NBNS2604 Psychiatric Mental Health Nursing - Eaug20

NBNS2604
Psychiatric Mental Health Nursing
Copyright © Open University Malaysia (OUM)

NBNS2604
PSYCHIATRIC
MENTAL HEALTH
NURSING
Assoc Prof Utharas Arumugam

Project Directors: Prof Dr Widad Othman
Dr Raziana Che Aziz
Open University Malaysia
Module Writer: Assoc Prof Utharas Arumugam
Moderator: Noraizal Mohd Nor University Malaysia
Developed by: Centre for Instructional Design and Technology

Open University Malaysia
First Edition, August 2020 (NBNS2603, August 2020)

Copyright © Open University Malaysia (OUM), August 2020, NBNS2604
All rights reserved. No part of this work may be reproduced in any form or by any means without
the written permission of the President, Open University Malaysia (OUM).

Table of Contents
Course Guide xiăxvii
Topic 1 Principles of Psychiatric Nursing: Current Theory and Practice 1

1.1 Mental Health 3
1.2 Elements that Contribute to Mental Wellbeing 5
1.2.1 Thinking 5
1.2.2 The Concept of „Self‰ 5
1.2.3 Self-image 6
1.2.4 Self-worth vs Self-esteem 10
1.3 Emotion and Regulation of Stress Response 11
1.3.1 Stress Regulation „HPA‰ Axis 12
1.3.2 Dynamic Interactionism 13
1.4 Understanding Stress and Its Management 15
1.4.1 General Adaptation Syndrome 16
1.4.2 Signs and Symptoms of Stress 17
1.4.3 Stress Management Strategies 18
1.5 Stress Coping Interventions 20
1.5.1 Mindfulness Based Stress Reduction (MBSR) 21
1.5.2 Progressive Muscle Relaxation (PMR) 22
1.5.3 Guided Imagery 23
1.6 Interpersonal Relationship 24
1.7 Mental Illness 25
1.7.1 Levels of Prevention 27
1.7.2 Promotion and Prevention in the Field of 27
Mental Health
1.7.3 Risk Factors and Protective Factors 29
1.7.4 Diagnostic Manuals in Psychiatry 31
1.8 The Roles of the Mental Health Nurse 33
1.8.1 Care Giver ă Delivery of Nursing Care 33
1.8.2 Patient Advocate 34
1.8.3 Therapeutic Agent 34
1.8.4 Patient Safety/Custodial Care 35
1.8.5 Mental Health Promotion/Psychoeducation 35
1.8.6 Clinical Leadership 35
1.9 Legal and Ethical Aspects in Clinical Practice 36
1.9.1 Mental Health Act 2001 (MHA 2001) 36
1.9.2 PatientÊs Rights Under the Act 37

iv  TABLE OF CONTENTS
Summary 38
Key Terms 40
References 40
Topic 2 Psychosocial Assessment in Mental Health Nursing 43

2.1 The Nature of Your Relationship with Your Patient 45
2.2 What is Therapeutic Relationship? 46
2.2.1 Core Conditions 46
2.3 Factors that May Influence Your Assessment 49
2.3.1 Factors within the Patient 49
2.3.2 Factors within the Nurse 50
2.3.3 Other Environmental and Cultural Factors 50
2.4 How Assessment is Conducted 51
2.4.1 Subjective and Objective Data 52
2.4.2 Types of Questioning 53
2.5 What to Assess? 55
2.5.1 History 56
2.5.2 General Appearance and Motor Behaviour 56
2.5.3 Mood and Affect 57
2.5.4 Thought Process and Content Speech 57
2.5.5 Sensory and Intellectual Process 58
2.5.6 Judgement and Insight 58
2.5.7 Self-concept 59
2.5.8 Roles and Relationships 61
2.5.9 Physiologic and Self-care Concerns 61
Summary 62
Key Terms 63
References 64
Topic 3 Nursing Practice for Anxiety and Anxiety Disorders 65

3.1 The Dynamic Relationship between Cognition, 66
Behaviour and Emotion
3.1.1 Physiology of Arousal 68
3.1.2 Anxiety as Unhealthy Negative Emotion 70
3.2 Physiology and Other Symptoms of Anxiety 71
3.2.1 Cognitive Symptoms 71
3.2.2 Behavioural Symptoms 72
3.3 Anxiety-related Disorders 72
3.3.1 Generalised Anxiety Disorder 73
3.3.2 Obsessive Compulsive Disorder (OCD) 73
3.3.3 Phobias 74
3.3.4 Panic Disorder 75
3.3.5 Post-traumatic Stress Disorder (PTSD) 76

TABLE OF CONTENTS  v
3.4 Care and Treatment of People Suffering from Anxiety 77

Disorders
3.4.1 Interventions Used in Anxiety Disorders 78
Summary 82
Key Terms 83
References 84
Topic 4 Nursing Practice for Mood Disorders: Depression and 85

Bipolar Disorder
4.1 Traditional Psychiatric Approach to Mood Disorders 87
4.1.1 Categories of Mood Disorders 87
4.2 Diagnosis of Major Depression 91
4.2.1 Psychosocial Nursing Assessment and Interventions 92
4.2.2 Treatment of Depression 95
4.3 Bipolar Disorder 98
4.3.1 Treatment of Bipolar Disorder 100
4.3.2 Nursing Interventions 100
Summary 101
Key Terms 103
References 103
Topic 5 Nursing Practice for Psychiatric Disorder: Schizophrenia 104

5.1 Schizophrenia 106
5.1.1 Characteristic Features of Schizophrenia 107
5.1.2 Aetiology of Schizophrenia 110
5.1.3 Diagnosis of Schizophrenia 111
5.1.4 Treatment of Schizophrenia 112
5.1.5 Understanding the Negative Symptoms of 114
Schizophrenia
5.1.6 Psychosocial Interventions (PSI) 117
Summary 120
Key Terms 121
References 122
Topic 6 Managing Substance Use and Abuse 123

6.1 Terms Used in the Explanation of the Substance Use and 125
Abuse
6.2 Substance Use, Abuse and Dependence 126
6.2.1 Reasons Why People Start Using Drugs 128
6.2.2 Dependence 129
6.2.3 The Reward Pathway in the Brain 129
6.2.3 Substance-related Disorder 130

vi  TABLE OF CONTENTS
6.3 Managing Substance Abuse and Dependence 133

6.3.1 Effects of Drugs 134
6.3.2 Treatment of Substance Use Disorder 135
6.4 Challenges for the Nurse 138
6.4.1 Motivational Interviewing (MI) 139
Summary 142
Key Terms 143
References 143
Topic 7 Challenges in Managing Psychiatric Emergencies 145

7.1 Self-harm and Suicidal Behaviour 146
7.1.1 Suicidal Behaviour 147
7.1.2 Assessment of Self-harm and Suicidal Behaviour 147
7.1.3 Nursing Interventions 148
7.2 Aggression and Violence in Everyday Social Relationships 149
7.3 Strategy for Reducing the Risk of Violence 151
7.3.1 Hospital and Team Culture 152
7.4 Factors that Indicate Increased Risk of Violence 152
7.5 Interventions in Managing Aggression and Violence 155
7.5.1 The Assault Cycle 155
7.5.2 Awareness of Warning Signs 157
7.5.3 Physical Interventions 158
7.5.4 Control and Restraint (C&R) 159
7.5.5 Seclusion 159
7.5.6 Rapid Tranquillisation 160
7.5.7 Conclusion 161
Summary 161
Key Terms 163
References 163
Topic 8 Therapies in Clinical Practice 165

8.1 Theoretic Perspectives 166
8.2 Freudian Theory (Sigmund Freud, 1856 to 1939) 167
8.2.1 Defence Mechanisms 169
8.2.2 Psychosexual Stages of Development 171
8.2.3 Psychoanalysis 174
8.3 Behavioural Learning Theories 176
8.3.1 Classical Conditioning (Pavlovian Conditioning) 176
8.3.2 The Conditioning Process 178
8.3.3 Operant Conditioning (B. F. Skinner, 1904 to1990) 180
8.3.4 Application of Behavioural Principles 185
8.4 Rogerian Humanistic Perspective 188
8.4.1 MaslowÊs Hierarchy of Needs 189

TABLE OF CONTENTS  vii
8.5 Therapeutic Milieu 190

8.5.1 Caring Environment for Nurses 191
8.5.2 The Patient Environment 192
8.5.3 Therapeutic Activities 193
8.6 Individual, Group and Family Therapy 194
8.6.1 Rational Emotive Behaviour Therapy (REBT) 194
(Albert Ellis, 1913 to 2007)
8.7 Electroconvulsive Therapy (ECT) 201
Summary 203
Key Terms 204
References 205
Topic 9 Psycho-pharmacology 206

9.1 Antipsychotic Drugs 207
9.2 Antidepressant Drugs 208
9.2.1 Common Side Effects of Antidepressants 209
9.3 Mood Stabilising Drugs 211
9.3.1 Side Effects of Mood Stabilisers 211
9.4 Antianxiety and Sedative-Hynotic Drugs 213
9.4.1 Selective Serotonin Reuptake Inhibitor (SSRI) 214
and Serotonin and Norepinephrine Reuptake
Inhibitors (SNRI)
9.4.2 Side Effects of Benzodiazepines 215
9.5 Aggressive and Violent Behaviours 216
9.5.1 Rapid Tranquillisation 216
Summary 217
Key Terms 219
References 219
Topic 10 Caring for Clients in the Community 221

10.1 Historic Perspectives 222
10.2 Roles of the Nurse 224
10.2.1 Psychiatric Home Care 225
10.2.2 Assertive Community Treatment 226
10.2.3 Crisis Intervention Teams 226
10.2.4 First Episode Psychosis Intervention Team 227
10.2.5 Early Onset Psychosis 228
10.2.6 Assessment and Brief Treatment (ABT) Team 228
10.2.7 Forensic Community Mental Health Team (FCMHT) 228
10.3 Current Community 229
10.3.1 „Mentari‰ Malaysia Initiative 229

viii  TABLE OF CONTENTS
10.4 Barriers to Treatment 230

10.4.1 Stigma 231
10.4.2 Manpower 231
10.4.3 Economy 231
10.4.4 Geographical Factors 232
10.5 Challenges for Caregivers/Family 232
Summary 234
Key Terms 235
References 236

COURSE GUIDE  xi
COURSE GUIDE DESCRIPTION

You must read this Course Guide carefully from the beginning to the end. It tells
you briefly what the course is about and how you can work your way through the
course material. It also suggests the amount of time you are likely to spend in order
to complete the course successfully. Please keep on referring to the Course Guide
as you go through the course material as it will help you to clarify important study
components or points that you might miss or overlook.
INTRODUCTION
NBNS2604 Psychiatric Mental Health Nursing is one of the courses offered at
Open University Malaysia (OUM). This course is worth 4 credit hours and should
be covered over 8 to 15 weeks.
COURSE AUDIENCE
This course is offered to all learners taking the Bachelor of Nursing Science
programme. As an open and distance learner, you should be acquainted with
learning independently and being able to optimise the learning modes and
environment available to you. Before you begin this course, please confirm the
course material, the course requirements and how the course is conducted.
As an open and distance learner, you should be able to learn independently and
optimise the learning modes and environment available to you. Before you begin
this course, please ensure that you have the right course materials and understand
the course requirements as well as how the course is conducted.

xii  COURSE GUIDE
STUDY SCHEDULE
It is a standard OUM practice that learners accumulate 40 study hours for every
credit hour. As such, for a four-credit hour course, you are expected to spend
160 study hours. Table 1 gives an estimation of how the 160 study hours could be
accumulated.
Table 1: Estimation of Time Accumulation of Study Hours
Study
Study Activities
Hours
Study the module 40
Attend 5 tutorial sessions 10
Assignment(s) 80
Examination(s) 30
TOTAL STUDY HOURS ACCUMULATED 160
COURSE LEARNING OUTCOMES

By the end of this course, you should be able to:
1. Describe the application of knowledge and skills in the principles of
psychiatric mental health nursing in the provision of relevant psychological
care using evidence-based best practice;
2. Demonstrate the ability to recognize pertinent issues in psychiatric mental
health nursing related to professional responsibilities and legal aspects to
help determine the provision of evidence-based nursing practice and
contemporary care of patients with mental illness; and
3. Initiate collaborative care within the interdisciplinary team to meet the
physical and psychological needs of the patients, families and community.

COURSE GUIDE  xiii
COURSE SYNOPSIS
This course is divided into 10 topics. The synopsis for each topic is as follows:
Topic 1 introduces you to mental health nursing, with a discussion and

clarification of some common concepts in mental health nursing, such as „mental
health‰ and „mental illness‰, together with the role and function of the mental
health nurse. Important elements that contribute to mental wellbeing such as
thinking, self-concept, body-image, identity, autonomy and self-worth are also
explored. In addition, you will examine the mechanism that underpin the
experience of emotion and the regulation of stress response. Strategies and
techniques that help to manage stress are also covered. Interpersonal relationships
and social functioning are considered as indicators of mental wellbeing. You will
be introduced to diagnostic manuals used in psychiatry and the mental health
legislations that apply to us.
Topic 2 addresses the assessment process in mental health nursing and the range
of factors that have a bearing on the process. The nurse patient relationship being
central to the process, will be explored in some detail, including „therapeutic
relationship‰ and Rogerian core conditions. You will also consider the factors that
can influence the assessment which are located within the nurse, the patient and
the environment. Overall, this topic shows you how to conduct the assessment and
what to assess.
Topic 3 explores the dynamic interaction between cognition, behaviour and

emotion. Emotion does not happen in a „vacuums‰, it is powerfully influenced by
cognition and behaviour. Though the focus in this topic is anxiety, the underlying
mechanism is the same for all emotions. You will appreciate the role of
physiological arousal in anxiety and learn to differentiate between anxiety, which
is unhealthy negative emotion and being concerned, which is still negative but
healthy. We will also cover a range of anxiety related disorders such as,
generalised anxiety disorder, obsessive compulsive disorder (OCD), phobias,
panic disorder and post-traumatic stress disorder (PTSD). You will also be
presented with a range of psychosocial interventions and the drugs used in the
treatment of anxiety.

xiv  COURSE GUIDE
Topic 4 introduces affective disorders or mood disorders which are disturbance in

an individualÊs emotional state. This can involve a range of disturbance in the form
of extreme depression to mania or a combination of these emotional states as in
bipolar, dysthymic and cyclothymic disorder. It is important we learn to recognise
when an emotion is unhealthy and require professional help. There are many
categories of mood disorders, and this topic will introduce them to you, along with
the psychosocial assessment, interventions and treatment for major depression
and bipolar disorder.
Topic 5 explores the overlapping concept of psychosis and schizophrenia, while

schizophrenia is an illness, psychosis is seen as a syndrome or cluster of symptoms
that is present and necessary for the diagnosis of schizophrenia and may be
present in other illnesses. Thus, it is important for you to recognise the features of
psychosis, the major characteristics and aetiology of schizophrenia. In addition,
the diagnosis and treatment of schizophrenia as well as the negative symptoms of
schizophrenia and the benefits of psychosocial interventions for patients suffering
from schizophrenia will also be covered.
Topic 6 discusses how Malaysia handles substance use and associated problems.
Criminalising and punishing substance use appeared not to have had the desired
effect and we are gradually moving away from the moral and legalistic approach
and towards a treatment model. You will learn about the terms used in substance
use and abuse, followed by the differences between substance use, abuse and
dependence. Then, explanation on how to manage substance abuse and
dependence as well as the challenges and strategies in keeping the client group
engaged with the treatment programme will be presented too.
Topic 7 focuses exclusively on self-harm and suicidal behaviour, followed by the

management of aggression and violence. Self-harm essentially is injuries caused to
oneÊs own body with the view to deliberately hurt oneself. Meanwhile, aggression
is usually the expression of hostility and may include threat of physical harm, as
in the angry threatening person; and violence which entails the actual harm (hurt
and injury) caused to another person through the use of physical force, verbal
abuse and intimidation. One cannot be violent without being aggressive. You will
review some of the causes and important variables in the assessment of risk of
violence including personal history, clinical and situational factors.

COURSE GUIDE  xv
Topic 8 helps you to get to know some of the major theories that have contributed
to our understanding and treatment of psychological disturbances. You will
review in some detail the Freudian psychodynamic theory, behavioural learning
theories, RogerÊs humanistic theory and cognitive behavioural theories. This topic
also reviews the effects of „therapeutic milieu‰ on patient recovery as well as the
ABC model of rational emotive behaviour therapy (RBET). Lastly, the use of
electro convulsive therapy (ECT), which still remains popular as a treatment of last
resort will be elaborated.
Topic 9 addresses the use of psychotropic drugs, which are powerful mind-
altering substances used in the treatment of mental illness. These medicines are
grouped according to the mental disorders they are in the main used to treat, such
as anti-psychotics, anti-depressants, mood stabilisers and anxiolytics.
Undoubtedly these drugs have transformed the way we care for people who are
mentally ill. Though care must be taken in minimising the serious unwanted
effects of the drugs. These drugs are used as antidepressants, mood stabiliser and
treatment for anxiety related problems. „Rapid tranquillisation‰ in mental health
care will also be explained in last part of this topic.
Topic 10 concludes with caring for clients in the community. Our current
community services are in need of development and consist mainly of hospital-
based nurses visiting patients in their homes, to monitor and administer drugs.
Primary care services are deemed to play a more active role in the assessment and
detection of mental illness. The Malaysian Health DepartmentÊs initiation of
Mentari teams are a small step in the right direction, but one team in each state
would not be adequate resources to meet the needs in the community. In addition,
the barriers to treatment and the impact of mental illness on care givers or family
will also be covered.
TEXT ARRANGEMENT GUIDE

Before you go through this module, it is important that you note the text
arrangement. Understanding the text arrangement will help you to organise your
study of this course in a more objective and effective way. Generally, the text
arrangement for each topic is as follows:
Learning Outcomes: This section refers to what you should achieve after you have
completely covered a topic. As you go through each topic, you should frequently
refer to these learning outcomes. By doing this, you can continuously gauge your
understanding of the topic.
Self-Check: This component of the module is inserted at strategic locations

throughout the module. It may be inserted after one subtopic or a few subtopics.
It usually comes in the form of a question. When you come across this component,
xvi  COURSE GUIDE
try to reflect on what you have already learnt thus far. By attempting to answer
the question, you should be able to gauge how well you have understood the
subtopic(s). Most of the time, the answers to the questions can be found directly
from the module itself.
Activity: Like Self-Check, the Activity component is also placed at various

locations or junctures throughout the module. This component may require you
to solve questions, explore short case studies, or conduct an observation or
research. It may even require you to evaluate a given scenario. When you come
across an Activity, you should try to reflect on what you have gathered from the
module and apply it to real situations. You should, at the same time, engage
yourself in higher order thinking where you might be required to analyse,
synthesise and evaluate instead of only having to recall and define.
Summary: You will find this component at the end of each topic. This component
helps you to recap the whole topic. By going through the summary, you should be
able to gauge your knowledge retention level. Should you find points in the
summary that you do not fully understand, it would be a good idea for you to
revisit the details in the module.
Key Terms: This component can be found at the end of each topic. You should go
through this component to remind yourself of important terms or jargon used
throughout the module. Should you find terms here that you are not able to
explain, you should look for the terms in the module.
References: The References section is where a list of relevant and useful textbooks,
journals, articles, electronic contents or sources can be found. The list can appear
in a few locations such as in the Course Guide (at the References section), at the
end of every topic or at the back of the module. You are encouraged to read or
refer to the suggested sources to obtain the additional information needed and to
enhance your overall understanding of the course.
PRIOR KNOWLEDGE
This is an introductory course. There is no prior knowledge needed.
ASSESSMENT METHOD
Please refer to myINSPIRE.

COURSE GUIDE  xvii
REFERENCES
Antai-Otong, D. (2008). Psychiatric nursing ă Biological & behavioural concepts
(2nd ed.). Boston, MA: Thomson Delmar Learning
Clarke, L. (2007). Reading mental health nursing: Education, research, ethnicity

and power. London, England: Churchill Livingstone.
Fortinash, K., & Holoday-Worret, P. (2012). Psychiatric mental health nursing (5th
ed). St. Louis, MO: Elsevier.
Meyer, J., & Quenzer, L. (2013). Psychopharmacology: Drugs, the brain, and
behavior. Sunderland, MA: Sinauer Associates.
Videbeck, S. L. (2014). Psychiatric mental health nursing (6th ed). Philadelphia, PA:
Lippincott Williams & Wilkins.
TAN SRI DR ABDULLAH SANUSI (TSDAS) DIGITAL

LIBRARY
The TSDAS Digital Library has a wide range of print and online resources for the
use of its learners. This comprehensive digital library, which is accessible through
the OUM portal, provides access to more than 30 online databases comprising
e-journals, e-theses, e-books and more. Examples of databases available are
EBSCOhost, ProQuest, SpringerLink, Books247, InfoSci Books, Emerald
Management Plus and Ebrary Electronic Books. As an OUM learner, you are
encouraged to make full use of the resources available through this library.

xviii  COURSE GUIDE

Topic  Principles of
Psychiatric
1 Nursing:
Current
Theory and
Practice
LEARNING OUTCOMES
By the end of this topic, you should be able to:
1. Describe mental health and the elements that contribute to mental
wellbeing;
2. Clarify emotion and regulation of stress response;
3. Identify the signs and symptoms of stress, and stress management
strategies;
4. Summarise the three stress coping interventions and interpersonal
relationship;
5. Review mental illness, its prevention, factors and manuals;
6. Critically review the various roles of the mental health nurse; and
7. Discuss the legal and ethical aspects in clinical practice.

2  TOPIC 1 PRINCIPLES OF PSYCHIATRIC NURSING: CURRENT THEORY
AND PRACTICE
 INTRODUCTION
Welcome to the Psychiatric Mental Health Nursing module. For some of you, this
may be be the first time you are engaging with mental health issues and learning
how to care for people who are mentally ill. It is my intention to make this
experience interesting and enjoyable. Those of you who have had some experience
of caring for someone who suffered from mental illness, it is my hope that you will
not only enjoy the module but also develop a clearer and deeper understanding
that will help you to build on your previous experience. It may also be useful to
keep in mind that this module (together with some clinical exposure) is designed
to give you an insight into mental health nursing and it is not about you being a
mental health nurse. Though I would like to think that some of you would consider
developing a career for yourself in mental health nursing.
It may be helpful at this early juncture to discuss the language we use and how it
reflects the current level of service development for the mentally ill and „on the
ground‰ realities for mental health nurses. Our services for the mentally ill is still
mainly delivered in large hospitals and in units attached to general hospitals
where the psychiatrists and junior doctors form the core of the team, assisted by
nurses, usually in uniform. You would recognise this, I am sure, as similar to
medical teams that you have worked with in other areas of nursing. You are also
likely to be very familiar with phrases such as „psychiatric services‰, „psychiatric
nurses‰, „psychiatric team‰ and so on. By extension, the people receiving the
service become „psychiatric patients‰. You would also be right if it reminded you
of what you understand to be the „medical model‰.
However, when we use the phrase „mental health‰ and „mental health service‰,
we are actually talking of teams with a much wider professional participation.
Such teams would include not only the doctors and nurses but also the
psychologists, psychotherapists, social workers, occupational therapists, art and
music therapists and others. This is what makes the team „mental health‰ as
opposed to „psychiatric team‰. The real impetus for this change in the use of
language, took place in the European countries, where by early 1980s, the large
psychiatric hospitals (in their early days called „mental asylums‰) were mostly
closed. The core of the services for the mentally ill was moved into the community.
With this, the custodial aspect of the nurses role had to give way to a more
psychotherapeutic approach, with the emphasis on social functioning in the
community. With strong contribution to the „mental health team‰ by social
workers and psychologists, power and decision-making within the team was
shared and incorporated a much broader psycho-social knowledge base.

TOPIC 1 PRINCIPLES OF PSYCHIATRIC NURSING: CURRENT THEORY  3
AND PRACTICE
During your mental health posting, you will meet clinical psychologists and social
workers, but they may not as yet feature as integral to the clinical team. The core
of our service(s) is still centred around in-patient care, clearly our „mental health‰
service is still not sufficiently resourced and developed to be a fully-fledged
multidisciplinary mental health team; neither is there much of a community based
team. Given this reality on the ground, you may wonder perhaps, is it still
appropriate to use the phrase „psychiatric team‰?
The qualified nurses you will meet in mental health settings are general nurses,
with a rather slowly increasing numbers of them who would have done their post
basic certificate in mental health nursing. You will find many of them to be
experienced in working with the mentally ill and only too willing to give help and
support, so do engage and talk with them.
Our business is communication, so do talk. We know from experience that it is not

uncommon for learners like yourselves at the commencement of the mental health
module to have questions, doubts and worries about working with the mentally
ill. This is only to be expected. Again, the best remedy for it is to talk! So speak to
the relevant people about what „worries‰ you the most about working with
mentally ill patients. Let us begin the journey!
1.1 MENTAL HEALTH

Mental health and mental illness are complex sets of ideas that would be useful to
explore and clarify, so that you have a clear understanding of the meaning that
you want to convey when you use the terms. Mental health is not merely the
absence of mental illness; it is about the positive attributes that we all have. Think
of „mental health‰ as a social functioning. How we relate with others such as
family, friends and work colleagues – overcoming differences, resolving difficult
problems and accepting and tolerating each otherÊs shortcomings and so on
require considerable cognitive ability and emotional resilience. So when we are
doing reasonably well at work, our family life is mainly satisfactory and we have
some close friends with whom we get on well – we are deemed to have good
mental health, even if we occasionally experience problems.

AND PRACTICE
So what is mental health? Let us look at the often quoted World Health
Organization (WHO) definition of mental health:
Mental health is defined as a state of wellbeing in which every individual

realises his or her own potential, can cope with the normal stresses of life, can
work productively and fruitfully, and is able to make a contribution to her or
his community.
(WHO, 2020)
The psychological aspect of social relating is important. You do not only relate to
others, perhaps more importantly how you relate to yourself, forms the basis upon
which you relate to others. What I mean here is that when we are conscious (as in
when we are awake) we are constantly talking and interacting with the self, as we
would normally do with others. If this internal dialogue or „self-talk‰ is realistic,
helpful and positive in nature, we will be comfortable with ourselves.
On the other hand, should the self-talk be negative, as in being critical, blaming
and putting ourselves down; the feeling will reflect the negative thoughts and we
are likely to be unhappy and feeling down. This unhappiness and discomfort
within will show and will have an effect on our relationships with others. You
could take this one step further and say it will colour otherÊs perception of us and
influence how they act towards us. For some, this feedback loop may become a
downward psychological spiral.
What are the specific elements that could be viewed as fundamental to mental
health? Social functioning is said to be not only important but a good indicator of
mental health. As such it is perhaps useful to outline the specific elements that
enable us to socially function in a manner that reflects the possession of good
mental health. Notice also there is no distinct boundary for each of the elements
discussed, depending on how we approach them, they do merge or blend into one
another. Where appropriate we will cover in our discussion as much of the
background knowledge, so as to form a basis for subsequent discussions.

AND PRACTICE
1.2 ELEMENTS THAT CONTRIBUTE TO

MENTAL WELLBEING
Certainly, there are many elements that contribute to mental wellbeing. This
subtopic will explain the major one which is thinking, the concept of „self‰, self-
image, self-worth and self-esteem.
1.2.1 Thinking
You will be aware of words like „cognition‰ or „cognitive process‰ which refer
generally to all activities in the brain. Thinking is one such activity, which in
mentally healthy people, is reality orientated; in other words, oneÊs understanding
of whatÊs happening in oneÊs environment is accurate and oneÊs reasoning,
judgements and decision-making are consistent with oneÊs self-interest. Hence, the
person is being realistic.
1.2.2 The Concept of “Self”

There are two major theoretical contributors to our understanding of „self‰:
(a) Rogerian humanistic perspective; and
(b) Symbolic interactionism (SI).
Carl Rogers developed his theory about „self‰ through his psycho-therapy work
with adults. Whilst the SI school, Mead and Blumer (Da Silva, 2007) studied the
development of the concept of „self‰ by focusing on childhood socialisation. Both
of these psycho-social perspectives have made significant contribution to our
understanding of mental health.
Briefly, according to SI perspective, self-concept is developed through early

childhood socialisation; or to put it simply, through playing. As the child
progresses through the physical milestone of development, there is a parallel
psychosocial development aided by the childÊs new found mobility, which enables
greater interaction with others and to engage in play. „Role playing‰ and „role
taking‰ are said to be two main means through which the child learns to see from
the point of view of „others‰.
For instance, a 3-year-old may engage in a make-belief play of being mummy or

daddy (specifically, her particular mummy and daddy), making up the rules as
she goes. A few years later, let say about seven years of age, she may play a rule-
based organised game of netball, where she gets to appreciate her role and others

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perspective of her role in the team. The earlier 3-year-old who played her
particular mummy and daddy, would now able to see mummy and daddy as in
the general „other‰ mummyÊs and daddyÊs.
The SI perspective would argue that the development of the concept of „self‰ is
necessary for us to be able to communicate through the use of language, which
essentially consists of symbols and the „meanings‰ we give them. We learn the
shared meaning of the sounds we make and the alphabets we write – and
incredibly, most of us can manage more than one language.
It is interesting to note that when we are „thinking‰ we are essentially talking or

interacting with the „self‰. The „self‰ has its origin in society (family and
community) and hence, „self‰ and society is the flip side of the same coin.
You can test this to verify it for yourself. When you wake up in the morning, you
say to yourself you have to get ready to go to work, the „generalised other‰ you
are interacting with may include the nurses you will be working with, the ward
sister, the patients and doctors, you would know what clothes to wear and how to
present yourself. Going to work may have become pretty routine and you may not
think much about it.
However, if you were one morning required to attend a job interview, or required
to go to court to provide evidence as a witness in a criminal case, what would you
be saying to yourself and who would you be interacting with?
The notion of „me‰ and „I‰ are integral to the concept of „self‰. The „me‰ is
essentially role related. At the present moment, as you are reading this, you are
„me‰ the learner. You may also be „me‰ the sister/brother, „me‰ the
daughter/son, „me‰ the nurse, „me‰ the mother/father and so on. We interact
with others mostly through the formal and informal roles that we may enact.
Whilst the „I‰ is the constant awareness and subjective experience that we take
with us to all the different situations. Perhaps, this is who you think you are.
1.2.3 Self-image
Self-image consists of how you view yourself including how you think others view
you. OneÊs physical appearance, personal traits and attributes matter. What you
think you look like to others and how much you think others like you, will
influence and shape your self-perception. Self-concept will consist of ideal-self
(and actual-self), body image and self-esteem.

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(a) Ideal-self
What is your ideal-self? Ideal-self is what you wish to be or think you
„should be‰, including ambitions and goals in life. For instance, the person
that your patient believes she ought to be, may be as follows – well-liked and
popular, successful in career, have a loving family and so on.
(b) Actual (or Real Self)

This relates to how you see yourself as behaving at the present moment. The
gap between the actual and ideal-self is what Rogers called incongruity; the
bigger the gap, the greater the possibility of distress.
(c) Self-esteem
Self-esteem is about how one values oneself. According to Argyle (2008), this
is influenced by a number of factors as explained in Table 1.1.
Table 1.1: Four Factors That Influence Self-esteem
Factor Description
Responses of If others react in an agreeable and approving manner, seeking
others your company, valuing your time and opinions – these are
positive strokes, you will feel good about yourself and your self-
esteem will be high. Consequently, you will be self-assured,
confident and optimistic.
On the other hand, should the reaction of others be unwelcome,
they avoid us and are critical of us, tell us things we do not want
to hear. We are not going to feel good about ourselves, our self-
esteem will be low, we will be lacking in confidence and
pessimistic in attitude.
Comparison Comparison of how well we are doing against our peers
with others (reference group) will also have a bearing on our self-image – if
they are more successful, better accomplished, happier, richer
and so on, our view of ourselves will be negative. Should we be
doing better than them, our self-image will improve and be
positive.
Social roles Social roles confer status, full-fledged professions such as
lawyers, doctors, engineers and so on, are held in high esteem and
are able to command better wages. On the other hand, manual
workers, cleaners and so on, are not accorded the same privilege,
held in low regard resulting in them having low self-esteem.
Identification The roles are simply more than objective and external – people in
the role will identify with it and internalise the status accorded to
them.
Source: Argyle (2008)

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(d) Body Image

Our physical shape and appearance will influence the way we feel about
ourselves and consequently affect our self-concept. You will be well aware
of the ideal physical image promoted by advertisers and in the media
generally. Body image is that which is in our minds (a picture of our body)
not necessarily what we see in the mirror. When we think and feel negatively
about ourselves, this may have to do with our poor body image, especially
so with young people going through their teenage years. Most of us are
comfortable and reasonably satisfied (never totally) with the way we
perceive our physical self, as it usually is close enough to our expectation
(our ideal body image).
Conversely, body image dissatisfaction has to do with the perception of the

actual as not matching oneÊs ideal body image. You may be aware of
instances of individuals who may obsess about their weight when they are
actually within normal range or even underweight. The unhappiness and the
belief that one is not „good enough‰ may result in further distortion of her
perception of her physical self. Meaning they distort what they see in the
mirror, making some of these individuals vulnerable to eating disorders and
depression (see Figure 1.1).
Figure 1.1: Bulimia nervosa is one of the eating disorder resulted from
body image issue

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(e) Identity
As we transition the teenage years into young adulthood, the physical and
psychological change together with the constant stream of meaningful
choices you make related to where you study and what to study, career,
sexuality, peer group you identify with, your romantic interest,
entertainments you enjoy, your political views and so on, will come to reflect
the values and beliefs you subscribe to and construct or shape a sense of who
you are, your independent self-identity, which distinguishes you from
others. As with self-concept, identity is essentially a socially-constructed
entity that will entail self-respect, dignity, pride and honour; at the same
time, it reflects belonging to or membership of a certain social category or
group. Now, try answering the question „who are you?‰
(f) Autonomy
The concept of autonomy as used in developmental psychology is an
important characteristic of good mental health, as it suggests maturation and
social functioning which is optimal. A key element to the concept of
autonomy is the idea of „locus of control‰. This locus of control for our
actions can be internal or external. Some authors prefer the use of the phrase
„frame of reference‰ which is internal or external. Nevertheless, they both
mean the same.
However, it is worth noting, you would need to take care not to use
„autonomy‰ interchangeably with the word „independent‰; they do not
mean the same. „Independent‰ simply means one is not reliant on others for
resources, support and so on.
In this self-determination theory, when the locus of control for your actions
are internal, it suggests that your motivation and the choices you make are
personal and meaningful to you. Your actions are based on principles that
you cherished and you would be more likely to accept the consequences that
may follow.
For instance, you may take up jogging because you think it is enjoyable and
it is a healthy thing to do. Or a nurse may choose to report an instance of
malpractice to senior management knowing it may lead to detrimental
consequences. External locus of control suggests oneÊs actions are being more
externally regulated by reward or punishment. Rewards can be material as
in money or other resources, and it can also be intangible like getting social
approval, being liked by others, achieve social status and so on.

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A behaviour is less likely to occur in the absence of reward. Punishment can

mean corporal punishment as in caning or internalised regulation as in
avoidance of shame and guilt may cause a person to refrain from stealing. I
hope you are getting the idea that it is on a continuum, the more internal the
locus of control for your actions the more autonomous you are. Because of
your belief that you are in control of your life, you are likely to be better
motivated and pro-active. Those who are least autonomous, whose actions
are more externally regulated, are likely to adopt a passive attitude to life
and attribute personal failings and success to fate and luck.
1.2.4 Self-worth vs Self-esteem

The way we see ourselves will inevitably reflect how we value ourselves. Hence,
nurses may talk of the patientÊs self-esteem being low when they hear the patient
says, „others donÊt like me‰ or „your time will be better spent with people who are
more deserving‰. What is self-esteem?
Self-esteem is essentially the way we value ourselves as a result of the

responses we receive from others.
For instance, on the ward when you make time and relate with the patient in a
warm and accepting manner, with plenty of „positive strokes‰, the patient will
soon enough feel good about herself. For example, „I feel pleased with myself
because the staff on the ward are nice to me.‰
However, when she returns home, people she relates with may not be so nice and
accepting; in fact, they may even be very critical of her. Consequently, in time she
will start to put herself down again.
For this reason, we need to take care in the way we promote the use of the concept
of self-esteem, as it is too dependent on other peopleÊs responses. Instead, it may
be better for our patients, for us to promote and teach them the idea of „self-
worth‰. The idea being that as human beings, we are all worthy and deserving
unconditionally, meaning it is a given. We accept that we are fallible human beings
(meaning we are not perfect), we may not sometimes do the right things even
when they are important to us, our backgrounds are different, we do different jobs
and we are on the face of it very different, but we are all equally worthy! We do
not need other peopleÊs approval to feel good about ourselves. Our health and
wellbeing is not dependent on otherÊs approval. We will discuss the beneficial
implications of teaching patientÊs self-worth as opposed to self-esteem later in the
module.
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SELF-CHECK 1.1
1. In your own words, define mental health.
2. What are the elements that contribute to oneÊs mental

wellbeing?
1.3 EMOTION AND REGULATION OF STRESS

RESPONSE
What is emotion? You will come to understand, is not only important in
determining our optimal social functioning and quality of life, it also has a
powerful influence on our mental wellbeing.
Hence, it is important to understand what emotion is and how it is regulated.

Studies suggest emotion and its regulation is learned very early on in infancy. The
significance of this as public health issue cannot be overstated; as such, we will
explore emotion and its regulation in some detail.
The psychiatrist Erik Erikson (1956) in his eight stages of development suggested
that a child who is well-loved and cared for, by the age of two years develops trust,
security and basic optimism. On the other hand, the poorly nurtured child may
become insecure and mistrustful.
Other psychologists (Bowlby, 1969; Ainsworth, 1978) who studied early childhood
attachment were able to show that dysfunctional or insecure attachment led to
secondary consequences such as inability to recognise body signals and difficulties
in reading and understanding emotion. These difficulties will further adversely
affect the childÊs ability to be empathetic and regulate his or her own stress.
Biology is an important component in the emotion response and its regulation, and
involves both the nervous system and the endocrine system. You will be well
aware of the autonomic nervous system as consisting of both the sympathetic and
parasympathetic nervous system (not to forget the enteric nervous system). This
system controls a wide range of important bodily process such as heart rate, blood
pressure, respiratory rate, digestion and others.

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You may have come across the idea of „fight or flight‰ response, where the
autonomic nervous system, almost instantaneously, readies the body by
marshalling resources to either confront the threat or to seek safety by getting
oneself out of the situation.
In general terms, this task is essentially accomplished by the sympathetic nervous

system (sympatho-adrenal response). The adrenal glands are triggered
(by acetylcholine) to release adrenaline (epinephrine) and noradrenaline
(norepinephrine). This affects in the main (not exclusively) cardio-vascular system
and causes the pupils to dilate, and also the blood pressure and heart rate to
increase. The bronchioles in the lungs are dilated allowing for greater oxygenation
and as you would expect the blood supply is increased to the skeletal muscles,
away from the digestive system. When the danger is over, the parasympathetic
system will de-escalate the arousal returning the system to a state of equilibrium.
1.3.1 Stress Regulation “HPA” Axis

Did you know that the involuntary stress regulation mechanism involves the
hypothalamus-pituitary-adrenal (HPA) axis? Under stressful condition (as in the
„fight or flight‰ situation), the hypothalamus releases CRH (corticotrophin-
releasing hormone). CRH stimulates the pituitary gland to release ACTH
(adrenocorticotropic hormone) into the blood stream. On reaching the adrenal
gland, it causes the adrenal cortex (the outer layer of the adrenal gland) to release
cortisol. Cortisol is involved in numerous actions in the body but for our present
purposes, it mobilises the bodyÊs resources by increasing blood pressure and sugar
levels in the blood to help cope with the stress, together with its anti-inflammatory
action. When levels of cortisol in the blood is high, the receptors in the
hypothalamus will detect this and start to block the release of CRH and
consequently the pituitary stops releasing ACHT, in a negative feedback loop.
We have earlier on briefly considered the importance of childhood secure

attachment and that attuned, responsive parenting gives meaning to the „inner
world‰ of body sensations such as hunger or feeling full in the stomach, bladder
and others. Any emotional response (usually crying) will be met with soothing
tenderness, which is reassuring and (externally) helps the child to learn to regulate
the emotional response. This also demonstrates to the child that others are aware
of his or her need, helping to develop a basis for trust, empathy, affectionate
relationships as well as verbal and non-verbal communication. This ability to
regulate stress is critical for subsequent exploration, learning, independence and
forming effective relationships.

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In the case of insecure or dysfunctional attachment, where the parenting has been
poor and inconsistent or neglectful even, this leads to inadequately regulated
infant stress response. Hence, it is not difficult to see how the involuntary stress
regulation (HPA axis) is „set‰ early in the babyÊs life, at a level that reflect the
prevailing social circumstance and the effectiveness of the pacifying or calming
efforts.
Traumatic childhood experiences such as serious abuse or gross neglect over a

period of time can cause the child to „switch off‰, where he or she experiences no
fear and relative bradycardia. You may have come across instances where a child
will go along with a complete stranger. Mal-adaptive or altered HPA axis function
will be disruptive of the childÊs social development, particularly affecting the
childÊs ability to form proper relationship with others. Leading to childhood
behavioural difficulties, attracting diagnostic labels such as „conduct disorders‰,
„attention deficit hyperactivity disorder‰, „AspergerÊs‰ and as they get much
older, they will develop anxiety, depression, obsessive compulsive disorder and
other disorders. Some may even show signs of post-traumatic stress disorder in
their adult life. Therefore, one cannot overstate the importance of early childhood
parenting for safety, stress regulation, adaptability and resilience.
1.3.2 Dynamic Interactionism

All emotions are underpinned by physiological changes and are largely brought
about by cognitive processes and the actual manifestation of them is behavioural.
Emotion, cognition and behaviour can be viewed as three domains that interact
and influence one another in a dynamic relationship. Hence, all emotions will have
its characteristic cognitive and behavioural features.
For instance, when a person is anxious (emotion) he will notice bodily changes, his
breathing becomes faster and his heart starts pounding, body feels warmer (may
even sweat) and the skin feels clammy. You will almost always see the following
cognitive and behavioural characteristics as shown in Table 1.2.
Table 1.2: Cognitive and Behavioural Characteristics When a Person Feels Anxious
Characteristic Description
Cognition The inference will be a perceived threat to the self. The problem will be
exaggerated and blown out of proportion in the mind („It is too big for
me to handle!‰). At the same time, the person will minimise his ability
to cope (its miniscule).
Behaviour The actual behaviour will be to avoid or run away from the feared object
or situation.

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We will discuss emotions in some detail when we cover depression and anxiety
later in the module. For now, think of emotion as a response to actual or imagined
situations that we experience in our everyday lives. When good things happen or
we are dealing with pleasant situations, our emotional response will reflect that
and you are likely to feel happy and you will be cheerful.
If, however, you were to experience an adverse situation, say you applied for a job
you really liked and wanted, but you were not successful. Your emotion will be
negative, you will be disappointed, dejected and you may even feel sad for a while.
We normally experience a range of emotions, the positive ones and the „not so
positive‰ ones. The question is, is it healthy or unhealthy to have this not so
positive emotions?
In the previous example, where one gets turned down at a job interview, to feel
disappointed and sad is negative but healthy. Should one depress one-self about
it, or make one-self anxious following the rejection, this would be unhealthy
negative emotion. Whether the negative emotion is healthy or unhealthy will
depend on what one is thinking (self-talk) in the situation and if oneÊs behaviour
is helping in achieving oneÊs goal.
SELF-CHECK 1.2
1. What is emotional self-regulation?
2. How is it related to infant attachment?
ACTIVITY 1.1
Write one thing that worries you the most in the myINSPIRE forum.
Then, discuss the level of how serious is the problem and how to
overcome it.

