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What is a recovery vision Model
A consumer-centred model of healthcare that focuses on hopes and goals for the future, optimism, and living life to the full
What is Mental Health
A sense of well being, confidence and self esteem. Good mental health is individual, and means the person has the abilities to carry out ADLs without dis-stress. And being able to deal with life stresses in a normal manner and the mood will soon pass
MH PLANS AND STATEGIES...
1. Natioinal Mental Health Plan(NMHP)
To promote the mental health of australians. And to reduce impact of mental illness in idividuals and their families. FOUR core principles PROMOTING and PREVENTING, increasing service responsiveness, strengthening quality, fostering research, innovation and sustainability.
What is the difference between MH and MI (Think Paradigm)
This is when the person is faced with psychological distress, and lasts longer then the normal time and instead of returning to the normal daily routine, the persons ADLs become affected. It is when cognitive, emotional and beavioral dis-function.
2. National Practise standards for the mental health work force.
Commonwealth goverment document that outlines the service standards for all MH services across australia. The standards are also intended to reflect a strong value base, related to human rights, dignity and empowerment.
3. Western Australian Mental Health Strategy
Providing a healthy future for WA. Enhancing the capacity of MH services. 2020..Making it personal and every bodies business a 10 year strategic policy for MH by the MH commission in WA.
4. National Action Plan for Promotion, Prevention, and early Intervention for MH
- To build a theraputic relationship and to build trust. And is important for gathering information. And will help to provide the best interventions needed.
- Enagement barriers
- Common sense skills
- Effective communication
- Simple rules
Simple interview rules to follow
- 1.Treat any consumer with respect
- 2. Ensure that your are truly Genuine
- 3. People can spot a fraud a mile away
- 4.Always remember your role.
Engagement Barriers From the worker
Working lacking time and/or skills.Scared to ask difficult questions, fearing the answer and not knowing how to deal with the answers. Seeing suicide attempts or self harm in people as manipulative and/or attention-seeking behaviours.
Engagement Barries from the client
low levels of MH literacy. Not knowing they have a problem. Distrust. fear of not being taken seriously and confidentiality. cultural. learing disabilitiy. Poor accessibility.
- This model looks takes a holistic approach to patients.
- Bio-(Medical) Medications including antidepressants, antipsychotics.understanding illness and hospitalisation
- Psycho-(Mind) Therapy
- Social-Infuences, rehabilitation, community re-intergration, education
Stress Vulnerability Model
- For biological reasons some people are more sensitive
Conducting an Interview
Start with a formal assessment, gathering information to formulate and diagnose specific problems requiring care. Comence a care plan formulation. Engaging and building nurse/client relationship.
In interviews Nurses need to gather what information
Demographics..Previous history of illness..Psychiatric problems or hospital admissions...Present problem or complaint..When problem first began or was noticed..what the client was like before problem..Brief family history..Personal history with childhood illnesses, education, adolescence, job record, marriage, children, hobbies, interests, use of drugs and alcohol and any other relevant items.
Mental Health Examination
MSE is an assessment of a patients level of cognitive ability, appearance, emontional mood, speech and thought patterns at time of evaluation. And is designed to obtain information about specific aspects of the individuals mental experiences and behavior at the time of the interview.
- Appearance--what the person looks like, age, gender, hairstyle and colour, build, apparent health, skin condition, level of hygiene, physical abnormalities, facial expression and mode of dress.
- Behaviour--eye contact, level of cooperation, motor activity, movement.
- Speech--abnormalities, rate, rhythm, volume, pitch
- Mood and Affect--Mood is subjective, what the patient says they feel. Affect is objective--what the nurse can measure or test.
- Thought Form-- patients thought organisation, flow and production of thought. Is it logical. Flight of ideas?, thought blocking.
- Thought Content--persons thought in the here and now(including suicidal thoughts and delusions) Ask questions, do u get an answer or is there evidence of tangentality, Blocking or derailment.
- Insight--Ability to recognise a problem and understand its nature and serverity..understanding they need help
determines a persons intent and level of risk. level of risk will determine what type of managerment plan is implemented. Comprehensive assessment must always complete before moving onto intervention.
Suicide questions to ask
- 1. are you thinking of killing yourself?
- 2. have you got a plan?
- 3. Have you got access to the mans to carry out the plan? eg rope, medication
- 4. have you ever tried to commit suicide before?
- 5.what has stopped you from doing it so far?
