then peace is more likely. Through a process of a detailed unpacking of the trauma, and also of the feelings around the incident, the person is able to heal and, eventually, to reconcile. The process is discussed in more detail in section 21.7 of this chapter. One Sinani youth group member said, 'We are carrying out the revenge for our parents. It is time for us to work out how to stop this cycle, because it is ruining our lives.' Another workshop participant said 'I was very aggressive with people. I never had any relationships with anyone. I was bitter and angry. Now I understand where this was coming from. I feel like I can go and make peace with all those that I hurt. This cycle of violence is a replica of me.'
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Figure 21.4 The cycle of peace 21.2 TRAUMA INTERVENTION AND COUNSELLING I feel like a breath of fresh air has blown through my heart. (Sinani trauma workshop participant)
Trauma intervention can never take away the memory of what happened to the survivor. However, it can help the person to find ways of coping with the event and to feel less lonely and isolated afterwards. The idea is to take a very frightening memory that is 'stuck' inside one, release it, and then integrate it, so that it becomes a memory that can be thought about without feeling afraid and out of control. The aims of trauma intervention can be summarized as follows: to allow expression of the traumatic experience and feelings around the experience; and to do this within a safe relationship with someone who is in control of the process. If we recall the two tendencies of avoidance and re-experiencing, trauma work attempts to help the person to release the trauma (from being 'stuck inside') by talking about it or expressing in some way what has happened. Trauma intervention takes care of the need for avoidance. By helping someone to face these bad experiences within a safe setting, and with someone highly trusted, it brings relief and helps the person to feel more in control. Re-experiencing the trauma is extremely frightening and painful for the survivor, since talking about it or even thinking about it is akin to living through it again. The trauma support worker needs to help the person to feel safe and contained while talking about what happened.
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The two main aspects of trauma support work are a combination of containment and re-experiencing. Some of the principles underlying this work are very important, as discussed below: Empowerment principle Most trauma survivors felt very out of control during the traumatic incident. Trauma counselling tries to restore a sense of control. Because of this, it is very important not to trick the person into telling their story, or push them into talking. This needs to be the choice of the survivor, when he or she feels ready to talk. A trauma support worker should help the person to feel more in control by explaining the process and by allowing the person to talk in stages, as and when he or she feels strong enough. Restoration of hope and trust Most trauma survivors attest to feeling very hopeless. Trauma work aims to restore a person's hope in the future and trust in other human beings. Hence it is very important for the trauma support worker to be completely trustworthy and reliable. The aims and principles of trauma intervention apply not only to individual counselling, but also to trauma work with communities affected by violence. The impact of the trauma tends to happen in certain phases, although these may differ for different people. The phase the survivor is in helps the trauma support worker to determine the best ways of helping the person. 21.1
Phases of the trauma experience
Phase
Response
Intervention
1. Impact 0-3 days
Shock, numbing. Nightmares, flashbacks etc.
Containment, practical assistance and care. Helping to feel safer. Helping person to be with family, friends or others who care about them. Some basic normalizing, especially with family.
after
Frightened and jumpy.
May have a 'survival high' on about the 3rd day.
2. Recoil 3 days1 month
Thinking about the event a lot, nightmares etc. Feelings of anger, guilt, sadness, fear. Questions 'why this happened?'
Trauma counselling may assist person to cope. Family support is essential.
3. Re-integration 1 month onwards
Dealing with prejudices. Learning to cope with the symptoms or integrating the trauma as a normal memory.
Trauma counselling and psychotherapy may assist. Dealing with impact of trauma on personal relationships. Dealing with spiritual questions.
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The process of trauma counselling Sometimes it is easier to go to someone from outside your area for counselling, because you know that they will not try to bewitch you or seek revenge for the things that you have done. (Ex-combatant)
Trauma counselling is one of the simplest, most effective forms of counselling. It can have a life-changing impact. Unlike other forms of counselling, trauma counselling tends to be structured and directive. In each trauma counselling session, one follows certain stages, as shown below, although this is not a recipe and not intended to be followed too rigidly: Stage 1 Stage 2 Stage 3 Stage 4 Stage 5 Stage 6
Establishing trust. Normalizing. Telling the story. Dealing with feelings such as anger and guilt. Coping. Follow-up.
During trauma support work, remember that each person is different. For example, if a person immediately starts telling the story of what happened, go along with it; you can return to the normalizing stage later. All of the above stages need to be covered at some point during the session, but the steps need not happen in sequence and they may begin to 'run together' during the actual session. This simply offers a useful structure and a checklist to assist the trauma support worker and make him or her more confident about the counselling. When I went to bed I felt as though I had lost something important. Then I realized it was because I was no longer carrying the burden of my painful story, and for the first time I felt truly free. (Sinani community arts trauma workshop participant)
A discussion of each of the stages of a trauma counselling session follows. 1. Establishing trust This is probably the most important part of any trauma intervention. Without a trusting relationship, the trauma counselling cannot hope to be effective and even the best techniques will not help the trauma survivor. It is essential to build a relationship of trust with the client, which can be achieved in the following ways: Be reliable. Always do what you said you would. Don't be late for appointments. Be consistent. Always try to keep the same time and place. Be the same person. Start an end sessions in the same way, and be predictable in everything you do. If you will be away or unavailable, let the person know well in advance and keep reminding him or her that you will be away. Be organized and confident. Act with confidence; act as though you know what you are doing, even during a moment of uncertainty, so that the trauma survivor may continue to feel safe. Be professional and well organized.
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Be non-judgemental. Do not look shocked or disapproving when a client tells you something. Always maintain a positive, caring attitude, to indicate acceptance of all aspects of the person. Be empathic. Even though trauma counselling differs from other forms of counselling, the basics of empathy should not be forgotten or ignored. Use reflections and encouraging non-verbal signals or body language to show that you care. Be calm. People are more likely to trust someone who is calm, secure and comfortable. Your demeanour should suggest that you have done this many times before. Try not to show your feelings of anxiety or helplessness. (More will be said on containment later.) Being in the group was a big shock for me. For the first time I realized I could talk about myself and I could trust other people. (Translated; a Zulu member of Sinani women's group)
As the counselling starts, it may be useful to spend a little time on introductions. This often gives a person time to settle down, to assess the situation and examine you more closely. Keep the introductions brief but informative. Don't forget to introduce yourself, ask the client's name and how she or he came to be referred to you. It may also be useful to ascertain whether this is the client's first experience of counselling. If so, briefly explain what trauma counselling is and clarify any expectations the client may have about the counselling. You may wish to briefly discuss time frames (how often you will see each other, for how long and until when). Finally, the confidentiality issue has to be addressed. Never promise complete confidentiality, because this may sometimes not be realistic. However, it may be useful to state that as far as possible the sessions will be treated as confidential, and to outline the limits of confidentiality. Always inform the client before you break confidentiality. Confidentiality may have to be breached under the following circumstances: If you fear the client is going to harm him or herself (that is, he or she is suicidal). If you fear the client is going to harm someone else (for example, a revenge attack). If you are asked to provide information to a court of law about what your client has told you. During supervision with another professional (in which there is also a contract of confidentiality). Many people, both clients and support workers, struggle with the opening stages of a trauma support session. It may a good idea to work out, in advance, some wording with which you feel comfortable, although each situation will differ. If a family or group of people come in together, it is helpful to go through the same initial points together. Before I came to this workshop I felt like I had a fire burning inside me, but after talking about my story I feel like the fire has been extinguished. I feel so fresh and new - thank you to Sinani. (Trauma workshop participant)
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2. Normalizing People who have survived a trauma often feel they may be 'going crazy'. This adds to their distress and may affect their recovery. One of the simplest, yet most effective parts of trauma counselling is simply to help the person understand the reaction he or she is experiencing. This offers enormous relief, because it helps the person to feel 'normal'. This is called 'normalizing the client's reaction' or psycho-education. It may be useful to go through some of the common symptoms with the client and to provide a simple explanation of why this is happening to him or her. Try to let the client take the lead in this process, instead of giving a lecture. It is particularly important to explain the client's reactions to family members and friends. We know that people who have survived trauma can be fairly difficult 'to live with' for a while after the event. Family members should be encouraged to be tolerant and to allow for some unusual behaviour. Remember that people with better social support, meaning those with understanding and caring family and friends, recover much better. Tell the family to allow the trauma survivor to talk about what has happened as much as is needed. Encourage them to ask the person how they may help him or her handle the situation. 3. Telling the story Once the process of trauma counselling has been properly explained, the client can be encouraged to talk about the event in as much detail as possible. Don't push or rush the person if he or she is not ready to talk. Gentle encouragement will suffice. When the client decides to tell his or her story, this helps to release the trauma from the body and mind. Start this stage of the trauma counselling session by asking the client to tell you in his or her own way what happened. Let the person tell the story in whatever way he or she chooses, even if parts are omitted or the order of events is mixed up. Do not interrupt or ask questions; simply be attentive and listen with your ears, eyes, head and heart. Once the client has told the story in his or her own way, explain that you would like to go over it again, this time in more detail. Let him or her know that you will be asking questions along the way. It is important to understand that this is not simply an information-gathering exercise, but an important part of the process of releasing the trauma. Also explain to the client that it is useful to take the time to think about what he or she felt during the experience and to try to put these feelings into words. The reason we ask clients to go through this painful process is to help them organize the event in their minds. If their memory of the event is mixed up and confused, it is much harder to integrate as a normal memory. Telling the story systematically and carefully helps the client to organize the memory (who did what when) and makes him or her feel more in control. I can't remember what happened next... I remember smelling something ... I think I know that smell... now it is beginning to make sense. (Trauma survivor)
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Telling the story in detail also helps to release more of the feelings around the event. Often important details, which the person has never told anyone, emerge in the detailed retelling. Speaking about painful details further helps to release feelings that are closely linked to the trauma. The process of telling and retelling is a way of uncovering what happened in order to release it, to allow the person to feel less lonely, and to reduce shame associated with the event. Societies often silence trauma survivors and discourage them to talk about the event, but this is unnatural. Natural healing takes place when we are able to express disturbing events and feelings. Silencing survivors makes them feel lonely, ashamed and cut-off from other human beings. The role of the trauma counsellor is to break the silence and encourage expression in whatever form the survivor finds most helpful. A useful format for retelling the story is to ask questions about separate key areas, in the order given in Table 21.2. Tsbfe 21,2 T&llinci ths story Telling the story Facts
Who did what when
Senses
Sights, sounds, smells, taste and touches that a person remembers strongly.
Thoughts
What the person was thinking at the time.
Feelings
What the person was feeling at the time.
Questions about remembered sounds, sights, smells, taste, and touch related to the traumatic experience may feel intrusive. However, the sensory aspects of the trauma are often what bother the person the most afterwards. Explain this, before asking, gently, about each of the five senses. Often a survivor of trauma keeps remembering one key aspect that he or she has never told anyone, usually because it is something the person feels ashamed or worried about. Explain this and ask whether there is anything he or she needs 'to let out', but feels especially uncomfortable about. A useful starting point is to explain the process, and then to ask a question such as, At what point did you first realize that something was really badly wrong?' One of the most critical aspects of helping the survivor to tell the story of what happened, is containment. This means keeping calm, and helping the survivor feel more in control. Containment is discussed later in the chapter. People who have not been through hard times often don't make it in life. Because we have been through so much we are strong, and when we make it, we will make it big. (Sinani youth group member)
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4. Dealing with anger and guilt Almost all trauma survivors feel extreme anger about what happened, and usually justifiably so, considering the degree of fear and helplessness experienced. During the later stages of the trauma counselling, the survivor should be helped to process the anger he or she feels. Some survivors have a strong desire for revenge and need much support. (See page 679 for more information on anger.) Most trauma survivors feel guilty about what happened. This may happen even if the event was clearly not their fault. Many also feel a strong sense of shame about aspects of the trauma incident. Helping the survivor talk more about his or her guilt facilitates the healing process. Do this by first talking openly about the guilt and then reassuring the person that he/she was in no way at fault. Guilt is a powerful emotion that can haunt a person for many years. It is also a very personal emotion. Many people feel others cannot really understand their guilt. This means guilt is a feeling that must be fought by the person who feels it; you cannot take guilt away from someone, or easily persuade him or her that he or she is not guilty. All a trauma support worker can do is to encourage the client to fully express the guilt. Create a non-judgmental 'space' in which the person talks about the guilt, and hopefully forgives him or herself. Here are some simple guidelines: Make space for the person to fully express his or her guilt. Don't rush into persuading the person that it was not his or her fault. Instead, focus on the guilt and try to get to the bottom of why the client feels guilty. Often this person has never shared these feelings and is greatly relieved to be able to express them now. Once the client is able to access the core of the guilt, it is often released. One needs to tread a fine line between offering space to express guilt and not being seen as agreeing with the person that 'it was his or her fault'. Be careful with your choice of words, so as to uncover feelings of guilt without reinforcing them. For example, you could say 'Help me understand why you feel personally responsible for what happened', or 'It seems you think you were responsible for what happened. What makes you feel this guilt?' If you think the person is feeling guilty (and most survivors do feel a sense of guilt), but he or she does not introduce the idea, simply try to be encouraging and allow the person to talk about the guilt when she or he is ready. If feelings of guilt remain private and unexpressed, and therefore unchallenged, the feelings are likely to grow over time. Be sensitive to the way you bring up the issue, or the client may think you feel that he or she should feel guilty. So you may say something like, 'A lot of people feel guilty after a trauma, even when they know in their heads that it was not their fault. Have you ever felt guilty about what happened?' Sometimes the links to the feelings of guilt may seem a bit magical or symbolic. For example, the person may have had an argument with someone just before going out and thinks that if he or she had not been so mean-spirited earlier on, the trauma would not have happened. Children often personalize traumatic events in a magical way, linking the trauma to 'something bad' they may have done just prior to the incident.
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Allow the person to talk about these links, which she or he might know to be unrealistic, but feels strongly about in his or her heart. After the violence I felt like I wanted to kill everyone and anyone. Now after talking I feel so relieved and I want to go and make peace with all those people who were my enemies. (Sinani youth group member)
5. Exploring coping and social support It is helpful to ask how the person has coped with the traumatic event. This reduces or removes the sense of helplessness and may help her or him to feel more of a survivor and less of a victim. For example, once the person has told the story in detail, you may ask a simple question such as 'How have you managed to cope with what happened?' Ask more specifically about individual coping strategies, for example, 'When you feel scared, what do you find helpful? 1 In examining what coping mechanisms might be available to the client, it is particularly important to explore the social support systems available to him or her, because this helps the person to feel less isolated. It usually involves identifying family, friends, traditional or spiritual leaders, etc. - that is, anyone the client could go to and speak to for different reasons. It is important for trauma survivors to have (and for them to be reminded that there are) people who care about them and whom they can trust and rely on for support. It has been shown that people with good social support (lots of caring people around them) recover from trauma far quicker. For this reason it is important to help the person identify sources of support and to encourage him or her to move beyond fear and begin to talk to other people about what had happened. The client's religious beliefs may also be helpful, so talk about ways of getting spiritual support (without imposing any beliefs of your own!). Explore coping strategies relating to distractors. These are things that help a person to not think about the event all the time and may include, for example, physical exercise, watching television, being with friends, etc. Take care in the case of alcohol, drugs and other substances or behaviours that may be harmful in the long run Certain coping mechanisms focus on the expression of what happened and the feelings involved. This may include writing about the event, or other forms of artistic expression such as drawing, painting, etc. In general, people should be encouraged to structure their life more. For example, it may be a good idea to return to work as soon as possible in order to get back into a regular routine. Discourage the use of alcohol, drugs and medicines, which encourages avoidance and can create other problems and delay the healing process. This is a new beginning for me. (Sinani trauma workshop participant)
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6. Follow-up Always make follow-up arrangements with the client, in order to check how she or he is progressing. Even if the person is not able to attend another session, make the effort to telephone or check how she or he is doing. Often people struggle for about six weeks after the trauma. Anticipate this and warn the client that this may happen to him or her. Also explain that after a difficult session of talking about a traumatic event, the person may initially feel worse. Retelling the story vividly brings back painful memories and, for a while, may reinforce the symptoms of the trauma. Reassure the client that this aspect will begin to improve soon and that it is a normal part of the healing process. Issues in trauma counselling Avoidance vs. talking One of the most difficult decisions in trauma counselling is when to encourage the person to express or uncover the trauma, and when to focus, instead, on coping and sealing over the trauma without going back into it in detail. This is a personal judgement decision, but here are some useful suggestions: Never force or 'push' anyone into talking about the trauma(s) if he or she does not feel ready to do so. The best counselling happens once a client feels safe in the relationship and spontaneously volunteers to talk about the trauma. Only encourage the client to talk about the trauma(s) once you have established a safe relationship and setting. Help the client to become fully informed about the process of trauma counselling, so that she or he can take a personal, informed decision about whether to deal directly with the trauma or to focus on coping instead. Only encourage the client to talk about the trauma(s) if you will have enough time together (that is, if you are able to follow up with other sessions). People living in situations of ongoing danger are often better assisted by practical and personal support. Trauma counselling may be more appropriate once the person is out of immediate danger. If a person has survived multiple traumas, be aware that she or he may need to talk about the traumatic experiences in layers (one by one). Explain this to the client, who may choose to talk about only one trauma at a time. Pace the process, so that the client is not trying to process too many traumatic experiences too quickly. If a person has survived complex trauma, be aware that the relationship between you and the survivor will become increasingly important. Take extra care to be trustworthy and consistent. If you are concerned that the person's core personality or ego may be fragile or unstable, rather focus on coping. For example, if a person seems potentially psychotic, care should be taken not to confront the trauma, as the process may destabilize the person.
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He comes to the office and sits for hours. I think it may be therapeutic so we offer him tea and the newspapers to read. (Sinani staff member)
Avoidance Because going back to a painful experience is painful in itself, most clients (and counsellors) will try to avoid talking about the worst aspects of the trauma. This is particularly common with rape survivors, who will often tell the details of what happened before and after the rape, but who avoid talking about the actual rape itself. Some common avoidance strategies are: Leaving gaps in the story. Changing the subject or diverting the conversation. Saying that there is nothing more to tell and/or nothing else worrying the person. Substituting words, for example, 'He shouted at me' rather than 'He was swearing at me', or calling it 'the thing that happened ...' instead of 'the rape'. As a counsellor it is important to respect a person's avoidance or defence mechanisms. At the same time, however, do not collude (go along) with the client. If a trauma counsellor colludes with such attempts at avoidance, it reinforces the client's ideas that 'this is too awful to talk about', or it may create the impression that the counsellor is afraid, feels out of control or does not want to hear the details of the experience. This would leave a client feeling alone and overwhelmed. One needs to strike a balance between giving a person space and helping him or her to deal with what happened. In listening to a client telling his or her story, keep the following important aspects in mind to help you not to collude with the client in his/her attempts at avoidance: Use the proper words for things. For example, say 'the attack' and not 'the incident'. Do not use 'easier' words, which may encourage the person to minimize his or her expression of what happened. Listen carefully for gaps in the story. This is often the point at which the worst things happened. Ask specifically about what happened during these times. Listen carefully to the person's voice and watch their behaviour and mannerisms. Usually a person will become anxious or unsettled when talking about the worst parts. Gently go back to these parts until the full horror is released. Remember that you are not asking questions for interest's sake or to be cruel; they are necessary in order to release the worst parts of the trauma. If the worst aspects remain unexpressed, the person will take longer to recover. These awful parts may continue to haunt the person long afterwards, and often these are the memories that come back to bother people when they are much older. Also bear in mind that talking is not the only form of release. Other means of expression, such as through drama or song, can often be just as valuable.