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1.4 UNDERSTANDING STRESS AND ITS

MANAGEMENT
Personal stress management for most of us would not be a big issue. In fact, most
of you very likely may have gone through most of your life without noticing the
so called „stress‰. Your childhood and family socialisation may have equipped
you with sufficient social and psychological capacity to handle with relative ease
the day-to-day demands of being with other people, your studies, work and close
friendship circles. It does not mean you did not encounter problems or life was not
tough, but you dealt with them without getting your-self unduly distressed. If you
did, it did not last long.
Your internal voluntary stress regulation (HPA axis) is busy at work for you,
responding in all the different social situations you engage in. Through all your
expectations, wishes, desires, successes, disappointments, frustrations and even
failures; you do not become „stressed‰ or ill.
Do not forget, in situations where you have had to respond, as in when you slam
on your brakes to avoid smashing into the car in front, it is the same system coming
to your aid, but also notice the difference in the way you feel, during the event and
immediately when you realise you managed to stop your car just in time. The
stress hormones are working for you furthering your interest and goals. Energising
and motivating you. You feel alive! You most probably are also helping yourself,
by doing healthy things like being socially engaged, talking, laughing, confiding
and even occasionally crying. Some of you may also exercise, there is no better
stress buster!
One other thing, to be this well, you are also helping yourself by being reasonable
and realistic in the way you perceive events and situations, non-dogmatic and
flexible in your attitude and you are also able to tolerate frustrations and some
degree of personal discomfort. You are not in the habit of blaming yourself or
putting yourself down if things do not go well.
Clearly, some people do become distressed and disturbed in the face of everyday
challenges and it is important we are empathetic and we understand how people
can disturb themselves. Stress response is a uniquely individual presentation, but
we understand the physiological mechanism and mental processes that underpin
the emotional response. We have already touched upon Walter CannonÊs (1932)

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fight or flight response. This is where the body is rapidly primed via the
sympathetic nervous system and the endocrine system to either confront the threat
or to flee from the situation (hence, the term „fight or flight‰ response). What
happens during a fight or flight response? Our body „fight or flight‰ response are:
(a) Heart rate increases;
(b) Rapid breathing;
(c) Raised blood pressure; and
(d) Muscles tighten.
However, in our day-to-day life we are unlikely to be consistently confronted with

an actual threat to our lives. But the body responds as if it is responding to a
physical threat, even in routine social situations. The involuntary stress regulation
(HPA axis) is altered in these individuals, most likely due to poor parenting or
troubled background. Consequently, their physiological response will be routinely
exaggerated. This level of arousal of the body will have a cumulative stress effect
(we will consider this in a moment).
But first, the cognitive processing (what one thinks) of the physiological changes
that one is noticing will also have an important role to play in creating the
emotional disturbance. Though the response may seem instantaneous and outside
our awareness, if we slow down the process it would look something like this. Let
say initially the person notices her heart beat, the act of noticing has the effect of
increasing the heart rate. The person is likely to think „whatÊs happening?‰ or
„something is not right‰. This is an alarming thought, causing the heart to beat
faster, body feels warmer, breathing gets shallower together with a sensation of
tightening in the chest. Fuelling further thoughts, „something terrible is
happening‰, „I am going to die!‰ By now this person will be sweating and
overwhelmed with the fear of dying.
1.4.1 General Adaptation Syndrome

SelyeÊs general adaptation syndrome suggested a 3-stage bodily response to any
threat posed to the wellbeing of the person (Selye, 1946). Essentially, the bodyÊs
response to any stressor will reflect the following stages (see Figure 1.2).

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Figure 1.2: Three stages in general adaptation syndrome

Source: Selye (1946)
As discussed just now, in this model, the hypothalamus-pituitary-adrenal axis

(HPA axis) prepares the body to respond to the demand. Let us learn more on
these three stages in Table 1.3.
Table 1.3: Three Stages in General Adaptation Syndrome
Stage Description
Alarm • In the face of a stressor, the sympathetic nervous system is activated

as in a „fight or flight‰ response.
• The bodyÊs resources are immediately mobilised – blood glucose
levels increase, hormones such as cortisol and adrenalin pumped into
the bloodstream to prime the body to confront the threat.
Resistance • At this stage, the parasympathetic nervous system brings some of the
physiological process back to normal, while the body focuses its
resources against the stressor.
• The outward appearance of the person may look normal but blood
glucose, cortisol and adrenalin continue to circulate at elevated levels.
• Heart rate, blood pressure and breathing remain raised.
• Body remains on high alert.
Exhaustion • In the event that the stressor continues beyond the bodyÊs capacity,
the personÊs resources are depleted and becomes vulnerable to
disease and death.
Source: Selye (1946)
1.4.2 Signs and Symptoms of Stress

Let us see how pervasive the symptoms of stress can be, affecting just about every
system in the body. As you go through the list of symptoms, try an indicate the
affected system. This list is not meant to be complete but consists of symptoms that
are commonly presented. Let us see the list in Table 1.4.

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Table 1.4: List of Signs and Symptoms of Stress
Aspect Sign and Symptoms
Physical • Frequent headaches, dizziness.

• Neck ache and/or back pain.
• Constant tiredness.
• Colds and frequent infections.
• Heartburn, stomach pain, nausea.
• Constipation, diarrhea.
• Difficulty breathing, frequent sighing.
• Chest pain, palpitations, rapid pulse.
• Frequent urination.
• Insomnia, disturbing dreams.
• Diminished sexual desire.
Emotional • Feeling overloaded or overwhelmed.

• Increased frustration, irritability, edginess.
• Overreaction to petty annoyances.
• Increased anger, frustration, hostility.
Behaviour • Tensed and nervousness.

• Nervous habits, fidgeting, feet tapping.
• Forgetfulness, disorganisation, confusion.
Mental • Difficulty concentrating, racing thoughts.

• Trouble learning new information.
• Difficulty making decisions.
1.4.3 Stress Management Strategies

As always, prevention is better than cure. Protective lifestyle factors, such as being
in control of your life, creating a good work life balance, with time for social
activity with family and friends; not to forget the exercise and balanced diet with
plenty of fluids, will help minimise the stress response and related problems.
Unfortunately, we are not perfect, as we may not always do what is in our best
interest and we cannot always anticipate, let alone control, external events and
othersÊ behaviours.

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What is stress management?
Stress management is all about taking charge of your lifestyle, thoughts,

emotions and the way you deal with problems.
Given our understanding of emotion, it is not overstating it to say, it is imperative

that until you accept responsibility for the role you play in generating and
sustaining it, your stress level will not be brought under control.
(a) Psychological Control and Self-efficacy

The concept of psychological control involves the belief that you can
determine your own behaviour, influence your environment and bring about
desired outcome. This is similar to the concept of „self-efficacy‰, the
perception that one has the „ability to take the necessary actions to obtain a
specific outcome in a specific situation‰ (Bandura, 1977).
This perception of control in oneÊs work life and in day to day task of living,
has been suggested to promote; successful coping with stressful events,
protect against risky life-styles that involve health compromising
behaviours, good health and improved performance on cognitive tasks. This
is what underpinned our practice of keeping patients well informed about
medical procedures, essentially a control enhancing intervention, with a
view to minimising their anxiety response, improve coping and make
quicker recovery from the effects of the medical procedure.
(b) Problem-focused and Emotion-focused Coping

When we are experiencing stress, we have two possibilities or options, one
is the source or the problem causing the stress and the other is our emotional
response. Hence, the two coping strategies as given in Table 1.5.
Table 1.5: Two Coping Strategies
Strategy Description
Problem-focused coping Involves our efforts to do something constructive

about the stressful conditions that we find are
harming, threatening or challenging.
Emotion-focused coping Describes our effort to regulate the emotions

experienced because of the stressful event.

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The choice we opt for will usually dependent on the nature of the event – for
instance, work related problems will lead us to attempt problem-focused
coping, where we take direct action through seeking help from managers and
colleagues. Health problems, may lead to more emotion-focused coping,
especially if the health problem is chronic – need to be tolerated, not always
amenable to direct action. In practice, we actually use both in combination.
It is worth noting that emotion-focused coping is likely to involve coping of

two types (see Table 1.6).
Table 1.6: Two Types of Emotion-focused Coping
Types Description
Emotional distress As may be experienced in rumination – negative recurrent

thoughts focused on a stressor, is detrimental to health.
Emotion-approach This involves clarifying, focusing on and working through

coping the emotions experienced in conjunction with a stressor. It
improves adjustments to many chronic conditions,
including pain.
SELF-CHECK 1.3
1. What is a „fight or flight‰ response?

2. Describe the three stages in general adaptation syndrome.
3. What are the signs and symptoms of stress?
4. In your own words, define stress management.
5. Describe stress management strategies.
1.5 STRESS COPING INTERVENTIONS

There are a number of interventions that can be helpful when we are experiencing
stress. Clearly, these interventions do not resolve the problem, but will help with
the coping or managing of the stress response. The reduction in stress will not only
provide some welcome relief, it will also help our thinking become more realistic
and consequently better able to work out solution for problems. You may also
think of these interventions as mixed approach, though initially emotion-focused
but supportive of problem-focused coping.

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Otherwise, they will only be distraction techniques, as they take our minds off the
problems, we experience temporary relief from the stress. We will discuss three
stress coping interventions in this subtopic (see Figure 1.3).
Figure 1.3: Three interventions of stress coping
These stress coping interventions are explained in the next subtopics.
1.5.1 Mindfulness Based Stress Reduction (MBSR)

MBSR has been around since the early 1980Ês and has become popular because it
has been shown to be effective not only in helping people cope with stress, pain
and other everyday hassle and challenges, promoting a better quality of life; it has
also shown to be helpful in the management of coronary artery disease,
hypertension, cancer, irritable bowel syndrome etc.
The goal of MBSR is to move towards a state of mind in which one is highly aware
and focused on the present moment, accepting and acknowledging reality as it is,
without being distracted or distressed by the stress. In mindfulness approach, you
are taught not to ignore distracting thoughts, physical sensations or discomfort,
instead, you are encouraged to focus on them.
In other words, to be fully present and alive in this moment, embarrassing the
good and the not so good. This way of „being‰ is accomplished through learning
a combination of body awareness and traditional meditation techniques. As with
most things in life, it takes some time and practice.

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1.5.2 Progressive Muscle Relaxation (PMR)

PMR has been around for a very long time, probably from around the mid 1930s.
In mental health settings, it was usually offered in conjunction with other
behavioural therapies and also for people who were treated with medication. In
hospitals or day-care settings, those who participated usually suffered from
anxiety.
However, in community settings, a much wider group of people would

participate, including those who were stressed and the „worried well‰.
PMR technique involved working on all of the body's major muscle groups,
tensing and relaxing them alternatively. A typical session would entail you finding
a quiet place, free of interruptions. You can either sit on a comfortable arm chair
or lie flat on a mat, making sure any tight clothing has been loosened, glasses
removed and so on. The usual groups of muscles targeted are in the following
order:
(a) Forehead;
(b) Jaw;
(c) Neck and shoulders;
(d) Arms and hands;
(e) Buttocks;
(f) Legs; and
(g) Feet.
For our present purposes, I will take you through one set of muscles, the neck and
shoulders. Before commencing, you would have done some diaphragmatic
breathing to relax the whole body and maintain a slow and even breathing
throughout. Focus your attention on your neck and shoulders. Slowly raise your
shoulders up towards your ears, notice the increase in tension, hold for 15 seconds.
Keep the rest of the body relaxed. Very slowly release the tension counting for 30
seconds. Repeat the process three times and notice the tension melting away.
When done, move your attention to the next set of muscles. When your body is
totally relaxed, it feels very pleasant. Alternatively, you can use voice recordings.
There are many freely available MP3 audio files which will guide you through
your practice of progressive muscle relaxation.

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1.5.3 Guided Imagery

This is another popular intervention that can provide relief from stress. Sometimes
also called „guided meditation‰. This intervention utilises a gentle but effective
approach to relaxation by focusing on visualisation as a means of distraction. It is
not just meant to be in the head but a whole body experience involving all the
senses. When done well (usually it will take some practice), the relaxed body can
naturally induce an altered state of mind, almost hypnotic in nature.
Firstly, you set yourself down as outlined in PMR and relax your body by doing a
few diaphragmatic breathing. In your mind, place yourself in the most pleasant
and relaxing place you can imagine. It can be a time and a place where you were
happy and relaxed, perhaps, floating on your back in cool crystal clear water off
Tioman island, drinks are brought to you by happy, smiling people. Or it may be
that you are taking a gentle stroll through the woods, as the morning sunÊs rays
penetrate the canopy above to light the mist in the cool air, something similar to
Figure 1.4.
Figure 1.4: Guided imagery interventions use wonderful, pleasant and relaxing place you
can imagine to provide relief from stress
Make the experience more vivid and immerse yourself in the relaxed happy feeling
by opening up all your senses and notice all the details. Notice the sound of the
sea, the water around you and the waves breaking up on the beach. The sound of
dry leaves you are walking on and the rustling of leafy branches as the monkeys
are being playful. The sound of birds. What does the water feel like on your skin?

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The coolness of the air on your face. Sense your body moving up with the swell of
the wave beneath you. Notice the ease with which you breathe the morning air.
The colour of the sparkling water and the clear blue sky. Take in the vibrant
colours, different shades of green, brown and orange all around you, basking in
the sunlight. Enjoy the smell of the sea, taste the salt in your mouth.
Enjoy the surroundings where you are, stay there as long as you like, free from
things that stress you. When you are ready to return from your „break‰, count
slowly back from 20, remember to tell yourself when you reach to number one,
you will feel calm and happy and you are going to enjoy the rest of the day. On
your return you will feel alert, refreshed and energised.
SELF-CHECK 1.4
Describe the three stress coping interventions.
1.6 INTERPERSONAL RELATIONSHIP

We started with the idea that a personÊs social functioning is a good indicator of
mental wellbeing. If we were not mentally healthy, we could not have functioned
effectively in all the different social situations. You may have noticed that most of
what we have discussed up to this point, the supposedly individual level issues,
such as thinking, self-concept, identity and others, are actually an outcome
brought about by our interaction and relationship with people who have been
caring for us and others around us.
As mentally healthy adults, we seek and sustain mutually beneficial relationships

at home with familyÊs members, at work with colleagues, people in our
neighbourhood we may be friendly with and we may even keep in touch with old
school friends. This may be an opportune moment to consider the importance of
social relationships for our patients.
Patient assessment in mental health will include both mental state assessment and
social functioning (including interpersonal skills and actual relationships). With
most of our patients, you will notice a history of difficulties in their social relations,
a marked degree of social withdrawal and sometimes even social isolation.
Chances are, by the time they are getting treatment, it is likely that very strong
anti-social attitude will be evident. Routine, everyday social situations would be
stressful, even for those who are living with a supportive family. They would find

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ways to avoid doing household chores, eating meals or watching television

together. When asked to join in, it would be under protest and for the briefest of
moment. Usually, they will end up taking the food to the room to eat. The natural
escalation of this avoidance of social stress would be to stay awake at night and
sleep through the day, solves the problem of having to interact with others!
ACTIVITY 1.2
Consider for a moment, in view of what had been said about social
functioning and mental health, what are the likely outcome of such anti-
social behaviour to oneÊs mental health? Discuss this issue in the
myINSPIRE forum.
1.7 MENTAL ILLNESS

For many young people due to their past maladaptive coping strategy, usually
involving avoidance of social contact or social situations, their threshold for
tolerance of social stress will be very low. Some may avoid secondary school
system all together, opting for home tutoring or study centres, where the focus is
on passing exams and not personal growth and development. These individuals,
if they make it into higher education, will find the adjustment and transitioning
very difficult and stressful. The symptoms of mental illness will be evident.
Others may show signs of mental illness in their adulthood, because of emotional
and psychological trauma such as death of someone close, relationship break-up
or repeated traumatic events like bullying, domestic violence, job insecurity and
so on.
Mental health and mental illness are usually viewed as being along a single
continuum. That is, oneÊs mental health can be anywhere on a continuum between
being mentally healthy and mental illness. Individuals can have periods when they
are mentally healthy and other times in their lives when they may have problems
with their mental health.
This single continuum, however, does not account for the vast majority of people
who never become mentally ill, regardless of the traumas they may have had to
cope with. This suggests there is a dual continuum and that these mentally healthy
people are on a different continuum (see Figure 1.5).

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Figure 1.5: Dual continuum of mental health
So what is mental illness? The most commonly used definition of mental illness is
from the US Department of Health and Human Services:
Mental illness is the term that refers collectively to all diagnosable mental
disorders. Mental disorders are health conditions that are characterised by
alterations in thinking, mood or behaviour (or some combination thereof)
associated with distress and/or impaired functioning.
(US Department of Health and Human Services, 1999)
The use of language in this field may not always be clear and often have
considerable overlap, the case in point being „mental illness‰ and „mental
disorder‰, which are generally used interchangeably. Though they both emphasise
the medical nature of mental health problems, „illness‰ is usually viewed as
subjective, the way the patient feels, it may or may not have a physical cause or
pathology.
As for „mental disorder‰, it gives the impression of a more severe, objective and
authoritative opinion. Regardless, both these concepts are not underpinned by any
demonstrable abnormalities in the blood, at cellular level or anywhere else for that
matter.
You may want to reflect on the previous definitions of mental illness for a moment.
Especially, the emphasis on some of the personal attributes that we have already
discussed, such as thinking, mood (affect or emotion and its regulation), and how
the thinking and emotion affect behaviour (as in how one behaves when
distressed) and consequently oneÊs social functioning. Also consider what
knowledge (and skills) do you think would be useful given this understanding of
mental illness.

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1.7.1 Levels of Prevention

It cannot be overemphasised that early childhood attachment is a public health
issue, as it is well established that about 50 per cent of all lifetime mental health
problems were evident before the age of 14 (Kim-Cohen et al., 2003; Kessler et al.,
2005). We also know that people suffering from severe mental illness die much
earlier than their peers, about 20 years younger (Chang et al, 2011; Brown et al.,
2010). This is likely due to the fact that people with mental illness are also heavy
users of alcohol, tobacco and illicit drugs.
You will be well aware of the relationship between the consumption of tobacco
and higher incidence of physical illness and reduced life expectancy too. But you
may not be as aware how dire the situation is. For instance, it is said that in
England, 42 per cent of all tobacco is used or smoked by people who are mentally
ill (McManus et al., 2010).
Mental illness is very disruptive of oneÊs life, as it affects all areas of oneÊs social
functioning, with its consequent emotional turmoil and deteriorating quality of life
for the patient and the family. Not to forget, in our culture, there are additional
consequences of social alienation, stigma and discrimination. We will have the
opportunity to discuss these later. In relation to prevention, we need to be aware
that this is about reducing the burden of mental illness on our families,
communities and the society as a whole.
1.7.2 Promotion and Prevention in the Field of

Mental Health
The concept of promotion and prevention will need clarifying. When we talk of
promoting mental health, the target is positive aspects of mental wellbeing, which
will contribute to improving the quality of our life. Some of these positive aspects
of mental health include (Lehtinen, 2008):
(a) Resilience, self-esteem, optimism and a sense of mastery and coherence;
(b) Ability to initiate, develop and sustain mutually satisfying personal
relationships; and
(c) Ability to cope with adversities.

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Prevention, on the other hand, is about targeting known risk factors to prevent
mental illness. Where mental illness has developed, it is about:
(a) Minimising the effects of mental illness;
(b) Promoting recovery; and
(c) Preventing relapse.
Though their focus is clearly different, there will be the inevitable overlap in the
two approaches.
Mental illness prevention is mainly based on the traditional public health

approach for physical illness involving the following three levels, primary,
secondary and tertiary prevention.
(a) Primary Prevention

Primary prevention places emphasis on various determinants (modifiable
risk and protective factors) in the whole population or in the high risk group.
Within primary prevention we have the universal, selective and indicated
approaches to preventive interventions. The following Table 1.7 is an outline
of each of the approaches as prescribed by the World Health Organization.
Table 1.7: Three Primary Prevention Approaches
Approach Description
Universal Targeting the general public or a whole population group.

prevention
Selective Targeting individuals or subgroups of the population whose risk

prevention of developing a mental disorder is significantly higher than that
of the rest of the population.
Indicated Targeting persons at high-risk for mental disorders.

prevention
Source: WHO (2002)
(b) Secondary Prevention

At this level, the emphasis is on early detection through screening and brief
treatment undertaken with a view to affecting the development of mental
illness and consequently reducing the prevalence.

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(c) Tertiary Prevention

Normally, this level involves interventions that minimise disability and
includes efforts at rehabilitation together with relapse prevention work.
1.7.3 Risk Factors and Protective Factors

As in prevention of mental illness, risk factors are those that increase the likelihood
or the vulnerability of a person developing mental illness, relapse or even increase
the severity of existing illness. The applicable risk factors will depend on the
developmental stage, such as childhood, adolescence, adulthood and old age. Each
stage has its unique tasks to be accomplished.
For example in early childhood, secure attachment will positively affect the childÊs
emotional self-regulation and influence the childÊs subsequent exploration,
learning and relationships.
Protective factors, on the other hand, has the effect of increasing resilience and
promoting mental wellbeing.
However, it is important that you do not view the risk factors as causing mental
illness; as a combination of them may lead to mental health problems in some but
not in others. Individuals are pretty unique and they are also distinctive in the way
they disturb themselves. Generally, there are three factors that affect mental health
and wellbeing as depicted in Figure 1.6.
Figure 1.6: Three factors that affect mental health and wellbeing
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Now, let us discuss the applicable risk factors and protective factors further as
follows:
(a) Applicable Risk Factors

Individual level resources and abilities (or the lack of it), social and economic
realities, combine with macro level environmental issues such as culture,
family, available mental health services and so on, can influence mental
health status and general wellbeing. These various factors are grouped into
three categories as explained in Table 1.8.
Table 1.8: Three Categories of Applicable Risk Factors
Category Description
Psychosocial • Social disadvantage, lack of access to education,

unemployment, poverty or debt.
• Social isolation, loneliness and stigma.
• Insecure attachment, abuse, trauma or neglect during
childhood.
• Violence in the home, bullying or other abuse as an adult.
• Drug and alcohol abuse – psychosocial dysfunction as a result
of consumption (cocaine, cannabis and amphetamines can in
some people induce mania or paranoia).
• Aggression, high levels of anger, interpersonal problems (for
example, due to divorce).
• Bereavement (loss of a loved one).
Physical • Chronic or long-term physical health condition.

• Genetic cause or vulnerability, some evidence of
schizophrenia but this is not conclusive. The risk is higher if a
close family member is diagnosed with mental illness.
• Physical trauma – for example, having a head injury or a
neurological condition such as epilepsy can have an impact
on your behaviour and mood.
• Childhood exposure to neurotoxins (lead or mercury).
• Civil conflict and living in a war zone can increase the risk of
post-traumatic stress disorder (PTSD).
Personality • Personal traits such as pessimism (and preferring own

factors company) perfectionism (having unrealistically high
expectations).
• Low self-esteem can make one more vulnerable to mental
illnesses such as depression or anxiety.

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(b) Protective Factors

These factors are grouped in two categories as explained in Table 1.9.
Table 1.9: Two Categories of Protective Factors
Psycho- • Positive early childhood development – for example, secure

social attachment as a child.
• Reliable support and discipline from caregivers.
• Following rules at home, school and work.
• Subjective sense of self-sufficiency.
• Emotional self-regulation and personal resilience.
• Good coping skills and problem-solving skills.
• The older the person, the better the ability to make friends and
get along with others.
• Adults in relationship.
• Good peer and supportive family relationship.
• Healthy balanced diet and regular exercise.
• Participation in community – clubs, sports team or religious
group.
• Economic/financial security.
• Access to support services.
Personality • Optimism and positive self-regard.

factors
• Thinking and attitude is flexible and realistic.
1.7.4 Diagnostic Manuals in Psychiatry

Firstly, what is diagnostic manual?
Diagnostic manual is about agreeing and standardising diagnosis of mental

illness.
Since mental illness usually has no pathology underpinning the condition i.e. there
is no test to demonstrate the condition exists, the diagnosis is largely based on
behaviours.

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Hence, the need for psychiatrists to get together to agree the symptoms and criteria
for the diagnosis. With the changing nature of our understanding of mental illness,
the language used (diagnostic labels) changes over time.
For our purposes, mental illness is a designation we have used and it is used
interchangeably with psychiatric disorder, psychological disorder and mental
disorder. The „official‰ preference as used in the diagnostic manuals given is
mental disorder.
Fortunately, as nurses we need not be too concerned with the intricacies of the
psychiatric diagnostic classifications. Nevertheless, it would be better for us to be
aware of their use of language and their reference manual. Psychiatrists the world
over, have the option of using either of the two following manuals for diagnostic
purposes (see Table 1.10).
Table 1.10: Two Manuals for Psychiatry Diagnostic
Manual Description
Diagnostic and Maintained by the American Psychiatric Association and the

Statistical Manual current version of the manual is the fifth major revision, hence it
of Mental Disorders is known as DSM 5. This diagnostic manual is exclusively for
(DSM 5) mental disorder cases and is used by psychiatrists throughout
Malaysia.
International This diagnostic manual is maintained by the World Health

Classification of Organization (WHO), the current edition is the tenth edition,
Diseases (ICD 10) hence ICD 10. Commonly used in United Kingdom and Europe.
SELF-CHECK 1.5
1. What is mental illness? Define it using your own words.

2. Explain mental illness prevention.
3. Distinguish between risk factors and protective factors.
4. What are the two manuals for psychiatry diagnostic?

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1.8 THE ROLES OF THE MENTAL HEALTH

NURSE
Now, let us have a discussion on the role of the mental health nurse. The qualified
mental health nurse who works in in-patient settings (on the wards) would usually
play a number of major roles as part of his or her hands on delivery of care. The
nurseÊs role will be shaped up by both the needs of the patients and the
bureaucracy (hospital). The major roles of a mental health nurse are listed in
Figure 1.7.
Figure 1.7: Six major roles of a mental health nurse
These roles are further explained in the next subtopics.
1.8.1 Care Giver – Delivery of Nursing Care

Certainly, the assessment of need and delivery of care will be central to the nurseÊs
role. The mental health nurse will assess the patient to identify physical, social,
emotional and psychological need, whilst encouraging patient participation and
autonomy. The nurse will plan and coordinate the delivery of care and monitor
progress. This activity is called medication management – checking for
understanding, safe use and compliance.

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1.8.2 Patient Advocate

In a multidisciplinary team, it is likely that the nurse will take on the task of liaising
with other professionals and agencies to coordinate the patientÊs treatment and
care. The nurse also makes sure the patientsÊ needs are met and interest is
protected. It is important for the patient and carers to be included in the patientÊs
care. Where available, independent advocates and user groups may make useful
contribution in supporting the patient.
1.8.3 Therapeutic Agent

As a therapeutic agent, the nurses need to have psychosocial interventions (see
Table 1.11).
Table 1.11: Psychosocial Interventions as Therapeutic Agent
Intervention Description
Social skills This covers areas such as life and self-care skills, relationship skills,
training assertiveness, problem-solving skills and others. In some patients,
deficits in social abilities will not only contribute to their mental health
problems but will also impede their recovery and rehabilitation.
Counselling The nurses work, mainly, on a one-to-one basis. Individual work,

requiring a satisfactory level of basic counselling skills. In addition,
there are now many nurses who have undertaken advanced
professional counselling/psychotherapy courses and are proficient in
humanistic, psychodynamic and cognitive behavioural counselling.
Group work In addition to individual work, mental health nurses are involved in
facilitating therapeutic change through groups. Group facilitation
skills are an important part of the mental health nurses core skills.
Patient groups can be wide ranging and focused on problems such as
anxiety, voice hearing, drug withdrawal, assertiveness and so on.
Milieu The ward environment was generally shaped up by the nursing team
(therapeutic with a wide range of therapeutic activity, and of course the rest of the
environment) multidisciplinary team will make their contribution.
However, they finish work at 5pm and it is often noticed that the
atmosphere of the ward will change – patients and nurses would be
more relaxed, as if the focus was not on the patientÊs problems, but
more on creating a positive social environment. Friendliness, warmth,
respect, social support, safety, time, own space and so on, are all
important in the patients sense of wellbeing and recovery. In mental
health nursing, the concept of „therapeutic use of self‰, refers to the
quality of your relationship which makes change possible in others.

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1.8.4 Patient Safety/Custodial Care

In creating a place of safety for the patient, the mental health nurse will be acutely
aware of the potential of the patient committing self-harm and/or suicide. The
nurseÊs role in assessing risk and taking appropriate measures to prevent self-harm
and suicide attempt would be instrumental in saving lives.
Providing a safe environment means that the patient (and staff) will not come to
any harm whilst on the ward. Thus, assessing patients for risk of violence and
ensuring the safety of others including the general public is crucial. Patients who
are potentially violent cannot be discharged and are usually detained against their
will as prescribed by the Mental Health Act. Hence, the nurseÊs custodial role – to
safely contain and control the potentially violent patient.
1.8.5 Mental Health Promotion/Psychoeducation

In order for patients to actively participate in their care, they will need to
understand the nature of their disturbance or illness, and for both the patient and
the nurse to develop a realistic and shared understanding of the patientÊs problems
and potential solutions. This psycho-educative and health promoting role of the
mental health nurse, will not only help manage the patientÊs immediate problems,
with better patient insight, but will also help in the patients rehabilitation and
prevention of relapse in the future.
1.8.6 Clinical Leadership

In addition to their managerial and supervisory role, senior nurses will lead by
example when it comes to clinical leadership, role modelling to ensure good
standards of clinical practice are maintained. The multidisciplinary team members
will usually look to the nurse to coordinate the seamless functioning of the team.
Last but not least, other advanced roles are nurse prescribing, psychotherapist,
researcher and educator.
SELF-CHECK 1.6
1. Explain the six major roles of a mental health nurse.
2. List other advanced roles of a mental health nurse.

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1.9 LEGAL AND ETHICAL ASPECTS IN

CLINICAL PRACTICE
Lastly, let us look at the legal and ethical aspects of clinical practice. You will be
well aware that our Nursing Code of Practice, makes explicit what are expected of
registered nurses, in terms of the standard of nursing care we provide and our
general professional conduct. As such, we need not re-visit it at this juncture.
Given that we are exploring care in mental health setting, it would be useful if we
are aware of the Mental Health Act (2001) which regulates the provision of mental
health care and all admissions to psychiatric hospitals and units attached to
general hospitals, including in the private sector. Though this Act was passed in
2001, it actually only came into effect in 2010. We will briefly consider the parts of
the Act that relate to hospital admissions.
1.9.1 Mental Health Act 2001 (MHA 2001)

This Act provides for the following types of admissions, namely voluntary,
involuntary and by order of the Court. These three types of admissions are further
explained in Table 1.12.
Table 1.12: Three Types of Admissions Under Mental Health Act 2001
Type Description
Voluntary An adult can request his own admission. In the case of a minor, a
admission guardian may apply on his or her behalf to the Medical Director of a
(Section 9) psychiatric hospital. Admission is at the discretion of the Medical
Director, who may refuse admission if he or she considered the person
was not likely to benefit from care or treatment in the psychiatric facility.
Discharge: You would be wrong to think as an informal patient you can

discharge yourself anytime. The patient has to request it (the guardian, in
the case of a minor) to the Medical Director. The patient can be detained
for not more than 72 hours from the date of request. Within this period,
the patient will be examined by a medical officer who has not been
involved in the management of the patient. The medical officer has the
authority to detain the patient for a period of one month if he considers
the patient to be „mentally disordered‰ or posed a risk to self or others.

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Involuntary A relative of a person who is thought to mentally ill may apply to the
admission Medical Director to admit the person in a psychiatric hospital. In addition,
(Section 10) involuntary admission would also require a recommendation of medical
officer or registered medical practitioner who examined the person
within five days prior to the admission.
The Medical Director will ensure the patient is examined by a medical

officer within 24 hours of admission, so that the Medical Director can
make the determination to discharge the patient or to continue the
detention for a period of one month. Under this section, the patient can
be detained for a further period of three months on the recommendation
of two medical officers, one of whom must be a psychiatrist.
PatientÊs right of appeal: The patient may appeal in writing to the Board
of Visitors within fourteen days to review the Medical DirectorÊs decision
to refuse discharge. Should the Visitors be satisfied that further detention
is justified, the patient may appeal within fourteen days of the VisitorÊs
decision, to the Director General.
Discharge: An involuntary patient may be discharged by the Medical

Director of a psychiatric hospital when it is in the best interest of the
patient, or the patient is no longer in need of further care or treatment in
the psychiatric hospital.
By Order of The court may make an order for the person to be detained in hospital if
the Court it is satisfied, following an inquiry, the person is suffering from mental
(Section 73) disorder, and is not capable of managing himself and his affairs.
Discharge: An application may be made to the court by the patient or on

his behalf or on the information of any other person, that the patient is
now capable of managing himself and his affairs. The court will request a
medical report to determine if the person should be discharged.
1.9.2 Patient’s Rights under the Act

According to the MHA (2001), it is the duty of the Medical Director of the
psychiatric hospitals to ensure patients and their relatives are aware of their rights
under the Act. Whilst we (as in the public) have a right to receive appropriate care
and treatment for our mental health problems, we also have a right to say no. The
Act provides some check and balance to protect the interest of the patients.
Information on oneÊs rights becomes particularly important when the admission is
involuntary.

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ACTIVITY 1.3
Discuss this statement in the myINSPIRE forum:
„There is no health without mental health‰
Do you agree with it? Justify your answer.
• Mental health and illness are complex concepts which are primarily related to
social functioning involving individual elements such thinking, self-concept,
identity, autonomy, regulation of emotion and stress response, managing and
coping with everyday stress and sustaining meaningful relationships.
• According to WHO (2020), mental health is defined as a state of wellbeing in

which every individual realises his or her own potential, can cope with the
normal stresses of life, can work productively and fruitfully, and is able to
make a contribution to his or her community.
• The „fight or flight‰ response, is where the autonomic nervous system, almost
instantaneously, readies the body by marshalling resources to either confront
the threat or to seek safety by getting oneself out of the situation.
• There are three stages in SelyeÊs general adaptation syndrome namely alarm,
resistance and exhaustion.
• The hypothalamus-pituitary-adrenal axis (HPA axis) prepares the body to

respond to the demand.
• Signs and symptoms of stress can be categorised into physical, emotional,

behaviour and mental.
• Stress management is all about taking charge, of your lifestyle, thoughts,

emotions and the way you deal with problems.
• There are three stress coping interventions namely mindfulness based stress
reduction (MBSR), progressive muscle relaxation (PMR) and guided imagery.
• Patient assessment in mental health will include both mental state assessment
and social functioning (including interpersonal skills and actual relationships).

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• Mental illness is disruptive of oneÊs life as it affects all areas of social

functioning with its consequent emotional turmoil and deteriorating quality of
life, not only for the patient but also for the family. Not to forget, in our culture
there is the additional problem of stigma, social alienation and discrimination
for them to contend with.
• Mental health promotion – the target is the positive aspect of mental wellbeing
which promotes better quality of life, such as resilience, positive self-
perception and optimism, autonomy and sustaining satisfying personal
relationships.
• Prevention is about targeting known risk factors to prevent illness – where

illness has developed; it is about minimising the effects of illness, promoting
recovery and preventing relapse.
• The applicable risk factors will depend on the developmental stage, such as
childhood, adolescence, adulthood and old age. Each stage has its unique tasks
to be accomplished.
• Protective factors, increase resilience and promote mental wellbeing. So, it is

important that you do not view the risk factors as causing mental illness; as a
combination of them, may lead to mental health problems in some but not in
others. Individuals are pretty unique and they are also unique in the way they
disturb themselves.
• Diagnostic manual is about agreeing and standardising diagnosis of mental

illness.
• The two manuals for psychiatry diagnostic are Diagnostic and Statistical
Manual of Mental Disorders (DSM 5) and International Classification of
Diseases (ICD10).
• Roles of the mental health nurse will include the following:

– Care giver (hands-on delivery of care);
– Patient advocate;
– Therapeutic agent;
– Custodial care/patient safety (assessment and management of risk) – self
harm, suicide and violence;
– Mental health promotion/psychoeducation; and
– Clinical leadership.

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• Mental Health Act (2001) is the relevant law that applies to the care of the
mentally ill in Malaysia. It provides for both voluntary and involuntary
admissions.
Diagnostic manual Mental wellbeing

Emotion Prevention
Fight or flight Promotion
General adaptation syndrome Protective factors
Hypothalamus-pituitary-adrenal axis Regulation of stress response
(HPA axis)
Risk factors
Interpersonal relationship
Roles of the mental health nurse
Legal and ethical aspects
Signs and symptoms
Mental health
Stress coping interventions
Mental Health Act (2001)
Stress management
Mental illness
Ainsworth, M. D., Blehar, M. C., Waters, E., & Wall, S. (1978). Patterns of
attachment: A psychological study of the strange situation. Hillsdale, NJ:
Lawrence Erlbaum Associates, Inc.
Argyle, M. (2008). Social encounters: Contributions to social interaction.

Piscataway, NJ: Aldine Transaction.
Bandura, A. (1977). Self-efficacy: Toward a unifying theory of behavioral change.

Psychological Review, 84(2), 191–215.
Bowlby, J. (1969). Attachment and loss. London, England: Hogarth Press.

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Brown, S., Kim, M., Mitchell, C., & Inskip, H. (2010). Twenty-five year mortality of
a community cohort with schizophrenia. British Journal of Psychiatry, 196(2),
116–121.
Cannon, W. B. (1932). The wisdom of the body. New York, NY: W. W. Norton &
Company.
Chang C. K., Hayes, R. D., Perera, G., Broadbent, M. T. M., Fernandes, A. C., Lee,
W. E., Hotopf, M., & Stewart, R. (2011). Life expectancy at birth for people
with serious mental illness and other major disorders from a secondary
mental health care case register in London. Retrieved from https://journals.
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Topic  Psychosocial
Assessment in
2 Mental Health
Nursing
LEARNING OUTCOMES
1. Describe the nature of nurse-patient relationship;
2. Identify the core conditions of therapeutic relationship;
3. Discover the factors that influence assessment;
4. Explain subjective and objective data;
5. Describe the four types of questioning in assessment; and
6. Do psychosocial assessment according to the nine categories of
what to assess.
 INTRODUCTION
In mental health nursing, as with in other disciplines in nursing, interviews are the
main means by which we gather information for a thorough patient assessment.
You will be very familiar with what assessment is and why we assess, so this topic
will be brief.

44  TOPIC 2 PSYCHOSOCIAL ASSESSMENT IN MENTAL HEALTH NURSING
In problem solving models – such as the nursing process, assessment is where you
start to address the problem. To state it simply, „assessment‰ is the process of:
(a) Gathering data (about a given problem);
(b) Organising it; and
(c) Making judgement about their relevance.
The importance of thorough and accurate assessment cannot be overstated. It will

set the scene for your patientÊs relationship with you and the team members. We
have discussed social functioning in Topic 1. Thus, in mental health nursing,
assessment is mainly psychosocial in nature.
In course of this topic, we will explore the whole assessment process beginning
with the management of the interview, interpersonal relationship with an
emphasis on the:
(a) Therapeutic use of self;
(b) Factors that can affect assessment;
(c) Listening and questioning skills; and
(d) Content of the assessment.
Some preparation for the assessment will help with the flow of the process and a
more pleasant experience for your patient. So make sure you familiarise yourself
with available information such as the reason and circumstance of admission. The
medical officer may have interviewed the patient, avoid duplication where
possible and also explain and agree to a suitable time with the patient.
Also be mindful that patients who are admitted against their will (involuntary
admissions) may not be enthused about collaborating or be forthcoming with
information. This is more so for newly-admitted patients, who are likely to be
apprehensive and uncertain as to what to expect. Your self-composure,
introduction(s), explanations and orientation of the patient will go some way to
reassuring the patient.
The assessment interview is an opportunity to connect and establish a reasonable

understanding with your patient. Let your patient get to know you and become a
little more familiar with you. This requires you to be friendly but professional in
your manner.

TOPIC 2 PSYCHOSOCIAL ASSESSMENT IN MENTAL HEALTH NURSING  45
In addition, do not forget your patientÊs relatives and family members. You need
a good working relationship with them too. In mental health nursing, you cannot
do a thorough assessment without the contribution from the family. In reality,
assessment is not a one-way process that is you gathering information about your
patient and his or her circumstance. Your patient (and his/her relatives) will want
to talk. They will want information, clarification, re-assurance and so on. They may
even want to complain. How you handle their concerns will determine how they
will cooperate with you! As such, I cannot stress enough, the importance of your
relationship with the people you are caring for. So let us continue with the lesson.
2.1 THE NATURE OF YOUR RELATIONSHIP

WITH YOUR PATIENT
Certainly, the relationship with your patient is important regardless of where you
work. In mental health nursing, the nurse-patient relationship becomes the focus
and is given a special prominence; as the communication within it forms the basis
for the nursing intervention and the desired outcomes. We normally use the phrase
„therapeutic relationship‰ – differentiating this from other types of relationship,
such as social or intimate relationship.
Your posting is about gaining insight into mental health nursing and you will learn
to be comfortable within yourself as you relate with others in mental health setting.
So watch and learn from experienced nurses who will be guiding you. The
patientÊs expectations of learner nurses are usually to do with being friendly and
sociable.
In considering the nature of relationships, briefly, in „Âsocial relationship‰ there is

little structure or formal goal, and no need for evaluation. ItÊs about meeting the
need for friendship, companionship and attending to tasks at hand.
Communication will usually be topical and neutral – exchange of experiences,
ideas etc., but mostly superficial in nature. Usually, you will be entertained by
some patients, so be ready to laughter with them.
Unlike social relationship, in intimate relationship there is an emotional bond and

commitments to one another, usually with shared goal and with each otherÊs need
being met. This level of familiarity may or may not include sexual intimacy. Of
course, this is inappropriate and has no place in a professional nursing
relationship. All professional relationships are formal relationships sanctioned by
society (the patient is with you for a purpose), governed by rules and professional
ethics.

2.2 WHAT IS THERAPEUTIC RELATIONSHIP?

This is the core of mental health nursing. In the therapeutic relationship, the nurse
is there for the patient. The focus is exclusively on the patients need – experience,
beliefs and feelings. Problems are negotiated and goals agreed; interventions and
outcomes are reviewed. The nurse is trained to use her interpersonal skills and
knowledge of human behaviour to benefit the patient. Remember, it is not about
the nurse.
A degree of self-awareness is also necessary to appreciate oneÊs own need and

limitations. It is usual for the nurse to discuss her needs with a supervisor
elsewhere. There is however, a clear boundary or well-defined limit in this
relationship.
2.2.1 Core Conditions

In all forms of helping or caring relationships, there is an emphasis on the quality
of that relationship and how the relationship is used to benefit the other. The
psychologist Carl Rogers talked of the „necessary conditions‰ that go to creating a
therapeutic experience in the relationship (Rogers, 1961). In the world of
humanistic counselling, it is referred to as the „core conditions‰. In order for the
relationship to be therapeutic, the following core conditions are necessary (see
Figure 2.1).
Figure 2.1: The core conditions of therapeutic relationship

The challenge is how we create and convey these experiences in our interaction
with others. As professionals, we need to be aware that it is the experience that
counts and not what we say – trust, in mental health work is illusory. If you need
to gain trust, it needs to be earned. Do you agree?
So let us learn more on the elements that contribute to a therapeutic relationship:
(a) Empathy
What is empathy? Think of the last time you were emotional and cried while
watching a movie (see Figure 2.2).
Figure 2.2: Why do we cry when we watch a sad scene in a movie?
That is empathy! You feel for the lead character because you have been
„seeing‰ and „experiencing‰ events from his/her point of view – that is
empathetic understanding.
(b) Genuineness
What is genuineness?
Genuineness is about a way of being with a patient.
When you are with your patient, you are there for your patient – and not
distracted by other issues. It is also about what is referred to as congruence.
When what you feel and what you say matches, your patient perceives you
to be genuine or authentic.

