WHAT IS MENTAL HEALTH?
o Self- acceptance
• Balance in person’s internal life and adaptation to
reality
• A state of well-being in which a person is able to cope
with the normal stresses of daily life and his ability to
realize his potential (WHO definition)
CHARACTERISTICS OF A MENTALLY
HEALTHY PERSON:
There are six (6) major conceptual approaches toward a
definition of mental health. This discussion is crafted
from Psychiatric Nursing, Student Guide by Edna
Cacanindin which discussed the guide to the evaluation
of an individual’s mental status.
• Attitude towards individual self involves aspects
related to a person’s self- awareness.
o Self-concept is the part of the self that lies within
conscious awareness. It represents also a collection of
attitudes and ideas about the self and is said to be a life
experience product. In addition, this encompasses too all
that an individual perceives, knows and holds to be true
about his/her identity. Self-concept has fours aspects and
these are:
▪ Body Image which refers to the physical dimension of
self-concept. How to present ourselves to others
physically affects how others perceive us socially and
emotionally as well as intellectually.
▪ Personal Identity which refers to the psychological
aspect of self-concept and is the unconscious stratum,
mental data by which the individual is unaware. Further,
this refers to the perception of internal and external
reality. Said to be the inner world of the client encased
by feelings, thoughts and previous learning.
▪ Self Esteem as the emotional component of self-
concept is described as the degree of value or worth
ascribed to the self. In addition, it represents an
individual’s perception of the worth attributed to him by
significant others on the basis of his own presentation to
the world.
When individuals do not feel as though there is much
value to who they are as human beings or what they are
able to contribute to others, they are said to be of low
self-esteem. One example of which are suicidal patients.
▪ Role Performance which refers to the expression of
self-concept, the totality of how one is known to others,
one’s representation and public roles.
▪ A mentally healthy person accepts the strengths and
limitations realistically and works to maximize strengths
and minimize limitations. This depends on self-concept.
People tend to behave in ways which reinforce self-
concept.
o Self- awareness
Involves noticing how the self feels, thinks, behaves and
senses at any given
• Growth, development and self-actualization refers to
what a person does with his abilities and potentialities
that are important. A person’s involvement in outside
interests and relationships, concerns with an occupation
or ideas and his goals are considered.
• Integrative capacity
A mentally health individual has a unifying and
integrated outlook in life. The individual must be
confident and sure of his role and directions in life. This
also refers to the balance of the Id, Ego and Superego. It
refers also to the ability to tolerate anxiety and
frustration in stressful situations.
Autonomous behavior
o A mentally healthy individual has the ability for
independent thinking and action and has the ability to
make one’s own decisions and react according to his
own convictions regardless of outside environmental
pressures and accept responsibility for his actions.
• Perception of reality
o A mentally healthy individual must perceive reality
accurately. This also deals with how the person
perceives his environment and other people as well as
his reactions toward them.
• Environmental mastery
o A mentally healthy individual has the capacity to feel
in control of self and environment. This is the ability to
adapt, adjust and behave appropriately in situations
according to approved standards so that satisfactions are
achieved.
WHAT IS MENTAL ILL HEALTH?
• A state of imbalance characterized by a disturbance in
person’s thoughts, feelings and behavior.
• Poverty and abuses are the major factors which
increase the risk of mental illness in the home.
PSYCHIATRIC NURSING • The nurse views the patient’s behavior non-
judgmentally while assisting the patient to learn more
• Interpersonal process whereby the professional nurse
adaptive ways of coping
practitioner through the therapeutic use of self, assist an
individual, family, group of community to promote • The nurse should explore the patient’s behavior for the
mental health, to prevent mental illness and suffering, to need it is designed to meet and the message it is
participate in the treatment and rehabilitation of the communicating.
mentally ill and if necessary, to find meaning in these
• The nurse has the potential for establishing NPR.
experiences.
