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Nursing 304
Frameworks and Basic Concepts for Providing Nursing Care
to Clients and Families Experiencing Psychiatric Disorders
Mental Health
--”is defined as successful performance of mental functions,
functions, resulting
in the ability to engage in productive activities,
activities, enjoy fulfilling
relationships,
relationships, and change or cope with adversity”
Mentally Healthy
A person is mentally healthy when a person possesses knowledge
of oneself; meets one’s basic needs; assumes responsibility for
one’s behavior and for self-growth; has learned to integrate
thoughts, feelings, and actions; and can resolve conflicts
successfully.
A mentally healthy person maintains relationships, communicates
directly with others, and respects others.
A mentally healthy person adapts to change in one’s environment.

Mental Illness
-- “is considered a clinically significant behavioral or psychological
syndrome experienced by a person and marked by distress,distress, disability,
disability,
or the risk of suffering disability or loss of freedom”
freedom”
Mentally Ill
The mentally ill show deficits in functioning; it is usually these
deficits that bring them to the facilities where you will encounter
them.
Mental illness occurs when an individual is not able to view oneself
clearly or has a distorted view of self, is unable to maintain
satisfying personal relationships, and is unable to adapt to one’s
environment.
The American Psychiatric Association defines mental disorder as
“clinically significant behavior or psychological syndrome or pattern
that occurs in an individual and is associated with present distress
(i.e., negative response to stimuli that are perceived as threatening)
or disability (i.e., impairment increased risk of suffering, death, pain,
disability, or an important loss of freedom).

Mental Health versus Mental Illness

Signs of Mental Health
• Happiness
Finds life enjoyable
Can see objects, people, and activities their possibilities for meeting his or her needs
• Control over behavior
Can recognize and act on cues to existing limits
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Can respond to the rules, routines, and customs of any group to which he or she
belongs
• Appraisal of Reality
Accurate picture of what is happening around the individual
Good sense of the consequences, both good and bad, that will follow his or her acts
Can see the difference between the “as if” and the “for real” in situations
• Effectiveness in Work
Within limits set by abilities, can do well in tasks attempted
When meeting mild failure, persists until determines whether or not he or she can do
the job
• A Healthy Self-Concept
Sees self as approaching individual ideals, as capable of meeting demands
Has reasonable degree of self-confidence that helps in being resourceful under stress
• Satisfying relationships
Experiences satisfaction and stability in relationships
Socially integrated and can rely on social supports
• Effective Coping Strategies
Uses stress reduction strategies that address the problem, issue, threat (e.g., problems
solving, cognitive restructuring)
Uses coping strategies in a healthy way that does not cause harm to self or others

Signs of Mental Illness

Major Depressive Episode
Loses interest or pleasure in all or almost all usual activities and pastimes
Describes mood as depressed, sad, hopeless, discouraged, “down in the dumps”
Control Disorder, Undersocialized, Aggressive
Shows repetitive and persistent pattern of aggressive conduct in which the basic rights
of others are violated
Schizophrenic Disorder
Shows bizarre delusions, such as delusions of being controlled
Has auditory hallucinations
Manifests delusions with persecutory or jealous content
Adjustment Disorder with Work (or Academic) Inhibition
Shows inhibition in work or academic functioning whereas previously there was
adequate performance
Dependent Personality Disorder
Passively allows other to assume responsibility for major areas of life because of
inability to function independently
Lacks self-confidence (e.g. sees self as helpless, stupid)
Borderline Personality Disorder
Shows pattern of unstable and intense interpersonal relationships
Has chronic feelings of emptiness
Substance Dependent
Repeatedly self-administers substances despite significant substance-related problems
(e.g. threat to job, family, social relationships)
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Prevalence of Psychiatric Disorders in the United

States

The prevalence rate is the portion of the population with a mental disorder at a
given time. According to NIMH (National Institute of Mental Health) 21.1% of
Americans aged 18+ --about 1 in 5 adults suffer from a diagnosable mental disorder.
o DSM-IV: Diagnostic and Statistical Manual – classification
system for mental disorders.
Multi-axial system.
Axis I:
Clinical Disorders, most V-Codes, and conditions that need
Clinical attention.
Diagnosis Flow Charts.
Axis II:
Personality Disorders and Mental Retardation.
Axis III:
General Medical Conditions.
Axis IV:
Psychosocial and Environmental Problems.
Axis V:
Global Assessment of Functioning Scale.
o ICD-9: International Statistical Classification of Diseases
and Related Health Problems - classification of medical
disorders.

Schizophrenia (1.1% prevalence over 12 months)

2.2 million
Affects men and women equally
May appear earlier in men than women
Any affective (mood) disorder (major depression,
dysthymic disorder, bipolar disorder (9.5%)
18.8 million
Women affected 2 x more than men
Depressive disorders may be appearing earlier in life in those born in recent
decades compared to the past
Often co-occurs with anxiety and substance abuse
Major Depressive Disorder (5%)
9.9 million
Leading cause of disability in US and established economies worldwide
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Nearly twice as many women as men

