Cultural Perspectives in Mental Health

• Unique challenges exist when accessing psychiatric care

Unique Challenges to Accessing Psychiatric Care

• Limited knowledge and misunderstanding of symptoms can affect recognition of care needs
• Fear of judgement, discrimination and internalized stigma can affect access to psychiatric care
• Fragmentation of care and lack of coordination between providers are systemic and structural barriers

Brief History of Psychiatric Care in the U.S.

• 1700s: Asylums were established but became overpopulated
• 1800s: Psychiatric nursing began in Massachusetts
• 1950s: The first antipsychotic medication, Thorazine, was introduced
• 1960s: Medicare/Medicaid was created, but without psychiatric funding
• 1999: The Olmstead Decision led to deinstitutionalization
• 2016: There was a drop in state psychiatric hospitals

Continuum of Care

• Outpatient care settings include primary care, community clinics, and telehealth
• Emergency care models include crisis stabilization units and psychiatric emergency services
• Prevention in outpatient care includes education, screenings and community programs

Case Study: Edgar

• Diagnosis: Major Depression and PTSD
• Treatment Approach: Patient-centered medical home plus collaboration
• Prevention Type: Secondary prevention (early intervention)

Inpatient Care Settings

• Hospitalization criteria include safety concerns and/or inability to self-care
• Types of inpatient facilities include crisis stabilization units(CSU), general hospitals, private hospitals, and state psychiatric hospitals(for long-term care and forensic populations)
• Patients retain civil rights, informed consent unless required in emergencies
• Team collaboration includes multidisciplinary planning and clinical pathways

Inpatient Psychiatric Nursing Roles

• Roles include data collection, care planning and crisis management
• Ensuring safety, facilitating health education are essential for nursing roles
• Nurses coordinate with healthcare teams

Discharge Considerations

• Housing, income and support system need to be considered
• Substance abuse and physical well-being need to be considered

Specialty Treatment Settings

• Settings include pediatric and geriatric psychiatry
• Veteran's administration centers are specialty treatment settings
• Forensic psychiatric care of incarcerated populations is considered a specialty treatment setting
• Substance use disorder treatment counts as a specialty treatment setting

Definitions to Know

• Minority: A group with fewer members or less power in society
• Race: Defined by physical characteristics; biological, anthropological, or genetic distinctions
• Ethnicity: Shared heritage, history, and worldview
• Culture: Shared beliefs, values, and practices influencing behavior and perception of illness

Importance of Culturally Relevant Care

• Reduces disparities in mental healthcare
• Helps establish trust and effective communication
• Ensures treatments align with patients' beliefs and values

Cultural Differences in Healthcare Beliefs

• Western cultures: Individuality, mind-body separation, disease has a specific cause, and a linear/future-focused timeline
• Eastern cultures: Family-based, mind-body-spirit connection, disease caused by energy imbalances and cyclical time
• Indigenous cultures: tribal identity, person connected to the environment, disease is disharmony with nature, and a holistic time-view

Cultural Barriers to Mental Health Care

• Communication barriers: Language differences can lead to misinterpretation
• Stigma of mental illness: Some cultures view mental illness as shameful
• Misdiagnosis: Symptoms may be expressed differently across cultures
• Genetic variations in pharmacodynamics: Medication responses can differ by ethnicity

Cultural Concepts of Distress

• Culture-bound syndromes: Disorders recognized only within specific cultures
• Cultural idioms of distress: Expressions of distress unique to a culture
• Cultural explanations of illness: How a culture interprets the cause of mental illness

At-Risk Populations

• Immigrants: Move voluntarily for better opportunities
• Refugees: Flee due to intolerable conditions
• Cultural minorities: Often face discrimination and limited access to healthcare

Culturally Congruent Care

• Cultural Awareness: Recognizing personal biases
• Cultural Knowledge: Learning about different cultures
• Cultural Encounters: Engaging with diverse patients
• Cultural Skill: Conducting culturally sensitive assessments
• Cultural Desire: A genuine willingness to understand and care for diverse patients