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Containment One of the most crucial aspects involved in balancing avoidance and expression is the skill of containment. Just as a container holds water, the counsellor tries, metaphorically, to hold the person who has been through a traumatic experience. This does not refer to holding the person physically, but the effect is similar. By creating a safe space, using listening skills, and hearing the story in a calm manner you help to contain the person's feelings. This approach focuses on the client and how he or she was affected by the traumatic event - it does not dwell on insignificant details and other matters. Containing means offering the person the support of another adult who is in control and cares about them, at a time when they feel out of control and alone. The counsellor thus encourages expression (the person tells the story of what happened several times), the counsellor listens calmly and carefully to all that is being said and asks gentle, probing questions. At all times the counsellor demonstrates that he/she is not 'freaked out' by the client's story, but can accept all the details in a caring, calm manner. Simple aspects of containment would include: Be calm and in control. Show no fear, and even when you do feel shaky, act calmly and confidently. Show that you are an experienced counsellor and that the particular client's story is not new to you. Bring this home by saying, for example, 'A lot of people say there are particular sounds that bother them afterwards.' Some phrases may be useful when a person is crying and you feel somewhat helpless. For example, 'Take your time', or 'It's okay, let it out', or 'It helps to have a good cry.' If a client seems very anxious and out of control, it may help if you do the talking for a while. Speak in a calm, steady voice about less emotional aspects. For example, if someone is experiencing a flashback, you could talk to him or her. In this case you could explain that what he or she is experiencing is a flashback, which is an intense memory of the event, and that flashbacks are a normal reaction to an abnormal event. Offer reassurance. Normalize what the client has experienced and give the reassurance that things will improve, or that he or she is doing well. Bringing a person back into the present time can also be a way of calming them. For example, if the client is experiencing a flashback, you remind the person where he or she is and who you are. If a person becomes very stressed, you can also focus on how they are feeling now, focusing particularly on the body. For example, 'How are you feeling now? Where can you feel this physically?' It is important to keep yourself in check and make sure you are not using too many containment strategies, for example, to avoid hearing more painful details. Note: It is not wise to attempt trauma counselling with your own family members and friends. By its very intrusive nature, this form of counselling should only take place within a formal counselling relationship. It is not something to attempt casually or with people with whom you interact in other settings. Instead, refer them to a colleague for counselling.
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A large part of containing involves monitoring one's own feelings as a counsellor. If particular feelings become apparent to you, take note of them, reflect on why this is happening, and remember that what you are feeling is probably a transfer of feelings from the client. Common feelings experienced by counsellors during trauma counselling are helplessness, hopelessness, feeling overwhelmed and incompetent, angry, guilty or sad. Do some 'self talk', such as, 'Gee, I am feeling so helpless here, probably because the client is feeling very helpless about the situation. But I am not actually helpless; I'm just feeling what she's feeling.' Then try to put these feelings aside for the time being. You can return to your own feelings at a later stage and examine them more carefully. Usually one is very focused on the client telling his/her story, and this process of 'setting aside personal feelings for now' tends to happen naturally anyway. An important part of containing ties in with the counsellor's firm belief that the client will recover. This optimistic attitude is felt by the trauma survivor and helps to reduce his/her panic. Gaining more experience as a trauma counsellor usually helps one to believe that these simple interventions do help people to recover from the most terrible experiences. People breaking down Most people become tearful, anxious and even angry when they start talking about the trauma. This is normal and healthy. It may be a sign that the person is processing and releasing the more difficult aspects of the trauma. Stay calm and offer reassurances that these reactions are normal and healthy. Allow the client time to cry without giving messages that 'he should pull himself together now'. Don't become active, for example, moving around offering tissues or a glass of water, as this may send the message that you are panicky and want the person to stop crying. (It is useful to have a box of tissues and water next to the person in case they are needed.) Make sure your focus stays on the person in distress while helping him or her to feel comfortable. If the client becomes angry with you, as counsellor, for encouraging him or her to talk, simply apologize. For example, say that you are sorry this is so difficult for the person, that you understand how hard it can be. Don't become defensive. Dealing with anger and revenge There are no men left in the family to revenge the deaths. This is a disgrace, and it is up to me and my sister to carry this out. We have bought guns and are training to use them. Now it is just a matter of time. (Young woman)
Counselling a person who is planning a revenge attack can be very stressful. Trauma support workers tend to feel afraid that others may get hurt, and that the client may end up being hurt or arrested. The counsellor's immediate approach upon hearing about a client's plans to take vengeance will have to be adapted to suit the circumstances and the client, but the following is useful to remember when dealing with thoughts of or plans for revenge: A person who has survived a trauma has a right to be extremely angry, and wanting to see justice done is justifiable. Most people have a strong desire to kill the perpetrators
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and to 'make them suffer'. This is normal, to be expected and justified under the circumstances. It is very important to acknowledge this within yourself and to the client. While a person's anger and need for revenge are justified, taking the law into one's own hands is not acceptable. We still have to abide by the law. The most important thing a counsellor can do when dealing with revenge is to stay calm. If, as the counsellor, you get stressed or uptight about the situation, it may increase the person's distress. You need to be calm, talk slowly and softly, and try to be as containing as possible. Identify your own panic and hold onto it - your own feelings will have to be dealt with later. Focus on the client. Take your time. Do not rush headlong into attempts to dissuade a person from carrying out his or her revenge. It is not your role to argue with the client or to supply reasons why revenge is a bad idea. These responses from a counsellor may make a person even more determined to follow through, or it may make the person feel even more alone in the aftermath of a traumatic experience. In fact, in many instances it would be advisable to encourage the client to talk more about his or her plans for revenge. Ask whether concrete plans have been made, what these plans are, what the client would do if the perpetrator was standing in front of them now, etc. This may increase the anger initially. A person may become so angry that he or she begins pacing the floor. This is healthy and allows a release of some of the anger, as the following shows: As I arrived back home after the workshop, it was unbelievable - all the family members with whom I have been in conflict were together in the same room. At first when I saw them, I turned away in anger. But then I decided to go inside and greet them all. It had such an amazing effect and I felt so relieved. We still need to talk about what happened but this was an important start. (Sinani youth group member)
Listen carefully and, without agreeing that the plans are a good idea, emphasize that the feelings of anger and wanting revenge are normal and justified. Once you are satisfied that the person has spoken fully about their anger and their plans for revenge, start exploring consequences. Ask questions such as: 'What would happen to you if you followed through with these plans?' or 'What are the advantages and disadvantages for you personally, if you follow through with these plans?' The client may reply that he or she does not care what happens to him or herself. You may reply that you are concerned and would like to find out what the consequences might be. Start with personal consequences, and if needed, consider the family and friends involved. Never try to get the client to empathize with the perpetrator, or to feel pity and forgiveness for the perpetrator. Try to explore creative alternatives to a violent act of revenge. You may ask, 'What is the least that will satisfy you?' Often people initially reply that they would only be satisfied
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once the perpetrator is dead. If you get this response from the client, continue your line of questioning, for example: 'Other than that, what would make you feel that justice has been done?' Help the client to consider alternatives such as making a public statement, or public humiliation (for example, writing an article in a newspaper) and other ways of channelling energy into preventing others from getting hurt. If by the end of the session you are not satisfied that the person has redirected his or her anger, make a contract to wait until the next session before he or she carries out the plans. If you are sure that the person will carry out the revenge plans, it is your duty to report the client to the police, in order to protect the safety of other people. Generally people follow through with plans for revenge if they feel alienated and unheard, that is, if they have not had their anger and hurt heard and acknowledged. This leads people to feel alone, misunderstood, and wanting to get justice by their own means. In the author's experience, once people have been properly heard, when you have acknowledged that their anger is justified, and when they have been given a chance to express and release anger, their plans for revenge often fall away and they begin to channel their energy more constructively. However, dealing with feelings of anger after a traumatic experience is a difficult process. Remind yourself that it is a privilege to be allowed to be involved in the process. Do not rush the client, and do not be disrespectful or judgemental. It is often a good idea to consult a colleague after a difficult session with an angry client who has expressed a desire for vengeance, if only to check that you did everything possible and made the right decisions in providing containment. Helper guilt The guilt that trauma survivors feel is often very strong. A similar process seems to apply to those who are in a helping role. Very often trauma support workers feel guilty that they have not done enough for the trauma survivor, probably because they feel they are in a helping role and should be able to make things better for the person. After the counselling time with the client, a counsellor may keep wondering what more he or she could have done. There may be feelings of incompetence and helplessness, and many helpers try to do extra things for the survivor, such as providing food, making calls, and giving lifts. It is important to realize that this is a normal and compassionate response. It means the counsellor has done well to empathize with the client's distress and has heard the client's own guilt about the event. Some ideas on how to handle your own guilt about 'not being able to do more' as a trauma support worker or counsellor: Name it and acknowledge that it is a healthy and compassionate response. Realize that it means you have done well in empathizing with the trauma survivor. Make an effort to speak to someone you trust about your feelings of guilt.
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Remind yourself that you cannot take pain away from a trauma survivor. Your role is to listen and facilitate by allowing the release of some of the painful feelings. You cannot do the healing for the client, but you can make a safe space in which this natural process can run its course. Remind yourself of the benefit of a calm listener in promoting healing. Check whether you are feeling guilty because the trauma survivor is feeling guilty (transfer of feelings). Sometimes it helps to be aware of the transfer of feelings. Try not to be helpful in too many additional ways, for example, by doing many extra things for the person. Too much help may end up being disempowering - it is more comforting to you than to the client - and it may encourage a dependent relationship. 213
LOSS AND BEREAVEMENT
Many survivors of trauma have lost loved ones during the incident. This is obviously extremely difficult to cope with. Generally it is a good idea to separate the traumatic experience and the feelings of loss. It is best to talk first about the trauma itself, following the usual model for trauma counselling. Once the trauma has been fully processed, make space to talk about the loss of the person. When helping someone with bereavement it is helpful to understand common phases of the grief reaction, as discussed below. Phases of grief Generally, people from all backgrounds tend to experience a similar set of stages following the loss of a loved one. The time taken to move through each stage may vary substantially. Kubler-Ross (1981) identifies the following stages of grief: Denial This first stage is characterized by shock and disbelief. The person may deny that their loved one has died and refuse to accept the news. Anger. Denial is usually followed by anger. It may be that the person becomes angry with the one who has died, and/or with God or others, and with him/herself. He or she may blame others or him/herself for what has happened. Bargaining. It is common for the bereaved person to engage in bargaining, usually with God. He or she may say things like, Tf I agree not to ... then the person will be brought back again.' Depression. Naturally, bereavement is associated with much sadness and the person may go through a very depressed period. This may include a loss of hope or lack of a sense of future, where the person cannot imagine a future without the loved one. Acceptance. Usually, once the person has had time to grieve, he or she starts to accept the death, and the idea of a life without the other person. Move to hope. In time the person may start feeling hopeful again. At this stage he or she may start believing in relationships and life.
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General principles People move through the above stages at different rates and may stay in one stage for quite some time. You cannot rush a person from one stage to another. At times, the bereaved person may even go back to an earlier stage. Bereavement counselling does not differ markedly from other supportive forms of counselling. The role of the counsellor is simply to listen carefully and to support the person through the stages. An accepting, non-judgemental stance is particularly important during the anger stage. Do not try to 'bully' a person out of the denial stage; usually people move on to the next stage when they are ready to deal with what has happened. Do not try to cheer up a person who is in the depressed stage. Crying and grieving are healthy and appropriate. Provide containment, and even encourage the person to express as much sadness as possible. Even if you feel awkward when a client starts crying, try to keep still, and if you feel you should say something, say something like 'Take your time', or 'I can understand your sadness.' Encourage the person to talk about the person who has died. He or she may like to show you photographs and tell stories about the person. Feel free to ask respectful questions about the one who has died. Do not encourage the idea - one many people are raised with - that we should not speak about someone who has died for fear of upsetting the grieving person. Be respectful of cultural traditions, for example, where a wife may not mention her deceased husband by name. Usually the early stages of bereavement involve idealizing the dead person (remembering him or her as all perfect and all good). Do not contradict this view; once the person feels ready, he or she will also remember the negative or irritating parts of the deceased and be able to integrate these to remember a whole person with good and bad aspects. Warn the person that he or she may feel very sad again on anniversaries of the death and on other special occasions, such as the deceased's birthday, Christmas, graduation ceremonies, etc. Emphasize that this is normal. Encourage the person to plan for these times, for example, by deciding beforehand to light a candle or spend time with family on that day. You may explain some aspects of bereavement counselling and the grieving process to family and friends, who often feel helpless and don't know what to say or do. Usually families and friends do not realize how long it takes to grieve. They may expect the person to 'get over it'. Emphasize that the bereaved person needs to take special care of self, and that there is no need to 'move on' quickly. Do not try to encourage a grieving person by saying that he or she will feel better soon, will find someone else soon, etc. The person may perceive such comments as disrespectful to the deceased, or it may indicate to him or her that you feel the process should be accelerated.
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If a person has survived a trauma in which someone close has died, try to separate the trauma process from the bereavement process. Deal with the trauma aspect first, and then talk about the loss. Sometimes a person will divert the conversation to talk more about the deceased, as an avoidance strategy, and this confuses the feelings of trauma and loss. As the bereavement counsellor, you may feel awkward or not know what to say. Keep in mind, generally, that there is probably nothing profound you can say - certainly nothing that would make things 'right' or bring the person back. Bereavement is a process, and your role is to listen and support people through that process in their own time and own unique manner. Note: It is interesting to note that divorce may lead to similar stages to those outlined above. A person finding out that he or she has a terminal illness may go through a similar process. Children and bereavement Many of us will have grown up with the belief that we should try to protect children from death by not talking to them about it. However, children go through similar stages of loss when someone they love has died. It is important to include children in grieving rituals. Children should be given a chance to talk about the loss. Here are some ideas for helping a child who has lost a loved one: Encourage the child to talk about the person who has died. Encourage the child to ask questions about the person who has died, even long after the death. Allow the child to be a part of the grieving rituals. Give the child a chance to come up with his or her own ways of expressing grief. Older children may have specific ideas about grieving rituals, and it can be very helpful to a particular child if these are included. Be honest about what has happened to the deceased person. Explain to the child that his or her life is going to change, and keep the child informed of decisions that affect him/her. Where possible, give the child some choice in what happens. Help the child to keep some special items of the deceased person in a safe place. Telling someone about a death A most difficult part of the helping profession involves having to tell someone that a person he or she cares about has died or is going to die. As counsellors, we feel the person's loss and often their reactions and sorrow stay with us long after the event. Some ideas on how to handle this difficult situation: Try to find a private room or place for the person or family. Let them be seated, but don't fuss or delay. Try to get to the point as quickly and compassionately as possible.
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People often 'know' what the news is going to be and for them the worst part is waiting to hear it stated as a fact. If possible, try to have a colleague present, since it helps to have support. Tell the family the news in as calm and gentle a manner as possible. You may start by saying something like, 'I am very sorry that you have to hear this bad news', or 'I know this is going to be very difficult to hear.' Then continue, 'Last night, at about 2 a.m., your ... died.' If the death was unexpected, briefly explain the cause, such as, 'He was shot dead' or 'She was killed in a car accident.' Wait, as calmly as possible, while the family tries to absorb what has happened. Be aware of the stages of bereavement. The family may cycle quickly through the stages, or vent in one of them. If the family denies that this is possible, for example, 'That's impossible, I saw her just yesterday', don't rush into correcting the person or arguing. Stay calm and empathic. You could say, for example, T know this is very hard to hear'. Do not offer to show the deceased's body or offer evidence unless asked. Be as gentle as possible during the denial stage. If the family members become angry, stay calm and do not take their anger personally, even if it is directed at you. They are suffering and need to vent their anger about the loss. Try to remain empathic. If there are questions about the circumstances surrounding the death, offer reassuring observations, if there are any to offer - for example, whether the person looked peaceful, whether you held the person's hand. Try not to burden one family member (for example, the father) with too much responsibility. It may be tempting to tell only the seemingly stronger person, so that he or she may tell the rest of the family, or to single out a person to identify the body, etc. If possible, tell all the relevant people together, and ask them who should be involved in further action. Remember that everyone copes differently. Upon hearing devastating news, some people react by becoming official, businesslike and busy; others prefer to sit quietly alone for a while; others cry loudly and don't want to be left alone. Respect these differences, and try to follow the individual's cues or simply ask what he or she would prefer or find most helpful. Where children are involved, try to have a supportive adult present. Never think that children should be 'kept out of it' and protected, or that they are too young to understand. Always encourage honesty with children, explaining clearly what has happened. 21.4 DOMESTIC VIOLENCE
Many people in South Africa, from all economic and cultural backgrounds, suffer repeated physical, emotional and/or sexual abuse from their partners. A recent study by Jewkes et al. (2001) reported a high prevalence of physical, emotional and financial abuse in all three
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provinces of South Africa where the study was undertaken. The prevalence of abuse by a current or former partner was 26,8 % in the Eastern Cape, 28,4 % in Mpumalanga, and 4,5 % in the Northern Province. Domestic violence is an example of complex trauma and very difficult to deal with because of the personal relationship between the perpetrator and victim. Cycle of domestic violence An understanding of the cycle of domestic violence is helpful both to the helper and to the person involved in the situation:
Figure 21,5 The cycle of domestic violence (The Domestic Violence Prevention Project)
Pointing out this cycle may help to increase the awareness of the person being abused about the ongoing nature of such violence, or at least help her or him to identify the warning signs in her or his own situation. Many people ask what can be done if one becomes aware that someone is caught in this cycle of violence. Usually rational argument is futile. Do not think that you can persuade a person to leave his or her partner, simply by logically pointing out the patterns. Initially the person may agree to leave the abusive situation, but he or she usually ends up returning soon afterwards. When this happens, people often may not want to return to you for assistance, because you had warned them that the abuse is likely to continue, and now they feel bad or expect to be judged. Many people wonder what makes it so difficult for someone to leave a situation of abuse, and why so many people return to abusive relationships.
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The central components of the cycle involve love, hope and fear, as follows: Love. The person knows that his or her partner has good points and is not 'all bad' as a person. He or she may choose to focus more on the good, as a way of rationalizing the bad. Although it may not seem possible to an objective onlooker, it helps to understand that the abused person often has a genuine and deep love for the partner. Hope. Many people hold on to the hope that things will change. They often remember that the relationship started out well, and they believe the abusive partner's promises that he or she will change and that the violence will stop. Fear. People are often trapped in relationships by fear. They believe the partner will carry out his or her threats, for example, to kill the person, or to harm the children or other family members. The wheel of violence Levels of violence usually increase as the abusing partner gains more control over the abused person's life. The wheel's centre is about power and control, and many abusers will try to reduce any control and power the person may have. The abuser uses coercion, threats and intimidation. Repeated verbal attacks from the abuser erode the person's self-esteem and beliefs about self and others who care about him or her. Isolation is common; many people describe how their partners gradually restricted their social movements, even cutting them off from family and close friends. Common strategies used by abusers are: minimizing the situation, denying that there is a problem, blaming others, and/or using loved ones as leverage against the abused person. Economic control (such as ensuring that the person has no access to money) is often a concrete way of gaining power and limiting options.
FigiK" /1,6 The wheel of domestic violence (The Domestic Violence Prevention Project)
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The wheel of non-violence A situation of non-violence relies on equality, including mutual respect, trust and support, honesty, responsibility, economic partnership, fairness and non-threatening behaviour.