• The quality of NPR determines the degree of change
What is the core of Psychiatric Nursing?
that can occur in the patient’s behavior
• The interpersonal process, that is, the human to human
LEVELS OF INTERVENTION IN PSYCHIATRIC-
relationship.
MENTAL HEALTH NURSING
Who are the Clients of the nurse in the psychiatric
• PRIMARY – interventions aimed at the promotion of
setting?
mental health & lowering rate of cases by altering the
• Individual stressors
• Family • SECONDARY – interventions that limit the severity
of a disorder
• Community
• TERTIARY – interventions aimed at reducing the
Both mentally healthy and mentally Ill
disability after a disorder
THERAPEUTIC USE OF SELF:
CHARACTERISTICS OF A PSYCHIATRIC
• Main tool of the nurse in the practice of psychiatric NURSE:
nursing
 EMPATHY
• Using one’s humanity – personality, experiences,
o Nurse should be able to perceive and experience the
values, feelings, intelligence, needs, coping skills and
feeling of the patient to be able to understand it.
perceptions to help client grow, heal and change.
 GENUINENESS
CORE CONCEPT of the Therapeutic Use of Self:
o Sincere and honest in her relationship with the patient.
• It is the positive use of one’s self in the process of the
therapy. o Open communication
• It requires SELF-AWARENESS o “Professional Relationship”
SELF-AWARENESS  UNCONDITIONAL POSITIVE REGARD
• Understanding of one’s personality, emotions and o The nurse who appreciates the client as a unique
sensitivity, motivation, ethics, philosophy of life, worthwhile human being can respect the client
physical and social image and capacities. regardless of his or her behavior, background, or
lifestyle.
PRINCIPLES OF CARE IN PSYCHIATRIC
NURSING: o Simply respect.
• The nurse views the patient as holistic human being ROLES OF THE NURSE IN THE PSYCHIATRIC
with interdependent and interrelated needs. SETTING:
• The nurse accepts the patient as a unique human being • Ward Manager
with inherent value and worth exactly as he is.
• Socializing Agent
• The nurse should focus on the patient’s strength and
• Counselor
assets and not on his weakness and liabilities.
• Parent Surrogate
• Patient Advocate
• Teacher
• Technician
• Therapist
• Reality Based Model
• Healthy Role Model
COMMUNICATION
Communication refers to the reciprocal exchange of
ideas, beliefs, attitudes or feelings, between or among
persons. It is the process that people use to exchange
information. Messages are simultaneously sent and
received on two levels : verbally through the use of
words and nonverbally by behaviors that accompany the
words (De Vito, 2008).
Communication can either facilitate the development of
a therapeutic relationship or serve as a barrier to it. All
behavior is communication, and all communications
affect behavior (Stuart and Laraia, 2005).
Levels of Communication
a. Intrapersonal – occurs when people communicate
within themselves
b. Interpersonal – takes place between dyads (groups of
2 persons) and in small groups. This level of person-to-
person communication is at the heart of psychiatric
nursing
c. Public – communication between a person and a
several other people
Basic Elements
a. Sender - originator of the message
b. Message - information transmitted; may have both
latent and manifest content
c. Receiver - recipient of the message
d. Feedback - receiver’s response to the message,
indicating understanding
e. Channel – mode of communication
f. Context – the setting of communication
I. Modes of Communication
1. Verbal / The Spoken Word
a. Denotation – the meaning that is in general use by
most persons who share a common language
b. Connotation – usually arises from a person’s
personal experience
c. Private and Shared Meanings
2. Non-Verbal
a. Action Cues (Kinetics) - body movements like
gestures, facial expressions and other mannerisms.
b. Space (Proxemics) - use of personal and social space
- physical spaces between communications
 intimate space - up to 18 inches
 personal space - 18 inches to 4 feet
 social consultative space- 9 to 12 feet
 public space - more than 12 feet
**Therapeutic communication generally takes place in
personal space
c. Vocal Cues (Paralanguage) - it is the voice quality
(pitch and tone of voice, quality of voice, loudness or
intensity, rate and rhythm of talking) or how a message
is delivered; unrelated non-language sounds (sobbing ,
laughing, groaning, nervous coughing). The nurse should
moderate voice quality according to the message being
given to the client.
