What is mental health?

The concept of mental health is difficult to define, as mental health is much more complex than merely the absence of a mental illness. There are numerous definitions of what constitutes mental health. It has been defined as a state in which people are able to cope with, and adjust to, the recurrent stresses of everyday living in an acceptable way (Watkins 2002). It has also been defined as the ability of people to cope well with stress both internal and external (Antai-Otong 2007). According to Barkway, ‘a person can enjoy mental health regardless of whether or not they are diagnosed with a mental illness if they have a positive sense of self, personal and social support with which to respond to life’s challenges, meaningful relationships with others, access to employment and recreation activities, sufficient financial resources and suitable living arrangements’ (cited in Elder et al 2009:120). For most people the feelings associated with mental health will be present sometimes and not others and will vary in intensity at different times. According to this view, then, mental health is a state that can change frequently and that can fluctuate according to specific circumstances. Touhy & Jett (2009) capture the concept of fluctuation in this definition:

The terms mental health and mental illness are often used interchangeably but they should not be: the difference between the two needs to be clear (Elder et al 2009). The American Psychiatric Association (APA) defines mental illness or mental disorder as an illness or a syndrome with psychological or behavioural manifestations and/or impairment in functioning due to a social, psychological, genetic, physical/chemical or biological disturbance (Shives 2005:12).

Clinical Interest Box 37.1 illustrates some differences between mental health and mental illness.

Development of mental health

According to Shives (2008) the factors that influence the development of mental health relate to three main areas: inherited characteristics, nurturing during childhood and life circumstances.

What is mental illness?

Just as it is difficult to arrive at a precise definition of mental health, so too is it difficult to succinctly define mental illness because it is often related to what a given society considers is normal or acceptable behaviour and, as with mental health, mental illness is a matter of degree.

Signs and symptoms of mental illness

Symptoms of mental illness occur on a continuum and range from minimal to severe (Antai-Ojong 2003). A person usually receives a diagnosis of having a mental illness when the level of mental distress causes them to seek professional help or when others in society perceive that they need professional psychiatric help. It is important to recognise that, in relation to the differences between mental health and mental illness, there is a ‘grey’ area into which all individuals may enter from time to time. Those with a severe and long-term psychiatric disorder may dip back into relative mental health and reality-based living for a while and, similarly, sometimes the stresses of everyday living are so overwhelming that the most well-adjusted ‘normal’ person may experience marked irrational thoughts, feelings and actions. Therefore, as in the case of physical illness such as diabetes, heart disease or cancer, anyone can develop a mental illness. A mental illness is not the fault of the person affected, and the cause may be related to a combination of biological, psychological and sociocultural factors.

Symptoms of mental illness include changes in personal habits, social withdrawal and changes in mood and thinking. While particular symptoms occur with specific disorders, there are warning signs that indicate the presence of a mental health problem. Clinical Interest Box 37.3 provides examples of early warning symptoms of mental illness that may occur in children, adolescents and adults.

Classification of mental disorders

There are more than 200 classified forms of mental illness. These include:

Diagnosis

The APA’s Diagnostic and Statistical Manual of Mental Disorders (DSM) is a respected and influential classification system under which a mental illness is determined according to the symptoms experienced and the clinical features of the illness. The International Classification of Disease (ICD) is produced by the World Health Organization and is mainly used In Europe. It also assists with diagnosis and classification. In Australia, New Zealand and the United States the fourth edition of the DSM (DSM-IV-TR) is most commonly used. (DSM-V is due for publication in May 2013.)

There are many categories of classification but mental illness is mainly classified within the following areas:

Diagnosis according to the DSM (IV) has the benefit that clients may feel great relief when they have a diagnosis that helps them make sense of what is happening to them, and a medical diagnosis can guide clinical treatment. But this diagnostic system has a disadvantage in that a diagnosis can also be a label that has negative connotations; for example, a label of schizophrenia or a personality disorder is associated with significant social stigma. Diagnostic labels describe certain types of behaviour but they indicate very little about the nature or causes of the experience.

Mental health nurses develop nursing diagnoses in response to the client’s experience, emotions and behaviours. Nursing care responds holistically to the client’s biological, psychosocial, spiritual and environmental needs and specifically addresses the client’s feelings and behavioural responses to those feelings, many of which are common across several different medically classified conditions. Examples of some nursing diagnoses commonly used in mental health nursing are provided in Clinical Interest Box 37.5.

A mental disorder can be categorised as temporary, episodic or chronic/enduring, according to the way it manifests:

Although use of the terms psychosis and neurosis to describe particular illnesses is no longer favoured, nurses need to be aware of the meanings associated with each as the terms are still used in some contexts. The terms are out of favour because symptoms ascribed to each condition can occur in the other, and this causes confusion. The term psychosis refers to disorders that are so marked and incapacitating that the person who is afflicted is out of touch with reality and lacks insight into the illness and the associated behaviours, which may be unusual or bizarre. Psychosis was the term traditionally used to describe disorders such as schizophrenia and bipolar disorder, in which the symptoms experienced were quite different to those experienced by other people and included delusions and hallucinations (Elder at al 2009). Clinical Interest Box 37.6 provides explanations and examples of delusions and hallucinations.