Figure 21,7 The wheel of non-violence (The Domestic Violence Project)
To achieve a cycle of non-violence is a long-term process, which may be facilitated by the following: Support. One of the most significant and perhaps simplest things that can be done if you suspect someone has been affected by violence or is currently trapped in the cycle of domestic violence, is to offer a supportive relationship. Remember that people do not leave this situation on the basis of logical arguments. Instead, knowing that there is someone out there who knows about the abuse, who cares, and who respects one's decisions, is often what is needed to give a person hope and the courage to change the situation. Gently encouraging him or her to talk about what is happening, and letting the person know that you respect his or her decisions, is often the best that can be done. Also essential is to facilitate access to legal support and family support. Often the best people to assist in abusive situations are the family members of the person. With permission, it may be helpful to make contact with the family and to encourage assistance. It may be useful to provide referrals to legal agencies that specialize in this area. Safety plan. In a situation of high danger and ongoing abuse, it is a good idea to bring up the idea of a safety plan for the person being abused. Identifying times of risk, based on the model of a build-up in tension, is essential. This will help the person to identify danger signs and, with a plan in place, enable him or her to leave the situation ahead of time, if only until things settle down. In some cases it is also important to develop
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an escape plan, to be implemented if violence suddenly erupts. This may mean drawing up a list of friends, family or neighbours to go to for help, or having money available for transport. These meetings have empowered me so much that I can live independently of a man. They have helped me to take decisions which previously would have been difficult for me to take. (Member of a Sinani women's group) 21.5 SPECIFIC TRAUMAS OR GROUPS Rape One of the most traumatic of experiences is rape. Rape also involves some of the most stressful types of counselling. The normal model of trauma counselling is usually helpful, bearing in mind the following key aspects: Avoidance is usually very strong with rape survivors and many fear talking about the rape itself. Most will talk about what happened before and after the act of rape, but will avoid mentioning aspects related to the actual time of the rape. The counsellor needs to be very gentle and patient. Be aware that it could take several sessions for the person to build up enough trust to talk in detail about the rape. However, take care not to collude with the avoidance. As a counsellor one usually feels great sympathy and it might seem cruel to 'make' someone talk about such a terrible act. But the person's rate of recovery depends on how soon he or she is able to begin talking about it. Trust in others is usually severely affected. Take time to build this trust, and don't take it personally if the rape survivor seems to take a long time to begin trusting you. Be prepared for 'stop and start' sessions, where the person talks about some aspects and then does not wish to continue. It is fine to cover the different aspects in stages. The person may also alternate: he or she may be willing to talk about the rape in one session, but only about general topics in the next session. This is normal. Don't try to rush things. Rape survivors almost always blame themselves for what happened. Let the person talk openly about this guilt, before trying to persuade him or her that it wasn't his/her fault. Once the person has expressed the guilt and self-blame, emphasize that no one deserves to go through such an experience. Even if the person placed him or herself at risk in some way - for example, by being in a dark area - he or she did not deserve to be attacked and raped. You may need to repeat this point many times. Male counsellors need to be particularly sensitive. Although both male and female counsellors need to proceed with caution, male counsellors in particular should guard against being perceived as 'too interested' in unnecessary details. A person will be hypersensitive to any sign that a counsellor is 'fascinated' by the rape. Exercise caution in the way you introduce the topic and ask questions about the details. Remain totally focussed on the person, and on the person's experience and feelings, not on the rapist's actions. Some people believe men should not counsel women who have been raped, because there is a high risk of secondary traumatization; others believe it may
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contribute to healing if a male counsellor deals sensitively with a female client. Always allow a woman the choice of speaking to a female counsellor. Be sure to discuss ways of feeling safe at home, or in other places, such as at work or while travelling to work. Find out whether there are people with whom the person feels safe, and explore ways he or she can spend more time with these people. Encourage the person to be open with a friend or friends about what has happened. Always try to speak to the immediate family about the rape, particularly the partner of the person who has been raped. For people in existing partnerships, couples counselling is almost always a good idea after a rape. A woman's partner will need to talk about his own distress, which usually includes anger or guilt. Let him talk about this at a session at which the client herself is not present. Once he has had a chance to express his feelings, try to sensitize him to her needs. Emphasize that it may take his partner a long time to recover, and that his patience and care are essential. Encourage him to ask his partner what she would regard as helpful or not helpful in terms of his behaviour towards her. Deal with the feelings of family and partners with regard to apportioning blame. They may be angry with her for placing herself in a risky situation. Again, emphasize that no one deserves rape or wishes for it to happen. Often, the feeling underlying blame is guilt (being unable to offer protection, etc.); try to make space for this guilt to be expressed. There are almost always problems with sexuality after a rape. A woman may experience fear during subsequent sexual encounters, even with a trusted partner. Often sexual contact creates strong flashbacks. Alert both partners to this likelihood. Where possible, the woman should initiate sexual contact with the man. He should be prepared for the fact that she may back away several times, even though she initiated the contact. This is completely normal; she should not be rushed, and he should expect her to be 'hot and cold'. On the other hand, if the partner is cautious about approaching the woman sexually, many women feel rejected by the man. They feel the rape has made them unattractive. Alert both to this possibility and talk about how this may be handled, for example, by the man explaining that he still loves her and is still interested, but that he will not initiate sexual contact. If this is clear to both, they may find things somewhat easier and make better progress. Obviously, talking openly about what is going on is the best for both partners. At times the woman may wish for intimate contact (for example, being held or hugged), without this contact being sexual. It helps if both are aware of this. It helps if she is able to communicate this clearly, and they may even need to develop a shared 'code' to let one another know the intentions. Remember that a rape case may reach the courts, so keep notes and make sure you explain the limits of confidentiality to the client.
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Remind yourself that one of the most healing aspects of rape is the fact that the person knows there is someone else who knows and cares. When are we going to that office in town again? (First words spoken after several weeks of silence, by a client to her family. She stopped communicating after being gang-raped at KwaMashu.)
Abuse of the elderly Abuse of the elderly has been receiving increased media attention in South Africa. GrayVickrey (2000) cautions that we should not only consider physical abuse of the elderly in terms of visible signs of assault, since neglect, financial and emotional abuse are also common. Gray-Vickrey reports that as many as 10 % of older adults may be abused and that these cases are seldom reported. The following factors may contribute to abuse of the elderly: The elderly person has an impairment which could be adding to the stress of the caregiving. The family has limited resources to look after the older person. There have been previous relationship problems with the older person. History of family violence The health care practitioner should look out for subtle as well as obvious signs of abuse or neglect. These may include unusual injuries or patterns of injuries. Repeated injuries may be a sign of abuse, as may delays in reporting the injuries. Knowledge of the relationship between caregivers and the older person may also assist with the assessment of the situation. Because abuse of the elderly tends to be very shocking, many practitioners are tempted to react in an extreme manner. However, it may be more helpful if time is taken to build a trusting relationship with both the caregivers and the older person. This may assist in identifying the underlying reasons for the abuse and in working together towards finding solutions. Many older people who are abused or neglected feel ashamed about the situation. It may take time to build enough trust for the person to talk about what is happening. Usually the families involved in the abuse feel very guilty about what they are doing. Often it is the stress of their lives or the strain of caring for a person with limited resources. It may help to talk generally about some of the stresses involved in caring for the person. Any intervention will be far more effective if the caregivers admit to the abuse. This enables one to work collaboratively with them on the problems. Try exploring alternative resources for support of the family and the elderly person. Helping the older person to remain socially active may relieve stress, both on the person and the family. Should the situation seem extreme, or should the abuse continue despite efforts to support the family, it is important to report the abuse to the relevant authorities.
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21.6 CHILDREN AFFECTED BY TRAUMA Many people believe that children are too young to understand what is happening during a trauma. Others believe that children will forget what happened. Yet, if we recall our own childhood, we did understand much of what was happening to us and around us. We often also remember a lot of the details of events, especially if they were frightening. This suggests that care should be taken to support a child who has experienced a traumatic event. Types of abuse Physical or emotional abuse One of the worst forms of early trauma is abuse by one's own parents. Living in an abusive family, the child's personality has to adapt to the environment of repeated trauma. Often the abusive environment involves a constant fear of harm or even death. Rules are usually arbitrary and unfair, leaving the child feeling very helpless. Punishments may be intrusive and may shame the child, for example, being linked to bodily functions. The child may also be isolated socially, which makes coping even more difficult. The child living in this situation has normal developmental needs, and so the child tries to find creative ways to: maintain a sense of trust in people whom he or she knows may present a serious danger to themselves; feel safe in a situation that is unsafe; maintain control in a situation that is unpredictable; gain power in a situation of helplessness; compensate for the failures of adult care. In order to achieve these goals, abused children may learn to cope by avoiding punishment, often by trying to make themselves inconspicuous. A child may become very obedient and try to work out the rules. In extreme cases of abuse, children sometimes develop dissociated states, such as altered personalities. Many children develop an active imagination. One of the saddest aspects of abuse is that often children try to excuse the behaviour of the parent. The children think the abuse is their fault and they see themselves as 'bad'. In severe cases these children may attempt suicide. Other children react angrily and may have fantasies of murder and revenge. Sexual abuse A recent study by Berard and Boermeester (1999) reported that one third of patients admitted into a psychiatric treatment centre for adolescents reported some form of sexual abuse. This does not necessarily mean that a child who has been sexually abused will have psychiatric problems, but it does indicate that sexual abuse is a common factor in psychiatric admissions.
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I see myself as a dog - this is what I grew up being called and I can't let go of this image of myself. (Youth group member)
Effects of trauma on children Children are affected by traumatic experiences in the same was as adults. Figure 21.1 is very relevant to children. In addition to the effects described for adults, children may show the following normal responses: Regression. This is when children go back to behaviour displayed when they were younger, that is, behaviour more common to a younger child. For example, children may start sucking their thumbs again or talk in baby language. Children who stopped wetting their beds may start bed-wetting again. Acting out. The children show anger and have tantrums. They may react sensitively to small things. They may bully other children or misbehave. Fantasy play. Often traumatic experiences are expressed during the child's play. Games such as 'funerals' are common. The child may also draw pictures of events. This is normal and healthy. Somatic complaints. Many children will try to get help by complaining about other aches and pains. Examples are complaints about sore arms or legs, stomach-aches, headaches. Avoidance. The avoidance behaviour is often strong with children. They may refuse to go near the place where the event happened. They may refuse to eat foods that were eaten just before the event took place, or refuse to wear clothing worn on the day it happened. Magical thinking. Children often make curious links between the event and things that happened just prior to the event. They may believe that something they saw or did caused the event to happen. Self-blame. Children tend to see themselves as the centre of their world. They often believe they did something to cause the event. For example, if a child had a fight with a brother on the morning of the event, he or she may believe the fight and the event are connected and that it is his/her fault that it happened. Fears. Children affected by trauma may show excessive concerns about safety and fears of violence. Sensitivity to sound. Traumatized children may be very sensitive to loud noises and unusual sounds. In addition, children who have been sexually abused may show the following behaviour: Seductiveness. Unusually seductive behaviour in young children is an indicator of sexual abuse. This should not be confused with normal emerging sexuality, which is common in all children.
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Secretiveness. Sexually abused children may become very secretive about certain behaviours or activities. Complaints about feeling dirty. Children who have been sexually abused may make comments about being dirty. They may wash themselves often. Complaints about genitals. Children who have been sexually abused may complain about problems and pain relating to their genital areas. Interest in sexual matters. Some children who have been sexually abused show excessive interest in things of a sexual nature. For example, they may become very interested in television programmes with a sexual content. This should not be confused with normal developing interest of children and adolescents in sex. Other children may actively avoid anything of a sexual nature. Once again, these reactions are completely normal. By helping parents and teachers to understand the child's reaction, they can be helped not to over-react. Handling disclosure about abuse When a child discloses that he or she has been or is being abused, special care needs to be taken to handle the disclosure in a calm and sensitive manner. By law the abuse must be reported to the police, but many practitioners make the mistake of doing so in a dramatic and chaotic manner. This leaves the child feeling more out of control and afraid. Care should be taken to deal with the matter in a calm and caring manner. Give the child as much control as possible, even if this is over small decisions such as whom to tell first. But do take important decisions for the child and give the impression that you are a calm and confident adult who is not overwhelmed by the situation. Always keep the child informed; explain to whom you will be talking about the abuse and what you will be saying. The child's caregivers need to be informed of the matter. Always tell the caregivers without the child present. Parents are likely to react in an emotional manner, which may make the child feel worse. Spend time with the parents to ensure that they are calm before they see the child. You may even discuss with them what they intend saying to the child during the first interaction. When you report the matter to the police, ensure the privacy of the child. For example, do not call the police to the clinic or school, or discuss the matter in front of other people. If one of the parents was involved in the abuse, for example, the father, rather have him removed from the home than taking the child away. Placing a frightened child in a strange environment is not helpful at all. If the child needs to be removed from the home, try to take him or her to a familiar place, such as another family member's house. Helping children affected by trauma The aims and structure of trauma counselling (described in section 21.2 of this chapter) can be helpful, although the following should be kept in mind when working with children: Children affected by trauma may take much longer to develop trust and to feel safe
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with an adult. You may need to spend several sessions with the child simply building trust. Many children express themselves better through activities such as playing games, drawing pictures and making clay models. Take the time to determine the way in which the child expresses him or herself best. Once a child is ready to talk about the trauma, he or she may talk in a stop-and-start manner. This is normal. The child will usually talk in small 'steps' and then not want to talk any more. It is important to be patient and not to push the child into talking about everything at once. Because children often feel confused about a traumatic event, time should be spent on helping them to understand what happened. If children are able to organize the event in their memory, they tend to recover better. It is important: to note that it is unhelpful to expose children to media about a traumatic event. For example, if they were involved in a train disaster, photographic images in newspapers, radio newscast descriptions, and television footage accompanied by sound have been shown to add to the horror. Children's tendency towards magical thinking and self-blame indicates that care must be taken to reassure children that the event was not their fault. First take time to understand exactly why the child thinks it was his or her fault. Then explain, several times, that the event did not take place because of'something bad' the child may have done. Do not be tempted to provide false explanations. Often we think these will make the child feel better, but they may confuse the child more. Also be careful about adding religious connotations to the event, for example, saying that 'God meant for this to happen'. Once children are older, they will be in a better position to understand and make sense of what happened and to attach their own meaning to it. Safety rituals may be developed. Ask the child what helps him or her to feel safer. For example, some children like to have a light on at night. Take the child's ideas seriously and never ridicule him or her, no matter how odd the request. It is important to get children back to their normal routine soon after the event. Get children back to school quickly and keep normal bedtimes and other routines. However, if the event occurred at a place to which a child has to return, care should be taken to ensure that the child feels safe. Make some allowances for acting out. Expect, and allow for, some tantrums and sensitive behaviour, while retaining some limits. This is a difficult balance to reach. Parents and teachers may need support in giving the child a chance to express feelings while, at the same time, keeping safe boundaries. Counselling children who have been abused usually involves a long-term relationship between the client and counsellor. Consistent caring, safety and support are important. Do not rush the client through any stages of the counselling process. Focus instead on
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developing a safe space where the client will spontaneously begin to deal with some of the painful past experiences. Children who have been severely physically, emotionally or sexually abused usually benefit from specialized counselling from a psychologist. This may be in the form of play therapy or art therapy for younger children and verbal therapy for older children. Bear in mind that one should not only consider the dramatic forms of abuse, that is, sexual abuse and rape. There are many subtle forms of sexual harassment taking place in our society and these also need to be addressed. A health care practitioner is in a position to play a constructive role in the education and empowerment of boys and girls regarding rights and responsibilities. This may prevent further abuse in future. I have learnt that it is OK to express my feelings. I was brought up and taught to obey and respect adults, but these days there are people who influence children with bad things, and I know I have the right to say no politely. (Sinani children's group member)
Supporting caregivers The most important factor in a child's recovery after a trauma is how the parents and other important caregivers cope with the trauma. This aspect of social support is more important than any counselling techniques. Always try to work also with the parents and teachers of the child who was abused. If the child's caregivers cope well with the trauma, the child is much more likely to cope well. Hence it is important to support caregivers of the child, as follows: Allow the caregivers to express their feelings about the traumatic event. Often caregivers feel angry and distressed about what happened. Speak to them without the child being present, and give them a space to talk about how this has affected them. Remember, the child should not hear about these feelings. Encourage caregivers to behave in a calm and controlled manner in front of the child. Children tend to get more upset if they see their parents falling apart after the trauma. Children cope far better if they feel that their parents are in control of what is happening. At the same time, caregivers should allow the child to talk about the event. They should not pretend that 'it never happened'. It is important, therefore, to encourage and help them to process the experience together as a family. Let the child ask many questions about what happened, even long afterwards. Explain to the caregivers some of the reactions they may expect from the child and emphasize that these reactions are normal. Talk to caregivers about ways of allowing the child to express his or her feelings about what happened, while at the same time balancing the need for normal structure and routine. Note: Key to how severely a child's development is affected by trauma is the child's relationship with his or her caregivers and how the caregivers handle the trauma. If the
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family is supportive and caring, the child may recover from the trauma with relatively few effects on his or her forming personality. It is particularly helpful to the child if the family is able to deal openly with the trauma and to make space for the child to talk about the trauma. 21 7 WORKING WITH GROUPS AFFECTED BY TRAUMA I realized that other people in this group felt the same as me, and we could understand each other. (Member of a Sinani women's group)
Families Sometimes a whole family may be involved in a traumatic experience together. This is a difficult situation, but if the family is well supported, the experience of what they went through together may even strengthen their relationships with one another. Be aware of the following dynamics when working with families affected by a traumatic experience: Family members may feel responsible for one another. Individuals often feel much guilt for not having been able to protect one another. There may also be some blaming, where family members feel betrayed by one another and/or angry with one another. A strong element of shame is often present, where family members feel embarrassed about what they have been through together. In some cases, families may feel that their dignity as a family has been damaged by the event. Remember that different family members will have different ways of coping with the event. Some may be very avoidant and not want to deal with the event, while others may want to talk about it openly and confront what happened. Care needs to be taken to make space for these differences within the healing process. It is usually helpful to see each family member individually. This gives people a chance to talk about their own experiences of the trauma. It is also important to deal with anger and blame towards other family members, so that these are not expressed in a harmful way towards others in the family. At some stage it may be helpful to see the whole family together, to talk about how the experience has affected them as a group. Very young children should not be included in family sessions, and it may be better to see children and caregivers separately. However, older children and teenagers may be involved in family sessions. Keep the following in mind during family sessions: Carefully structure the sessions so as to make people feel safer. The trauma support workers should be organized and have a clear plan for the session.
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Remember, as the trauma support worker, you are dealing only with the trauma incident. Do not be tempted to deal with other family dynamics that may be of concern at this stage. If other issues arise and need to be dealt with, they should be focused on as a separate process. Allow each family member to express his or her version of what happened. Other family members may find it helpful to hear these different perspectives and to find out about other aspects of the event. It is important to deal with feelings of guilt and self-blame. Allow each person to talk about why he or she feels guilty. Encourage other family members to reassure those who feel guilty that they are not to blame. Normalize reactions to the trauma. Talk about different individual styles of coping with trauma and how the family might make space for these. Discuss how the family will cope with the event together. Encourage family members to deal openly with the event and not to pretend that it never occurred. It is always helpful to work together with a colleague when supporting families affected by trauma. Whatever medicine you have given my son this past week, please don't stop. He is a totally different person. (Sinani youth group member)
Survivor groups Group work with survivors of trauma can be one of the most effective forms of support. There are many reasons why groups work well for many trauma survivors, as follows: Many people feel safer working in a group rather than alone. In many cultures, it is more appropriate to process a major event, such as trauma, together with other people. Hearing other people's stories can offer a sense of relief. Survivors often feel less alone when they know others have also been through difficulties. Members of the group are able to support one another. Having your story heard and accepted by several people similar to yourself can be a powerful step in the healing process. However, there are some aspects to bear in mind when working with groups: Some people feel less safe in a group and more comfortable talking to just one person. This is often true for people who have been raped or sexually abused. Once again, never force anyone to share, but wait until people are ready to share. Encourage group members to talk, but allow them the choice not to.