It is not uncommon for nurses to say things to patients that we do not really
mean. It is like when a lecturer ask his students if they have understood what
he have said; they may nod their head and even say „Yes‰. But he is not
convinced because their non-verbalÊs language say something different.
Likewise, our patients can see when we are not being genuine.
(c) Unconditional Positive Regard

Counsellors view this as the primary change agent in which the patientÊs
need for acceptance and positive self-regard are met. In other words, the
patient experiences unconditional acceptance and positive regard. The two
central concepts are:
(i) Self and other acceptance; and
(ii) Self-worth.
Let us discuss this further. Self-acceptance is about accepting ourselves (and

others) as fallible human beings – meaning, we are not perfect and we are
capable of making mistakes. We accept the good and the not so good within
us.
You may recall that we have briefly discussed self-worth in Topic 1. Self-
worth is inherent, a given, by virtue of the fact that we are human beings. All
of us are worthy and deserving, unconditionally! Self-worth is not something
that can be diminished or subtracted from. No matter what jobs we do, we
are all equally worthy and deserving.
In practical terms, should one fail in a task, it does not follow that he or she
is a failure. You can rate the performance as not good enough to pass. But
you cannot globally rate the person as a failure. Let say when a student does
not behave well, the lecturer should be disapproving of her behaviour but
still be supportive of her. Remember, rate the performance, not the person.
People disturb themselves partly because they internalise conditional self-

values learnt from parents and others around them. It is not uncommon to
hear people say they „dislike‰ or even „hate‰ themselves, usually for not
being „good enough‰. It may have to do with not having done well in an
exam or in a relationship.
As a result, they tell themselves that they are „no good‰, „a failure‰ as a
person (global self-rating). To these individuals, their self-worth is
conditional. So a negative experience like failing an exam or ending a
relationship can feel bad enough, but these individuals will „beat‰

themselves up afterwards (because of their lack of self-acceptance) and make

themselves even more unhappy.
Therefore, the nurse through her positive regard and acceptance of the
person, conveys to the person that he or she is worthy and deserving,
regardless of his or her apparent lack of success. Remember, you accept the
person – even as you disapprove of his or her unacceptable behaviour.
(d) Trust
Nurses use the word „trust‰ a lot in mental health. Again, keep in mind that
trust is earned. Let us make a mental list of other peopleÊs behaviours that
encourages you to trust them. Here are some that come to mind; keeping
promises, being reliable, honest and a good listener. Can you add other
attributes to this list?
2.3 FACTORS THAT MAY INFLUENCE YOUR

ASSESSMENT
There are numerous factors that can get in the way of your assessment. Some of
the problems will be factors within the patient, others will be factors within the
nurse and there will be those that arise from the immediate environment and
wider culture. Let us find out what these factors are in the next subtopics.
2.3.1 Factors within the Patient

Undeniably, your patient may be too ill to understand what is happening. This
may take several forms. Your patient may not be orientated to the time, place and
people. Others may be too distracted by „voices‰ in their head, lack of energy, pain
and so on to be able to engage. You are also likely to see individuals who are
psychologically too withdrawn into themselves to participate.
For some patients, their problem may be that they „lack insight‰ into their problem
and they cannot think that they have a problem. Consequently, they will be
unwilling to engage in activities designed to help them.
Of course, the patientsÊ previous experience will influence their present behaviour
too. Individuals may have very negative attitude towards the hospital staff
because of their previous unpleasant ward experience.

2.3.2 Factors within the Nurse

Again, the nurseÊs self-awareness is important. Some individuals may not be
aware how they come across to others. A combination of lack of experience, poor
interpersonal skills and knowledge may convey in their approach attitude which
can be perceived as unhelpful by patients. This will affect the patientÊs level of
cooperation and participation in their care.
The nurseÊs personal problems can be overwhelming and affect her optimum
functioning whilst at work. It is not easy to keep personal problems away from the
workplace. In mental health work, emotions will usually „leak-in‰ and thus,
therapeutic supervision is important for mental health workers.
2.3.3 Other Environmental and Cultural Factors

Ward teams that are poorly led and supervised can develop team dynamics that
may affect the optimum functioning of the team. Where there are interpersonal
conflicts among nurses, there will not be a cohesive team and the standard of
nursing care will usually suffer.
Social class and perceived social status are known to influence how we attend to
patients. The nurseÊs awareness of her attitude towards people she likes and
dislikes will be important in managing its effects. The poor and other
disadvantaged groups will usually get the short end of the stick.
In addition, language and cultural barriers can be major sources of communication

dislocation resulting in poor nurse-patient relationship. Therefore, cultural
awareness and sensitivity is important, without these, we might risk imposing our
values, beliefs and judgments on patients. The use of friends and family to
interpret, in the absence of trained interpreter, can also be a source of
misunderstanding.
SELF-CHECK 2.1
1. Differentiate between social relationship and intimate
relationship.
2. Define therapeutic relationship. What are the elements that make it?
3. Explain the factors that may influence your assessment towards

a patient.

ACTIVITY 2.1
Let us do the following activity:
Aim To develop awareness of social attitudes that can influence

assessment.
Scenario Life on planet Earth is coming to an end. Planet Earth is being

evacuated. You have to fill the last five spaces on your space
craft. But you have eight people on your list. You have to
decide who gets to go and who remains behind. Your
passenger list consists of:
(a) A second-year medical student;
(b) A lesbian computer expert;
(c) An alcoholic plumber;
(d) A 70-year-old clergyman;
(e) A policeman;
(f) A lecturer in Philosophy;
(g) An illegal motorcycle racer (mat rempit); and
(h) A vegetarian environmentalist.
Based on the given scenario:

(a) Make a list of the people you would take with, noting your
reasons. Also note your reasons for the individuals that you are
leaving behind.
(b) Discuss your individual lists in the myINSPIRE forum to come
out with one final list for the whole class.
(c) Summarise your learning experience from this activity.
2.4 HOW ASSESSMENT IS CONDUCTED

Be mindful that you are going to be talking with your patient for about an hour, if
not longer. You should essentially control the interview. So use your judgement to
gauge the pace of your interview, accounting for your patientÊs level of functioning
and the available time. If your patientÊs ability to concentrate is an issue, be
prepared to take short intervals.

It is important to create the right physical and psychological environment for your
patient to talk. Really, it is not different from your class room learning experience.
What conditions would encourage you to relax and talk freely? What would help
you to experience the psychological freedom to express yourself – your thoughts
and feelings? Let us look at the answer in the following list. You may wish to add
to the list provided, remember to include the following physical conditions:
(a) No fear of consequence;
(b) Safe – No personal criticisms/attacks;
(c) Not being judged; and
(d) Accepted for who you are.
Remember, you would want the same for your patient. Create the right conditions
and your patient will freely talk to you. Again, assessment is not about making
judgement or giving advice.
2.4.1 Subjective and Objective Data

The information provided by your patient will be mainly subjective information.
It is important to have them verified by others, usually by family members and
friends. Social worker and police, if involved, may be useful in corroborating your
patients account.
You will soon discover most peopleÊs mental health problems revolve around
relationship issues. So we should not be surprised to hear different accounts from
family members. Some of you may not be old enough to appreciate this – you will
notice some individuals will blame their parents for all their problems; until their
children are old enough and then, they will blame their children for their
unhappiness.
What does subjective data consist of? Subjective data include the patientÊs:
(a) Account of history;
(b) View of his or her present situation;
(c) Thoughts; and
(d) Feelings.

How about objective data? Unlike subjective data, objective data is what is
collected by the nurse through observation or provided by other professionals
from their observation. Objective data will include:
(a) Physical examination;
(b) Medical history;
(c) Social relationships; and
(d) Religious and cultural practices.
2.4.2 Types of Questioning

Asking question is necessary to obtain information. Keeping your patient talking
about issues that matter to her shows your willingness to learn about and
understand your patientÊs real needs. You are probably aware of open-ended
questions and closed-ended questions. Your choice of the type of question will
depend on your intention and the kind of information you are looking for. There
are four types of questions as shown in Figure 2.3.
Figure 2.3: Four types of questions

Table 2.1 explains more on these four types of questions.
Table 2.1: Four Types of Questions
Type Description Example
Open- These are very useful especially at the • How have things been since
ended beginning of your assessment where we last talked?
questions your intention is to encourage your
• Tell me, what brought you
patient to talk and help you to get to
here this morning?
know your patient and better
understand her need. Open-ended • What would you like to talk
means exactly that. Your patientÊs about?
scope of response is wide and she
chooses what to talk about. In
addition, it does not encourage a
„yes‰ or „no‰ answer.
Closed- Limit your patientÊs options to • What is your name?

ended respond. They are often answered
• Is this your correct address?
questions with a „yes‰ or „no‰, or with a direct
specific answer. These are a quick and • Would you like to talk to a
efficient way to gather bio-data. doctor about your problem?
• Do you want to go for a
walk?
• How much do you get paid?
Probing When your open-ended question • What concerns you most

questions gives only part of the information you about that?
are looking for, a follow-up probing
• Can you tell me more about
question will help you develop a
what was said to you?
fuller picture. It is essentially another
open-ended question with a narrower • What is worrying you about
focus. your new job?
Leading These questions are rarely helpful in • You are with me on this one,
questions the context of an assessment. We are arenÊt you?
essentially asking the patient to give
• You understand what IÊm
the answers we want. If used
saying?
excessively the relationship will be
nurse centred instead of being patient • This is a good idea, isnÊt it?
centred. These will be good questions
if you were a salesperson.
Last but not least, keep your questions simple, clear and direct. Avoid asking
multiple questions such as, „Are you getting enough sleep and do you take your
sleeping medicine?‰

SELF-CHECK 2.2
1. State the differences between subjective and objective data.
2. Explain the four types of questions. Give three examples for each
of them.
2.5 WHAT TO ASSESS?

Before we end this topic, let us a have discussion on what to assess. The
experienced nurses will gather and subsequently organise the information into
appropriate categories. As a learner, you will need to know what information to
gather.
In order to be thorough and systematic, you will need an organising framework.

Though there is no standard or one right way of doing this, most assessment tools
will have similar categories. For our purposes, we will use the categories suggested
by Videbeck (2008) (see Figure 2.4).
Figure 2.4: Nine categories of what to assess

Source: Videbeck (2008)

It is always helpful to create the right conditions by attending to the patientÊs need
first – if your patient is anxious or overly depressed, talk about what concerns her
first. If she does not feel like answering questions, agree to do it at another time.
Giving priority to your patient will encourage her to respond to your priority.
There will be circumstances where the nurse will dictate the priority during the
interview. These are exceptional and involve life-threatening situations.
Make sure you have a private and conducive environment to assess your patient.
If the family members are present, ask your patient if it is okay with him for them
to be present. At every stage of the process, explain and give some indication of
how long it will take. Sometimes, it may be necessary to have short breaks. It is a
good practice to seek your patientÊs permission first before talking to his family
members.
Let us learn more on these nine categories in the next subtopics.
2.5.1 History
History consists of personal details, such as:
(a) Name;
(b) Age;
(c) Address; and
(d) Marital status.
In addition to history, educational background and work history also need to be

assessed as well as information about family history on mental illness.
2.5.2 General Appearance and Motor Behaviour

In this category, you need to assess:
(a) Grooming and hygiene (physical appearance, how they dressed);
(b) Eye contact, mannerism and posture;
(c) Motor activity (pacing, slow, rigid, restless, unusual); and
(d) Speech pattern (slurring, volume, speed, dysphasia).

2.5.3 Mood and Affect

In terms of mood and affect, you can assess their:
(a) Facial expression, intensity, duration;
(b) Different moods like sadness, anxiousness, euphoric, irritable; and
(c) Blunted affect, flat affect, labile (rapid mood swings from depressed to
euphoria to depressed and crying).
2.5.4 Thought Process and Content Speech

Your patientÊs speech will give a good indication of the content of his or her
thought, which is what he or she actually thinks. We assess for:
(a) How the speech content is organised;
(b) Its appropriateness;
(c) Responses made in sentences or whether they are monosyllabic;
(d) Whether it is logical and makes sense (coherent) and understandable;
(e) Whether the rate or speed of speech increased (pressured) or decreased
(poverty of speech); and
(f) Quality – Rapidly jumping from one topic to the next.
Here are some examples of thought disorders to look for (see Table 2.2).
Table 2.2: Examples of Thought Disorders
Example Description
Delusional Fixed false beliefs, not amenable to reasoning and not shared by others.
thoughts This can take in many forms:
(a) Paranoid and persecutory – Suspicious of others motives such as
„People are watching me‰, „Someone is following me‰, „They are
out to get me and harm me‰.
(b) Ideas of reference – Patient draws personal significance from
general events such as the newscaster on TV is talking about him.
(c) Thought insertion – Denies his ideas belong to him, it has been
„inserted by other forces‰.
(d) Thought broadcasting – Belief that others can hear his thoughts.

Flight of ideas Fast paced change in ideas, pressure of speech, ideas are unrelated and
unrealistic.
Loose Expression of a string of vaguely related or unrelated ideas reflecting a

association disorganised thought process.
Thought Sudden interruption of speech, unable to continue with his sentence

block because he cannot remember what he was talking about.
Confabulation Patient makes up stories to fill in gaps in the memory; this is usually
associated with alcohol abuse (Korsakoff syndrome).
2.5.5 Sensory and Intellectual Process

Some examples of intellectual process are given in Table 2.3.
Table 2.3: Examples of Sensory and Intellectual Process
Example Description
Orientation Person, place and time. Knowing who and where he or she is. Awareness
of the day, date, month and year.
Memory Ask only verifiable questions such as, „Who is the current Prime
Minister?‰ or „What is the capital of this country?‰
Ability to Such as repeat the days of the week in reverse, or you can do „serial
concentrate sevens‰– subtract sevens starting with a hundred.
Abstract Assesses your patientÊs intellectual ability to interpret and make

thinking reasonable associations in relation to the situation. You can use common
proverbs such as „crying over spilt milk‰, „raining cats and dogs‰, „donÊt
count your chickens before they are hatched‰ and others. Where there is
intellectual impairment, the patient is likely to repeatedly give the
concrete meaning for the different proverbs and will not grasp the abstract
meaning.
2.5.6 Judgement and Insight

What is judgement?
Judgement is essentially oneÊs ability to assess and interpret environmental

cues accurately so as to be able to make adaptive responses and meet oneÊs
need with relative ease.

Mentally ill people will sometimes display poor judgement as they describe their
relationships, decision about jobs, finance and so on.
What is insight?
Insight is oneÊs accurate understanding of his or her present social realities

and a clear acceptance of some responsibility for the problems.
You will find both extremes, where some patients will deny they have a problem
and they are here (on the ward) because of other people. Whilst others will display
a similar lack of insight into their problems; they will complain a lot and blame
themselves and even rather unrealistically take responsibility for other peopleÊs
behaviour.
2.5.7 Self-concept
In Topic 1, we have discussed self-concept from a symbolic interactionist
perspective and considered its development through childhood socialisation. Self-
concept will include our physical appearance, personal traits and attributes, family
role-relationships, the job we do, values and beliefs we subscribe to, and other roles
we may play – we not only internalise the roles and values but it is more
fundamental than that; it helps define us.
For assessment purposes, a personÊs self-concept gives us access to the patientÊs

subjective world, for example:
(a) How she sees herself; and
(b) What she thinks she looks like to other and how much she thinks others, like
her, will influence and shape her self-perception.
For instance, individuals who have poor relationship with others, are likely to be
self-critical and will lack self-acceptance. Others can suffer from an inflated sense
of self-image, or may unduly worry about personal flaws that others do not even
notice. In general terms, we will assess the following (see Table 2.4).

Table 2.4: Elements to Assess for the Self-Concept
Element Description
Self-esteem This is about one valuing oneself. We have explored this concept in
Topic 1, together with problems associated with it (please refer back for
revision). For instance, it is likely that your patient will be highly self-
critical and be „feeling low‰ in herself – depressing herself. This may
have come about because she has internalised the harsh and critical
attitude of her husband. Now, she does the punishing herself, by saying
things like „I dislike myself‰, „I am never good enough‰ and so on.
Hence, the idea of how you value yourself, self-worth, sense of pride
and dignity, will reflect not only how you view yourself but also how
significant people around you relate with you.
Body image This is an important component of self-image. There are many people
that have something to change in their physical appearance. The ideal
body shape one desires will impact the way one feels about her actual
physical appearance. School yard bullies will body-shame vulnerable
children, for some the consequences of this will continue into
adulthood. In mental health care, there will be some individuals whose
perception of their body will be distorted to the extreme – this is known
as body dysmorphic disorder.
Ideal-self This is what you wish to be or think you „should be‰ and this includes
ambitions and goals in life. The person that your patient believes she
ought to be – well-liked and popular, successful in career, have a loving
family and so on. Actual or real self is how your patient sees herself as
behaving at the present moment. The gap between actual and ideal self
is what Carl Rogers called incongruity; the bigger the gap the greater
the possibility of distress (Rogers, 1961).
The following are some suggested questions/prompts to explore self-concept:

(a) Could you please talk about the way you feel about yourself at the present
moment?
(b) Talk to me about people who are close to you.
(c) When you think about yourself, what is it that you are most unhappy about?
(d) Is there something you wish you could change about yourself?
(e) On a scale of 0 to 10 (0 is negative and 10 is positive), how do you think others
see you?

2.5.8 Roles and Relationships

This is an important area to assess, being the likely source of most of your patientÊs
problems. Throughout our lives we play numerous roles. You will be discussing
this module in your role as a student. You will also have other role relationships
such as daughter, mother, father, brother, sister and others. Your school life, work
life, family life, social circle and so on contribute to your understanding of yourself
and your psychological and emotional health.
In the same token, you need to be mindful that the person you are interacting with
on the ward will be in „patient role‰ – suggesting things have not gone well and
likely to have not only limited but also difficult relationships. She may lack social
support and may have develop a negative attitude about herself. So encourage
your patient to talk about the relationships that has worked well and the important
ones that she wishes was better.
Consider for a moment why relationships sometimes do not work? For some
individuals this may be a recurrent problem – why may this be so? How may this
affect the person? You will notice the different areas you assess will be inter-related
and affect one another.
2.5.9 Physiologic and Self-care Concerns

You should be familiar with the daily activities, so this subtopic will not discuss
this further. It is important though, not to neglect this in the field of mental health
care. We will need to have a clear idea of the patientÊs ability to perform or meet
these self-care needs.
SELF-CHECK 2.3
What are the categories of psychological assessment in mental health

nursing?

ACTIVITY 2.2
Let us do the following activity:
Time: 45 minutes
Aim : Develop questioning skills
In a groups of three, do an online video meeting with Google Meet,

Google Hangout or Zoom to take turns to play the following role:
(a) Nurse;
(b) Patient; and
(c) Observer.
The nurse will pick any two areas from the list of psychosocial
assessment to assess the patient (for not more than five minutes). The
observer will give feedback on the type of questions used and their
appropriateness.
Discuss your experience in doing this activity in the myINSPIRE

forum.
• In mental health nursing, the nurse-patient relationship is called „therapeutic

relationship‰.
• In a therapeutic relationship, the nurse is there for the patient. The focus is
exclusively on the patientÊs needs – experience, beliefs and feelings.
• In the therapeutic relationship, problems are negotiated and goals agreed;

interventions and outcomes are reviewed. The nurse is trained to use her
interpersonal skills and knowledge of human behaviour to benefit the patient.
• The core conditions of therapeutic relationship are empathy, genuineness,

unconditional positive regard and trust.
• There are numerous factors that can get in the way of your assessment.
Specially, these factors can be categorised into three, namely factors within the
patient, factors within the nurse and other environmental and cultural factors.

• Subjective information or data is mainly the information provided by your

patient.
• Objective data is what is collected by the nurse through observation or

provided by other professionals from their observation.
• Questioning skill is an important skill to obtain information. There are four

types of questions namely open-ended questions, closed-ended questions,
probing questions and leading questions.
• There are nine categories of what to assess suggested by Videbeck (2008),

namely history, general appearance and motor behaviour, mood and affect,
thought process and content speech, sensory and intellectual process,
judgement and insight, self-concept, roles and relationships, and lastly,
physiologic and self-care concerns.
Assessment Physiologic and self-care concerns

Empathy Questioning skills
Factors located within the nurse Roles and relationships
Factors located within the patient Self-concept
General appearance and motor Sensory and intellectual process
behaviour
Speech
Genuineness
Subjective data
History
Therapeutic relationship
Judgement and insight
Thought process and content speech
Mood and affect Trust
Nurse-patient relationship Unconditional positive regard
Objective data
Other environmental and cultural
factors

Argyle, M. (2008). Social encounters: Contributions to social interaction.

Piscataway, NJ: Aldine Transaction.
Baputty, S., Arumugam, U., Hitam, S., & Sethi, S. (2016). Mental health and
psychiatric nursing (2nd ed.). Kuala Lumpur, Malaysia: Oxford University
Press.
Barker, P. (Ed). (2003). Psychiatric and mental health nursing: The craft of caring.
London, England: Arnold.
Rogers, C. (1961). On becoming a person: A therapist's view of psychotherapy.
Boston, MA: Houghton Mifflin.
Varcarolis, E. M., & Halter, M. J. (2011). Essentials of psychiatric mental health
nursing: A communication approach to evidence-based care. Singapore:
Saunders Elsevier.
Videbeck, S. L. (2008). Psychiatric-mental health nursing (4th ed.). Philadelphia,

PA: Lippincott Williams & Wilkins.

Topic  Nursing
Practice for
3 Anxiety and
Anxiety
Disorders
LEARNING OUTCOMES
1. Describe the dynamic relationship between cognition, behaviour
and emotion;
2. Distinguish between healthy concern and anxiety;
3. Identify physiological, cognitive and behavioural features of
anxiety;
4. Explain five examples of anxiety-related disorders; and
5. Discuss the care and treatment of anxiety.
 INTRODUCTION
In this and remaining topics, we will consider the commonly presented mental
health problems, which may become severe enough for people to require in-
patient care. Specifically, we will cover anxiety in this topic, depression in Topic 4
and schizophrenia in Topic 5.

66  TOPIC 3 NURSING PRACTICE FOR ANXIETY AND ANXIETY DISORDERS
You will be presented with the defining features and major manifestations of the
distress, together with the appropriate nursing care. Though the material will be
adequate for your purposes, it will be helpful to do some further reading to get a
fuller picture of the disturbances.
Again, our prime concern is caring for the person who is in distress or suffering in
some way. We cannot do this without a good relationship and some degree of
empathetic understanding of the person and the situation in which she is
disturbing herself. We have discussed the therapeutic nature of the nurse-patient
relationship in Topic 2.
Now, in this topic, we will emphasise on developing a good understanding of

emotions generally and anxiety in particular. However, where appropriate,
references will be made to other emotions, such as depression and unhealthy
anger. These are powerful unhealthy negative emotions that can be devastating
for both the individual and the family. Hence, the important challenge for us will
be:
(a) To understand the characteristics of a given emotion; and
(b) To provide meaningful psycho-social support for the patient and the family.
So are you ready to learn more about anxiety? Let us continue with the lesson.
3.1 THE DYNAMIC RELATIONSHIP BETWEEN

COGNITION, BEHAVIOUR AND EMOTION
Understanding of emotion is the dynamic relationship between our thoughts
(cognition), actions (behaviour) and feelings (emotion). In other words, it is
important that you recognise that these three domains interact and influence each
other (see Figure 3.1).

TOPIC 3 NURSING PRACTICE FOR ANXIETY AND ANXIETY DISORDERS  67
Figure 3.1: Three domains of emotion that interact and influence each other
The three domains are considered equal, but cognition has primacy. Emotion
cannot emerge on its own in a vacuum. Let us use an example to illustrate this
dynamic relationship:
A student who is thinking about the forthcoming exam, entertains the

thought that she will not pass. She may not be aware that her body has
already responded to this „threat‰ with raised heart beat and the body
feels warm.
In addition, she thinks she cannot face her friends and family should
she not do well. „How could I face them, if I failed in my exam?‰, she
thinks to herself! She notices her heart pounding faster and her
breathing becomes more laboured. She now says to herself, „I canÊt face
them, IÊm afraid‰ or „I donÊt want them to think of me as a failure.‰
Her emotion will lead to anxiety. When anxious, she has very little control over
her own behaviour and she will avoid the people and situations that she thinks
will make her anxious, such as meeting her lecturers, attending class and even
talking to her friends.
Her anxiety will in turn generate more negative thoughts about her future career,
relationship and soon resulting in higher levels of anxiety and more avoidance
behaviour.
Avoidance and social withdrawal are among the behavioural components of

anxiety and these will make it more difficult for her to function socially and to
overcome her anxiety. The bodily sensations and responses can be subsumed
under the behavioural domain.

Anxiety (and all other emotions) is a response to something we focus upon, that is
noted and interpreted. In the case of anxiety, one perceives a threat to oneself. If
one were to infer or perceive a loss, the emotion will be depression. In the case of
anger, the inference will be one of unfairness or injustice.
In the case of our student, she is likely, given some time, to become a little
pessimistic and even negative in her thoughts about herself. She may develop
other negative thoughts which will most likely lead to her feeling down or even
depressed – thoughts related to her perceived loss, such as:
(a) „Why am I such a failure?‰;
(b) „I am unworthy‰;
(c) „I am undeserving‰; or
(d) „I am unloved‰.
Our depressed feeling will in turn influence our thinking – creating more negative
thoughts. The behavioural component of depression will be social withdrawal. We
may not feel like doing the things that we normally do, like spending time with
friends, shopping, going to work and so on. We can become withdrawn and
socially isolating. Our withdrawn and isolating behaviour will in turn distort our
thinking further and maintain our depressed feeling for a lot longer.
In order to understand the emotion, you need to learn to recognise the specific sets
of behaviours that are usually associated with a given emotion. We will discuss
this further as we consider anxiety and depression.
3.1.1 Physiology of Arousal

It is usual for people to talk of „anxiety‰ as a common problem and that anxiety
was part of everyday life. From a professional point of view, it is important to
understand the difference between the everyday stresses or „arousal‰ which
motivates us to confront and deal with every day challenges; and anxiety which
can be harmful and incapacitating.
In Topic 1, we have examined in some detail the role of autonomic nervous system
and the endocrine system (HPA axis) in the regulation of stress response. We also
discussed the „fight or flight‰ response when confronted with an actual or
perceived threat to the self. Thus, our discussion now is very brief.

In situations where there was a real threat to your physical self, for example, whilst
you were out for a walk you were confronted by a large unfriendly dog. Even
before you think „the dog looks fierce‰, your body has responded to the threat.
Fortunately for you, the dogÊs owner suddenly appeared and got the dog under
his control. The threat was over and your arousal level gradually returns to
normal. Of course, there are many other situations where there was an actual or
real physical threat. For most of us, the actual threat to our physical self would not
be an everyday occurrence.
There is another set of circumstances when our body also appeared to respond in
a similar way, even when there was no physical threat. For example:
(a) Being asked to give a presentation or public talk;
(b) Finding that there was less money in your bank account than you expected;
(c) Losing your purse or wallet with your money and credit cards; or
(d) Being late for an important interview.
These are examples of actual situations.
Meanwhile, you can also have situations which are not actual or inferred
situations, in which our body becomes aroused. For examples, thoughts such as:
(a) „What if he turns me down?‰;
(b) „What if I donÊt get on with people in my new job?‰;
(c) „Why do these bad things happen to me?‰; or
(d) „I must know why others donÊt like me."
In our modern day life, arousal related to such negative thoughts (related to need
for approval and so on) are perhaps more common than arousal related to an
actual physical threat.
In any emotional response, the physical components of the response would

comprise the behavioural, autonomic and hormonal system. The behavioural
response will be specific to the situation that elicits it. In the previous example
when you were confronted with a fierce looking dog, your physical action
involving your muscles would most likely be to fend off the dog, protect yourself
or to make a run for it!

Your autonomic nervous system responds in support of your behaviour, ensuring

energy is available quickly for energetic action. As you would have guessed the
activity of your sympathetic nervous system increases whilst the parasympathetic
system decreases. This will account for your increased heart rate, increased air
intake and your blood supply will be diverted front the digestive organs to the
muscles.
The hormonal response adds further support to the sympathetic responses. The
hormones epinephrine and norepinephrine released by the adrenal medulla also
increases blood supply to the muscles; nutrients in the muscles and glycogen
stored in the liver are converted to glucose for food. Steroid hormones secreted by
adrenal cortex also make glucose available to the muscles (Carlson, 2007). As the
threat passes, the activity of the parasympathetic system will increase whilst the
sympathetic system will decrease. Arousal is over and the body slowly returns to
normal.
3.1.2 Anxiety as Unhealthy Negative Emotion

So what is anxiety? Take note that the everyday arousal that we experience as
described previously is not anxiety and usually does not lead to anxiety. Most
people do not suffer from anxiety. Though all of us would have been concerned or
even may have been profoundly concerned about one thing or another – given the
adverse events that can and do happen in our lives – we do not suffer from anxiety.
Some authors will talk of this as mild or moderate anxiety and that it can be
motivating and helpful. Implying it is healthy – this refers to people who are
concerned but not anxious.
However, anxiety is neither normal nor healthy. This loose use of the word
„anxiety‰ can be unhelpful.
Anxiety is an unhealthy negative emotion which can be debilitating to the

sufferer, with its characteristic physiological, cognitive and behavioural
features.
(Halgin & Whitbourne, 2008)
The next following subtopics will characteristic the features associated with
anxiety.

SELF-CHECK 3.1
1. Explain the three domains of emotion.
2. What is the difference between the everyday stresses (arousal)

and anxiety?
3. What are the the physical components of the response?
4. Define anxiety by using your own words.
ACTIVITY 3.1
Is it okay to have negative thoughts? How do you handle them? Justify
your answer and share your experience in the myINSPIRE forum.
3.2 PHYSIOLOGY AND OTHER SYMPTOMS OF

ANXIETY
There are many physiological symptoms of anxiety such as muscle tension,
restlessness, headaches, dry mouth, diaphoresis (excessive sweating), trembling,
pale, tachycardia (abnormally rapid heart rate), chest pain, nausea, vomiting and
diarrhoea, and others.
Now, let us identify the cognitive and behavioural features of anxiety.
3.2.1 Cognitive Symptoms

With anxiety, the inference the patient will make is threat to the self. Patient
usually anticipates and complaints of impending doom/dread but feels powerless
to affect it. It is also usual for the anxious person to exaggerate the perceived threat
or the actual difficulty, while minimising personal ability to cope.
Other symptoms will include:

(a) Inability to concentrate or reason logically;
(b) Focus on task-irrelevant activity;
(c) Distorted perception;

(d) Narrowed perceptual field; and

(e) Cannot solve problems or learn effectively.
3.2.2 Behavioural Symptoms

The main behavioural symptom will be avoidance or withdrawal from the feared
situation or object and the „action tendency‰ will be to curl-up, make one-self small
and hide. Behaviour is directed at relieving anxiety; it can become ritualised but
usually ineffective.
SELF-CHECK 3.2
What are the cognitive and behavioural symptoms of anxiety?
3.3 ANXIETY-RELATED DISORDERS

There are a number of specific disorders which are clearly fuelled by anxiety or
anxiety is the predominant feature. Some relatively common examples are shown
in Figure 3.2.
Figure 3.2: Five examples of anxiety-related disorders
These examples are further explained in the next subtopics.

3.3.1 Generalised Anxiety Disorder

What is generalised anxiety disorder?
Generalised anxiety disorder happens to individuals who are social worriers

– distressed with anxiety for at least six months accompanied by persistent
and excessive worrying.
What are the symptoms of generalised anxiety disorder? Some of the symptoms
will include:
(a) Restless;
(b) Muscle tension;
(c) Nervousness; and
(d) Apprehension.
In addition, your patient will get tired and even exhausted easily and will
experience difficulties in sleeping.
3.3.2 Obsessive Compulsive Disorder (OCD)

What is OCD?
Obsessive compulsive disorder (OCD) is persistent and intrusive negative

automatic thoughts (may also be images or impulses) that cause considerable
anxiety.
These individuals tend to have an exaggerated sense of responsibility and would

want to be 100 per cent sure that he/she will not be the cause of something terrible
happening.
Among others, an OCD person will check or clean a particular place over and over
again. Compulsive (repetitive) behaviours and mental acts are usually attempts at
reducing anxiety, though they are usually ineffective. For example, excessive or
ritualised hand washing (see Figure 3.3), showering, tooth-brushing or grooming.

Figure 3.3: Excessive or ritualised hand washing is a symptom of OCD
3.3.3 Phobias
What is a phobia?
A phobia is an irrational and extreme fear of specific social situations or

objects, resulting in severe distress and disruption of normal functioning.
In the main, most people with phobias manage to avoid the feared situation or
object without too much difficulties and continue to function pretty much
normally.
However, some may develop „anticipatory anxiety‰ – that is even the thought of
going out and encountering the feared situation or object will generate
considerable anxiety. So you see, even if they avoid the situation or object, they are
not free from the anxiety. Phobias generally get grouped in three types (see
Table 3.1).

Table 3.1: Three Types of Phobia
Type Description
Agoraphobia It is essentially fear of open spaces or of being in crowded, public

places like markets, as such they will avoid these places. Your patient
will usually be fearful of having a „panic attack‰ in public places and
will, where possible, avoid situations or places from which escape may
not be easy. In time, some will begin to fear leaving a safe place like
home.
Specific phobia It is an irrational fear of a specific situation or object. For examples,

fear of heights, getting into lifts and flying in an aeroplane (specific
situations) or needles, knives, spiders, cats, dogs and germs (objects).
Social phobia It is essentially worrying about what others think of us; the fear of
being evaluated negatively in social situations. For examples, making
a presentation, attending a meeting at work and introducing oneself
to the class. To people suffering from social phobia, any social contact
can become a problem and therefore avoided.
3.3.4 Panic Disorder

As stated in Table 3.1, patients with agoraphobia sometimes also complain of
„panic attack‰. How does it relate to panic disorder?
Panic disorder is characterised by a sudden overwhelming anxiety attack,

comes on quickly and lasts for about 30 minutes.
The patient often thinks he or she is going to die because of chest pain or
discomfort. Physiological symptoms will include some of the following:
(a) Palpitation;
(b) Sweating;
(c) Tremor;
(d) Nausea;
(e) Difficulty in breathing;
(f) Cold or hot flushes; and
(g) Stomach upset.

The patient will associate the attack with the place where it occurred and will be
very afraid that it will occur again, leading to avoidance of the place, for example,
supermarkets, hospital, beach, river or forest. Hence, the development of
agoraphobia like symptom will occur.
3.3.5 Post-Traumatic Stress Disorder (PTSD)

Now, let us move on to PTSD.
Post-traumatic stress disorder (PTSD) is a condition that is characterised by

the re-living or re-experiencing of a traumatic experience.
For examples, soldiers, policeman, paramedics and fire fighters are trained to cope
with very difficult situations. Even for them, there will be circumstances so
extreme that they may be affected by their experience. Likewise, survivors of
physical assault, rape, serious accidents, major natural disasters and so on can be
traumatised by their experience.
How do we diagnose PTSD? To be diagnosed as having PTSD, the symptoms must

be present for more than a month and the disturbance sufficiently distressing to
interfere with oneÊs everyday functioning. So what are the symptoms? The
symptoms include:
(a) Persistent re-experiencing of the event;
(b) Intrusive images of horror;
(c) Intense fear;
(d) Helplessness;
(e) Nightmares; and
(f) Persistent increased autonomic arousal.
You are also likely to find patients talking about their guilt feeling for having
survived whilst others did not. As you now know with anxiety avoidance,
behaviour can be unhelpful and may affect interpersonal relationships leading to
marriage break-up, loss of job, isolation and so on.

SELF-CHECK 3.3
What are the examples of anxiety-related disorders? Give definition
for each of them.
ACTIVITY 3.2
Discuss personal experience of „being anxious‰ in the myINSPIRE
forum. In your discussion:
(a) Identify the physiological, behavioural and cognitive features of
your responses.
(b) Work out whether each of the experience described was either a
case of „being concerned‰ or actually an anxiety.
3.4 CARE AND TREATMENT OF PEOPLE

SUFFERING FROM ANXIETY DISORDERS
Did you know that the vast majority of people suffering with anxiety will respond
well to treatment? All treatment and care must be tailored to meeting individual
need after a careful and thorough assessment.
In this subtopic, we will consider a range of interventions in general term without

specifying the anxiety disorder. We have discussed in earlier unit the importance
of your relationship with your patient. People suffering from anxiety or anxiety-
related disorders will generally want help and will collaborate well with the nurse,
so encourage them to participate in the assessment and planning of their care; as
you build a good rapport with your patient (Videbeck, 2008). The following are
some guidelines for you to follow:
(a) For the anxious patient, the presence of a supportive and understanding
nurse can have a reassuring and calming effect;
(b) Anxious patients cannot process complex information, so keep your
language and the message simple and calm; and
(c) Anxious patients are likely to misinterpret cues; it will be helpful to keep the
environmental stimuli minimal.

Some individuals would want to be allowed some space whilst others would seek
constant reassurance and would want to be close to the nurse. The patientÊs
constant need for reassurance can become a problem for the nurse, if not handled
properly. There are cases where nurses avoid the patient and display uncaring
attitude.
Be mindful that giving reassurance only fuels the patientÊs insecurities, leading to
greater need for reassurance. It is easier said that teaching patients to tolerate the
uncertainty (not knowing) together with relaxation training, will be much better
use of the nurseÊs time. Most importantly, here are what anxious patients do not
want to hear from you:
(a) „Have you tried relaxation?‰;
(b) „You have nothing to worry about‰;
(c) „ItÊs all in the mind‰;
(d) „DonÊt be dramatic‰; or
(e) „You are such a drama queen‰.
3.4.1 Interventions Used in Anxiety Disorders

All behavioural interventions usually begin with the patient learning what anxiety
is, and to become aware how he or she responds physically, behaviourally and
cognitively when experiencing anxiety. So let us set the goals and work out the
strategies to achieve those goals.
You now know anxious patients will avoid the feared object or situation. In fact, it
is their avoidance behaviour that will ensure they never learn that their anxiety
will come down in due course. In their mind, their anxiety will increase
exponentially and that they must do something to neutralise it. Let us look at the
anxiety graph in Figure 3.4 in order to figure out the strategy to overcome anxiety
disorder.

Figure 3.4: Anxiety graph
In the anxiety graph, it shows that anxiety can increase quickly in a short time. „X‰
marks the point where the patient engages in avoidance or other ritualised
behaviours to stop the escalating anxiety. In his or her mind, without engaging in
avoidance behaviour the anxiety will continue to escalate as depicted by the dotted
lines. In reality, the anxiety would have come down on its own (as shown in the
graph). The behaviour to neutralise the emotion can take many form, avoiding or
getting oneself out of the situation will be common. Taking medicine, consuming
alcohol, tobacco, recreational drugs etc. may also be used to neutralise the emotion.
The behaviour is repeated because of the relief the person experiences from anxiety
as a consequence. Hence, the behaviour is a type of negative reinforcement.

The following are well established behavioural interventions (see Table 3.2).
Table 3.2: Well Established Behavioural Interventions in Anxiety Disorder
Intervention Description
Exposure In exposure work for anxiety disorder, the patient is helped to confront
therapy his or her fears in a safe, controlled environment. It would be useful for
the patient to master a relaxation technique before undertaking
exposure work. There are two options in exposure therapy:
(a) Systematic Desensitisation

Gradual and repeated exposures (from least to most anxiety-
provoking) either through imagination or in reality, to the feared
object or situation. Only when the patient demonstrates success at
one stage (i.e. manages to relax and remain calm) can the patient
move on to the next stage. The final stage is where the patient
actually handles the feared object or remains in the formerly
feared situation without experiencing anxiety.
(b) Flooding (or Implosion)

This is a quicker process, but need to be handled by an
experienced therapist following careful preparation of the patient.
This technique involves maximum exposure of the patient to the
source of the anxiety, initially through imagination and
subsequently in reality. The idea was to increase the anxiety to a
high level. Because the patient was not able to avoid the feared
object or situation, he or she learns that there was no actual harm
– in time, the object or situation stops producing anxiety in the
patient.
Cognitive- This approach combines both the proven behavioural techniques and
behaviour cognitive strategies that focus on unhelpful thoughts. This helps the
therapy patient identify and challenge the negative thought patterns and
irrational beliefs that are associated with the patientsÊ anxiety.
Relaxation Patients are usually taught relaxation techniques to be used in

techniques conjunction with behavioural interventions. The concept of „reciprocal
inhibition‰ is important; that is one cannot be both relaxed and anxious
at the same time.
(a) Progressive Muscle Relaxation

For the anxious person, progressive muscle relaxation helps
release muscle tension and gives a break from the worrying. The
technique involves progressive tensing and then releasing
different muscle groups in the body.

(b) Deep Breathing Exercises

Anxious people tend to breath fast and shallow. This may lead to
some dizziness, breathlessness and light-headedness which may
further fuel the personÊs anxiety and sense of panic. Deep
breathing will help minimise the symptoms and reduce anxiety.
(c) Biofeedback
Patients learn to manage their anxiety faster when there is
biofeedback that they can respond to. Sensors that measure
galvanic skin response, heart rate, breathing and muscle tension
can help the patient to learn how to control the bodyÊs response
to anxiety using relaxation techniques.
Exercise It is difficult not to emphasise this; exercise is the best stress buster there
is! Regular exercise – minimum 30 minutes, three to five times a week
can make a huge difference to oneÊs sense of wellbeing.
Assertiveness Many anxious people worry because they have a need for approval
training from others and to know what others think of them. Hence, they become
very concerned about upsetting others and become unable to
reasonably and appropriately assert themselves in relationships.
Assertiveness training helps to minimise anxiety by developing the
patients understanding of his or her rights, self-acceptance and
confidence in relating with others.
Drug A large number of drugs are available to treat anxiety disorders and
treatment they are quite freely prescribed in general practice. It is important for
the nurse to make sure the patient knows how the drug should be used
and understands its unwanted effects. These drugs do reduce the
physiological response, providing good relief for the patient from
anxiety but unlike human beings, drugs cannot teach the patient
anything. The nursing team can help through psycho-education, in
making sure the patient is aware of the range of options available in
managing anxiety-related problems.
The following are some common drugs used to treat anxiety-related
disorders:
(a) Diazepam (Valium): Anxiety and panic disorder.
(b) Fluoxetine (Prozac): Anxiety, obsessive compulsive disorder
(OCD) and panic disorder.
(c) Alprazolam (Xanax): Anxiety, agoraphobia, panic disorder, OCD
and social phobia.
(d) Clomipramine (Anafranil): OCD.
(e) Imipramine (Tofranil): Anxiety, agoraphobia, panic disorder.

ACTIVITY 3.3
1. Develop a psycho-education plan for a patient (and his family)
recovering from anxiety. Share your plan for discussion in the
myINSPIRE forum.
2. Discuss in the myINSPIRE forum how a nursing team can help

patients who have been taking benzodiazepine (anti-anxiety
drugs) over a long period.
• Emotion is the dynamic relationship between our thoughts (cognition), actions

(behaviour) and feelings (emotion).
• Anxiety (and all other emotions) is a response to something we focus upon,

that is noted and interpreted. In the case of anxiety, it is where one perceives a
threat to oneself.
• Arousal is related to such negative thoughts (related to the need for approval
and so on) that are perhaps more common than arousal related to an actual
physical threat.
• In any emotional response, the physical components of the response would

comprise the behavioural, autonomic and hormonal systems.
• Anxiety is essentially an unhelpful (unhealthy) emotional response to adverse

life situations where we perceive a threat of some sort – actual or imagined.
Given the negative situation it would be helpful (or healthy) to feel concerned
or even profoundly concerned, which will be motivating – but the same cannot
be said for anxiety.
• There are many physiological symptoms of anxiety such as muscle tension,

restlessness, headaches, dry mouth, diaphoresis (excessive sweating),
trembling, pale, tachycardia, chest pain, nausea, vomiting and diarrhoea, and
others.
• One of the cognitive symptoms of anxiety is the patient usually anticipates and
complains of impending doom/dread but feels powerless to affect it.

• The main behavioural symptom will be avoidance or withdrawal from the

feared situation or object and the „action tendency‰ will be to curl-up, make
one-self small and hide.
• There are many specific disorders which are clearly fuelled by anxiety or
anxiety is the predominant feature. Five examples of anxiety-related disorders
are generalised anxiety disorder, obsessive compulsive disorder (OCD),
phobias, panic disorder and post-traumatic stress disorder (PTSD).
• Your patientÊs treatment and recovery often starts with an awareness of his or
her physiological, behavioural and cognitive response when anxious. Psycho-
education on how to handle everyday challenges without disturbing ourselves
is important too.
• Among the behavioural interventions that we can use are exposure therapy,
cognitive-behaviour therapy, relaxation techniques and drug treatment.
Anxiety Exercise
Arousal Exposure therapy
Assertiveness training Generalised anxiety disorder
Behaviour Obsessive compulsive disorder (OCD)
Cognition Panic disorder
Cognitive-behaviour therapy Phobias
Drug treatment Post-traumatic stress disorder (PTSD)
Emotion Relaxation techniques

Carlson, N. R. (2007). Physiology of behavior (9th ed.). Boston, MA: Pearson.
Halgin, R. P., & Whitbourne, S. K. (2008). Abnormal psychology: Clinical

perspectives on psychological disorders (5th ed.). New York, NY: McGraw-
Hill.
Videbeck, S. L. (2008). Psychiatric-mental health nursing (4th ed.). Philadelphia,

PA: Lippincott Williams & Wilkins.