Bipolar Affective Disorder (1.2%)
2.3 million
Affects men and women equally
Anxiety Disorders (panic disorder, OCD, posttraumatic
stress, generalized anxiety and phobias (13.3%)
19.1 million
Anxiety disorders frequently co-occur with depressive disorders, eating disorders,
and/or substance abuse
Panic Disorder (1.7%)
2.4 million
Typically develops in adolescence or early adulthood
About 1 in 3 people with panic disorder develops agoraphobia (Agoraphobia
describes a condition where the sufferer becomes uneasy is environments that are
unfamiliar or where he/she perceives that he or she has little control. Triggers may
include crowds, wide open spaces or traveling alone even for short distances. The
anxiety is often compounded by a fear of social embarrassment in case of panic
attacks or appearing distraught in public)
Obsessive–compulsive Disorder (OCD) (2.3%)
3.3 million
First symptoms begin in childhood or adolescence
Post-traumatic stress Disorder (PTSD) (3.6%)
5.2 million
Can develop at any time
About 30% of Vietnam veterans experienced PSTD after the war; percentage high
among first responders of 9/11 terrorists attacks on the US
Generalized anxiety Disorder (2.8%)
4.0 million
Can begin across the life cycle; risk is highest between childhood and middle age
Social phobia (3.7%)
5.3 million
Typically begins in childhood or adolescence
Agoraphobia (2.2%)
3.2 million
Specific phobia (4.4%)
4.4 million
Any substance abuse/Alcohol dependence (11.3%/7.2%)

Chapter 2: Psychiatric Nursing Evolution of a

Specialty

Careof the Mentally Ill

Early Civilization
The insane were treated through magical rituals, prayer, and
exorcism.
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The Greek and Roman cultures developed ideas of body

“humors” – blood, black bile, yellow bile, and phlegm-which
could influence emotional stability.
Hippocrates believed that excesses of black bile caused
melancholy and that bloodletting could remove this excess.
Middle Ages and Renaissance
The term “lunatic” emerged to refer to one controlled by the
lunar body.
Treatment of the mentally ill was influenced by beliefs that the
mentally ill were evil, witches, or heretics.
The mentally ill were excluded from community life or
institutionalized.
Care was custodial; they were poorly fed and clothed and were
restrained.
Eighteenth and Early Nineteenth Centuries
The mentally ill were committed to asylums.
They were place in prison if they committed a crime.
Their care was performed by persons without training or interest
in helping others and was often lacking in compassion.
A few physicians in the U.S. and England began to view the
insane as persons suffering disease and needing some kind of
treatment.
English physician William Battie’s word elevated mental
services to something respectable physicians could do. He also
believed that the care of the mentally ill should be done by
carefully selected and trained.
Insanity was viewed as a disease.
Physicians began to classify mental disorders.
They described moral and physical causes of mental illness.
In 1846, the term psychiatry was introduced by physicians and
they published their work in The Journal of Mental Science.
Asylums were built for the treatment and cure of the insane.
Nineteenth Century
Conditions in the asylums became unbearable.
There was a called for reform.
Dorothea Lynde Dix became a leader for reform. She
advocated for humane treatment as well as safe and comfortable
environments for the patient. Through her efforts, care was
improved in the U.S., Canada, and Scotland.
Nursing Education
Eighteenth and Nineteenth Centuries
In 1882, the McLean Asylum in Somerville, Massachusetts,
opened the first training school in the world for mental health
nurses.
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Edward Cowles, the physician superintendent of McLean,

believed that the presence of a “nurse” indicated not only that
the patient was ill but also that there was a hope of recovery.
Other schools were opened:
Bellevue Training School in New York

Connecticut Training School in New Haven

These schools operated under the Nightingale model.

The year 1893 marked the first meeting of organized nursing
in the U. S.
Important Nurse Leaders included: Isabel Hampton and
Lavinia Dock.
Dock.
Mental health nurses continued to be trained at asylums and
their training evolved to keep up with new approaches in
psychiatric care.
Twentieth Century
The American Psychiatric Association established a committee
on Training Schools for Nurses.
Johns Hopkins Hospital School included psychiatric nursing in
the training of general nurses. This was the first time a hospital
program offered training in psychiatric care to all students.
By 1920, the first psychiatric nursing textbook was publish,
Nursing Mental Disease by Harriet Bailey.
In the 1930s, somatic therapies emerged
In 1946, the U.S. Congress passed the National Mental Health
Act, which established the National Institutes of Mental Health.

Peplau and the Therapeutic Relationship

Peplau was the first nurse to identify psychiatric nursing both as a
essential element of general nursing and as a specialty area that
embraces specific governing principles” (p. 24).
She was the first nurse to describe the nurse-patient relationship as
foundation of nursing practice (p. 24).
She emphasizes the shifting the focus from what nurses do to patients
to what nurses do with patients.
She described that stages of the nurse-patient relationship (p. 24).
The skills of the psychiatric nurse include: observation, interpretation,
and intervention.
She also applied Sullivan’s theory of anxiety to nursing practice.

Dorothea Orem
Proposed a general self-care deficit theory of nursing.
Has three constitute theories –self-care, self-care deficit, and nursing
systems which are based on six central and one peripheral concept.
Self-care
Self-care agency
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Therapeutic self-care demand

Self-care deficit
Nursing agency
Nursing system
Focus: Goal of self-care as integral to the practice of nursing (p. 25)
She emphasized the role of the nurse in promoting self-care activities
of the client; this has relevance to the seriously and persistently
mentally ill client (p. 25).

Jean Watson
She first differentiated between nursing and medicine by stating that
curing is the domain of medicine, and caring is the domain of nursing.
She proposed 10 carative factors that involved forming a humanistic,
altruistic system of values: instilling faith-hope; cultivating sensitivity
to one’s self and
To others; developing helping-trust relationships; expressing positive
and negative feelings’ using scientific problem-solving methods for
decision making; promoting interpersonal teaching-learning; providing
an environment that supports, protects, and corrects mental, physical,
sociocultural, and spiritual aspects;
Assisting with the gratification of human needs; and allowing for
existential-phenomenological forces.

