COMMUNITY AND HOSPITAL

PSYCHIATRY NURSING

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 Ground rules
Attendance must
Punctuality
No Side talk
Participation
Apply Student centered vs Teacher centered
approach of learning
Silent cell-phone
Doing activities timely (assignment)….10
Quiz (2) ----10
Test (once -----30
 Session outline

Community mental health

History of community mental health

Concepts of community mental health

 Primary prevention

 Secondary prevention

 Tertiary prevention

 Maturational and situational crisis

12/29/22 CMH Services 3

 Session objectives

At the end of this session the students will be able to:

Define community mental health and services

Understand the historical development of

community mental health
Describe the benefits of community mental health

Explain the concepts of community mental health

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 Brainstorming
• What is community?
• What is community mental health?
• What is the importance of CMH service?

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 Community mental health
• Community :
 a group, population, or cluster of people
with at least one common characteristic,
such as geographic location, occupation,
ethnicity, or health concern

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 Community mental health / Psychiatry
• The branch of Psychiatry concerned with the
development of an adequate and coordinated
program of mental health care for residents of
specified catchment areas.
• Psychiatry focusing on prevention, detection, early
treatment, and rehabilitation of emotional, behavioral
and social disorders as they develop in a community.

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 Community mental health……
 A decentralized pattern of mental health , mental
health care or other services for people with mental
illness.
 Designed to supplement and decrease the need for
more costly inpatient mental health care delivery in
the hospitals.

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 Community mental health services
• Community mental health services (CMHS), also known as
Community Mental Health Teams (CMHT).

 Support or treat people with mental disorders (mental illness or

mental health difficulties) in a domiciliary setting (community),
instead of a psychiatric hospital (asylum).

 The provision of psychiatric services to the patient within their

community environment with an aim to achieve full social
integration.
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 Conti….
• It derives its values, beliefs, knowledge, and practices from the
behavioral and social sciences.
– Eg. Emotional and behavioral problems; recieves CMH care.

• Mental health services provided in the community includes:

 24-hour psychiatric emergency care, crisis intervention,

 Screening clients those considered as involuntary admission

to state mental health facilities,
 Case management, consultation and support, &

 Psychiatric home care.

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 Cont…
 We must serve the consumer by providing the
essential services:
 To assist with health promotion or prevention ,

 To initiate early intervention, and

 To ensure rehabilitation or prevention of long-term

disability.

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 Goal of CMH

• Delivering a comprehensive care by a

professional multidisciplinary team using
innovative treatment approaches.

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 History of Community Mental Health

 Before 1840, there was no known treatment for

individuals who were mentally ill
 They believe that MI is/are “incurable” lead to
isolating patients and confined them into asylums

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 Cont…
• The era of so called moral treatment of the mentally
ill until mid-19th century.

• The formation of Association of Medical

Superintendents in 1844 heralded the transition
from the era of moral treatment to the custodial/
guardianship era of psychiatric care.

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 Cont.…

• In 1841, Dorothea Dix, a former school teacher, began

a personal crusade across the land on behalf of
institutionalized mentally ill clients.

• The efforts of this self-appointed “inspector” resulted

in more human treatment of persons with mental
illness and the establishment of a number of hospitals
for the mentally ill.
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 History….
 The community mental health movement gained
impetus in the 1940s.
 By 1940-60 there were large progress made on
biological treatment of MI though not widely
practiced,
 Community mental health was also started to be an
agenda.
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 History of Community Mental Health…
The US National Mental Health Act of 1946:
 Government awarded grants to the states to
develop mental health programs outside of state
hospitals.
 Deinstitutionalization
 Outpatient clinics and psychiatric units in
general hospitals were inaugurated (began).

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 Cont…

 Then, in 1949, the National Institute of Mental Health

(NIMH) was established as an outgrowth of the
National Mental Health Act.
• It was pivotal in funding essential health research for
developing the mental health field

 In 1963,the Mental Retardation Facilities and

Community Mental Health Centers Construction Act
(often called the Community Mental Health Centers
Act) .
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• These centers provide in-patient care, outpatient
care, partial hospitalization, emergency care,
consultation, education services; follow up care and
transitional housing.

• In 1980 the Community Mental Health Systems Act

was established, which was to have played a major
role in the renovation of mental health care.

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 CURRENT ERA
• From 1963, the number of Community Health Centers has grown.
• Different types of community residences have come up. These are:

1. Group home.

2. Personal Care Home.

3. Foster home.

4. Natural Family Placement.

5. Satellite Housing and

6. Independent Living.

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1. Group home
• Group homes are residential facilities providing
community care for a group of patients.
•Living in the same building are staff who supervise a
program that uses group processes for psychosocial
rehabilitation.