Topic  Nursing
Practice for
4 Mood
Disorders:
Depression
and Bipolar
Disorder
LEARNING OUTCOMES
1. State the difference between healthy and unhealthy negative
emotion;
2. Identify the categories of mood disorder;
3. Describe the psychosocial assessment and interventions as well as
treatment for major depression; and
4. Discuss the treatment and nursing interventions for bipolar
disorder.

86  TOPIC 4 NURSING PRACTICE FOR MOOD DISORDERS:
DEPRESSION AND BIPOLAR DISORDER
 INTRODUCTION
In Topic 3, you have learned that anxiety is an unhealthy emotional response to
actual or imagined adverse situation, with its characteristic cognitive and
behavioural symptoms. Now in this topic, you will have the opportunity to
explore what being depressed is like, its characteristics, treatment and outcome.
Did you know that depression is the most common mental health problem
presented by patients in the wards? You will see a wide range of social problems
associated with people with depression. These individuals will have no problems
in interacting with you; unless the individual is so severely depressed, his/her
symptoms may get in the way. The more severe the depression, the harder you
may have to work to engage with him or her, because the individual will often be
withdrawn and agitated, sometimes with psychomotor retardation, lacking in
energy and interest. The problem of depression is so common; it is sometimes
referred to as the „common cold of psychological disorders.‰
You will come across mental health nursing textbooks with chapters entitled
„mood disorders‰, „affective disorders‰ or „emotional disorders‰ – they all
essentially mean the same. Remember, our interest is in the person with
depression. So, what is depression?
Depression is an emotional response to adverse situations, which can be either

actual or inferred, in the present, past or future. The inference is about loss.
As we discussed in earlier topics, all emotions will have its characteristic cognition
and behaviour symptoms that will be associated with it. You will in time learn to
recognise what thoughts and behaviours will normally go with a given emotion.
In this topic, we will consider the thoughts and behaviours that go with the
unhealthy negative emotion which is depression.
The word „depressed‰ or „depressing‰ is sometimes used in everyday

conversation without implying a clinically significant condition. For our purpose,
it is important we use the word „depressed‰ to mean clinically depressed or to
mean unhealthy negative emotion.

TOPIC 4 NURSING PRACTICE FOR MOOD DISORDERS:  87
On the other hand, the use of the word „sad‰ or „sadness‰ is preferable for healthy
negative emotion, as opposed to depression or feeling depressed. Hence, if a
person faced a negative or adverse situation, such as failing an exam, death of a
loved one, falling severely ill and others, it will be normal and healthy for him to
feel negative emotion such as sadness or even profound sadness. However, it
would be unhealthy and abnormal if one becomes depressed about the adverse
situation.
In other words, it is okay to feel sad but not depressed! Hopefully by now, you can
get a clear picture that it is not normal or natural to experience „depression‰ – an
unhealthy negative emotion.
SELF-CHECK 4.1
State the difference between the two emotions − sadness and
depression.
4.1 TRADITIONAL PSYCHIATRIC APPROACH

TO MOOD DISORDERS
It is a common practice in Malaysia for psychiatrists to refer to DSM 5 (Diagnostic
and Statistical Manual of Mental Disorders, 5th edition by the American
Psychiatric Association). This is the guideline that discusses on „psychiatric
conditions‰. An outline of their current categories of affective disorders is given in
the next subtopics. Based on these categories, we will explore major depressive
disorder and bipolar disorder together with the respective treatment and nursing
care.
4.1.1 Categories of Mood Disorders

Generally, mood disorders are grouped into two distinct categories namely
„depressive disorders‰ and „bipolar disorders‰ (see Figure 4.1).

Figure 4.1: Categories of mood disorders
These categories are further explained in Table 4.1.
Table 4.1: Categories of Mood Disorders
Type Description
Major depressive This is what psychiatrist call clinical depression or simply

disorder major depression. It involves a very low mood, lack of energy
and motivation, and feelings of hopelessness that last for more
than two weeks. This will be further explained in Subtopic 4.2.
Seasonal affective Apparently some peopleÊs depression is associated with the

disorder (SAD) short days in winter and the fact that they do not get to see
much of the sun. Thankfully, in our country you will not see
anyone diagnosed with seasonal affective disorder as we have
do not have four seasons but a mostly nice sunny weather all
year long!
Bipolar I disorder People who suffer from mania that is euphoria and/ or
irritability together with increased energy or activity. This is
basically what was known in the past as manic depression.
Bipolar II disorder This is characterised by having a major depressive disorder

either currently or in the past; and there must have been at
least one episode of hypomania but no experience or history of
mania. These two concepts (hypomania and manic episodes)
will be explained in Subtopic 4.3.

Cyclothymic disorders A much milder version of bipolar disorder with more than a
two-year history of episodes of symptoms that do not qualify
for hypomania and major depression.
Others In this category, depression or bipolar disorder are lumped by

an assortment of causes, such as medical condition,
medication, alcohol and/or substance use and so on.
There are also additional mood disorders in DSM 5. The three new depressive
disorders are explained in Table 4.2.
Table 4.2: Three New Depressive Disorders
New Depressive
Description
Disorder
Disruptive mood This applies to children and young people up to the age of 18
dysregulation disorder who display frequent episodes persistent and extreme
irritability and behavioural problems resulting from lack of
self-control – low threshold for violent and anti-social
behaviours.
Persistent depressive This new label covers chronic major depressive disorder that
disorder has lasted more than two years and a mild form of depression
that was known as dysthymic disorder.
Premenstrual dysphoric This diagnosis is confined to the presence of symptoms in the

disorder week prior to commencement of menstruation and the
symptoms ease or stop upon commencement. The symptoms
must have been experienced during most of the menstrual
cycles of the past year and the symptoms must have been
severe enough to disrupt work or social functioning. The
symptoms must include one or more of the following:
(a) Irritability or anger;
(b) Mood swings;
(c) Depressed mood or hopelessness; and
(d) Anxiety or tension.

As well as one or more of the following additional seven

symptoms, making a total of at least five symptoms:
(a) Lack of interest in daily activities and relationships;
(b) Trouble thinking or focusing;
(c) Tiredness or having low energy;
(d) Food cravings or binge eating;
(e) Trouble sleeping;
(f) Feeling out of control; and
Physical symptoms consist of cramps, bloating, breast

tenderness, headaches and joint or muscle pain.
Let us learn more on cyclothymic disorder and dysthymic disorder.
(a) Cyclothymic Disorder

This is a chronic condition, it can last for more than two years, in which the
individualÊs mood fluctuates in a recurrent and dramatic manner. It is similar
to bipolar disorder but never as intense. In other words, when they feel high
or hypomanic, it is never severe enough to be diagnosed as mania. When
they feel down, it is never severe enough to be a depressive episode.
Nevertheless, the condition can be distressing and sufficiently disruptive of

the patientÊs life. Though some individuals welcome the periods of high
energy and creativity, but because of the mood disorder, their work and
relationships can suffer as others may come to regard them as moody,
unpredictable and unreliable. They also have a high risk of a full-blown
bipolar illness.
(b) Dysthymic Disorder

This diagnosis in DSM 5 is subsumed under persistent depressive disorder
(see Table 4.2). Take note that we are only considering dysthymic disorder as
what it is used to mean. Some individuals suffer from a milder form of
depression, not as deep or intense but enough to make oneÊs life miserable.
To be diagnosed as dysthymic disorder, the person would have been

suffering similar symptoms as a major depression, such as sleeping
difficulties, poor appetite, tiredness (fatigue), problems concentrating,
difficulties in making decision and feelings of hopelessness.
Though the symptoms are not as many or as severe as a major depression,

the patientÊs quality of life will suffer, particularly so when he or she feel

inadequate and unable to experience pleasure in everyday activities. This

could last for a period of at least two years or more.
It is the chronic nature of this condition which distinguishes it from major

depression. Some of these patients will try, unwisely though
understandably, to get rid of their depressive and hopeless feelings by
consuming alcohol or taking drugs. Usually, these individuals would not
need to be admitted, unless they become severely depressed or suicidal.
As nurses, we do not need to be too concerned with the finer details of diagnosis.
You will know when the patient is depressed, but it will be useful for you to be
aware of the major presentations and symptoms as it will help with your
communication within the team.
SELF-CHECK 4.2
Explain the different categories of mood disorder.
4.2 DIAGNOSIS OF MAJOR DEPRESSION

For someone to be diagnosed as suffering from major depressive disorder, the
person must be depressed for at least two weeks and during this period,
experiences a loss of pleasure in almost all activities (anhedonia). Other additional
symptoms must include at least four of the following:
(a) Changes in appetite or weight;
(b) Changes in sleep pattern;
(c) Psychomotor activity;
(d) Decreased energy;
(e) Feeling of worthlessness or guilt;
(f) Difficulty in thinking, concentrating or making decisions; and
(g) Persistent thoughts about committing suicide, or even planning or
attempting suicide.
For diagnostic purposes, it is expected that these symptoms will be present every
day for two weeks and cause the patient sufficient distress to affect his/her work,
social and other important areas of functioning.

It is important to bear in mind that people are unique and a wide range of
symptoms may be present. Most are likely to complain about a limited range of
symptoms and will be preoccupied with their everyday social realities. As a
consequence, the patient may develop negative view of self, self-blame, feelings of
guilt and extreme dejection and loss of interest in normally pleasurable activities.
It is also worth noting that when a patient is severely depressed it is likely, though
not common, for psychotic symptom such as delusions, hallucination,
disorientation and derealisation to be present.
SELF-CHECK 4.3
What are the symptoms of major depression?
ACTIVITY 4.1
There are many explanations as to the cause of depression. Find out
three of them and then discuss your answer in the myINSPIRE forum.
4.2.1 Psychosocial Nursing Assessment and

Interventions
It is important the nurse responds to the patientÊs immediate concerns and
develops a working relationship with the patient. We dealt with assessment and
relating with patients in some detail in the previous topic; thus, this subtopic will
not cover nurse-patient relationship and assessment, but simply to remind you of
their importance. The nursesÊ assessment will include the following areas:
(a) History;
(b) General appearance and motor behaviour;
(c) Mood and affect;
(d) Speech, thought process and content;
(e) Sensory and intellectual process;
(f) Judgement and insight;
(g) Self-concept;

(h) Roles and relationships; and

(i) Physiologic and self-care concerns.
In addition to the psychosocial assessment, tools such Beck Depression Inventory

and Zung Self-Rating Depression Scale may be routinely used in some teams. It is
likely that some of the areas of concern identified from the nursesÊ assessment will
include the following:
(a) Risk of self-harm and/or suicide;
(b) Self-neglect involve inadequate nutritional intake, poor personal hygiene
and so on;
(c) Hopelessness;
(d) Negative self-regard and lacking in self-acceptance;
(e) Fatigue;
(f) Difficulty sleeping;
(g) Agitation;
(h) Financial and relationship problems; and
(i) Guilt, anxiety and so on.
Take note that it will not be possible to address all of the patientsÊ problems at the
same time. In the interest of working in a client-centred manner, it is important to
negotiate which problems the patient perceives to be his or her priority, clarify the
problems and agree clear goals for each of the problem.
Unless of course the patient was highly suicidal or likely to harm self or others,
under those circumstance the nurseÊs priority will be imposed, whilst still
responding to the patients other immediate need.

The following are some interventions that you can do:
(a) Therapeutic Use of Self

Through her interaction with the patient and others, the nurse models
appropriate interpersonal relationship skills; teaches patient to value self and
conveys unconditional acceptance of the patient. You can do this by your
presence, spending the time and be with the person will be reassuring and
conveys your valuing of the person.
(b) Patient Safety

The nurse will ensure a safe environment for the patient, both physically
(self-harm or exploitation by others) and psychologically (freedom to express
her views and emotion without being censured or judged).
According to Sudak (2005), when people are depressed, the risk of suicide is
a high. Any talk of suicide, threats of self-harm or behaviours that are
secretive (such as hoarding of tablets, hiding a razor blade and so on) must
be taken seriously and communicated to the team.
Often you are likely to become aware of these behaviours first. Also bear in
mind, some patients become more actively suicidal when they are recovering
(they now have more energy to act, but the suicidal thoughts are still there,
the thoughts take much longer to dissipate); and the risk of suicide is also
high in the first six weeks following discharge (Rihmer, 2007).
(c) Self-care Need

The nurse will focus on identified self-care deficits and assess the level of
intervention and support needed to ensure that the patientsÊ basic self-care
needs are met. A depressed patient with pronounced psychomotor
retardation will experience routine self-care activity or a simple request as
overwhelming, such as „Would you like to have a shower and a change of
clothes?‰ Prompt and encourage the patient to do as much as possible, so be
patient and persevere; try not to rush to do things for the patient.
(d) Let Them Talk

It is also likely that your patient may prefer to talk instead, encourage it.
Talking and sharing of problems help lighten the load. Use your judgement;
your patient may be perfectly comfortable talking about personal problems
whilst doing things together with you.
On other issues, you may decide it is better handled on a „one-to-one‰ basis

with some privacy and uninterrupted time. In supporting your patient to
talk, you would have done a good job in leading your patient to the road of

recovery. This interaction can bring them hope, and people who are
depressed will, given time, eventually return to their normal level of
functioning.
SELF-CHECK 4.4
What patient behaviour(s) would indicate a risk of suicide?
4.2.2 Treatment of Depression

There are numerous treatment options available for people suffering from
depression. In most developed countries, they use psychopharmacology (drug
treatment) as the main treatment option.
However (unlike other countries), the broader psychosocial options are not as
readily available for patients in this country, even though it has long been
recognised that the combination of drug and psychosocial interventions produce
better outcomes for patients (Rush, 2005). The discussion of treatment in this
subtopic will cover what you are likely to see in the wards. This can make you
wonder why psychosocial interventions are not well developed in this country.
(a) Psychopharmacology
The following are the four major categories of antidepressants you will see
on the ward. It will be helpful for you to familiarise yourself with the
commonly used antidepressants and the categories they belong to and their
side effects (see Table 4.3).
Table 4.3: Four Major Categories of Antidepressants
Category Example
Tricyclic antidepressants Amitriptyline, imipramine and doxepin.
Monoamine oxidase Phenelzine and tranylcypromine.

inhibitor (MAOI)
Selective serotonin Fluoxetine, sertraline and paroxetine.

reuptake inhibitor (SSRI)
Atypical antidepressants Venlafaxine, bupropion and nefazodone.
You will learn more on this in Topic 9 (Subtopic 9.2).

(b) Electroconvulsive Therapy (ECT)

Psychiatrists still use ECT for depressed patients who they think are not
responding well to antidepressant drugs. Mostly, this is used as a last resort.
ECT remains controversial but has support from relatively small group of
psychiatrists working in in-patient areas.
What is ECT? ECT is basically the application of modified electrical

stimulation to the brain via electrodes placed on both sides of the forehead.
Short acting anaesthetic is used to render the patient unconscious during the
treatment and a muscle relaxant is used to keep the convulsion to a
minimum.
The nurseÊs roles in the preparation and post-ECT recovery and care are
important. The preparation is much like your outpatient minor surgical
procedure involving both psychological and physical preparation. Your
patient must be clear as to what to expect before, during and after the
procedure. The nurse will check for the patientÊs understanding and
offer the appropriate support. You will learn more on ECT in Topic 8
(Subtopic 8.7).
(c) One-to-One Session

The nurse may arrange to give fixed time for the patient to talk and explore
personal issues. We have discussed the therapeutic aspects and value of the
nurseÊs relationship with patients. This session gives the nurse an
opportunity to check the patientÊs experience on the ward and to monitor
progress.
(i) Experienced nurses could also undertake psycho-education and
relapse-prevention work. Often it is a simple matter of opportunity to
reflect on what they have learnt or even discovered about themselves.
(ii) The nurse should be aware of what they were distressing themselves
about and how they responded – including their thoughts and feelings,
how realistic were their thoughts and how it affected their emotion.
Upon reflection, what thoughts would have been more helpful in their
situation.
(iii) The principle here being we take responsibility for the way we feel
(emotional responsibility). Our emotion has to do more with the way
we think. It is not the events, it is the way we perceive it that disturbs
us!

(iv) One other important benefit of psycho-education for recovering

patients is that they learn not to see themselves as somehow „faulty‰
or something „pathological‰ about them, a „psychiatric case‰ – it stops
them asking questions like „Am I psychotic?‰
(v) You want your patients to go home thinking „I accept myself as a
fallible human being, both the good and the not so good within me. I
know my problem situation is likely to occur again and I am better
prepared to deal with it without disturbing myself. If I screw things up
again, I accept I am not perfect and I do not have to beat myself up
about not doing it right.‰
(vi) The person who is being discharged, hopefully has learnt to recognise
early signs of relapse and knows how to get timely help.
(c) The Ward Environment (Milieu Therapy)

The ward should ideally be well-organised and structured with activities for
patients with clear expectations that patients will participate and in time take
some responsibilities for the activities. This will be a major contribution
towards the patientÊs social rehabilitation. You will learn more on this in
Topic 8 (Subtopic 8.5).
(d) Occupational Therapy

Interacting and doing things with people outside the ward environment
(even in the ward) can be very helpful in focusing the patientÊs thoughts on
things other than his/her personal problems. Activities such as art and crafts,
cooking, playing games, playing music and so on will give valuable
information about the patients mental and emotional state, and level of social
and problem-solving skills.
(e) Other Interventions

Interventions such as group therapy, family therapy, individual
psychotherapy (humanistic, cognitive behavioural and psychodynamic) can
help patients overcome long-standing unresolved issues and improve
patientÊs quality of life.

ACTIVITY 4.2
1. What would you do to encourage a depressed patient (with
poor appetite) to eat?
2. List three features of depression for cognitive, affective and

behavioural domain.
Discuss your answers in the myINSPIRE forum.
4.3 BIPOLAR DISORDER

Now, let us look at bipolar disorder. The diagnosis of bipolar disorder is not as
common as depression, though it has been getting quite a lot of publicity over the
last decade. Some individuals who become depressed will also experience
emotions at the other end of the spectrum, that is they will feel elated or manic
(hence the term bipolar which means two poles). In the old diagnostic system, it is
used to be called „manic-depressive disorder‰ or commonly „manic depression‰.
Now, this extreme mood swing is diagnosed as „bipolar disorder‰.
Of course, when you are working with the person you are likely to see one or the
other phase, most likely in his or her depressed phase. As a matter of fact, one does
not have to experience a depressive episode to be diagnosed as having bipolar
disorder. During the manic phase, the patient is likely to be elated, outgoing,
energetic, sleepless and grandiose. Because of the high level of energy, the patientsÊ
thought and speech will be rapid, jumping from one idea to another (also known
as „flight of ideas‰) or activity to activity, very distractible and usually display
poor judgement. If you were to ask the patient how he/she felt, the response will
most likely be „on top of the world‰.
Meanwhile, during the depressed phase, the patientÊs mood, thought and
behaviour are the same as in major depression. Whilst a major depressive episode
develops slowly and will subside gradually, a manic episode can appear rapidly
and end just as suddenly. Symptoms can appear in a matter of days and last from
a few weeks to even a few months.

To be considered a „manic episode‰, the patient must experience a period of

abnormally and persistently elevated, expansive or irritable mood lasting at least
one week. During this period, three of the following must be present; four if the
mood was only irritable:
(a) Inflated self-esteem or grandiosity;
(b) Decreased need for sleep;
(c) Increased talkativeness;
(d) Flight of ideas or racing thoughts;
(e) Distractibility;
(f) Increase in goal-directed activity or psychomotor agitation; and
(g) Excessive involvement in pleasurable activities with potentially
painful consequences.
The symptoms are severe enough to cause significant distress or impairment or

necessitate hospitalisation to prevent harm to self or others. Thus, it is important
to conclude that the symptoms are not a result of a medical condition or substance
use.
There is a related condition called „hypomanic episode‰. In hypomania, there are

no psychotic features, and the episode is not severe enough to cause much
disruption to the patientÊs life or the need for hospitalisation. To be diagnosed
hypomania, the patient must experience a period of persistently elevated,
expansive or irritable mood lasting at least four days, which should be different
from the patientÊs normal mood and is observable by others. During this period,
three or more of the symptoms listed for mania as mentioned earlier must be
present; four if the mood was only irritable. And of course, the symptoms are not
attributable to a medical condition or the effects of substance abuse. To put simply,
hypomania is a mild version of mania.
Just as a matter of interest, the DSM 5 recognises a variation in the manifestation

of the bipolar disorder. When an individual experiences one or more manic
episodes and one or more depressive episodes (though this is not necessary) – this
clinical course is diagnosed as „bipolar I disorder‰.
In contrast, when an individual has one or more major depressive episodes and at
least one hypomanic episode will be considered „bipolar II disorder‰. Hence, it is
not necessary for one to have to experience mania to be diagnosed as bipolar.

SELF-CHECK 4.5
What is meant by „hypomanic episode‰? List four clinical features
of it.
4.3.1 Treatment of Bipolar Disorder

Medical treatment of bipolar disorder mainly involves the use of lithium carbonate
as a mood stabiliser – preventing the highs and lows that is one of the symptoms
of bipolar disorder and specifically in treating the acute manic episodes.
For the small group of patients who cannot tolerate lithium, a number of
anticonvulsants drugs may be used as mood stabilisers such as carbamazapine
(Tegretol) and valproic acid (Depakote). Antidepressant drugs will also be used
during the severe depressive phase and antipsychotic drugs to treat the psychotic
symptoms.
4.3.2 Nursing Interventions

Nursing interventions will largely be dependent on the individual and the severity
of the illness. When patients are in a depressed phase, the care will be similar to
major depression.
Nevertheless, caring for the patient during a manic episode can be challenging.
When a patient is elated and is full of ideas about „how he is going to change the
world‰, he is hardly going to be interested in you completing his assessment.
Of course, at the height of his mania, it will not be easy. The nurse may need to
resort to breaking the assessment up into several short sessions and refer to family
and friends to gather further information. Providing for safety and adequate
nutritional intake will be a major concern for nurses.
Some of the common problems from the assessment are likely to reflect the patients
impaired judgement and insight, and will include the following:
(a) Nutritional status – Patient will go without food and drink for days but will
not feel hungry or tired;
(b) Over familiarity, disrupts and interferes with other patients;
(c) „Flight of ideas‰ and pressure of speech, can lead to compliance problem;
(d) Difficulties sleeping;

(e) Unable to recognise and meet self-care need;

(f) Risk of violence – Largely due to frustration. Any restriction imposed will be
an irritant to the patient; and
(g) Disinhibited behaviour, inappropriate questions, comments and sexual
behaviour.
This is a brief account of some likely nursing care challenges presented by patients
during a manic episode. It is not uncommon for elated patients to become
delusional, especially delusion of grandeur, such as „I am super rich‰ and „on
special mission for God.‰ The delusion of persecution is also likely – as in powerful
forces are working to harm him.
From a nursing care point of view, we just accept the way the patient is in the
moment, without reinforcing the delusional beliefs. As long as it is just thoughts
and ideas, we do not need to confront or challenge it, as it would be a pointless
exercise anyway!
You will notice in a matter of a few days, the delusions will change or even
completely disappear. Refer back to our discussions on how our emotions affect
our thoughts, high levels of elation (as with other emotions, such as anxiety and
anger) will have the effect of distorting our thinking. As the elation is lowered, the
thoughts will become more realistic.
• The use of the word „sad‰ or „sadness‰ is preferable for healthy negative
emotion; while depression or feeling depressed is an unhealthy negative
emotion.
• It would be unhealthy and abnormal if one were to become depressed about

an adverse situation.
• Generally, mood disorders are grouped into two distinct categories namely
„depressive disorders‰ and „bipolar disorders‰.
• Major depressive disorder and seasonal affective disorder (SAD) fall under
depressive disorders category.
• As for bipolar disorders, it includes bipolar I disorder, bipolar II disorder and

cyclothymic disorders.

• In addition, there are three new depressive disorders namely disruptive mood
dysregulation disorder, persistent depressive disorder and
premenstrual dysphoric disorder.
• For someone to be diagnosed as suffering from major depressive disorder, the

person must be depressed for at least two weeks and during this period,
experiences a loss of pleasure in almost all activities (anhedonia).
• The nursesÊ psychosocial assessment will include history, mood and affect,
self-concept, roles and relationships and others.
• In addition to the psychosocial assessment, tools such Beck Depression

Inventory and Zung Self-Rating Depression Scale may be routinely used by
some teams.
• Among the treatment of depression includes psychopharmacology,

electroconvulsive therapy (ECT), one-to-one session and occupational therapy.
• Some individuals who become depressed will also experience emotions at the
other end of the spectrum, that is they will feel elated or manic (hence, bipolar
– two poles). In the old diagnostic system, it used to be called „manic-
depressive disorder‰ or commonly „manic depression‰. Now, this extreme
mood swing is diagnosed as „bipolar disorder‰.
• The symptoms are severe enough to cause significant distress or impairment

or necessitate hospitalisation to prevent harm to self or others.
• Medical treatment of bipolar disorder mainly involves the use of lithium

carbonate as a mood stabiliser – preventing the highs and lows that are a
feature of bipolar disorder and specifically in treating the acute manic
episodes.
• Nursing interventions will largely be dependent on the individual and the

severity of the illness.

Bipolar disorder Mania

Bipolar I disorder Mood dysregulation disorder
Bipolar II disorder Mood stabiliser
Cyclothymic disorders Nursing interventions
Depression Persistent depressive disorder
Depressive disorders Premenstrual dysphoric disorder
Dysthymic disorders Psychosocial assessment
Hypomania Seasonal affective disorder (SAD)
Major depressive disorder Treatment
Press.
Rihmer, Z. (2007). Suicide risk in mood disorders. Current Opinion in Psychiatry,

20(1), 17−22.
Rush, A. J. (2005). Mood disorders: Treatment of depression. In B. J. Sadock &

V. A. Sadock (Eds.), Comprehensive textbook of psychiatry (Vol. 1, 8th ed.)
(pp. 1652−1661). Philadelphia, PA: Lippincott Williams and Williams.
Sudak, H. S. (2005). Suicide. In B. J. Sadock & V. A. Sadock (Eds.), Comprehensive

textbook of psychiatry (Vol. 1, 8th ed.) (pp. 2442−2453). Philadelphia, PA:
Lippincott Williams and Williams.

Topic  Nursing
Practice for
5 Psychiatric
Disorder:
Schizophrenia
LEARNING OUTCOMES
1. List major features of psychosis;
2. Describe the major characteristics of schizophrenia;
3. Identify the aetiology of schizophrenia;
4. Explain the diagnosis and treatment of schizophrenia; and
5. Discuss the negative symptoms of schizophrenia and the benefits

of psychosocial interventions for patients suffering from
schizophrenia.
 INTRODUCTION
Mental illness has been a popular subject in the movies, especially from
Hollywood. For example, A Beautiful Mind movie (released in 2001) is based on a
true story of John Forbes Nash, Jr. (played by Russel Crow), a mathematical savant
who lived with schizophrenia. Figure 5.1 shows you the poster of the movie.

TOPIC 5 NURSING PRACTICE FOR PSYCHIATRIC DISORDER: SCHIZOPHRENIA  105
Figure 5.1: A Beautiful Mind movie poster
Public fear and prejudice against the people with mental illness is usually conjured
up by mental images of crazy, „psychotic‰ or mad people, unpredictable and
dangerous, but this is not what the film portrays. Have you seen this movie? If not,
you should see this interesting film to understand what is like to live with a person
suffering from schizophrenia.
Meanwhile, let us ponder on something that you are familiar. Have you ever seen
a man on the street muttering and walking at a fast pace? Every so often, he will
stop and talk loudly to someone invisible to you; very animated with hands
waving in the air and finger pointing.
He will stop to stare at a passer-by but will not engage. You may, quite
understandably, quickly cross the road and walk on the opposite side to avoid
him. You may wonder what was the matter – why such strange behaviour?
His behaviour may have been caused by a host of factors such as infections,
electrolyte imbalance, a brain tumour, drug or alcohol abuse and so on. He could
also be suffering from a severe form of mental illness known as schizophrenia.

106  TOPIC 5 NURSING PRACTICE FOR PSYCHIATRIC DISORDER: SCHIZOPHRENIA
What is schizophrenia?
Schizophrenia is an illness that is grouped under „psychosis‰ (Greek

„psyche‰, means mind or soul and „oasis‰ for abnormal condition, in other
words abnormal condition of the mind).
Before we get to know schizophrenia, we need to know psychosis first. One of the
central features of psychosis is the distortion in their perception of reality – that is
the way they see themselves and the external world has becomes altered. The
phrase „loss of contact with reality‰ is often used to describe this experience.
Because of this, their thinking and speaking will appear jumbled and does not
make sense to others. They may also suffer from hallucination and delusions.
These will be explained in a moment.
Take note that psychosis is not schizophrenia. You can have psychosis without
schizophrenia, but to be diagnosed with schizophrenia the person must have
symptoms of psychosis.
Psychosis may also be present in other illnesses such as severe depression and in
mania. Unmistakably this is a very distressing and frightening experience for the
patient. The patient will be anxious and sometimes depressed. It makes it very
difficult for others to understand and their responses may further alienate the
patient.
5.1 SCHIZOPHRENIA
Over the years, schizophrenia has remained a contentious diagnosis. The issues
would not be rehearse here, but to say that there is no „construct validity‰ – there
is still no way of demonstrating that this condition exists: there are no X-ray, scan,
blood test or post-mortem findings to confirm the condition. The diagnosis is made
exclusively on the basis of the observed behaviour. Do read around the history of
schizophrenia – it will hold your attention.
It is generally accepted that about one percent of the population will have this
disorder (APA, 2000). Usually, it is noticed and diagnosed in late adolescence and
early adulthood, with a slight variation in the peak incidence of onset for man and
women. The incidence of onset peaks around the ages of 15 to 25 years for man
and 25 to 35 years for women.

5.1.1 Characteristic Features of Schizophrenia

Schizophrenia is not a simple disorder; it is complex and can take many forms.
Take note that some of these symptoms can appear in other conditions too such as
mania and severe depression. The symptoms are explained as follows:
(a) Hallucinations
Sensory experiences (or false perception) without an external stimuli. In
other words, hallucination is false perception without a stimulus. All the
senses can be affected but the most common being auditory or „hearing
voices‰. Other hallucinations are:
(i) Visual hallucination: Seeing things being the next most common;
(ii) Tactile (the skin misperceives): Sensing something crawling on the skin
without a stimulus; and
(iii) Olfactory (smell and gustatory on taste).
(b) Illusion
Misinterpretation of a stimulus. For example, a piece of rope is mistaken for
a snake as shown in Figure 5.2.
Figure 5.2: A rope or a snake?

Source: https://www.pinterest.nz/pin/525795325218443394/

(c) Delusions
A fixed false belief that is not shared by others and is so deeply held, it cannot
be shaken through reasoning or evidence. They indicate a severe disturbance
in the thinking process particularly the content of thought. Some examples
of delusions are given in Table 5.1.
Table 5.1: Examples of Delusions
Type Example
Delusion of „The CIA has decided to eliminate me, they track me

persecution using satellites.‰
Delusions of grandeur „I can help all of you. I am the chosen one who will save
the planet.‰
Ideas of reference „The newscaster on TV is talking about me.‰
Thought insertion „The thoughts in my head are not mine – they have been
put there.‰
Nihilistic delusion „The food I eat is falling into a vacuum.‰
Thought broadcasting „Other people can hear my evil thoughts; the police will
be around to arrest me anytime.‰
(d) Loose Association

Ideas are fragmented and unrelated but strung together in a sentence. For
example, when asked what he had for lunch, the patient responds, „chicken
and the floor was wet, got to go to town now.‰
The symptoms of schizophrenia are usually thought of as belonging to two major

groupings, namely positive symptoms and negative symptoms. There are many
other concepts that you will come across in the course of our discussion, followed
by appropriate explanations. Let us learn more on these symptoms as follows:
(a) Positive Symptoms

These are exaggerations or distortions of normal thoughts, emotions and
behaviour for example, hallucinations, delusions, disorganised thinking −
affecting speech and behaviour.
(b) Negative Symptoms

On the other hand, these are characterised by behavioural deficits (absence)
or functioning below what is normal. The following are some examples of
negative symptoms (see Table 5.2).

Table 5.2: Some Examples of Negative Symptoms
Negative
Definition
Symptom
Avolition Lack of energy and inability to persist in routine activities.
Alogia (poverty Reduction in the amount or content of speech.

of speech)
Anhedonia Inability to experience pleasure.
Asociality Severe impairment in social relationships.
Flat affect Lack of facial or bodily response that indicate emotion or

mood.
Catatonia A psychological state in which the patient is immobile as

though in trance; can also become excited and agitated.
You will learn more on these negative symptoms in Subtopic 5.1.5.
SELF-CHECK 5.1
1. Define schizophrenia.
2. What are the symptoms of schizophrenia? Give two examples for
each of them.
3. State the difference between positive symptoms and negative
symptoms of schizophrenia.
ACTIVITY 5.1
Form a group of three with your friends or family and take turns to
role play the experience of „hearing voices‰. One will take role of
telling a story, one to listen and the third person, will be „invisible‰.
This third person will whisper into the ears of the listener from
behind, insisting he or she was listened to (the use of an earpiece to
speak through would be ideal).
Share your experience of doing this activity in the myINSPIRE forum

for comparison and discussion.

5.1.2 Aetiology of Schizophrenia

Did you know that there is no one thing that caused schizophrenia? The cause or
causes are yet unknown. Researchers have investigated genetic, physical,
psychological and environmental factors as likely contributing factors in the
development of the disorder. Clearly for some individuals who are susceptible, a
stressor such as an emotional life event can bring about a psychotic episode.
The following are said to be risks that increase the possibility of developing
schizophrenia:
(a) Genetics
It is often said that schizophrenia run in families, and yet no genetic cause
has been established (as an aside, a more plausible explanation for this may
be that some behavioural characterises are transmitted socio-culturally from
one generation to another). It is speculated that several genes combine to
increase the susceptibility of the individual to the condition but not causing
schizophrenia. Twin studies and more recently genome-wide association
studies are often cited to support the role of genetics in the genesis of
schizophrenia.
(b) Brain Development

Proponents of schizophrenia as a disorder of the brain, cite studies that show
people with schizophrenia as having subtle differences in the structure of
their brains as compared with normal people. For example, spaces in the
brain referred to as ventricles were larger. The medial temporal lobes (area
involved in memory) were smaller and reduced the connection between
brain cells. There is always the customary caution that these changes are not
seen in everyone diagnosed with schizophrenia and that it can also be
present in normal people.
(c) Brain Chemicals (Neurotransmitters)

The synthesis of chlorpromazine in 1951, in France, led to the transformation
in the treatment and care of the mentally ill (most of whom were in large
mental institutions). This was mainly due to difficult behaviours like
excitability, agitation, mania and aggression were controlled with the
tranquilising effect of chlorpromazine. Since antipsychotic drugs were
shown to work through their ability to block dopamine and other
neurotransmitter receptors between the brain cells, it encouraged the belief
that the symptoms of schizophrenia were the result of abnormal neural
signalling that involved neurotransmitters such as dopamine and serotonin.
Both the medical and pharmaceutical industries continue to push this theory
and promote numerous drugs designed to boost their profit.

In addition, life events can be psychological triggers in vulnerable people.

Stressful life events are as follows:
(i) Childhood attachment problems (insecure attachment) due to poor
parenting;
(ii) High expressed emotions – Critical and high levels of anxiety in the
family environment;
(iii) Career with mental health/drug problems;
(iv) Loss of a loved one/end of a relationship;
(v) Divorce;
(vi) Abuse – Physical, sexual or emotional; and
(vii) Losing oneÊs job or home.
(d) Recreational Drug Use

We know some young people who use cannabis develop psychotic
experiences. Users who are under 15 years old are said to be four times more
likely to develop schizophrenia by late 20Ês. Amphetamines, cocaine, lysergic
acid diethylamide (LSD) are powerful mind-altering drugs. If abused, it will
cause psychotic symptoms and in susceptible individuals will even bring
about symptoms of schizophrenia.
5.1.3 Diagnosis of Schizophrenia

The DSM 5 has simplified the diagnosis of schizophrenia by removing the
subtypes of schizophrenia. The following is an outline of the criterion to make a
diagnosis of schizophrenia:
(a) It is a requirement that two or more from the following list with at least
one from the first three on the list:
(i) Delusions;
(ii) Hallucinations;
(iii) Disorganised speech;
(iv) Grossly disorganised or catatonic behaviour; and
(v) Negative symptoms, such as diminished emotional expression.

(b) It is also necessary that since the onset of the disturbance important areas
of social functioning have been adversely affected such as work,
interpersonal relations and self-care.
(c) Some of the symptoms must have been present continuously for a period
of at least six months. This must include a period of one month with acute
symptoms that meets the diagnostic criteria, this period can be less than
one month if treated. The six-month period may include residual periods
with only negative symptoms:
(i) No evidence of major depressive or manic episodes during the
acute phase symptoms;
(ii) Other disorders to be ruled out: Schizo-affective disorder and
bipolar or depressive disorder with psychotic features; or
(iii) The disturbance is not caused by the effects of substance use or
another medical condition.
5.1.4 Treatment of Schizophrenia

Of course, the treatment of schizophrenia involves drugs. Drugs used in the
treatment schizophrenia are usually called antipsychotic medication, neuroleptics
or in the old days, major tranquilisers. The most notable of these is chlorpromazine
(Thorazine) developed in 1952. Examples of other early antipsychotic drugs are
thioridazine (Mellaril or Melleril) and trifluoperazine (Stelazine) (see Figure 5.3).
Figure 5.3: Early antipsychotic drugs

Source: https://om.rosheta.com/en/4297/melleril; https://ph2050.com/2020/01/15

These antipsychotic drugs are used for their sedative effects and to generally
control the positive symptoms of schizophrenia such as hallucination, delusion
and disordered thinking.
However, they do not have much of an effect on the negative symptoms.

Nevertheless, they did make a major contribution in improving the patientÊs
treatment regime and the general ward environment, including making it possible
for many patients to be cared for in the community. These conventional drugs are
sometimes referred to as the first generation antipsychotics (FGAs) and these are
mainly dopamine antagonists − that is, they block the dopamine receptor sites.
Other more recent drugs referred to as atypical or second generation

antipsychotics (SGAs) are weak blockers of dopamine receptor sites, which are
said to produce fewer side effects (Daniel, Copeland & Tamminga, 2006).
In addition, the SGAs are also said to improve the negative symptoms because
they also block the reuptake of serotonin (Davis, Chen & Glick, 2003). Examples of
SGAs or atypical antipsychotics are clozapine (Clozaril), risperidone (Risperdal)
and olanzapine (Zyprexa).
It is important to bear in mind that these drugs do not cure schizophrenia; they
merely control and offer some relief from distressing symptoms. This so-called
symptom control comes at a cost, a trade-off between the symptoms and side-
effects of the drug. Some of the side effects of the antipsychotic drugs can be quite
distressing. The conventional antipsychotics or FGAs produce a range of side
effects. Some of the important ones are given as follows:
(a) Extrapyramidal Side Effects

These are also known as extrapyramidal symptoms (EPS). Further details of
the symptoms are listed in Table 5.3.
Table 5.3: Extrapyramidal Side Effects
Effect Symptom
Dystonia Muscle rigidity, difficulty swallowing due to stiff or thick

tongue.
Akathisia Restlessness, anxiety and agitation; rigid gait and lack of

spontaneity.
Pseudo- Stiff stooped posture, mask-like face, small shuffling

parkinsonism (drug steps, tremor, drooling, bradycardia and others.
induced)

Tardive dyskinesia Involves permanent (irreversible) involuntary movement

of the tongue, facial and neck muscles, resulting in
blinking, tongue protruding and grimacing.
Neuroleptic A potentially fatal reaction in which the patient will be

malignant syndrome confused and mute, involving muscle rigidity, high fever,
(NMS) unstable blood pressure, excessive sweating, pallor and
delirium.
(b) Anticholinergic Side Effects

These include dry mouth, constipation, urinary retention, hypotension,
blurred vision, dry eyes and photosensitivity.
(c) Other Side Effects

Increased blood prolactin levels result in enlarged and sensitive breast in
both men and women. Patients also suffer from diminished libido, erectile
dysfunction, menstrual irregularities and increased risk of breast cancer.
In addition, weight gain is a problem with all antipsychotics, but particularly so

with the atypical antipsychotics (such as clozapine and olanzapine). Clozapine has
additional problem of causing neutropenia (reduced neutrophil count) requiring
weekly blood test for the first four months and subsequently every two weeks.
Given the nature and extent of the side effects of the antipsychotic drugs, patients
need to be well-informed, carefully monitored and managed in order to maintain
compliance.
Non-compliance is usually the result of a combination of the patient being

unhappy with the side effects of the medication, lack of knowledge, poor
relationship with staff and lack of monitoring.
5.1.5 Understanding the Negative Symptoms of

Schizophrenia
The positive symptoms of schizophrenia are relatively easily treated or at least
controlled with medication, but this is not the case with negative symptoms, which
can be treatment resistant. Though some negative symptoms associated with the
active phase will respond to treatment designed to control positive symptoms,
most will persist long after the active phase.

The negative symptoms are still poorly understood and it certainly does not attract
the same attention as positive symptoms. Professionals and carers tend to show
greater concern, perhaps understandably, about the positive symptoms. I am
raising this here in this context so that when you think of people suffering from
schizophrenia, you donÊt just think of hallucinations and delusions (positive
symptoms).
It is as a consequence of the negative symptoms that patients experience low levels

of social functioning and reduced quality of life. We now know those individuals
whose symptoms are dominated by negative symptoms have poorer prognosis
compared to those whose symptoms are dominated by positive symptoms.
What are the causes of negative symptoms? As with schizophrenia, we do not have
a clear idea of what causes the negative symptoms, though there are several
possible explanations based on the following factors:
(a) Physical
The dampening of biochemical processes may explain some of the mental
and physical withdrawal. The negative symptoms can be attributed to
changes at the cellular levels in the brain involving low levels of dopamine
in the neural tract. This is much like the dopamine and serotonin over-
activity for the positive symptom of schizophrenia.
(b) Psychological
The experience of positive symptoms such as hallucination and delusions can
have a profound effect on the self. One of the ways an individual can try to
cope with distress is to psychologically (and physically) withdraw as a
protective response, as one would do when they are scared or anxious. It is
also possible, as we have seen in traumatised people, the mind can switch off
the emotional response until much later after the event. When the psychotic
experience (which itself essentially is a response to severe stress) is
sufficiently traumatising that the mechanism used to regulate emotional
response is overwhelmed and shuts down – as a protective measure (do refer
to our discussion of HPA axis and emotional self-regulation in Topic 1).
(c) Low-threshold for Social Stress

In other words, individuals diagnosed with schizophrenia will be sensitive
to stress. They will most probably have a pre-morbid social history of poor
interpersonal relationships and social withdrawal, with an unhappy primary
and secondary school experience. These individuals would have found it
difficult to function in everyday social situations, they are self-conscious and
worry about what others may think. The subsequent experience of positive
symptoms such as „hearing voices‰ and say „paranoid delusions‰ will

further actively entrench their social withdrawal and isolation because they
now belief there is a threat, „others are hostile‰ towards them.
This will result in individuals who are already socially anxious, to have a
much lowered threshold for social stress, making it difficult to spend time in
the company of others. Their low frustration tolerance means they have
difficulties in handling the mildest of discomfort. In an effort to avoid social
contact and discomfort, some will stay awake at night and sleep much of the
day.
When the active symptoms subside, they are left traumatised, exhausted and
with an altered sense of self. Not in control of their thoughts – there is no
„thoughts‰ or „thought process‰ as we would understand it and can be
experienced as unusual sensations, shapes and patterns in the head. You are
already aware that our thoughts influence the way we feel.
Now, consider what thoughts can bring about experiences such as blunting
of affect, anhedonia, apathy, poverty of speech and thought, lack of drive,
social interest, loss of motivation and even catatonia in some instances –
surely, there cannot be much organised, purposeful thought!
(d) Stigma
People who suffer from mental illness, particularly so with a diagnosis of
schizophrenia become stigmatised by the community they live in. This
problem of social distancing is very real and psychologically damaging for
the patient, the resulting social isolation and loneliness is devastating to the
patientÊs morale and engender a feeling of hopelessness. It could be
suggested that this is as bad as experiencing the acute paranoid delusional
symptoms. Let alone that these people will be discriminated against in other
important areas like education, employment, housing and so on.
(e) Social Relationships

Especially with family and friends, those with schizophrenia would not have
much chance against the combined dampening effects of lack of interest,
apathy and anhedonia. Such inattention and lack of responsiveness to social
cues will serve to maintain their low level social functioning, which will in
turn maintain the negative effect. Regardless of the cause of the negative
symptoms, rehabilitation will involve gradual social re-engagement, starting
with self-care and progressing to functioning in groups.

