Principles and Skills of Mental Health Care

Most people manage to adapt to changes in their lives and remain contributing members of their society. Problems exist, but mentally healthy adults are content with who and where they are in life. They are able to love and express love freely without the fear of losing their independence. Flexibility and a willingness to try something different lead to an eagerness for learning. Life is considered important, and special moments are cherished. Adversity is viewed as a challenge or an opportunity for growth. To simplify: a mentally healthy adult is a person who can cope with and adjust to the recurrent stresses of daily living in an acceptable way. Although mentally healthy adults experience unhappiness, anxiety, or other psychic distresses, they manage to mobilize their resources, rise above the negativity, and continue on with their lives.

Citizens of the industrialized cultures label a person as mentally ill only after his or her ability to function independently in society is impaired for a period (Giger, 2017). In our culture, mental illness results when an individual’s problems become so overwhelming that one is unable to carry out the activities of daily living or function independently. Other cultures have different definitions of mental illness.

The skills developed when working with the mental and emotional needs of people will be used throughout your career, for yours is the profession of caring. The seven principles of mental health care listed in Box 8.1 will help guide you.

People with mental problems suffer from a socially imposed stigma. The word stigma is defined as a sign or mark of shame, disapproval, or disgrace, of being shunned or rejected. Because people feel uneasy about discussing behaviors that are different, they shy away from mentally troubled individuals. One of the barriers to recovering from a mental illness is the social stigma that clients experience. Caregivers should set examples by acting as advocates for clients and educating themselves about psychiatric illnesses.

The principle of acceptance (allowing others to be who they are without passing judgment) is important in health care because you will care for many different people. Those differences do not have to be understood, but they must be accepted. You may even disapprove of clients’ attitudes and behaviors, but you must accept the person because it is the person who is the focus of your health care activities.

The word trust means assured hope and reliance on another. Erikson’s theory (see Chapter 5) lists the development of trust as the first core task of the infant. Trust is an important concept for human beings, who are social and group oriented. Trust implies cooperation, support, and a willingness to work together, and it occurs on many levels. For example, when you drive your vehicle, you are engaging in an act of trust: you trust that oncoming drivers will stay on their side of the small, painted yellow line that divides the road. Numerous other small acts of trust occur throughout the day; we are usually too busy to notice them, yet to care providers, the concept of trust holds much importance.

Individuals who are unable to trust cannot rely on others for help. Many people with mental-emotional problems struggle with problems of trust. Care providers must routinely demonstrate that they can be trusted. To communicate the messages of trust, remember to do what you say you will do. If you tell a client that you will return in 10 minutes, be back in 10 minutes (better yet, be there sooner). Clients soon learn which caregivers follow their words with actions. Trust begins to grow when clients know they can depend on their caregivers.

Trust is the foundation of therapeutic relationships and it forms the basis for the success or failure of all actions. People who become your clients, no matter what their diagnoses, need to trust that they will be cared for in a safe and supportive manner. The development of trust between clients and caregivers involves three concepts: caring, empathy, and advocacy (Keltner and Steele, 2019).

For people with mental illness, caring plays an especially important role. They know, subconsciously, whether you actually care or regard them as just another client. Before trust can be developed, clients must truly believe that their nurses and other providers care.

Empathy is the ability to recognize and share the emotions of another person without actually experiencing them. It includes an understanding and acceptance of the meaning and significance of that person’s behavior. It is a willingness to see the world as the client does. Clients with mental illnesses frequently live in a lonely world of personal suffering, detached from society. Empathy, in these cases, becomes a powerful therapeutic tool that can help reestablish one’s self-worth and dignity. If clients believe that you are willing to share their discomforts, they become more interested in learning to help themselves.

Advocacy is the process of providing a client with the information, support, and feedback needed to make a decision (Keltner and Steele, 2019). Client advocacy adds the obligation to act in the client’s best interest. People with mental-emotional difficulties are not always capable of making informed decisions. Here, caregivers intervene to ensure that the client’s basic needs are being met. For example, if a client decides not to eat, the care provider may act in the client’s best interest by making the food easily available. The client cannot be forced to eat, but he or she can be encouraged to make more healthful choices. Client advocacy also involves the concept of empowerment. Many mentally ill people are quite capable of taking part in their care and treatment. Some are not, but all deserve the opportunity to make the decisions they are capable of making. Nurses and other caregivers act as advocates by assisting clients through the decision-making process. Providing information and education assists clients in making appropriate decisions about their care. When clients feel that their care providers understand and act in their best interests, trust is established. The therapeutic relationship is discussed more fully in Chapter 11.