Neuroscience as a Basis for Practice

Mentalphenomena are somehow caused by an array of biochemical
and neurophysiologic processes that take place from moment to
moment.

Psychotropic Drugs
Pharmacological treatment of mental disturbances is directed at the
suspected transmitter receptor problem.
Transmitters (p. 40)
Dopamine
Fine muscle movement
Integration of emotions and thoughts
Decision making
Stimulates hypothalamus to release hormones (sex, thyroid, adrenal)
Decreased in Parkinson’s, Depression
Increased in Schizophrenia, Mania
 Norepinephrine
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Affects mood
Stimulates sympathetic branch of ANS for “fight or fright” in response to stress
Decreased in Depression
Increased in Mania, Anxiety, Schizophrenia
Serotonin
Sleep regulation, hunger, mood, stress, and pain perception
Plays a role in aggression and sexual behavior
Decreased in Depression
Increased in Anxiety
Histamine
Alertness
Inflammatory response
Stimulates gastric secretions
Decreased in Depression, Sedation, Weight gain
GABA
Plays a role in inhibition; reduces aggression, excitation, and anxiety
May play a role in pain perception
Has anticonvulsant and muscle-relaxing properties
Decreased in Anxiety, Schizophrenia, Huntington’s chorea
Increased in reduction of anxiety
Acetylcholine
Plays a role in learning, memory
Regulates mood: mania, sexual aggression
Affects sexual and aggressive behavior
Stimulates PNS
Decreased in Alzheimer’s, Huntington’s chorea, Parkinson’s
Increased in Depression
Substance P (SP)
Centrally active SP antagonist has antidepressant and anti-anxiety effects in
depression
Promotes and reinforces memory
Enhances sensitivity to pain receptors to activate
Involved in regulation of mood and anxiety
Role in pain management

Somatostatin (SRIF)
Altered levels associated with cognitive disease
Decreased Alzheimer’s
Decreased levels of SRIF found in the spinal fluid of some depressed
clients
Increased in Huntington’s chorea
Neurotensin
Endogenous antipsychotic-like properties
Decreased levels found in spinal fluids of schizophrenic clients
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What is Psychiatric Mental Health Nursing? (p. 64)

Psychiatricnursing is “the diagnosis and treatment of human
responses to actual or potential mental health problems” (p. 64)
Box 4-1: Psychiatric Mental Health Nursing Phenomena of Concern

Actual or potential mental health problems of clients pertaining to the following:

Maintenance of optimal health and well-being and prevention of psychobiological
illness
Self-care limitations or impaired functioning related to mental and emotional stress
Deficits in the functioning of significant biological, emotional, and cognitive systems
Emotional stress or crisis components of illness, pain, and disability
Self-concept changes, developmental issues, and life process changes
Problems related to emotions such as anxiety, anger, sadness, loneliness, and grief
Physical symptoms that occur along with altered psychological functioning
Alterations in thinking, perceiving, symbolizing, communicating, and decision making
Difficulties relating to others
Behaviors and mental states that indicate the client is a danger to self or others or has a
severe disability
Interpersonal, systematic, sociocultural, spiritual, or environmental circumstances or
events that affect the mental and emotional well being of the individual, family, or
community
Symptom management, side effects and toxicities associated with
psychopharmacological intervention and other aspects of the treatment regimen

What do psychiatric Nurses Do?

(p. 65)
“to promote and maintain optimal mental functioning, to prevent
mental illness (or further dysfunction), and to help clients regain or
improve their coping abilities” (p. 65)

Psychiatric Mental Health Nursing Interventions (p.

66)
Basic Level Nursing
Counseling
Milieu therapy (homelike environment)
Promotion of self-care activities
Psychobiological interventions
Health teaching
Case management
Health promotion and health maintenance
Advanced Level Nursing
All of the above plus
Psychotherapy
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Medication prescription and treatment

Consultation
Where do psychiatric nurses work? (p. 87)
Primary Prevention (keep clients in a healthy state)
Adult and youth recreational center
Schools
Day care centers
Churches, temples, synagogues, mosques
Ethnic cultural centers
Secondary Prevention (screening, detection of early symptoms)
Crisis
Shelters (homeless, battered women, adolescents)
Correctional community facilities
Youth residential treatment centers
Partial hospitalization programs
Chemical dependency programs
Nursing homes
Industry/work sites
Outreach treatment in public places
Hospices and acquired immunodeficiency syndrome programs
Assisted living facilities
Tertiary Prevention (in need of treatment)
Community health treatment centers
Psychosocial rehabilitation programs

Cultural and Ethnic Considerations

Cultural is a complex whole, including knowledge, belief, art, moral,
law, custom, and any other capabilities and habits acquired by man as
a member of society.
It comprises every verbal or behavioral system that transmits
meaning.
It is learned, shared, and ever-changing
It is learned through socialization, shared by all group members, and
associated with adaptation to the environment.
Cultural blindness is the attempt to treat all persons fairly by
ignoring differences and acting as though the differences do not exist.
Can be perceived as insensitivity just as readily as are stereotyping
and ethnocentrism.