DSM-IV-TR and ICD-10
- are coding systems used to dioganosie and base treatment on. Coding disorders under seperate axises insures they are not overlooked.
- ICD-10 is a world health manual and used through out the world
Axis 1 Disorders...mood and thought disorders
Is affective Anxiety and Psychotic disorders and includes disorders such as uni-polar depression, (affective)Anxiety, and psychotic such as schizophrenia and bipolar
Depression- Axis 1 (Affective)
- symptoms surround thought, Behaviour, moods then physical. To diagnose depression they must have 1-be sad and irritablility that does not go away. 2- loss of enjoyment in activities. 3- Lack of energy and tired. then be mixed with the following. 4- feeling worthless. 5-thinking about death. 6-difficulty concertrating. 7-moving slowly or agitated. 8-sleeping difficulties. 9-loss of appititte.
- Depression involves one mood state and must last at least 2 weeks to be called clinical depression.
- Chronic depression (emotions lasting at least 2 weeks)
- Uni-polar depression( group all depression types, mild, chronic etc)
- Psychological and family therapies. Cognitive Behaviour Therapy(CBT)
- ECT-electro convulsive therapy
2 Majo neurotrasmitters associated with depression and mania
Nor-adrenaline and serotonin
- Is a response to an unknown danger..fear is of a specific danger.
- physical symptoms include,
- (cardio) palpitations, chest pain, rapid heartbeat, flushing..(Respiratory) hyperventilation, shortness of breath.. (Neurological) dizziness, headache, sweating, tingling, and numbness..
- (Gastrointestinal) choking, dry mouth, nausea, vomiting, diarrhoea..
- (Musculoskeletal) muscle aches and pain
Types of Anxiety disorders
- Generalised anxiety disorder(GAD)
- Panic disorder and Agoraphobia
- Phobic disorders: specific disorders and social phobia
- seperation anxiety disorder
- Acute stress disorder(ASD)
- Post-traumatic stress disorder(PTSD)
- Obsessive complulsive disorder (OCD)
- If you have anxiety you are more than likley to suffer depression
- Psychological therapies are preferred for the treatment of anxiety:CBT and graded exposure
- Medication if required for more servere disorders..Medication is used to contol physical symptoms
Anxiety Risk Factors
- They have a more sensitive emotional nature and tend to see the world as threatning.
- Were very anxious or very shy in childhood
- Had a difficult childhood
- Have a family history of anxiety disorders
- Have parents with alcohol problems
- Have certain medical conditions
- This diognoses can not be made before 6months and must be in the abstance of drug and alcohol.
- Psychosis is a mental illness in which a person has lost some contact with reality.
- Psychosis is characterised by delusions, hallucinations and thought disorder.
- There may be severe disturbances in thinking, emontion, motivation and behaviour
- Psychosis severely disrupts a persons life
- Relationships, work, study, and self care are difficult to initiate or maintain. Loss of drive, blunted emotion, social withdrawal.
Drug induced psychosis
Brought on by drugs. Drugs that can cause psychosis are cannabis, cocaine, ecstasy, amphetamines.
Psychosis Risk Factors
- Genetics-a family history of psychotic disorder
- Cannabis use- especially in those most vulnerable
- stress- can bring on episodes of psychotic disorder
- Frontal and temporal brain injuries can mimic common psychotic symptoms.
- To treat the positive symptoms medication is needed=Anti psychotics and mood stabilizes.
- Psychological counseling can be helpful to improve functioning.
- Treatment of other mental problems is important
- People with psychotic disorders often have poor physical health-ongoing regular check ups are a good idea.
- Early intervention is important to stop a snowball effect of health problems. Also it will aid in a more complete recovery.
Axis 2 Disorders
- is personality disorders such as boderline personality and anti-social personalitiy disorder. These orders show patterns or traits of thinking and feeling, enduring, pervasive, maladaptive and causes significant functional impairment. Maladaptive behaviours. Chronic feelings of emptyness, Excessive efforts to avoid abandonment.
- They can never be cured just managed
Personality disorder Assessments
Comprehensive interview and must include drug and alcohol use, self harm, Suicidal ideation or attempts, Unexplained visible injuries to body, sexual activity, family relationships.
Personality disorder treatments
- Hospital admission rare.
- Long term managerment plans including 1.Interactive therapies, CBT and Dialectical Behavioural Therapy (DBT)=this is a type of congnitive and behavioural therapy used with positive outcomes.