d. Object Cues – speaker’s intentional and non-
intentional use of all objects (dress, furnishings,
possessions). These communicate something to the
observer about the speaker’s sense of self.
e. Touch – can be used in therapeutic communication
but
should be done in a deliberate manner with the nurse
analyzing the client’s condition and the client’s likely
response. Touch can be inappropriate in some situations
and with some clients:
 Client who is suspicious and mistrustful
 Client who is a victim of abuse
 Client who has tenuous ego boundaries
 Client whose culture prohibits or restricts touch
f. Silence – can be a powerful tool for therapeutic
communication; may facilitate the client’s expression of
thoughts and feelings
THERAPEUTIC COMMUNICATION
TECHNIQUE
Therapeutic Communication - is an interpersonal
interaction between the nurse and the client during
which the nurse focuses on the client’s specific needs to
promote an effective exchange of information (Videbeck
2020).
Goals:
✓ Establish a therapeutic nurse-client relationship.
✓ Identify the most important client concern at that
moment (the client-centered goal).
✓ Assess the client’s perception of the problem as it
unfolds. This include detailed actions (behaviors and
messages) of the people involved and the client’s
thoughts and feelings about the situation, others, and
self.
✓ Facilitate the client’s expression of emotions.
✓ Teach the client and family the necessary self-care
skills.
✓ Recognize the client’s needs.
✓ Implement interventions designed to address the
client’s needs.
✓ Guide the client toward identifying a plan of action to
a satisfying and socially acceptable resolution.
Non-Therapeutic Techniques:
» Overloading – talking rapidly, changing topics too
often, asking for more information than can be absorbed
at one time
» Underloading – remaining silent and unresponsive,
not picking up cues, and failing to give feedback
» Value judgments – giving one’s own opinion
» Incongruence – sending verbal and nonverbal
messages that contradict one another
» Internal Validation – making an assumption about
the meaning of someone else’s behavior that is not
validated by the other person
» Defending – Your doctor is very good. This hospital
has a fine reputation.
» Requesting an Explanation – Why did you do that?
» Rejecting – You are not supposed to talk like that.
» Literal Response – If you feel empty then you should
eat more.
Ex. P : I’m an Easter egg; N : What shade?
» Looking too busy
» Appearing uncomfortable in silence
» Being opinionated
» Avoiding sensitive topics
» Arguing and telling client he is wrong
» Having a closed-posture-crossing arms on chest
» Making false promises – I’ll make sure to call you
when you get home
» Ignoring the patient – I can’t talk to you now
» Making sarcastic remarks
» Laughing nervously
» Showing disapproval – You should not do these
things
» Cliché’ – Always look at the brighter side of life so
you will not feel depressed
» Challenging – If you’re dead then why is your heart
beating?
» Belittling feelings expressed –
Ex. P: I have nothing to live for... I wish I was dead
N : I’ve felt that way sometimes.
» Denial
Ex. P : I’m nothing;
N : Of course you’re something. Everybody is
somebody.
» Introducing unrelated topic
Ex. P : I’d like to die.;
N : Did you have visitors this weekend?
III. THEMES OF COMMUNICATION
Themes of Communication – while showing empathy,
the nurse must be objective and skilled enough to
identify recurring themes in patient’s communication
and interpret the message that the patient is consciously
and unconsciously sending (Sia, 2004)
• Content Theme – the thoughts patient wishes to
express directly and indirectly.
• Mood Theme – refers to the emotion, feeling tone and
mood of the patient: sadness, happiness, crying,
laughing, fearful. It is observed in the patient’s personal
appearance, facial expressions and gestures.
• Interaction Theme – pertains to the way the patient
reacts and interacts or relates with the nurse and other
persons, including the role the patient assumes while
interacting.