Normal vs. Abnormal Behavior

What is normal in one culture may not be normal in another.
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Mental health nurse need to practice culturally relevant nursing if

they are to meet the need of their culturally diverse clients.
clients

A Global Perspective
Terms
Minority - connected more to economic and social standing in
society than to cultural identity. However, many cultural, racial ant
ethnic minority groups are also economically and socially
disadvantaged.
Culture - shared beliefs, values, and practices that guide a group’s
members in patterned ways of thinking and acting. The cultural
norms help members of the group make sense of the world around
them and make decisions about appropriate ways to relate and
behave.
Ethnicity - ethnic groups of common heritage and history. These
groups share a worldview. From this worldview, they develop beliefs,
values, and practices that guide members of the group in how they
should think and act in different situations.
Worldview - a system for thinking about how the world works and
how people should behave in the world and in relationship to one
another
Enculturation – the process through which members of a group are
introduced to the culture’s worldview, beliefs, values, and practices.

Understanding Culture in the Context of Mental

Illness
Table 7-3: Selected Nonverbal Communication Patterns
Nonverbal Predominate
Communication American
Pattern Patterns
Eye contact Eye contact is associated with
attentive-ness, politeness, respect,
honesty, self-confidence.
Personal space Intimate space: 0-1 1/2 ft
Personal space: 1 ½-3 ft
In personal conversation, if a person
enters into the intimate space of the
other, the person is perceived as
aggressive, overbearing, and offensive. Latin American
If a person stays more than expected,
the person is perceived as aloof.
Patterns Seen
in Other Cultures
Eye contact is avoided as a
sign of rudeness, arrogance,
challenge, or sexual interest.
Personal space significantly
closer or more distant than in
American culture.
Closer- Middle Eastern,
Southern European, and
Farther- Asian
When closer than the norm,
standing very close
frequently indicates
acceptance of the other.
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Touch Moderate touch indicates personal Touch norms vary.

warmth and conveys caring.
Facial A nod means “yes.”
expressions Smiling and nodding means “I agree.”
Thumbs up means “good job.”
Rolling one’s eyes while another is
talking is an insult.
Low-touch cultures – touch
may be considered an overt
sexual gesture capable of
“stealing the spirit” of
another or taboo between
women and men.
High-touch cultures – People
touch one another as
frequently as possible
Raising eyebrows or rolling
the head from side to side
means “yes.”
Smiling and nodding means
“I respect you.”
Thumbs up is an obscene
gesture.
Pointing one’s foot at another
is an insult.

“Deviance from cultural expectations is considered by others within

the culture to be a problem and frequently is defined by the cultural
group as “illness” (p. 103)

Legal and Ethical Guidelines

Terms
Ethics- major branch of philosophy, is the study of values and
customs of a person or group. It covers the analysis and
employment of concepts such as right and wrong, good and evil,
and responsibility.
Bioethics – ethical dilemmas surrounding client care.

Five Principles of Bioethics

Beneficence - the act of doing good; helping others.
Autonomy - right to make one’s own decision. (concept of informed
consent).
Justice - treating others fairly and equally.
Fidelity (nonmaleficence) - maintaining loyalty and commitment to the
client and doing no wrong.
Veracity - one’s duty to tell the truth.
Guidelines
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Box 8-1: Code of Ethics for Nurses (p. 117) – guides the nurse in
tough ethical decisions.
Civil Rights - persons with mental illness are guaranteed the same
rights under federal and state laws as any other citizen.
Specific Client Rights
Client Consent - proper order for specific therapies and treatment are
required and must be documented in the client’s chart.
Communication - right to communicate fully and privately with those
outside the facility; right to visitors; phone/mail access; etc.
Freedom from Harm - freedom from unnecessary or excessive
physical restraint, isolation, and medication, as well as freedom from
abuse and neglect.
Dignity and Respect - right to be treated with dignity and respect; free
from discrimination on the basis of ethnic origin, gender, age,
disability, or religion.
Confidentiality - records must be kept private; no photographs without
written consent; maintain privacy according to HIPPA.
Participation in Plan of Care - involve the client in decision making in
all aspects of care.

Nursing Process
Assessment
Mental status assessment
Psychosocial assessment
Physical exam
History taking
Interviews
Standardized rating scale
Verification of all data
Diagnosis
Identify problem and etiology
Construct nursing diagnoses and problem list
Prioritize nursing diagnoses
Outcomes
Identify outcomes
Planning
Identify safe, pertinent, evidence-based actions
Strive to use interventions that are culturally relevant and compatible with health
beliefs and practices
Implementation
Basic level: counseling, milieu therapy, self-care activities, psychobiological
interventions, health teaching, case management, health promotion and maintenance
Advanced level: psychotherapy, prescription meds, consultation

Evaluation
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If outcomes have not been achieved at desired level: additional data gathering,
reassessment, revision
Documentation
Documentation is the responsibility of the entire mental health team.

Goals of a Therapeutic Relationship

A therapeutic nurse-client relationship has specific goals and functions. Goals in a
therapeutic relationship include the following:
Facilitating communication of distressing thoughts and feelings
Assisting clients with problem solving to help facilitate activities of
daily living
Helping clients examine self-defeating behaviors and test
alternatives
Promoting self-care and independence

Factors that Enhance Growth in Others

Genuineness – self awareness of one’s feelings as they arise within
the relationship and the ability to communicate them when
appropriate.
Empathy – one understands the ideas expressed, as well as the
feelings that are present in the other person.
Positive Regard – implies respect; It is the ability to view another
person as being worthy of caring about and as someone who has
strengths and achievement potential.

