The aim of this assignment will be to demonstrate my interventions designed to promote mental health and well being using current national and local policies and campaigns in relation to the patient’s identified needs as well as evidence based therapeutic interventions. Finally I will evaluate my package reflecting on its success or failure. In order to gain a better understanding of mental health promotion, it is important to gain a definition of promoting mental health.
Rosie Winterton (2006) quotes ‘Mental health promotion is key to changing attitudes about mental health across society. The National framework for mental health (DOH 1999) implemented national standards and service models for promoting mental health. Rosie Winterton (2006) continues ‘the National Service Framework for mental health.. outlines the need for the promotion of mental health for whole communities in schools, the workplace and neighbourhoods, as well as combating the discrimination against individuals and groups with mental health problems, and promoting their social inclusion.
As a nurse, I have a duty of care NMC (2008) to support and promote patients recovery so that he/she can be a productive member of society without feelings of feeling socially excluded. The client chosen will be called Elizabeth* for the purpose of this assignment in line with the Nursing and Midwifery Council (NMC 2008) Code of professional Conduct and Data Protection Act (1998) which require health care professionals to protect and maintain their clients confidentiality.
Elizabeth is a 38 year old woman who originates from Didsbury. Elizabeth is currently an inpatient on an adult psychiatric ward. Elizabeth was referred on recommendations from her Drugs Misuse worker. Elizabeth presented with signs of self neglect, low self esteem, feeling faint, disorientated, anxiety, irritability and aggression amongst others. Elizabeth has recently separated from her husband with whom she had no children.
This was due to her cannabis addiction; this caused problems between Elizabeth and her husband mentally, emotionally and financially. Elizabeth is now living with her mother, having accumulated debts to dealers, led to Elizabeth’s low mood and admission. During the initial interview Elizabeth claimed she had been dependant on cannabis since the age of 14. She had been admitted onto the ward for a detoxification from drugs on the recommendation from her Drug Worker and husband who felt her drug taking was affecting her mental health.
It is my duty to work in partnership with Elizabeth, to make her feel in control of her life and to successfully recover her from her drug dependence in accordance with the National Service Framework (NSF 1999) standard 1 which states, ‘health and social services should combat discrimination against individuals and groups with mental health problems, and promote their social inclusion’. To promote Elizabeth’s mental health I will need to assess her needs. ‘A need is a problem or barrier that makes people or communities less healthy than they can be.. or interferes with optimum health’ Bradshaw (1972).
The nursing care begins with a comprehensive, systematic and accurate assessment. (Shives 2005). It would be vital to gain as much information as possible from Elizabeth and any other relevant sources in order to evaluate Elizabeth needs. (Barker 2003) state’s ‘collections of relevant information.. contributes to an overall evaluation’. This information would assist me in formulating a psycho-educational package. I prioritised her needs in identifying and implementing care using Specific, Measurable, Achievable, Realistic and Time framed’. (SMART) model DOH (2001).
I introduced myself to Elizabeth as her Nurse. It is important to establish a therapeutic and understanding relationship with Elizabeth in order for recovery to take place. This can be achieved through communication. Communication is the key to gaining trust in any relationship. The DOH highlighted ‘Communication is a fundamental aspect of any relationship’. (DOH 1994). The assessment interview was conducted in an isolated room to avoid distractions that may threaten confidentiality and interfere with the effective listening, privacy and dignity of the client, (NMC 2008).
I explained to Elizabeth that any information gathered from her would be shared with other health care professionals involved in her care without breaching her confidentiality in compliance to the (NMC 2008) and the (Caldicott Report 1997) unless it was required by the law. Elizabeth’s response was very responsible saying she understood and was willing to co-operate. I continued to engage with Elizabeth using my interpersonal skills; listening, attentiveness, assertiveness, humour, self disclosure and my body language, (Riley 2008).
Without these skills I would not have been able to attain the information required to understand her difficulties and formulating sessions. During our initial session, Elizabeth was very open with me about her cannabis use and personal life. Elizabeth explained how cannabis had changed her and destroyed her marriage. Elizabeth expressed her desire of detoxification, to stay clean and to gain employment. Elizabeth explained how her cannabis use had started off in her young teens where smoking cannabis was seen as ‘being cool’. Elizabeth also explained that it had started to affect her mentally in her late 20’s.
I assured Elizabeth that her detoxification would be a tough process for her but as a Nurse I will support her. According to Murray et al (2004) ‘Cannabis use alone does not cause psychosis, but it is one of the things that may contribute to its development; therefore, using cannabis increases the risk. Alongside this drugs.. cause a massive surge of dopamine to be released and this extra dopamine leads to the sensation of pleasure, (Creek and Lougher 2008). This contributes to Elizabeth’s low mood since dopamine receptor sites have been either reduced or shut down.
Elizabeth and I both agreed to use Cognitive Behaviour Therapy to correct distorted conceptualizations and dysfunctional beliefs underlying her illness. CBT is the only psychological treatment in chronic psychosis with proven durability at short-term follow-up (Gould et al, 2001). Cognitive behavior therapy takes into account not only the symptoms of the illness but also the impact the illness on the individual such as isolation from family and friends, damage to social and working relationships, depression and increased risk of self harm.
