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Mental Health Standards and communication

Mental Health Standards and communication. Rebecca Sposato MS, RN. Standard 1: Assessment. Physical exam Labs, Neuro diagnostics, Review of systems Mental Health Status Exam Thinking patterns, Emotional affect, Perceptual disturbances, Speech, Appearance, Behavior, Safety/Harm Psychosocial

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Mental Health Standards and communication

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  1. Mental Health Standards and communication Rebecca Sposato MS, RN

  2. Standard 1: Assessment • Physical exam • Labs, Neuro diagnostics, Review of systems • Mental Health Status Exam • Thinking patterns, Emotional affect, Perceptual disturbances, Speech, Appearance, Behavior, Safety/Harm • Psychosocial • Home, family/friends, employment, income, substance use

  3. Standard 2: Diagnosis • Problem – what needs help • Clinical judgment • NANDA diagnoses • Etiology – probable cause • Medical, psychosocial, etc. • ‘related to . . .’ • Supporting Data – objective signs and symptoms • ‘as evidenced by’

  4. Standard 3: Identify Outcome Goals • The maximum level of health that can be realistically achieved through nursing interventions • Customized per patient situation • Nursing Outcomes Classification (NOC) -385 items in 7 categories • Set time period

  5. Standard 4: Planning • Most places use standardized clinical plans and pathways • Safe, Compatible, Realistic, Individualized, Evidenced-Based • Nursing Interventions Classification (NIC) – 542 accepted interventions

  6. Standard 5: Implementation • Standard: • Coordination of Care • Health Teaching/Promotion • Milieu Therapy • Pharmacological, Biological • Advanced: • Prescriptive • Psychotherapy • Consultation

  7. Standard 6: Evaluation • Should be ongoing and criteria based • Reassess for outcomes and compare to goal • If they don’t match, review each standard and revise as needed

  8. Milieu Management • All parts of the patient’s environment are designed to contribute to sense of security, support and comfort • Safety and protections • Unit exhibits calm and positive mood • Communicated rules and routines • Communicated consequences for behavior • Consistency and flexibility

  9. Therapeutic Relationship • Therapeutic use of self – the living part of the milieu • Purposeful conscious use of personality (words, actions and attitudes) • Every moment counts • Communicate trust on all levels • Safe • Reliable • Consistent • Confidential • Benevolent

  10. Peplau’s phases • Pre-orientation: internal state and beliefs • Orientation: • Establish rapport - connect • Establish parameters – extent of role • Formal/informal contract - expectations • Confidentiality – terms of privacy • Terms of termination – time period, behavioral deal-breakers

  11. Paplau’s Phases • Working: • Problem-solving/coping skills • Substance of therapy • Termination • Resolution of the problem • Incorporating therapy growth into the real life situation • Passing of the relationship

  12. Professional Boundaries • The nurse is an extension of the employer and profession • Clear limits • Professional layer over nurse’s personal needs and beliefs • Transference and Counter- transference: fitting the other person with pre-existing pattern of perception

  13. Features of Professional Communication • Needs of patient identified and explored • Clear boundaries established • Use of problem-solving approaches • New coping skills developed • Behavioral change encouraged

  14. Therapeutic Communication Techniques • Active Listening and silence: empathy • Clarify statements: Summarize, paraphrase, restate, reflect, explore • Questions and Response: Open ended vs. close ended • Reality Testing: presenting reality, stating the implied, voicing doubt, suggest alternatives

  15. nontherapeutic Communication • Excessive questioning – patient feels interrogated • Approval/disapproval – imply judgment • Advising – change should come from within • Asking ‘why’ – as a form of criticism

  16. Non-Verbal Communication • Believed to stem from the subconscious • Less precise and more powerful then verbal communication • Voice features • Body/hand movement • Eye contact • Personal space • Cultural filters/interpretation

  17. Types of Therapy • Classic Psychoanalysis and Psychodynamic Therapy– searches for greater understanding of unconscious processes’ contributions to thoughts, emotions and actions • Long-term - can be years • Open-ended – general improvement • Unstructured – free association • Little input/direction from the therapist

  18. Cognitive Behavior Therapy • CBT- seeks to change distorted beliefs and habits and replace with logical and functional beliefs and habits • Preset time frame • Specific goal oriented • Homework assignments

  19. Rational-Emotive Behavior Therapy (REBT) • Introspective therapy about a person’s beliefs toward on event as the main contributor of one’s behavior and quality of life • A: activating event • B: belief surrounding the event • C: consequences/emotions of their actions

  20. REBT: 3 types of irrational Beliefs • A: I must do well and please others to be good • Leads to anxiety and depression • Replace with self-acceptance • B: Others must treat me well and fair. If not they are bad and should be punished • Leads to anger, passive-aggression • Replace with other-acceptance • C: I must get what I want, when and how I want. If not, I can’t stand it • Leads to self-pity, passivity, intolerance • Replace with life-acceptance • http://www.rebtnetwork.org/whatis.html, 2011

  21. REBT strategy • A: the kitchen is messy, and the sink is full of dishes • B: My roommate is a lazy slob • C: Resent the roommate and bicker about dishes • A: The kitchen is messy, and the sink if full of dishes • B ? • C ? Without REBT With REBT

  22. Dialectical Behavioral Therapy • Derived from CBT by Dr. Linehan, to treat a person who is emotionally escalated and self destructive (originally suicidal borderline personality patients) to create ‘a life worth living’ • Believes extreme behavior happen when emotional vulnerability occurs in an invalidating environment • Individual Therapy • Group sessions • Phone Coaching • http://www.youtube.com/watch?v=9ZuwEWLHHHY

  23. Stages of DBT • One: Out of control to in control of behavior • Target 1: Decrease life threatening behaviors • Target 2: Decrease behaviors interfering with treatment • Target 3: Decrease behaviors destroying quality of life • Target 4: Life/relationship skills • Two: Move to emotional shut down to full emotions • Fill in middle of the emotional spectrum • Three: Strategies for life’s ordinary problems • Four: Move to completeness/connectedness • http://behavioraltech.org/downloads/dbtFaq_Cons.pdf, 2011

  24. Communication - SET • SET – structured communication technique designed for speaking with an emotionally escalated person • S: Support – established benevolent intentions • E: Empathy – acknowledge/validate present emotion • T: Truth – realistic/honest assessment about situation of concern http://www.youtube.com/watch?v=ckyGJr5DiJY&feature=related (Keisman & Strauss, 1991)

  25. References • Behavioral Tech LLC (2011). Retrieved from http://behavioraltech.org/resources/whatisdbt.cfm • Kreisman, J. & Straus, H. (1991) I Hate You; Don’t Leave Me. Harper Collins: New York • REBT Network (2011) retrieved from http://www.rebtnetwork.org/whatis.html

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