Chapter 1
Foundations of Psychiatric–
Mental Health Nursing
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Mental Health
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Difficult to define
No single, universal definition
Many components influenced by factors
Dynamic, ever-changing state
Influencing factors:
– Individual (personal)
– Interpersonal (relationship)
– Social/cultural (environmental)
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Mental Illness
• Includes disorders that affect:
– Mood
– Behavior
– Thinking
• These often indicate signs of distress and/or impaired
functioning.
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Mental Illness (cont.)
• General criteria for diagnosis:
– Dissatisfaction with characteristics, abilities,
accomplishments
– Ineffective or unsatisfying relationships
– Dissatisfaction with one’s place in the world
– Ineffective coping with life events
– Lack of personal growth
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Diagnostic and Statistical Manual of
Mental Disorders
• DSM: Taxonomy of American Psychiatric Association
• Purposes:
– Standardize nomenclature, language
– Identify defining characteristics or symptoms
– Assist in identifying underlying causes
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DSM Classification
• Allows the practitioner to identify all factors that relate to
a patient’s condition:
– Major psychiatric disorders
– Medical conditions
– Psychosocial and environmental problems
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Question
• Is the following statement true or false?
• The definition of mental health is standardized and
universally accepted.
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Answer
• False
• Rationale: There is no single universal definition of
mental health, which has many components and is
influenced by myriad factors.
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Historical Perspectives
• Ancient times
– Sickness as displeasure of gods; punishment for
sins; viewed as demonic or divine
– Aristotle and imbalances of the four humors (blood,
water, yellow and black bile); balance restoration via
bloodletting, starving, and purging
– Early Christians’ view as possession by demons
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Historical Perspectives (cont.)
• Period of enlightenment (1790s)
– Creation of asylums; moral treatment
– Dorothea Dix
• Sigmund Freud: scientific study, treatment of mental
illness
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Historical Perspectives (cont.)
• Psychopharmacology (1950s): development of
psychotropic drugs
• Community mental health movement
– Deinstitutionalization
– Legislation for disability income
– Changes in commitment laws
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Mental Illness and the 21st Century
• Current state
– More than 26% of Americans aged 18 years and
older have diagnosable mental disorder (NIMH,
2008)
– 15 million adults, 4 million children and adolescents
with impaired daily activities
– Economic burden exceeds that by all types of cancer.
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Mental Illness and the 21st Century
(cont.)
• Current state (cont.)
– Leading cause of disability in the United States and
Canada for those 15 to 44 years of age
– Increasing number of both adults and
children/adolescents are being treated for mental
illness.
– Treatment still lagging in homeless and those with
substance abuse problems
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Mental Illness and the 21st Century
(cont.)
• Issues and concerns:
– “Revolving-door” effect due to deinstitutionalization
– Shorter hospital stays, decompensation,
rehospitalization, dual diagnoses
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Mental Illness and the 21st Century
(cont.)
• Issues and concerns (cont.):
– Homelessness (1/3 estimated to have serious mental
illness; over 1/2 with substance abuse problems)
– Increase in physical illness comorbidities
– Lack of adequate community resources
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Question
• Which statement best reflects the current state of mental
health and mental illness?
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A. Mental health-care costs exceed the costs for
cancer care.
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B. Most adults and children receive adequate
mental health care.
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C. Community resources for the homeless with
mental illness are adequate.
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D. Deinstitutionalization has reduced the
revolving-door effect.
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Answer
•
A. Mental health-care costs exceed the costs for cancer
care.
• Rationale: The economic burden of mental illness
exceeds that for all types of cancer care.
– Only 1 in 4 adults and 1 in 5 children received the
necessary mental health care. Community resources
for homeless clients with mental illness are
inadequate. Deinstitutionalization has led to the
“revolving-door” effect.
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Objectives for the Future
• Healthy People 2020 objectives:
– Increase number of people identified, diagnosed,
treated, helped to live healthier lives
– Decrease rates of suicide, homelessness
– Increase employment for those with serious mental
illness
– Provide more services for incarcerated persons with
mental health problems
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Community-Based Care
• Lack of appropriate number of community mental health
centers to provide services
• Development of community support programs
– Availability, quality of services highly variable
– Inaccurate anticipation of extent of people’s needs
– Despite flaws, positive aspects making them
preferable for treatment
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Cost Containment and Managed Care
• Managed care movement (early 1970s)
• Development of utilization review firms/managed care
organizations (1990s); case management
• Separation of mental health care from physical care for
insurance coverage
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Cost Containment and Managed Care
(cont.)
• Mental health-care management through privately owned
behavioral health-care firms
– If no private insurance, reliance on counties of
residence for payment
• HCFA: Medicare, Medicaid
• Mental health parity, insurance coverage
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Cultural Considerations
• Culturally diverse population
• Cultural differences influencing mental health, treatment
of mental illness
• Changes in family structure
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Question
• Is the following statement true or false?
• Community-based programs are preferable for treating
many people with mental illness.
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Answer
• True
• Rationale: Although there are flaws in the system,
community-based programs have positive aspects that
make them preferable for treating many people with
mental illness.
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Psychiatric Nursing Practice
• Linda Richards: first American psychiatric nurse
• McLean Hospital, Belmont, MA: site of first training for
nurses to work with persons with mental illness
• Expansion of role with development of somatic therapies
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Psychiatric Nursing Practice (cont.)
• First psychiatric nursing textbook (Nursing Mental
Diseases) published in 1920
• Johns Hopkins: first school of nursing to include
psychiatric nursing course (1913)
• National League for Nursing (1950) requiring schools to
include psychiatric nursing experience
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Psychiatric Nursing Practice (cont.)
• H. Peplau: therapeutic nurse–client relationship;
interpersonal dimension (foundation for current practice)
• J. Mellow: focus on client’s psychosocial needs, strengths
• American Nurses Association and Standards of Care (see
Box 1.3)
• Psychiatric–Mental Health Nursing Phenomena of Concern
(see Box 1.2)
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Psychiatric Nursing Practice (cont.)
• Basic-level functions
• Advanced-level functions
– Counseling
– Psychotherapy
– Milieu therapy
– Prescriptive authority
for drugs
– Self-care activities
– Psychobiologic
interventions
– Consultation, liaison
– Evaluation
– Health teaching
– Case management
– Health promotion,
maintenance
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Student Concerns and Psychiatric–Mental
Health Clinical Experience
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Saying the wrong thing
Knowing what to do
Being rejected or not talking to the student
Asking personal questions
Handling bizarre, inappropriate, or sexually aggressive
behavior
• Handling feeling unsafe
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Student Concerns and Psychiatric–Mental
Health Clinical Experience (cont.)
• Seeing someone known on the unit
• Dealing with similar problems or backgrounds
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Question
• Is the following statement true or false?
• The National League for Nursing required schools to
include a psychiatric nursing experience before the first
nursing school included a psychiatric nursing course in its
curriculum.
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Answer
• False
• Rationale: Johns Hopkins was the first school of nursing
to include a course in psychiatric nursing in its
curriculum; this was done in 1913. It was not until 1950
that the National League for Nursing required schools to
include an experience in psychiatric nursing.
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Self-Awareness Issues
• Everyone has unique or different values, ideas, and
beliefs.
• Possible conflict between personal values/beliefs, those
of client
• Need to accept differences; view each client as
worthwhile regardless of opinions or lifestyle
• Self-awareness through reflection
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