I discussed CBT in depth with Elizabeth and allowed her to have literature on the subject which she could refer to in her own time. Elizabeth was experiencing hallucinations, I explained how reality testing worked and belief modification. ‘Milton et al. (1987) suggested that belief modification and reality testing are effective strategies in reducing the conviction associated with delusional beliefs. This involves helping clients to question the evidence underlying their beliefs and to set up behavioural experiments to test the reality of the evidence for their beliefs (Chadwick & Lowe, 1990).
Elizabeth was willing to use CBT and later realised the voices were not real. Alongside this with all the information gathered Elizabeth was prepared to assume the role of a self-therapist, (Williams, 2004). During the next weeks of Elizabeth’s treatment I was able to continue my assessment. Elizabeth portrayed irritability, self neglect, poor concentration, agitation and lack of sleep. Elizabeth’s symptoms continued and she also expressed thoughts about staff, which were out to hurt her and hated her. I reassured Elizabeth that her thoughts were not reality using CBT reality testing.
I also asked her to ask the staff she accused whether they expressed these thoughts about her. Although this was difficult as Elizabeth’s symptoms grew she became adamant that they hated her. It takes time to change and many individuals like Elizabeth, no matter what the change, are not successful on their first attempt stated by Prochaska and Di Climente (1998). My interaction with Elizabeth was positive, through me engaging her in decision making and allowing her to be involved in her care, this allowed us to build a therapeutic relationship.
Elizabeth was able to open up to me and share her feelings with me, she expressed how important it was for her detoxify and to rebuild her life. Elizabeth began to show some insight into her illness in the second session. Elizabeth realised her problematic behaviour and expressed a desire to change. I used motivation enhancement therapy encouraging her desire to change. Elizabeth was a voluntary patient in the hospital and claimed she had no desire to leave until the drug detoxification had taken place.
I made positive comments regarding this and encouraged Elizabeth. Elizabeth expressed that she felt better within her mental state, I had noticed this too as she had been more engaging with myself and other staff with whom previously she didn’t. Elizabeth said she was grateful towards me and the nursing team for listening and helping her. She also felt as though she was being treated as an individual whose dignity was respected rather than drug addict in compliance with the NMC (2008).
Elizabeth expressed her desire to build her life again with her family including her husband and her mother. I asked her to use this as an inspiration and to act on this thought positively. I also asked Elizabeth to elaborate on this thought; we looked at positive and negative outcomes that could happen so Elizabeth was ready to deal with them if they arose. My role as a nurse was to act as a witness and a facilitator to Elizabeth’s battles. Elizabeth expressed her desire to get involved with the groups that took place within the ward with the Occupational Therapist.
I encouraged her to join the groups and pointed out there was a gardening group who worked on the hospital garden. I remember from an earlier session that Elizabeth had expressed a passion for gardening. Elizabeth agreed to attend the group, she later expressed that she had made friends with a lady from another ward in the group. This was promoting her mental health and also boosting her social skills. Elizabeth’s food intake was poor; she claimed she did not like the hospital food and that it made her feel sick.
I discussed with the multi disciplinary team and we agreed to commence sessions with the Occupational Therapist with whom she was already working with to start cooking sessions. This would allow the O. T to assess Elizabeth’s skills and to assist her with activities of daily living. Alongside this Elizabeth would be able to cook, prepare and eat the foods she liked. This would boost Elizabeth’s confidence and avoid relapse. Relapse prevention is a self management programme designed to enhance the maintenance phase in the model of change, Miller and Rollnick (2002).
It can be defined as a wide range of strategies to prevent relapse in the field of addictive behaviour with the emphasis on self management and the techniques and strategies aimed at enhancing maintenance of habit of change, (Creek and Lougher 2008). Through motivational interview, Elizabeth recovered some of her coping strategies in situations that could lead to relapse. Researchers have shown that the people who are aware of potential relapse situations and use specific strategies can effectively reduce the risk of relapse. (Kirby et al 1995).
Elizabeth’s mental health and well being was also promoted using the Humanistic approach. Humanism emphasises the study of the whole person (Aanstoos et al 2000). This concentrates on Elizabeth’s behaviour from her point of view and allows Elizabeth to analysis her behaviour. This also promotes empathy. However it is unarguable whether Elizabeth’s behaviour is connected to her inner feelings and self image, (Clay 2002). Using open questions with Elizabeth, unstructured interviews and diary accounts, allows Elizabeth to have insight into her illness and promote her mental health and well being.
The humanistic approach offers new set’s of values for approaching an understanding of human nature and their condition. This offers expanded horizons of methods of inquiry in the study of human behaviour and needs. The information gathered from Elizabeth from using the humanism approach gave insight and more holistic information in her problems; she was also involved in making decisions to meet her needs and kept a diary account to see if she was meeting these needs. The humanism approach helped Elizabeth’s mental health and well being as suggested by Maslow’s hierarchy of need as the baseline (Maslow 1954).