Establishing Boundaries
Problem Areas
Overhelping – doing for clients what they are able to do themselves or
goes beyond the wishes and needs of the client.
Controlling – asserting authority and assuming control of clients “for
their own good.”
Narcissism – having to find weakness, helplessness, and/or disease in
clients to feel helpful, at the expense of recognizing and supporting
clients’ healthier, stronger, and more competent features

Peplau’s Phases of Nurse-Client Relationship

Orientation Phase - During the orientation phase, the nurse assessed
the client, identified problems, and discussed plans for the visit.
Working Phase - In the working phase, the client identified their
problems, asked questions, and recognized the nurse was beneficial.
Termination Phase - In the termination phase, problems were solved,
the client became independent and established goals, and the
relationship ended.
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Tools of Psychiatric Mental Health Nursing

Communication is the key to successful psychiatric – mental healthy
nursing.
Psychiatric mental health nurses use tools of self and tools of
knowledge in their work
Therapeutic communication is the purposeful use of dialog to bring
about the client’s insight, control of symptoms, and/or healing.
To accomplish therapeutic communication, the nurse needs to
understanding communication theory and how to build a positive
nurse-client relationship.

Physical Space
Denotes a sense of relationship between two people
Has meaning in communication.
Public space = approximately 12 feet
Social space = 9 to 12 feet
Personal space = 18 inches to about 4 feet
Intimate space = closer than 18 inches

Actions or Kinetics
Refer
to movements, expressions, question, and posture that
accompany interactions and influence communications.
NOTE: They are almost always culture-bound.

Paralinguistic Cues
Provide the context in which the words are delivered, and they
influence meaning directly.
Include tone, pitch, emotions expressed verbally (such as anxiety or
anger or fear), and sounds of hesitation, nervous laughter, and nervous
coughing.
Must be interpreted within the context of the client’s cultural and
social/familial norms.

Touch
Is a form of communication used almost daily by nurses providing
direct physical care and support to clients.
Can convey warmth, positive regard, and support during silence, and
reassurance that the nurse is fully present and caring.
Have many meanings (appropriate and inappropriate touching).

Verbal Communication
Is the use of words, written and spoken, to send messages to another.
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For communication to be most therapeutic, it must convey a

respectful attitude, one that supports the individuality and self-esteem
of both the client and the nurse.

Nonverbal Communication
Refersto all of the messages sent by others than verbal or written.
Includesbehaviors, cues, and presence (such as proximity) that send
a message.

Techniques To Enhance Communication (p. 187-188)

Using Silence - absence of verbal communication, which provides
time for the client to put thoughts or feelings into words, to regain
composure, or to continue talking.
Silence often encourages the client to verbalize, provided that it is interested and
expectant. Silence gives the client time to organize thoughts, direct the topic of
interaction, or focus on issues that are most important. Much nonverbal behavior
takes place during silence, and the nurse needs to be aware of the client and his or her
own nonverbal behavior.
Accepting – indicates that the person has been understood.
An accepting response indicates the nurse has heard and followed the train of thought.
It does not indicate agreement but is nonjudgmental. Facial expression, tone of voice,
and so forth also must convey acceptance or the words lose their meaning.
Giving Recognition - acknowledging, indicating awareness.
Greeting the client by name, indicating awareness of change, or noting efforts the
client has made all show that the nurse recognizes the client as a person, as an
individual. Such recognition does not carry the notion of value, that is, of being
“good” or “bad.” Sometimes clients cannot verbalize or make themselves.
 Offering Self - making oneself available; offers presence, interest,
and desire to understand.
The nurse can offer his or her presence, interest, and desire to understand. It is
important that this offer is unconditional, that is, the client does not have to respond
verbally to get the nurse’s attention.
Offering General Leads - giving encouragement to continue.
General leads indicate that the nurse is listening and following what the client is
saying without taking away the initiative for the interaction. They also encourage the
client to continue if he or she is hesitant or uncomfortable about the topic.
Giving Broad Openings - allowing the client to take the initiative in
introducing the topic.
Broad openings make explicit that the client has the lead for the interaction. For the
client who has trouble talking, broad openings may stimulate him or her into taking
the initiative.
Placing the Events in Time or Sequence - clarifying the
relationship of events in time.
Putting events in proper sequence helps both the nurse and client to see them in
perspective. The client may gain insight into cause-and-effect behavior and
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consequences, or the client may be able to see that perhaps some things are not
related. The nurse may gain information about recurrent patterns or themes in the
client’s behavior or relationships.
 Making Observations - verbalizing what the nurse perceives; calls
attention to behavior
Sometimes clients cannot verbalize or make themselves understood. Or the client may
not be ready to talk.
Encouraging Description of Perception - asking the client to
verbalize what he or she perceives.
To understand the client, the nurse must see things from his or her perspective.
Encouraging the client to describe ideas fully may relieve the tension the client is
feeling and he or she might be less likely to take action on ideas that are harmful or
frightening.
 Encouraging Comparison - asking that similarities and
differences be noted.
Comparing ideas, experiences, or relationships brings out many recurring themes. The
client benefits from making these comparisons because he or she might recall past
coping strategies that were effective or remember that he or she has survived a similar
situation.
Restating - repeating the main idea expressed.
The nurse repeats what the client has said in approximately or nearly the same words
the client has used. This restatement lets the client know that he or she communicated
the idea effectively. This encourages the client to continue. Or if the client has been
misunderstood, he or she can clarify his or her thoughts.
Reflecting - directing client actions, thoughts, and feelings back to
client.
Reflection encourages the client to recognize and accept his or her own feelings. The
nurse indicates that the client’s point of view has value, and that the client has the
right to have opinions, make decisions, and think independently.
Focusing - concentrating on a single point.
The nurse encourages the client to concentrate his or her energies on a single point,
which may prevent a multitude of factors or problems from overwhelming the client. It
is also a useful technique when a client jumps from one topic to another.
Exploring - delving further into a subject or idea.
When clients deal with topics superficially, exploring can help them examine the issue
more fully. Any problem or concern can be better understood if explored in depth. If
the client expresses an unwillingness to explore a subject, however, the nurse must
respect his or her wishes.
Giving Information - making available the facts that the client
needs.
Informing the client of facts increases his or her knowledge about a topic or lets the
client know what to expect. The nurse is functioning as a resource person. Giving
information also builds trust with the client.
Seeking Clarification – helps clients clarify their own thoughts and
maximize mutual understanding between nurse and client.
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Helps to ensure that what the client said or needs is clearly identified and not
misunderstood.
Presenting reality – indicates what is real.
When it is obvious that the client is misinterpreting reality, the nurse can indicate what
is real. The nurse does this by calmly and quietly expressing the nurse’s perceptions or
the facts, not by way of arguing with the client or belittling his or her experience. The
intent is to indicate an alternative line of thought for the client to consider, not to
“convince” the client that he or she is wrong.
Voicing Doubt – expressing uncertainty about the reality of the
client’s perceptions.
Another means of responding to distortions of reality is to express doubt. Such
expression permits the client to become aware that others do not necessarily perceive
events in the same way or draw the same conclusions. This does not mean the client
will alter his or her point of view, but at least the nurse will encourage the client to
reconsider or re-evaluate what has happened. The nurse neither agreed nor
disagreed; however, he or she has not let the misperceptions and distortions pass
without comment.
Seeking Consensual Validation - searching for mutual
understanding, for accord in the meaning of the words.
For verbal communication to be meaningful, it is essential that the words being used
have the same meaning for both (all) participants. Sometimes, words, phrases, or
slang terms have different meanings and can be easily misunderstood.
Verbalizing the Implied - voicing what the client has hinted at or
suggested.
Putting into words what the client has implied or said indirectly tends to make the
discussion less obscure. The nurse should be as direct as possible without being
unfeelingly blunt or obtuse. The client may have difficulty communicating directly. The
nurse should take care to express only what is fairly obvious; otherwise, the nurse may
be jumping to conclusions or interpreting the client’s communication.
Encouraging Evaluation – asking client to appraise quality of their
experiences.
Encourage clients to develop the habit of continual self-assessment. Helps client to
establish a sense of self.
Attempting to Translate into Feelings - seeking to verbalize
client’s feelings that he or she expresses only indirectly.
Often what the client says, when taken literally, seems meaningless or far removed
from reality. To understand, the nurse must concentrate on what the client might be
feeling to express himself or herself this way.
Suggesting Collaboration - offering to share, to strive, to work with
the client for his or her benefit.
The nurse seeks to offer a relationship in which the client can identify problems in
living with others, grow emotionally, and improve the ability to form satisfactory
relationships. The nurse offers to do things with, rather than for, the client.