SELF-CHECK 5.2
What are the possible causes of negative symptoms of
schizophrenia?
ACTIVITY 5.2
Discuss in the myINSPIRE forum the differences between negative
symptoms and negative effects of schizophrenia.
5.1.6 Psychosocial Interventions (PSI)

You would appreciate by now that the patientÊs level of psychosocial functioning
is a good indicator of his or her mental wellbeing; hence, PSIs are an integral part
of the mental health nurseÊs skill set. Patients suffering from severe long-term
mental illness tend to suffer from a loss of confidence, especially in their own
abilities, including in their ability to self-care and handle social situations.
Consider for a moment what brings this about? Let us not forget, our patients also
have to overcome the dehumanising and stigmatising effects of long-term
hospitalisation, for many recovering patients this can be a major challenge.
Thus, it would require a multidisciplinary team effort to assess and plan care to
meet the patients complex need. Care must be taken to avoid overwhelming the
patient with stressful interventions as it may exacerbate the symptoms. Be mindful
that their tolerance of social stress will be low. The intention here is for you to
become aware of what mental health nursing teams can do to minimise the
negative effects and negative symptoms of schizophrenia, with a view to
enhancing our patientÊs quality of life. Your presence, interest and attention can
make a difference to the patientÊs experience. The following are some of the
interventions:
(a) Individual and Group Therapy

There is a good range of PSIs that could benefit people suffering from
schizophrenia, most notably through individual and group therapy. The
objective is to be supportive, that is providing the opportunity for social
contact and to develop meaningful relationships in an accepting
environment. In addition, these sessions can also be therapeutic in nature.
Patients sharing their experience of their symptoms can have the effect of
lessening their burden and provide an opportunity to reflect. Patients learn

and benefit from the experience of others especially experiences such as

„voice hearing‰, delusional thoughts, severe depression, medication
management and so on (Pfammatter, Junghan & Brenner, 2006). It makes a
lot of difference to patients when the „horror‰ is removed from their
experience. It is also that much more credible and effective when a recovering
patient offers a new patient reassurance.
(b) Group Work

This can take many different forms. Patient-support groups (sometimes
facilitated by ex-patients) where patients share their experiences and provide
support for each other, helps them to think that they are not alone. ItÊs not
easy for some patients to speak up about their need or about things that they
are not happy with on the ward. Other groups may work on the patientÊs
assertiveness and social competence through social skills training.
Through group work, complex tasks are broken down into smaller
manageable steps and taught through role play and simulation with a view
to applying the new learning in the community or in an actual situation. Such
groups can address the need for assertiveness, development of interpersonal
and problem-solving skills, handling money, shopping, using the washing
machine (even at the launderette) and so on.
(c) Individual Psychotherapy

There are numerous individual psychotherapy approaches with a great deal
of overlap in what they aim to do, such as helping patients learn about their
illness and how it affects them, telling the difference between what is real
and what is not real. And of course, helping them to manage their everyday
life.
The most prominent of the individual therapy is cognitive behavioural

therapy (CBT), which can help regulate their emotional responses to their
symptoms by minimising fear (anxiety) depression, anger, shame and others.
For instance, the therapist will show the patient ways to deal with the
„voices‰ and even learn to appreciate what brings about or triggers their
psychotic experiences. This can create possibilities for the patient to learn to
manage the trigger and minimise the psychotic experience.
(d) Patient Education

The patient education process can be undertaken either individually or in
groups, the involvement of the family and carers in the learning process as
early as possible cannot be overstated (Birchwood, Smith & Cochrane, 1992).
This is because the improvement in the knowledge of schizophrenia and its

course helps us achieve better compliance and satisfaction with the care
provided. Family involvement also has the effect of minimising the negative
effects of schizophrenia and prevent relapse (Penn, Wldheter, Perkins,
Mueser & Lieberman, 2005). This is particularly so in families with „high
expressed emotion‰, the result of a lot of criticisms, hostility and over-
involvement.
An important component of patient education is their need to understand

the medicines they are taking and what to expect in terms of its desired effect
and unwanted effects. Patients are more in control when they know what to
expect and how to manage some of the unwanted effects.
There is an expectation that patients with a diagnosis of schizophrenia will

mainly have complex need and will require long-term support, some being
subject to numerous admissions.
Therefore, a properly planned long-term support in the community can help

prevent relapses and readmissions which will require effective case
management, assertive outreach programmes, compliance therapy and so on
to be in place.
At the present moment, our resources centred on hospitals and community

resource for people with mental health problems, appear somewhat
underdeveloped. Community services such as community mental health
teams, assertive outreach teams, crisis intervention teams and voluntary
groups will be required to provide sustained long-term care in the
community.
ACTIVITY 5.3
Imagine that you wake up one morning and you realise that you are
hearing voices in your head. The voices are not very clear but you
know they are critical.
What would your immediate response be? What would you think,
feel and actually do?
(a) Make your own list of responses.
(b) Compare your responses with the signs and symptoms of
schizophrenia.
Discuss your responses in the myINSPIRE forum.

• There is a considerable overlap between the concept of psychosis and

schizophrenia.
• Schizophrenia is an illness, while psychosis is seen as a syndrome or cluster of

symptoms that is present and necessary for the diagnosis of schizophrenia and
may be present in other illnesses as well.
• There are individuals who will have one psychotic episode only without the
full-blown experience of schizophrenia.
• Schizophrenia is a severe form of mental disorder with its negative and very
debilitating effects that for some may last a good part of their life.
• Some of the major symptoms of schizophrenia are hallucinations, illusions,

delusions and loose association.
• The symptoms of schizophrenia are categorised into positive and negative

symptoms.
• The positive symptoms are the exaggerations or distortions of oneÊs thought

process, expression of emotion and behaviour.
• The negative symptoms reflect the lack of or insufficiency in the functioning

such as lacking in motivation, poverty of speech, flat affect, lack of social
responsiveness and withdrawal.
• The factors that increase the possibility of developing schizophrenia are

genetics, brain development, brain chemicals and recreational drug use.
• The diagnosis of schizophrenia was revised and simplified in the latest version
of the DSM 5 (2013) – many subcategories of schizophrenia were removed.
• The treatment of schizophrenia is largely dominated by the use of

antipsychotic drugs.
• The drugs that are used today are either conventional (first generation
antipsychotics) or atypical (second generation antipsychotics). In other words,
there are both old and new drugs available.
• The old drugs tended to be more sedating, while the new drugs controlled the
positive symptoms with less sedative effect. Their extrapyramidal and

anticholinergic side effects can be sufficiently troublesome for patients who

want to discontinue them. There are severe side effects too, some of which can
be distressing, irreversible or even fatal.
• The positive symptoms of schizophrenia are relatively easily treated or at least

controlled with medication, but this is not the case with negative symptoms,
which can be treatment resistant. Though some negative symptoms associated
with the active phase will respond to treatment designed to control positive
symptoms, most will persist long after the active phase.
• Psychosocial interventions are usually carried out by mental health nurses and
this is an important part of the nurseÊs role.
• There is a wide range of psychosocial interventions, both individually and in

groups, available for people suffering from schizophrenia, but what is offered
will depend on the level of development of the mental health nursing team.
• Some of them are individual and group therapy, group work, individual
psychotherapy and patient education.
Aetiology Loose association

Antipsychotic drugs Negative symptoms
„Hearing voices‰ Positive symptoms
Delusion Psychosis
Diagnosis Psychosocial interventions
Hallucination Schizophrenia
Illusion Treatment

American Psychiatric Association (APA). (2013). Diagnostic and statistical manual

of mental disorders (5th ed.). Washington, DC: American Psychiatric
Association.
Birchwood, M., Smith, J., & Cochrane, R. (1992). Specific and nonspecific effects of
educational intervention for families living with schizophrenia. A
comparison of three methods. British Journal of Psychiatry, 160, 806–814.
Daniel, D. G., Copeland, I. F., & Tamminga, C. (2006). Ziprasidone. In A. F.

Schatzberg & C. B. Nemeroff (Eds.), Essentials of clinical pharmacology
(2nd ed.) (pp. 297–305). Washington, DC: American Publishing.
Davis, J. M., Chen, N., & Glick, I. D. (2003). A meta-analysis of the efficacy of
second-generation antipsychotics. Archives of General Psychiatry, 60(6),
553−564.
Penn, D. L., Wldheter, E. J., Perkins, D. O., Mueser, K.T., & Lieberman, J. A. (2005).
Psychosocial treatments for first-episode psychosis: A research update.
American Journal of Psychiatry, 162(12), 2220–2232.
Pfammatter, M., Junghan, U. M., & Brenner, H. D. (2006). Efficacy of psychological

therapy in schizophrenia: Conclusions from meta-analysis. Schizophrenia
Bulletin, 32(Suppl. 1), 564–580.
Schizophrenia Working Group of the Psychiatric Genomics Consortium. (2014).

Biological insights from 108 schizophrenia-associated genetic loci. Nature,
511, 421–427.

Topic  Managing
Substance
6 Use and Abuse
LEARNING OUTCOMES
1. Identify the terms used in substance use and abuse;
2. Differentiate between substance use, abuse and dependence;
3. Explain how to manage substance abuse and dependence; and
4. Discuss the challenges and strategies in keeping the client group

engaged with the treatment programme.
 INTRODUCTION
You may wonder why substance use or abuse is associated with mental health
services, as it is clearly not a mental illness. Historically, in developed countries,
social problems that comes under the purview of the health department gets
conveniently allotted to the mental health services.
In other parts of the world, issues like homosexuality, HIV and AIDS, alcohol, drug
abuse and so on, are some of the social problems the mental health services have
to deal with on a regular basis. This has not been the case in Malaysia, where the
legal system was much more prominent and only in recent years, drug possession
led to a mandatory two years remand in a government „rehabilitation‰ centre.
With our approach of criminalising drug use, we should not be surprised that the
majority of our prison population is made up of drug users. It is also worth noting
that our drug treatment and rehabilitation services are a separate service under the
Ministry of Home Affairs and not managed by the Health Department and
manned by mental health nurses.

124  TOPIC 6 MANAGING SUBSTANCE USE AND ABUSE
Without going too much into the history of the development of anti-drug policy
and services, the ineffectiveness and poor outcome (it failed to deter drug
addiction and high relapse rate) led to the upgrading and re-branding of the
services for drug users from about 2010.
Our National Anti-Drugs Agency (AADK – Agensi Antidadah Kebangsaan)

website provided the following figures for 2016, 2017 and 2018 (see Table 6.1).
Table 6.1: Drugs Statistics in Malaysia for 2016, 2017 and 2018
Case Year 2016 2017 2018
New 22,814 18,112 17,315
Relapse 4,648 3,242 2,908
Total 27,462 21,354 20,223
Source: AADK (2018)
The table shows only new cases (as in newly detected) and the relapse refers to
individuals who have been rehabilitated by the service before. The figures exclude
instances of multiple detections and relapses. It would be reasonable to assume
that the official figures understate the problems, given punitive nature of our law,
people are less likely to volunteer for treatment. In addition, there are also
numerous private treatment and rehabilitation clinics locally (about 60) and many
more in our neighbouring countries.
Let us find out more on how to manage substance use and abuse in the next
subtopics. Happy reading!

TOPIC 6 MANAGING SUBSTANCE USE AND ABUSE  125
6.1 TERMS USED IN THE EXPLANATION OF

THE SUBSTANCE USE AND ABUSE
In this subtopic, we will take a moment to clarify some of the terms used and basic
concepts associated with the problem of substance use.
Table 6.2: Terms Related to Substance Use and Abuse
Term Definition
Drug abuse This refers to the use of illegal drugs or the inappropriate consumption of
legal drugs. The purpose of the repeated use of the drug(s) is to produce
pleasure, to neutralise pain or stress, or to alter or avoid reality and in
some instances all three may apply.
Addiction Addiction is a chronic and relapsing condition characterised by a loss of

control in limiting the intake of the substance, together with compulsive
drug-seeking behaviour, regardless of the harm it may cause to self of
others. It is largely, brought about by long-lasting chemical changes in the
brain.
Craving A powerful, often uncontrollable desire for drugs. In another words, it is

a „subjective experience of wanting to use a drug‰ (Tiffany, 2009).
Withdrawal The cluster of symptoms that occur after chronic use of a drug is reduced
or abruptly stopped.
Tolerance A state in which an organism no longer responds to a drug as it did

initially; requiring a higher dose to achieve the same effect.
Ingestion The act of taking in food or other material into the body through the
mouth.
Inhalant Any drug administered by breathing in its vapours. Inhalants commonly

are organic solvents, such as glue and paint thinner, or anaesthetic gases,
such as ether and nitrous oxide.
Inhalation The act of administering a drug or combination of drugs by nasal or oral

respiration. Also, the act of drawing air or other substances into the lungs.
Nicotine in tobacco smoke for instance, enters the body by inhalation.
Injection A method of administering a substance such as a drug into the skin,

subcutaneous tissue, muscle, blood vessels, or body cavities, usually by
means of a needle.

SELF-CHECK 6.1
Explain the five terms that are related to substance use and abuse.
6.2 SUBSTANCE USE, ABUSE AND

DEPENDENCE
Drugs that are commonly abused are no different from the prescribed medicines
that are used to treat diseases, in that they are either plant based or chemically
synthesised in the laboratories (synthetic drugs). Some of the synthetic drugs are
„copies‰ of the plant-based drugs and are designed to mimic similar effects.
However, sometimes the effects of the synthetic drug can be designed to be much
more powerful.
The examples of some commonly used drugs derived from plants are marijuana
(cannabis), cocaine, morphine and nicotine. Plant-based drugs have a long history
of use in tribal cultural rituals, traditional medicine and for recreational purposes.
On the other hand, synthetic drugs are generally grouped into two distinct
grouping, reflecting their basic chemical makeup. One is cannabinoids (derived
from marijuana such as K2 and Spice). Synthetic cannabinoids are chemicals that
mimic the effect of THC (delta-9-tetrahydrocannabinol), the most significant
psychoactive ingredient in marijuana.
The other grouping is synthetic cathinones, sometimes also known as „bath salts‰
(not something you add to your bath water). These are stimulants based on the
chemical substance „cathinones‰ found naturally in khat plants (see Figure 6.1).

Figure 6.1: Khat plant
There are also a whole host of „designer‰ stimulants that are said to mimic the
effects of methamphetamine and lysergic acid diethylamide (LSD) for instance
MDMA (or „ecstasy‰). Again, the synthetic cathinones are much stronger that the
natural ones. You would have heard of syabu (essentially methamphetamine), an
amphetamine type stimulant that goes by numerous street name such as „crystal,‰
„meth,‰ „ice,‰ „speed,‰ „chalk,‰ „glass‰ „china white‰ and pil kuda.
These substances are usually synthesised in clandestine make shift laboratories, as

such the purity can vary from lab to lab and also the strength can vary within the
same packet. In addition, the tablets may be augmented by combining with other
cheaper compounds, which the user is not to know. Some common
„contaminants‰ used are caffeine, ketamine and ephedrine.
ACTIVITY 6.1
Discuss in the myINSPIRE forum on why people love to drink coffee.
What are the effects of caffeine?

6.2.1 Reasons Why People Start Using Drugs

Did you know that the most commonly abused drugs are heroin and opium
followed by marijuana and cocaine? Not forgetting of course alcohol and tobacco.
According to the UK Royal College of Physicians, "Smoking should be viewed as
a drug of dependence second to no other.‰ They also added, „Nicotine is as
addictive as heroin or cocaine.‰
So what are the reasons why people start using drugs? Table 6.3 summarises the
reasons.
Table 6.3: Why People Use Drugs
Reason Description
To enhance Drugs can help combat tiredness when there is a need to stay alert. Long
mental and distance drivers, clerical workers, soldiers, athletes and even students
physical may resort to using stimulants in an effort to stay awake, alert and
performance concentrate longer. Most people will use caffeine and nicotine, whilst
others, may resort to abusing prescription drugs such as Adderall and
Dexedrine (amphetamines) or even Ritalin which is used to treat
attention deficit hyperactive disorder.
Feel good In addition to giving a boost to oneÊs energy levels, these drugs also
factor make one feel good! Long desk-bound working hours, combined with
constant hassle, pressure of performance targets and deadlines, may
make one feel stressful and unappreciated. Work-related unhappiness
will compromise the quality of emotional health. The use of drugs
neutralises the negative feelings and makes one feel good and tolerate
the frustrating working environment. To some, taking drugs may seem
like a good choice.
Weight loss Amphetamines, such as Adderall, do get abused for its other side effect
which is to suppress appetite. So in addition to helping the user
concentrate and feel good, users think it also helps them to be physically
good looking. As such, in fashion and advertising industries where
being slim is the difference between having a job or not, it is no contest,
and Adderall wins!
Why do teenagers start taking drugs? Usually for reasons not too different from
why adults do. That is, the need to feel different, to change the quality of their
emotion. For most people, the teenage years are all about socialising, being part of
a group, experimentation, taking risks and developing a sense of who one is – i.e.
identity. The use of drugs becomes part of „risk taking‰, not dissimilar from doing
stunts on motorbikes, or even better to be chased by the police. Young peopleÊs use
of drugs can also be about relaxation and sharing a sense of feeling good or fun,

eliminating boredom at the same time. There will also be a small group of troubled
young people whose drug use may provide an escape from their social and
psychological distress.
SELF-CHECK 6.2
What are the factors that contribute to people starting to use drugs?
6.2.2 Dependence
At this juncture, it would perhaps be useful to clarify the concept of dependence.
It is sometimes used interchangeably with addiction. The notion of „dependence‰
usually refers to physical dependence on a substance which will include
symptoms of both tolerance and withdrawal. Dependence is essentially the
response or adjustment in the body to a substance.
For instance, some people take medication on a long-term basis for conditions such
as diabetes. As such, you can have physical dependence without the addictive
behaviour. However, it is highly likely that the clientele we are dealing with will
also be addicted.
6.2.3 The Reward Pathway in the Brain

There are neural networks that are stimulated when the activity or experience is
perceived as pleasurable. Experiences that are pleasurable are repeated. It is
thought that the neurotransmitter dopamine (an excitatory neurotransmitter) has
an important role in this pleasure and reward system. In addition, dopamine is
also said to be involved the regulation of our emotion, pleasure seeking activity
and physical movement.
For instance, when you eat a piece of cake, the release of dopamine registers it as
a significant event and commits to memory the salient features of the experience,
the sight, taste, smell of the cake, where and with whom. Later, the very thought
of the place, people or cake will cause small amounts of dopamine to be released
creating a pleasant sensation and the possibilities of a repetitive behaviour.
There are a number of dopamine pathways connecting different parts in the brain,
but the following two are more dominant (see Table 6.4).

Table 6.4: Two Dominant Types of Dopamine Pathways
Type Description
Mesolimbic pathway Also known as the „reward pathway‰, where dopamine is

produced in the ventral tegmental area and transmitted into
the limbic system via the nucleus accumbens. The limbic
system is responsible for our experience of emotion.
Mesocortical pathway Dopamine produced in the ventral tegmental area, and then
transmitted to the frontal cortex. This is the area of the brain
that process the cognitive aspect of the experience related to
short-term memory, motivation and emotion (Puig, Rose,
Schmidt & Freund, 2014).
You will already be aware of the normal communicative process in the neuron
involving neurotransmitters at the synapse. The mesolimbic dopaminergic
(reward) pathway would be activated by naturally occurring rewards such as food
or sex. The groups of substances that are abused are able to affect this natural
process in different ways.
For instance, amphetamines cause an increase in dopamine in the synapse by

directly stimulating the release of dopamine from the synaptic vesicles. The
mechanism of action of cocaine is somewhat different in that it is said to block the
re-uptake or removal of dopamine in the synapse by occupying the dopamine
transporters. Subsequently, this will lead to a higher concentration of dopamine in
the synapse, that will in turn continuously stimulate the post-synaptic dopamine
receptors.
Whatever the mode of action of the drugs, the net effect is the increased dopamine
transmission and the activation of the reward pathway. The „high‰ is caused by
the intensity of the activation of the reward system. It is worth noting that nicotine
and alcohol (and non-stimulant substances) may affect different areas of the brain
but the neurons communicate with the reward pathway.
6.2.4 Substance-Related Disorder

The use of the terms drug „dependence‰ and „addiction‰ have been somewhat
made less central in the diagnosis of substance related disorders. The current
Diagnostic and Statistical Manual (DSM-5) recommends new diagnostic categories
„substance use disorders‰ and „substance induced disorders‰.

The DSM 5 establishes nine types of substance-related disorders, as follows:

(a) Alcohol;
(b) Caffeine;
(c) Cannabis (for example, marijuana);
(d) Hallucinogens;
(e) Inhalants;
(f) Opioid (for example, heroin);
(g) Sedatives, hypnotics or anxiolytics (for example, Valium and Quaaludes);
(h) Stimulants (for example, cocaine, methamphetamine); and
(i) Tobacco.
The diagnosis is drug specific and viewed as a separate use disorder, for instance,
„cannabis use disorder‰, „cannabis intoxication‰ and „cannabis withdrawal‰. It is
the same for all the substances listed except for caffeine, there is no caffeine use
disorder.
The DSM 5 diagnosis of substance use disorder is based on 11 criteria that are
grouped into the following four categories (see Figure 6.2).
Figure 6.2: Four categories of DSM 5 diagnosis of substance use disorder

The 11 criteria for diagnosis are given as follows:

1. Substance is often taken in larger amounts and/or over a longer period than
the patient intended.
2. Persistent attempts or one or more unsuccessful efforts made to cut down or
control substance use.
3. A great deal of time is spent in activities necessary to obtain the substance,
use the substance or recover from the effects.
4. Craving or strong desire or urge to use the substance.
5. Recurrent substance use resulting in a failure to fulfil major role obligations
at work, school or home.
6. Continued substance use despite having persistent or recurrent social or
interpersonal problem caused or exacerbated by the effects of the substance.
7. Important social, occupational or recreational activities given up or reduced
because of substance use.
8. Recurrent substance use in situations in which it is physically hazardous.
9. Substance use is continued despite knowledge of having a persistent or
recurrent physical or psychological problem that is likely to have been
caused or exacerbated by the substance.
10. Tolerance, as defined by either of the following:
(a) Markedly increased amounts of the substance in order to achieve
intoxication or desired effect.
(b) Markedly diminished effect with continued use of the same amount.
11. Withdrawal, as manifested by either of the following:
(a) The characteristic withdrawal syndrome for the substance.
(b) The same (or a closely related) substance is taken to relieve or avoid
withdrawal symptoms.
To be diagnosed as substance use disorder, the person is required to meet at least

two of the criteria. Should a person who is being evaluated for treatment show
signs of withdrawal the person will be diagnosed for both substances use and
withdrawal.

The assessment of the degree of severity of the disorder, mild, moderate or severe
is dependent on the number of criteriaÊs met as follows:
(a) Mild: 2 or 3 criteria out of 11.
(b) Moderate: 4 or 5 criteria out of 11.
(c) Severe: 6 or more criteria out of 11.
SELF-CHECK 6.3
1. What are the four categories of DSM 5 diagnosis of substance
use disorder?
2. What are the criteria for diagnosis?
6.3 MANAGING SUBSTANCE ABUSE AND

DEPENDENCE
In mental health work, the combination of poverty, substance use and mental
illness can make the treatment and care of this client group very challenging. It is
likely that the patient in mental health settings with a substance use disorder will
also present symptoms of drug-induced mental illness. Usually with most
substance-induced mental illness, when the patient stops using the substance,
within a period of one or two weeks the florid symptoms (having a flushed
complexion) would have subsided.
However, in some instances, the patient may also suffer from mental illness
independent of the substance use and substance-induced disorder. Young people
who develop mental health problems in their teenage years may attempt to cope
with their psychological difficulties by „self-medicating‰ and the substances used
may exacerbate their underlying mental illness.
So just to clarify and restate, we have substance use disorder – which will also
come with its intoxication and withdrawal problems. The substance(s) used will
also likely induce mental illness (substance induced mental illness) when taken for
a period of time in sufficient amounts. Some of these individuals may also have
formal mental illness, independent of their substance use, in another word they
have dual diagnosis.

6.3.1 Effects of Drugs

In this subtopic, we will briefly give an overview of the effects of drugs. How an
individual respond to substance use will depend on a range of factors, such as
gender, physical build, expectations, frequency of use, whether on an empty
stomach, general health and so on. The type of substance(s), amount, purity and
other contaminants will also be important. The grouping or class of drugs may be
as follows – though some substances may belong to more than one group (see
Table 6.5).
Table 6.5: Three Grouping of Drugs
Group Description
Depressants These have the effect of slowing down the function of the central
nervous system. For example, alcohol, cannabis, opioids,
benzodiazepines (such as Valium). In small amounts will feel pleasant,
calm and relaxed also somewhat less inhibited. In larger doses, it will
induce sleepiness, nausea and vomiting. When overdosed – patient
will become unconscious and it may even be life threatening.
Hallucinogens Affects oneÊs perception – alters the sensory information from the
sensory organs, visual, sensation on skin, smell, hearing and taste. For
example, LSD, PCP (phencyclidine), ketamine, cannabis and
psilocybin (magic mushrooms). In small amounts dizziness, confusion
and disorientation, a light and floating sensation. Bigger amounts of
the substance will cause an increase in heart rate, possible distress,
anxiety and panic, paranoia, aggression, memory loss and visual
hallucination.
Stimulants Activates (speeds up) the functioning of the central nervous system.
For example, amphetamines, nicotine, MDMA (ecstasy), caffeine and
cocaine. In small amounts symptoms include increases in heart rate,
elevated blood pressure and high body temperature. The user will feel
energised, alert and self-assured. Reduced appetite, heat exhaustion,
dehydration, agitation and sleeplessness. Larger amounts will lead to
anxiety and panic attacks, paranoia, convulsions and stomach cramps.
Now, what are the effects of caffeine withdrawal? The effects of caffeine withdrawal
are:
(a) Headache;
(b) Fatigue;
(c) Anxiety;
(d) Difficulty concentrating;
(e) Irritability;
(f) Hand tremors; and
(g) Low energy.
SELF-CHECK 6.4
1. What are the three categories of drugs?
2. What are the effects of drugs?
6.3.2 Treatment of Substance Use Disorder

Given the complex nature of the challenges presented by this client group, it will
usually require a multi-disciplinary team approach, the duration of treatment can
vary considerably, depending on the patientÊs problems and needs. Substance use
disorders are usually a long-term problem requiring multiple treatment
interventions and monitoring. Even with the teamÊs and the patientÊs best effort,
relapses and readmissions are part of the course of recovery.
For the majority of patients, it will be usual to expect a period of at least 12 months
in treatment to overcome their problem. It is often said a good outcome is
dependent on the length of treatment.
It is worth restating the principle that for the treatment to be effective the team
must respond and attend to the range of other associated needs the individual may
have and not just the use of drug. As such the success of the treatment will also be
dependent on addressing the patients vocational, social, psychological, medical
and legal problems, if any.
In this subtopic, we will review the managed withdrawal and related issues; and
deal with the challenges faced by nurses (and the rest of the team) in keeping this
client group engaged with the services in the subsequent section.
(a) Medically Managed Withdrawal (Detoxification)

This is the initial stage of treatment, which is to medically manage the
withdrawal and detoxification. This systematic process helps manage the
acute physiological effect of withdrawal and purging the body of the drug,
in a safe manner. It is perhaps noteworthy to point out that not all substance
users would be requiring to go through this managed withdrawal. Some
individuals may not be heavy users as such they may not experience
withdrawal.

Others who are heavy users, say opioids for instance, may agree to go on
methadone maintenance treatment, in which case will not need managed
withdrawal. The completion of the withdrawal process will take several
weeks; this marks the beginning of the treatment. Patients who stop at this
stage will likely return to using the substance.
(b) Nurses Role

From a nursing care point of view, withdrawal symptoms can be distressing
and the patient will require medical and psychological support throughout.
Therefore, the patient should be cared for in a quiet and calm environment
away from other patients. The patient will be on continuous close
observation, with a staff designated for the patient. The withdrawal
symptoms will be specific to the substance, but generally (as with opioids)
you can expect the patient to be anxious, experiencing difficulties sleeping,
nausea, vomiting and diarrhoea; hot and cold flushes, perspiration and
muscle cramps.
The responsible medical staff will respond to any medical issues that may
arise. The nurse will administer the prescribed medication, provide
information, monitor and reassure as necessary. Given the loss of fluid from
perspiration and diarrhoea, the nurse will need to ensure the patient drinks
at least between two and three litres of fluid daily. Making sure that the
patient is resting or sleeping on the bed and activity is limited to some
walking. It is likely that some patients may become anxious (scared),
agitated, confused and can become difficult to manage; even angry and
aggressive.
The nurses will initially manage the patient behaviourally. For instance,
when the patient is anxious, disorientated and confused, engage the patient
in a manner that conveys to him or her that he or she is „in control, calm and
confident.‰ Explain and orientate the patient to where he is and what is going
on, keeping the environmental stimulation (including staff) to a minimum.
The patient must be constantly supervised, as there is a risk of self-harm.
Similarly, should the patient become angry, the nurse maintains her
composure, remain calm and reassuring to the patient, personalise the
interaction by using the patientÊs name. Question using open-ended
questions and listen to what the patient has to say. Avoid getting into a
struggle with the patient (by challenging or defending others), acknowledge
that the patient is feeling angry. The patient will notice and agree that he is
angry – the nurse is on the way to de-escalating the emotion. Once the anger
is out of the way, the nurse can discuss and do some problem solving with
the patient.

However, it is important to bear in mind not to try and do „therapy work‰

at this stage as the patient will be vulnerable and in no state to benefit
from it.
Table 6.6: Medications Used in Managed Withdrawal
Medication Treatment for
Buprenorphine
Methadone
Heroin and other opiates
Levo-alpha-acetylmethadol (LAAM)
Codeine phosphate
Naltrexone Opiate and alcohol addiction
Nicotine replacement Buproprion, patches, gum
(c) Psychosocial Interventions and Follow-up Care

The follow-up care will be psychosocial in nature and it is important that
there is a well thought out support plan put in place to reduce the risk of
relapse. The preparation for discharge will need to commence following
managed withdrawal – the fact that the patientÊs body has been cleanse from
the drug (for example, opioid), the actual „withdrawal phase‰ will continue
for another six months. The patient will continue to be vulnerable to relapse
for two reasons, one being the patient will continue to experience physical
discomfort and intense craving for opioid; the other being, the patient has
yet to learn how to handle the triggers for substance use in his home
environment. Hence, the importance of keeping the patient engaged.
Most drugs teams will have both short-term and long-term strategy. In the
short term, the interventions will be brief and will benefit all patients – the
focus will be on drug education, drug refusal skills, relaxation training and
discharge planning. The longer term or extended interventions will be
offered to individuals whose dependence was moderate to severe. The focus
will be on attitude to change in substance use behaviour, cognitive
behavioural therapies, problem-solving skills and craving management.
In our context, the „Cure and Care‰ (C&C) centres are perhaps a move in the
right direction in the promotion of a more holistic treatment-based approach
to substance use rehabilitation. The development of the earlier-mentioned
brief and extended interventions would need to be developed and
adequately resourced with well-trained staff to be able to offer a satisfactory
level of after care.

(d) Self-Help Groups

Again in Malaysia, we suffer from a lack of resources to nurture voluntary
and community support groups to play a meaningful role in sustaining
people recovering from substance use. Apart from a few alcoholic
anonymous groups in the capital city, there is not much else that
complements and extends treatment efforts into the local communities. Just
as a matter of interest, the most commonly used models include 12-step
(alcoholic anonymous, narcotic anonymous) and smart recovery. Where it is
available, patients should be encouraged to participate in self-help group.
The „treatment‰ approach to the problem of substance abuse has a number

of advantages, in that it minimises the moralising and criminalising of the
users. The treatment programmes and the effort made in keeping patients
engaged with the service, together with self-help groups, is the best way to
return the person to productive functioning. It is well accepted that treatment
reduces drug use, increases the possibilities of returning to work and also
reduces crime.
6.4 CHALLENGES FOR THE NURSE

The biggest challenge for nurses in working with this client group is keeping them
engaged with the service. Given that there are numerous medical conditions
associated with substance use disorder, the treatment of drug abuse is a form of
disease prevention. It presents opportunities for screening, counselling and
referral for HIV/AIDS, hepatitis and other infectious diseases.
As such, keeping them engaged with the service, in addition to public health
issues, also means staff can help minimise the harm, through initiatives such as
needle exchange, methadone maintenance treatment, proper dispensing of
condom and so on. It is likely that patients may drop out of treatment programmes
for numerous reasons and that we may not be in a position to do much about it.
But as professionals, we should do what we can about the things that are under
our control to help keep this client group engaged.
The complexity of needs and challenges presented by this client group calls for a
more specialised training (and development) of staff. We will review one approach
that was developed to specifically work with this client group that emphasises the
nurse-patient relationship as the motivating factor for change in patients, namely
motivational interviewing (MI) (Miller & Rollnick, 2002). This approach is now
well received in other areas of mental health work and health care generally. We
will review the approach in brief, if you think it resonates with you, do some
reading, there are plenty of materials available.

6.4.1 Motivational Interviewing (MI)

The defining features of MI are that the approach is collaborative, person-centred,
evidence-based, guiding method of communication for enhancing and
strengthening intrinsic motivation for change.
Now, let us look at the MI style and spirit. At the heart of this approach is the
Rogerian „core conditions‰ which you would now be familiar with. It is the way
you are in the relationship, holding the other in unconditional positive regard.
Accepting the other in a non-judgemental manner; empathetic, seeking to
understand things from the otherÊs perspective.
Collaborative means sharing power and control, working together in partnership,

pursuing common goals, joint decision-making (as in dancing rather than
wrestling) and the most human of all qualities, warmth and friendliness.
What are the primary goals of MI? The primary goals of MI are about
accomplishing the following:
(a) Minimise resistance;
(b) Elicit change talk;
(c) Explore and resolve ambivalence; and
(d) Nurture hope and confidence.
MI recognises that clients will be at different stages of readiness to change and the
nurse needs to take this into account in her interaction with the patient. Talking
about taking action to change, may not resonate with someone who is not even
aware that he has a problem. So the „change talk‰ the nurse engages in need to
reflect the patientÊs readiness.
The following are the six stages of the change cycle, but note that the patient will
usually move progressively forward, but may also move backwards. So the nurse
will revisit the patientÊs current state of readiness. These six stages are explained
in Table 6.7.

Table 6.7: Six Stages of the Change Cycle
Stage Description
Pre- It is the state in which people may be unaware that a problem exists
contemplation and that even if they thought their behaviour was unhealthy, they
are not considering changing or initiating a change in behaviour.
Contemplation It is the stage characterised by ambivalence about changing or

initiating a behaviour. This is a necessary and natural process
where the patient resolves the ambivalence in the direction of
change. In helping the patient resolve his/her ambivalence, the
nursesÊ change talk will be about weighing the pros and cons about
maintaining an unhealthy behaviour (say smoking) against the
pros and cons of quitting smoking. It is for the patient to choose.
Preparation It is the stage characterised by reduced ambivalence and

exploration of options for change. The patient may consider the
range of options available to choose from, as in à la carte menu.
Action It is the stage characterised by the taking of action in order to

achieve change.
Maintenance In this stage, the new behaviour is reinforced and made part of the
patientÊs lifestyle; minimising the possibilities of relapse.
Relapse The new behaviour is not sustained and the old undesirable habit
has returned. The patient may return to being ambivalent.
Source: Prochaska & DiClemente (1992)
What are the key principles of MI? The key principles of MI are actually the insight
drawn from a wide range of contemporary psychosocial theories. The most
important and pervasive being the humanistic „critical conditions for change‰ by
Rogers, 1959; reactance theory by Brehm and Brehm, 1981; self-determination
theory by Deci and Ryan, 2000; self-perception theory by Bem, 1972; self-efficacy
theory by Bandura, 1997; cognitive dissonance theory by Leon Festinger, 1957; and
finally, the transtheoretical stages of change by Prochaska and DiClemente (1992).

MI proponents usually list the following key principles (see Table 6.8).
Table 6.8: Six Key Principles of MI
Principle Description
Control and Health professionals know when we tell people what to do, they will
choice often not do it. They are better motivated and committed to doing it
when it is their own choice and decision. So, do support self-efficacy.
„Change talk‰ OneÊs own reasoning and arguments for change are more persuasive
than by what someone tells them. Elicit and foster more change talk.
Thus it is important for people to hear their own arguments for a
change, sort of self-motivational statements (self-perception theory).
Hope and Activate the capability that we all have for beneficial change. Fostering
possibility oneÊs belief in oneÊs own ability to make change can help determine
the outcome (self-efficacy theory).
Acceptance It is the unconditional positive regard (acceptance) of the person,

regardless of their actions means one is free to consider change
without the need to resist (Rogerian).
Committed The strength of commitment to act to bring about change is important

decisions in making it happen.
Less is more Talk less, listen and show empathy – but let the client do the rest.
„Reflective listening‰ is the key to this work. The best motivational advice we can
give you is to listen carefully to your clients. They will tell you what has worked
and what has not; what moved them forward and what led them backward.
Whenever you are in doubt about what to do, listen (Miller & Rollnick, 1991).
Remember, no „fixing‰, simply means just that. Resist the urge to sort the problem.
SELF-CHECK 6.5
1. What are the four primary goals of motivational interviewing or
MI?
2. MI recognises that clients will be at different stages of readiness

to change. What are the stages?
3. What are the key principles of MI?

• Some of the terms used in substance use and abuse are drug abuse, addiction,
craving, withdrawal, tolerance, ingestion, inhalant, inhalation and injection.
• Drugs that are commonly abused are no different from the prescribed
medicines that are used to treat diseases, in that they are either plant based or
chemically synthesised in the laboratories (synthetic drugs).
• Some commonly used drugs are derived from plants – marijuana (cannabis),
cocaine, morphine and nicotine. Plant-based drugs have a long history of use
in tribal cultural rituals, traditional medicine and for recreational purposes.
• The synthetic drugs are generally grouped into two distinct grouping,
reflecting their basic chemical makeup. One is cannabinoids and the other is
cathinones (bath salt).
• The most commonly abused drugs are heroin and opium followed by
marijuana and cocaine. Not forgetting of course alcohol and tobacco.
• The use of the terms drug „dependence‰ and „addiction‰ have been somewhat
made less central in the diagnosis of substance related disorders. The current
Diagnostic and Statistical Manual (DSM 5) recommends new diagnostic
categories „substance use disorders‰ and „substance induced disorders‰.
• In mental health work, the combination of poverty, substance use and mental
illness can make the treatment and care of this client group is very challenging.
• How an individual respond to substance use will depend on a range of factors,

such as gender, physical build, expectations, frequency of use, whether on an
empty stomach, general health and so on.
• Substance use disorders are usually a long-term problem requiring multiple

treatment interventions and monitoring.
• The biggest challenge for nurses in working with this client group is keeping
them engaged with the service.
• There are numerous medical conditions associated with substance use

disorder, the treatment of drug abuse is disease prevention. It presents
opportunities for screening, counselling and referral for HIV/AIDS, hepatitis
and other infectious diseases.

• The defining features of motivational interviewing (MI) are that the approach
is collaborative, person-centred, evidence-based, guiding method of
communication for enhancing and strengthening intrinsic motivation for
change.
Abuse Hallucinogens
Ambivalence Managed withdrawal
Cannabinoid Motivational interviewing (MI)
Cathinones Opioids
Dependence Stimulants
Depressants Substance use disorder
DSM 5
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Freeman.
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Psychology, 6, 1–62.
Brehm, S. S., & Brehm, J. W. (1981). Psychological reactance: A theory of freedom

and control. New York, NY: Academic Press.