Unlike people suffering from a psychotic disorder, those with what used to be termed a neurosis have insight into their condition. For example, a person who has an obsessive-compulsive disorder may experience persistent and intrusive thoughts (obsessions) about personal cleanliness. To decrease the level of anxiety the person may wash their hands hundreds of times a day, even if their hands become red and raw (compulsion to act). When they are extreme, such thoughts and acts may be so unusual and disrupt the person’s life to the degree that to the observer the person is mentally ill. Unlike those experiencing a psychotic disorder, the affected person is aware that the behaviour is abnormal (there is insight into the behaviour and the illness). Despite their condition, people who have what was once classified as a neurosis can often continue to function in society, whereas a person who is psychotic cannot function effectively (Varcarolis et al 2010). Nursing diagnosis should always be developed through the lens of a client-centred approach which respects the client’s social and individual experience of their illness.

Theoretical models and causation of mental illness

Historically the medical profession was prominent in the care of people with mental illness and as a result there has been, and still is, a strong focus on identifying physical causes of mental illness. However, others have looked at psychological, sociocultural, interpersonal and human development factors and there are now many theoretical models used to explain the presence of a mental disorder. Mental health nurses select concepts from the various relevant models that best explain the client’s behaviours, problems and needs. They then draw on these concepts as a basis for client assessment and then for planning, conducting and evaluating care (Varcarolis et al 2010). The following provide very basic examples of a small selection of theoretical models. To work effectively in the area of mental health, however, nurses need a deep and sound understanding of a wide range of models.

The multidisciplinary team

Many people may be involved in assisting a person who is experiencing a disruption or potential disruption to their mental health. Mental healthcare commonly employs an interdisciplinary team approach to care management. The client’s care, according to individual needs, is planned and implemented by a team composed of mental health nurses, psychiatric social workers, counsellors, clinical psychologists, general or specialist medical officers (depending on the client’s physical status) and pharmacists. Additional team members may be required and, depending on individual needs, these may include: a dietitian; an occupational therapist; a recreational, art, music or dance therapist; complementary healthcare therapist; and a chaplain or other spiritual support person. (See Clinical Interest Box 37.7.)

It should never be forgotten that the most important member of the team is the client, and often clients know what they need to promote their own recovery. Some clients have reflected on the times when they have been at their most vulnerable. For example, some clients who have experienced admissions to acute-care settings have identified that what they need most at times of severe mental distress is somewhere they can feel safe and supported, somewhere they can relax and calm down and someone to be with them who will listen and really hear them (Watkins 2002). While the client may feel the need for medication, it is not appropriate or helpful to implement other therapeutic interventions, such as group therapy, recreational therapy or family therapy, until the client is feeling less distressed and can collaborate in decisions about what sort of interventions will be most helpful. Skilled helping involves actively listening to the client and working collaboratively with the client to achieve a process of recovery. (See Ch 6 for information concerning active listening as a therapeutic measure.) The therapeutic process involves health professionals, including nurses, as facilitators who use their knowledge to help the client become more resourceful and self-reliant. This helping relationship needs to be a participative but never a directive process (Watkins 2002). The model of helping relationships established by Carl Rogers (1961) and the model of skilled helping established by Gerard Egan (1994) are client-centred models of caring on which mental health nurses can reliably base their therapeutic interactions with clients.

Responsibilities of the mental health nurse

Mental health nursing may be described as an interpersonal process in which the nurse uses the presence of self, interpersonal communication skills and a knowledge of physiology, psychology and sociology to help clients in mental distress. A combined understanding of biological processes and psychodynamic processes is essential for the mental health nurse because many people with mental illness have a concurrent physical problem, and the two are often interconnected (Elder et al 2009).

Mental health nurses are very involved in psychiatric inpatient services and in community mental health services. They play a major role in education and health promotion, as well as in the provision of continuing care and counselling for people with mental health problems. For some experienced mental health nurses the role may include conducting specific psychological therapies such as cognitive behaviour therapy, solution focused therapy and acceptance and commitment therapy.