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It may be unhelpful for people to compare their traumatic experiences, for example, by saying, 'Well, if that is what you went through, my experience wasn't so bad.' Trauma is a personal experience; group members should not rate their traumas in comparison to those of other members. Make sure that each person has enough time to share his or her story. Some members may try to block a person's sharing if they become overwhelmed by the story. This may reinforce the idea that the trauma is too terrible to talk about. The initial phase of establishing safety is very important and should not be rushed. The issues around confidentiality and trust should be discussed fully. Give group members time to get to know one another properly in the beginning. Structuring shared experiences As with individual trauma counselling, sharing experiences should be well structured. The following stages of the counselling model may be applied to groups: The idea is to give each group member an opportunity to talk about his or her experience in detail. Group members should be encouraged to respect individual differences with regard to how much detail the person is willing to share. Be guided by the person telling the story as to how much detail he or she is ready to share. Groups offer a powerful way of normalizing trauma responses. Allow group members a chance to talk about how the trauma has affected them. Usually it brings a measure of relief to hear that their responses are normal and that others went through similar reactions. Groups also offer a valuable chance to process feelings such as anger and guilt. Having several people acknowledge these feelings is very helpful. Sharing ideas about coping is helpful in that it tells people how others are managing under difficult circumstances. This sharing of ideas may assist people in finding better ways of coping themselves, or it may let them know that they are, in fact, doing well. Group debriefing Trauma support workers may be called in to offer support when several people have been involved in a single traumatic incident. For example, after a train accident in which many people were killed or injured, it may be helpful to work simultaneously with several people who were involved in or affected by the accident. When to debrief Some people recommend that group debriefings take place as soon as possible after the incident. However, Sinani recommends that a group debriefing be conducted at least three days after the event. The reason is that the people involved often feel very fragile and shaky immediately after an event. Most often they simply want to be with their families. There is a heightened need to feel safe soon after a traumatic incident, and this is very important.
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So when people are debriefed too soon after the event it may make them feel abused and angry. It may be better to offer more generalized support in the early stages, for example, advising Management on how to support the staff, if it is an organization. Helping people to connect with their families is also important. Later, once people are ready to talk about the event, the group debriefing session may be organized. Once again, the five-stage trauma-counselling model may be adapted for a group debriefing. Do not choose an 'upbeat' icebreaker, since this may seem inappropriate to the participants. Instead, do something simple, quiet and respectful. Do not hesitate to include people who, though not directly involved, feel themselves to be peripherally involved, since they might also be traumatized. A group debriefing is a sensitive process to conduct. Often such debriefings are requested by people who were not even part of the incident, and not everyone is always a willing participant. This means that the first important task of the process is to gain people's trust. It is important that no one feels forced to participate, and that everyone is treated as an individual with his or her own needs and rights. Supporting communities affected by trauma Many communities affected by trauma, and especially by violence, have had the normal social fabric of the community unravelled. This means that the usual relationships and social structures have been challenged. The work of re-weaving the social fabric involves reconnecting people to one another and rebuilding or repairing structures. It is important for people to participate once again in activities that link them to other people. Reestablishing these links is the main role of the trauma support worker. The attitude displayed by a trauma support worker towards community members who have been affected by trauma, is a most important aspect. Working with communities requires the same principles of respect and trust as those mentioned in relation to individuals. However, long-term commitment is also necessary. Trauma support workers are often tempted to rush in after a community has been affected by a trauma, and certainly their main aim is to help. But many trauma support workers are only able to work with the community for a short space of time. This can actually be more harmful than helpful. Many communities feel abused when people, who rushed into the area during the hype of the trauma, leave again soon afterwards. If one has only a short period of time available, it is better to support the people who will be working in the community for a long time (such as nurses and police). Always check to find out what these people would find helpful, or extend an open invitation for them to contact you if they need help at any stage. Trauma support workers should not see themselves as the ones who are going to make the changes in a community. Instead, they should try to build on what is already happening and empower the community itself. Community members know what is best for them. They should be encouraged to support one another, rather than relying on the trauma support worker. Try to build on resources already present in the community, rather than creating new projects. Try to link different structures, for example, if you are
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doing training in trauma support work, invite representatives from government departments, churches and traditional healers' associations to attend the training. This promotes connections between community members, which is the main aim of support work in communities affected by violence and other forms of trauma. Trauma support workers commonly make the mistake of assuming they know what is best for a community. A trauma support worker should take seriously the needs of the community. Work with expressed needs and support people affected by trauma while working on meeting these needs. For example, it would not be helpful to set up a trauma counselling office when people really need food and shelter. Take time to find out what the most urgent needs of the community are and offer trauma support at the same time or later, once a trusting relationship has been built. Violence and trauma tend to affect every person in the community. Where one has sufficient time, it is better to work with different groups within the same community. Some of the community groups affected by trauma include: leadership; service providers (such as nurses, social workers, traditional healers, police); adults (both men and women); youth (especially ex-combatants where there has been civil conflict); children and their caregivers. Since a trauma support worker usually does not have the resources to work with every member of a community, it is a good idea to look for 'points of leverage'. This means thinking carefully about existing structures within which you can work in order to reach the largest number of people. Examples of community structures - in which you work with a few people, and these people then have an impact on a lot of other community members - include: leadership structures, such as development committees; schools and creches; support groups, for example, burial societies, savings groups; churches and other religious or spiritual groups; traditional healers1 associations; government workers, such as doctors, nurses, social workers and police. Remember to discuss the community's needs with community members and leaders. Trauma support work is much more effective if it happens in response to a request from a community or group. Bear in mind that individual counselling is not necessarily the most effective way to reach people. The trauma support worker should also consider: utilizing sport and arts activities such as singing and drama; training others to do trauma support work;
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initiating projects to raise awareness and normalize the effects of trauma; organizing income-generating and career-development activities; organizing leadership skills development workshops; and running parenting skills development projects. Consult community members for advice on the kinds of activities that would be most suitable in the particular community. We are so happy here, and feel so connected with one another. But remember that we will return back to the reality of our situation tomorrow, and it will be just as bad. But I ask that we remember this moment, and hold on to it. We should visit one another and keep supporting one another. Let us take back to our community some of what we have experienced here. (Youth group member)
21,3 CARE OF CAREGIVERS Trauma work can be very inspiring, because many people recover relatively quickly with little input. However, trauma work is also extremely stressful. Responsible caregivers constantly monitor their own responses to trauma. Listening intently to someone else's traumatic story, as you would during trauma counselling, may evoke intense reactions, almost as if you had experienced the trauma yourself. As the client describes the sensory detail or extremely distressing aspects, the trauma support worker will absorb some of the impact of the trauma. This means that you, as caregiver, may exhibit signs of the impact of the trauma, including: avoiding places or things associated with the client's trauma; becoming anxious or jumpy; thinking about the trauma or remembering certain details; sleep disturbance; eating disturbance; increased substance use, for example, alcohol or sedatives; withdrawal from friends and family; irritability and increased aggression; feeling less caring towards other people. Be vigilant about the ways trauma counselling may affect you. For example, take note of your behaviour at home the week after a difficult session with a client. Linking it to the trauma counselling session may help you to feel more normal and in control of your reactions, instead of feeling guilty. The longer-term effects of trauma on communities (discussed in section 21.7), could also start to affect counsellors, for example, mistrust, control, avoidance and dependence.
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It has not been easy to listen to all these painful stories. When I see people talk I see in my mind what they see, and it stays with me afterwards. (Sinani staff member)
Self-care Unsurprisingly, when dealing with secondary trauma and counter-transference, the same principles are applied to trauma support workers as to clients: Talk about it. If particular details are bothering you, share them with someone else, and you will find they lose their hold on you. There is no shame in this; we all need to release the horror of trauma cases. Share even the seemingly irrelevant details that bother you. It helps to let it out. Formal and informal debriefing is very useful. Trauma support workers are well equipped to support one another; we should keep making space for this and talk to one another about the cases we find distressing. Proper supervision with someone you trust can help. Take a risk, let the supervision go deeper and explore links between your cases and your personal life. It is better to have a set time for supervision; otherwise you might be inclined to avoid sessions, usually when you need them the most. Know yourself. Know what type of cases 'get to you' the most. Know how you react when you are stressed. Know what is the best way, for you personally, to release stress. Learn more about the type of case that causes you stress. Research shows that people with more experience and who read and learn more become less stressed, because they can make sense of what is happening and become less overwhelmed. Socialize. Interact with 'normal' people! Do not isolate yourself from friends and family. Do not only 'hang out' with friends from your work environment, and if you do spend a lot of informal time with co-workers, talk about things other than work. Focus on developing a healthy lifestyle, for example, eat healthily, get exercise, etc. Take breaks during which you really distance yourself from your work. Do not go to the office, take calls or check e-mail when it is your day off or you are on leave. It is far better to take some solid blocks of leave rather than small breaks such as afternoons off, because it usually takes time to unwind and forget about work-related matters. Develop boundaries from work. Small rituals might be important, such as leaving work files and materials at work. Discourage clients from calling you at home, and do not encourage colleagues to contact you after hours about non-essential work matters. Mutual care The focus of care can also fall on developing a supporting work environment where colleagues offer support to one another. This is very important when working in a setting where one encounters many traumatized people.
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Here are some suggestions on how trauma support workers can help one another: Offer space for informal debriefing. If you know someone has been facilitating a trauma workshop or a debriefing, make an effort to ask how it went. Do not do this when you are in a rush, in case the person needs to talk more. Do it soon after the workshop or even during the process. Respect one another's time off. Do not intrude on a colleague's personal time unless it is a matter of life and death! Keep an eye on one another's health and well-being. If you notice that someone is stressed or irritable, let him or her know you are concerned. At the same time, make space for some stress release from colleagues. For example, if someone has an aggressive outburst or is rude to you when he or she is clearly stressed, try not to react negatively. Work out one another's emotional currency and take time to listen to this aspect of the person's life. Try to offer care in a way that is relevant to the person. CONCLUSION Supporting someone in a sensitive and caring manner can be one of the most helpful ways of facilitating recovery from a traumatic experience. If a trauma survivor receives the appropriate support during the difficult period after the trauma, the person may even be strengthened as an individual and be better equipped to cope with other life experiences. In many cases, understanding and care shown by the relatives and friends of the trauma survivor enrich these relationships and bring people closer together. WEB RESOURCES
www/survivors.org.za This website describes the work of the Sinani/KwaZulu-Natal Programme for Survivors of Violence. It is especially useful for survivors of violence in that province. www. aware. o rg/ This website of Arming Women Against Rape and Endangerment assists women in identifying their own risk and in planning how to make themselves safer. www.hopeforhealing.org and www.geocities.com/Hotsprings/2402 These are two linked sites created by a woman who was raped and then discovered the need for more resources for rape survivors. The sites are useful in that they offer survivors of rape many resources, including how to get information and help. REFERENCES American Psychiatric Association. 1994. Diagnostic and Statistical Manual of Disorders (DSM-IVTR) Berard, R M F & Boermeester, F. 1999. Sexual Abuse in Adolescents - Data from a Psychiatric Treatment Centre for Adolescents. South African Medical Journal, Vol 89, No 9
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Bronfenbrenner, U. 1986a. Ecological systems theory. In R.Vasta (ed.). Annals of child development, Volume 6, 187-251. Greenwich, CT: JAI Press Gray-Vickrey, P. 2000. Protecting the Older Adult. Nursing 2000, Vol 30, No 7 Hamber, B. 2000. Have no doubt it is fear in the land: An exploration of the continuing cycles of violence in South Africa. SA Journal of Child and Adolescent Mental Health, 12 (1), 5-18. Herman, J. 1998. Trauma and recovery: from domestic abuse to political terror. Pandora: London Higson-Smith, C & Killian, B J. 2000. Caring for children in a fragmented society. In Donald, D, Dawes, A & Louw, J (eds). Addressing childhood adversity. David Phillip: Cape Town Holtman, B. 1998. Best practice in victim empowerment. A special report on victim empowerment in South Africa. Institute for Security Studies and Public Welfare: South Africa Hope, A & Timmel, S. 1995. Training for transformation: a handbook for community workers. Book Two. Mambo Press: Zimbabwe Jewkes, R, Penn-Kekana, L, Levin, J, Ratsaka, M & Schriber, M. 2001. Prevalence of Emotional, Physical and Sexual Abuse of Women in South Africa. South African Medical Journal., Vol 91, No 5 Killian, B J. 2003. Lecture series on the effects of violence and abuse on children. University of Natal, Pietermaritzburg: School of Psychology Kubler-Ross, E. 1981. Living with death and dying. Souvenier Press: Great Britain Lewis, S. 1999. An adult's guide to childhood trauma: understanding traumatized children in South Africa. David Phillip: Cape Town Seedat, S, Van Nood, E, Vythilmgum, B, Stem, D J & Kaminer, D. 2000. School survey of exposure to violence and Posttraumatic Stress symptoms in adolescents. SA Journal of Child and Adolescent Mental Health, 12 (1), 38-44 South African Network of Trauma Service Providers & South African Department of Health. A Training Programme for Primary Health Care Practitioners in Victim Empowerment and Trauma Support Work: Unpublished Training Manual Van der Merwe, A & Dawes, A. 2000. Prosocial and antisocial tendencies in children exposed to community violence. SA Journal of Child and Adolescent Mental Health, 12 (1), 19-28
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SECTION 5
Appendices
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APPENDIX ONE
Inpatient Evaluation Scale This evaluation scale was drawn up to: 1. assist the nursing staff to gather basic information about patients in an orderly, thorough and scientific manner; 2. assist the nursing staff to obtain the information they require for the day-to-day and long-term planning of nursing care; 3. assist the nursing staff to see in which areas the patients are making progress and in which they are making no progress; and 4. serve as a research instrument. The scale consists of two sections. Section 1 Section 1 consists of 20 items in the form of a questionnaire that the nurse fills in with the patient on admission. It covers the patient's general background and expectations. Section 2 Section 2 takes the form of a rating scale, each item being rated on a 5-point scale as follows: A scale point of 1 represents seriously abnormal conduct, while a scale point of 5 represents normal conduct. Scale points 2, 3 and 4 represent various successive behavioural conditions on this continuum. It can be schematically represented as follows: Scale points
1 Seriously abnormal
2
3 Continuum
4
5 Normal conduct
This section is completed by the nurse within the first week of admission and at regular intervals thereafter. The following points are important to remember when evaluating a patient: 1. Every scale is drawn up in such a way that it measures the entire spectrum of possible behavioural intensity. Do not be afraid to use the extremes, i.e. 1 or 5. Some patients' conduct often justifies this. The most common mistake in the use of evaluation scales is always to remain 'in the middle'.
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2. Take enough time to complete the scale, otherwise it will be less valid. If you are not sure of an item's point value, make sure by observation before completing the item. You may allow yourself to be influenced by the observations of other team members but only in the case of first-hand observations that the members personally share with you. 3. Date your evaluation and sign it in the appropriate column. 4. Do not omit items. Fill them all in, even if it is difficult to decide where the patient fits in. Use the Remarks column to describe your problems with the evaluation or important symptoms for which there are no points on the scale. 5. Give a point based only on the patient's conduct during the period of evaluation and not on previous conduct. 6. It sometimes seems as though a patient could be classified on more than one point on the scale. Choose the point best suited to the patient. 7. If the patient's conduct is changeable or episodic, record the most pathological conduct during the prescribed period. IMPATIENT EVALUATION SCALE Part 1: Evaluation scale Section 1 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17.
Name: Age: Reg. no.: Ward: Sex: Religion: Home language: Diagnosis: Educational standard: Occupation: Address: Name and address of next-of-kin: What problems or complaints brought you to the hospital/clinic today? Has something like this happened to your family before? What do you think caused it? What helps it or makes it worse? What effect do the problems have on your and your family's daily life? Is there anything about which you are worried, such as the care of your children or your work? 18. What do you expect of the treatment and/or the hospital? 19. Have you ever been visited by a social worker? 20. What are your hobbies? How do you spend your free time?