Ethical Concepts

• Ethics: Study of right and wrong in society
• Bioethics: Ethical dilemmas in healthcare
• Ethical dilemma: Conflict between two justifiable courses of action

Principles of Bioethics

• Beneficence: Promote good
• Autonomy: Respect patients' decisions
• Justice: Fair distribution of resources and care
• Fidelity (Nonmaleficence): Maintain loyalty, do no harm
• Veracity: Be truthful with patients

Types of Admissions

• Informal Admission: Patient seeks treatment voluntarily
• Voluntary Admission: Patient or guardian requests admission
• Involuntary Commitment: Without patient consent of a mentally ill person, danger to self/others, or unable to meet basic needs

Involuntary Commitment Types

• Emergency Commitment: 24-96 hours for evaluation
• Assisted Outpatient Treatment: Court-ordered outpatient care

Due Process in Involuntary Commitment

• Writ of Habeas Corpus: Patient can challenge unlawful detention
• Least Restrictive Alternative Doctrine: Use the least restrictive means for treatment

Discharge Procedures

• Conditional Release: Ongoing outpatient treatment required
• Unconditional Release: Complete discharge from care
• Release Against Medical Advice (AMA): Patient leaves despite medical recommendations

Patient Rights

• Right to Treatment: Cannot be denied care
• Right to Refuse Treatment: Including medication unless legally overridden
• Right to Informed Consent: Patients must understand risks, benefits, and alternatives before treatment
• Rights Regarding Restraint & Seclusion: Use only when necessary and follow legal & ethical guidelines

Confidentiality in Psychiatric Care

• HIPAA: Protects patient privacy
• Confidentiality After Death: Rights continue after the patient passes
• Confidentiality in Professional Communication: Protects provider-patient interactions
• Confidentiality & HIV Status: Legal protections apply

Exceptions to Confidentiality

• Duty to Warn & Protect: Required if patient poses a threat to others

• Mandated Reporting: Duty to report child and elder abuse

Civil Wrongs (Tort Law)

• Intentional Torts:

  • Assault: Threat to harm
  • Battery: Unwanted physical contact
  • False Imprisonment: Unjustified restriction of movement
  • Invasion of Privacy: Unauthorized sharing of personal information
  • Defamation (Slander/Libel): False statements harming reputation

• Unintentional Torts:

  • Negligence: Failing to act reasonably
  • Malpractice: Professional negligence leading to harm

Elements of Negligence

• There must be a duty of care
• Nurse failed to meet the standard of care
• Direct link between breach and harm
• Harm was foreseeable
• Patient suffered harm or injury

Nursing Care Standards

• Governed by: - Nurse Practice Acts - Professional Organizations (APA, APNA) - Institutional Policies

• Duty to Report: - Negligence - Impairment (drug/alcohol use) - Criminal activity

Documentation Guidelines

• Ensure accuracy and completeness
• Used for legal protection and quality improvement
• Electronic records are increasingly common

Forensic Nursing & Violence Prevention

• Forensic Nursing: Assist courts in psychiatric cases
• Violence in Psychiatric Settings: - Nurses must document risks - Report threats to colleagues - Employers are not liable for injuries from violent patients

Insight-Oriented Family Therapy

• Focus: Developing increased awareness among family members regarding themselves, others, and their family unit
  • Approach: Encourages insight and emotional understanding
  • Examples: Psychodynamic and humanistic family therapies

Behavioral Family Therapy

• Focus: Changing behaviors to influence overall family interaction patterns
  • Approach: Uses reinforcement, modeling, and other behavior modification techniques
  • Examples: Cognitive-behavioral therapy (CBT), and operant conditioning

Contextual Therapy

• Goal: Gain insight into problematic relationships
  • Approach: Focuses on ethical dimensions of family interactions and fairness