THERAPEUTIC RELATIONSHIP
- a nurse-client interaction that is directed toward
enhancing the client’s well-being. The client may be an
individual, a family, a group or a community.
- a mutual learning experience and a corrective
emotional experience for the patient. It is based on the
humanity of the nurse and patient, mutual respect, and
acceptance of sociocultural differences. In this
relationship the nurse uses personal qualities and clinical
skills in working with the patient to effect insight and
behavioral change. Most importantly, the core of mental
health nursing is providing hope for a better future to
patients and their families (Stuart, 2010).
Elements of Therapeutic Relationship
a. Contract
- the time, place and purpose of the meetings as well as
conditions for termination are established between the
nurse and the client.
- the tasks in this phase of the relationship are to
establish a climate of trust, understanding, acceptance,
and open communication and formulate a contract with
the patient (Stuart, 2017).
- Establishing a contract mutual process is a in which the
patient participates as fully as possible (Stuart, 2017).
The contract begins with the introduction of the nurse
and patient, exchange of names, and explanation of roles
(Stuart, 2017).
ELEMENTS OF A PATIENT-NURSE
RELATIONSHIP
1. Contract
• Names of individuals
• Roles of nurse and patient
• Responsibilities of nurse and patient
• Expectations of nurse and patient
• Mutually agreed on goals
• Confidentiality
This is followed by a discussion of mutually agreed on
specific goals, in which the nurse focuses on what the
patient identifies as important problems to be resolved.
Because establishing the contract is a mutual process, it
is a good opportunity to clarify misperceptions held by
either the nurse or the patient.
b. Boundaries
- the therapeutic nature of the relationship ( as opposed
to a social relationship ) is established. Roles of
participants are clearly defined. The nurse is defined as
professional helper. The client’s needs and problems are
the focus of the interaction.
Confidentiality
- This is a basic condition of the therapeutic relationship
and needs to be maintained by the nurse. The nurse
shares client information only with professional staff
who need to know. The nurse obtains the client’s written
permission to share information with any others outside
treatment team.
- The issue of confidentiality is an important one to
discuss with the patient at this time.
- Confidentiality involves the disclosure of certain
information only to another specifically authorized
person. This means that information about the patient
will be shared only with people who are directly
involved in the patient’s care in the form of verbal
reports and written notes.
- This is important in providing for the continuity and
comprehensiveness of patient care and should be clearly
explained to the patient.
d. Therapeutic nurse behaviors
- consistent practice by the nurse of the following items;
self-awareness, genuine, warm and respectful behavior,
empathy, cultural sensitivity, collaborative goal setting,
responsible, ethical practice.
Phases 0f Therapeutic Relationship
1. Preinteraction Phase - two major tasks which should
be completed prior to the first interaction with the
patient:
• to develop nurse’s thoughts and feelings
• to conceptualize what she wishes to accomplish during
the interaction
• this is the only phase during which the patient is
excluded as an inactive and equal participant.
• This begins when the nurse selects or is assigned to
initiate a Nurse-Patient relationship and includes all that
the nurse thinks, feel or does immediately prior to the
first interaction with the patient.
• A major assumption is that most nurse experiences
anxiety of varying degree during the pre-interaction
phase.
GOAL: To encourage patient to verbalize as a step
toward assisting him to communicate and socialize.
Tasks of the nurse in this phase:
1. Self-exploration of feelings and fears
2. Gathering data about patient if information is
available
3. Planning for the first interaction with the patient
COMMON CONCERS OF PSYCHIATRIC
NURSING STUDENTS
• Acutely self-conscious
• Afraid of being rejected by the patients
• Anxious because of the newness of the experience
• Concerned about personally overidentifying with
psychiatric
patients
• Doubtful of the effectiveness of skills or coping ability
• Fearful of physical danger or violence
• Insecure in therapeutic use of self
• Suspicious of psychiatric patients stereotyped as
“different”
• Threatened in nursing role identity
• Uncertain about ability to make a unique contribution
• Uncomfortable about the lack of physical tasks and
treatments
• Vulnerable to emotionally painful experiences
• Worried about hurting the patient psychologically
2. Orientation Phase (Introductory Phase)
- The nurse establishes trust with the client
- The nurse assess the client
- A nursing diagnosis is formulated
- The nurse and client establish mutually agreed-on
goals.