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1
2
3
Totally dependent on nursing care
Needs help, supervision and training by nurses
Needs supervision by nurses
Manages with help | Independent of family or others
1.8 Appetite
Does not eat, refuses to eat or eats too much, over- or underweight
Eats too much or too little more than 50 % of time, is obviously overor underweight
Episodes of eating too much or too little, e.g. during stress, or weight changes
Occasionally too much or too little
Normal
1.9 Table manners
Poor or must be fed
Eats with minimum cutlery, must be fed at
Not very good, for example speed;
Normal
times
Eats very untidily with normal cutlery
Needs supervision more than 50% of time
Needs supervision for long periods
Needs supervision occasionally for short periods
Independent
4
5
1. PHYSICAL 1.1 Bath
1.2 Wash 1 .3 Dress 1.4 Hair and/or beard 1.5 Teeth 1 .6 Pressure parts 1.7 Nails
1.10 Supervision required for own and others' safety
Is totally dependent on nurses, always
Date
Remarks
1
2
3
4
5
1.11 Sleep
Cannot fall asleep for hours every night, very restless, sleeps more than 12 hours/24 or wakes very early
Has definite sleep disturbances (as described in 1) more than 50 % of time
Has many sleep disturbances for long periods
Happens occasionally for 1 or 2 nights or days
Normal
1.1 2 Urine
Incontinent or has indwelling catheter
Has control with much supervision and encouragement by nurses
Usually has control, Occasionally has but has long periods a single incident of incontinence of incontinence during physical or psychological setbacks
Normal
2.1 Contact with family
Patient or family refuses contact
Contact from one side only or very unsatisfactory
Sometimes letters and/or visits that satisfy
Can be discharged to family; satisfactory
2.2 Contact with patients
No real contact
Alone more than 50 % Good contact with 1 Extends good Good contact of time or makes contact to more I with most ! o r 2| superficial contact if than 1 or 2 patients approached
2.3 Social activities
No participation
Can be persuaded to participate
1.13 Faeces 2. SOCIAL
i Evidently enjoys i going, does not I participate
Goes to family for leave
Sometimes takes limited part
Normal participation
Date
Remarks
1 2.4 Social conduct : Unacceptable
2.5 Contact with'• staff
No real contact
2 \ Unacceptable more ! than 5 0 % of time
Alone more than 50 % of time or makes superficial contact if approached
4
5
Episodes of unacceptable conduct
Will be accepted to some extent in some social circles
Will be accepted = in most social circles
Makes good contact with 1 or 2
Extends good contact to more than 1 or 2
Good contact with staff
3
3. ORIENTATION 3.1 Time
No concept of time ; Reacts to certain learnt stimuli, e.g. bell for meals
Usually does all routines on time
Can do simple planning for use of time
Can plan day sensibly, not unsettled by busy programme j
3.2 Own abilities;
No concept of own \ Completely out of proportion, too much abilities or too little
Seeks outside judgement
Judgement according to premorbid performance
Realistic
3.3 Routine
Must always be told to follow routine
Follows ward routine passively, sleeps when not guided in activities
Can learn more complicated routines, does routine work
Can deviate from routine if initiative comes from outside, flexible
Takes initiative to changes in routine but can keep to set routine
3.4 Money matters
No management
Asks only for requirements, not money
Interested only in pocket money
Reliable with small amounts, e.g. to buy clothes
Manages own business well
Date
Remarks
1
2
3
4
5
3.5 Instructions
No reaction
Usually reacts to simple Usually reacts to instructions more complicated instructions
Can use own discretion to a limited extent
Can be trusted to • carry out instructions but also to use discretion to act differently
3,6 Perseverance
Cannot complete simplest tasks, play and work impossible
Can focus attention on one thing for only a few minutes
Can focus attention on pleasant things or short tasks
Can work for a few hours a day
Normal work day, relaxation and problem solving possible
3.7 Own faults
No concept of exactly what own faults are
Takes all blame or puts it all on others
Realizes faults but makes excuses
Can acknowledge faults privately
Can acknowledge ' faults realistically in a group
3.8 Sense of responsibility
Takes no responsibility
Takes responsibility for little self-care with supervision and encouragement
Takes responsibility satisfactorily for own care •
Takes responsibility for self and own work
Takes responsibility for self, own work and others
3.9 Settling of limits necessary
Locking up or transfer to closed ward essential, as well as large doses of strong sedatives
Large doses of strong sedatives enough
Firm, clear verbal control
Ward rules and good supervision necessary, takes chances if supervision is relaxed
Acts within ward rules even without supervision
3. 10 Taking of decisions
Takes no decisions
Asks others to take decisions
Always takes irresponsible decisions or very ambivalent
Occasionally takes irresponsible \ decisions and sometimes ambivalent I
Seeks advice, takes own decisions and bears consequences
Date
Remarks
1
2
3
5
4
3.11 Medication (do 3. 12 if none prescribed)
Refuses to take or does : Takes only under strict not swallow supervision or if forced
Takes if preferred
3.12 General reliability regarding own therapy
Refuses all cooperation
Comes to therapy only under very good supervision or if forced
Comes to therapy of own accord but | is very passive and j takes part only superficially
Participates actively and enthusiastically in some therapy
Constantly but not very intense, talks about it but can continue with routine
Sometimes sad, but not too bad, talks about it if asked
No signs of depression
, Fetches own medication usually on time
Knows own medication, fetches it regularly and on time Uses all forms of therapy enthusiastically
4. PSYCHOPATHOLOGY 4.1 Depression
Severe, uninterrupted and intense feeling of sadness, thoughts morbid, negative about self, not able to do anything
4.2 Suicide
Constant thoughts, has i Less serious attempts, a definite practical plan, ! plans unformed or ! impractical previous serious attempts
4.3 Anxiety or fear
Constantly seeks reassurance, anxiety/fear so bad that routine not followed, sometimes looks frightened, starts, trembles
Anxious more than 50 % of time, but sometimes lighter
More passive wish, Admits old no attempt so far thoughts of suicide, denies now Talks of anxiety/fear but continues with routine
Transient, mention only if asked
No signs
No signs of , anxiety
Date
Remarks
1
2
3
4
5
General attitude surly, abrupt or rude
Sometimes brief outbursts of rage
No signs of aggression or rage
Restlessness so bad for long periods that gets very little done, yet constantly busy
Restlessness for short periods, a few days
Sometimes restless for short periods at night or during the day
No signs of restlessness
Very bad, can do little, stuporous, very dependent on nursing care
Movements noticeably slow more than 50 % of time, gets little done
Long periods of retardation or some short, acute episodes
Just observable retardation of movements
No signs of retardation
4.7 Delusions
Established, general basis of most conduct
Very loose system, leaves out, adds, yet influences conduct
Ideas and thoughts at times, no system
Ideas can be questioned at times
No signs of delusions
4.8 Hallucinations
Constantly hallucinates, basis of most conduct, not at all influenced by presence of staff, no contact
Starts hallucinating in presence of staff, yet has contact
Talks about it without being asked, present for long periods
Looks as though is hallucinating
No signs of hallucination
4.9 Thought disturbance
Word salad or just impossible to understand
Very difficult to follow
Many loose associations, woolly
Ambiguous at times
No signs of thought disturbance
4.4 Rage or aggression
Extremely physical or verbal, difficult or impossible for staff to control
4.5 Motor restlessness
Generally intense, uncontrollable, does not sit still for a moment, even has trouble finishing meals
4.6 Motor retardation
Noisy, threatening, ; rude, sarcastic more than 50% of time
Date
Remarks
1
2
3
4
Occasional signs of elation for one day or part of a day
4.10 Elation
Extreme euphoria and ; Euphoric, noisy more i than 50 % of time or a elation in facial few very acute expression, attitude episodes and speech constant
Constantly in high spirits, not too bad, signs such as flamboyant dress
4.11 Memory
General amnesia, cannot function
Short-term memory Vague signs of disturbance memory disturbance
4.12 Verbal productivity
Only answers Answers questions Very low verbal Total mutism (aphasia), never says a i productivity, questions i questions but does completely but not expand seldom begins a must usually be word conversation or repeated subject
Medium and/or shortterm memory seriously disturbed
5 No signs of elation
No signs of memory disturbance Normal verbal productivity
Date
Remarks
APPENDIX Two
University of Natal Functional Assessment Scale (UNFAS) First contact date Use the following key when filling in the scale: Criterion fully met 2 Criterion partially met 1 Criterion not met 0 Not observed or not applicable 1. Interpersonal status 1.1 Has a friendship relationship with at least one person 1.2 Shows acceptable social habits and behaviour 1.3 Relationship with family stable and satisfactory 1.4 Engages in simple conversation about concrete subjects 1.5 Is generally satisfied with his/her life 2. Self-care status 2.1 Appears clean and neat 2.2 Dresses appropriately 2.3 Copes with situations that are moderately stressful 2.4 Alcohol and/or drug intake not a problem 3. Treatment and mental status 3.1 3.2 3.3 3.4 3.5 3.6 3.7 3.8
Has attended clinic regularly over the last year Takes prescribed medication regularly without assistance Behaviour free from positive signs of mental illness Is oriented to time, place and person Has remained out of the hospital for the last two years Short-term memory is normal Shows insight in own situation Shows good judgement in everyday situations
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Appendix 2
4. Community adjustment status 4.1 Handles own finances effectively 4.2 Uses appropriate community services effectively 4.2.1 Medical facilities 4.2.2 Recreational facilities 4.2.3 Transport 4.2.4 Church 4.2.5 Shops The following two aspects of functioning are addressed by choosing the appropriate category for the patient to get the score for that section. 5. Employment status Category 0. Unemployed, little or no evidence that patient takes responsibility for any jobs at home. 1. Unemployed, but works consistently on jobs around the house. Takes responsibility for these. 2. Unemployed, but does voluntary work outside the home, or is working in protected workshop. 3. Works in sheltered employment, or is retired due to age. 4. Takes full responsibility for housework (housewife), studies or works in the open labour market, not necessarily in a full-time capacity. 6. Living status Category 0. Unstable living conditions 1. Living with family of origin or other relatives 2. Living in a sheltered environment, such as a half-way house or special home 3. Lives in boarding establishment with minimal supervision 4. Lives independently with own spouse and children, or alone, or with friends without supervision TOTAL: [54] Percentage:
Total Possible total
Assessment done by:
, x 100 = Date:
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MENTAL HEALTH NURSING - A SOUTH AFRICAN PERSPECTIVE
PSYCHIATRIC OUTPATIENT: FUNCTIONAL ASSESSMENT GUIDELINES 1. Interpersonal status Items 1.1 and 1.3 need to be assessed with the input of the family and a home visit will probably be necessary. Items 1.2 and 1.4 can be assessed in an interview with the patient. Item 1.2 refers to whether the patient will stand out in a crowd because of behaviour, or whether he/she behaves quite acceptably. 2. Self-care status Items 2.1 and 2.2 can be assessed in an interview with the patient, while the other items need the input of family. Item 2.3 refers to everyday situations like having to deal with household appliances that break, or toothache, or a visit by family. It does not refer to highly stressful events such as major loss. On the SPS Scale in the DSM-IV-TR the stress should not rate higher than 2 (mild). Item 2.4 is scored as 1 if the person has a history of abuse, but there is no current evidence of abuse. 3. Treatment and mental status Items 3.1 and 3.5 can be assessed by studying the patient's record. Item 3.3 may need some input from the family. The other items can be assessed during an interview with the patient. Positive signs of mental illness refer to the presence of abnormal behaviour, thought, perception, and not the absence of motivation or friendships or social interaction. 3.1 Regular attendance means that the patient has not missed more than three appointments over the last year. 3.2 If the patient gets assistance from the family, mark 1. 4. Community adjustments status This whole section can be assessed during an interview. 5. Employment status This section has to be assessed with the help of the family. 6. Living status This section can be assessed during an interview with the patient.
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Appendix 2
Dear Parent/Relative/Friend Please read the following questions carefully and provide us with answers concerning 's behaviour at home, and if possible give us more details on each answer that might be helpful to us in our joint effort to help him/her to continue to get better. Question 1
Does he/she have friends or at least a friend with whom he/she is intimate enough to share secrets or whom he/she approaches for certain problems? Answer
Question 2
Is he/she able to maintain good interpersonal relationships with family members, for example, when he/she is in need of help does he/she consult other family members or do members also ask for help from him/her as a family member? Answer
Question 3
Does he/she cope well with moderate stress at home, for example, when he/she is worried about any event such as losing valuable articles in the house or when there is misunderstanding in the home or when he/she feels bodily pain or is in trouble? Answer
Question 4
Does he/she have any history of alcohol abuse and if so, does he/she have problems when he/she has taken liquor, for example, fighting with others or any other abnormal behaviour? Answer
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MENTAL HEALTH NURSING - A SOUTH AFRICAN PERSPECTIVE
Question 5 How is his/her general behaviour at home? Does he/she show any positive signs of mental illness - if so, what does he/she do that you see as abnormal? Answer
Question 6 If he/she is not employed does he/she take any responsibility for jobs at home or not, for example, gardening, cleaning, cooking, etc.? Answer
Question 7 Does he/she consistently do jobs around and outside the home and take full responsibility for these as indicated above? Answer
Question 8 Does he/she do voluntary jobs outside the home, for example, help neighbours with a job to be done, such as preparing for a party, cleaning the yard, painting, etc.?
Answer
Question 9 Does he/she take full responsibility for the housework (housewives), for example, ironing, cleaning, cooking, without being urged to do these tasks, and does he/she use his/her discretion
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Appendix 2
about jobs to be carried out or doing private study, or does he/she work in the open labour market as a part-time or full-time worker? Answer
Thank you Signature N.B. These questions should be translated into the language of the family. (Dube 1989)
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APPENDIX THREE
Examples of Questions Used in a Psychiatric History
HALLUCINATIONS Did you hear voices or sounds that could not be heard by other people when you were sick? If yes: What did you hear? When did these voices first start? (If the patient can't remember, ask: How old were you when the voices started? Was it winter/summer/nearly winter/nearly summer?) Did the voices give a running commentary on your behaviour or thoughts? How many voices did you hear? Did they talk to each other or to you? Did you ever see things that other people could not see? If yes, what did you see? (Visual hallucinations.) Did you have strange feelings in your body or did it feel as if there were things crawling on your skin? When? (Tactile hallucinations.) Did you smell things others could not smell? (Olfactory hallucinations.) Did you have strange tastes in your mouth? (Gustatory hallucinations.) DELUSIONS Have parts of your body changed or stopped functioning? Has there been an outside force controlling your thoughts and actions? Have thoughts been taken out of your head/put into your head? Are there people who want to harm you, speak badly about you or take too much notice of you? Who are these people? Why do you think they do this? Compared to other people, do you see yourself as better than most people or are you the same as others? Are you a prominent, rich, strong or clever person? Are you especially close to God/Christ? (Name the patient's specific religious deity.) In what way? Do you have any special powers or abilities? Are there people or forces out to get you? Who?
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Appendix 3
(Traditionally, illness or misfortune may be attributed to bewitchment by others, including family members, therefore it is not delusional unless it includes many people or hospital/clinic staff or other patients.) Affect or mood Did you feel so good or happy that other people thought you were not yourself? When did this start? Do you feel more irritable than usual, or get into fights? Have you felt especially full of energy or full of exciting ideas (at work, with friends, at home)? Have you felt very sad or depressed nearly every day for two weeks? Are you disenchanted with the things you used to enjoy (frequency, duration)? Has your appetite changed? How? Was there a change in the fit of your clothes? How were you sleeping? Did you have trouble falling asleep, waking often in the night, waking up too early while others were asleep? Did you sleep too much, even in daytime? Did you feel worthless about things you had done or not done? Did you feel tense inside your body? Were you more tired than usual every day? Psychomotor activity Were you so fidgety and restless that you were unable to sit still? Or did you talk or move more slowly? Thought disturbances Do you have trouble thinking or concentrating? Do you feel as if your thoughts are racing away and you can't control them? Have you been thinking a lot about death or wanting to kill yourself? How are you going to kill yourself? Have you worked out a plan? Were you more talkative than usual? Orientation Do you know where you are? Where? What is the time now? If not sure: Is it morning, midday, afternoon, night-time, middle of the night? Who brought you to the hospital/clinic?
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Intellectual ability How did you do at school? If below Grade 4 and mental disability is suspected, ask: How many legs does one cow/dog have? Two cows? Three cows? Did you go to college/university? PRECIPITATING FACTORS
Just before you became ill, did you have any stresses at home/work/with a loved one? What happened? How did you feel about yourself? What did you do to get rid of the stressful feelings? Did you stop taking your medication before you became ill? Can you remember what made you stop taking your medication? Have you been in an accident where you were hit on the head? Just before you became ill, were you taking too much alcohol/dagga/other drugs? If yes: How much each day and for how long? Did you become ill after you stopped taking alcohol, etc.? If the person is female and of child-bearing age, ask: How old is your last-born child? (Buntting 1991)
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APPENDIX FOUR
Evaluation of Group Work Nurse: Evaluator:
Date:
Instructions to the evaluator Mark each criterion with a cross on a scale of one to five as you believe it applies to the nurse. 1 = ineffective 5 = exceptionally effective (For office use only) Questionnaire no: (1-3) Evaluation criteria 1. Did the nurse decide on an objective for the group beforehand? 2. Has the nurse set criteria for the inclusion of members? 3. Is the chosen activity appropriate for the achievement of the objective of the group work? 4. Were individual interviews conducted with prospective members? 5. Do members comply with the criteria set for inclusion in the group? 6. Is the number of members suitable for the particular group work? 7. Is the nurse sensitive to the physical set-up of the group? 8. Does the nurse provide opportunities for introduction to the group? 9. Is the goal of the group work discussed? 10. Are rules made and accepted by the group? 11. Does the nurse come up to the expectations of the group?
Interval scale 1 2
3 4 5 (4)
1 2
3 4 5 (5)
1 2
3 4 5 (6)
1 2
3 4 5 (7)
1 2
3 4 5 (8)
1 2 3 4 5 (9) 1 2 3 4 5 (10) 1 1 1 1
2 2 2 2
3 3 3 3
4 4 4 4
5 5 5 5
(11) (12) (13) (14)
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Evaluation criteria 12. Are activities introduced to the group in a stimulating and concrete way? 13. Is group activity linked to the normal functioning of the members? 14. Does the nurse apply techniques to encourage group interaction? 15. Does the nurse succeed in activating the group here and now? 16. Does the nurse cope with obstacles during the group process? 17. Does the nurse succeed in maintaining a balance between the various leadership functions? 18. Does the nurse succeed in identifying dynamics during the group process and in responding appropriately? 19. Does the nurse use summaries during group work? 20. Does the nurse apply mental health nursing skills to initiate and maintain the group process? 21. Does the nurse succeed in keeping individual interactions goal-directed? 22. Does the nurse succeed in getting all the members involved 23. Does the nurse succeed in keeping the group process goal-directed? 24. Does the nurse follow the cues given by individual members and the tempo of the group process? 25. Does the nurse succeed in balancing group leadership and group participation? 26. Does the nurse avoid the use of his/her own frame of reference in group work? 27. Does the nurse offer members an opportunity to verbalize their experience of the group process? 28. Are the group-work goals evaluated and achieved? 29. Is the group work summarized succinctly and in a concrete manner at the end of the session? 30. Is an opportunity for follow-up presented? 31. Does the nurse keep to the structure and process of group work? 32. Does the duration of the group work correlate with the identified objective?
Interval scale 1 2 3 4 5 (15) 1 2 3 4 5 (16) 1 2 3 4 5 (17) 1 2 3 4 5 (18) 1 2 3 4 5 (19) 1 2 3 4 5 (20) 1 2 3 4 5 (21) 1 2 3 4 5 (22) 1 2 3 4 5 (23) 1 2 3 4 5 (24) 1 2 3 4 5 (25) 1 2 3 4 5 (26) 1 2 3 4 5 (27) 1 2 3 4 5 (28) 1 2 3 4 5 (29) 1 2 3 4 5 (30) 1 2 3 4 5 (31) 1 2 3 4 5 (32) 1 2 3 4 5 (33) 1 2 3 4 5 (34) 1 2 3 4 5 (35)
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Appendix 4
Evaluation criteria
Interval scale
Evaluation of the nurse's ability to analyse group dynamics To what extent does the nurse: 33. describe and analyse group interaction?
1 2 3 4 5 (36)
34. describe and analyse the group atmosphere?
1 2 3 4 5 (37)
35. identify and motivate the roles of the members?
1 2 3 4 5 (38)
36. identify, explain and motivate the style of leadership used?
1 2 3 4 5 (39)
37. identify less-than-effective aspects of the way in which the group is handled?
1 2 3 4 5 (40)
38. identify positive aspects of the way in which the group is handled?
1 2 3 4 5 (41)
39. identify problem areas in the way in which the group is handled?
1 2 3 4 5 (42)
Remarks: Average mark: 42-55 56-82 83-107 108-135 136-160 161-187 188-210
= = = = = = -
Ineffective Less than effective Below average Average Above average Effective Exceptionally effective
= = = = = = =
0-26 % 27-39 % 40-51 % 52-64 % 65-76 % 77-89 % 90-100 %
(Greeff 1988)
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APPENDIX FIVE
Evaluation of Mental Health Education
Student: Evaluator:
Date:
Instructions to evaluator Mark each criterion with a cross on a scale of one to five as you believe it applies to the student. 1 = ineffective 5 = exceptionally effective (For office use only) Questionnaire no: (1-3) 1. 2. 3. 4. 5. 6. 7. 8. 9.
To what extent did the nurse assess the target group or person? To what extent were objectives set for the mental health tuition? To what extent did the nurse make use of teaching media and aids? How effectively did the nurse create learning opportunities for the target group?
1 2
3 4 5 (4)
1 2
3 4 5 (5)
1 2
3 4 5 (6)
1 2
3 4 5 (7)
How appropriate was the content of the mental health tuition?
1 2
3 4 5 (8)
To what extent did the nurse make use of interpersonal skills in the teaching process?
1 2
3 4 5 (9)
To what extent did the nurse encourage participation of the group or person in the teaching process? To what extent were the objectives of the mental health tuition achieved? To what extent were opportunities for follow-up offered?