Family of Origin Therapy

• Goal: Foster differentiation and decrease emotional reactivity
  • Approach: Identifies patterns rooted in the family of origin that affect current functioning

Experiential-Existential Therapy

• Goal: Guide the family to identify and develop their own solutions to dysfunctional behavior
  • Approach: Emphasizes authenticity and self-expression within family units

Structural Therapy

• Goal: Improve family relationships by restructuring family hierarchy and boundaries
  • Approach: Examines and modifies the organization of the family system

Strategic Therapy

• Goal: Realign family hierarchy through the use of rituals to change repetitive and maladaptive patterns
  • Approach: Uses strategies and directives to initiate change

Cognitive-Behavioral Therapy (CBT)

• Goal: Improve patterns of negative behaviors through changing thought patterns
  • Approach: Cognitive restructuring to correct distorted thinking

Goals of Family Therapy

• Improve individual coping and problem-solving abilities of family members
• Strengthen family functioning: Foster resilience, cohesion, and healthy interaction patterns as a whole
• Reduce dysfunctional behavior: Correct maladaptive behaviors and resolve conflicts
• Mobilize family resources: Encourage adaptive problem-solving behaviors and improve communication skills
• Increase emotional support: Heighten awareness of each other's emotional needs and foster a supportive environment

Core Concepts in Family Therapy

• Identified patient: The family member regarded as the symptomatic problem
• Family triangles: Occurs when one family member communicates indirectly with another family member through a third member
• Boundaries: Refers to the rules and roles within the family system that dictate how members interact
• Clear boundaries: Members maintain individuality while supporting each other
• Diffuse or enmeshed boundaries: Excessive communication, leading to loss of autonomy
• Rigid or disengaged boundaries: Lack of communication, leading to isolation

Assessment Tools Family Therapy

• Sociocultural Assessment
• Genogram

Nursing Process Application in Family Therapy

• Family Assessment
• Nursing Interventions
  • Communication Techniques
  • Counseling
  • Advanced Practice Interventions

Characteristics of a Healthy Family

• Safety and Support: Providing a secure environment and robust support systems
• Effective Communication: Clear, open, and respectful interactions
• Proper Boundaries: Balanced rules that support individuality and togetherness
• Emotional Support: Showing empathy, care, and understanding
• Socialization: Teaching social norms, values, and adaptive behaviors

Key Concepts of Nurse-Patient Relationships

• Patient-Centered Care: Emphasizes dignity, respect, information sharing, patient and family participation, and collaboration in policy development
• Therapeutic Use of Self: Involves the intentional use of personal attributes to establish patient trust and engagement

Goals and Functions of Therapeutic Relationships

• Facilitating communication of distressing thoughts and feelings
• Assisting patients with problem solving
• Examining self-defeating behaviors and testing alternatives
• Promoting self-care and independence
• Providing education about disorders and treatments

Building Healthy Relationships

• Assessing patient needs and unmet needs
• Implementing de-escalation strategies
• Differentiating between personal and therapeutic relationships
  • Personal Relationships: Based on mutual needs, socialization, friendship, and superficial communication
  • Therapeutic Relationships: Focus on patient needs, clinical competence, and appropriate boundaries

Necessary Behaviors for Nurses

• Accountability: Ensuring responsibility for one's actions in patient care
• Focus on Patient Needs: Maintaining patient-centric communication
• Clinical Competence: Staying informed and skilled in nursing practices
• Delaying Judgment: Avoiding premature conclusions about patients
• Supervision: Seeking and providing professional oversight and guidance

Relationship Boundaries and Roles

• Importance of Boundaries:
  • Protect legal, ethical, and professional standards
  • Create a safe space for patient exploration of feelings and treatment concerns

Risks of Over-Involvement

• Boundary Crossings: Minor deviations from professional boundaries
• Boundary Violations: Severe issues potentially leading to patient harm
• Professional Sexual Misconduct: Inappropriate intimate interactions
• Blurring of Roles: When nurse's role shifts from professional to personal