Fact of contract:
- an agreement to work with patient for the purpose of
assisting him toward social recovery.
- Introduction of self (use of family name), time of
interaction, frequency and termination.
Barriers:
1. Manner in which a nurse and patient perceive each
other.
2. Social class of participation
3. Status – profession
4. Anxiety level of those participants
5. Other being a replication of a significant individual in
the past
6. Privacy
3. Working Phase
- Most of the therapeutic work is carried out during the
working phase. The nurse and the patient explore
stressors and promote the development of insight in the
patient by linking perceptions, thoughts, feelings, and
actions. These insights should be translated into action
and a change in behavior. They can then be integrated
into the individual’s life experiences. The nurse helps the
patient master anxieties, increase independence and self-
responsibility, and develop constructive coping
mechanisms. Actual behavioral change is the focus of
this phase.
Tasks:
1. The nurse plans outcomes and related interventions to
assist client to meet goals.
2. The nurse facilitates the client’s expression of
problems, thoughts and feelings.
3. The nurse uses the problem-solving approach in
collaboration with the client to resolve problems.
4. The nurse encourages and teaches coping measures to FOR DETERMINING PATIENT READINESS FOR
the client TERMINATION
5. The nurse encourages the client to practice adaptive • The patient experiences relief from the presenting
behavior and evaluates the effectiveness of this effect. problem.
Barriers: • The patient’s functioning has improved.
1. Patient testing the nurse • The patient has increased self-esteem and a stronger
sense of identity.
2. The nurse’s unrealistic assumption as to the progress
the patient should be making. • The patient uses more adaptive coping responses.
3. The nurse’s unwillingness to engage in the • The patient has achieved the planned treatment
tremendous task of improving her ability to collect and outcomes.
interpret data, to apply concepts and to share finings
Tasks:
with others.
1. The nurse evaluates outcomes, reassessing the
4. Nurse’s fear of closeness.
problems, goals and interventions, if necessary.
PROBLEMS:
2. The nurse and client express feelings about
a. Resistance- is the patient’s reluctance or avoidance of termination.
verbalizing or experiencing troubling aspects of oneself.
3. The nurse observes the client for regressive behaviors.
- It is often caused by the patient’s unwillingness to
4. The nurse evaluates the entire nurse-client
change when the need for change is recognized.
relationship.
b. Transference – is an unconscious response in which
Patient’s response to termination:
patients experience feelings and attitudes toward the
nurse that were originally associated with other 1. denial of the separation
significant figures in their life.
2. expression of anger and hostility
- Transference reduces self-awareness by allowing the
patient to maintain an inaccurate view of the world in 3. manifestation of symptoms and maladaptive behavior.
which all people are seen in similar terms. Denial – is a refusal, and often means a refusal to
c. Counter-transference- it is a therapeutic impasse believe or accept something as the truth.
created by thenurse’s specific emotional response to the Manifestation – a symptom or sign of an ailment.
qualities of the patient.
Regressive- refers to an unconscious, emotional defense
Counter transference reactions are usually of the mechanism where an individual’s personality reverts to
following three types: an earlier point of development.
1. Reactions of intense love or caring
2. Reactions of intense disgust or hostility
3. Reactions of intense anxiety, often in response to
resistance by the patient
4. Termination Phase (Evaluation)
Termination is one of the most difficult but most
important phases of the therapeutic nurse-patient
relationship. It is a time to exchange feelings and
memories and to evaluate mutually the patient’s progress
and goal attainment. Levels of trust and intimacy are
heightened, reflecting the quality of the relationship and
the sense of loss experienced by both nurse and patient.