“Behavior consists of perceptions, thoughts, feelings, and actions” (Stuart, 2013) (Fig. 8.1). A disruption in any one of these areas can result in behavioral problems. Distorted perceptions, impaired thought processes, and alterations of emotional expression lead to maladaptive actions. Behaviors also must be understood in terms of the context or setting in which they occur. For example, a particular environment may be threatening because of uncomfortable past experiences in similar settings.

It is sometimes difficult to accurately interpret the messages a client’s behavior is sending. Actions may be clouded with symbols or influenced by chemical substances. Alcohol and other drugs affect perceptions, emotional expression, and judgment, as well as behavior.

Responsible people are capable of making and fulfilling obligations, and they are accountable for their decisions or actions. Responsibility implies that a person is able to exercise capability and accountability; individuals who are unable to make or keep obligations are not considered responsible. Health care providers work with clients who exhibit a wide variety of coping styles and behaviors. Encouraging responsibility is a primary mental health intervention because it helps build self-worth, dignity, and confidence. It also assists clients in learning more successful coping behaviors. Responsibility is a cornerstone of modern societies and a goal of mental health care.

As children grow, developing the necessary skills for living within a society, so do their responsibilities. Responsibility is learned early, starting when the child begins to explore and manipulate his or her environment. The primary instructor is the family, but the child’s social group and culture exert strong influences. As children learn about “right behaviors,” they develop the responsibility to engage in them. There is a saying that states, “If the family does not teach responsibility, then the school will. If the school does not teach responsibility, then the group will. If the group does not teach responsibility, then society will, and society sends irresponsible people to jail.”

Many people with mental-emotional problems have difficulty behaving in responsible ways. Some have never been taught because of their dysfunctional family or childhood experiences. Others cannot remember or hold on to a logical picture long enough to be responsible. However, every person has the capacity for growth and therefore some degree of responsibility. Nurses and other professionals who work with the mentally ill population plan and implement specific interventions designed to help clients achieve their highest possible level of responsibility.

The first step in developing self-responsibility relates to care of the self. The basic physical needs of life (Maslow’s lower-order needs) must be met, no matter what the circumstances. Every adult—and, sadly, many children—must procure food, clothing, and shelter for themselves. People with mental-emotional problems commonly have difficulty in meeting basic needs, so lessons of self-responsibility usually begin with something as basic as caring for one’s daily personal hygiene.

Caregivers should assess their clients’ abilities to perform the skills associated with the activities of daily living. For example, sometimes the reason for poor hygiene is a lack of knowledge; a person may never have been taught to bathe frequently or brush teeth after every meal. In such cases the caregiver must teach and the client must learn the basic skills of personal cleanliness. When the client assumes responsibility for basic needs, it leads to improved feelings of self-worth—when one looks good, one feels better. Small successes become positive steps that help equip clients with the skills necessary for effective functioning.

The next step in assuming self-responsibility is to be accountable for one’s emotions. Mental health clients frequently have poor control over their emotions (poor impulse control). They immediately react without considering the consequences of their behaviors. “I’m sorry. I lost my temper” does not excuse the action. Becoming responsible for one’s emotions involves the willingness to identify and then “own” the problems and emotions. It also requires a willingness and determination to try new and more effective ways of coping with emotional reactions.

When clients learn to replace an unacceptable behavior with a more effective action, they achieve a degree of control over their lives. As individuals become responsible, they begin to succeed. Those small successes help to remove them from the role of victim and to realize the value of becoming responsible.

People who seek treatment for mental or emotional problems must assume the responsibility for cooperating with and following their therapeutic plan of care. This involves a commitment to becoming actively involved by sharing personal information, being open to new ideas, and being willing to try new ways of doing things.

Clients are also responsible for the effects of their actions on others. The enjoyment of social interactions is accompanied by the responsibility of behaving appropriately. People who have problems with emotional (impulse) control can become a threat to the safety of others when their behaviors are inappropriate. It is important for caregivers to assist clients in controlling their behaviors because people who act in irresponsible ways are soon removed from social settings.

Responsibility is a fundamental concept in mental health care. It is a key to developing more effective behaviors and building self-worth. Some psychiatric therapies are designed around the concept of responsibility. For example, William Glasser’s reality therapy (1998) uses responsibility as a therapeutic tool (Box 8.2). Reality therapy is used to help clients recover from addiction. It is often used to “help individuals with relationship problems, behavioral problems (e.g., teens who act out), cultural conflicts, depression, anxiety, and challenging life situations such as coping with a serious medical condition” (www.addiction.com/addiction-a-to-z/drug-addiction).

The last principle for mental health care providers relates to the concept of consistency, which is displaying behaviors that imply being steady, regular, and dependable. People with mental illness often lack the security of someone who is there when needed. In some cases, the consistency and reliability of mental health care providers are their only stability. The link that serves as a bridge between the client’s world and the world of reality is frequently the reliability of the therapeutic relationship.