Nursing care aims to help clients cope with the experience of mental illness, prevent relapse and to promote a return to mental health through a successful rehabilitation program. The primary aims of mental health nursing (Watkins 2002) are to help individual clients to:

Rehabilitation is important for people who have been discharged from a psychiatric ward or unit. Some people need minimal support but others represent a population of chronically ill clients who return to hospital periodically over many years and require support in several different areas of their lives. The community mental health nurse and other members of the community mental health team may be involved in:

Recovery and mental illness

The concept of recovery has been apparent for the last few decades and is manifest mainly in policy at various levels such as health services management, practitioners and consumer/survivors of healthcare services (Edward et al 2011). Many consumer/survivors, some of whom were mental health professionals, began to speak about their experiences of mental illness and their individual journey of recovery which led to the development of the consumer-recovery movement (Deegan 1988; Lovejoy 1984). In the United States the consumer-recovery movement was boosted by William Anthony, a rehabilitation expert who challenged the state health system on their vision of recovery that was based on a belief that mental illness was essentially a ‘chronic’ condition with very little hope of getting back to full health (Anthony 2000). According to Anthony (2000), mental health services need to be grounded in the idea that people can recover from mental illness, and that the construction of the service delivery system must be based on this knowledge. From that period of time most western countries adopted an approach to recovery that is based on practices and principles of autonomy and self-determination.

Contemporary mental health nursing care is now based on the recovery principles that refer to the person’s rights to self-determination and inclusion in community life regardless of their diagnosis of mental illness. Recovery principles are based on an approach that hope is central to recovery and that shifting the focus from symptom management and diagnostic labels to one which keeps people well gives their lives value and meaning. Personal and social recovery is the primary focus of contemporary mental health nursing care.

Facilitating development of constructive coping mechanisms

The nurse’s role in stress and stress management has some specific points that need to be highlighted here. To recognise and deal with stress, individuals need to be provided with information about, and helped to recognise:

There is a wide variety of activities that clients may find helpful in promoting coping, but there is no one right or best activity. What works for one person may not work for another. Nurses have a responsibility to provide clients with information and options, but only the client can know what feels appropriate, so the choice of what activities to attempt or to become involved with should ultimately rest with the client. Clinical Interest Box 37.8 provides examples of constructive coping strategies, coping resources and destructive coping mechanisms.

The nurse’s role in educating the public and reducing stigma

One particularly important facet of the community mental health nurse’s role is educating the public about mental illness to reduce the stigma that for many mentally ill people is the biggest hurdle to overcome (Watkins 2002). There is a general lack of knowledge in the community about what constitutes mental illness and about the prognoses of mental disorders; this ensures that mental illnesses are often surrounded by mystery, misinformation and stigma (Weir & Oei 1996). Despite positive interventions in recent years, people suffering from mental illness remain among the most stigmatised, discriminated against, marginalised, disadvantaged and vulnerable members of society (Johnstone 2001) (see Clinical Scenario Box 37.1).

Several myths about mental illness create fear of those affected and this fear serves to increase stigmatising behaviours and attitudes. For example, there is a widely held perception that people with mental illness are often out of control, unpredictable and may pose a threat. The truth is that most people with mental illness do not behave in this way; however, severe mental distress is often highlighted in the media, and this links images of dangerous behaviour with mental illness in the minds of the public (Watkins 2002). In addition, single, isolated and often very minor criminal acts committed by mentally ill people tend to be sensationalised by the media, contributing to negative stereotypes (Jewell & Posner 1996). Overall, violence in society associated with mental illness is not significant (Elder et al 2009). The Sane Australia Stigmawatch website monitors misuse, misrepresentation or inappropriate references to mental illness in the media (Elder et al 2009).

The lack of accurate knowledge about mental illness that leads to fear, mistrust and sometimes violence against people living with mental illness and their families can also serve to:

The picture is not always as dismal as this. Many mental healthcare users are themselves excellent ambassadors for people with mental illness. By calling themselves consumers or clients they have empowered themselves to become advocates for other people experiencing mental health disorders. Mental healthcare users or consumers now have a vital role to play in participating and planning the delivery of mental health services (Happell & Roper 2003). Consumer advocacy groups now exist in every state and territory of Australia and in New Zealand to promote participation of consumers in planning, implementation and evaluation of mental health services. Accordingly, many consumers live and work within a local community, use the same facilities (e.g. shops, library, cinema, sports centres) as everyone else, are accepted by the people within the community and experience no harassment and attract no hostility from the local residents (Markowitz 2007). All nurses can play a part in highlighting and reducing stigma by:

In part it is the way people with mental disturbance were treated in the past that influences current perceptions of mental illness and the associated stigma. The next section provides a brief overview of historical perspectives relevant to understanding societal attitudes today.

Mental healthcare today

Mainstreaming of mental healthcare has resulted in the provision of psychiatric care to consumers in general hospitals with an inpatient psychiatric unit, hostels and other residential care facilities and sometimes in forensic centres for the mentally impaired who have committed crimes. However, mental healthcare is primarily provided in the community and in Australia the community setting has become the place where most consumers receive their care.