2. Personal care home

•Is a residence run by a proprietor unrelated to the
residents. It serves 4 or more adults who are mildly or
moderately disturbed.
•The program focus is on maintenance of current level
of functioning.
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3. Foster home
•Is a full time residential care program provided by a
family unit, living in its own home, for a small group
of clients, unrelated to the family.
•The program focus is on treatment based on the
family model.

4. Natural family placement

•Here the patient lives with the immediate family or
relatives and these families receive subsidies to
facilitate such patients.

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5. Satellite housing
•This refers to semi-independent living arrangements
in which one to four patients occupy apartments or
houses scattered in the community.
•The level of impairment ranges from mild to
moderate.
•Patients placed in these settings are usually expected
to do their own cooking and housekeeping.

6. Independent living
•Encourage autonomy and patients live independently.

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Reform movement Era Setting Focus of reform

Moral treatment 1800-1850 Asylum Human restorative

treatment

Mental hygiene 1890-1920 Mental Prevention, scientific

hospital/clinic orientation

community mental 1955-1970 Community mental Deinstitunalization,

health health center social integration

Community support 1975-present Communities Mental illness as a

social welfare
problem (treatment
housing,
employment)

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 Benefits of Community mental health
Responsibility to a population and community participation

Being closer to the patient

Continuity of care

Client-centered approach

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 Cont…
Avoidance of unnecessary hospitalization

 Economical,

Avoids the stigma of being hospitalized in a mental

hospital and
Evaluation and research

Prevention

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 Concepts of community mental health
 The premise of the model of public health is based
largely on the concepts set forth by Gerald Caplan
(1964) during the initial community mental health
movement. They include:
Primary prevention

Secondary prevention

Tertiary prevention

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 Primary Prevention
 This services aimed at reducing the incidence of
mental disorders within the population.
 Its targets both individuals and the environment.
Emphasis is twofold:

1. Assisting individuals to increase their ability to

cope effectively with stress.

2. Targeting and diminishing harmful forces

(stressors) within the environment.
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 Cont.….
Nursing in primary prevention is focused on the
targeting of groups at risk and the provision of
educational programs . Examples
 Teaching parenting skills and child development to
prospective new parents.
 Teaching physical and psychosocial effects of
alcohol/drugs to elementary school students.
 Teaching techniques of stress management to
virtually anyone who desires to learn.
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 Cont.…

● Providing education and support to unemployed or

homeless individuals.
● Providing education and support to other individuals in
various transitional periods (e.g., widows and widowers,
new retirees, and women entering the work force in
middle life).
● Teaching groups of individuals ways to cope with the
changes associated with various maturational stages.
● Teaching concepts of mental health to various groups
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Populations at Risk: In primary prevention

 One way to view populations at risk is to focus on

types of crises that individuals experience in their lives.

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 Crisis
• It is a dramatic, acute, time limited event experienced as
overwhelming emotional reaction.
• It is self limiting (4-6 weeks)

Two broad categories are

1.Maturational crises

2. Situational crises.

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 Maturational Crises/ internal

 Maturational crises are crucial experiences that are

associated with various stages of growth and
development.

 It is the transitional periods where individuals into

successive stages often generate disequilibrium.

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 Maturational Crises…..

 Crises can occur during any of these stages,

although several developmental periods and life-
cycle events have been recognized as having
increased crisis potential:
• adolescence,

• Marriage

• Parenthood

• midlife, and retirement.

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 Adolescence
• Adolescence is a transition into young adulthood.

• Commonly, there is conflict over issues of control.

• Adolescents have many issues to deal with and many
choices to make. These includes
education and career selection

 establishing a set of values and ideals, sexuality

and sexual experimentation
drug and alcohol abuse

physical appearance
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 Cont…
Nursing interventions with adolescents at the primary level
of prevention:
Educational program
 for adolescents with alcoholic parent.
Other support groups for teenagers who are in need of
assistance to cope with stressful situations.
about sexuality, pregnancy , contraception, and sexually
transmitted diseases.
 inform about the use and abuse of alcohol and other
drugs.
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 Marriage

 Today’s young women are choosing to pursue careers

before entering into marriage, to continue their careers
after marriage, or to not marry at all.
 Many couples are deciding to live together without
being married.

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 Nursing interventions
 Encouraging honest communication.

 Determining what each person expects from the

relationship.
 Ascertaining whether or not each individual can accept
compromise.