The concept of consistency is usually addressed in the client’s plan of care, but each therapeutic intervention must be routinely used by every member of the care team. Clients often test staff members by “playing one against the other” or attempting to manipulate the situation and gain control. However, when each care provider responds by giving the same message, clients learn that members of the care team can be relied on to do what they say they will do. In many cases, assertiveness training has proven effective for care providers in working with manipulative clients (Yoshinaga, et al., 2018). Two general guidelines for providing consistency are (1) to set limits and (2) to focus on the positive changes that clients are making.

Setting limits involves clients, staff members, and institutional policies (Chenevert, 1994). As the plan of care is developed, each rule or limitation is established. Facility policies define some of the limitations; the remainder relate to therapeutic activities, social interactions, and personal behaviors. Whatever the limitations, the client must be informed and willing to cooperate with the plan of care.

Each member of the care team is responsible for understanding the purpose of each limitation and the methods for enforcing them. To illustrate: the facility’s policy is for all clients to remain out of bed during the day. To accomplish this, the staff informs each client every morning that the doors to the rooms will be locked by 9 a.m. Then the aide makes 9 a.m. rounds and locks the door to each room. The clients were first informed and then reminded of the rule. Then the enforcement or actual action demonstrated that the limitation would be enforced. Something as simple as providing a routine can teach clients about the values of reliability, consistency, and stability.

This brings us to a valuable point: do not commit yourself unless you are able to fulfill the commitment. If your actions are not reliable, if you do not behaviorally demonstrate stability and consistency, then the therapeutic relationship will be established with great difficulty. Clients are people, and they need to know whether someone truly cares and is willing to make the connection that helps them to heal.

Simply defined, self-awareness is a consciousness of one’s personality. It is the act of looking at oneself: of considering one’s abilities, characteristics, aspirations, and concepts of self in relation to others. It is an awareness of one’s personal and social behaviors and how they affect others (Morrison, 1993). In short, self-awareness is the ability to objectively look within.

The development of self-awareness requires time, patience, and a willingness to routinely consider your behaviors, attitudes, and values. The rewards, however, are worth the efforts because both clients and caregivers benefit when therapeutic goals are achieved. Personally, self-awareness allows individuals to direct and mold the pattern of their lives, to be in charge of their own direction and development. Caregivers who encourage the development of self-awareness in their clients must be ready to practice it themselves. To improve self-awareness requires caring, insight, acceptance, commitment, a positive outlook, and the willingness to nurture oneself. If you are willing to put effort into these areas, you will evolve into a person who is able to use your personality to achieve therapeutic change and personal fulfillment.

Everyone has the universal human need for love. Maslow’s hierarchy of needs (Fig. 8.3) lists the need for love and belonging as the first nonphysical requirement after safety. Without love, infants fail to grow or thrive and adults become isolated, lonely, and depressed. Human beings are gregarious creatures; we are meant to live with others. Although physical appearances, behavioral patterns, and communication styles may differ, each person carries within the need to belong and be loved.

A pyramid for Maslow’s hierarchy of needs is as follows: First level: Physiological needs: air, water, food, shelter, rest and sleep, activity, and temperature maintenance. Second level: Need for safety and security: physical and psychological safety, feels safe in environment, and feels secure with others. Third level: Love and belonging needs: gives and receives love, attainment of place in group with feeling of belonging. Fourth level: Esteem needs: self-respect, self-esteem, recognition, and respect from others. Fifth level: Need for self-actualization: achievement of one’s full potential.

Caring is the energy on which the health care professions are built. It is defined as a concern for the well-being of another person, and it includes behaviors such as accepting, comforting, honesty, attentive listening, and sensitivity. Caring is the glue that binds individuals to one another. It is energy of the soul, freely given in hopes of helping another human being. Caring cannot be taught as a procedure or skill; it must be developed, encouraged, and molded into the therapeutic personality of the caregiver. Caring serves as a thread that connects people and moves them toward recovery. Box 8.3 lists several therapeutic actions that demonstrate caring.

We all are responsible for our own development, both professionally and personally. We gain insight and wisdom through experience. Insight is the ability to clearly see and understand the nature of things; it relies on common sense, good judgment, and prudence. Although not always comfortable, our insights provide us with new opportunities to take risks, explore our own potentials, and fail as well as succeed. For care providers, insight includes sensitivity to people, the ability to make keen observations, and a willingness to seek new knowledge.

Self-awareness is developed through the practice of introspection, the process of looking into one’s own mind. Introspection is an analysis of self—one’s feelings, reactions, attitudes, opinions, values, and behaviors. It is also a process for observing and analyzing one’s behavior in various situations. Introspection allows us to “step out” of an interaction and watch our own behaviors; this process is assisted when caregivers can view themselves interacting with clients on video. Introspection allows caregivers to identify both personal and professional learning needs. Practice professional introspection by keeping a small notebook. Throughout the day, jot down any questions or subjects that relate to the care of your clients—anything about which you feel you need to know more. After work, make it a point to research at least one question or topic every day. This practice will serve as a valuable aid for gaining new knowledge. Knowledge breeds competence, and from competence grows the confidence to provide the best possible care.