- 2. Pharmacological- Mood stabilizers(lithium), anit-depressants(SSRIs)
- 3. Therapeutic Communities
- 4.Team Nursing intervention
Anti-social personality Disorder
a disorder characterized by a pattern of disregard for and violation of the rights of others..Callous unconcern for others feeling, blaming others. Unable to experience guilt related to inappropriate behavior.. More common in prisons than hospitals.
Avoidant personality disorder
patterns of social interaction and feelings of inadequacy and being hypersensitive to negative evaluation.
Borderline personality Disorder
a disorder characterized by a pattern of instability in interpersonal relationships with marked impulsivity. carries a high risk for suicide and self harm. Most commonly presents in the ED
Paranoid personality disorder
patterns of distrust and suspiciousness such as other peoples motives.
Personality Disorder Risk factors
- Genetic vulnerability
- Childhood abuse, neglect, or trauma
- Genetic vulnerability + Abuse, neglect, trauma = personality disorder
is marked by shifts in mood, energy and ability to function. Moods shifts vary between depression and manic epiosodes. Mood shifts are often calandar related. And can be brought on by stress.
Assesment-mood, behavior, thought processes, and speech pattens, cognitive functions. Restlessness, grandiose, lack of insight
4 or more cycles within 12months is called rapid cycling.
- Bi-polar 1- have at least 1 manic episode
- Bi-polar 11-A person who has experienced both hypomanic and dysthymic episodes.
- Rapid cycling bi-polar- 4 or more cycles within 12 months
Bi-polar Risk Factors
- Stressful life events
- Neurotransmitters-high or low level of specific neurotransmitter= serotonin, nor adrenaline, or dopamine or an imbalance of these substances.
first line of therapy for bi-polar disorder is lithium.
Lithium is which is an Anti-manic
stimulus that adds to the problem. eg Delusions, hallucinations
takes away from ones normal life, such as depressive symptoms
What is clang associations
are the stringing together of words by rhymic sound instead of meaning
What is Grandiosity
Inflated self-regard.. People with mania can experiance grandiosity exagerating their achievements or importance..stating they know famous people. Delusions and hallucinations are not present.
Flight of Ideas
Quickly shifting from one idea to another
low level cronic depression, symptoms must last longer than 2 years
co-occurrence of disorders
an elevated mood accomanied by hyperactivity, grandiosity and loss of reality. In servere manic episodes the patient may suffer from cardiac problems
Fixed false belief
- involves the false senses
- Tactile Hallucinations usally occur when withdrawal from drugs eg picking the skin
- Depressants- Alcohol, Heroin, Benzodiazepines
- Stimulants- Caffine, Tobacco, Amphetamines, Cocaine, Ecstasy.
- Hallucinogens- LSD, 'Magic Mushrooms'
- Other- cannabis
- Substance use-is using a substance
- Substance mis-use- is using a substance to an extant to affect the persons ADLs ( in the MSE use goes under behaviour).
MODELS TO EXPLAIN USE..Thorleys Model(patterns of use)
- INTOXICATION- (Can be single use) Accidens, Violence, Drink Driving, Suicides, O/Dose.
- REGULAR USE-Organ disease, Financial, Relatioships
- DEPENDENCE-Cant resist use, Withdrawal cravng obsessive, Cognitive Conflict, Isolation.
DRUG SET AND SETTING MODEL- The cycle of change Model (Zinbergs Model)
- Interactive Factors are, Drugs, Individual, Environment.
- DRUGS- Purity, Route, Dosage, With what other drugs, Price, Availability, Legality, Form of drug eg powder, home baked etc
- (set)Individual- Age, gender, health, expectations of the experience, previous experience, mood, tolerance, view of oneself, family background, genetic factors, beliefs/attitudes
- (setting) Environment- Where, with whom, what time, how, safety of setting, peer influence, cultural factors, influence of advertising, media influence, poverty setting.
ROIZENS MODEL- Model of the Four Ls
Liver, Lover, Livelihood, Law
- Liver- represents all physical problems and psychological problems caused by drug use, such as depression, anxiety and psychosis, hepatitis, blood born viruse, cardiovascular.
- Lover- Represents problems with relationships with family and/or friends
- Livelihood- Problems of employment, unemployment, study, financial.