Summarizing – organizing and summing up that which has gone

before.
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Summarization seeks to bring out the important points of the discussion and to
increase the awareness and understanding of both participants. It omits the irrelevant
and organizes the pertinent aspects of the interaction. It allows both client and nurse
to depart with the same ideas and provides a sense of closure at the completion of
each discussion.
Encouraging Formulation of a Plan of Action - asking the client
to consider kinds of behavior likely to be appropriate in future
situations.
It may be helpful for the client to plan in advance what he or she might do in future
similar situations. Making definite plans increases the likelihood that the client will
cope more effectively in similar situation.

Obstructive Communication
(pp. 191 – 192)
Giving Premature Advice – assumes the nurse knows what is best
and the client can think for self. Inhibits problem-solving and fosters
dependency.
Premature advice may interfere with enabling the patient to be the agent of change.
Minimizing Feelings - misjudging the degree of the client’s
discomfort.
When the nurse tries to equate the intense and overwhelming feelings the client has
expressed to “everybody” or to the nurse’s own feelings, the nurse implies that the
discomfort is temporary, mild, self limiting, or not very important. The client is
focused on his or her own worries and feelings; hearing the problems or feelings of
others is not helpful.
Falsely Reassuring – underrates a person’s feelings and belittles a
person’s concern. May cause the client to stop sharing feelings if he or
she thinks they will not be taking seriously.
Attempts to dispel the client’s anxiety by implying that there is not sufficient reason for
concern completely devalue the client’s feelings. Vague reassurances without
accompanying facts are meaningless to the client.
Showing Nonverbal Signs of Boredom or Resentment - tells the
client that you are not interested or distracted and that she or she is
not important.
Most of us often give way our inner feelings non-verbally. (Non verbal self portrait).
Such communications more often than not, are consistent with our emotions and
attitudes and in a subtle manner portray our emotional spectrum. Where words fail, a
subtle gesture speaks volumes. It can reflect and unfold the intriguing art of
negotiations. Non verbal clues can reveal whether the person you are talking to is
lying, friendly, bored, defensive, eager or anxious. Gestures are often like words in a
language. Be always confident, sincere, open hearted, truthful and have positive
expressions
Making Value Judgments – believing your own values and beliefs
are superior are more important than the client’s.
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Listening to, understanding and respecting the client’s values, opinions, needs and
ethnocultural beliefs and integrating these elements into the care plan with the client’s
help.
Asking “why” question – asking the client to explain why he or she
believes, feels, or has acted in a certain way.
Clients frequently interpret “why” questions as accusations or think the nurse knows
the reason and is simply testing them. Regardless of client’s perception of the nurse’s
motivation, “why” questions can cause resentment, insecurity, and mistrust.
Asking Excessive Questions - probing.
Probing tends to make the client feel used or invaded. Clients have the right not to talk
about issues or concerns if they choose. Pushing and probing by the nurse will not
encourage the client to talk.
Giving Approval, Agreeing - indicating accord with the client.
Approval indicates the client is “right” rather than “wrong.” This gives the client the
impression that he or she is “right” because of agreement with the nurse. Opinions
and conclusions should be exclusively the client’s. When the nurse agrees with the
client, there is no opportunity for the client to change his or her mind without being
“wrong.”
Disapproving – denouncing the client’s behavior or ideas.
Disapproval implies that the nurse has the right to pass judgment on the client’s
thoughts or actions. It further implies that the client is expected to please the nurse.
Disagreeing - opposing the client’s ideas.
Disagreeing implies the client is “wrong.” Consequently, the client feels defensive
about his or her point of view or ideas.
Changing the Subject - Introducing an unrelated topic.
The nurse takes the initiative for the interaction away from the client. This usually
happens because the nurse is uncomfortable, doesn’t know how to respond, or has a
topic he or she would rather discuss