Nurses may meet with clients in a variety of community settings, including:

Current healthcare policy promotes not admitting people to a treatment centre unless essential, and, when it is necessary for clients to be admitted to treatment centres, they are discharged back into the community as early as possible. Ideally, community-based mental health services provide appropriate networks of supports and resources for those who need it. The aim of service providers is to ensure that there are caring interventions aptly suited to assist each person to rehabilitate successfully and to cope well in society. The policy of community-based care has enabled many of those who once lived in psychiatric institutions to resettle successfully in the community and to be well supported. It is important to remember that the environment in which the consumer is seen affects the therapeutic relationship. In community settings the mental health nurse enters the home of the consumer as a guest, engaging with the consumer on a more relational and contextual basis.

Unfortunately, however, there are other instances in which the deinstitutionalisation process has not been supported with adequate community care. The result of this is that some people who experience mental ill-health have merely been relocated to substandard boarding houses or other semi-institutionalised accommodation, or face homelessness (Grigg et al 2004).

While there are still many problems for mentally ill people and health professionals to contend with and resolve, there is now more cause for optimism in relation to mental illness than in the past. Success rates for the treatment of many common mental disorders such as bipolar disorder, major depression and schizophrenia now equal or exceed the success rates for many other medical disorders (Goldberg 2007).

While this chapter does not aim to inform the nurse about the range of treatments available to assist clients with specific disorders, the next section provides a summary of possible nursing responses to some common emotional and behavioural problems that challenge clients with mental illness. The terminology used in mental healthcare, some of which is contained in the next section, is extensive and different from terms used in other areas of nursing. Some of the more common terminology is defined in Table 37.2.

Table 37.2 Terms associated with mental illness

The client experiencing anxiety

Anxiety is an internal feeling usually experienced as an unpleasant or uncomfortable emotion and which is frequently associated with conflicts and frustrations. While a certain mild degree of anxiety can be beneficial when it stimulates motivation and energy, severe anxiety can be devastating and is the basis of many mental health disorders. Anxiety differs from fear in that anxiety attacks the person at a deeper level than fear, and the source of the anxiety may be unknown. Sometimes, in extreme anxiety, a person may experience panic attacks that result in markedly disturbed behaviour. The person may be unable to process what is happening in the environment and may lose touch with reality. During a panic attack behaviour may be erratic, uncoordinated and impulsive. There are three different forms of panic attack: ‘out of the blue’ attacks, which are not brought on by a trigger; situation-bound attacks which are brought on by exposure to a trigger; and situation-predisposed attacks that are comparable to situation-bound but which do not happen every time the person is exposed to a trigger.

Anxiety invades the very centre of a person’s being. Severe anxiety is profound and persistent and can erode and destroy a person’s sense of self-esteem and self-worth that contribute to a sense of being fully human (Varcarolis et al 2010).

Anxiety is experienced in a wide variety of situations and is generally the result of a threat to a person’s self-esteem or physical integrity. Threats to self-esteem include factors such as interpersonal difficulties, change in job status, social or cultural group pressures, a change in role or confusion over one’s identity. Threats to physical integrity include factors such as decreased ability to perform the activities of daily living, for example, as a result of injury or illness, or lack of basic requirements such as food, shelter and clothing. Mild and moderate levels of anxiety can alert the person to the fact that something is wrong and may be the stimulus to take appropriate action. Severe levels of anxiety interfere with problem-solving abilities, so that those affected have difficulty finding effective solutions to problems. For example, someone who experiences panic attacks may use unproductive relief behaviours to avoid the attacks from occurring, such as refraining from leaving the house to avoid the risk of a panic attack when driving the car, at work or at the supermarket. Unproductive relief behaviours perpetuate the cycle of anxiety (Varcarolis et al 2010).

Whether the source is known or unrecognised, anxiety can produce physiological responses, behavioural changes and emotional reactions. The type and extent of response depends on the level of anxiety experienced. Table 37.3 lists some physiological and other responses to different levels of anxiety. Emotional reactions are usually apparent in the person’s descriptions of their experience. For example, they may state that they feel apprehensive, irritable, angry, depressed, helpless, on edge, unable to concentrate or remember things or they may feel detached from events and the environment. The person may experience angry outbursts or a tendency to cry frequently.

Table 37.3 Physiological and other responses to anxiety

Specific treatment and care of a person experiencing anxiety depends on the level of anxiety experienced and the effects on the individual, but generally interventions are directed towards reducing intense anxiety to a more manageable level and helping the person to develop self-help strategies to prevent overwhelming anxiety. Cognitive behaviour therapy (CBT), for example, helps clients develop strategies for controlling their anxiety and reducing the incidence of panic attacks. Minor tranquillisers such as diazepam (Valium), lorazepam (Ativan) and clorazepate (Tranxene) are sometimes prescribed to suppress the client’s feelings of anxiety but, as medications do not cure the condition and there are problems with dependence, long-term use is not advocated (Healy 2002).