The final session between me and Elizabeth was on motivation. Motivational strategies are used to increase commitment to change and boost motivation. It is a relatively simple, transparent and supportive talk therapy based on the principles of cognitive behaviour therapy, (Bundy 2004). A great deal of commitment and effort is required by me and Elizabeth in CBT. It is important for the Elizabeth to give me feedback, both positive and negative, at each session. This allows me to alter the speed, style, and content of future sessions in order to meet the specific needs of Elizabeth.
Motivational interviewing assisted Elizabeth in identifying and measuring her emotional reactions to problems she has faced, to also identify how her thoughts and feelings interact to produce the patterns in behaviour and to challenge this thought process. Alongside this i had to fully utilize my listening skills to ensure engagement between me and Elizabeth. This gave Elizabeth the opportunity to express herself and feel valued with my attention. I also expressed empathy by using eye contact that made her feel comfortable with myself.
I used phrases like ’I understand’ and ‘I can see you feel strongly about that’ as suggested by Riley (2008). I also waited until Elizabeth had finished what she was saying, avoiding interruption allowed Elizabeth to continue with what she was saying. The National Services Framework (DOH 1999) Standard one states ‘Individuals who misuse alcohol or drugs are at a significantly increased risk of suicide’. The standard one puts mental health promotion as their main goal. Individuals like Elizabeth have stigma attached to them because of the discrimination and social exclusion they face.
In order to tackle this, educating the public on mental and drug and alcohol related issues would gain mental health promotion. The NSF standard one allows opportunities for promotion in mental health such as employment, housing, education, benefits to reduce discrimination against individuals with mental health problems. Mental Health prevention is important in psychiatric nursing care. (Caplan 1964). Promotion of mental health is divided into three levels. 1. Primary – lowering mental disorders or reducing the rate at which new cases of disorders occur.
By using Motivational Interviewing Elizabeth was able to understand her thought process which was linked to her behaviour, thus reducing the rate at which the incidences of mental disorders occur. 2. Secondary prevention would involve reducing the prevalence of mental disorder by reducing the number of existing cases. This involves finding, screening and effective treatments. By Elizabeth committing herself to treatment and detoxification, has allowed us to treat her and reduce the number of existing cases. 3.
Tertiary prevention allows activities to reduce the severity of mental disorders and associated disability through rehabilitative activities. Elizabeth found Gardening relaxed her mental state and reduced the severity of her mental disorder. Elizabeth showed determination and improvement with her treatment. This allowed me and the multidisciplinary team to start working with her for her life after discharge. Employment opportunities and help with housing will be in place for Elizabeth’s discharge. This plan allows Elizabeth to see discharge and abstinence from drugs as a reality.
The National Treatment Agency for Substance Misuse have published many documents to assist with recovery from substance misuse. The NTA works in partnership with national, regional and local agencies to develop standards for treatment and that there are local accessible services to support drug users. The ‘Making it Happen’ (DOH 2001) document states that mental health promotion helps to improve physical health, enhance social inclusion and participation. By assisting Elizabeth through her treatment, allowed Elizabeth to become part of the society again.
By reducing the stigma and discrimination associated with mental health problems. This strengthens the capacity of communities to support social inclusion. Elizabeth was able to follow the treatment programme designed for her to allow her to recover from drugs and to stay abstinence from them. However it is vital for Elizabeth to continue this treatment whilst in the community to promote recovery and avoid relapse. I discussed with Elizabeth possible triggers that may trigger a relapse or become weak. Elizabeth shared with me that her brother was also a cannabis user.
I expressed that Elizabeth could educate her brother with the knowledge she now shared about the drug and the problems it poses. I also advised Elizabeth to advise her brother on the help she received from her local Drug and Alcohol team. This may help her brother to seek help for his own addiction and allow Elizabeth not to be influenced by her brother. I was impressed by Elizabeth’s determination she had shown me throughout her treatment and her consistency of hard work. I advised Elizabeth to join a local support group to remove the stigma on drug users, to boost her confidence within her community and to socialize.
In order for this mental health promotion to be a success ongoing assessment of Elizabeth was necessary. This allowed Elizabeth to become engaged with the interventions proposed and to express her own concerns. Although Elizabeth’s behaviour was monitored Elizabeth felt able to approach me and express that she had noticed changed in her behaviour via using the motivational interviewing skills, the demonstration of care and concern by the nursing team and her desire to achieve her goal of regaining relationships with her family.
The package that was created for Elizabeth allowed her to promote her health and well being in many ways, building her confidence with the nursing team, allowing her to socialize with other patients from other wards in her Occupational Therapy groups/activities, building her knowledge on her treatment allowing her to be in control and to make decisions.
Elizabeth was able to analyze her behaviour through keeping a diary. Elizabeth was able to advise other patients through her experience of the detoxification. Elizabeth turned into a confident young woman allowing her to build her broken life into success with her family and gaining voluntary employment with her local Drug and Alcohol team where she advised drug users on the experience of her detoxification programme.