Center for Substance Abuse Treatment. (2012). Enhancing motivation for change
in substance abuse treatment. Treatment improvement protocol (TIP) series,
No. 35. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK64967/
pdf/Bookshelf_NBK64967.pdf
Deci, E. L., & Ryan, R. M. (2000). The „what‰ and „why‰ of goal pursuits: Human
needs and the self-determination of behavior. Psychological Inquiry, 11(4),
227–268.
Festinger, L. (1957). A theory of cognitive dissonance. Stanford, CA: Stanford

University Press.
Miller, W., & Rollnick, S. (2002). Motivational interviewing: Preparing people for
change (2nd ed). New York, NY: Guilford Press.
Prochaska, J. O., DiClemente, C. C., & Norcross, J. C. (1992). In search of how

people change: Applications to the addictive behaviors. American
Psychologist, 47, 1102–1114.
Puig, V., Rose, J., Schmidt, R., & Freund, N. (2014). Dopamine modulation in
learning and memory in the prefrontal cortex: Insights from studies in
primates, rodents, and birds. Retrieved from https://www.ncbi.nlm.
nih.gov/pmc/articles/PMC4122189/
Rogers, C. (1959). A theory of therapy, personality and interpersonal relationships

as developed in the client-centered framework. In S. Koch (Ed.), Psychology:
A study of a science. Study 1, Vol. 3: Formulations of the person and the
social context (pp. 184–256). New York, NY: McGraw Hill.
Tiffany, S. T., Warthen, M. W., & Goedeker, K. C. (2008). The functional

significance of craving in nicotine dependence. In R. Bevins & A. Caggiula
(Eds.), Nebraska symposium on motivation: The motivational impact of
nicotine and its role in tobacco use (pp. 171–197). Lincoln, NE: The University
of Nebraska Press.
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abel use and safety. Retrieved from https://springerplus.springeropen.
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management and treatment of drug dependence in closed settings. Retrieved
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NBK310654.pdf

Topic  Challenges in
Managing
7 Psychiatric
Emergencies
LEARNING OUTCOMES
1. Elaborate self-harm and suicidal behaviour;
2. Describe aggression and violence in everyday social relationships;
3. Identify the strategy for reducing the risk of violence;
4. Describe the factors that indicate increased risk of violence; and
5. Discuss the interventions in managing aggression and violence.
 INTRODUCTION
In mental health, nursing the idea of „emergency‰ usually evoke images of a
patient attempting suicide or having to deal with a potentially violent patient. Of
course, the medical emergencies of the kind you will be familiar with do also
happen, but itÊs not „psychiatric‰ in nature. Perhaps, itÊs worth noting that in
mental health care, some specific drug related acute side effects can be distressing
and even in some instances life threatening.
For example, neuroleptics (or anti-psychotic medicines) can induce what is known
as „neuroleptics malignant syndrome‰, affecting the nervous system, causing
raised temperature, muscle rigidity and acute mental distress. Oculogyric crises is
also caused by neuroleptics, distressing but not life threatening. Due to the

146  TOPIC 7 CHALLENGES IN MANAGING PSYCHIATRIC EMERGENCIES
dystonia of the ocular muscles, the eyes roll straight upwards and to either side.
Because these are still medical emergency, we will exclusively focus on self-harm
and suicidal behaviour, followed by the management of aggression and violence.
Before we move on, let us briefly clarify the distinction between an „emergency‰
and a „crisis‰. In an emergency, one has to respond immediately, it cannot wait.
Meanwhile, crisis is a stressful event with the potential to overwhelm an
individual ability to cope effectively with a challenge.
So let us learn more on the challenges in managing psychiatric emergencies in the

next subtopics. Happy reading!
7.1 SELF-HARM AND SUICIDAL BEHAVIOUR

What is self-harm?
Self-harm essentially is injuries caused to oneÊs own body with the view to
deliberately hurt oneself.
This can take many form as it may involve physical cuts, burns and scratches or less
visible but equally damaging as in consuming drugs or excessive amounts of alcohol
or even engage in unsafe sexual activities, all designed to hurt oneself.
Usually, the intension is to harm and not to kill oneself, though sometimes the
behaviour can be dangerous and over time, some individuals may go on to attempt
suicide. History of self-harming behaviour is a risk factor for suicide. Thus, itÊs
important to bear in mind that close to half of the people who die by suicide have a
history of self-harming!
Self-harming behaviours do occur in all age groups but are much more common
among teenagers and young adults. Both girls and boys self-harm but the rates are
said to be higher in girls. It may be that some of the boyÊs self-harming behaviours
such as kicking or punching a wall may not be viewed as self-harming.
It is not difficult to work out that these are young people who are clearly not coping
with the challenges of their life circumstances, however maladaptive, their drastic
measure may distract them from their mental preoccupation and give some
momentary relief to their unbearable tension. Young people have a tendency to
punish themselves for not being good enough, even dislike themselves for it. It may

TOPIC 7 CHALLENGES IN MANAGING PSYCHIATRIC EMERGENCIES  147
be a reasonable view to take that self-harm is about a combination of punishing

oneself, communicating oneÊs distress and attain relieve from tension. ItÊs also
noteworthy that they usually want help and appreciate the help given.
Self-harming young people are usually socially withdrawn, even at home they may
spend more time in their room. Likely not enjoying school, not mixing well with
others, erratic attendance and not keeping up with academic work. Self-harm fits
into this private world where it will be concealed from others. They will cover up
the cuts and avoid talking about it. The secret is about shame; they may also fear
being found out.
It is well established that the onset of mental illness first occurs in childhood or
adolescence (Kessler et al., 2007). Insecure childhood attachment, trauma, abuse and
others is known to lead to problems with emotional self-regulation, predisposing
them to mental disorders. Negative self-perception, worthless and hopelessness,
together with intense anger and guilt, poor impulse control would suggest that the
teenage self-harming behaviours need to be seen as symptoms of underlying
problems.
7.1.1 Suicidal Behaviour

Suicidal is a major public health concern and the word that every parent, child,
friend and health professional dreads. Suicidal knows no bounds of person, age,
class race or gender. Suicidal ideation is defined as thoughts of engaging in
suicidal behaviour and the person have plan of suicidal will organise the
timeframe and method for killing himself.
Most will muddle through this period in their lives with support from family and
friends. Those who come in contact with professional services, may not necessary be
any worse than those who donÊt, but they have the opportunity to work through
their issues and learn how to think about their problems more realistically, and be
in a better position to handle future challenges. ItÊs important that an assessment of
needs and risk is done in addition to the self-harm.
7.1.2 Assessment of Self-Harm and Suicidal Behaviour

This include:
(a) Physical examination and health screening;
(b) Relationships at home, in school and with friends (living arrangements);

(c) Self-harming behaviour  The methods used, for how long and how often
specific triggers (events or feelings that occur before self-harm such anger,
guilt, anxiety, hopelessness, intense sadness, loneliness happened;
(d) Efforts at reducing self-harming ă What helped?
(e) Explore likelihood of future self-harm/stressor ă Eating habit, sleeping
pattern, mood, physical health, daily activity;
(f) Explore reasons for self-harming; and
(g) Explore suicidal thoughts ă Suicide risk.
SELF-CHECK 7.1
1. Distinquish between self-harming and suicide attempt.
2. Describe how childhood attachment affects adolescent.
7.1.3 Nursing Interventions

In in-patient areas, the nurse will work to nurture a nurse-patient relationship that
reflect person-centred approach to care in promoting patient well-being. In
previous topics, we have explored the therapeutic nature and value of your
relationship. So it wonÊt be necessary to cover the same material, but to underline
the need to seek to understand the person as unique. You will be helped by the
fact that these are young people who want to connect with others. ItÊs just that we
need to see beyond the cuts and the scars, and see the person you are engaged
with.
The medical officer will assess and determine if there is diagnosable mental
disorder and prescribe as appropriate. The team will also decide on the risk of self-
harm and suicide, and the level of observation and supervision required for
possible mental illness such as depression, anxiety, anorexia and personality
disorder. We explored depression and anxiety in earlier topics, now we will focus
exclusively on self-harm related issues.
Thus, you need to negotiate and agree a plan of care that will cover most of the
following:
(a) Opportunity to talk and explore ă Thoughts and feelings;
(b) Meaning of self-harming act to patient ă How does the patient make sense of
her actions?

(c) Promote acceptance of self ă Fallible but worthy and deserving

unconditionally;
(d) Increasing social engagement and interpersonal effectiveness, including
assertiveness;
(e) Role model appropriate interpersonal skills ă Acceptance of the other
unconditionally for who she is;
(f) Work at harm minimisation ă Making self-harming less severe and less
frequent; and
(g) Promote wellbeing in lots of different ways ă ItÊs not always about fixing, itÊs
about building into life things that can be helpful, supportive, enjoyable and
loving.
The patientÊs time on the ward need to be well planned and structured. She is
expected to work at her agreed problems, it will be tough, but without
overwhelming her. PatientÊs permission must be sought to involve family in the
treatment plan ă connectedness with others is a protective factor. In addition,
follow up appointments and home visits by community nurse will be important in
monitoring patientÊs social functioning and general progress.
Referral may be made for further specialist help if necessary. The therapies that
can be choose are:
(a) Cognitive behaviour therapy;
(b) Dialectical behaviour therapy;
(c) Solution focused therapy; or
(d) Psychodynamic treatment and family therapy.
7.2 AGGRESSION AND VIOLENCE IN

EVERYDAY SOCIAL RELATIONSHIPS
Fortunately, for most of us aggression and violence is not part of our routine daily
life. Though we are very aware that it can occur in peopleÊs relationships. Violence
can be present in the context of family relationships, work situations and in crimes
such as theft and burglaries. We are also perhaps fortunate with our cultural
protective factors, in that we are more accepting and tolerant of frustrations, we
do not readily resort to violence.

However, it is important that we draw a line to say physical violence has no place
and will not be to tolerated or accepted in our personal relationships.
What is aggression?
Aggression is usually the expression of hostility and may include threat of

physical harm, as in the angry threatening person.
Meanwhile, violence entails the actual harm (hurt and injury) caused to another
person through the use of physical force, verbal abuse and intimidation. One
cannot be violent without being aggressive.
Aggression can be brought about by many factors including individual factors

such as biology, psychological state, emotions; there are also other determinants
such as the „social situation‰. The social psychologists tend to view human
behaviour as situation specific. From this perspective, given the right situation, all
of us can become aggressive.
In the context of our work, aggression and violence, when they do occur, it will
make it difficult to deliver a good standard of care and safely. It also affects the
emotional quality of the working environment, significantly raising the stress
levels of nursing and other staff.
It is also known that nursing students face the brunt of these challenging
behaviours compared to other groups of staff. It cannot be easy for vulnerable and
inexperienced individuals to cope with the aftermath of a violent incident. You
will be pleased to know in mental health nursing, the staff know their patients
usually quite well and if you work closely with the staff, it is safer on the wards
than on the streets. Assessment of risk of violence have three important variables
as shown in Figure 7.1.
Figure 7.1: Three variables in the assessment of risk of violence

What causes aggression? There are many causes of it as explained in Table 7.1.
Table 7.1: Intrinsic Causes of Aggression
Physical Causes Cognitive Factors Emotional Factors
Lack of sleep Disorientation-time, place and people Anger
Pain Comprehension Grief
Drugs or alcohol Memory problems Frustration
Hearing impaired Paranoia, delusions, hallucinations Fear/anxiety
Delirium Lack of insight Guilt
SELF-CHECK 7.2
What are the three variables in the assessment of risk of violence?
ACTIVITY 7.1
Discuss in the myINSPIRE forum:
(a) The three extrinsic causes of aggression.
(b) The groups of patients you consider to be high risk of aggression.
7.3 STRATEGY FOR REDUCING THE RISK OF

VIOLENCE
There are things that are within our control that will go some way to reducing the
risk of violence. In spite of our best effort, violence may still happen, we will have
to deal with it. From the hospital management perspective, the risk management
has to do with:
(a) How the hospital is organised;
(b) How the hospital environment is controlled and managed; and
(c) Training and staff development.

For instance, measures such as adequate staffing in high demand areas, no area is
allowed to becomes over crowded, regulating and enforcing visiting hours, staff
training in dealing with the public, and handling difficult and violent individuals.
Understanding the person who becomes aggressive is important, as you may

already know there is always a cause for aggression. There will be issues that will
specifically relate to the individual, intrinsic factors like the patientÊs current state
of mind, distressing physical symptoms or simply his personality. There will also
be the situational or extrinsic factors like waiting time, poor staff attitude, warm,
noisy and chaotic environment.
Aggressive behaviour means the person is angry and he is letting us know he has
a problem, which is usually an unmet need! Though he is clearly not
communicating, perhaps, not able to communicate that need in the way we expect
him to. It may be that he is simply fearful, itÊs our job to understand his need and
respond.
7.3.1 Hospital and Team Culture

Good, well managed and led teams, tend to mitigate risk of aggression through
their good standards of practice. They tend to be more cohesive and communicate
effectively within the team, and are empathetic and responsive to patients needs
due to their patient centred approach. The patient centred approach together with
personal style of being courteous, politeness and friendly, helps avoid getting into
a struggle with patients and minimises conflicts and frustrations.
In addition, a team culture that promotes individualised and collaborative

approach to care would be therapeutic and responsive to the patientÊs
psychological and emotional needs. As such, the therapeutic nurse-patient
relationship must form the basis for risk minimisation strategies.
7.4 FACTORS THAT INDICATE INCREASED

RISK OF VIOLENCE
In mental health settings, the risk factors are usually well documented and
communicated. This allows for the staff to familiarise and be prepare with
contingencies. We know from experience listing, the diagnosis as a risk factor for
aggression, such as psychosis, personality disorder, learning disability and others
is meaningless.

In mental health, we need to know about the personÊs actual behaviour, as in

current and recent behaviour. The best predictor of future behaviour is past
behaviour. There is no substitute to the knowledge of the patient.
We know from experience of working with patients that certain factors suggested
an increased risk of violent behaviours. A number of areas normally considered
important to assess for risk of aggression and violence.
Personal history will include first and foremost the patientÊs history of disturbed
and/or assaultive behaviour. In addition, other information to be considered
include nature of assault, known triggers, frequency, use of weapons, extent of
injury caused, victim profile and so on.
A thorough assessment will highlight the following:

(a) A full account of substance and/or alcohol abuse would be important;
(b) Other peoplesÊ report especially carers, of expressions of anger and threats
of violence (intentions to harm others);
(c) Social restlessness ă Drifting, no fixed address and unable to hold onto jobs;
(d) Previous dangerous impulsive act;
(e) Denial of previous established dangerous acts;
(f) Evidence of recent severe stress, especially loss or threat of loss; and
(g) Cruelty to animals, reckless driving and so on.
In terms of clinical variables, they are:

(a) Abuse of substances and/or alcohol;
(b) Drug effects ă Restlessness and disinhibition;
(c) Positive symptoms such as hallucinations (especially command
hallucination) and delusions, particularly if related to specific individuals;
(d) Obsession with violent fantasy and control;
(e) Excitable, impulsive, overt hostility and paranoia; and
(f) Poor treatment compliance.

As for situational variables, they are (the immediate environment):

(a) Availability of social support;
(b) Potential weapons in the immediate vicinity;
(c) Relationship problems (especially with potential victim) and access to this
person; and
(d) Compliance with ward routine and rules ă Limit setting, staff attitude and so
on.
When symptoms are poorly managed or are not responding to treatment as

expected, this may increase the risk of aggression, as in the experience of pain, lack
of sleep, hearing impairment and consumption of alcohol or drugs. Risks can also
increase when cognition is impaired, as in disorientation to time, place and people.
More central in mental health work is the patients mental state.
Individuals who are delusional, especially of the paranoid kind or patients who
are hallucinating, where „the voices are commanding to do harmful things.‰ These
are powerful motivators for aggression. Individuals who are poor at regulating
their emotions, especially anger, may pose an increased risk for aggression.
You are already aware that emotions will have cognitive and behavioural
components. In anger, the inference (part of cognition) will be injustice or
unfairness. The cognition will be „they cannot do this to me‰, „how dare they treat
me so unfairly.‰ The anger will increase; you can see the hardening of the arteries.
The action tendency (behaviour) will be the urge to punch. The person may not
always follow through with the behaviour.
Unlike other medical disciplines, in mental health care, we usually have all the
information we need to form a realistic risk profile for aggression. For instance, the
grossly delusional, paranoid patient in his acute phase, his behaviour will be
predictable ă he has been there before, itÊs all documented. The behaviour will be
repeated, unless the team intervenes with the contingency plan. There should be
no surprises and no emergency. It would reflect badly on the team when they had
the information but did not use it to good effect.
For some of the challenging behaviours presented by patients, the staff may
negotiate (when the patient is quite well) and agree with the patient an „advance
directive‰. Basically, the patient is having a say in how his behaviour should be
managed in its acute phase.

Following on from what has been stated, we could reasonably suggest the risk of
aggression will be high if the team is not settled and functioning for various
reasons, poorly resourced and managed, sickness and high staff turn-over, new
and inexperienced staff and so on. This level of team dysfunction would be the
responsibility of hospital management.
7.5 INTERVENTIONS IN MANAGING

AGGRESSION AND VIOLENCE
Clearly, a number of elements must come together for violent incidents to occur
and attention to each of the following elements may go some way to minimising
the risk of the situation escalating into violence.
(a) A trigger is always present, usually in the form of an event or circumstance
that the person reacts or responds to;
(b) It was common for a high level of arousal to accompany aggression and
violence;
(c) A weapon ă This can be anything, including a fist, knife, cups and so on; and
(d) A target.
7.5.1 The Assault Cycle

Once the individual has got to the point of being aggressive or violent, he/she has
entered the assault cycle (see Figure 7.2).
Figure 7.2: The assault cycle in sequence

Source: Kaplan & Wheeler (1983)

As you can see in Figure 7.2, there are five phases in this model of violent incident.
These are further explained in Table 7.2.
Table 7.2: Five Phases of Assault Cycle
Phase Description
Trigger We all have a baseline or normal behaviour which is usually non-

aggressive. You are now aware of a range of possible triggers. Depending
on how well you know the patient, the triggers are often missed. A trigger
moves ones emotion and behaviour away from the baseline
(psychological discomfort) into an escalation phase.
Escalation Emotion in the form of anger increases and clearly the potential for
violence is present. It is important for the nurse to recognise the need to
de-escalate the situation and take the appropriate actions.
Or if one is in a situation where there is no support, such as during a home

visit, one may decide to leave the situation. The very angry person is
unlikely to listen to reason or consider others point of view, it is better to
validate his anger and listen to what he has to say in a non-defensive
manner. Accept what he has to say without disagreeing or arguing.
Acknowledge his anger. Having expressed his feelings, allows the patient
time to compose himself ă check with him if he would like to discuss his
problem, give him control of the situation and respect, he may be more
willing to negotiate. More often than not, inappropriate actions and
attitude on the part of the nurse will escalate the situation into a crisis
phase.
Crisis The crisis point will be different for different individuals, as such it will
vary considerably; some individuals will simply retreat to their room and
may even slam the door, others may kick furniture, there will be
individuals who will refuse to cooperate or complete a task and yet there
will be some who will remain at the crisis point and intentionally and
violently physical assault others.
Once in this phase, communication will become extremely difficult and

should the situation become unsafe ă the nurse will need to prioritise the
safety of the patient, self and others; immediately clear other patients,
visitors etc. from the surrounding area, and staff in numbers will contain
the situation. We will explore physical interventions to prevent or
manage a crisis situation in a moment.
Recovery Here the agitation subsides and the patient begins to look calm ă the crisis
has ended. However, staff should still be vigilant and not assume the
patient was back at his baseline behaviour. The risk of further crisis
remains high. The patientÊs adrenaline will take some time to abate (up to
90 minutes) and the staff who were called to help should remain to ensure
control of the situation.

In practice, there have been many instances where well-meaning nurses

get assaulted during this phase because they intervened therapeutically,
to talk and reassure the patient, too soon! The patient may still be highly
aroused; it does not take much for him to escalate into a crisis again. The
graph in Figure 7.2 shows the crisis points in the recovery phase.
Depression In this post-crisis period, the patientÊs behaviour dips below his baseline
behaviour. He will be fatigued and will likely be tearful and sad, feel
ashamed, guilty and even angry at himself.
During this phase, the patient may be willing to accept care designed to
relieve feelings of guilt and other concerns he may have, and also to
discuss the incident with a view to preventing future occurrence. At this
point, close observation will be an integral part of the plan of care.
Source: Kaplan & Wheeler (1983)
SELF-CHECK 7.3
Explain the five phases of the assault cycle.
7.5.2 Awareness of Warning Signs

Experienced mental health professionals will be alert to the typical signs or
changes in behaviour that precede a potential violent incident. You would agree
prevention is much better than having to deal with a full-blown incident. The
nurseÊs knowledge of the patient is vital, particularly knowledge of warning signs
from previous incidents. These warning signs are:
(a) Increased restlessness and agitation  Pacing;

(b) Bodily tension;
(c) Increased volume of speech;
(d) Facial expression is tensed and angry;
(e) Refusal to communicate, withdrawal;
(f) Thought processes unclear, poor concentration; and
(g) Verbal threats or gestures.

7.5.3 Physical Interventions

When experienced mental health nurses notice the possibility of an incident
developing, they will need to do the following:
(a) Assess the situation;
(b) If necessary, telephone for assistance; and
(c) Avoid getting involved until adequate support is available.
An important principle in the management of aggression and violence is for the

staff to respond appropriately and proportionately in a manner as the patientÊs
behaviour escalates. The nursesÊ intervention should be least restrictive given the
patientÊs behaviour and the circumstances. Though we are discussing physical
interventions, you would agree that wherever possible, verbal communication
must be maintained, and the patient is offered the opportunity to choose to comply
with the instructions.
Restraint may be necessary in some circumstances as a last resort for the following
reasons:
(a) Significant physical attacks;
(b) Significant threats or attempts at self-injury;
(c) Prolonged over activity, risk of exhaustion;
(d) Prolonged and serious verbal abuse, threats, disruption on ward; and
(e) Risk of serious incident to self or others.
In any potentially aggressive or violent situation, it is important that one member

of the staff take on the role of an incident co-ordinator. This person need not be the
person in-charge or even a registered nurse. This personÊs role will be to take an
overview of the situation in the clinical area, especially in relation to the available
staff support, those who might be at risk and what action needs to be taken to
contain the situation. The coordinator will also direct staff responding to the call
for assistance as to what their roles will be, which are:
(a) Part of the control and restrain (C&R) team;
(b) Care for other patients;
(c) Make the environment safe (clear the area); and
(d) Stand-by for further instruction.

There must be sufficient support staff present before any physical intervention to
control an aggressive patient takes place. The incident coordinator will not
normally be part of the C&R team, unless there is a change of plans, in which case
someone else will take over the role of the coordinator.
7.5.4 Control and Restraint (C&R)

Should the need to physically restrain a violent patient arise, this must be
undertaken by the staff who are trained in team restraint. Team restraint involves
three C&R trained staff physically bringing the violent patient under control, with
minimal risk of injury to the patient and staff. The primary objective is safety ă
safety of the patient concerned, staff members, other patients and visitors.
The techniques used should be in accordance with current practice ă mechanically

sound and should avoid undue stress on the limbs and joints. The patientÊs head
must always be supported by one team member and no pressure should be applied
on the patientsÊ back, neck or chest. The time spent on the floor in a prone position
should be kept to an absolute minimum (no more than three minutes), bringing
the patient to a kneeling, sitting or standing position as soon as practicable. The
application of flexion on the wrist joint will cause pain, which can be used to gain
the patientÊs compliance in the process of restraint.
However, pain tends to also produce fear, anger and resentment in the patient and
should be avoided if at all possible. Once restrained, the patient may be secluded
in a seclusion room and/or sedated.
Control and restraint training is a specialised five-day training after which staff are
expected to attend annually to keep up-to-date with current changes. Members of
the staff who are not C&R trained should not get involved in physically restraining
the aggressive patient.
7.5.5 Seclusion
Usually, a specially designated room will be used for the purposes of secluding
patients for short periods. Mental health units will have policies about the use of
seclusion, review and medical supervision. However, there is no real therapeutic
benefit from the use of seclusion.

7.5.6 Rapid Tranquillisation

What is rapid tranquillisation?
Rapid tranquillisation is a process of using medicine to reduce the risk of harm

from violence.
Nurses should always take care of this process to avoid the patient from being
over-sedated causing loss of alertness or even consciousness. There is also the
possibility of respiratory and cardiovascular collapse or other underlying physical
disorders. Adverse drug interaction may be an issue as the patient is likely to be
on prescribed medication, some may use self-purchased or even illicit drugs. It is
likely that an important consequence of restraint and rapid tranquillisation will
damage the therapeutic relationship; hence, later on everything must be done
to rebuild the relationship. You will learn more on rapid tranquilisation in
Subtopic 9.5.1.
Now, let us discuss documentation. You will already appreciate the need for
nurses to clearly document the nursing care delivered to patients, as a matter of
both professional and legal requirements. In mental health care, the same applies
and there was additional law relating to the care of the mentally ill ă in this country
it will be the Mental Health Act 2001, though this Act has yet to come into force.
When we are treating people against their will or restraining and rapidly
tranquillising them, you would agree you would want some legal protection in
doing so. It was important for nurses under these circumstances to understand and
work clearly within the law and institutional policies. Failure to abide by the rules
will leave the nurses open to a host of accusations, violation of human rights,
assault, illegal detention or kidnap.
Incidents need to be documented clearly and objectively. Among others, the

following must be recorded: the date, time, place, who was involved and what
actually happened, nature of injury and so on. Nurses also need to document
clearly what was done as a result, why and by whom, and what was the outcome.
It is important to avoid interpreting the patientÊs behaviour by using phrases such

as „patient was angry‰, „his behaviour was very bad and threatening‰ and so on.
It would be better to document exactly what the patient said and did. For example,
the „patient pointed his fingers at S/N Jones and said, ÂI will get you! You stupid
bitch!Ê‰ In the documentation, there must be clear justification for the use of
restraint or rapid tranquillisation and it must reflect the hospital policy on
such interventions. You will learn more on rapid tranquillisation in Topic 9
(Subtopic 9.5.1).
7.5.7 Conclusion
It is not your role as learners to be involved in the management of aggressive and
violent individuals. However, it is important for you to understand how violent
incidents may be avoided by understanding and managing the risk factors ă
personal history, clinical and situational variables.
You should by now be aware of the four factors that must come together for a
violent incident − trigger, high emotion, weapon and a target. We were clear
throughout that it is much better to prevent a violent incident than having to
manage one. In this respect, oneÊs interpersonal skills and techniques in de-
escalation should be emphasised. Remember, always convey respect to the patient
and preserve his dignity.
The assault cycle as depicted earlier in Figure 7.2 is made up of the following five
phases ă trigger, escalation, crisis, recovery and depression. A graph is used to
show the sequence of the assault cycle. Clearly, each phase requires different
interventions and I emphasised the need for care in the recovery phase, as there is
still a high level of arousal and the patient could easily go back into a crisis phase.
We considered physical interventions in the prevention and management of

aggression and violence. Namely, the use of control and restraint and the
administration of rapid tranquillisation in ensuring safety for all concerned. In
doing this, care should be taken to ensure the nurseÊs response was appropriate
and proportionate.
Finally, we considered the need for a thorough, accurate and objective

documentation of the incident and the nurseÊs interventions with clear
justifications for the actions taken and outcomes.
 Self-harm essentially is injuries caused to oneÊs own body with the view to
deliberately hurt oneself. This usually takes the form of cutting, burns and
scratches or less visible but equally damaging acts of consuming drugs or
excessive amounts of alcohol, or even engage in unsafe sexual activities.
 Self-harming behaviours may lead to suicide. Many people who die from
suicide have a history of self-harm.
 Assessment of self-harm must also include needs assessment.

 Aggression is usually the expression of hostility and may include threat of

physical harm, as in the angry threatening person.
 Violence entails the actual harm (hurt and injury) caused to another person
through the use of physical force, verbal abuse and intimidation. One cannot
be violent without being aggressive.
 Important variables in the assessment of risk of violence include personal

history, clinical and situational factors.
 In spite of our best effort, violence may still happen, we will have to deal with
it. From the hospital management perspective, the risk management has to do
with how the hospital is organised, how the hospital environment is controlled
and managed, and training and staff development.
 In mental health settings, the risk factors are usually well documented and
communicated. This allows for the staff to familiarise and be prepare with
contingencies. Among the risk factors for aggression are psychosis, personality
disorder, learning disability and others.
 In addition, the personÊs actual behaviour, as in current and recent behaviour

as well as past behaviour need to be explored.
 The assault cycle shows the escalation and de-escalation of emotion together
with the potential crisis during recovery. It consists of trigger, escalation, crisis,
recovery and depression.
 Physical restraint of patients should only be carried out by staff trained in

control and restrain (C&R) team.
 Patients may be secluded and/or tranquilised following physical restraint.
 Rapid tranquillisation should be done under medical supervision preferably

in the presence of a psychiatrist.
 Documentation is important should anything go wrong.

Aggression Psychosis
Anger Rapid tranquilisation
Assault cycle Risk factors
Base-line behaviour Seclusion
Control and restraint (C&R) Self-harm
Documentation Suicide
Intentional harm Trauma
Physical restraint Violence
Protective factors
Press.
Dodge, K. A., Coie, J. D., & Lynam, D. (2006). Aggression and antisocial behavior
in youth. In N. Eisenberg, W. Damon, & R. M. Lerner (Eds.), Handbook of
child psychology: Social, emotional, and personality development
(pp. 719ă788). Hoboken, NJ: John Wiley & Sons, Inc.
Fetherston, M., & Morrison, P. (2018). Aggression and violence in healthcare and
its impact on nursing students: A narrative review of the literature. Nurse
Education Today, 62, 158ă163.
Harwood, J. H. (2017). How to deal with violent and aggressive in acute medical
settings. Journal of the Royal College of Physicians of Edinburgh, 47, 176ă182.
Kaplan, S. G., & Wheeler, E. G. (1983). Survival skills for working with potentially
violent client. Social Casework, 64, 339ă345.

Kessler, R. C., Amminger, G. P., Aguilar Gaxiola, S., Alonso, J., Lee, S., & Ustun, T.
B. (2007). Age of onset of mental disorders: A review of recent literature.
Current Opinion in Psychiatry, 20(4), 359ă364.
Krug, E. G., Mercy, J. A., Dahlberg, L. L., & Zwi, A. B. (2002). The world report on
violence and health. Lancet, 360, 1083ă1088.
Lascelles, K., Brand, F., & Alfoadari, A. (2017). Helping young people who self-
harm. Nursing in Practice, 94, 46ă50.
Tofthagen, R., Talseth, A. G., & Fagerström, L. (2014). Mental health nursesÊ
experiences of caring for patients suffering from self-harm. Retrieved from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4248333/

Topic  Therapies in
Clinical
8 Practice
LEARNING OUTCOMES
1. Describe the Freudian theory by Sigmund Freud and behavioural
learning theories;
2. Explain the operant and classical conditioning theory in the
explanation and treatment of phobias;
3. Elaborate the Carl RogerÊs „core conditions‰;
4. Discover the effects of „therapeutic milieu‰ on patient recovery;
5. Summarise the ABC model of rational emotive behaviour therapy
(RBET); and
6. Discuss the nurseÊs role in the preparation of the patient for

electroconvulsive therapy (ECT) and post-treatment care.
 INTRODUCTION
In this topic, we will review and explore some of the major theoretical perspectives
and therapeutic approaches that have helped shape contemporary mental health
theory and practice.
Clearly, it will not be necessary or even possible to cover every theoretical

perspective. However, we will cover the behavioural and Freudian
psychodynamic theories in some detail as they have influenced the clinical
therapeutic work most.

166  TOPIC 8 THERAPIES IN CLINICAL PRACTICE
We will also revisit some of Carl RogerÊs (humanistic) ideas and its acceptance in
mental health practice. Cognitive behavioural therapies have dominated clinical
practice for some years; as such we will review the approach of rational emotive
behaviour therapy (REBT) to psychological disturbance. If you are wondering the
appropriateness electroconvulsive therapy (ECT) (a physical treatment) slotted
into this topic, do not worry as we will briefly cover it anyway. So, let us continue
with the lesson.
8.1 THEORETIC PERSPECTIVES

Theoretical perspectives are essentially attempts at understanding and explaining
behaviours, both normal and abnormal. There are competing theoretical
explanations in our understanding of mental illness; hence, the changing nature of
our understanding of mental illness.
Depending on the prevailing socio-cultural climate, certain theories will come to

the front and others will recede into the background. The rise of the medical model
(biomedical approach) in the care of the „insane‰ was well established by early
1800s, what we today call the field of psychiatry.
Only in the early 1900s that Sigmund Freud (a neurologist) promoted the idea that
mental illness may have its roots in the unconscious. The Freudian theory became
very influential and dominated our explanation of human behaviour for a long
time, giving rise to the development of psychotherapy (talking therapy). However,
it was gradually challenged by the behavioural theorists with their more scientific
and evidence-based approach.
From around the early 1950s, more powerful and effective drugs started to change
the face of psychiatric care. You are already aware of the biochemical explanations
and the powerful role the pharmaceutical industry plays in the contemporary
psychiatry. For our present purposes, we will first explore Freudian theory;
followed by behavioural learning theory, Rogerian humanistic approach, rational
emotive behavioural therapy (REBT) and we will finish with an overview of the
role of electroconvulsive therapy (ECT) in mental health care.

TOPIC 8 THERAPIES IN CLINICAL PRACTICE  167
8.2 FREUDIAN THEORY (SIGMUND FREUD,

1856 TO 1939)
In Freudian theory, the mind is composed of the two parts, the conscious and the
unconscious.
(a) The conscious part consists of all the things that we are aware of or can
readily bring to our awareness.
(b) The unconscious part consists of thoughts, wishes, desires, urges etc., which
is not accessible to the conscious mind but influences behaviour.
Then, there is a transitional area known as the pre-conscious.
Freud theorised further that the structure of the mind consisted of id, ego and
superego (see Figure 8.1).
Figure 8.1: FreudÊs structure of the mind

Each being unique and developing at different time but interact to form a whole.
The id being the bundle of instinct one is born with, primitive and impulsive; is
the source of psychic energy referred to as eros, life instinct which also includes
libido, the psychosexual energy that drives all human behaviour. Thanatos is the
death (wish) or aggressive instinct. All of the id are in the unconscious, governed
by what is known as the „pleasure principle‰.
Id demands instant gratification of its desires and biological urges and has no
conception of time or reality. As it is not in touch with reality, it does not benefit
from experiences or even change with time. The part of id that is developed in time
and faces reality is referred to as the ego.
Ego draws all of its energy from id. The conscious part of the ego processes the
sensory input through the sensory organs and works to ensure the survival of the
organism. To this end, it is governed by the „reality principle‰.
Hence, ego serves the demands of id, but accounts for reality and may have to
work to defer gratification. While a good part of ego is in the conscious part facing
reality, it extends into the pre-conscious and the unconscious. Ego deploys what is
referred to as „defence mechanisms‰ to cope with the demands of id. We will
review some of the defence mechanisms in a moment. The third force in FreudÊs
model of the mind is called superego.
Superego is said to develop through childhood socialisation. The childÊs parents

set boundaries and impose „rules‰ (doÊs and donÊts) for the child. The child
internalises these externally set rules and subsequently operates by these rules
even when the parents are not around. It has been suggested that in this way,
societal norms, morals and values are transmitted from one generation to the next.
Depending on the strictness of the upbringing, the superego can be exacting and
severe, as it acts as a moral police in imposing constraints on the behaviour of ego.
As such, the ego essentially serves three masters, in that it has to mediate between
the demands of id, reality and superego. When the needs are not met, the
individual experiences tension and when there is conflict, the person feels anxiety
and guilt. For example:
(a) Conflict between ego and id is said to manifest as neurotic anxiety;
(b) Conflict with superego leads to moral anxiety; and
(c) EgoÊs conflict with reality leads to realistic anxiety.

8.2.1 Defence Mechanisms

In its effort to satisfy the demands of id, the ego mediates with reality and
superego. Ego applies the reality principle and if it is not successful, anxiety will
be experienced. The ego will then deploy defence mechanisms to help ward off the
ensuing anxiety.
What are defence mechanisms?
Defence mechanisms are strategies that are deployed at the unconscious level
to cope with the demands of id and/or superego, usually in the form of
thoughts and feelings that are unacceptable to the conscious self; hence,
sparing the individual from experiencing anxiety and guilt.
The excessive use of defence mechanisms can become psychopathological

(neurosis). It is in the same way that dreams are also thought of as pathological
product where the ego presents a demand of id as gratified but the individual
cannot make sense of it. There are numerous defence mechanisms; the following
are some of the important ones (see Table 8.1).
Table 8.1: Some Mechanisms of Defence
Mechanism Description
Repression Ego keeps a lid on disturbing or threatening thoughts from becoming

conscious. Unacceptable sexual thoughts or thoughts of violence are
suppressed before they get anywhere near consciousness. Ego expends
considerable energy in maintaining this lid.
Denial Preventing an actual event from being integrated into ones consciousness
or awareness because it was unbearable, too much to handle.
Projection This involves attributing to others oneÊs own flaws and unacceptable
thoughts and feelings. If one were to despise or feel hatred towards
another, due to the values of not looking down on other (superego), the
individual accuses the other of hating her.

Reaction The individual who experiences an urge, feelings or thoughts that are
formation unacceptable to the self, but the conscious behaviour is exaggerated
and publicly against it. The person who is fascinated by the perverse
pleasure of torturing animals, for instance, but campaigns against
cruelty to animals. Freud suggested that individuals who are
homophobic and are harsh in their attitude against homosexuals are
trying to convince themselves of their heterosexuality.
Displacement This is simply redirecting oneÊs aggressive impulse on to a substitute

individual or object. For example, instead of confronting the
unreasonable manager at work, one kicks the cat at home.
Sublimation Impulses such as aggression is channelled or expressed in a socially

acceptable way. Sports is a good example of sublimation; one may
take up rugby or kick-boxing.
Regression When confronted with an overwhelmingly challenging situation, the

individual abandons coping strategy and resorts to earlier childhood
behaviour that was fixated in one of the psychosexual stage of
development, when one might have felt safer. For instance, if fixated
in the oral-stage, the person may eat or smoke more; anal-stage
fixation may lead to obsessive or excessively tidy (or messy)
behaviour.
Rationalisation Explaining (in a rational manner) behaviours which are unacceptable

to the conscious self and in the process avoid confronting the real
issues. It is also often about protecting oneÊs „self-esteem.‰ For
instance, when oneÊs application for a promotion gets turned down,
the person may rationalise it as, „It is not a good post to be in anyway,
as there is too much unhealthy politics at that level.‰
SELF-CHECK 8.1
1. What is psychological defence mechanisms?
2. How does ego deploy defence mechanisms?
3. Explain repression.

8.2.2 Psychosexual Stages of Development

Freudian theory is credited for our present day emphasis on childhood experiences
as being important for the personÊs mental wellbeing in adult life. Freud theorised
that the child developed through a series of predetermined stages known as
psychosexual developmental stages. The stages are essentially zones of new bodily
sensation the baby experiences and explores throughout childhood (and
adulthood), known as „erogenous zones‰. The pleasurable sensations are to do
with libido (the energy that fuels the mind) and this may become fixated in a
particular stage of development if not adequately resolved. This has the potential
to shape oneÊs personality and influence adult behaviour. FreudÊs stages of
psychosexual development are given in Table 8.2.
Table 8.2: Stages of Psychosexual Development
Developmental Stage Age Range (Approximately)
Oral Birth to 18 months
Anal 18 months to 3 years
Phallic 3 years to 6 years
Latency 6 years to puberty
Genital Puberty onwards
These stages are further explained as follows:
(a) Oral Stage

This is the first stage of psychosexual development; the babyÊs mouth is the
focus of pleasurable sensation, both through feeding at the motherÊs breast
and exploring the environment  as in all objects will go to the mouth (the
erogenous area). The baby is said to act purely on pleasure principle, as the
ego may be in rudimentary form and superego has yet to develop.
The experience of weaning (the process of stopping breastfeeding) is the

major task in the oral stage. The infantÊs first experience of loss, of being
deprived the comfort of being fed at the breast. The infant learns to tolerate
delayed gratification and that the environment is not always responsive and
controllable; creating a healthy foundation for future independent and
trusting behaviour.

The fixation during this stage (oral stage fixation) has to do with too much
indulgence or gratification or conversely too little gratification. The
personality of the over-gratified child is likely to be immature, gullible and
effusing unrealistic optimism. The under-gratified child however, is likely to
be passive and untrusting, as the childÊs best efforts has not counted for
much. It has been suggested that regressive behaviours such as thumb
sucking, chewing of fingernails and pencils and smoking, may well have to
do with oral stage fixation.
(b) Anal Stage

The second stage of the psychosexual development is called the anal stage.
This stage neatly coincides with the period when the child is toilet trained. It
is suggested by the Freudians that the erogenous zone is now centred on the
anus. The infant is beginning to learn how to control the anal sphincter and
is said to experience pleasure in controlling the bowel and bladder. In
addition, it is also the power over the parents as the infant is able to defy and
withhold bowel motion at will.
Hence, the parenting style in a large measure affects the successful resolution
of the tensions experienced in this stage. Parents whose use of language is
measured and who use praise and other tangible rewards during the toilet
training will help the child master the process with relative ease. It also
results in the child developing a sense of accomplishment and self-control.
Conversely, parents whose language is harsh, ridiculing the childÊs efforts

and even being punitive during toilet training will elicit a more negative
response (uncooperative, resistive and withholding). It is suggested that in
order for the ego to be in control and defer the demands of id for gratification,
a much more moderate parental approach will help the child to learn
hygiene, cleanliness and some order.
Over emphasising toilet training, is said by Freudians, to nurture an „anal-

retentive personality‰, more obsessive, concerned with tidiness, order and
stickler for rules and are even said to be tight with money.
On the other hand, a more liberal or indulgent parental approach, where the
child soiled the pants whenever he pleases to resist toilet training and
derived some pleasure in doing it, is said to develop an „anal-expulsive
personality‰. As adults, these individuals are said to be messy, disorderly,
dislike being told to do things, stubborn and somewhat insensitive to other
peopleÊs feelings.

(c) The Phallic Stage

In this third stage of FreudÊs psychosexual development, the genitals become
the new erogenous zone. It is suggested the childÊs awareness and interest in
own and others genitals, gives rise to conflicts. In boys, it takes the form of
„Oedipus complex‰ and in girls „Electra complex‰.
The Freudian narrative suggests the boyÊs attachment to the mother becomes
somewhat sexual, as his libidinal focus is on his genitals. The child starts to
view the father as a rival for motherÊs affection and is envious and angry
towards his father; at the same time fears the father will destroy him.
Given the psychosexual stage, this anxiety is referred to as „castration

anxiety‰, the fear of losing oneÊs penis. The anxiety is overwhelming causing
him to suppress his urges and begins to identify with his father and takes on
his characteristics ă the superego is soothed somewhat, allowing the child to
move on to a much calmer phase, the latency stage. The Electra complex is
the female version of the same dynamics.
It is suggested by the Freudians that individuals who are fixated at the phallic
stage may develop a personality described as „a phallic character‰. That is
shallow self-centred (narcissistic) character that is self-assured but somewhat
thoughtless and stubborn. Unresolved conflict from the phallic stage can
affect oneÊs capacity for close intimate relationship. Freud was of the view
that homosexuality was the result of fixation in this stage.
(d) Latency Period

The latency stage follows the resolution of the tumultuous phallic stage, a
brief period of reprieve from sexual drives and urges. During this stage,
sexual impulses are suppressed and the libido is channelled into social
pursuits like sports, same gender friendships, studies and music. That is until
of course when the child reaches puberty, when the libido is once again
focused on the genitals.
(e) Genital Stage

The libidinal energy in this stage is focused on the genitals and greater
interest in relationships with the opposite sex. The less unresolved issues or
fixations especially from the phallic stage, the greater capacity the young
person will have for normal adult relationships. Otherwise, there will be
further struggle with anxiety, which will result in more repression and
defences.

SELF-CHECK 8.2
Differentiate the five stages of psychosexual development as

suggested by Freud.
8.2.3 Psychoanalysis
Freudian theory was not only about personality but also about how to do therapy
work. Freud popularised what is now considered as „talking therapy‰ and showed
how childhood experiences may continue to affect the adult behaviour. Freudian
therapy is normally referred to as psychoanalysis. You may want to read further
to put more flesh on the skeletal outline provided here as you will find it
interesting.
As you would expect, the Freudians see psychological disturbances as rooted in

the unconscious mind and symptoms are mere manifestation of the actual
unresolved fixation, hidden conflict (or trauma) that had been repressed during
the developmental stages.
In psychoanalysis, the therapist helps the patient to develop insight, both into his
or her behaviour and the „meanings‰ of the symptoms. The goal of therapy was to
bring the repressed conflict to consciousness so that the patient can deal with it. To
this end, the therapist may use a range of techniques such as „free association‰,
ink blots, interpretation, dream analysis, parapraxes, transference analysis and
resistance analysis. It is likely that you will not be familiar with the techniques
listed, hence the following brief clarifications are given in Table 8.3.
Table 8.3: Techniques of Psychoanalysis
Technique Description
Free This is a technique developed by Freud to access the unconscious

association mind. The thoughts we express in normal interactions are usually
censored or screened by the critical mind. To get around this
censorship, patients are told to be relaxed on a couch in a prone
position with the analyst sits behind taking notes. The patient is
trained to relax and talk about anything that comes to mind, usually a
stream of thoughts that may not be connected. The psychoanalyst will
help interpret and make sense of the material in the light of the
patientÊs experiences.

Ink blots This is a projective test that assesses perception, where patients are
(Rorschach asked to make sense of ink blots. The meaning ascribed to the ink blot
test) will be unique to the individual, giving additional information for the
therapist to interpret.
Dream Dreams are viewed as „pathological products‰ that expresses

analysis unconscious desires and repressed conflict. As such dreams are said
to be „the royal road to the unconscious.‰ It is suggested that when we
sleep, our level of consciousness is lowered, allowing the ego to
conserve energy by expending less energy on repression.
Through the dream, ego is able to present to id that its wishes have
been gratified. The dream work involves the manifest dream and
latent meaning. The manifest dream is what we are able to remember
upon waking, which is usually thoroughly censored and wrapped up
in symbolism so as not to disturb our conscious self, as we have no
idea what the dream was about.
The latent meaning is what has been disguised; Freudians again use
free association in conjunction with the themes in the dream to help in
the interpretation and transformation of the manifest dream to a latent
one.
Parapraxes These refer to minor faulty actions that are performed unintentionally,
such as a slip of the tongue, forgetfulness and misplaced objects that
are thought to reveal unconscious desires or wishes.
Transference Essentially, this refers to the process of projection of oneÊs feelings

towards an important person in oneÊs life onto another. In the context
of therapy, the patient may project her feelings towards her father (she
may have disliked him) on to the therapist by becoming hostile
towards him.
Hence, transference may become an important process in therapy,

giving the therapist opportunity to address the unresolved issues.
Resistance In psychotherapy work, it is common to experience resistance from

patients. In psychoanalysis, resistance is viewed as the patientÊs
unconscious attempt to prevent or repress painful memories or even
insights from entering consciousness. The patient may talk a lot about
unrelated issues, become quieter and uncooperative, and in extreme
cases may rearrange or cancel appointments. Again, the therapist will
work with the resistance as integral to therapy.