General care involves:

The most common coping mechanisms taught and encouraged are:

The client experiencing depression

Depression is an emotional state that most people experience at one time or another. It can manifest anywhere along a continuum from intermittent feelings of sadness to a persistent deep sense of unending despair accompanied by hallucinations and delusions (Shives 2008). At the onset of depression the mood begins with a feeling of sadness that may be described as ‘feeling down in the dumps’. As depression worsens, sad feelings deepen until those affected feel gloomy and dejected much of the time. At this level of depression people may describe the experience with statements such as ‘I have no joy in my life anymore’ or ‘I just feel unhappy’. For some people the depressed mood can deepen even further until there is a persistent feeling of utter desolation. Severely depressed people have a sense of hopelessness about the past and the present, and the future looks black and bleak. The heavy feelings of despondency, wretchedness and acute misery are relentless. People affected feel desperately low and worthless, and this experience is accompanied by a sense of despair so profound that they do not believe the feelings will ever lift (Elder et al 2009).

Feelings of sadness and even intense grief, such as might be felt at the death of a loved one, are normal reactions to the various losses encountered by most people during their lives. Sadness and depression in such cases may be transitory, with the person moving through a grieving process and recovering successfully after the loss. Sometimes recovery after a significant loss does not occur and the person moves into a level of persistent and severe depression that does not resolve without professional assistance. This would be termed dysfunctional grieving. In some cases sadness, moderate and severe depression can occur without the person affected being able to identify a particular trigger for the low mood. Depression caused by biochemical imbalance is an example of this (Shives 2008).

Feelings of depression are so common that depression is known as the ‘common cold’ of psychiatry. It can occur at any age, even in very small children. Children with parents diagnosed with a depressive disorder have a higher risk of experiencing depression than others, and certain events may predispose young people to develop depressive symptoms (Keltner et al 2003). These events include:

Depression has a wide range of signs and symptoms but even so some people are able to hide their depression from others. Clinical Interest Box 37.9 lists the common signs and symptoms of depression. For some people depression may also be accompanied by anxiety. Some people experience alternating moods of depression and elation that can be disruptive to their lives. The periods of elation may be accompanied by significant hyperactivity. Such conditions are categorised as bipolar affective (mood) disorders, whereas mood disorders that have only the one dimension of depression without periods of elation are termed unipolar (Videbeck 2001).

Care of a depressed client is directed towards first addressing immediate safety needs in those at risk of self-harm. This will require hospitalisation and frequent or constant observation of those so seriously depressed as to be actively contemplating suicide. Antidepressant medication, when necessary, is started immediately, but the symptomatic relief is not generally achieved for at least several days, and possibly up to 4 weeks after therapy starts. Other specific interventions include individual, family, group, cognitive and behavioural psychotherapy (Keltner et al 2003; Shives 2008). The major goals are to lift the client’s mood, improve self-esteem, identify and reduce the impact of any major identified stressors, promote the development of constructive coping mechanisms, assist the client to regain interest and motivation in life and also to address any concurrent problems associated with physical health. General care involves:

Table 37.4 outlines nursing interventions and care for the client with depression.

Table 37.4 Key nursing interventions and principles of care for clients with depression

Adapted from Keltner et al 2011

People who are depressed are very vulnerable and this may be, in part, why they often withdraw and isolate themselves. This can make it very challenging for the nurse needing to establish effective communication. Clinical Interest Box 37.10 provides some strategies for promoting effective communication with clients who have depression.

Depression is a major problem in older adults and may also be accompanied by worry and anxiety. Symptoms of depression in the older age group are relatively common but often go undetected. This may be because sadness is considered a normal response to the losses associated with ageing, such as physical decline, loss of social role and loss of a spouse, and it may not be recognised when normal sadness and grief has developed into clinical depression requiring treatment. In addition, the complexities of physical illness, the side effects of medication and the symptoms of dementia may combine with symptoms of depression; making diagnosis of what is happening complex and difficult (Keltner et al 2011). It is very important for nurses working with older clients, particularly those with dementia, to be alert for, and report, changes such as unusual expressions of sadness, voicing the wish to die, decrease in appetite, reduced enjoyment, loss of interest in activities or other symptoms that may indicate the presence of depression. Clinical Interest Box 37.11 lists some issues relating to the mental health of older adults.

The client experiencing feelings of anger and hostility

Anger is a feeling experienced by most people at certain times. It generally occurs in response to fear, confusion or frustration. Anger often occurs in response to the anxiety a person feels when a threat is perceived. Most people have little difficulty in handling mild anger, which is experienced as annoyance and usually subsides quickly. Feelings of anger, disappointment and frustration may be expressed verbally or non-verbally, for example, by cursing or kicking a car when it won’t start. When a person is very frustrated, such as when they are unable to attain an important goal, anger may become more intense. A person experiencing intense anger may try to disperse the unpleasant feeling through an angry outburst or an act of aggression. Occasionally a person may be so consumed by feelings of anger that they become violent and pose a threat to themselves and to others nearby.