Personal introspection is the process of learning who you are. This type of introspection may be accompanied by emotional discomfort, but for those individuals who can overcome their emotional defenses, introspection serves as a valuable tool for developing self-awareness.

The process of developing self-awareness includes the elements of risk and failure. If one is to grow, then one must take risks. Risk-taking implies the possibility of failure. For most of us, the word failure has a negative meaning that implies defeat and a lack of success. However, failure can be filled with positive, growth-promoting experiences. Failure provides the opportunity for change. It encourages creativity, stimulates learning, and sharpens one’s judgments. Failure is a price that must be paid for improvement. When used as a learning tool, the experience of failure can provide insight and the foundation for the next step toward success. The person who never fails cannot savor the rewards of success.

How do we grow from our failures? The first and most important step is to understand that failure is a necessary part of change. The second step is to give yourself permission to fail. The odds of a person living a lifetime without a failure are about zero. Failure, learning, and growth are all partners in the development of self-awareness. The third step is to consider your failure as a learning experience. Examine the elements of the failure and discover what improvements could be made. More effective actions in the future can avoid the failures of the past. The fourth and last step is to discover the opportunities that are created by failure. Often a failure opens new doors or presents a problem in an entirely different light. Examining and learning from failure can create new options and opportunities. Box 8.4 lists several suggestions for using failure as a positive experience. Remember that one fails only when one refuses to grow from the experience.

Although people may engage in behaviors that are considered inappropriate, every individual has worth and some degree of dignity. Each client must be given respect and the opportunity to participate in care if treatment is to be successful. Acceptance in this context means the receiving of the entire person and the world in which he or she functions.

Accepting clients does not necessarily include approving of their behaviors. This is an important distinction; you must accept the person, but you do not have to accept the behavior. Many caregivers who work with mentally and emotionally troubled clients do not hesitate to tell a client when his or her behavior is inappropriate, but no mental health caregiver should ever directly attack or correct the person. Table 8.2 presents examples of communications that focus on the difference between correcting the behavior and correcting the person. The very reason clients with mental-emotional problems seek help is to correct their ineffective behaviors. As their care providers, we must accept the entire person as a complete package, regardless of our own reactions. This acceptance then becomes the foundation on which other therapeutic actions are based.

A commitment is a personal bond to some course of action or cause. The health care professions are undergoing radical changes; if provision of high-quality care for every person is to remain a primary goal of our society, then a strong commitment from each health care provider will be needed to maintain the focus on our clients. Caregivers must be committed to providing competent health care, no matter what the setting or circumstances.

The first and most important commitment is to yourself: the commitment to consciously take charge of your personal and professional growth. Self-commitment involves a promise to do the best you can in every situation and to be the best that you can be. Each person has a unique set of talents, an individual personality, and areas that need improvement. People who are committed to improving themselves are able to consider both the positive and negative aspects of their personalities without guilt or remorse. They realize their mistakes and attempt to profit from them by extracting the lessons hidden in each error. They then commit themselves to applying these hard-earned lessons to new situations, which in turn enhances self-awareness and expands their ability to cope with new experiences.

Health care providers have stronger commitments than most people. They are committed to caring about the welfare of humankind. They demonstrate this dedication by continually seeking out new knowledge, keeping up to date with the latest professional developments, and striving to improve their therapeutic effectiveness.

You are committed; otherwise, you would not be reading these words. Take the time to discover what you feel is most important in life. Then look behind the topic, and you will find yourself committed to a certain course of action. The exercise of describing one’s commitments helps to expand self-awareness and reminds us of the interconnectedness of all human beings.

Achieving and maintaining a positive outlook is especially important for caregivers who work with mentally and emotionally troubled individuals. A positive attitude is the secret weapon for coping with the adversity of life. It is the key to maintaining physical and emotional health, especially for those who share their energies therapeutically. Developing a positive attitude (Box 8.5) is a process that requires persistent and patient efforts because our current attitudes and habits are deeply ingrained. However, the process can be assisted by following these five tips:

A critical first step in the development of self-awareness is to recognize and tend to your own needs. To nurture someone is to encourage their development. Caregivers are expected to work hard for the welfare of their clients, but energy cannot be continually spent without being renewed. Care providers must function at a high level of wellness to provide the energy required by their clients. You have chosen to care for others, and part of the responsibility you accepted when making this decision was to care for yourself. To effectively care for your clients, you must first care for and nurture yourself (Box 8.6).