Levels of Psychiatric Mental Health Clinical Nursing

Practice (p. 65)

Basic Level - registered nurse; manages the inpatient or outpatient

nursing care of clients; administers medications; completes
assessments on clients, establishes outcomes, writes nursing
diagnoses, and implements plan of care, including client/family
teaching.
Advanced Level – RN with psychiatric mental health specialty; has
passed a certification exam.
Advanced practice RN – psychiatric mental health (APRN-PMH); MSN
with psychiatric nursing specialty; provides psychotherapy; prescribes
psychotropic medications (in most states); manages and coordinates
client care.

Levels of Anxiety
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Mild Anxiety - common in all of us. An example of mild anxiety is if

you have a big presentation or test coming up. You may feel nervous to
the point you perform better. This is an optimal level of anxiety. Mild
anxiety comes and goes. It gives us energy to get the job done and
move on.
Moderate Anxiety - a level of anxiety in which problem solving is
impaired, but can be accomplished with assistance. Physiological
changes occur with moderate anxiety; examples of this include
increased respirations and heart rate. Psychologically, a person
experiencing this level of anxiety will have a difficult time
concentrating and staying on task.
Severe Anxiety - a level of anxiety in which problem solving is not
possible. The ability to attend to details is lost. This person will need
treatment to avoid going into panic. Physiologically, body systems
speed up. This is an uncomfortable state to be in.
Panic Level of Anxiety - the highest level of anxiety. Behavior can
be bizarre and contact with reality is lost. Tending to the safety of this
individual is paramount. Anxiety results when an actual or perceived
threat is directed toward

Two Common Features of Defense Mechanisms

“They all (except suppression) operate on an unconscious level, so
that we are not aware of their operations” (p. 17).
“They deny, falsify, or distort reality to make it less threatening” (p.
17).

Common Defense Mechanisms

Most Healthy Defenses (pp. 217-218)
Altruism - The individual deals with emotional conflict or internal or
external stressors by dedication to meeting the needs of others. Unlike
the self-sacrifice sometimes characteristic of reaction formation, the
individual receives gratification either vicariously or from the response
of others.
others
 Sublimation - Attenuating the force of an instinctual drive by using
the energy in other, usually constructive activities. This definition
implies acceptance of the Libido Theory; the examples do not require
it. Sublimation is often combined with other mechanisms, among them
aim inhibition, displacement, and symbolization. Examples: (1) a man
who is dissatisfied with his sex life but who has not stepped out on his
wife becomes very busy repairing his house while his wife is out of
town. Thus, he has no time for social activities. (2) a woman is forced
to undertake a restrictive diet; she becomes interested in painting and
does a number of still life pictures, most of which include fruit.
The conscious use of work or hobbies to divert one’s thoughts from a problem or from
a rejected wish is an analog of this. Sublimation is often a desirable mechanism.
 22

However, the consequences may, in addition to preventing instinctual satisfaction,

interfere with the person's life in other ways if disproportionate time, money, or effort
activity.
is used in the activity.
Humor - The individual deals with emotional conflict or external
stressors by emphasizing the amusing or ironic aspects of the conflict
or stressors.
Suppression - Usually fisted as an ego defense mechanism but
actually the conscious analog of repression; intentional exclusion of
material from consciousness. At times, suppression may lead to
subsequent repression. Examples: (1) a young man at work finds that
he is letting thoughts about a date that evening interfere with his
duties; he decides not to think about plans for the evening until he
leaves work. (2) a student goes on vacation worried that she may be
failing; she decides not to spoil her holiday by thinking of school. (3) a
woman makes an embarrassing faux pas at a party; she makes an
effort to forget all about it.
In the first example, suppression was probably a desirable mechanism since it
permitted concentration on work and deferred dealing with plans for the evening until
a more appropriate time. In the second instance, suppression would have been
undesirable if failing work could have been corrected during vacation or if a realistic
appraisal of probable consequences of the school situation would have permitted
battery planning.
Intermediate Defenses (p. 218)
Repression - The involuntary exclusion of a painful or conflictual
thought, impulse, or memory from awareness. This is the primary ego
defense mechanism; others reinforce it.
Displacement - One way to avoid the risk associated with feeling
unpleasant emotions is to displace them, or put them somewhere
other than where they belong. A common example is being angry at
your boss. Displaying that anger could cost you your job. You might be
afraid that you can not contain it, but also afraid of what will happen if
you express it toward your boss. You might instead express it, but
redirect it toward some other, safer source, such as your partner or
best friend. You yell at them and pick a fight. They will forgive you or
ignore it, and then you are able to express your anger but without
risking your job.
Reaction Formation - Going to the opposite extreme;
overcompensation for unacceptable impulses. Examples: (1) a man
violently dislikes an employee; without being aware of doing so, he
"bends over backwards" to not criticize the employee and gives him
special privileges and advances. (2) a person with strong antisocial
impulses leads a crusade against vice. (3) a married woman who is
disturbed by feeling attracted to one of her husband's friends treats
him rudely. Intentional efforts to compensate for conscious dislikes and
prejudices are sometimes analogous to this mechanism.
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Somatization - Conflicts are represented by physical symptoms