Nurses may encounter anger in the course of providing nursing care; for example, a person whose health is disrupted becomes frustrated, and frustration can lead to anger. Sometimes people express their anger through verbal or physical abuse towards others, including staff members. Therefore it is important that nurses are aware of the reasons why a person may be angry, of their own responses to outbursts of angry feelings, and of how to help an individual to express anger in an appropriate manner. Anger may be the result of various stressors. Some of the factors that may cause anger or aggression in people who are in hospital for any reason include:

Some of the specific risk factors leading to a potential for aggression in clients with mental illness have been identified (Watkins 2002) as:

Aggressive outbursts may occur when a person is unable to find a solution to a problem that is causing fear, confusion or frustration. Aggressive action may be directed towards the person or object perceived as the source of the frustration, or at other persons or objects in the vicinity. Displacement is a defence mechanism whereby an individual discharges pent-up feelings, such as anger, on a person or object other than the one that aroused the feelings (Varcarolis et al 2010). Approaches for dealing with anger and hostile behaviour in the mental healthcare environment are outlined in Table 37.5. Nurses may apply the principles of these approaches, when necessary and appropriate, in any healthcare setting.

Table 37.5 Approaches for dealing with anger and hostile behaviour in the mental healthcare environment

Shives 2005; Watkins 2001

Preventing aggression and violence is important for the wellbeing of clients and others. Assertive behaviour is one constructive way of dealing with anger. To be assertive is to stand up for oneself while taking into account other people’s interests and feelings. It takes time to develop the ability to be assertive when people are in the habit of being subservient or responding to situations they are unhappy with by being aggressive. It is within the role of mental health nurses to conduct training for clients who will be helped by developing assertiveness skills.

The client who is at risk of self-destructive behaviour

Self-destructive behaviour is that which results in physical harm and, sometimes, in the person’s own death by suicide. Self-destructive behaviour includes self-mutilation and any form of suicidal activity.

Suicidal behaviour

Self-destructive behaviour may result from any stress a person perceives as overwhelming, and is commonly associated with low self-esteem. When the sense of self-worth is extremely low, self-destructive behaviour reaches its peak and it is at this point that the risk of suicidal behaviour is likely. Suicidal behaviour implies a loss of the ability to see oneself as being of any value or worth at all (Stuart & Laraia 2005). Some of the risk factors for suicide are identified in Table 37.6.

Table 37.6 Suicide risk factors

Adapted from Ryrie 2000 & Muir-Cochrane, Barkway and Nizette 2010

Risk assessment is a crucial intervention in estimating a person’s intent to self-mutilate or end their own life, and a formal risk assessment should be conducted whenever there is any indication of the possibility of either, whether the client is in a general acute-care hospital, a mental healthcare facility, residential care or living in the community. It should be noted that the successful use of an assessment tool involves the ability to establish effective open and honest communication with the client, and expertise in the art of therapeutic communication is perhaps the most important component of the mental health nurse’s contribution to care (see Ch 6).

The first priority in dealing with a person who is at risk of, or exhibits, self-destructive behaviour is to protect the person from harm. All dangerous or potentially dangerous objects that could be used in an act of self-harm must be removed from the individual’s environment. This includes knives and other sharp implements, matches, glass, items of clothing such as belts, scarves or stockings or anything else that may be used by the client to inflict self-harm. Other approaches for dealing with self-harm and suicidal behaviour are outlined in Table 37.7. While it takes time and experience to become an accomplished mental health nurse, and the care and management of at-risk clients requires particular expertise, the principles of care, when necessary and appropriate, may be applied by others in any healthcare setting to protect clients.

Table 37.7 Approaches for dealing with self-harm and suicidal behaviour in the mental healthcare environment

Kelly 2000; Stuart & Laraia 2005; Watkins 2001

Self-mutilation and suicide are complex issues, and a simple and brief overview has been provided here. As people with depression and self-harming tendencies may be encountered in every area of nursing, it is recommended that nurses explore the issues further by accessing psychiatric or mental health nursing textbooks and state government policies. See, for example, Working with the Suicidal Person (Department of Health (Victoria) 2010).

The client who experiences hyperactivity

Hyperactivity can be a manifestation of a variety of mental health disorders, caused by the misuse of certain substances such as cocaine and amphetamines (Chitty 2004), but is particularly associated with bipolar disorders. Bipolar disorders are a group of mood disorders that manifest with periods of depression and mania. The hyperactivity associated with mania is quite different to the normal exuberant activity engaged in by most people at various times. Hypomania is a clinical syndrome similar to, but not as severe as, mania which is sometimes termed hypermania (Stuart & Laraia 2005). Previously people who experienced the mood cycles associated with bipolar disorders were said to have a manic–depressive illness.