1 2 3 4 5 (10) 1 2 3 4 5 (11) 1 2 3 4 5 (12)
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Appendix 5
Remarks: Average mark: , , , 9-17 18-23 24-29 30-36 37-44 45-51 52 and more
= = = = = =
Ineffective Less than effective Below average Average Above average Effective Exceptionally effective
= = = = = = =
29 % and lower 30-39 % 40-49 % 50-60 % 61-74 % 75-85 % 86 % and more
(Poggenpoel 1986)
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A P P E N D I X Six
Time-event Chart for a Patient with Anxiety Symptoms Left college Occasional anxiety gradually disappeared Uncle died aged 40, heart attack 1970 Separated from partner Severe generalized anxiety increased Night panics
Began oxazepam Job insecurity; felt trapped by children
Daytime panics Stopped oxazepam; began taking vitamins Rapid improvement in symptoms 1980 Mother died Youngest daughter left home, no longer trapped, began to travel Slightly uptight Panic attacks rapidly increased Panic attacks lessened but continued with moderate generalized anxiety and occasional attacks
Began trip overseas Shortened trip, began avoiding travelling locally; began to exercise; took large amounts of vitamins
(Adapted from Hawton et al. 1989: 24)
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APPENDIX SEVEN
Hamilton Anxiety Rating Scale
Mild
-
Occurs irregularly and for short periods
Moderate
-
Occurs more constantly and for longer periods
Severe
-
Continuous and dominates patient's life
Very severe -
Incapacitating
1.
Anxiety Worries, anticipation of the worst, fearful anticipation, irritability
2.
Tension Feelings of tension, fatigue, moved to tears easily, trembling feelings of restlessness, startle response, inability to relax
3.
Fears Of dark, of strangers, of being left alone, of animals, of traffic, of crowds
4.
Insomnia Difficulty in falling asleep, night terrors, unsatisfying sleep, fatigue on waking, dreams, nightmares
5.
Intellectual (cognition) Difficulty in concentration, poor memory
6.
Depression Loss of interest, lack of pleasure in hobbies, depression, early waking, diurnal swing
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7. Somatic (muscular) Pains and aches, twitchings, stiffness, myoclonic jerks, grinding of teeth, unsteady voice, increased muscle tone 8. Somatic Tinnitus, blurring of vision, hot and cold flushes, feelings of weakness, prickling sensation 9. Cardiovascular symptoms Tachycardia, palpitations, pain in chest, throbbing of vessels, feeling faint, missed beat 10. Respiratory symptoms Pressure or constriction in chest, choking feelings, sighing, dyspnoea 11. Gastrointestinal symptoms Difficulty in swallowing, wind, burning sensations, abdominal pain, nausea, vomiting, looseness of bowels, loss of weight, constipation 12. Genitourinary Frequency and urgency of urination, amenorrhoea, menorrhagia, frigidity, loss of libido, impotence, premature ejaculation 13. Autonomic symptoms Dry mouth, flushing, pallor, sweating, giddiness, tension headache 14. Behaviour at interview Fidgeting, restlessness or pacing, tremor, furrowed brow, strained face, sighing or rapid respiration, facial pallor, swallowing, belching TOTAL
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Appendix 7
STANFORD PANIC APPRAISAL INVENTORY Listed below are 20 statements reflecting some common feelings and thoughts that people report during sudden attacks of panic or extreme anxiety. Read each item carefully and then choose the number from the scale that best describes the degree to which you are troubled by the feeling or thought. Then write the number on the line opposite each statement. 0
1
Not at all troubling
2
3
Mildly troubling
4
5
6
Moderately troubling
7
8
Markedly troubling
9
0
Extremely troubling
1. I may faint. 2. People will stare at me. 3. I may become hysterical. 4. I may have a heart attack. 5. I may drive off the road and crash. 6. I may do something uncontrollable like jump out of a window. 7. I may scream. 8. I may not be able to move from one spot. 9. I may be put into a mental hospital. 10. I may get sick to my stomach. 11. People will laugh at me. 12. I may lose my balance and fall. 13. I may suffocate. 14. I will be an embarrassment to my family and friends. 15. I may die.
16. I may go insane. 17. I may lose control of my bowels. 18. 1 will be trapped. 19. Others will think I am weird. 20. I may have a brain tumour.
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FEAR QUESTIONNAIRE Choose a number from the scale below to show to what extent you would avoid each of the situations listed below because of fear or other unpleasant feelings. Then write the number you have chosen on the line opposite each situation. 0
1
Would not avoid it
2
3
Slightly avoid it
4 Definitely avoid it
5
6 Markedly avoid it
7
8 Always avoid it Leave this area blank
Main phobia you want treated (describe in your own words). Eating or drinking with other people. Being watched or stared at. Talking to people in authority. Being criticized. Speaking or acting before an audience.
Soc
Travelling alone by bus or coach. Walking alone in busy streets. Going into crowded shops. Going far from home alone. Large open spaces.
AG
Injections or minor surgery. Hospitals. Sight of blood. Thought of injury or illness. Going to the dentist.
BI
Section 2 1. Have you ever had attacks of extreme anxiety or panic that seem to come on suddenly in situations or places that pose no real danger? Yes No 2. If yes, please check each of the symptoms below that you experienced during your last bad panic attack. Shortness of breath Choking or smothering sensations Palpitations (heart racing or pounding)
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Appendix 7
Chest pain, pressure, tightness or discomfort Sweating Feeling faint (doesn't mean you actually have to faint) Dizziness or unsteadiness Nausea or abdominal distress Depersonalization or derealization (things seem unreal or you feel detached from your body) Numbness or tingling in any part of your body Hot or cold flushes Trembling or shaking Fear of dying Fear of going crazy or doing something uncontrolled Other (please describe) 3. How many panic attacks (including milder ones) have you had in the last seven days? 4. How many panic attacks (including milder ones) have you had in the last month? 5. Do some of your panic attacks occur out of the blue in safe situations, such as when you're at home? Yes No Section 3 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13.
Are you bothered by many different symptoms? Do you find that you are often aware of various things happening in your body? If a disease is brought to your attention through the radio, television, newspaper or someone you know, do you worry about getting it yourself? Is it easy for you to forget about yourself and think about all sorts of other things? Do you think that you worry about your health more than most people? Are you afraid of illness? Is it hard for you to believe the doctor when he tells you there is nothing for you to worry about? Do you get the feeling that people are not taking your illness seriously enough? Have you always had one thing or another wrong with your health? Have others told you that you spend too much time talking about your health? Do you think something is wrong with your health that the doctors haven't been able to find? Do you find yourself worrying about your health? Do you feel you need to see your physician even though you are not always able to?
Section 4 1. Have you been depressed or down or without interest in most things every day for the past two weeks? 2. Do you have a poor appetite or significant weight loss?
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3. 4. 5. 6. 7.
Have you had trouble falling asleep, waking frequently, staying asleep, waking too early or sleeping too much? Have you lost interest or pleasure in your usual activities? Have you been having trouble thinking or concentrating? Have you been thinking about death or hurting yourself? Have you had some kind of pain in your body nearly every day for the last six months?
Section 5 Below is a list of problems and complaints that people sometimes have. Check one of the spaces to the right that best describes how much that problem bothered or distressed you during the last week, including today. Not at i A little \ Moderately all bit
Quite ; Extremely a bit
Nervousness or shakiness inside Trembling Suddenly scared for no reason Feeling fearful Heart pounding or racing Feeling tense or keyed up Spells of terror or panic Feeling so restless you couldn't sit still The feeling that something bad is going to happen to you Thoughts and images of a frightening nature
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Appendix 7
Section 6 Circle a number that best describes your situation now. Work Because of my problems my work is impaired. 0
1
Not at all
2
3
4
Mildly
5
6
Moderately
7
8
Markedly
9
0
Very severely (cannot work)
Social life/leisure activities (With other people at parties, socializing, visiting, dating, outings, clubs and entertaining) Because of my problems my social life/leisure is impaired. 0
1
Not at all
2
3
4
Mildly
5
6
Moderately
7
8
Markedly
9
10
Very severely (I never do these)
Family life/home responsibilities (For example, relating to family members, paying bills, managing home, shopping and cleaning) Because of my problems my family life/home responsibilities are impaired. 0 Not at all
1
2 Mildly
3
4
5 Moderately
6
7
8
Markedly
9
0
Very severely (I never do these)
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EIGHT
Beck Depression Inventory
Read through the statements grouped under each letter, A to U. Select the statement in each group that best describes the way you feel today. Circle the number next to that statement. If two or more statements in a group describe the way that you feel equally well, circle the number next to each one. Be sure to read through all the statements in each group before you select one. A (sadness) 0 I do not feel sad. 1 I feel blue and sad. 2 (a) I am blue or sad all the time and I cannot snap out of it. (b) I am so sad or unhappy that it is quite painful. 3 I am so sad or unhappy that I cannot stand it. B (pessimism) 0 I am not particularly pessimistic or discouraged about the future. 1 I feel discouraged about the future. 2 (a) I feel I have nothing to look forward to. (b) I feel that I will never get over my troubles. 3 I feel that the future is hopeless and that things cannot improve. C (sense of failure) 0 I do not feel like a failure. 1 I feel I have failed more than the average person. 2 (a) I feel I have accomplished very little that is worthwhile or that means anything. (b) As I look back on my life all I can see is a lot of failures. 3 I feel I am a complete failure as a person (parent, husband, wife). D (dissatisfaction) 0 I am not particularly dissatisfied. 1 (a) I feel bored most of the time. (b) I do not enjoy things the way I used to.
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2 I do not get satisfaction out of anything anymore. 3 I am dissatisfied with everything. E (guilt) 0 I do not feel particularly guilty. 1 I feel bad or unworthy quite often. 2 (a) I feel quite guilty. (b) I feel bad or unworthy practically all the time. 3 I feel as though I am very bad or worthless. F (expectation of punishment) 0 1 2 3
I do not feel I am being punished. I have a feeling that something bad may happen to me. I feel I am being punished or will be punished. (a) I feel I deserve to be punished. (b) I want to be punished.
G (self-dislike) 0 I do not feel disappointed in myself. 1 (a) I am disappointed in myself. (b) I do not like myself. 2 I am disgusted with myself. 3 I hate myself. H (self-accusatory) 0 1 2 3 I
I do not feel I am any worse than anybody else. I am critical of myself for my weaknesses and mistakes. I blame myself for my faults. I blame myself for everything bad that happens.
(suicidal) 0 I do not have any thoughts of harming myself. 1 I have thoughts of harming myself but I would not carry them out. 2 (a) I feel I would be better off dead. (b) I feel it would be better for my family if I were dead. 3 (a) I have definite plans about committing suicide. (b) I would kill myself if I could.
J
(crying) 0 I do not cry more than usual. 1 I cry more than I used to.
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2 I cry all the time; I cannot stop crying. 3 I used to be able to cry, but now I cannot cry at all even though I want to. K (irritability) 0 I am no more irritated now than I used to be. 1 I become annoyed or irritated more easily than I used to. 2 I feel irritated all the time. 3 I do not become irritated at the things that used to irritate me. L (social withdrawal) 0 I have not lost interest in other people. 1 I am less interested in other people now than I used to be. 2 I have lost most of my interest in other people. 3 I have lost all my interest in other people and do not care about them. M (indecisiveness) 0 I make decisions about as well as I used to. 1 I try to put off making decisions. 2 I have great difficulty in making decisions. 3 I cannot make decisions. N (body-image change) 0 I do not feel I look any worse than I used to. 1 I am worried that I am looking older and unattractive. 2 I feel that there are permanent changes in my appearance and they make me look unattractive. 3 I feel that I am ugly and repulsive. 0 (work retardation) 0 I can work as well as I used to. 1 (a) It takes extra effort to get started at doing a task or job. (b) I do not work as well as I used to. 2 I have to push myself very hard to do anything. 3 I cannot do any work at all. P (insomnia) 0 I can sleep as well as I used to. 1 I wake up more tired in the morning than I used to. 2 I wake up one or two hours earlier than usual and find it hard to get back to sleep. 3 I wake up early every day and cannot get more than five hours of sleep.
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Q (fatigue) 0 I do not become more tired than usual. 1 I become tired more easily than I used to. 2 I become tired from doing anything. 3 I become too tired to do anything. R (anorexia) 0 1 2 3
My appetite is no worse than usual. My appetite is not as good as it used to be. My appetite is much smaller. I have no appetite at all.
S (weight loss) 0 1 2 3
I have not lost much weight, if any. I have lost more than 2 kg. I have lost more than 4 kg. I have lost more than 8 kg.
T (somatic preoccupation) 0 I am no more concerned about my health than usual. 1 I am concerned about aches and pains and an upset stomach or constipation. 2 I am so concerned with how I feel or what I feel that it is difficult to think of much else. 3 I am completely absorbed with what I feel. U (loss of libido) 0 I have not noticed any recent change in my interest in sex. 1 I am less interested in sex than I used to be. 2 I am much less interested in sex. 3 I have lost interest in sex completely. (Beck 1967)
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APPENDIX NINE
Classification of Psychiatric Disorders of Infancy, Childhood and Adolescence (According to the DSM-IV-TR)
(DD = Developmental disorder) (NOS = Not otherwise specified) 1. Mental retardation Mild Moderate Severe Profound Unspecified 2. Pervasive developmental disorders Autistic disorder (specify if childhood onset) Pervasive developmental disorder NOS 3. Specific developmental disorders Academic skill disorders: - DD: Arithmetic - DD: Expressive writing disorder - DD: Reading Language and speech disorders: - DD: Articulation - DD: Expressive - DD: Receptive Motor skills disorders: - DD: Co-ordination - Specific DD NOS 4. Other DDs: DDNOS
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DISRUPTIVE BEHAVIOUR DISORDERS 1. Attention-deficit hyperactivity disorder 2. Conduct disorder: Group type Solitary-aggressive type Undifferentiated type 3. Oppositional defiant disorder ANXIETY DISORDERS OF CHILDHOOD OR ADOLESCENCE 1. Separation anxiety disorder 2. Avoidant disorder of childhood adolescence 3. Overanxious disorder EATING DISORDERS 1. 2. 3. 4. 5.
Anorexia nervosa Bulimia nervosa Pica Rumination disorder of infancy Eating disorder NOS
GENDER IDENTITY DISORDERS (GID) 1. GID of childhood 2. Transsexualism Specify sexual history: Asexual, homosexual, heterosexual, unspecified 3. GID of adolescence or adulthood, non-transsexual type Specify sexual history: Asexual, homosexual, heterosexual, unspecified 4. GID NOS TIC DISORDERS 1. Tourette's disorder 2. Chronic motor or vocal tic disorder 3. Transient tic disorder Specify: Single episode or recurrent 4. Tic disorder NOS ELIMINATION DISORDERS 1. Functional encopresis Specify: Primary or secondary type
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2. Functional enuresis Specify: Primary or secondary type Specify: Nocturnal only, diurnal only, nocturnal and diurnal SPEECH DISORDERS NOS 1. Cluttering 2. Stuttering OTHER DISORDERS OF INFANCY, CHILDHOOD AND ADOLESCENCE 1. 2. 3. 4. 5.
Elective mutism Identity disorder Reactive attachment disorder of infancy or early childhood Stereotype or habit disorder Undifferentiated attention-deficit disorder
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APPENDIX
TEN
Glossary of Psychiatric Terms
Abstract thinking: Ability to understand the meaning of events, experiences and communications. The person can also use and understand metaphoric speech appropriately, for example, the proverb 'a rolling stone gathers no moss' is correctly interpreted to mean that people who move around a great deal seldom put down roots. Active phase: The second stage of schizophrenia, during which the patient begins showing prominent psychotic features such as delusions, hallucinations, incoherence or marked loosening of associations, catatonic behaviour, flat or grossly inappropriate affect. Affect: A person's observable emotional responses, seen in the person's non-verbal behaviours such as facial expression, posture, gestures and tone of voice. Affect is what the examiner sees; it is the outward manifestation of emotion. Affect may be referred to as inappropriate, flat or blunt, depending on the degree of apathy. A disturbance in affect is common in schizophrenia but may also be found in severe depression. Blunt affect: A mood disorder in which the person shows little emotional response, regardless of what he/she is saying or what is going on around him/her, for example, Didi is talking about the recent death of her cousin Jamie in a car accident; there is some evidence of emotion in her non-verbal behaviour, such as evidence of tears in her eyes, but her voice is flat and her face is expressionless. Flat affect: A mood disorder in which the person shows no emotion; the face remains expressionless and the voice tone is monotonous, regardless of what the person is saying or what is going on around him/her, for example, Mimi talks about the loss of her child; she sits immobile, her face shows no expression, her voice is monotonous. There is no evidence of any emotion in her non-verbal behaviour, even though the experience she is talking about is tragic. Inappropriate affect: A mood disorder in which the person's emotional responses are totally unsuited to what he/she is saying or what is going on around him/her, for example, Sally laughs when talking about her father's abuse of her as a child. Aggression: Forceful goal-directed action that may be verbal or physical. It is the behavioural part of the emotion of rage, hostility or anger, for example, Prudence is feeling angry; she shouts at the nurse and slams the door.
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Ambivalence: Simultaneous conflicting feelings, attitudes or thoughts in a person towards another person, object or event, for example, Israel desperately wants to get married, but at the same time he is terrified of committing himself to one person for the rest of his life. Anxiety: A term used to describe feelings of uncertainty, uneasiness, apprehension or tension that a person experiences in response to an unknown object or situation. Apathy: Lack of feeling, concern, interest or emotion. The person seems detached from the environment and totally indifferent to it. Bipolar mood disorder: A type of mood disorder involving both manic and depressive episodes. This disorder usually appears first in the form of a manic episode. The subsequent episodes may appear in a variety of patterns: a) Manic episode alternating with a depressive episode, with a normal period of functioning between the two, that is, an initial manic episode, then a normal period, depressive episode, normal period, manic episode and so forth; b) Manic episode followed immediately by a depressive episode followed by a period of normal functioning, that is, a manic episode, depressive episode, normal period, manic episode, depressive episode, normal period and so forth; c) In rare cases the mood may shuttle back and forth between mania and depression with no intervals of normal functioning (cycling type) OR depressive and manic symptoms may occur at the same time (mixed type). Catatonia: A disturbance in psychomotor behaviour that can either take the form of stupor, rigidity, excitement or waxy flexibility. Catatonia is most commonly related to schizophrenia but is not often seen any more. It is regarded as one of the positive and active signs of schizophrenia. Catatonic excitement: The person shows agitated, purposeless motor activity which is influenced by external stimuli. Catatonic rigidity: The person may hold a rigid posture for hours and resist efforts to be moved. Catatonic stupor: Motor activity is markedly slow and the person seems unaware of the environment. Waxy flexibility: The person can be 'moulded' into positions which are then maintained. When the examiner moves the limbs, they feel as if they are made of wax. Cognition: Mental processes such as thought, memory, attention, perception and interpretation. Concrete thinking: An inability to find the meaning of events, communications and experiences. Communications are taken literally, for example, the proverb 'a rolling stone gathers no moss' is interpreted to mean that stones which roll do not gather moss because they are moving all the time.