- Law- Refers to all the legal problems which may result from drug use DUI, domestic violence, possession, armed robbery
THE STAGES/CYCLE OF CHANGE MODEL(Prochaskaand Di Celmente) 5 stages
- Precontemplation- I do not have a problem
- Contemplation- Oh shit i MAY have a problem
- Preparation- I think i have a problem and i think i may need help(looking on the net)
- Action- I do have a problem and i actioned a treatment plan
- Maintance- Seeking a reduction in use/or non-use
- Relapse- You either exit the cycle forever or can relapse and start cycle over again.
LEVELS OF PREVENTION
- Primary- To prevent Mental illness and reduce identified cases of MH disorders within a population.
- Secondary- Focuses on intervention that identifies MH problems early and reduces both the prevalence and duration of the illness.
- Tertiary- Final level of prevention. Focuses on rehabilitation and ways to reduce the residual effects of those suffering mental illness
Pharmacology in MH
- Medications are an important role in MI management and ongoing treatment. There are four phases in drug administratioin
- 1. Initiation-prior to commencment, the patient will undergo several assessments.
- 2. Stabilisation- during this phase there are often changes made to the dose. or changes in medication
- 3. Maintenance- when symptoms improve medications are continued until either relapse or discontinuation.
- 4. Discontinuation- most psychiatric medications require a tapered discontinuation. patient must be monitored.
- or the management of depression. Types of medication are
- Tricyclics (TCAs)= Amitriptyline etc
- SSRIs= Citalopram etc
- SNRIs= Venlafaxine etc
- MAOs= Phenalzine etc
- these need too be monitored for the presence of serotonin syndrome.
Anxiolytics and Hypnotics
- Management of anxiety states and insomnia
- Beta Blockers
- Need to monitor for issues relating to tolerance and dependance
- Management of psychosis=1. Acute states 2. Maintance
- Typicals= haloperidol
- Atypicals(newer generation)=Aripiprazole, Olanzapine, Clozapine, Risperidone
- Extra pyramidal side effects(EPSE)
- Neuroleptic malignant syndrome (NMS)
- Management of side effect due to antipsychotics
- Benhexol and benztropine
- Delirium risk
- Management of unstable moods
- Lithium= Sodium Valproate
- Need to monitor for signs of toxicity
- Management of ADHD
Treatment option for low level and hazardous mis-use
- ADIS(Alcohol and drug information services
- PDIS(Parent drug information services)
- Allied health counseling
Treatment options for harmful/dependant misuse
- Withdrawal options
- home based, inpatient, out patient
Treatmeat approaches to co-morbidty
- harm minimisation
- Reflects the reasons for use and relationship between their substance use and mental health problems
- Not necessarily involve the abstinence as a goal
- Possibility involve the use of anti craving medication
- Be based on the clients readiness to change and not pre determined by the clinician
- Involves outside supports where available
More specific approches to treatment
- Structured problem solving
- Motivational interviewing
- Brief congitive approaches
- Brief behavioural approaches
- Supportive therapy
- Appropriate pharmacotherapy
- Utilisation of external supports
The Mental Health Act
The aim of the MHA is to protect the public and provide care for people with MI in the least restrictive manner possible. It represents a sharing responsibility across the whole community for the care and protection of people who have a MI
MHA key features
- 1. to ensure that persons with MI receive the best care and treatment with the least restriction of their freedom and the least interference with their rights and dignity.
- 2. To ensure the proper protection of patients as well as the public.
- 3. To minimise the adverse effects of MI on family life.
MHA core principles
- 1. Protectioin of patients rights
- 2. Least Restrictive Environment- the indroduction of community treatment orders and the requirement to always consider a CTO before detaining a patient puts this into practise.
- 3. Mental Illness alone is not sufficient to warrent compulsory admission- section 26 of the act makes it clear that having a MI is only one of the criteria necessary before detaining order can be made.
- 4. Balance of rights and responsibilities- As well as patient rights the act recognises the responsibilities of a duty of care to patient and to the community at large. The act in removing judicial authority enhances the role of Mental health practitoners and details the role of police.
MHA and patient rights
- The act outlines all patients detained under authority of the act have the following rights:
- Explanation, Complaints, Personal records, Not to be ill treated, Second opinion, Personal possessions, send and recieve mail, receive and make phone calls, visitors, Restrictions or denial of entilement, voting, consent and refusal to certain treatments, Appeals.
- Criteria required for an individual to be detained for compulsory assessment treatment. There are four main conditions ALL being reqired for an involuntary admission to be granted.
- 1. the person has a MI requiring treatment and suffering from a disturbances of thought, mood, volition, perceptioin, orientation or memory that impaires judgement or behaviour to a significant extent.