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 Parenthood
• The coming of the child is a crisis.

• Because the family operates as a system, the addition

of a new member influences all parts of the system as
a whole.
• Nurses can provide the following type of information:

Prepared childbirth classes

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 Cont…
 Information about what to expect after the baby
arrives:
 Parent–infant bonding.

 Changing husband–wife relationships.

 Clothing and equipment

 Feeding.

 Other expectations.

 Stages of Growth and Development

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 Midlife

What is middle age?

•marked that upon turning 50 years of age

Midlife crisis is
•a number of patterns have been identified within three
broad categories:
•An alteration in perception of the self.

• An alteration in perception of others.

• An alteration in perception of time.

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 An alteration in perception of the self/ others.
 The individual looks in the mirror and sees changes
that others may have noticed for some time.
 Gray thinning hair and wrinkles

 Coarsening features

 Decreased muscular tone

 Weight gain

 In women, a gradual decrease in the production of

estrogen initiates the menopause, which results in a
variety of physical and emotional symptoms.
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 An alteration in perception of time.

• Middle age has been defined as the end of adult and

the beginning of old age.
• Individuals often experience a sense that time is
running out:
• “I haven’t done all I want to do or accomplished all I
intended to accomplish!”

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 Nursing intervention
• Nutrition classes to inform individuals in this age

• Inform having regular physical examinations

• Support and information related to care of aging

parents should be given
• Classes on menopause should be given

• Support and information related to physical changes

occurring in the body during this time of life.

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 Situational Crises

 Situational crises are acute responses that

occur as a result of an external circumstantial
stressor.
 Some types of situational crises:
• High Rate of Life Change Events.
• Poverty
• Environmental Conditions.
• Trauma

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 Poverty

 The direct consequences of poverty, such as:

inadequate and crowded living conditions,

nutritional deficiencies,

medical neglect,

unemployment, or being homeless.

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 High Rate of Life Change Events
 These include life change events such as death of a
loved one, divorce,
Being fired from a job, a change in living conditions,

A change in place of employment or residence,

Physical illness, or a change in body image caused

by the loss of a body part or function.

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 Nursing intervention
• At the primary level of prevention with individuals
experiencing situational crises is aimed at
 Maintaining the highest possible level of functioning
 Offering support and assistance with problem solving
during the crisis period.

 Establish a rapid working relationship by

 Showing unconditional acceptance,
 Active listening, and
 Attending to immediate needs.

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 Cont..
• Clarify the problem that the individual is facing.
• Guide the individual through a problem-solving
process in the direction of positive life change
• Acknowledge feelings of
 Anger
 Guilt
 Helplessness
 Powerlessness

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 Primary prevention

These services can be offered in a variety of settings

that are convenient for the public e.g.
 Churches, Schools, Colleges , community centers

Workplace of employee organizations

Meetings of women’s groups,

 Civic or social organizations such as health fairs, and

community shelters.

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 Secondary Prevention
Interventions aimed at minimizing early symptoms
of psychiatric illness and directed toward reducing
the prevalence and duration of the illness.
 It is accomplished through early identification of
problems and prompt initiation of effective treatment.
Nursing in secondary prevention focuses on
recognition of symptoms and provision of, or referral
for , treatment.
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 Examples include:
Ongoing assessment of individuals at high risk for
illness exacerbation.
Provision of care for individuals in whom illness
symptoms have been assessed.
Referral for treatment of individuals in whom illness
symptoms have been assessed.
Nursing assessment, diagnosis/outcome
identification, plan/implementation, and evaluation
should be applied.
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 Secondary Prevention
Populations at Risk
•Secondary prevention within communities relates to
using early detection and prompt intervention with
individuals experiencing mental illness symptoms

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 adolescence
• The need for intervention at the secondary level of
prevention in adolescence occurs when disruptive and
age-inappropriate behaviors.
• Nursing intervention may occur
 In the community setting at community mental health
centers,
 Physician’s offices
 Schools
 Public health departments
 Crisis intervention centers

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 Marriage
 The disruption of a marriage relationship include
substance abuse on the part of one or both partners

Disagreements on issues of
o sex

o Money

o Children

o Gender roles

o Infidelity.
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 Nursing intervention

 Counseling with the couple or with one of the spouses

on a one-to-one basis.

● Referral to a couples’ support group.

● Identification of the problem and possible solutions;

support and guidance as changes are undertaken.

● Referral to a sex therapist.

● Referral to a financial advisor.

● Referral to parent effectiveness training

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 Parenthood
 Intervention at the secondary level of prevention with
parents can be required for a number of reasons.