ACTIVITY 8.1
Find out more on psychoanalysis through the Internet. Share your
finding in for discussion in the myINSPIRE forum.
8.3 BEHAVIOURAL LEARNING THEORIES

The challenge to the long-held position of dominance of the Freudian theory was
in mainly led by the behavioural theorist. The behaviourist, unlike the Freudians,
took a much more objective and scientific approach to the development of the
behavioural theory and its application. Modern behavioural theories have their
roots in the works of well-known behaviourists such as Pavlov, Watson, Thorndike
and Skinner. For this subtopic, we will briefly review the work of Ivan Pavlov
(classical conditioning) and Burrhus F. Skinner (operant conditioning).
8.3.1 Classical Conditioning (Pavlovian Conditioning)

PavlovÊs work is called classical conditioning because it was the first type of
learning to be described within behavioural tradition. Pavlov was a biologist
studying the digestive system of dogs. The dog was placed in a harness and its
salivary duct was brought out to empty into a test tube to measure salivary
secretion. Food was presented for the dog to salivate. Pavlov was intrigued with
his observation that the dog began to salivate when one of his assistants walked
into the room. His study of this phenomena led to the discovery of the principles
of classical conditioning (see Table 8.4).

Table 8.4: Principles of Classical Conditioning
Concept Description
Neutral stimuli Any stimulus in the environment that may draw your attention but
not elicit a specific response. For instance, you hear a car horn whilst
in class or notice the light was switched off; it draws your attention
to it.
Similarly, the sound of a tuning fork to the dog in PavlovÊs
experiment was a neutral stimulus.
Unconditioned These are stimulus that elicits a specific natural response (built-in);
stimuli (UCS) for instance, shining a torch light into the eye will elicit a specific
response, the pupils will constrict. A sudden loud noise behind you
will startle you. These are unconditioned stimulus because they elicit
a specific response which is not learned.
Unconditioned The specific responses to the UCS (pupil constricting, being startled)
response (UCR) are referred to as unconditioned responses, again these are not
learned responses.
Conditioned The neutral stimulus after conditioning process becomes a

stimuli (CS) conditioned stimulus. Meaning it now elicits the specific response as
the UCS did.
Conditioned The new learned response to the conditioned stimulus.

response (CR)
These principles can be summarised as follows (see Figure 8.2):
Figure 8.2: Principles of classical conditioning

8.3.2 The Conditioning Process

This process has been organised into three stages, as follows:
(a) Stage One: Pre-conditioning

Naturally occurring unconditioned stimulus (UCS) produces an
unconditioned response (UCR) (for instance, in a child). The mother screams
in the kitchen as she accidentally scalds her hand while ironing. The child
becomes startled and anxious, thus starts to cry. Mother screaming (UCS)
and the anxious child (UCR), both are natural reactions and involve no
learning.
During this stage, there are neutral stimuli (NS) in the childÊs environment
that do not have an effect on the child. The NS could be the toys, the cat, radio
being on, tiny harmless spider and so on. In classical conditioning, the NS
does not have a specific effect until it is paired with UCS. This condition can
be summarised as in Figure 8.3.
Figure 8.3: Stage one: Pre-conditioning process

(b) Stage Two: Conditioning

The NS in this stage produces no response until it is paired (or associated)
with the UCS. For instance, the tiny spider (NS) is paired with a mother
screaming (UCS). When the NS (spider) elicits anxiety response in the child,
it becomes conditioned stimulus (CS). It is important that the NS occurs
immediately before or at the same time as the UCS for it to be associated.
Normally, the pairing need to occur a number of times, but under certain
conditions, one pairing will be sufficient to elicit the conditioned response.
Figure 8.4 summarises this situation.
Figure 8.4: Stage two: Conditioning process
(c) Stage Three: Post Conditioning

Now that the spider (CS) has been associated with mother screaming (UCS),
the spider elicits the new conditioned emotional response anxiety (CR) (see
Figure 8.5).
Figure 8.5: Stage three: Post conditioning process
PavlovÊs conditioning work in laboratory using a tuning fork (CS), food (UCS) and
salivation (to tuning fork) is known as conditioned response (refer back to
Figure 8.2). Presenting the CS (tuning fork) without UCS (food), after a number of
trials the salivation (CR) weakens and eventually becomes extinct.

However, after a period of interval when the CS (tuning fork sound) is presented,
the dog will salivate (CR) again. This is referred to as spontaneous recovery;
though this will again weaken quickly to become extinct. The conditioning is not
completely lost; if the dog was to be conditioned again it will learn fast.
If you are wondering about the example of the spider (CS) and the childÊs
conditioned emotional response (CR) anxiety, unlike the dog in harness, the child
will avoid the feared object, the reduction in anxiety will maintain the avoidance
behaviour (negative reinforcement). This we will explore in a moment, when we
review operant conditioning.
8.3.3 Operant Conditioning (B. F. Skinner,

1904 to1990)
Skinner was behaviourist from the US, who preferred to study observable
behaviour as opposed to intra-psychic events. Like his predecessors, Skinner
believed in the stimulus-response pattern of conditioned behaviour and
investigated the causes of an action and its consequences. What is operant?
„Operant‰ refers to the fact that organisms freely operate on the environment and
perform more of the behaviours that have favourable consequence; hence,
„operant conditioning‰.
Behaviourist are renowned for their work with cats, birds and rodents; Skinner
was no exception. He was well-known for his work with mice, in what is now
called „Skinner box‰. The essentials of the box are a lever, a mechanism for
dispensing food pellets and light which can be switched on and off (see Figure 8.6).
Figure 8.6: Skinner box

The mice are allowed to wonder in the box and when it happens to press the lever,
food pellet is delivered. In time, the mice will make a connection between pressing
the lever and food, as you would expect, the lever pressing behaviour increases.
The introduction of light as an additional variable, that is food pellet is delivered
only when the mice presses the lever when the light is on; the mice will soon
demonstrate that it is able to learn to discriminate.
Now, let us discuss schedules of reinforcement. The researchers realised that there
was no need to reinforce every time the lever was pressed, it can be varied and the
researchers can still maintain the behaviour. When the mice (or a person) performs
the desired behaviour and is rewarded each time, it is called continuous
enforcement and it is effective in learning new behaviours. Once the behaviour is
established, usually it is switched to partial or intermittent reinforcement. There
are four types of partial reinforcement schedules, namely:
(a) Fixed interval;
(b) Variable interval;
(c) Fixed rati; and
(d) Variable ratio.
These are further explained in Table 8.5.

Table 8.5: Four Types of Partial Reinforcement Schedules
Type Description
Fixed interval Reinforcement is delivered at fixed time intervals (for example, after 2,
5 and 10 minutes).
Variable The reinforcement based on varying amounts of time, which are

interval unpredictable.
Fixed ratio A predetermined (fixed) number of responses that must occur before
the behaviour is rewarded. For instance, every three presses of the
lever will result in reinforcement.
Variable ratio The number of responses needed for a reward varies, say an average
of four presses. This is said to be a powerful partial reinforcement
schedule, a favourite of the gambling industry, built into slot machines
(one arm bandits). This makes gambling very addictive and resistant
to extinction (see Figure 8.7).
Figure 8.7: Slot machines uses reinforcement schedule to

attract their users
Now, what are reinforcers?
Reinforcers are consequences of a behaviour that causes the behaviour to be

more likely to occur.

We have already seen the use of food as reinforcers with mice in laboratory studies.
There are several categories of reinforcers and it is important that the reinforcer is
carefully selected and delivered immediately after the desired behaviour occurring
or as close as. Bear in mind that what works for one person may not work with
others. The appropriate use of reinforcers can be helpful when working with
patients, and in all teaching and learning situations.
Examples for primary positive reinforcers are food, drink, warmth and air. These
reinforcers are useful with children, particularly children with learning disabilities
who have to learn basic skills like getting dressed in the morning. A reinforcer like
a sip of fruit juice through a straw from a small carton, every time the child
performs a task, like getting one arm into the shirt sleeve, can be very motivating
for the child.
Examples for secondary positive reinforcers are touch, eye-contact, smile,

proximity and praise. You know that these can be useful reinforcers ă but how do
touch, smile and others acquired the power to reinforce? Can you support this
statement?
Tokens are a good example of generalised positive reinforcers. There will be

circumstances when it may be convenient and more immediate to use tokens
which can be exchanged for other benefits later. Take note that this is not similar
to the tokens people receive at the end of every month in the form of money.
Negative reinforcer involves the removal of noxious or unpleasant stimulus. For

instance, if a child was unhappy and anxious in school ă staying away from school
will reduce her anxious feeling and that reduction in anxiety will reinforce her
school avoidance behaviour. In the Skinner box that uses a bird, the floor was
mildly electrified but sufficiently uncomfortable for the bird. Any of the birdÊs
action that removed the discomfort will be repeated. The birdsÊ newly learned
behaviour was being negatively reinforced. Skinner used this technique to teach
pigeon complex behaviours.
Next is punishment. Punishment is the application of corporal punishment such

as caning and smacking. What are your views about corporal punishment? Do you
think it works?
Consider for a moment the following domestic scenario. A woman living in a high-
rise apartment with her husband and two boys; five and seven years of age. Her
husband goes to work early in the morning and returns late in the evening. She
has told the boys they are not to play with the new hi-fi unit. She loses her temper
with them for misbehaving one morning; she says their father will have to deal
with them when he returns after work. In the evening, the boys were reading when

the father heard what had happened in the morning, he promptly gets angry and
smacks the boys. Which behaviour do you think will suffer ă the behaviour in the
morning or the behaviour immediately preceding the delivery of punishment?
Shaping is a technique where the behaviours that are likely to take one to the target
behaviour are reinforced. It was not always possible to wait for the final or finished
behaviour to reinforce. In behavioural terms, the phrase „successive
approximation to the target behaviour‰ best describes the reinforcement process.
For instance, a lecturer may wish to shape the behaviour of a very quiet student in
class so as to increase her verbal contribution and generally increase her interaction
and performance level during class. The lecturer may first reinforce her for
attending class, subsequently she has to attend class and answer questions directed
at her for the same reinforcement (she does not have to be correct with her
answers). The lecturer may than add other behaviours, such as cooperating and
contributing in small group work, for her reinforcement. Ultimately, the student
will be volunteering answers, asking questions and initiating discussions for her
reinforcement.
In chaining, a complex task or behaviour is broken down into smaller discreet

units. Each unit must be learnt and mastered successfully with the appropriate
reinforcement/feedback. Upon successful mastery of all the units, the task is
performed as a whole in the right sequence. A procedure like giving injection for
example, could be broken down and learnt in smaller units.
On the other hand, in reverse chaining, the learner is encouraged to finish the end
part of a procedure  the easy, clean and pleasurable part. For instance, when
doing a wound dressing, the new learner is asked to do the final stage of covering
the wound with a clean dressing. Subsequently, the learner is required to do the
more difficult part like wound cleaning, etc.
Token economy is used as reinforcers in carefully designed behaviour

modification programmes as a way of encouraging desirable behaviours in
patients. The tokens were exchanged for privileges such as going to the cinema,
walks with staff and cigarettes.

ACTIVITY 8.2
Discuss in the myINSPIRE:
(a) Real-life application of classical conditioning in
advertisements.
(b) How a phobia may be developed and maintained by using
classical and operant conditioning.
(c) How eye-contact, touch and smile have acquired the power to
reinforce.
(d) What would be appropriate reinforcers in the context of the
classroom?
8.3.4 Application of Behavioural Principles

Behavioural theories are widely used in just about every walk of life. This is
particularly the case in teaching and learning, and in health care. For instance, your
nursing course, it will reflect the influence of behavioural knowledge, in that your
curriculum will be broken down into smaller distinct units, with objectives and
learning outcomes (related to cognitive, psychomotor and affective domain),
assessments and feedback. Does that not remind you of chaining and the use of
reinforcement?
In mental health care, behavioural theories are very important and are used to
explain a wide range of behaviours or conditions we would generally consider as
abnormal. To demonstrate the application of classical and operant conditioning
principles, we will overview its use in the explanation and treatment of phobias
and anxiety disorders. (Please refer to Topic 3, where we considered interventions
for anxiety disorders). Now, in this topic, we will emphasise the principles
underpinning the interventions.
(a) Phobias and Systematic Desensitisation

Joseph Wolpe (South African psychiatrist) in the 50Ês worked with cats using
Pavlovian ideas. He devised what is now called systematic desensitisation
(or exposure). In specific phobias, such as fear of open or crowed space, or
even leaving home (agoraphobia), fear of heights (acrophobia), fear of dogs
(cynophobia), fear of closed spaces (claustrophobia) and so on, are not only
irrational, it can be distressing and debilitating, compromising the suffers
quality of life.

Phobias are learned behaviours; consider the application of classical

conditioning in the following scenario. Johan (a 6-year-old boy), is sent by
bus once a week to visit his grandmother, who lives on her own. She talks to
herself and has strange mannerisms which actually scares Johan;
consequently, he has been refusing to visit his grandmother. His mother
noticed that Johan was also anxious at the sight of red buses and would
refuse to get on them (see Figure 8.8). You are already aware anxious
individuals will avoid the feared object (person or situation).
Figure 8.8: Conditioning process of Johan
The principle underpinning this intervention is to de-sensitise the sufferer to

the CS, to a point where it does not evoke anxiety and ceases to be a CS. This
procedure will unfold in three stages (see Table 8.6).

Table 8.6: Three Stages of De-sensitisation
Stage Description
One This is about creating an anxiety stimulus hierarchy. Meaning

identifying and listing what is the least anxiety provoking to most
anxiety provoking. To Johan, getting into and travelling on a red bus
will be at the extreme end, most anxiety provoking. Looking at
pictures of buses in a magazine may be at the tolerable end; watching
moving red buses on television, seeing an actual red bus at a distance,
followed being close to and so on. Johan can have any number of
steps, the slower the process, the better.
Second It is about teaching Johan breathing and relaxation exercises (this has
been covered in progressive muscle relaxation). There is a concept
called „reciprocal inhibition‰, meaning one cannot have muscles
which are relaxed and be anxious at the same time, in anxiety, muscles
tense up. It is also a good idea to identify positive reinforcers to use
during the process.
Third It is about helping Johan confront the conditioned stimulus, the red
bus, in the order of least to most difficult on the stimulus hierarchy
list. He must be relaxed and comfortable with the conditioned
stimulus before he moves to the next step. The reinforcement is
important, praising him for his success, little success is important, it
is said, and success builds success. The final step will involve Johan
riding a red bus without feeling discomfort. Depending on JohanÊs
determination to confront the stimulus and his mastery of the
relaxation technique, this stepwise process can take several weeks.
(b) Flooding
The principle in this intervention being to prevent the avoidance or escape
behaviour. The sufferer has the opportunity to discover that the anxiety will
come down on its own, without the need to engage in neutralising behaviour.
This procedure involved exposure to the feared situation or object at a much

higher level of difficulty. In the scenario of fear of tiny spiders, the person is
placed in a room with a number of tiny spiders (CS). The person is not
allowed to „escape‰ from the situation. You may remember this avoidance
behaviour is maintained by reduction in anxiety (negative reinforcement).
In other words, the individual associates the avoidance behaviour with

reduction of anxiety (relief). Preventing the avoidance behaviour gives the
sufferer the opportunity to learn that the anxiety will, in time, come down on
its own. This procedure can be uncomfortable but much quicker.

8.4 ROGERIAN HUMANISTIC PERSPECTIVE

Carl Rogers was both an academic and a clinical psychologist who worked in
conjunction with Maslow to promote what is referred to as „humanistic
psychology‰ and established „person centred psychotherapy‰. He viewed the two
dominant schools of thought of the time, Freudian and behavioural theories as too
„deterministic‰; human behaviours were determined by forces outside the
individuals control ă Freudians invoked dynamic forces in the unconscious and
the behaviourists environmental contingencies of reinforcements.
Reflecting the humanist perspective, Rogers promoted a much more optimistic

view of human nature. He maintained that we act the way we do because of the
way we perceive our situation. He argued that humans are inherently good and
are motivated by higher ideals such as creativity and have a drive or tendency to
self-actualise.
From the personality development perspective, Rogers viewed the individual as

essentially the „self‰ or the way we see oneÊs self, in other words „self-concept‰.
This is essentially an outcome of childhood socialisation, through which oneÊs
understanding and beliefs about oneÊs self becomes more organised and consistent
but not quite set; this is said to be made up of self-image, self-worth and ideal-self.
We have covered this in Topic 1. Can you still recall?
Self-image has to do with the way one „sees‰ oneself, the evaluation whether
pleasing or otherwise will affect not only what one experiences, also how one acts.
Self-worth relates to how one values oneself, sometimes used interchangeably
with self-esteem. We are brought up to view ourselves in a conditional manner,
meaning ones self-worth is contingent upon doing well in a particular task or being
perceived as „good‰ by others. Meanwhile, ideal-self, refers to the kind of person
one would like to be. This image of the ideal-self is likely to change in view of
personal growth and changes in social circumstances.
ACTIVITY 8.3
Discuss in the myINSPIRE, the concepts of:
(a) Unconditional positive regard;
(b) Empathy;
(c) Genuineness; and
(d) Congruence.

8.4.1 Maslow’s Hierarchy of Needs

Maslow viewed human need in hierarchical terms, which is often presented in the
shape of a pyramid of needs (see Figure 8.9).
Figure 8.9: MaslowÊs hierarchy of needs
This hierarchy of needs starts with a basic physical need, such as food, shelter and
sleep. Then, the next stage is the safety need which includes security and stability,
followed by the social need, encompassing friendships, intimacy and belonging.
The next stage is the esteem need, such as social acceptance and achievement.
Then, we have the cognitive need which has to do with knowledge and intellectual
curiosity, followed by aesthetic need which stands for appreciation of art, beauty
and harmony. Finally, the top of the pyramid is self-actualisation, said to be the
goal of human development. Self-actualised people are said to be living fulfilled,
these are people who are motivated to maximise their potential, joyful, empathetic
and sharing. According to Maslow, the lower stage needs must be met before
moving to the higher needs. It makes sense in that if one were to be poor and
hungry, oneÊs preoccupation will be with food.

Rogers described the self-actualised person as a „fully functioning person‰ and

suggested seven characteristics that distinguished them. These characteristics are:
(a) Openness to experience and non-defensive in attitude;
(b) Live in the „here and now‰, in the moment without distorting it;
(c) Belief in oneself;
(d) Self-directed and take responsibility for their choices;
(e) Adapt well, creativity and non-dogmatic; do not seek to conform;
(f) Reliable individuals who are considerate and thoughtful in arriving at their
decisions; and
(g) Live life to the full and experience the range of healthy human emotions.
RogerÊs ideas about „person-centred approach‰ is not only well accepted in the
field of modern psychotherapy and mental health work, it is also widely accepted
in other disciplines such as education, training (especially in interpersonal
relations), nursing, human resource and social work. Perhaps, what is attractive
about Rogerian approach, is its emphasis on the centrality of the person (as
opposed to symptoms and disorder), the psychological health of the whole person;
who is viewed as the expert on his life, trusted to choose and to a large extend
direct his own therapy.
8.5 THERAPEUTIC MILIEU

The idea that the ward environment was important when caring for people who
were unable to care for themselves has been around for a very long time. You may
not be as aware that the word „ward‰ (as in hospital ward), is to entrust vulnerable
people in protective care. This has always been the responsibility of nurses. Just a
little background so that you appreciate how the idea evolved. The concept of
„therapeutic milieu‰ as used to mean what we mean today goes back to late 1940Ês;
where experimental work was done in the use of the total environment in re-
socialising neurotic individuals and also in the treatment of disturbed children.
The work of Max Well Jones (1953) in London was credited as pioneering work in
promoting the concept of therapeutic community as primary therapeutic modality
for people with mental health problems; his „patients‰ were described as suffering
from personality disorder (anti-social people). It is important to bear in mind that
the ideas promoted by people like Max Well Jones and the therapeutic community
movement were radical and anti-bureaucracy (by now there was ample evidence
that long term hospitalisation was damaging for patients).
Patients were actively involved in day to day decision-making about matters that
affected them and rules about communal living and expectations of each other.
You might think of it as a more democratic environment with communication and
decision-making being transparent; power arrangements are much more shared
between staff and patients. This makes the „traditional roles‰ of doctors, nurses
and patients are not as important in this environment.
Staff and patients were encouraged to be themselves and creative, as they explored
problems and traumatic experiences through psychodrama, role plays, talks,
discussions and others. Patients took responsibility for themselves by:
(a) Learning to value and trust themselves and each other; and
(b) Learning social and interpersonal skills through the therapeutic experiences
they helped to create on the ward.
Today, when we talk of therapeutic milieu or therapeutic environment, we are

talking of applying some selective ideas in our ward environment without
disrupting our role relationships and the power arrangements. It is true even
within the constraints, the patient care environment in psychiatric units and
hospitals are primarily the domain of professional nurses. Therefore, the
therapeutic environment is essentially created and led by nurses.
8.5.1 Caring Environment for Nurses
First and foremost, the milieu needs to be caring and supportive environment for
nurses to work in; meaning caring for ourselves and one another to work well
together. In addition, it has to be free of distraction preoccupations and mindfully
responsive to the needs others. How the nurses are in themselves and the manner
in which they practice will set the general tone and the vibe on the ward. If milieu
therapy is anything, it is about the nursesÊ humanity, their personal qualities and
interpersonal abilities; and of course the use of the whole environment so that
every patient encounter whilst on the ward is considered therapeutic.

8.5.2 The Patient Environment

For patients, the characteristic therapeutic elements in the environment will
provide and perform a number of functions. For convenience, they are organised
around the following themes:
(a) Therapeutic Containment, Safety and Healing

Patient who are not in touch with reality, sometimes even confused and
hallucinating will need a safe and understanding place, where they will have
their needs met without being ridiculed or belittled. The therapeutic practice
of containment, especially the imposition of external control in setting
boundaries needs to communicate to the patient that it is done to keep the
patient and the environment safe.
Calm and safe handling of maladaptive and anti-social behaviour will clearly
convey what is not acceptable; whilst at the same time working to establish
a working relationship, by being available, showing empathy, provide
reassurance, encouragements and guidance to draw on the intact aspect of
the self that promotes self-control and independence, especially self-care.
(b) Structured Ward Environment

The well organised and structured ward environment engenders a sense of
safety and reassurance in patients. It provides predictability for patients,
knowing what to expect when and where, with the expectation that patients
will get involved. The variety of activities and people involved can provide
both change and stimulation.
Always be mindful that patients need their private time to rest and reflect.
As we have discussed, the patientÊs social functioning is a measure of his or
her mental well-being, as you would expect as they get better, their voluntary
engagement, and level of social functioning and participation will also
increase.

8.5.3 Therapeutic Activities

Among the therapeutic activities are:
(a) Nurse Led Individual Sessions

In addition to nursing assessment and orientation of the patient, nurses are
usually well placed to offer patients individual time to talk and discuss
personal issues. Individual time with patients will help foster better
understanding of patients need and improve the working relationship with
patients, also making the nurse a much better advocate for the patient.
The therapeutic value for the patient cannot be overstated, especially if the
patient feels that she has been listened to and valued as a human being with
another person. You will be aware by now the non-judgmental,
unconditional acceptance when relating to patients has the effect of
disarming them (no need to be defensive), it is not only a pleasant experience
and a relief, the patient can be herself; she is always bigger than her problem.
This is a good place to start exploring the possibilities of making changes.
(b) Planned Ward Activities

The range of planned therapeutic activity on the ward will vary, but it would
be reasonable to expect occupational therapist and nurse led sessions.
Examples of therapeutic sessions may include, learning relaxation and
mindfulness, learning to be assertive in social situations through
assertiveness training groups, current affairs and discussion groups. There is
also usually cookery session for patients to join in. In addition, you would
also expect opportunities for impromptu board games, jigsaw puzzles, table
tennis, darts, leisurely walk and so on.
We should appreciate that the milieu is the nurseÊs domain and it is an integral
and a potent therapeutic ingredient in the recovery and psychological well-being
of patients. Ultimately, it is about the social acceptance, in the patient being
comfortable in the company of other people (greater capacity for closeness),
interacting and relating in a manner that is supportive of oneself and the other. In
other words, it is about providing the validation for the uniqueness of the
individual and onesÊ self-worth.

8.6 INDIVIDUAL, GROUP AND FAMILY

THERAPY
Therapies whether it is individual, group or family will be based on a theoretical
model and there are literally thousands of counselling modalities. However, not
all are able to produce research evidence in support of their model. Even Freudian
psychoanalysis, which used to take many years of therapy has had to respond to
consumer demand for outcome studies, by developing a briefer version of therapy.
The evidence based approach that is interventions have been developed through
experimental studies, such as behavioural theories, dialectical behavioural therapy
and cognitive behavioural approaches have in the main driven the more scientific
approaches. Unsurprisingly, there will be considerable overlap in theory and
techniques, when the models draw from the same pool of theoretical knowledge.
For instance, rational emotive behavioural therapy (REBT), cognitive behavioural

therapy (CBT) and dialectical behaviour therapy (DBT), utilise current cognitive
and behavioural theories in their understanding of emotional and behavioural dis-
regulation. To be fair to the humanists (RogerianÊs), these approaches also
incorporate RogersÊ core conditions.
The individual, group and family approaches depending on the model may or may
not utilise the theories we have reviewed. Group and family therapy tend to draw
from systems theory, group dynamic theories and sometimes also from non-
Freudian psychodynamic theories.
Given the popularity of cognitive behavioural approaches, we will briefly review

the essential components of one such model developed by Albert Ellis in the early
50Ês, rational emotive behavioural therapy (REBT). There is no expectation that
you will use this model in your work with patients, though you may find some of
the ideas useful in making yourself more emotionally resilient.
8.6.1 Rational Emotive Behaviour Therapy (REBT)

(Albert Ellis, 1913 to 2007)
In the early 1950Ês, Ellis had to contend with both Freudians who were dominant
in clinical practice and the behaviourist were a growing force in the academic
world. Ellis was essentially a humanist who drew from philosophy (Stoic
philosophers) and was prepared to integrate the developing behavioural and
cognitive knowledge in addressing human disturbance.

The following two quotes convey the essence of his thinking which informed the
development of the first cognitive behavioural therapy model:
(a) „People are disturbed not by things, but by the views they take of them‰ by
Epictitus; and
(b) „There is nothing either good or bad, but thinking makes it so‰ by
Shakespeare (Hamlet).
You would not be wrong if you thought these people have been way ahead of our
modern attributions psychology; perhaps, also not many things are really new!
In REBT, the three domains interact and influence one another, this is known as
„dynamic interactionalism‰. For instance, our behaviour or what we actually do,
will influence the way we think and feel. In turn, our emotion will affect the way
we act and think. Finally, our thinking will affect our actions and the way we feel.
For teaching and learning purposes, we separate them, but in practice, it is actually
one. The three domains, however, are treated as equals, but cognition is given
primacy.
Emotion and behaviour are mediated by cognitive processes. For our purposes,
cognition refers to all process in the brain, such as thoughts and images. Our
interest is specifically in the way we reason and the beliefs we hold in a given
situation. The beliefs can either be rational or irrational. We will return to discuss
the beliefs in a moment.
Meanwhile, emotion refers to the way we feel. In REBT, emotion is viewed as

healthy or unhealthy (we will deal with the difference in a moment); and all
emotions will have its characteristic cognitive and behavioural (including
physiological changes) features.
For instance, when you are experiencing „anger‰, you will notice physiological
changes, your thoughts (cognition) may go something like, „He doesnÊt know me,
how dare he says that about me!‰ When you are unhealthily angry, your behaviour
will be the first to use strong language, followed by chucking, hitting or kicking.
Even if you do not actually engage in the behaviour, if the emotion is unhealthy,
there will be an urge to do so; this is called action tendency.
In REBT, behaviour refers to the overt actions that we actually are engaged in,
observable physiological changes and behaviours that we actively do not perform.
For instance, „I would like to have that piece of cake‰ (belief), „but I wonÊt have
it‰ (action).

Now, let us look at ABC of REBT. In this model, the „A‰ represents „activating‰
events. The AÊs can be actual, as in „my car had a flat tyre this morning‰; or
inferred as in „my course leader doesnÊt like me.‰ Internal (bodily sensations or
thoughts) or external. Finally, the AÊs can also refer to the past, present or future
events. The AÊs can be literally anything we focus on. Aspects of the activating
event can be personally significant to the person concerned. Hence, one may make
inferences about the A. Inferences are hunches (making forecasts, guessing the
intentions of others and so on) about reality and need to be tested out, as such they
may be accurate or inaccurate. REBT theory suggests one (or more) of the
inference(s) will trigger the belief at B, this inference is called „critical A‰.
The „B‰ represents „beliefs‰. In REBT, a limited set of beliefs that are deemed to
be explicitly evaluated and are said to be at the core of a personÊs emotions and
significant behaviours. Beliefs can be rational or irrational. Ellis reduced a list of
about 14 beliefs to four core beliefs as shown in the following Table 8.7.
Table 8.7: Four Core Beliefs in REBT
Rational Beliefs (rBÊs) Irrational Beliefs (iBÊs)
Preferences Musts
Anti awfulising Awfulising (terrible, awful, horrible and

gutted)
High frustration tolerance Low frustration tolerance („I canÊt stand it,
unbearable and intolerable‰)
Self and other accepting Self and other downing („I am a failure,
unworthy and undeserving‰g)
REBT is clear about distinguishing the rational beliefs from the irrational beliefs.
The rational beliefs are said to be rational for the reasons that they are flexible,
consistent with reality, logical and they are helpful to the individual in achieving
his/her basic goals and purposes.
According to REBT theory, humans do not just perceive and make interpretation
of events, we more importantly engage in evaluating what we perceive. The
evaluation will indicate ones preferences or demands, which are known as beliefs.
It is usual for people to express their preferences of wanting, wishing, desiring and
so on, there is nothing wrong with them. REBT theory suggests that the non-
dogmatic preferences are at the core of our psychological well-being. The REBT
therapist would want the client to express preference in this form, „I would like to
win this weekÊs lottery jackpot, but I do not have to do so.‰ The first part is a

preference, „I would like to win this weekÊs lottery jackpot‰ (referred to as part
preference) but the client can subtly change it into an irrational belief by adding
„and therefore I have to do so.‰ To prevent this, clients are taught to express their
rational beliefs (preferences) in full form.
Ellis considered the preference as a primary rational belief from which three other
rational beliefs are derived, namely:
(a) Anti-awfulising;
(b) High frustration tolerance; and
(c) Self and other acceptance.
The anti-awfulising belief acknowledges that it is bad if you do not get what you
want, but in life; nothing is ever 100 per cent bad. The more important the
preference to you, the more unfortunate if you do not get it. „ItÊs bad that I did not
win the lottery, it is not awful that I did not get what I wanted.‰
High frustration tolerance acknowledges that not getting your preferences met
would be difficult to bear, but you can tolerate it.
Lastly, self and other acceptance in REBT theory suggests that if our preferences
are not met because of our failings or otherÊs blocking behaviour, then it is rational
for us not to like ours and others behaviour, but we accept ourselves and other
people as fallible human beings whose behaviours have been poor.
Hence, the final rational belief will be, „It would be bad if I do not get what I want
(not the end of the world scenario), it would be difficult, but bearable, I can tolerate
it; I can accept myself as a fallible human being, who is worthy and deserving
unconditionally.‰
The irrational beliefs, according to REBT theory, are central to psychological

disturbance. It is suggested that the irrational beliefs are essentially rational beliefs
that gets transformed into unhelpful and self-sabotaging irrational beliefs with the
following four characteristics:
(a) Rigid;
(b) Inconsistent with reality;
(c) Illogical; and
(d) It hinders oneÊs pursuit of basic goals and purposes.

„Musts‰ are rigid evaluations that are expressed as musts in absolute terms 
should, have to, ought to or got to and so on. According to REBT, these dogmatic
demands are at the core of psychological disturbances. It is suggested that when
the desire is very strong it is easy to make it into a must. For example, „I must pass
my forth coming exam.‰ As opposed to the preferential belief, „I want to pass my
forth coming exam, but I donÊt have to do so.‰
Ellis suggested that the „must‰ is the primary irrational belief from which the
following three further beliefs are derived, namely:
(a) Awfulising;
(b) Low frustration tolerance; and
(c) Self and other downing.
Briefly, awfulising involved using a scale which is 101 ă infinity! Earlier, when we
considered anti-awfulising belief we said nothing that can happen to us can be 100
per cent bad. In awfulising, it starts from 101, so one demands one must pass the
forthcoming exam; „If I didnÊt, it will be horrible, terrible, gutted and so on.‰ The
low frustration tolerance is „I cannot stand it‰; „It is unbearable‰, „Intolerable‰.
Together with the self-downing beliefs, which involved globally rating the self,
such as, „IÊm no good, useless, failure and so on.‰ So when one fails to obtain what
one absolutely demands one must have, it will be terrible, awful; one cannot stand
it and one is a no-good, failure as a person.
Now, let us look at the consequences. The „C‰ in the ABC model represent
„consequences‰ can be emotional, behavioural (also cognitive). The consequences
are the result of holding a set of belief at B about the A (usually something
personally significant). It is usual for people to present emotional and sometimes
behavioural consequences as the presenting problem. REBT distinguishes between
healthy and unhealthy negative emotions. It is suggested, healthy negative
emotions are experienced when our preferences are not met. These negative
emotions are healthy because they allow us to deal with the situation in a
constructive manner, making changes, adjustments and so on.
On the other way around, unhealthy negative emotion is experienced when people
do not get what they demand they must get; or get what they demand they must
not get. Unhealthy negative emotions are unhealthy because they do not allow one
to constructively address the adverse situation. Thus, you have healthy negative
emotion when one holds rational belief at adverse AÊs; unhealthy negative emotion
when one holds irrational belief at negative AÊs (see Table 8.8).

Table 8.8: Healthy vs. Unhealthy Negative Emotions
Healthy Negative Emotion Unhealthy Negative Emotion
Concern Anxiety
Sadness Depression
Remorse Guilt
Sorrow Hurt
Disappointment Shame
Healthy anger Unhealthy anger
Concern for oneÊs relationship Jealousy
Healthy envy Unhealthy envy
What is an emotional responsibility? This refers to the fact that in the ABC model,
the A cannot cause the C. This is referred to as A-C connection. An example of this
will be, „My managerÊs behaviour made me depressed.‰ The activating event
being the managerÊs behaviour and as a result of his behaviour, „I am depressed‰
(emotional consequent).
In all CBT models, it is the B that results in C. Though the C (depression) is about
the A, it is the beliefs about the A that leads to the C. It is common for the average
person to think in terms of A-C connection.
According to REBT, unless the client understands and accepts her role in her
disturbance, that is the beliefs she brings to the activating event which causes the
C (B-C connection), she is unlikely to regain control over her depression. This
principle is referred to as emotional responsibility.
Next is the therapeutic style and sequencing. Firstly, we look at the therapeutic
style. REBT accepts the Rogerian core conditions, in that the client is held in
unconditional positive regard. It is regarded as important to be genuine and open
in the relationship with clients. The client is never made to feel attacked or
diminished in anyway.
However, unlike the Rogerians, REBT therapist do not treat their clients as fragile
and that the core conditions are viewed as desirable but not sufficient in them self
to bring about change in clients. REBT is a structured, active-directive,
philosophically and empirically orientated psychotherapy. Yes, clients will be

listened to (they will feel better for it), but to get better, they have to learn how they
disturb themselves, and work at overcoming their problems. So yes, in REBT, the
patientÊs brain has to take the strain.
Integral to the therapy process is what is called disputing. Once the iBÊs have been
sorted, the client is helped to generate more helpful rBÊs for that specific adverse
A. Both the default iBÊs and the new rBÊs are in turn subjected to Socratic
questioning, the idea being to weaken the iBÊs and strengthen the rBÊs. For
example:
(a) Logical or sensible? (As a philosopher would ask);
(b) Practical or useful? (As a plummer would ask);
(c) Supported by evidence, what evidence is there? (As a scientist would ask);
and
(d) Beneficial for me? (As an accountant ask).
How do we sequence the therapy process? The process is as follows:

(a) Presenting problem(s), assess emotional „C‰.
(b) If unhealthy assess ABC.
(c) Agree goals.
(d) Teach emotional responsibility.
(e) Understanding the person in the context of his problems (UPCP).
(f) Prepare client for disputing, homework and so on.
(g) Engage in disputing process:
(i) Disputing through Socratic questioning;
(ii) Role play/rehearsal; and
(iii) Role reversal.
(h) Rational emotive imagery.
(i) Give homework  Behavioural and cognitive.

(j) In-vivo exposure.
(k) Monitoring, practice and so on.
(l) Review homework beginning of each session.

(m) Relapse prevention work.

(n) Self-help/support groups.
SELF-CHECK 8.3
1. In the ABC model, what does A, B and C represent?
2. List four healthy and unhealthy negative emotions.
8.7 ELECTROCONVULSIVE THERAPY (ECT)

Lastly, let us look at ECT. It is said that the observation (in the old asylum system)
that patients who had convulsion did not develop symptoms of schizophrenia,
drove the search for ways of inducing convulsions in patients. In 1934 (Budapest,
Hungary), camphor-in-oil was injected to induce seizures in schizophrenic
patients, this was soon replaced by Metrazol which was much easier to administer.
This was the case until 1938, when it was replaced by the use of electric current,
introduced by the Italians. They „discovered‰ that abattoirs in Rome stunned pigs
using electric current before slaughter and the pigs were observed to convulse. As
they say, the rest is history.
There were other physical treatments during this period, deep sleep treatment
(continuous narcosis) using barbiturates, insulin coma therapy and
psychosurgery. All these treatments were around for a long time before they fell
into disuse.
It has been suggested that ECT has outlasted the other treatments because of its
effectiveness. Others have countered that by suggesting it was essentially cheaper,
more patients could be treated because it was quicker and no need for specialised
care for the unconscious for long periods.
Psychiatrists still use ECT for depressed, psychotic and aggressive patients (and
others), who they think are not responding well to the treatment (drugs). Usually,
it is viewed as a treatment of last resort. ECT remains controversial, but has
support from a relatively small group of psychiatrists working in in-patient areas.
What is ECT?

Electroconvulsive therapy (ECT) is basically the application of modified

electrical stimulation to the brain via electrodes placed on both sides of the
forehead (bilateral) or on the same side, applied to the less dominant
hemisphere (unilateral).
Short acting anaesthetic is used to render the patient unconscious during the
treatment and a muscle relaxant is used to keep the convulsion to a minimum.
Though the MO will explain the procedure and obtain patientÊs signed consent;
the nurseÊs role in the pre-treatment and post-ECT recovery and care is important.
The preparation is much like your outpatient minor surgical procedure; involving
both psychological and physical preparation. So make time for your patient to talk,
explore feelings, concerns and expectation. Your patient must be clear as to what
to expect before, during and after the procedure. If needed, check for the patients
understanding and offer appropriate support. A family member being around on
the morning of the ECT can be reassuring for some patients.
Because of the anaesthetic, it is important your patient understands he/she must

have nothing by mouth from midnight, remove nail varnish, dentures and so on.
Furthermore, bowels and bladder awe voided before being taken to the ECT unit.
During post-treatment, it is common for patients to experience some memory loss

(confusion and disorientation) and may also experience headache after treatment.
These symptoms do resolve fairly quickly. So explain, reorientate and reassure as
necessary. Last but not least, the nurse being with the patient, a familiar face, will
offer some reassurance.
SELF-CHECK 8.4
1. What is the key element that is said to be therapeutic in the ECT
procedure?
2. What are the common patient complaining immediately after

treatment?

 The theories that made major contributions in the understanding and

treatment of psychological disturbances are Freudian psychodynamic theory,
behavioural learning theories, RogerÊs humanistic theory and cognitive
behavioural theories (rational emotive behaviour therapy, REBT and cognitive
behavioural therapy, CBT).
 Freud was an early therapist to emphasize the importance of childhood

experiences.
 In Freudian theory, the mind is composed of the two parts: the conscious and
the unconscious.
 FreudÊs stages of psychosexual development are oral, anal, phallic, latency and
genital.
 The behaviourists did not dispute the existence of mind, but believed it was
more fruitful to focus on overt behaviour to study.
 PavlovÊs classical conditioning and SkinnerÊs operant conditioning are two

important learning processes.
 The behavioural and cognitive approaches are popular at the present time
because of their evidence based approach.
 Reinforcers are consequences of a behaviour that causes the behaviour more

likely to occur.
 The Rogerian humanistic approach, particularly the core conditions

(unconditional positive regard, acceptance, genuineness and congruence) are
well received by mental health professionals.
 MaslowÊs hierarchy of needs consists of physical need, safety need, social need,
esteem need, cognitive need, asthetic need and self-actualisation.
 The therapeutic milieu is the domain of the professional nurse. It is a physical

as well as a psychological environment led by the nurse in ensuring the
recovery and healing of patients.

 Albert Ellis is credited with being the first person to develop the cognitive
behavioural approach to the understanding of human disturbance. His rational
emotive behaviour therapy (RBET) theory and practice is one of the cognitive
behavioural approaches that are popular in clinical practice.
 Electro convulsive therapy (ECT) still remains popular with a small group of
psychiatrists in in-patient areas; in the main being used as a treatment of last
resort.
Classical conditioning Primary positive reinforcement

Conditioned response Psychoanalysis
Conditioned stimulus Psychological defence mechanism
Desensitisation Psychosexual stages
Electroconvulsive therapy (ECT) Rational beliefs
Extinction Rational emotive behaviour therapy
(RBET)
Flooding
Reinforcement
Freudian theory
Secondary positive reinforcement
Generalised positive reinforcement
Structure of the mind
Levels of consciousness
Therapeutic milieu
Milieu therapy
Unconditioned response
Negative reinforcement
Unconditioned stimulus
Operant conditioning

Austad, C. S. (2009). Counselling and psychotherapy today: Theory practice and

research. New York, NY: McGraw-Hill.
Corey, G. (2009). Theory and practice of counselling and psychotherapy (8th ed.).
Belmont, CA: Thompson.
Cramer, P. (1991). The development of defence mechanisms: Theory, research, and

assessment. New York, NY: Springer-Verlag.
Kaplan, J. S., & Tolin, D. F. (2011). Exposure therapy for anxiety disorders.
Retrieved from https://www.psychiatrictimes.com/view/then-now-
advancing-our-knowledge-mdd-comorbidities
Leiknes, K. A., Jarosh-von Schweder, L., & Hoie, B. (2012). Contemporary use and
practice of electroconvulsive therapy worldwide. Brain and Behaviour, 2(3),
283344.
Rogers, C. R. (1980). Way of being. Boston, MA: Houghton Mifflin.
Salas, L. M., Roe-Sepowitz, D. & Le Croy, C. W. (2012). Small group theory. In B.

A. Thyer, C. N. Dulmus, & K. M. Sowers (Eds.), Human behaviour in the
social environment: Theories for social work practice (pp. 327369).
Hoboken, NJ: John Wiley & Sons.
Taylor S. (2007). Electroconvulsive therapy: A review of history, patient selection,

technique, and medication management. Southern Medical Journal, 100(5),
494ă498.

Topic  Psycho-
pharmacology
9
LEARNING OUTCOMES
1. State the major grouping of antipsychotic drugs and their common
side effects;
2. Describe the mode of action of commonly used antidepressants and
their side effects;
3. Explain the use of mood stabilising drugs;
4. Discuss the use of benzodiazepines in the management of anxiety
related problems; and
5. Debate the use of „rapid tranquillisation‰ in mental health care.
 INTRODUCTION
In most developing countries (we are no exception), the treatment of mental health
problems revolves around the psychiatrist who tend to be heavily reliant on
prescribing medication. This is not about blaming the psychiatrist, who has not
much of a choice, but the political situation does not allow the decision makers to
invest the necessary resources to develop range mental health professionals. This
leads the psychiatrist with just one tool in his or her toolbox, which is drugs. This
is the reality in Malaysia; supported by this example:
An Iranian doctor in Malaysia saying that, all he kept hearing was

makan ubat. However, once he understood what it meant; he was
fine.