involving parts of the body innervated by the sympathetic and
parasympathetic system. Example: a highly competitive and
aggressive person, whose life situation requires that such behavior be
restricted, develops hypertension.
Undoing – makes up for an act or communication. A common
behavioral example is compulsive hand washing. This can be viewed as
cleansing oneself of an act or thought perceived as unacceptable.
Cheating husband giving gifts.
Rationalization – justifying illogical and unreasonable ideas, actions,
or feelings by developing accepting explanations that satisfy the teller
as well as the listener.
Everybody cheats, so why shouldn’t I.
Immature Defenses (pp. 218-220)
Passive aggression - The individual deals with emotional conflict or
internal or external stressors by indirectly and unassertively expressing
aggression toward others. There is a facade of overt compliance
masking covert resistance, resentment, or hostility. Passive aggression
often occurs in response to demands for independent action or
performance or the lack of gratification of dependent wishes but may
be adaptive for individuals in subordinate positions who have no other
way to express assertiveness more overtly.
Acting-Out Behaviors - The individual deals with emotional conflict
or internal or external stressors by actions rather than reflections or
feelings. This definition is broader than the original concept of the
acting out of transference feelings or wishes during psychotherapy and
is intended to include behavior arising both within and outside the
transference relationship. Defensive acting out is not synonymous
with "bad behavior" because it requires evidence that the behavior is
related to emotional conflicts.
Dissociation - Splitting-off a group of thoughts or activities from the
main portion of consciousness; compartmentalization. Example: a
politician works vigorously for integrity in government, but at the same
time engages in a business venture involving a conflict of interest
without being consciously hypocritical and seeing no connection
between the two activities.
Some dissociation is helpful in keeping one portion of one's life from interfering with
another (e.g., not bringing problems home from the office). However, dissociation is
responsible for some symptoms of mental illness; it occurs in "hysteria" (certain
somatoform and dissociative disorders) and schizophrenia. The dissociation of
hysteria involves a large segment of the consciousness while that in schizophrenia is of
numerous small portions. The apparent splitting of affect from content often noted in
schizophrenia is usually spoken of as dissociation of affect, though isolation might be
a better term.
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Devaluation - The individual deals with emotional conflict or internal

or external stressors by attributing exaggerated negative qualities to
self or others.
Idealization - Overestimation of the desirable qualities and
underestimation of the limitations of a desired object. Examples: (1) a
lover speaks in glowing terms of the beauty and intelligence of an
average-looking woman who is not very bright. (2) a purchaser, having
finally decided between two items, expounds upon the advantages of
the one chosen.
Splitting - This term is widely used today to explain the coexistence
within the ego of contradictory states, representative of self and
others, as well as attitudes to self and others; other individuals or the
self is perceived as "All good or all bad.
Projection - Projection is something we all do. It is the act of taking
something of ourselves and placing it outside of us, onto others;
sometimes we project positive and sometimes negative aspects of
ourselves. Sometimes we project things we don't want to acknowledge
about ourselves, and so we turn it around and put it on others (i.e., "It's
not that I made a stupid mistake, it's that you are critical of everything
I do!"). Sometimes it is simply our experiences (i.e., "My father was a
reasonable man when we disagreed, so if I use reason with my boss we
can work out our disagreement").
The problem with projecting negative aspects of ourselves is that we still suffer under
them. In the above example, instead of feeling inadequate (our true feeling) we suffer
with the feeling that everyone is critical of us. While we escape feelings of inadequacy
and vulnerability, we nonetheless still suffer and feel uneasy. The more energy you put
into avoiding the realization that you have weaknesses, the more difficult it eventually
is to face them. This is the main defense mechanism of paranoid and anti-social
personalities.
Denial - the simplest defense to understand. It is simply the refusal
to acknowledge what has, is, or will happen. "My partner didn't have an
affair, but was simply traveling for work a lot." A related defense is
Minimizing. When you minimize you technically accept what happened,
but only in a "watered down" form. "Sure, I have been drinking a bit
too much lately, but it's only due to stresses at work; I don't really have
a drinking problem since this is situational and not an inner weakness
or something."
Regression - Repression is often thought of as the parent of all
defenses. Repression involves putting painful thoughts and memories
out of our minds and forgetting them. All defenses do this to some
extent. Traditionally, repression is unconsciously "forgetting," that is,
forgetting and not even realizing that you are doing it. You have no
conscious memory or knowledge of that which is repressed.
The problem with repression is that the memory, feeling, or insight repressed doesn't
go away. It continues to effect us because our unconscious gives it a life of its own. It
 25

becomes all the more powerful because we repress it, and it can effect our decisions,
may.
reactions, etc... in ways that we don't see but others may.