Mania is characterised by excitability, optimism, marked hyperactivity, talkativeness and a decreased need for sleep. The symptoms vary in intensity. In the milder form, people can appear to have excess energy, they may present as the ‘life and soul of the party’, be able to work long hours and be very productive in work and leisure activities. If the symptoms increase to the most severe level, people may experience serious impairment in judgment that allows them to behave in ways not usually in keeping with their personalities. For example, a normally shy and quiet woman may become loud, dress in bright and gaudy clothing and become overtly sexually provocative; a normally sensible and frugal young man may run up huge and unmanageable debts on his credit card, drive his car at outrageously dangerous speeds and yell obscenities out of the car window as he narrowly misses other vehicles and pedestrians. Such dangerous and life-threatening behaviours may be of no concern to the affected person if they have psychotic symptoms, because delusional thoughts may make them believe that they are indestructible; for example, the young man above may believe that he is immortal because he is a new god come to save the world. Common symptoms associated with mania are summarised in Table 37.8. People who are experiencing the severe form of mania may need to be admitted to an inpatient unit for their own protection and for the protection of others.

Table 37.8 Common symptoms associated with mania

Stuart & Laraia 2001; Videbeck 2001

Treatment includes firm limit-setting, seclusion (only when essential), cognitive therapy, counselling and chemical restraint (medication). Lithium is one drug that is effective in treating the symptoms of acute mania and in reducing or preventing recurrence of the mood swings associated with bipolar disorders. However, lithium and other drugs often cause unwanted side effects and levels in the blood require strict monitoring to prevent lithium toxicity. In addition, some of the feelings of elation and mania are enjoyed, so clients are understandably not always willing to take the medications that stop the feelings so drastically and they may seek alternative ways of controlling the illness. Nursing interventions vary according to the level of hyperactivity and include:

The overall goals of care are to help the client establish constructive coping mechanisms and increase the client’s satisfaction gained from interaction with the world (Stuart & Laraia 2005). To do this the mental health nurse must establish and maintain a trusting relationship with the client. Attempting to do this can be challenging and frustrating for the nurse, partly because particular unusual speech patterns are common in people experiencing episodes of mania that impact on the ability to communicate effectively, particularly when clients are in the acute phase of mania. The speech patterns associated with mania are listed in Clinical Interest Box 37.12.

Some of the factors that present challenges to nurses in developing therapeutic relationships are that the client may:

Management includes setting clear limits on behaviour while being supportive but firm. Setting limits involves reinforcing that it is the behaviour and not the person that is rejected. For example, it is preferable to say, ‘That sort of language is not accepted in this unit’, rather than, ‘You are so crude speaking like that’.

The nurse at all times needs to remain calm, speak clearly and explain what is required simply and firmly but in a caring manner. All staff must be aware of the limits and rules set for the client’s behaviour, which must be constantly reinforced to assist the client to regain control of their behaviour. It must be remembered that behaviours that appear manipulative, fault finding or exploitative of others’ vulnerabilities are the outward expression of inner turmoil, distress and often serious emotional need. Such behaviour is the client’s way of trying to gain a sense of control at a time when they have no control of most aspects of their life; not even their own thoughts or feelings (Varcarolis et al 2010). Table 37.9 provides some approaches for dealing with hyperactivity associated with the manic phases of bipolar disorders, but the principles apply to clients experiencing excessive or uncontrolled hyperactivity from any cause.

Table 37.9 Approaches for dealing with hyperactivity associated with bipolar disorders (manic phase)

Adapted from Varcarolis et al 2010

Bipolar disorders and any disorder in which hyperactivity is a serious problem can be potentially devastating for clients and their families. It is an important part of the mental health nurse’s role to ensure that everyone affected understands about the illness causing the behaviour, is aware of what can and cannot be done to control the illness and what services and supports are available to help them to cope.

Clients experiencing confusion or disorientation

A person may become confused or disoriented for a variety of reasons, including as a result of delirium, dementia or from the toxic effects of alcohol and some prescribed and non-prescribed drugs. The effect in each case is a significant marked change in cognitive abilities from the client’s previous level of functioning. Cognitive functioning includes the mental processes of memory, reasoning, judgment, orientation, problem solving, decision making, the acquisition of knowledge and the ability to use and comprehend language. Some causes of cognitive dysfunction are reversible, others are not. Delirium, for example, is a syndrome that involves a disturbance to a person’s state of consciousness, which is accompanied by changes in cognition, almost always due to an identifiable cause that can in most cases be rectified. Dementia, on the other hand, is a progressive, irreversible and disabling condition in which changes in cognitive function are caused by gradually increasing, permanent damage to the brain. The focus here is on caring for those with progressive dementia.