A few of these include:

● Physical, emotional, or sexual abuse of a child.

● Physical or emotional neglect of a child.

● Birth of a child with special needs.

● Diagnosis of a terminal illness in a child.

● Death of a child.
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 Midlife.
 Nursing care at the secondary level of prevention during midlife
becomes necessary when the individual is
 unable to integrate all of the changes that are occurring during
this period.
 An inability to accept the physical and biological changes, the
changes in relationships between themselves and their adult
children and aging parents.
 The loss of the perception of youth may result in depression for
which the individual may or which the individual may require
help to resolve.
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 Retirement.
• Retirement can also result in depression for
individuals who are unable to satisfactorily grieve for
the loss of this aspect of their lives.

• Severely depressed clients with suicidal ideations will

need close observation in the hospital setting,
• whereas those with mild to moderate depression may
be treated in the community.
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 Tertiary Prevention

 Services aimed at reducing the residual defects that

are associated with severe and persistent mental
illness.
 Tertiary prevention is accomplished in two ways:

1. Preventing complications of the illness.

2. Promoting rehabilitation that is directed toward

achievement of each individual’s maximum level of
functioning.
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 Cont…
 Chronic mental illness: has been associated with
long hospitalizations that resulted in loss of social
skills and increased dependency
 Some individuals may never have experienced
hospitalization,
 but they still do not possess adequate skills to live
productive lives within the community.

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 Cont.….
Examples include:
 Consideration of the rehabilitation process at the time
of initial diagnosis and treatment planning.
Teaching the client daily living skills and encouraging
independence to his or her maximum ability.

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 Cont….
Referring clients for various aftercare services

● Monitoring effectiveness of aftercare services

 (e.g. through home health visits or follow-up
appointments in community mental health centers).

● Making referrals for support services when required

 (e.g., some communities have programs linking
individuals

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• Nursing care at the tertiary level of prevention can be
administered on an individual or group basis and in a
variety of settings, such as
Inpatient hospitalization

Day or partial hospitalization

Group home or halfway house

Shelters, home health care, nursing homes

Community mental health centers.

12/29/22 64
 Cont...

The 1946 US National Mental Health Act named four

major mental health disciplines:
Psychiatry

Clinical psychology

Social work

Nursing.

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Case management
Inpatient case managers are nurses or social
workers who follow the client from admission to
discharge and
•Serve as liaisons between the client and community
resources, home care, and third-party payers.

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 In the community, the case manager works with clients on
a broad range of issues, from accessing needed medical and
psychiatric services
• To carrying out tasks of daily living such as using

public transportation,

managing money, and

buying groceries.

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 Discharge planning
• Crucial activities for successful discharge planning are
Environmental supports, such as
Housing and
Transportation, and
Access to community resources and services.

 Impediments to successful discharge planning include

– alcohol and drug abuse,
– criminal or violent behavior,
– Noncompliance with medication regimens, and
– Suicidal ideation.
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 Three types of intervention which are significant in
preventing re-hospitalization for individuals with four or
more prior inpatient stays.

These interventions are

Symptom education,

Service continuity, and

Establishment of daily structure.

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 Case study
• You have faced a 4-year-old girl named Tigst. She had
younger brother named Joseph, age 2. The mother was 5
months pregnant with the family’s third child. The family
had been referred to the nurse you. Tigst was placed in
foster care following a report to the Department of
Health and Human Services by her nursery school
teacher that the child had marks on her body suspicious
of child abuse.

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• The parents, Tadesse and Kidst, were in their mid-20s.
Tadesse had lost his job at an accountant 3 months ago
and had been unable to find work since. Kidist brought in
a few money from cleaning houses for other people, but
the family was struggling to survive.
During therapy
• You have focus on the factors in the family’s life that
could be considered as a stressors.
• Discussed about the behaviors associated with various
developmental levels.
• The parents also discussed their own childhoods. They
had history of physical punishment during their
childhood.
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• With the parents, you explored feelings and behaviors
from their past so that they were able to understand
the correlation to their current behaviors.
Based on this case
• Which type of crisis is occur in this family?
• Which type of prevention you provided?
• What additional intervention this family requires?

Family communications, respect, active listening, barriers

to effective care should be identified and modified.