TOPIC 9 PSYCHO-PHARMACOLOGY  207
Based on that situation, the nurses have an important part to play in ensuring
patients understand the medicines they take and to consume it safely. You spend
more time talking to the patients; you have the advantage in that your
understanding of the patient is informed by what the patient has freely chosen to
share with you (volunteered information), which is likely to reflect the patientÊs
actual experiences more closely. We know patient compliance to medication
regime can be poor, that is with in-patients, let alone people who are out-patients.
Why do people not take their medicines as prescribed?
In this topic, we will be familiarise with the major groups of psychotropic drugs,
together with their desired and unwanted effects. Early recognition of the
unwanted effects will help avoid unnecessary patient distress; some side effects
can not only be severe, but there are ones that can also be permanent. We will first
overview drugs used to treat psychosis (including schizophrenia), followed by
antidepressants, mood stabilisers and antianxiety drugs. Let us continue with the
lesson.
ACTIVITY 9.1
Do you agree that „society is looking to medicine to solve every day
social problems‰? Discuss this issue in the myINSPIRE forum.
9.1 ANTIPSYCHOTIC DRUGS

Did you know that drugs used in the treatment psychosis (schizophrenia) are
usually called antipsychotic medication, neuroleptics or in the old day, major
tranquilisers? The most notable of these is chlorpromazine (Thorazine) developed
in 1952.
As explained in Subtopic 5.1.4, thioridazine (Mellaril or Melleril) and

trifluoperazine (Stelazine) are used for their sedative effects and to generally
control the positive symptoms of schizophrenia such as hallucination, delusion
and disordered thinking.
You can refer back to Subtopic 5.1.4 for the explanation of these antipsychotic
drugs.

208  TOPIC 9 PSYCHO-PHARMACOLOGY
9.2 ANTIDEPRESSANT DRUGS

There are literally hundreds of antidepressants on the market. The manufacturers,
in fact all of them, claim their product to be effective in alleviating the symptoms
of depression and they will show evidence for it. The newer antidepressants are so
popular; they are probably the most prescribed drugs in medicine.
However, the reality in clinical practice may not always reflect this, as you are
likely to see, the patients who do not respond to the prescribed antidepressants
being told that there will be one that will work for them, it is a matter of finding it,
through trial and error. If one were to adopt a more critical stance on the claimed
effectiveness of antidepressants, you are likely to see a much less rosy picture than
the one being promoted to the public (Turner et al., 2008; Kirsch et al., 2008;
Ioannidis, 2008). If you are sceptically inclined, do follow up the sources cited.
There are four major categories of antidepressants, as listed in the Table 9.1.
Table 9.1: Four Major Categories of Antidepressants
Category Example
Tricyclic antidepressants Amitriptyline, Imipramine and Doxepin.
Monoamine oxidase Phenelzine and Tranylcypromine.

inhibitor (MAOI)
Selective serotonin Fluoxetine, Sertraline, Escitalopram and Paroxetine.

reuptake inhibitor
(SSRI)
Atypical Venlafaxine, Duloxetine (serotonin and norepinephrine

antidepressants reuptake inhibitors, SNRI) and Bupropion (norepinephrine
and dopamine reuptake inhibitor, NDRI).
The SSRIÊs are more frequently prescribed at the present moment. It will be helpful
for you to familiarise yourself with the commonly used antidepressants and the
categories they belong to, together with their side effects. It is also worth noting
the trend in the wider use of these newer drugs in treating insomnia, anxiety, pain
and even adult attention deficit hyperactivity disorder (ADHD).

SELF-CHECK 9.1
What are the four major grouping of antidepressants?
9.2.1 Common Side Effects of Antidepressants

It is suggested the popularity of SSRIÊs and SNRIÊs has to do with the much-
improved side effect profile; hence, better tolerated by patients. All
antidepressants have side effects; the question is finding one with manageable side
effects. Of course, care must also be taken when prescribing antidepressants so as
to avoid serious drug-drug and drug-food interaction, as they do not mix well.
When switching between MOAIÊs and SSRIÊs (and SNRI), a gap of two weeks
without medicine is suggested before prescribing the new medicine. Patients on
MAOIÊs must not consume cheese, broad beans and cured meat (dried and salted
meat). The mixing with wrong medicines and eating the stated food will produce
a reaction called „serotonin syndrome‰, characterised by raised temperature and
fluctuating blood pressure, patient agitation and hallucination.
What are the common side effects of antidepressants? Let us find out the answer
in Figure 9.1.
Figure 9.1: Five common side effects of antidepressants

The following are some of the additional problems for which the United States
Food and Drug Administration suggest patients should immediately contact their
doctor:
(a) Thoughts about suicide or dying;
(b) Attempts to commit suicide;
(c) New or worsening depression;
(d) New or worsening anxiety;
(e) Feeling very agitated or restless;
(f) Panic attacks;
(g) Trouble sleeping (insomnia);
(h) New or worsening irritability;
(i) Acting aggressively, being angry or violent;
(j) Acting on dangerous impulses;
(k) An extreme increase in activity and talking (mania); and
(l) Other unusual changes in behaviour or mood.
These medicines are taken over long periods, sometimes for many years. It has
become evident over the years that people experience withdrawal symptoms when
the drug is discontinued. It is called „antidepressant discontinuation syndrome‰
to distinguish it from addictive drugs that are taken for a different purpose.
It is important to note the increased risk of suicide during both antidepressants use
and antidepressant discontinuation. So, maintaining a good relationship with the
patient and monitoring the patient will be important. Patients are likely to want to
stop their medicine early because they feel better, whilst others may experience
relapse even if they are taking their medicine. Thus, patients need to be prepared
for the withdrawal and it has to be gradual over a period of several months to help
make the withdrawal symptoms bearable.
SELF-CHECK 9.2
What are the common side effects and the problems of
antidepressants?

ACTIVITY 9.2
Discuss in the myINSPIRE forum on how you would respond when a

patient says to you, „IÊve been taking my Escitalopram for 18 months
and IÊm told to keep taking it. IÂm not getting better and the drug gives
me more problems.‰
9.3 MOOD STABILISING DRUGS

We have discussed mood stabilising drugs in Topic 4. Can you still recall? What
are mood stabilising drugs? As stated in Topic 4, mood stabilising drugs are drugs
that are used to treat mania, as in bipolar disorder, preventing the highs and lows
that are a feature of bipolar disorder and specifically in treating the acute manic
episodes. Medical treatment of bipolar disorder mainly involves the use of lithium
carbonate as mood stabiliser (and as a maintenance treatment).
For the small group of patients who cannot tolerate lithium, a number of
anticonvulsants drugs may be used as mood stabilisers such as carbamazepine
(Tegretol) and valproic acid (Depakote).
It is suggested that mood stabilisers work by decreasing abnormal activity in the

brain. In the treatment of bipolar disorder, you are also likely to see that
antidepressant drugs being used during the severe depressive phase and
antipsychotic drugs to treat the psychotic symptoms. Likewise, mood stabilisers
are used in the treatment of depression (together with antidepressants), disorders
involving impulse control, Schizo-affective disorder and so on.
9.3.1 Side Effects of Mood Stabilisers

Blood lithium levels need regular monitoring to keep within the optimum
therapeutic levels. The side effects can become severe if the blood lithium levels
are excessive. Some of the common side effects of mood stabilisers are:
(a) Altered levels of consciousness;
(b) Changes in vision;
(c) Convulsions;
(d) Excessively thirsty;

(e) Frequency of urination;

(f) Hallucinations;
(g) Hand tremors;
(h) Irregular heartbeat;
(i) Itchy rash;
(j) Nausea and vomiting;
(k) Speech is slurred; and
(l) Swelling in the face affecting the eyes, lips, tongue and throat; hand, feet and
ankle.
In addition, side effects related to anticonvulsants (carbamazepine and valproic

acid) include:
(a) Abnormal thinking;
(b) Agitation;
(c) Back pain;
(d) Blurred or double vision;
(e) Changes in appetite;
(f) Constipation;
(g) Diarrhoea;
(h) Dizziness;
(i) Drowsiness;
(j) Headache;
(k) Loss of coordination;
(l) Mood swings;
(m) Ringing in the ears;
(n) Uncontrollable movements of the eyes;
(o) Uncontrollable shaking of a part of the body; and
(p) Weight changes.

SELF-CHECK 9.3
1. What are mood stabilising drugs?

2. State the side effects of mood stabilisers.
9.4 ANTIANXIETY AND SEDATIVE-HYNOTIC

DRUGS
What is the function of antianxiety medications? Antianxiety medications, as you
would expect, calm the physiological response which has the effect of reducing the
intensity of the emotion (fear or anxiety). Even if the anxiety provoking thoughts
are unchanged, the absence of strong physiological response (symptoms of
anxiety) gives a sense of relief, leading to the cognitive appraisal (or at least the
impression) that the fear is under control.
There are a number of groups of drugs used in the treatment of anxiety related
disorders. The most common and well known antianxiety medications are the
group of drugs known as benzodiazepines; the first of which was
chlordiazepoxide created in 1955, marketed as Librium in 1960 (see Figure 9.2).
Figure 9.2: Librium

Source: https://kevopharmaceuticals.com/product/librium-chlordiazepoxide-10mg/

By the mid-70Ês, diazepam (Valium) was the drug of the time. These are essentially
psychoactive drugs that depress the central nervous system (hence, its
tranquilising or sedative effect).
In fact, they were referred to (in hospitals) as minor tranquilisers. They are said to
work by increasing the inhibitory neurotransmitter gamma-aminobutyric acid
(GABA) by binding to its receptor sites.
Today, benzodiazepines are used on an „as needed‰ basis, taken for short periods
of time, to keep physical symptoms manageable, such as trembling, rapid
heartbeat and sweating. Its rapid onset of effect is especially helpful, during
extreme anxiety, panic attacks; or people suffering from specific phobia, such as
public speaking and helping someone with fear of flying, to get on the plane.
Drugs in benzodiazepine group include:
(a) Diazepam;
(b) Clonazepam;
(c) Alprazolam; and
(d) Lorazepam.
9.4.1 Selective Serotonin Reuptake Inhibitor (SSRI)

and Serotonin and Norepinephrine Reuptake
Inhibitors (SNRI)
The newer generation of antidepressants are the treatment of choice for anxiety
disorder, though the tricyclic antidepressants are also sometimes used. The
benzodiazepines are used to augment the antidepressants, to produce a much
quicker effect. The following are some common drugs used to treat anxiety related
disorders (see Table 9.2).
Table 9.2: Some Common Drugs Used to Treat Anxiety Related Disorders
Drug Type Anxiety Related Disorders
Diazepam (Valium) Benzodiazepine Anxiety and panic disorder.
Fluoxetine (Prozac) SSRI Anxiety, obsessive compulsive disorder

(OCD) and panic disorder.
Alprazolam (Xanax) Benzodiazepine Anxiety, agoraphobia, panic disorder,

OCD and social phobia.

Clomipramine Tricyclic OCD.

(Anafranil) antidepressant
Imipramine (Tofranil) Tricyclic Anxiety, agoraphobia and panic disorder.

antidepressant
Buspirone (Buspar) Anxiolytic, non- Chronic anxiety disorder.

antidepressant
9.4.2 Side Effects of Benzodiazepines

Did you know that benzodiazepines are addictive and difficult to stop when used
inappropriately such as long periods? As you would expect, drowsiness and
dizziness are the most common side effects for benzodiazepines. The following are
other possible side effect of benzodiazepines:
(a) Blurred vision;
(b) Confusion;
(c) Difficulty thinking or remembering;
(d) Frequent urination;
(e) Headache;
(f) Increased saliva;
(g) Muscle or joint pain;
(h) Nausea and vomiting;
(i) Nightmares;
(j) Problems with coordination;
(k) Tiredness; and
(l) Unsteadiness.
SELF-CHECK 9.5
1. What are the drugs used to treat obsessive compulsive disorder
(OCD)?
2. State the side effects of benzodiazepines.

9.5 AGGRESSIVE AND VIOLENT BEHAVIOURS

Lastly, let us look at the medicine used to treat aggressive and violent behaviours.
Psycho-pharmacological interventions are usually chosen after careful
consideration of the nature of the psychiatric problem, such as psychosis or mania,
personality disorders, poor impulse control, substance abuse and self-destructive
tendencies. Information about previous instances of violent behaviours and how
patient responded to its management can be helpful. Usually for drugs to be used
the agitated, hostile and potentially violent patient was not responding to staff effort
at de-escalation and there was a significant immediate risk to the patient or others.
Once the decision has been made to use medicine, it is good practice to offer and
administer the medicine orally and only when this is not feasible consider the use of
intramuscular injection. Whichever method is used, the medicine needs to be fast
acting and work for about three hours. This process of using medicine to reduce the
risk of harm from violence is referred to as „rapid tranquillisation‰. You have learnt
on this in Topic 7. Can you still recall? Now, you will learn more on rapid
tranquilisation from the psycho-pharmacology perspective.
9.5.1 Rapid Tranquillisation

The aim of using medication at this stage was to rapidly achieve a reduction in
agitation and aggression without necessarily sedating the patient and with minimal
side effect. It was important for the patient to be conscious, communicating and
participating in his care. Rapid tranquillisation should be done under medical
supervision preferably in the presence of a psychiatrist. You could suggest rapid
tranquillisation has taken place whenever parenteral intramuscular (IM) medication
has been given to a patient against his or her will.
This was an intervention of last resort that is all other measures have been exhausted
and there was a high risk of violence, and harm to the patient and others: that is the
patient was still fighting and threatening to assault others.
Remember, rapid tranquillisation as an intervention was not about treating the

patient but more to calm the patient, reducing the risk of violence and consequently
harm to the patient and others.

It was usual for the following medication to be administered intramuscularly for the
purposes of rapid tranquillisation:
(a) Lorazepam 1 to 2mg;
(b) Olanzapine 5 to 10mg; or
(c) Haloperidol 2.5 to 5mg.
It is important that the staff that use rapid tranquillisation must be familiar with the
unit or hospital policy on the use of rapid tranquillisation and should be trained in
the assessment and management of such patients. This is because there are serious
risks involved in the use of benzodiazepine and antipsychotic medicines.
Therefore, the nurses need to ensure that they maintained the techniques and
equipment needed for cardiopulmonary resuscitation. They must also make sure
that before rapid tranquillisation was carried out, a set of drugs in injectable form
for side effects (Benzatropine, Procyclidine) and benzodiazepine antagonist
(Flumazenil) must be available and at hand.
SELF-CHECK 9.5
1. What is „rapid tranquillisation‰?
2. What is the medicine used for it?
ACTIVITY 9.3
Discuss in the myINSPIRE forum what de-escalation techniques
would you use when a patient is angry and hostile?
 Drugs used in the treatment psychosis (schizophrenia) are usually called

antipsychotic medication, neuroleptics or in the old day, major tranquilisers.
 Psychotropic drugs are powerful mind-altering substances used in the

treatment of mental illness. These medicines are grouped according to the
mental disorders they are in the main used to treat, such as antipsychotics,
antidepressants, mood stabilisers and anxiolytics.

 Undoubtedly these drugs have transformed the way we care for people who
are mentally ill. Care must be taken in minimising the serious unwanted effects
of the drugs.
 Antipsychotic drugs are conventional drugs. They are sometimes referred to

as first generation antipsychotics (FGAs) and consist of mainly dopamine
antagonists, that is, they block the dopamine receptor sites. They are effective
in controlling the positive symptoms such as hallucination, delusions and
agitation.
 The newer drugs are known as atypical or second-generation antipsychotics

(SGAs), said to not only produce less side effects, but also is useful in managing
the negative symptoms of psychosis.
 There are numerous antidepressants available on the market for the treatment
of depression and they are also used in the treatment of anxiety.
 There are four main categories of antidepressants:

ă Tricyclic antidepressants (Amitriptyline, Imipramine and Doxepin);
ă Monoamine oxidase inhibitor (MAOI) (Phenelzine and Tranylcypromine);
ă Selective serotonin reuptake inhibitor (SSRI) (Fluoxetine, Sertraline,
Escitalopram and Paroxetine);
ă Atypical antidepressants (Venlafaxine, duloxetine (serotonin and
norepinephrine reuptake inhibitors, SNRI) and Bupropion
(norepinephrine and dopamine reuptake inhibitor, NDRI).
 Mood stabilising drugs are used to treat mania, as in bipolar disorder,

preventing the highs and lows that are a feature of bipolar disorder and
specifically in treating the acute manic episodes.
 Medical treatment of bipolar disorder mainly involves the use of lithium

carbonate as mood stabiliser (and as a maintenance treatment).
 Antianxiety medications calm the physiological response which has the effect
of reducing the intensity of the emotion (fear or anxiety).

 There are a number of groups of drugs used in the treatment of anxiety related
disorders. The most common and well-known antianxiety medications are the
group of drugs known as benzodiazepines.
 Rapid tranquillisation is the term used to describe the process of using

medication to rapidly achieve a reduction in agitation and aggression without
necessarily sedating the patient.
Antidepressants Monoamine oxidase inhibitor (MAOI)

Antipsychotics Psychotropic drugs
Anxiolytics Rapid tranquillisation
Atypical antidepressants Second generation antipsychotics
(SGAs)
Benzodiazepines
Selective serotonin reuptake inhibitor
First generation antipsychotics (FGAs) (SSRI)
Mood stabilisers Tricyclic antidepressants
Cipriani, A., Furukawa, T. A., Salanti, G., Chaimani, A., Atkinson, L. Z., Ogawa, Y.
et al. (2018). Comparative efficacy and acceptability of 21 antidepressant
drugs for the acute treatment of adults with major depressive disorder: A
systematic review and network meta-analysis. The Lancet, 391, 13571366.
Ioannidis, J. P. (2008). Effectiveness of antidepressants: An evidence myth

constructed from a thousand randomized trials? Retrieved from
https://peh-med.biomedcentral.com/articles/10.1186/1747-5341-3-14

Kirsch, I., Deacon, B. J., Huedo-Medina, T. B., Scoboria, A., Moore, T. J., & Johnson,
B. T. (2008). Initial severity and antidepressant benefits: A meta-analysis of
data submitted to the Food and Drug Administration. PLoS Medicine, 5(2),
02600268.
Medical Development Division, Ministry of Health. (2016). Guidelines on

management of aggressive patients in ministry of health facilities. Retrieved
from https://www.moh.gov.my/moh/resources/Penerbitan/Garis%20
Panduan/Pengurusan%20KEsihatan%20&%20kawalan%20pykit/GUIDELI
NES_ON_MANAGEMENT_OF_AGGRESSIVE_PATIENTS_14042017.pdf
National Institute for Health and Care Excellence (NICE). (2015). Violence and
aggression: Short-term management in mental health, health and community
settings. Retrieved from https://www.nice.org.uk/guidance/ng10/
resources/violence-and-aggression-shortterm-management-in-mental-
health-health-and-community-settings-pdf-1837264712389
Rizkalla, M., Kowalkowski, B., & Prozialeck, W. C. (2020). Antidepressant

discontinuation syndrome: A common but underappreciated clinical
problem. Retrieved from https://jaoa.org/article.aspx?articleid=2761944
Turner, E. H., Matthews, A. M., Linardatos, E., Tell, R. A., & Rosenthal, R. (2008).
Selective publication of antidepressant trials and its influence on apparent
efficacy. The New England Journal of Medicine, 358(3), 252ă260.

Topic  Caring for
Clients in the
10 Community
LEARNING OUTCOMES
1. Describe the development of mental health services in Malaysia;
2. Explain the role of community psychiatric nurses (CPNs);
3. Discuss the current community mental health services;
4. Deliberate the barriers to treatment; and
5. Review the impact of mental illness on caregivers or family.
 INTRODUCTION
In this last topic, we will discuss on how to care for clients in the community. One
of the most importance of learning when working in the community was that the
power arrangement in the relationship with clients was much better balanced. The
contrast between working on the ward, in a hospital, with all the clearly defined
role-relationships, trappings of power, status and support that went together with
the total control of the environment; and working with a client in his or her home,
where you are essentially a „guest‰ and your client is in control could not be
greater.

222  TOPIC 10 CARING FOR CLIENTS IN THE COMMUNITY
With this changed context, oneÊs use of language also changes. We talk of „clients‰
as opposed to patients. Yes, you are a nurse and there will be doctors, but the
doctor is not with you and you are not wearing a uniform. The question is, can
there be a nurse (or a doctor) without the „patient‰? In the „community‰, the role
and the relationships amongst the professionals and with the client will be very
different from what we are used to in hospital settings.
Just to develop this theme a little further, nursing staff on the ward spend a large
proportion of their time responding to the needs of the organisation, including the
organisation at ward level, catering for the needs of a group of people, such as
attending to doctorÊs ward rounds, medicine time and meal time. The knowledge
and skills of the nurse is about servicing such routine tasks. This is overly
simplified.
However, when you work with individuals and their families, in their home
environment; the focus is on you specifically, the person you are. Your personal
qualities, how you relate and how you are received by others will form the basis
of the work you will do with the family. As you are responsible and accountable,
you are accorded a level of autonomy not possible on the ward.
Therefore, the nurses role and function, language used, knowledge and skills
required to work effectively in the community, will be the focus of this last topic.
Happy reading!
ACTIVITY 10.1
Can you list the advantages of working on the ward and in the
community? Discuss this matter in the myINSPIRE forum.
10.1 HISTORIC PERSPECTIVES

The period of British colonial rule saw the building of a number of „lunatic
asylum‰ style mental hospitals in the late 1700Ês and early 1800Ês in Singapore, the
Island of Penang to treat their sailors, and in Taiping which was mainly a mining
town.
Then, the famous federal lunatic asylum near Tanjung Rambutan in Perak was
established much later in 1911. Said to have started off with 280 beds and was
renamed „Central Mental Hospital‰ in 1928 (Haque, 2005) and later, in no time
grew into 4,000 bed hospital. Now, this institution is renamed as Hospital Bahagia
with just over 1,000 beds. Figure 10.1 shows you the signage of this hospital.
TOPIC 10 CARING FOR CLIENTS IN THE COMMUNITY  223
Figure 10.1: Hospital Bahagia landmark

Source: https://says.com/my/lifestyle/m-sian-city-life-34-trip-to-hospital-bahagia-
tanjung-rambutan
The next large mental hospital (3,000 beds) was set up in Tampoi, Johor, in 1933.
In Sabah, SandakanÊs Sim-Sim centre was the place for „lunatics‰, but since 1971,
Bukit Padang Mental Hospital is the sole hospital in Kota Kinabalu, with about 500
beds. In Sarawak (during the same period), a mental hospital was established on
Penrissen Road in Kuching, now called Sentosa.
Since our independence, there have been developments in both the mental health
policy and services, but it can be said that it was slow in coming. When it did
happen, it was not thorough and barely kept pace with the demands in a fast
changing society. The focus was almost exclusively on the medical doctors and the
training of psychiatrists, very little attention was paid to the other professionals;
till today there is no mental health nursing training in the country, other than the
one-year post-basic psychiatric nursing certificate, taught by doctors.
This will give you some idea as to the sense of urgency in our policy makers. The
Mental Health Act 2001, eventually came into force in 2010. The mental health
legislation which supposedly regulated our mental health services prior to 2010,
was what we had inherited from the British when they left; the Lunatic Ordinance
of Sabah 1951, the Mental Disorders Ordinance of 1952 for Peninsular Malaysia
and the Mental Health Ordinance Sarawak was passed in 1961 (Haque, 2005).

Surprisingly, it has taken us 53 years to getting around to updating our mental

health legislation. Mental health legislations are about formalising the mental
health work people undertake, giving them the legal support they need and at the
same time, ensuring our rights and interest (as members the public) are protected,
with checks and balances; the Mental Health Act 2001 does that part well, but the
legislation does no enshrine the peopleÊs right to mental health, that would mean
committing resources!
In terms of total number of beds, at the present moment, it is estimated that the
four old hospitals operate with a total of about 4,000 beds and the units attached
to general and district hospitals, 32 units have a total of 1,000 beds. These units
usually have a small group of staff who will visit some patients to administer their
monthly depot injections (long acting antipsychotic medicines), the group may
consist of a couple of nurses, a medical staff and a few nursing and medical
students. This group is usually referred to as the „community team‰.
There have been talks about community mental health teams, but often not a
serious attempt at planned, sustained provision of services in a locality. It has been
promoted (since around 1997) that the staff in primary care services are trained to
assess mental health needs and coordinate with the psychiatric services to help
patients access the appropriate mental health care. Primary care clearly has a role
to play in promoting mental wellbeing and early detection of mental health
problems. However, without committing additional resources, it is no substitute
to properly developed community mental health teams.
SELF-CHECK 10.1
Describe the development of mental health services in Malaysia.
10.2 ROLES OF THE NURSE

In this subtopic, we will explore the range of roles community psychiatric nurses
(CPNs) play in providing mental health services in non-institutional settings.
Clearly in our context, given the current state of the development of the mental
health services, the services in the community will also reflect the need for
development.
In developed countries, the services attempt to respond to needs in groups of

people in the community, by creating specific teams to respond to certain
challenges.

Hence, the type of community services the CPN is working with will determine
the role(s) of the nurse. The community mental health team (CMHT) will usually
be made up of CPNÊs, psychiatrists, psychologists, social workers and
occupational therapists.
In contemporary teams, each patient will have a named team member responsible
for coordinating all aspects of patient care. Regardless of the team, the CPN would
perform the following core function:
(a) Treatment planning;
(b) Medication management;
(c) Mental health assessment;
(d) Counselling/psychotherapy;
(e) Family education and support;
(f) Psycho-education;
(g) Group support; and
(h) Facilitate/liaise with psychiatrists.
Some of the services that the CPNÊs can be involved are explained in the next
subtopics.
10.2.1 Psychiatric Home Care

In the early days, staff from the ward would visit the patient at home to administer
medication and to generally monitor the patient. This was possible in part because
in the early 1950Ês, the of arrival of anti-psychotic medicines made it possible to
care for some people in the community. The first hospital to initiate home visits
was Warlingham Hospital in Croydon, England in 1952.
CPNÊs today operate in multidisciplinary teams based in the community and

visiting patients at home continue to be core part of their function. These
community mental health teams were part of the specialist mental health services
(secondary prevention) in that they worked closely with hospital staff to provide
continuing care following patient discharge.
Thus, the core function of this team was to provide long term support to resettled
patients. The CPN would attend patient case conference, reviews, discharge
planning and so on, in order to know the patient well in the process.

Depending on the assessment of the patientÊs social functioning and symptom

control, the CPN will explore a range of options for accommodation in the
community. Group homes or „half way house‰ for long term hospital patients who
could benefit from extra time or stepwise gradual adjustment to independent
living in the community.
Depending on the size of the accommodation, it could be a group of four to six

patients, with individual rooms, but they share the kitchen and the living room.
The CPN and the social worker will visit regularly to support and ensure the
arrangements are working for the patient. The CPN will monitor the patientÊs
mental state and make sure the patient is managing the medication and the meals
satisfactorily.
Other options for patients may be warden managed accommodation, living

independently on oneÊs own or back with family; it will depend on the patientÊs
level of preparation, mental well-being and social functioning.
10.2.2 Assertive Community Treatment

These teams are sometimes referred to as „assertive outreach teams‰. They work
with individuals who experience severe and enduring mental health problems,
who are known to the service and present uniquely challenging behaviours such
as non-compliance and non-engagement with the service. Consequently, they are
deemed to be at risk of a deterioration in their mental health and unable to function
in the community.
Thus, this team works to maintain the client in the community through their active
and assertive engagement. They offer practical support and treatment; for
instance, in symptom management, psycho-social interventions and social
inclusion.
10.2.3 Crisis Intervention Teams

When people are experiencing crises and their distress is such that professionals
are concerned for their mental welfare and safety, understandably they will admit
them to the hospital. The role of the crisis intervention team is to work to prevent
the admission of such patients to hospital. People with mental illness will be prone
to „mental health crisis‰, as they may experience acute phases of their illness, after
a period of relative stability.

In addition, they are also likely to experience crises in their lives, like everybody
else. What is a crisis?
A crisis is usually a non-life threatening situation, but the response to a

triggering event can be intense emotional, behavioural and even psychiatric
in nature; and the person is likely functionally compromised, out of touch
with reality and may pose a risk to self or others.
The team members are experienced in taking control of the situation and work to
de-escalate or calm the emotion. The skills are mostly interpersonal, quickly
establishing rapport, listening and exploring; assessing the mental state and
prioritising the presented problems. The team will work with the client until the
crisis is resolved and emotional equilibrium is regained, as the client returns to
pre-crisis functioning. This could mean working continuously with the client for
two or three days to several weeks. The client will then be transferred back to the
referring team.
10.2.4 First Episode Psychosis Intervention Team

These are evidence led service innovations that have been around for about 20
years. Sometimes they are referred to as „early intervention psychosis service.‰
This is a stand-alone specialised multi-disciplinary community mental health team
that focused exclusively on people experiencing first episode psychosis.
This team aims to intervene at an early stage of an illness, consequently reducing

the untreated period of a severe illness. The team operates along the lines of
assertive outreach model and intervene with a comprehensive package of care,
which will include the use of medication, psychosocial interventions, and patient
and family psychoeducation.
The goal is to reduce impairment and promote recovery, consequently the

prognosis will look better. The team will work intensively for long periods (though
still time limited), sometimes for more than two years.
Thus, cushioning the traumatic impact of the illness on the client and the family,
shielding them from further trauma of experiences of involuntary hospitalisation,
with the added advantage of avoiding intensive long term specialist treatment
later. The CPNÊs in these teams will have a much reduced caseloads to allow for
intensive treatment work. The work is demanding and challenging, consider for a
moment the personal qualities, knowledge and skills that would be required to
deliver this level of care.

10.2.5 Early Onset Psychosis

This team is similar to first episode psychosis intervention team, in that they are
active, assertive outreach team, except that they work exclusively with children
and adolescents. This is again a service innovation responding to emerging
evidence pointing to the fact that the majority of people with severe mental illness
develop their illness before or during their adolescence.
10.2.6 Assessment and Brief Treatment (ABT) Team

This team provides access, assessment and brief intervention service in the
community for adults with mental health problems. The focus of this team is on
well-being and recovery. They offer initial mental health assessment and short
term support, for about six months. They are easily accessible locally; clients can
self-refer and they will provide a range of support for clients, including the
following:
(a) Complete assessment of mental health and social care needs, help access
other mental health services or social services;
(b) Access a psychiatrist, talking therapies and other psychological help;
(c) Advice and information;
(d) Provide crisis intervention service;
(e) Psychiatric medication review and management where necessary;
(f) Self-help support groups;
(g) Support with social problems; and
(h) Promote recovery and well-being.
10.2.7 Forensic Community Mental Health Team

(FCMHT)
This team works with people who, because of their mental illness, personality
disorders and so on, have committed a crime or are high risk of offending, as such
they are a risk to themselves or others. The team works to improve the clientÊs
mental health and quality of life, and consequently manage the risk of re-
offending.

As with other assertive outreach teams, the core function and interventions in
relation to client mental health care and treatment will be the same, but this team
will very likely coordinate its work with the courts, probation services, in-patient
services, social services (housing, benefits and others) and the police.
For certain category of offenders (violent and sexual), the team will also coordinate
multi-agency public protection arrangements (MAPPA) that are put in place to
ensure the successful management of offenders.
SELF-CHECK 10.2
What are the role and function of the community psychiatric nurses
(CPNs)?
10.3 CURRENT COMMUNITY

Community mental health services remains pretty basic, both in terms of staff and
service development. In the large mental hospitals and some units attached to
general and district hospitals, small groups of nurses are designated as community
nurses, who will go out to visit patients.
In the local literature, this is sometimes referred to as „assertive outreach‰, where

the medicine is taken to the patient. The psychiatrist involved will usually see the
patients in the hospital out-patientsÊ clinic. It has already been suggested, since
1997, the primary health services have been co-opted to highlight their role in the
mental health promotion and early detection, even in the treatment of common
mental disorders.
Primary care services have a role in promoting mental health or in early detection
of mental illness. Thus, it should be part and parcel of what they routinely do, and
it is good that they have received some mental health training; but it is stretching
it a little bit to consider it as a substitute for a specialist community mental health
service.
10.3.1 “Mentari” Malaysia Initiative

Following the mental health legislation in 2010, the Malaysian Ministry of Health
initiated a project called „Mentari‰ in an effort to „improve outreach and re-
integration of people with mental health problems.‰

The services they provided include:

(a) Individual placement and support supported employment (IPS-SE);
(b) Assertive community treatment; and
(c) Support groups for patients and their careers.
There are apparently 20 Mentari, with at least one in each state, managed by the
Department of Psychiatry in the nearest hospital. The team is led by a psychiatrist
and team members including medical officers, occupational therapists, nurses and
medical social workers.
ACTIVITY 10.2
You can read the activities of Mentari team at https://www.moh.gov.my/

index.php/pages/view/1555?mid=580. Discuss in the myINSPIRE what
other activities that you can suggest to the team.
10.4 BARRIERS TO TREATMENT

There are four barriers to treatment that have been identified, as stated in
Figure 10.2.
Figure 10.2: Four barriers to treatment
These four barriers are further explained in the next subtopics.

10.4.1 Stigma
We have discussed stigma in mental health in the earlier topic. Suffice to say,
stigma is often the next biggest struggle for patients after their symptoms. The
responses of others, often unintentional may convey negative stereotypes towards
those experiencing mental health problems.
People do worry about what others think of them, as they may feel shame,
embarrassment and hopelessness; also not helped by their experience of
discrimination on a day-to-day basis, when looking for a job, housing or even
getting treatment. Making it extremely difficult for people to talk openly about
their difficulties and seek professional help. This barrier will mean the illness is
not treated for longer. Unfortunately, this delay may also be compounded by the
more discreet services of the traditional healers.
10.4.2 Manpower
The lack of investment in the mental health services is reflected in the poor quality
physical environment and a rudimentary community mental health presence;
discouraging the middle classes from using the service. With limited resources,
teams revolve around the psychiatrists exclusively; this does not allow for the
growth and development of the other team members, hampering the development
of multi-disciplinary expertise and services offered by the team. The public
perception of the team membersÊ performance matters if only to minimise their
scepticism towards mental health services and the treatments offered.
10.4.3 Economy
Mental health problems are an increasing public health burden with implications
both for the individual and national productivity. It is a vicious cycle, as low
income economies usually have under developed mental health service; untreated
or poorly managed mental illness undermines productivity, as we know severe
mental illness has its origins in early adulthood, diminishing the individualÊs
capacity for productivity and economic activity. Resulting in a loss to the economy,
consequently less resource to invest in peopleÊs mental health.
Hence, the prevalence of mental illness amongst the poor. Low income economies
become a barrier, as insufficient resources affect the availability and accessibility
to mental health services, simply not enough to go around.

10.4.4 Geographical Factors

Insufficient resources usually mean the rural areas will have even less access to
mental health services. Whilst in the urban areas people may resort to consulting
private services, however in rural areas, people usually cannot afford to pay and
consequently there will not be much private services either.
In fact, travelling from rural areas to access mental health services will add on cost
and time, a definite disincentive to seek help for mental illness. This may explain
why some people may resort to consulting the traditional and religious healers,
not that there is anything wrong with it, except that in cases of severe mental
illness, it is not much of an option either.
ACTIVITY 10.3
What are other factors that you think can be the barriers to treatment?
Discuss your answers in the myINSPIRE forum.
10.5 CHALLENGES FOR CAREGIVERS/FAMILY

Lastly, let us look at the challenges for the caretakers or family with a mental illness
person. We often hear our politicians and sometimes medical people argue that in
our community, „the family‰ has to look after the mentally ill. The implied
suggestion being that, unlike us in developed countries, the family is not there to
look after their mentally ill, so the state has to organise and provide the care, using
public funds. This means the families and the loved ones, having to shoulder the
burden of caring for the mentally ill on their own, sure they do it willingly, that is
why they are called „caregivers‰. They will tell you it is not all doom and gloom,
and burdensome. Caregiving transforms people, both emotionally and the way
they think.
Mental illness will be tough on the individual concern, it is also tough on the rest
of the family; spouse, children, parents and grandparents. The severity of the
illness (symptoms), behavioural disturbance and disability will be a measure of
what emotional burden the family has to bear.
By the time the mentally ill person gets to see a doctor in a hospital, it would have
been many months of emotional turmoil in the family, the main caregiver (may
also be the breadwinner) will be at the point of exhaustion, extreme tiredness,
sleeplessness and headache.

In fact, some caregivers may also show signs of depression and anxiety.
Remember, there is no substitute to effective treatment in reducing the caregiverÊs
burden. The nature of severe mental illness is that it will require long-term
treatment and care, and will likely progress in phases, whilst in acute phase may
require hospitalisation. Over time, the numerous hospital visits, periodic
admissions, frustrations with the service and so on will soon impact the caregiver.
The negative symptoms can be very difficult for the family to deal with, without
professional support. Their efforts to help the patient can become a struggle,
creating an environment we refer to as „high expressed emotion‰, this heightened
tension may lead to further flare-up of symptoms.
The family members have to make constant adjustments to their routine and
everything they do will revolve around the patient. The dynamics within the
family can become fraught with difficulties.
Some of the impact can be physical ill health, psychological problems (such as
depression and anxiety), social isolation and stigma. The main caregiver, if also the
main breadwinner, financial security may become an issue and also food
insecurity. Unemployment, poverty and divorce are only some of the
consequences.
In addition, children can be under nourished, school attendance and academic

performance can be poor. However, what will not be obvious to us will be the
trauma they have had to endure and the psychological scars they will grow up
with, if they are lucky!
Coming back to „our families care for the mentally ill‰, you can only appreciate
what that means if you had to give care to a loved one in the family. In the
developed countries, they invest in community mental health services because
they appreciate what burden the family endures in caring for a loved one who is
suffering from mental illness. It is a mark of a mature, caring and compassionate
society.
Well trained professionals, especially community mental health nurses, social

workers, psychologists and occupational therapists; working closely with clients
and families, making sure they do not feel that they are on their own, will help to
mitigate some of their burden. The professionals working collaboratively and
flexibly with the family, with respect, will go some way in helping to destigmatise
the family. Psycho-education will be the main intervention. In addition, the
caregiversÊ needs must be assessed and an agreed care plan should be in place.

SELF-CHECK 10.3
What are the impacts of mental illness on the family or caregivers?
 The development of mental health services in Malaysia started in the British

era with the „lunatic asylum‰ style mental hospitals in the late 1700Ês and in
the early 1800Ês, in Singapore and the Island of Penang.
 The Federal Lunatic Asylum near Tanjung Rambutan in Perak was established
much later in 1911.
 Since our independence, there have been developments in both the mental
health policy and services, but it can be said that it was slow in coming.
 The Mental Health Act 2001, eventually came into force in 2010.
 The role of the community psychiatric nurses (CPNs) will largely depend on
the type of community team they work with. The core function of the of the
CPN will include the following:
ă Treatment planning;
ă Medication management;
ă Mental health assessment;
ă Counselling/psychotherapy;
ă Family education and support;
ă Psycho-education;
ă Group support; and
ă Facilitate/liaise with psychiatrists.

 In developed countries, in an effort to be flexible and responsive to the needs

of groups of people in the community, evidence based innovative services are
developed. As examples, we considered the following community mental
health teams: psychiatric home care, assertive community treatment teams,
crisis intervention teams, first episode psychosis intervention team, early onset
psychosis teams, assessment and brief treatment (ABT) teams as well as
forensic community mental health teams (FCMHT).
 Our current community services are in need of development and consist

mainly of hospital based nurses visiting patients in their homes, to monitor and
administer drugs. Primary care services are roped in to play a more active role
in the assessment and detection of mental illness. The Health DepartmentÊs
initiation of Mentari teams are a small step in the right direction, but one team
in each state would not be adequate resources to meet the needs in the
community.
 There are four barriers to treatment that have been identified, namely stigma,
manpower, economy and geographical factors.
 The lack of well-developed community mental health resources and the

unrealistic expectations of the families to shoulder the burden of caring for the
severely mentally has far reaching implications for the family, local
communities and the economy. One might suggest that it is false economy.
Assertive outreach Geographical factors

Caregiver Lunatic asylum
Community psychiatric nurses Manpower
(CPNs)
Mental Health Act 2001
Community team
Mental illness
Crisis intervention
Psycho-education
Early onset psychosis
Stigma
Economy
First episode psychosis
intervention team

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Jamaiyah, H. (2000). Community mental health in Malaysia: Marriage of

psychiatry and public health. Buletin Kesihatan Masyarakat Isu Khas, 155ă
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National Institute for Health and Care Excellence (NICE). (2016). Implementing the
early intervention in psychosis access and waiting time standard: Guidance.
Retrieved from
https://www.nice.org.uk/guidance/qs80/resources/implementing-the-
early-intervention-in-psychosis-access-and-waiting-time-standard-guidance-
2487749725
Parameshvara Deva, M. (2004). Malaysia mental health country profile.

International Review of Psychiatry, 16(1ă2), 167ă176.
Royal College of Psychiatrists. (2017). Standards for community-based mental health

services (2nd ed.). Retrieved from https://www.rcpsych.ac.uk/docs/default-
source/improving-care/ccqi/ccqi-resources/ccqi-resources-core-standards-
for-community-based-mental-health-services.pdf?sfvrsn=eee5269a_2

MODULE FEEDBACK
MAKLUM BALAS MODUL
If you have any comment or feedback, you are welcome to:
1. E-mail your comment or feedback to modulefeedback@oum.edu.my
OR
2. Fill in the Print Module online evaluation form available on myINSPIRE.
Thank you.
Centre for Instructional Design and Technology

(Pusat Reka Bentuk Pengajaran dan Teknologi )
Tel No.: 03-78012140
Fax No.: 03-78875911 / 03-78875966


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NBNS2604

Psychiatric Mental Health Nursing

Copyright © Open University Malaysia (OUM)

Copyright © Open University Malaysia (OUM)

Module Writer: Assoc Prof Utharas Arumugam

Moderator: Noraizal Mohd Nor University Malaysia

Developed by: Centre for Instructional Design and Technology

First Edition, August 2020 (NBNS2603, August 2020)

Copyright © Open University Malaysia (OUM)

Topic 1 Principles of Psychiatric Nursing: Current Theory and Practice 1

Copyright © Open University Malaysia (OUM)

Topic 2 Psychosocial Assessment in Mental Health Nursing 43

Topic 3 Nursing Practice for Anxiety and Anxiety Disorders 65

Copyright © Open University Malaysia (OUM)

3.4 Care and Treatment of People Suffering from Anxiety 77

Topic 4 Nursing Practice for Mood Disorders: Depression and 85

Topic 5 Nursing Practice for Psychiatric Disorder: Schizophrenia 104

Topic 6 Managing Substance Use and Abuse 123

Copyright © Open University Malaysia (OUM)

6.3 Managing Substance Abuse and Dependence 133

Topic 7 Challenges in Managing Psychiatric Emergencies 145

Topic 8 Therapies in Clinical Practice 165

Copyright © Open University Malaysia (OUM)

8.5 Therapeutic Milieu 190

Topic 9 Psycho-pharmacology 206

Topic 10 Caring for Clients in the Community 221

Copyright © Open University Malaysia (OUM)

10.4 Barriers to Treatment 230

Copyright © Open University Malaysia (OUM)

COURSE GUIDE DESCRIPTION

Copyright © Open University Malaysia (OUM)

Table 1: Estimation of Time Accumulation of Study Hours

Study the module 40

Attend 5 tutorial sessions 10

TOTAL STUDY HOURS ACCUMULATED 160

COURSE LEARNING OUTCOMES

Copyright © Open University Malaysia (OUM)

Topic 1 introduces you to mental health nursing, with a discussion and

Topic 3 explores the dynamic interaction between cognition, behaviour and

Copyright © Open University Malaysia (OUM)

Topic 4 introduces affective disorders or mood disorders which are disturbance in

Topic 5 explores the overlapping concept of psychosis and schizophrenia, while

Topic 7 focuses exclusively on self-harm and suicidal behaviour, followed by the

Copyright © Open University Malaysia (OUM)

TEXT ARRANGEMENT GUIDE

Self-Check: This component of the module is inserted at strategic locations

Activity: Like Self-Check, the Activity component is also placed at various

Copyright © Open University Malaysia (OUM)

Clarke, L. (2007). Reading mental health nursing: Education, research, ethnicity

TAN SRI DR ABDULLAH SANUSI (TSDAS) DIGITAL

Copyright © Open University Malaysia (OUM)

Copyright © Open University Malaysia (OUM)

Copyright © Open University Malaysia (OUM)

Copyright © Open University Malaysia (OUM)

Our business is communication, so do talk. We know from experience that it is not

1.1 MENTAL HEALTH

Copyright © Open University Malaysia (OUM)

Mental health is defined as a state of wellbeing in which every individual

Copyright © Open University Malaysia (OUM)

1.2 ELEMENTS THAT CONTRIBUTE TO

1.2.2 The Concept of “Self”

Briefly, according to SI perspective, self-concept is developed through early

For instance, a 3-year-old may engage in a make-belief play of being mummy or