The Phases of Nurse-Patient Relationships (Peplau's Model)

• Preorientation Phase:
  • Preparing for patient engagement by researching history and setting ground rules
• Orientation Phase: - Establishing rapport, setting relationship parameters, confidentiality, and terms of termination
• Working Phase:
  • Maintaining the relationship, gathering further data, and promoting problem-solving skills and self-esteem
  • Facilitating behavioral change and overcoming resistance
• Termination Phase:
  • Summarizing and evaluating the patient's progress and institutionalizing learned behaviors

Factors Promoting Patient Growth

• Genuineness: Being authentic in interactions
• Empathy: Understanding the patient's perspective without sympathy
• Positive Regard: Respectful and non-judgmental attitude
• Attending: Active listening skills
• Suspending Value Judgments: Avoiding personal bias

Therapeutic Communication Models

• Transactional Model: Emphasizes the active exchange between sender and receiver
  • Clarity: Ensures the message is accurately understood
  • Continuity: Fosters connected ideas, feelings, and events
  • Feedback: Confirmation and interpretation of the message received

Factors of Therapeutic Communication

• Personal: Depression, cognition, and cultural barriers can impact communication Environmental: The setting and relationship dynamics play a critical role

Verbal and Nonverbal Communication

• Verbal Communication: Utilizes words to express beliefs, values, and meanings which can convey interest, judgment, or honesty

• Nonverbal Communication: Uses body language, facial expressions, and other non-verbal cues, often communicating more than words alone

• Double-Bind Messages: Mutually contradictory messages that are difficult to address

• Barriers to Effective Communication: Arguing, minimizing patient concerns, false reassurance, probing, and joining in negative behavior against others

Age and Cultural Considerations:

• Children, adolescents, and older adults require different communication strategies and assessment (recognition of cues) approaches Cultural Sensitivity: Communication styles, eye contact, and perceptions of touch vary significantly across cultures

Nursing Process and Standards of Care

• Assessment: Recognizing cues through systematic data collection, the mental health status and psychosocial evaluations
• Diagnosis (Hypothesis): Defining the problem, its probable cause, and symptoms
• Outcomes Identification: Setting realistic and patient-centric health outcomes
• Planning: Setting individualized care plans based on evidence-based practices
• Implementation: Executing the care plan through coordination of care, health teaching, and therapy
• Evaluation: Continuously assessing the effectiveness of the interventions, documenting outcomes, and revising plans as necessary

Objectives Behavioral Health Nursing

• Assessment - Tailor approach to age
• Language barriers - Differentiate between interpreters and translators
• MSE - mental status examination
• Psychosocial assessments - incorporate cultural and spiritual

QSEN

• Patient-Centered care
• Teamwork and collaboration
• EBP - evidence based practice
• Quality improvement
• Safety
• Informatics

1.Assessment Cues

• Age considerations
• data gathering (psych, spiritual, cultural, social)

2. Diagnosis

• Problem
• Etiology
• Supporting data - Risk for suicide related to stating, " I want to kill myself"

3. Outcome Identification

NOC- Nursing outcome classification

4. Planning

• planning principles
• safe, compatible, appropriate, realistic, and individualized Utilization NIC - Nursing interventions classification

5. Implementation

Basic interventions

• coordinate care
• health teaching
• milieu therapy
• pharmacology Advanced practice
• psychotherapy

6. Evaluation

• systematic, ongoing, criteria based
• Documentation
• accurate legal record

Case studies

• scenario: Mr. R exhibits weight loss
• intervention - finger foods
• teaching and evaluation- evaluate sister under evaluation phase

Explore cultural perspectives in mental health, including the concept of 'qi' imbalance and cultural idioms of distress. Learn about cultural awareness, healthcare disparities, and considerations for treating refugees. Understand the impact of cultural factors on mental health treatment.