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 Group assignment
Topics
1.Care plan for the client who has experienced a traumatic
event*
2.Chart review then prepare your nursing plan at
community after discharge
3.Mental illness and homelessness (interventions at the
community level)
4.Nursing care plan for suicide patient at hospital and
community level.
5.Assertive community treatment
6.Care plan on the inpatient unit: anger/aggression management
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Components of community mental
health services
 Session objectives
• At the end of this session you will be able to:-
– Identify the different components of community
Psychiatry services
– Discuss about and list the goals or aims of
psychiatry rehabilitation
 Components of community mental health services

 Psychiatric emergency care

 Day/Evening Treatment/Partial Hospitalization

Programs.
 Psychiatric Home Health Care.

 Community Residential Facilities

 Psychiatric services in Long term care

 Rehab and aftercare in mental health center

 Psychiatric emergency care
 CMHC act of 1963 mandated that communities make
the necessary provisions for emergency psychiatric
care.
 Accessible emergency services were needed to
provide:
 Crisis intervention

 Prevent unnecessary hospitalizations

 Attempt to decrease chronicity and dependence on

institutional care
 CMH administrators and clinicians were give the
service by establishing an emergency clinic at the
local mental health center or
 Contracting with general hospital in the same
community to provided emergency care on 24 hours
per day bases.
 Other methods of providing PEC by using

1. Mobile crisis units

2. Crisis resident units

 Cont…
 Crisis resident units providing a short term (less than
15 days) crisis intervention and treatment.
 Clients receive 24 hours per day supervision.

 People who use community based emergency

services most commonly tends to be
 Young

 Unemployed veterans of the mental health system

 Chronically mentally ill or chronic substance abusers

 Cont…
 Psychiatric emergency room often located in a
separate room or a specially allocated section of
hospital emergency department .
 The triage staff may include members of several
psychiatric disciplines :
 Psychiatric nurses
 Social workers
 Mental health counselors
 Marriage and family therapist
 Cont….
 The primary focus is on
– Crisis stabilization through the therapeutic interview and

– Immediate mobilization of available community and client

centered resources and support systems

 The nurse may have a collaborative agreement with a

consulting psychiatrist to prescribe necessary
psychotropic medication or
• To support admission to psychiatric inpatient unit.
 Cont…..
• The priorities and goals of an emergency
psychiatric assessment are as follows
– To control aggressive behavior in order to protect
other patients, the PES staff, and the patient him-
or herself
– To rule out any etiology for a patient's behavior
that might be life threatening or increase medical
morbidity
– To facilitate the clinical evaluation and an
appropriate disposition
 Cont…
– Safe PES environment

– Rule out medical etiology (psychiatric illness with

medical etiology is 15-90% times)
– Comprehensive psychiatric evaluation and
appropriate treatment
 Partial Hospitalization Programs(PHP)
 Day or evening treatment programs are designed to

 Prevent institutionalization and prevent readmission.

 Ease the transition from inpatient hospitalization to

community living.
 Located in/ near CMHC or inpatient setting at psychiatric
hospital.
 The programs usually provide treatment for 30 to 90 days,
operating 6 to 8 hours a day, 5 days a week.
 Most of this programs accompanied by 25 persons.
 Cont…
 During PHP the following treatments offered
o Therapeutic community activities
o Individual, group, and family therapies
o Psycho-education
o Alcohol and drug education
o Crisis intervention
o Therapeutic recreational activities
o Occupational therapy
o Expressive therapies
Cognitive–behavioral therapy is beneficial for
clients to achieve program goals
– Relapse prevention,
– Improved community functioning, and increased
social adjustment
– Increased self esteem,
– Feelings of hope, and a sense of empowerment.
 Cont…
The services offered by PHPs include Groups
For building communication and social skills,
 Solving problems, monitoring medications, and
 Learning coping strategies and skills for daily living .

 PHP generally offer a comprehensive treatment plan

formulated by an interdisciplinary team of
– Psychiatrists

– Psychologists

– Occupational and recreational therapists

– Social workers.
 Mental health professionals (BSc level) take a
leading role in the administration of PHP
– Crisis intervention

– Conduct individual counseling

– Act as role models

– Make necessary referrals for specialized treatment

– Evaluate the program and make necessary

modification.
 PARTIAL HOSPITALIZATION PROGRAM GOALS
 Stabilizing psychiatric symptoms

 Monitoring drug effectiveness

 Stabilizing living environment

 Improving activities of daily living

 Learning to structure time

 Developing social skills

 Obtaining meaningful work, paid employment

 Providing follow-up of any health concerns

 Community Residential Facilities(CRF)
 It is transition between hospital and independent
living.

The services provide

 Facilities to the basic needs,

 Individual and group counseling

 Medical care

 Job training

 Employment assistance, and leisure time activities.