Dementia is one of the most common causes of confusion and disorientation, with over 280 000 people in Australia currently identified as having the illness. It is a disorder normally associated with older clients but, although the risk of dementia does increase with age, more than 16 000 of those identified as having dementia are under age 65 (Alzheimer’s Australia 2011). Alzheimer’s dementia (AD) is the most common form of the illness, but all types of dementia share similar symptoms and require similar interventions. The symptoms depend on the sequence in which areas of the brain are damaged by the disease process, so the progression of symptoms varies in different people. Symptoms change and increase in severity over the duration of the illness, which in the case of AD can be 3–20 years, the average span being 7 to 10 years (Alzheimer’s Australia nd). Symptoms include:

Legal issues relating to informal and formal admission

Treatment in a mental healthcare facility or by a community mental healthcare team may take the form of informal or formal admission. Informal (voluntary) admission is when an individual chooses to receive treatment. Treatment may be at personal request or based on the advice of family or a health professional, and the client is able to withdraw from treatment or leave the healthcare facility whenever they choose.

Formal (involuntary) admission is when the request for admission comes from a source other than the mentally ill person, who is deemed incompetent to make an informed decision. An individual may be referred for admission if they pose a danger to themself or others or if they require treatment but are too confused or disorganised to seek voluntary admission. A medical officer completes a recommendation for admission form after examining the person. The admitting psychiatrist at the treatment centre then examines the person and decides whether or not to act on the recommendation by admitting the individual as a formal (involuntary) client, which means that the client may be given treatment deemed necessary whether or not they consent to the treatment.

In a crisis situation it may be a team of professionals based in the community, such as a crisis assessment and treatment team (CATT) that is called to assist. The team can request formal (involuntary) admission for a client but a medical officer must examine the client and sign the recommendation form as soon as possible. There are five criteria, all of which must be met to justify a person being admitted involuntarily. These are that:

As soon as a client no longer meets all five criteria they must be discharged from their involuntary status, or what is termed formal detention. There are strict guidelines governing who should review formal clients and how often they should be reviewed. Two psychiatrists must independently review formal clients on, or within 24 hours of, admission. All clients should be provided with a statement of rights on admission and given details of whom they can contact for support. Clients have a right to appeal against involuntary admission. The Mental Health Review Board reviews clients who appeal, but in any case automatically reviews formal clients on a regular basis.

Treatment orders and issues of consent

Mental health clients who are admitted involuntarily to a mental health service are sometimes treated under a community treatment order (CTO) or a restricted community treatment order (RCTO) while living in the community. The CTO may require that the person lives in a particular place to facilitate treatment; the RCTO may stipulate which psychiatrist will provide treatment, where and how often treatment will be applied and how long the order will last. It may also stipulate other specific conditions under which the client may remain in the community while receiving treatment. All formal clients, whether treated in the community or in a hospital, are legally obliged to accept recommended treatment, and treatment can be enforced against the client’s will if necessary. Even though this is the case it is in everyone’s best interest for formal and informal clients alike to be given all relevant information connected with any treatment, and informed consent should be gained whenever possible. The right of formal and informal clients to seek a second opinion must be respected.

The mental health Acts in each state and territory have clear guidelines concerning issues such as informed consent to treatment, the way treatments may be implemented (e.g. electroconvulsive therapy) and the use of restraint, including the use of seclusion as a therapeutic measure. It is an offence to restrain or seclude someone if it is not conducted within the requirements of the mental health Act applicable to where the practice occurs, and the mental health service can be prosecuted and fined if an offence is committed. All consumers admitted to hospital under the Victorian Mental Health Act 1986 (section 19A(1)) must have a treatment plan, the purpose of which is to provide a clear statement about the treatment and services to be provided to the consumer and to establish mutual expectations. The authorised psychiatrist must prepare, review on a regular basis and revise as required a treatment plan for each consumer.

Legal issues and electroconvulsive therapy

Electroconvulsive therapy (ECT) is a prescribed treatment and as such it is regulated under the different mental health Acts and regulations in each state. The use of ECT is indicated when the client has an increased risk of suicide, not responded to psychotropic medication or had an adverse reaction to medication. It is also indicated when the client has had a previous history of a good response to ECT (Henderson 2011).

ECT involves the client being given a light general anaesthetic and muscle relaxant medication. A regulated electrical current is passed through the brain until a seizure occurs (a therapeutic fit). This is sometimes referred to as shock treatment. A course of ECT involves a series of treatments. Informed consent must be gained whenever possible for any form of treatment, but there are some issues specific to ECT. The client can only consent to one course of ECT at a time. One course must not exceed any more than six treatments. No more than 7 days can pass between two treatments without the client’s consent being sought again. The client’s consent must be sought for each new course of treatment. ECT can be performed without consent on involuntary clients but only if set criteria are met. The criteria are that:

Further information about ECT and the law can be located in mental health nursing texts, mental health Acts and at mental health legal centres. References and websites for accessing legal information are provided at the end of this chapter.