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Content of thought: Refers to the information conveyed in a sentence. Delusions, overvalued ideas and concrete thinking are the common symptoms of disturbed content of thought. Conversion: see Somatoform disorder. Delusion: An irrational belief which has no basis in reality but which cannot be changed by logic or argument. These are among the most common schizophrenic thought disorders. There are many different types of delusions. Delusions of persecution (often called paranoid delusions): The belief that one is being plotted against, spied upon, threatened, interfered with or otherwise mistreated, particularly by a number of parties joined in a conspiracy, for example, Nonhlana believes that the security police are spying on her and watching her every move. Delusions of control (also called delusions of influence): The belief that other people, forces or perhaps extraterrestrial beings are controlling one's thoughts, feelings and actions, often by means of electronic devices which send signals directly to one's brain. The common delusions of control are thought broadcasting, thought insertion and thought withdrawal. Thought broadcasting: The belief that one's thoughts are being broadcast to the outside world, for example, by radio, television or any electronic device, so that others can hear them. For example, Nonhlana says the security police are broadcasting her political beliefs over the radio. Thought insertion: The belief that others are inserting thoughts, especially obscene ones, into one's head, usually by means of electronic devices or mental telepathy, for example, Mary claims that the TV announcer is telling her that her psychologist wants to have sex with her. Thought withdrawal: The belief that other people are removing thoughts from one's head, for example, Simon says his neighbours are drawing out his thoughts from his head with a vacuum cleaner. Delusions of grandeur: The belief that one is an extremely famous, powerful and important person, for example, God. Common in schizophrenia and manic disorders. Delusions of reference: The belief that events or stimuli unrelated to the individual are actually referring to the patient, for example, while watching a TV programme on wildlife, Jenny thinks her life is being depicted on TV. Delusions of sin and guilt: The belief that one has committed a terrible sin or inflicted great harm on others, for example, Harold claims he has killed his children and can never be forgiven. Delusions of nihilism (nihilistic delusions): The belief that one, others or the whole world has/have ceased to exist, for example, Mdu claims he is a spirit returned from the dead.
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Delusions ofhypochondriasis (hypochondriacal delusions): The unfounded belief that one is suffering from a hideous physical disease or a bizarre physical affliction, for example, Patience claims her liver is being carried away in pieces. Depersonal isolation: A subjective sense of being unreal, strange or unfamiliar to oneself, for example, James says he feels as if he is not really present in his daily life, as though he is walking in his sleep. Depression: A mood state characterized by a feeling of sadness, dejection, despair, discouragement or hopelessness. Depression is thought to be precipitated by a loss of some kind, real or imagined, such as self-esteem, a love object, independence, freedom, physical integrity, autonomy, youth, material possessions, for example, Zacharia became depressed when his crop was lost during a severe drought. Derealization: A subjective sense that the environment has changed in some way or is strange and unreal, for example, John walks into his office and feels as if it is a stranger's office and he is a visitor. Distractibility: Rapid shift of attention from one stimulus to another, for example, while talking to his mother, Madoom notices a magazine lying on the couch and abruptly turns his attention to it. As he picks it up, he notices someone passing by and runs to the window to have a look. A person who is distractible seldom focuses his/her attention on something for more than a few seconds or minutes at a time. Echolalia: Pathological repetition of the words or phrases of one person by another; tends to be repetitive and persistent, and may be spoken with mocking or staccato intonation. Echopraxia: Pathological imitations of the movements of one person by another. Form of thought: The way in which words are put together so that ideas, feelings and thoughts are expressed in sentences that make little sense. The most common forms of thought disorders are: Circumstantiality: A pattern of speech in which the person starts talking about something and gives a great deal of unnecessary detail before eventually coming back to the topic. Clanging: A characteristic speech pattern of schizophrenia in which a series of words are used together because they rhyme or sound similar, without regard to logic: 'Sister Lee is a flea, she pees in a tree'. Flight of ideas: Rapid, continuous verbalizations or a play on words produce constant shifts from one idea to another; the ideas tend to be connected and in less severe forms can be followed by the listener. Common in a manic episode. Example: 'I went to the shop and what a flop did you know that she flipped her lid when I left her driving on the left side of the road is a real pain I nearly had an accident and the last time I had a pain was when I had my tonsils out'. Incoherence: Pattern of speech that is generally not understandable. Thoughts and words run into each other with no logical or grammatical connection.
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Loosening of associations: Form of thought in which ideas shift from one to another in an indirectly related way or in a completely unrelated way. When the problem is severe, speech may be completely incoherent. This is characteristic of schizophrenic speech patterns. Neologisms: A schizophrenic speech pattern in which new words are made up by combining parts of other words or in which common words are used in a unique fashion. It is sometimes possible to understand this form of communication, for example, a nurse asks a patient why she is not eating supper. The patient replies: 'No, I had a belly bad luck and brutal and outrageous' (I have a stomach-ache and I don't feel well). Tangentiality: A pattern of speech in which the person starts talking about something, wanders off the point and never returns to it. Thought blocking: An abrupt interruption in the train of thinking, before a thought or idea is finished; the person indicates no recall of what was being said or was going to be said. Word salad: A schizophrenic speech pattern in which words or phrases are combined in a disorganized fashion, seemingly devoid of logic and meaning. It is generally not possible to understand this form of communication, for example, a patient says 'rapid is falling and too much mayonnaise ice in the cinema'. Hallucination: A sensory perception that occurs in the absence of any appropriate external stimuli. May occur in any of the five senses. Hallucinations may be mood-congruent or mood-incongruent. Auditory hallucinations: False perceptions of sound, usually voices but also various noises such as music, etc. In depressive disorders auditory hallucinations involve themes such as guilt, deserved punishment, inadequacy and worthlessness. In manic disorders auditory hallucinations involve themes of inflated worth and power. When auditory hallucinations first start, the person often regards them as friendly because their content is friendly. As they become established, the content (what the voices are saying) becomes more threatening and the person becomes more frightened by them. The content of the voices schizophrenics hear are usually derogatory and hostile towards the hearer. More than one voice may be heard at a time, and the voices might talk directly to the person or to each other about the person, for example, Moses hears three voices talking to one another about what an evil person Moses is. Gustatory hallucinations: False perceptions of taste, such as unpleasant tastes. Often associated with temporal lobe epilepsy. Olfactory hallucinations: False perceptions of smell. Somatic hallucinations: False sensations of things occurring in or on the body, for example, snakes crawling inside the stomach. Tactile hallucinations: False perceptions of touch or surface sensations, as from an amputated limb (phantom limb) or a crawling sensation on or under the skin.
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Visual hallucinations: False perceptions of sight involving formed images, for example people, and unformed images, for example flashes of light. Hyperactivity: Increased activity and restlessness; activity is usually goal-directed, unlike psychomotor agitation. Hyperactivity is common in a manic episode and usually accompanies an expansive mood. Hypochondriasis: see Somatoform disorders. Ideas of reference: A belief that one is being talked about by others or that events in the environment somehow refer to oneself, even though there is no objective evidence for this. An idea of reference is similar to a delusion of reference but is less firmly held than a delusion. Illusion: A false interpretation or perception of a real environmental stimulus that may involve any of the five senses, for example, a person mistakes a belt for a snake. Visual and auditory illusions are the most common. Insight: The ability to analyse a situation and understand the true meaning of an experience, for example, Vani hears voices; she knows that hearing voices is not normal and realizes she needs help. Insight can be impaired, for example, Alpheus forgets to phone his girlfriend for a week; when he sees her again, she is angry with him and he can't understand why. His insight is impaired; he is unable to recognize that his behaviour has offended his girlfriend. Judgement: The ability to assess a situation correctly and act appropriately within that situation. Insight and judgement often go hand in hand, that is, if insight is impaired, judgement might also be impaired. Judgement may be normal or impaired. Impaired judgement: A decreased ability to assess a situation correctly and act appropriately in that situation, for example, a patient walks naked in the street; a person swears and shouts at a stranger for dropping litter on the pavement. Mania: An emotional state characterized by intense and unrealistic feelings of elation. A manic episode begins suddenly over the course of a few days. It may last from several days to several months and usually ends as abruptly as it began. The prominent features are: elated, expansive or irritable mood; hyperactivity; talkativeness; flight of ideas; inflated self-esteem; sleeplessness; distractibility; reckless behaviour. A person in a manic phase may show thought disorders similar to those of schizophrenia, for example, illogical thinking, incoherence, loosening of associations and grandiose delusions. Magical thinking: The belief that one's thoughts, words or actions can cause or prevent events, for example, Princess believes that if she says the word 'help', God will come down out of the sky to help her. Major depression: A type of mood disorder characterized by major depressive episodes occurring without intervening manic episodes. Onset is usually gradual, occurring over a period of several weeks to several months; the mood disorder lasts longer than a
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manic episode and ends slowly and gradually. The prominent features are: depressed mood; loss of pleasure or interest in usual activities; disturbance of appetite; sleep disturbance; psychomotor retardation or agitation; loss of energy; feelings of worthlessness and guilt; difficulties in thinking; recurrent thoughts of death or suicide. A severely depressed person may show psychotic features, for example, delusions of guilt, nihilistic delusions, auditory hallucinations of worthlessness and guilt. Mannerisms: Stereotyped involuntary movements, for example, Harold continually wrings his hands. Memory: The ability to recall stored information. Immediate retention and recall: The ability to recall information immediately after it was presented, for example, an examiner gives a patient five words and then one minute later asks him/her to recall the five words. Recent: The ability to recall information about events of the past few days. Recent past: The ability to recall information about events of the past few months. Remote memory: The ability to recall information about childhood and important events known to have occurred when the person was younger. Mental disorder: A clinically significant behavioural or psychological syndrome or pattern that occurs within a person and is associated with distress or disability. It is not an expectable response to a particular event or experience. The term mental disorder is used instead of mental illness. Mental illness is too vague a term and implies that people who don't meet the criteria for mental health are therefore mentally ill. Mental health: A state of being in which a person is simultaneously successful at working, loving and resolving conflicts by coping and adjusting to the recurrent stresses of everyday living. This doesn't mean that a mentally healthy person has no problems. He/she might at certain times experience severe distress but is generally able to cope with the distress. Mood: A prolonged, sustained emotion subjectively reported by the patient. A mood refers to an emotion that the person experiences most of the time and one that colours the person's whole life. A mood may be expansive, irritable, elevated, euphoric, labile, depressed, sad, anxious or happy. Elevated: Air of confidence and enjoyment; a mood more cheerful than normal but not necessarily pathological. Euphoric: An exaggerated sense of physical and emotional well-being inconsistent with reality. People in an euphoric mood have limitless enthusiasm for whatever they are doing or plan to do and feel they can accomplish anything. Expansive: Expression of one's feelings without restraint, frequently with an overestimation of one's significance or importance. Generally considered pathological. Irritable: The person is easily annoyed and provoked to anger, especially when someone tries to interfere with his/her behaviour, for example, Simon becomes
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intensely annoyed when the nurse reminds him to take his medication or asks him to stop banging on the door. Labile: Unstable, rapidly shifting mood, usually shifting between sadness, anxiety, euphoria, in a very short space of time. Mood-congruent hallucinations and delusions: Hallucinations and delusions the content of which is appropriate to the mood, for example a depressed person hears voices telling him/her he/she is bad, and a manic person hears voices telling him/her he/she has god-like powers (mood-congruent auditory hallucinations); a depressed person believes he/she has committed a terrible sin for which not even God can forgive him/her, and a manic person believes that he/she is the incarnation of God (moodcongruent delusions). Mood-incongruent hallucinations and delusions: Delusions and hallucinations the content of which is not consistent with the mood, for example, a depressed person hears voices telling him/her he/she is a fantastic person; a manic person hears voices telling him/her he/she is worthless. Mood disorder: A disturbance of mood in which feelings of sadness or elation become intense and unrealistic. Previously called affective disorders. The mood disorders are major depression, mania, bipolar mood disorder. Negative symptoms: In schizophrenia the absence of something, for example, poverty of speech, flat affect, withdrawal, inattention. Non-verbal communication: Communication between two or more people without the use of words. Facial expressions, body posture, gestures and tone of voice are examples. Orientation: A level of consciousness in which a person is aware of the position of self in relation to time, surroundings or other people. Disorientation is common in people with an organic brain disorder. Sometimes depressed people can seem disoriented but this is more because they lack the energy to think about the question that was asked. Orientation to person: The ability to know who one is and who other people are. Orientation to place: The ability to know where one is, that is, name of town, city, country, hospital. Orientation to time: The ability to know what year it is, what day it is, what date it is, the season of the year. To be disoriented to time, the person must be more than one day off the correct day of the week and more than several days off the correct date. Overvalued ideas: Unreasonable, sustained false beliefs maintained less firmly than a delusion. The person values his/her ideas too much and is reluctant to change them, even if presented with alternative information. Overvalued ideas don't seem as bizarre as delusions. Overvalued ideas include suspicious ideas, suicidal ideas, ideas of reference and ideas of inference. Overvalued ideas are a disturbance in content of thought.
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Suicidal ideas: Recurring thoughts of wanting to kill oneself and/or preoccupation with methods of suicide. Suspicious ideas (sometimes called suspicious ideation): Suspicious ideas are a less severe form of paranoia where the person seems mistrustful of the intentions of others, is often hostile and guarded. Panic: Acute, episodic intense attack of anxiety associated with feelings of dread and unbearable autonomic arousal, for example, increased respiration and pulse rate. Patients sometimes feel as if they are having a heart attack. Perceptual processes: The experience of sensing, interpreting and comprehending the world. It is the mental process by which sensory stimuli are brought into awareness. Hallucinations affecting the five senses, and illusions, are the most common perceptual disturbances. Positive symptoms: In schizophrenia the presence of something, including hallucinations, delusions, bizarre behaviour and incoherent thought patterns. Post-traumatic Stress Disorder (PTSD): The term PTSD is used to signify a disorder or illness (as opposed to a normal post-traumatic stress response). PTSD is diagnosed when symptoms are severe enough to interfere with the person's normal living, symptoms are present for at least one month after the trauma and include avoidance, re-experiencing and increased arousal (anxiety). Poverty of content of thought: The result of loosened associations is that the language of the psychotic person conveys very little information. The person might use many words, all grammatically correct, but communicate poorly. Poverty of speech: There is a restriction in the amount of speech used. Replies may be monosyllabic. Pressured speech: Rapid speech that is increased in amount and difficult to interrupt. This is commonly associated with a manic disorder. Premorbid functioning: The level of social, occupational, self-care and interpersonal functioning before the onset of the disorder. Prodromal phase: The initial stage of schizophrenia, during which the person generally becomes withdrawn and socially isolated. Blunted or flat affect is common, speech may be rambling and hygiene poor. Behaviour is often strange, for example, talking to oneself in public or collecting garbage. Role-functioning, for example, as wageearner or home-maker, is impaired. The person may have unusual perceptual experiences, for example, recurrent illusions, sensing the presence of a force or person not actually present and odd ideas, for example, overvalued ideas, ideas of reference or ideas of inference. Psychiatric nursing: A speciality within the nursing profession in which the nurse directs efforts towards the promotion of mental health, the prevention of mental disturbances, early identification of and intervention in emotional problems and follow-up care to minimize long-term effects of mental disturbance.
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Psychoeducation: An approach used with patients and family caregivers which emphasizes the goals of (1) decreased client vulnerability to environmental stimulation through educated psychopharmacology, (2) increasing family stability by increasing both knowledge and coping strategies. Psychomotor agitation: Excessive overactivity, usually non-productive and in response to inner tension. Psychomotor retardation: Decreased activity, visible slowing of thought, speech and movements. Psychosis: A state in which a person's mental capacity to recognize reality, to remember, think, communicate with others, respond emotionally and behave appropriately is impaired, thus interfering with the person's capacity to deal with life's demands. Examples include schizophrenia, bipolar depression and paranoia. Residual phase: The third phase of schizophrenia, during which behaviour is similar to that seen in the prodromal phase. Schizophrenic disorders: Serious psychiatric disorders characterized by impaired communication and a loss of contact with reality (see definition of psychosis), a deterioration from a previous level of functioning in work, social relations and selfcare, and a duration of at least six months. Slow speech: Slow, hesitant speech. The person may take a long time to answer questions. May be accompanied by thought blocking. Social withdrawal: A lack of attention to or interest in the goings-on of the external world, accompanied by emotional detachment. This is an early sign of schizophrenia. Preoccupied with their own thoughts, schizophrenics gradually withdraw from involvement with other people and the environment. Social withdrawal is also found in a major depressive episode. Somatoform disorders: The primary feature of these disorders is that psychological conflicts take a somatic or physical form. Some patients complain of physical discomfort, for example, stomach pains and headaches. Others show an actual loss of or disturbance in some normal physiological function, for example, suddenly being unable to see or to move a limb. In either case there is no organic evidence to explain the symptom while there is evidence from the person's history that the symptom is linked to psychological factors. The three main forms of somatoform disorder are hypochondriasis, somatization disorder and conversion disorder. Conversion disorder: In conversion disorder there is an actual disability - the loss or impairment of some motor or sensory function. Conversion symptoms vary considerably but among the most common are blindness, deafness, paralysis and loss of sensation. There is no organic evidence for these symptoms, but they are not faked. They are involuntary responses not under the person's conscious control. The DSM-IV-TR regards this disorder as an expression of psychological conflict or need. These symptoms serve two important psychological purposes.
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Appendix 10
First, they block the person's awareness of internal conflict (primary gain) and, second, they excuse the person from responsibilities and attract sympathy and attention (secondary gain). Many people with this disorder are undisturbed by their symptoms and are eager to discuss them but not to part with them. With conversion disorder, differential diagnosis is important and difficult. Malingering (conscious faking of symptoms in order to avoid some responsibility) must be excluded and this is often hard to do. Sometimes symptoms are very similar to those of true organic disorders. There are three signs that differentiate organic disorders from conversion disorders: a) Rapid appearance of symptoms, especially after some psychological trauma. Organic symptoms tend to emerge more slowly. b) Indifference to their symptoms - patients with organic symptoms are more likely to be upset by their symptoms. c) Selective symptoms - if paralyzed legs move during sleep, the cause is generally not organic. Hypochondriasis: The primary feature of this disorder is a terrible, enduring fear of a specific disease, for example, cancer. This fear is maintained by constant misinterpretation of physical signs and sensations as abnormal. The person has no real disability but is convinced that a disability is about to appear and so spends each day waiting for the signs to emerge. When a sign emerges, for example, a new body pain, the person becomes convinced that a disease process is at work throughout his/her body. The person is usually an avid reader of medical journals and related literature, so by the time he/she arrives at the doctor, he/she has already diagnosed his/her illness. The person generally disbelieves the results of medical tests and examinations and will often try to cure him/herself through strenuous medical regimes or by dosing him/herself with pills, for example, vitamins. The person does not fake the symptoms but genuinely believes he/she is ill and suffers terribly as a result. This disorder affects men and women equally. Somatization disorder: This disorder is characterized by many and recurrent physical complaints that have persisted for several years and have caused the person to seek medical help. Like hypochondriasis there is no organic base for the symptoms. This disorder differs from hypochondriasis in that the person is preoccupied with the symptoms rather than with a fear of disease. A second difference is the way the two groups approach their symptoms. Whereas the hypochondriac may try to be scientific about his/her symptoms, for example, measuring his/her blood pressure five times a day, the person with a somatization disorder usually describes his/her symptoms in a vague, dramatic and exaggerated way. A third difference is that the hypochondriac usually fears a single disease and his/her complaints tend to be fairly specific. In somatization disorder, on the other hand, the complaints are many and varied. This disorder is more common in women than in men but is still rare, affecting only two or three women per thousand.