- 2. Treatment can be provided through detention in an authorized hospital or through community treatment order and is required to be so provided in order.
- (1) protect health and safety of that person or any other person
- (11) to protect the person from self-inflicted harm
- (111) to prevent the person doing serious damage to any property.
- 3. The person has refused or, due to the nature of the MI, is unable to consent to treatment.
- 4. The treatment cannot be adequately provided in a way that would involve less restriction of the freedom of choice and movement of the person than would result from the person being an involuntary patient.
MH Practitioners Vs Authorised MHP
- The cheif psychiatrist may designate as an authorized MHP any MHP who in his opinion has qualifications, training and experience appropriate for the performance of the functions vested in an authorized MHP.
- The cheif psychiatrist is responsable for montoring all forms and CTOs and to ensure the MHA is followed and upheld and to ensure care and welfare of involuntart patients.
- Mental Health Review board(is an independant board) and Mental health law centre(provides legal advice)
MH forms and CTOs
- Form 1- Referral to the hospital
- Form 3- Transport order with police
- Form 4- Seen by a psychiatrist and detained for a further 72hours
- Form 6- Seen by a psychiatrist and detained for a further 28days
Community Treatment Orders (CTO)
- A Psychiatrist is not to make a community treatment order in respect of a person unless satisfied that
- a) treatment in the community would not be inconsistent with the objectives set out in section 26
- b) suitable arrangements can be made for the care of the patient in the comunity.
- c) a Medical practitioner or MHP who is suitably qualified and willing to do so will be available to ensure the patient receives the treatment outlined in the order.
- d) a psychiatrist who is willing to do so will be available to supervise the carring out of the order.
- Camhs aims to reduce symptoms experienced by the younger person and assist or support the families.
- Uses play therapy such as puppeets drawing, doll houses, using some type of mediator.
- CAMHS sees the child in the bigger picture.
- Major stage of neuroplastic pruning and development
- •Major Endocrine changes
- •Pubescent growth spurts
- •Radical social and personal development
- •Pressures of career and scholastic pathways
- •Life-shaping phenomenology
- Psychoanalytic/Foundation –Freud
- •Infant Theory –Lacan
- •Stage of Life -Erickson
- •Cognitive-Developmental -Piaget
- •Moral Development -Kolberg
- •Social Learning -Bandura
- •Attachment Formation –Bowlby and Ainsworth
- •Learning Acquisition –Pavlov and Skinner
- •Separation/Individuation -Mahler
Dementia and delirium
- Delirium is acute onset and toxicity is mainly the under lying cause and once fixed the delirium will disappear.
- Dementia is a slow onset and can not be cured
Jigsaw for transcultural care
- The world is familiar with the jigsaw puzzle no matter the ethnicity
- •The Jigsaw no matter how simple ,complex, large or small is made up of pieces.There may be a few pieces or hundreds of pieces.
- Each piece is a picture on its own and fits next to the the other to give an overall picture
- •When there are pieces missing the picture is not finished and is not quite right
- When assessing any person I use the jigsaw analogy.
- This can have a calming effect on the situation .It puts many people at ease as they can relate to a jigsaw.
- After establishing rapport with the person I explain to them that their life to this point is one big jigsaw puzzle and they and their family/mob are aware most of the pieces and what pieces sit next to each other to give the overall picture of where they are at today
- •Some of the pieces overlap to form a three dimensional picture or sit on top of other pieces and become layered
- The client is then advised that for me to help them and their family,they need to help themselves first by telling their story and letting me know of as many of those pieces as possible.
- •Some of the pieces may not make sense to them however to me and my team they will make sense.
- I need all the pieces no matter if you think they don’t matter and make sense.
- •Some of the pieces may not make sense to us and is it ok if we get the pieces or information about the piece or pieces from your family and friends.
- •We will then work with you ,your family and supports to get you back on track again
- A plan then can be formulated based on the assessment using the jigsaw process.
- •When discussed with the client/family the plan can be related back to the jigsaw to make the change to make the pieces fit better on a level understandable to the family.
- Or to provide for some relief to pieces that are causing much pain and problems for the client ,family and friends wellbeing and functioning.
- •In the event of hospitalisation the hospital becomes a necessary temporary piece in the jigsaw to ensure safety and well being for the client /family and needs to be reinforced that it is as a temporary piece and the only one to guarantee their safety.