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Stereotypy: Repetitive, purposeless actions that may be carried out for hours at a time, for example, head-rubbing or pacing. Trauma: An emotionally painful and damaging event. While many experiences are painful, not all can be called traumatic. Traumatic experiences are sudden and shocking, involve high danger and intense feelings of fear, helplessness or horror. The distinction between traumatic and painful events is made in reference to the specialized ways of assisting the person's recovery. Classifications of traumatic experiences: Single traumatic experience: Usually a once-off trauma involving a stranger, for example, a violent mugging. Multiple trauma: When the same person has been exposed to several traumatic experiences. For example, someone may have survived several car accidents, or someone is abducted during a vehicle robbery, subjected to a terrifying highspeed car chase and then injured in a car accident. Continuous trauma: The person is living in a situation of ongoing danger, for example, police officers working in dangerous situations. Complex trauma: The traumatic experiences happen within a particular relationship, for example, domestic violence, which leads to people adapting their behaviour according to the requirements of the perpetrator in order to avoid further danger or harm. References American Psychiatric Association. 1994. Diagnostic and Statistical Manual of Mental Disorders, 4 ed. Washington, DC: American Psychiatric Association Bootzin, R. & Acocela, J. R. 1988. Abnormal psychology: Current perspectives, (5 ed.) New York: Random House Kaplan, H & Sadock, B. 1988. Synopsis of psychology, (5 ed.) Baltimore: Williams & Williams Shriver, L. R. 1990. Basic concepts of psychiatric-mental health nursing, (2 ed.) Philadelphia: J. B. Lippincott
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Index A ABC model of analysis 294, 473 Abortion 107, 113, 114 Abuse of Dependence-producing Substances and Rehabilitation Act 110 Abuse of children 692 disclosure 694 effects 693 helping 694 domestic 685 of the elderly 449,691 risk profile 449 Acceptance 143,144,470 Acting out 24, 254, 255, 470 Activating event 294, 296 Active phase 747 Activity groups 213 Admission assisted 94 emergency 93 forced 122 involuntary 94 ot mentally ill prisoner 100 of State patient 98 voluntary 93, 94 Advocacy by consumers 85 Affect 747 African traditional concepts of health and healthcare 129-140 ancestors 130, 132-133 cultural differences 137 herbalist 136 family 134 prophet 136 traditional healer 134 Aggression 81,254,747
Aids see HIV/Aids Akathisia 383 Al-Anon family groups 425 Alcohol-related disorders 402-427 acute intoxication - nursing care 418 assessment 413-418 dependence 403 employee assistance programme 425 integrated drinking 404 medication guidelines 411 patient education 420 prevention 404 price control 405 treatment 411 withdrawal - nursing care 419 Altruism 23,213 Ambivalence 748 Amphetamines 432 Ancestral belief systems 132 Ancestors 130-133 Antidepressants 334 classification 334 EDL 341 MAOI 338 patient information 339 RIMA 340 SSRI 337 tetracyclics 336 tricyclics 335 Antisocial personality disorder 632 Anxiety 269-317,748 anxiety response 275 assessment 290 characteristics 270 cognitive behavioural therapy 294 cognitive model 272 defined 270-271 EDL 315
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generalized anxiety disorder 282, 566 intervention 293 Hamilton rating scale 292 normal and pathological 278 Anxiolytics 312 Apartheid 9 Apathy 748 Assertiveness 154 Assessment 162-201 for a medical diagnosis 169 for a nursing diagnoses 183 inpatient 183 of children 566 of the psychiatric patient 162-201 outpatient 188 of own learning needs 163 Attachment behaviour 29 Attention-deficit hyperactivity disorder 543 Avoidant personality disorder 647
B Battered women programme model 53 Beck depression inventory 740 Behaviourally disturbed children 579 behaviour control 581 communication 580 family involvement 582 fantasy control 580 individual therapy 582 limit setting 580 management of 579 medication 581 occupational therapy 581 restraint 581 structure 580 special schools 582 Behaviour modification 467 Behavioural mapping 455 Behavioural strategies 298 Benzodiazepines 312 Bereavement see Grief Best practice see Joanna Briggs Best Practice Guidelines Beta-blockers 314 Bipolar mood disorder 356, 748 Borderline personality disorder 643
c
Cannabis see Dagga Caregiving Stages 77 Explanation of mental illness 78 Guidelines 79 Perspective 77 Case management 245 models 246 process 247 Catatonia 748 Child behaviour, evaluating 566, 579 Child Care Act 111 Child interview 567 Child psychiatric interview 570-572 Child psychiatry 125 Children and adolescents 541 assessment of mental health disorders 566 attention-deficit and disruptive behaviour disorders 563 classification of psychiatric disorders 744 eating disorders 556 elimination disorders 551 generalized anxiety disorder 566 learning disorders 542 major depressive disorder 556 management of, see Behaviourally disturbed children mental health disorders 542 mental health nursing of 542 obsessive-compulsive disorder 559 pervasive developmental disorders 543 poor mother-infant interaction 656 post-traumatic stress disorder 559 schizophrenia 566 separation anxiety disorder 554 tic disorders 565 trauma 692 Children's drawings 579 Classification of groups 212 Client assessment, necessary information 24 Cluster A personality disorders 618 Cluster B personality disorders 628 Cluster C personality disorders 647 Cocaine 433 Cochrane review 35
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Index
Cognition 748 Cognitive disorders assessment 452 causes 439 classification 441 environmental manipulation 548 family coping 454 goal-setting 457 intervention 458 nurse-patient relationship 450 patterns of lifestyle functioning 445, 453 psychopharmacology 473 Cognitive patterns 25 all-or-nothing thinking 26 arbitrary inference 26 catastrophizing 26 dichotomous thinking 26 overgeneralization 26 selective abstraction 26 stimulus 22 Cognitive behavioural strategies 298 Cognitive behavioural therapy 294 Comprehensive mental health care 39-58 primary prevention 42 secondary prevention 46 tertiary prevention 47 Conduct disorder 547 Confidentiality 124 Confrontation 154 Congruence 144 Consultation 69 Consumers in mental health 73-87 Consumers' perceptions on recovery 75 Content of thought 749 Conversation groups 2 12 Coping behaviour 27, 477 strategies 26 Counselling 15, 17 interview 230 trauma counselling process 670-676 vs. psychotherapy 15 Criminal responsibility 588 Crisis intervention 234
D Dagga 428 Debriefing after trauma 239 survivor groups 698 Defence mechanisms 22 acting out 24 compensation 25 denial 25 displacement 24 dissociation 24 distortion 25 fantasy 25 hypochondria 25 identification 25 intellectualization 24 passive-aggressive behaviour 24 projection 25 reaction-formation 24 regression 24 repression 24 Delirium 443 vs. dementia 444 Delusion 749 of control 749 of grandeur 749 of hypochondriasis 750 of nihilism 749 of persecution 749 of reference 749 of sin and guilt 749 paranoid see Delusion of persecution thought broadcasting 749 thought insertion 749 thought withdrawal 749 Dementia 443 and pseudodementia 444 Deontology 119 Dependence-producing substances 428 Dependent personality disorder 650 Depersonal isolation 750 Depression 319,750 antidepressants 334 Beck inventory 320,740 cognitive patterns 322 coping mechanisms 325
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EDL 341 DSM-IV-TR diagnostic criteria 320 medication 335 nursing assessment and intervention 322 Derealization 750 Detachment 29 Developmental disorders 543 Didactic-inspirational groups 212 Displacement 24 Dissociation 24 Distortion 25 Distractibility 750 Distraction techniques District health system 60 Domestic violence 685 DSM-IV-TR diagnostic criteria acute stress disorder 282 alcohol-related disorders 403 anorexia nervosa 561 antisocial personality disorder 632 anxiety disorders 279 attention-deficit hyperactivity disorder 544 avoidant personality disorder 647 bipolar disorder 320 borderline personality disorder 643 bulimia nervosa 562 cognitive disorders 442 conduct disorder 547 dependent personality disorder 650 depression 320 encopresis 563 enuresis 551 generalized anxiety disorder 282 histrionic personality disorder 628 major depressive disorder 557 manic episodes 320 narcissistic personality disorder 637 obsessive-compulsive personality disorder 280,654 oppositional defiant disorder 646 paranoid personality disorder 624 passive-aggressive personality disorder 652 post-traumatic stress disorder 280, 559 schizoid personality disorder 610 schizotypal personality disorder 623 separation anxiety disorder 555
substance dependence 399 DSM-IV-TR multiaxis system use of 179-180 Dual diagnoses 390
E Eating disorders 561 Echolalia 750 Echopraxia 750 Ecochart 192 Ecstacy 398, 428, 432, 433 ECT see Electroconvulsive therapy Ego states 609 egograms of 610 Electroconvulsive therapy 123 myths 343 Elimination disorders 551 Emotionally disturbed children 579 Empathy 144 Encopresis 553 intervention 554 Enuresis 551 intervention 552 Epilepsy 475 481 cognitive appraisal 477 coping behaviours 477 psychosocial nursing management 478-481 Essential drug list (EDL), overview 36 Establishment of psychiatric hospitals in South Africa 5 Ethical dilemmas in mental health 117-128 child psychiatry 125 Christian approach 119 confidentiality 124 drugs that alter consciousness 123 electroconvulsive therapy 123 forced admission 122 patient rights 126 research 125 structure 120 theories 118 Evaluation of group work 727 Evaluation of mental health education 730 Evidence-based practice 34 overview 34 Cochrane Collection 35
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Index
Joanna Briggs Best Practice Guidelines, overview 35 levels of evidence 35-36
F Family perspective 77 Fantasy 23,25,603 Fear questionnaire 736 Fitness to stand trial 588 Focusing 215 Forensic psychiatric patients 585-599 aggression and violence 594-595 classification according to legal status 591 classification according to type of problem 592 current legal provisions 587 first-rank predictor variables 597 observation 592, 594 potential for future violence 595, 597 reintegration into society 596 services provided for 591 Form of thought 750 Functional assessment 202 listing critical skills 203 describing skill use 205 evaluating skill functioning 206 teaching the skill 207 G
Generalized anxiety disorder 287 Genogram 191 Grief 682 phases 682 general principles 683 children 684 Group debriefing 699 Group therapy 211 Group work, evaluation of 727 Guidelines for families 79
H Hallucination 751 auditory 751 gustatory 751 olfactory 751
somatic 751 tactile 751 visual 752 Hallucinogens 433 Hamilton anxiety rating scale 733 Health promotion approach 43 Herbalist 136 High expressed emotion High-risk approach 43 History of mental health nursing 3-13 nineteenth century 4 Reformation 4 twentieth century 6 Histrionic personality disorder 628 HIV/Aids 482-483 delirium 483 HIV-related dementia 482 HIV-related encephalopathy 482 nursing diagnoses 483 Home stimulation programme 503 Hyperactivity 752 Hypochondriasis see Somatoform disorders I
Ideas of reference 752 Identification 29 Illusion 752 Infancy, childhood or adolescence disorders diagnosed in 541-584,744 Inhalants 429 Inpatient evaluation scale 709 Insomnia 332 sleep-wake cycle 33 Intellectual disability 486-538 adult 534 assessment 492 definition 490 development of features of subtypes 491 development stimulation chart 504-509 dressing and undressing 529 evaluation of development 492 feeding skills 521 group activity therapy 533 home stimulation programme 503 institutional care 531
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management of problem behaviour 534, 579 motor skills 510 music therapy 533 play or games 533 primary prevention 488 secondary prevention 488 sexuality 500 support of the parents 498 tertiary prevention 489 toilet training 529 Interpersonal nursing attitudes 143 Interpersonal nursing competencies 149 Interviewing the child 567 content of the child interview 570 process 570 guidelines 569 Interviewing the family 573 Interviewing the individual 576 Inpatient evaluation scale 709 Involuntary mental health care 94 Isangoma 134
Criminal Procedure Act 107 Health Professions Act 115 Medicines and Related Substances Control Act 108 Mental Health Care Act 89 Mental Health Review Boards 97 Mentally Retarded Children's Training Act 112 Protection of the community 107 Regulation of property of person's under care 106 South African Schools Act 112 State patients 98-100 Sterilization Act 114 Lesson plan outline 209 Life skills approach 44 Life-review therapy 465 Lifestyle functioning 19, 28-32 Patterns 19 Psychodynamics 20 Listening skills 150
M J
Joanna Briggs Best Practice Guidelines overview 35 guidelines 268,382 levels of evidence 35-36 lohari windows 21
K Kernberg's model of narcissistic disorder 639, 640 Kohut's model of narcissistic disorder 639, 640, 641
L Learning disorders 542 Legal structure 88-116 Legislation Abortion, counselling and participation 114 Abuse of Dependence-producing and Rehabilitation Centres Act 110 Child Care Act 111 Choice on Termination of Pregnancy Act 113
Magical thinking 752 Major depressive disorder 341, 752 in children and adolescents 556 intervention 559 Management practice scale 228 Mandrax 429 Mania 356,752 diagnostic criteria 356 medication 356 nursing assessment and intervention 357 Memory 753 immediate 543 recent 753 recent past 753 remote memory 753 Mental health 753 definition 13, 753 Mental Health Act 89 Mental health care in the health-care system 59-72 Mental health education 216 community approach 217 evaluation of 730
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gatekeeper approach 217 high-risk approach 217 milestone approach 217 total population approach 216 Mental health nursing 13-38 conceptual model 18 process 141-161 Mental health programmes evaluating 55 implementation 54 planning 50 Mental health services tiers of service 66 Mental retardation see Intellectual disability Mentally ill offender, services provided for 591 Mentally Retarded Children's Training Act 112 Milieu therapy 225 Mini mental-state examination 451-452 Minor tranquillizers 312 Mood disorder 753 Mood disorders 318-365 assessment and intervention 322 categories 319 coping mechanisms 325 diagnosis 321 psychodynamic patterns 322 Mood-congruent hallucinations and delusions 754 Mood-incongruent hallucinations and delusions 754 Mother-infant interaction 565 Multiprofessional team 36 N
Narcissistic personality disorder 637 Kernberg's model 639, 641 Kohut's model 639, 640 National Council for Mental Health Negative symptoms 754 Neuroleptic malignant syndrome 383 Non-benzodiazepines 313 Non-verbal communication 150, 754 Normalization scale 229 Normalization principle 531 Nurse-patient empathy functioning scale 145 Nurse-patient relationship 157
levels 158 problems 159 stages 158 Nursing interventions 202-266 Nursing diagnosis 191 Nursing process 143,159
o Obsessive-compulsive personality disorder 285,654 Opioids 433 Oppositional defiant disorder 546 Organically impaired person 450 Orientation 754 Overvalued ideas 754 P
Panic 755 Panic disorder 283 Paranoid personality disorder 652 Passive-aggressive personality disorder 652 Patient rights 127 Patterns of building and maintaining relationships 29 Patterns of fulfilling biophysical needs 28 Patterns of participation in group and community life 30 Patterns of participation in work 31 Patterns of utilizing resources 32 Perceptual processes 755 Personality adaptation therapy 616-618 Personality disorders antisocial 632 avoidant 647 borderline 643 classification 602 defence mechanisms 602-605 dependent 650 four common characteristics 602 generalized anxiety 287 narcissistic 637 obsessive-compulsive 285, 654 panic 283 paranoid 624 passive-aggressive 652 phobic 284
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post-traumatic stress 287 psychodynamics 606 schizoid 618 schizotypal 623 staff reactions 605 transactional analysis model 607 Phobic disorder 284 Physical restraint 471 Police service, intervention 96 Positive symptoms 755 Post-traumatic stress disorder 287, 663 avoidance 662 impact 665 in children 559 intervention 561 re-experiencing 662-663 Poverty of speech 755 Premorbid functioning 755 Primary health care 11 integration of mental health 64 Primary mental health education 218 teaching of life skills 218 Primary prevention 42 Principles of mental health nursing Probing 154 Prodromal phase 755 Programme planning 50 evaluating 55 implementing 54 model 53 problem-based 51 process of 51 service-based 52 Pseudodementia 444-445 Psychiatric disorders of infancy, childhood and adolescence classification 744 Psychiatric history, questions used 724 Psychiatric medicines, schedules 2 to 5 110 Psychiatric report, example of 194 Psychodynamic patterns 18, 20, 25, 31, 33 Psychoeducation 222 Psychomotor agitation 756 Psychomotor retardation 756 Psychosis 756 Psychosocial rehabilitation technology 48
R Rape 689 Reaction formation 23, 24 Reality orientation (RO) 462 guidelines for 24-hour RO 463 Redecision therapy 614-616 Referral 70 Regression 24 Repression 24 Rehabilitation 11 vs. treatment 48 Relapse 243 Relaxation training 306 Reminiscence and life-review therapy 465 Remotivation therapy 469 Residual phase 756 Responding skills 151 Review boards 97
s SAD CHILDREN - suicide potential assessment scale 348 Scale for the global evaluation of functioning 182 Schizoid personality disorder 618 Schizophrenia 366-394 cognitive patterns 375 diagnosis and treatment 367 DSM-IV-TR classification and diagnostic criteria 368 EDL 372 facilitation of healthy lifestyle 373 in children 566 medication guidelines 371 psychodynamic patterns 374 Schizotypal personality disorder 623 Seclusion 258 Secondary prevention 46 Self-awareness 156 Self-concept 20 Self-reporting questionnaire 47 Sense of self 20 ideal self 22 self-concept 20 self-esteem 22 Separation anxiety disorder 554
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Index
Services advocating for 251 linking client to 250 monitoring use and delivery 251 Sexual abuse of children 692 Skills training 202 Sleep therapy 316 Sleep-wake cycle 33 Social phobia 279 Social skills teaching 220 Social vs. therapeutic groups Social withdrawal 756 Sociogram 192 Somatization disorder 757 Somatoform disorders 756 conversion 756 hypochondriasis 757 Special groups children and adolescents 541 elderly 691 forensic patients 585 rape 689 state patients 98 survivor groups 698 trauma 659 Stages of caregiving 77 Stanford panic appraisal inventory 735 State patients 98 absconding 98 discharge 100,590 fitness to stand trial 587 procedures 99 right of appeal 588 Stereotypy 757 Sterilization 114 Stigma of mental illness 74 Substance abuse 400 intoxication 400 withdrawal 401 Substance-related disorders 395-437 classification of substances 396 common dependence-producing substances 428 symptoms associated with dependenceproducing substances 430 treatment 434
Suicide 348 care of suicidal patient 351 care of survivors 354 no-suicide contract 354 profile in South Africa 348 psychological care for caregivers 355 Suicide potential assessment scale 349-351 Support groups for consumers 82 functions 83 starting a support group 83 Survivor groups 698 Symptom management 245
T Tardive dyskenisia 383 Team functioning skills 68 Termination of pregnancy the Act 113 counselling 114 participation 114 Tertiary prevention 47 Thought blocking 749 Thought broadcasting 749 Thought disorders 379 Tic disorders 656 Time-event chart for patient with anxiety symptoms 188-189,732 Traditional healing 134 Tranquillizers minor 312 major 381 Transactional analysis antisocial personality disorder 632 avoidant personality disorder 647 dependent personality disorder 650 narcissistic personality disorder 637 obsessive-compulsive disorder 654 paranoid personality disorder 624 passive-aggressive personality disorder 652 Transactional analysis model 605-607 application 613 development of the three ego states 609 egograms 610 analysis of interpersonal problems 610 analysis of intrapersonal problems 610 complementary transactions 610
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crossed transactions 612 ulterior transactions 612 Trauma 659 696 care of caregivers 696, 702 counselling process 670-676 cycle of violence 667 definition 660 impact 662 community 666 family and friends 665 individual 662 intervention and counselling 668 loss and bereavement 682 in children 684 normal post-traumatic stress response 662 phases 669 post-traumatic stress disorder 663 specific traumas or groups children 692 families 697 domestic violence 685 elderly 691 rape 689 survivor groups 698 types 661
u Ubuntu 130 Ulterior transactions 612 University of Natal Functional Assessment Scale 718 Utilism 118
V Validation therapy 146 Violence assessing for potential 256 causes 255 control strategies 258-263 domestic 685 elder abuse 449,691 patient 254-265 rape 689 Voluntary and assisted mental health care 94
w Washington guide 492, 497 Withdrawal, of self 325 nursing intervention 328
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