Mental Health Exam 1 PDF

Mental illnesses are medical conditions that affect a person’s thinking, feeling, mood, ability to relate to others, and daily functioning. Mental health is multifaceted and involves our emotional, psychological, and social well- being. It can be affected by a variety of influences, such as genetics...

Mental illnesses are medical conditions that affect a person’s thinking, feeling, mood, ability to relate to others, and daily functioning. Mental health is multifaceted and involves our emotional, psychological, and social well- being. It can be affected by a variety of influences, such as genetics, brain chemistry, and life experiences (e.g., trauma or abuse or a family history of mental health issues). Positive mental health leads to reaching full potential, coping with stressors, increased productivity, and making meaningful contributions to society (USDHHS, 2020). According to the National Alliance on Mental Illness (NAMI, 2021a), mental illnesses affect a person’s thinking, feeling, and mood, which can make it difficult to relate to others and maintain daily functioning. Basically, mental illness can be seen as the result of flawed biological, psychological, or social processes. Fortunately, mental illness is treatable, and individuals can experience symptom relief and a return to a high level of functioning (NAMI, 2021a). Mental illness as one of the leading causes of disability in the United States. Over 18% of years lost to disability are attributed to mental illness. Psychiatry’s definition of mental health evolves over time and reflects changes in cultural norms, society’s expectations and values, professional biases, individual differences, and even the political climate of the time. Resiliency is the ability to bounce back from stressful circumstances. Diagnostic and Statistical Manual of Mental Disorders DSM-5 The DSM-5 provides clinicians, researchers, regulatory agencies, health insurance companies, pharmacological companies, and policy makers with a standard language and criteria for the classification of mental disorders. he DSM-5 is used by psychiatrists, psychiatric nurse practitioners, therapists, and other clinicians as a guide for assessing, diagnosing, and planning care. The DSM-5 lists specific diagnostic criteria for each mental disorder, which were developed using research and clinical observation. Another significant change is that the coding system now mirrors International Statistical Classification of Diseases and Related Health Problems, 10th Revision, Clinical Modification (ICD-10) codes, which are often used as part of the billing and tracking process. In 1996 the Mental Health Parity Act was passed by Congress, and a series of laws and commissions supporting parity followed over the next decade. This legislation required insurers to offer mental health benefits at the same level provided for medical coverage. Many of the most prevalent and disabling mental disorders have been found to have strong biological influences. Some of these include schizophrenia, bipolar disorder, depression, posttraumatic stress disorder, autism, and anorexia. We can look at these disorders as “diseases” with an underlying biological component. Some of these factors include support systems, family influences, developmental events, cultural beliefs and values, health practices, and negative influences impinging on an individual’s life. The DSM-5 cautions that the emphasis on the term mental disorder implies a distinction between “mental” disorder and “physical” disorder, which is an outdated concept, and stresses mind–body dualism. In physical health there is a component of mental health, and in mental health there is a physical component. The two cannot be separated as one versus another In the DSM-5, the mental disorders are clinically significant behavioral or psychological syndromes or patterns that occur in an individual and that are associated with distress (a painful symptom); disability (impairment in one or more important areas of functioning); or an increased risk of suffering death, pain, disability, or a loss of freedom or independence. Deviant behavior (e.g., political, religious, or sexual) and conflicts between the individual and society are not considered mental disorders according to the DSM-5 unless the deviance or conflict is a symptom of a dysfunction in the individual. Culture includes traditions of thought, behavior, knowledge, and practices that are socially acquired, shared, and passed on to new generations. Culture also includes sexual orientation, age groups, physical abilities or disabilities, gender, religion, or socioeconomic status. The DSM-5 and prior versions are strongly biased toward a Western view of what is acceptable behavior. Some criteria considered as mental illness could, in fact, be normal in another culture. One way the DSM-5 attempts to correct for this is through the inclusion of the Cultural Formulation Interview (CFI). The CFI assesses the client’s cultural perception of distress; social supports such as family and religion; and relationship factors between the patient and provider, including language and discrimination experiences in the societal majority. The DSM-5 also provides a brief glossary of cultural concepts of distress, which includes culture-bound symptoms The International Classification for Nursing Practice (ICNP) allows nurses to identify nursing diagnoses and interventions. Having a common language supports global communication, research, and policy making (International Council of Nurses, 2018). Terms are internationally accepted, which fosters communication between different regions or specialties DSM-5 includes information related to culture in the discussion of each individual disorder, in the glossary of cultural concepts of distress, and by providing the CFI. The CFI assesses the client’s cultural perception of distress, social supports such as family and religion, and relationship factors between the patient and provider including language and discrimination experiences in the societal majority. While useful resources, none of the remaining options focus on these cultural perceptions. Health care providers must consider the influence of culture in determining the mental health or mental illness of the individual. Culture can influence how symptoms are viewed, the ability to cope with symptoms, and health- seeking behaviors A number of culture-bound syndromes (or culture-related syndromes) appear only in particular cultures and do not appear globally in all societies or parts of the world. For example, anorexia nervosa is view as a psychobiological disorder that entails voluntary starvation. However, not all mental illeness are culture base. Spirituality can include but is not limited to religion. Spirituality can be defined as a belief in a higher power, connection to the universe or universal energy, feeling “one” with nature, or calling on ancestors for wisdom and can include practices such as meditation, prayer, and helping others. Meditation has many health benefits, is a valuable tool for dealing with chronic pain and stress, is a component of dialectic behavioral therapy (DBT) and stress-reduction programs, and plays a role in many other types of therapy. Also, a traditional helping strategy that is also identified as evidence-based practice is the use of storytelling. Stigma is defined as a collection of negative attitudes, beliefs, and thoughts that influence public perception of the mentally ill. Stigma contributes to fear, rejection, and discrimination against the mentally ill that taint and discount the individual, and stigma has been acknowledged as a major barrier to mental health treatment and recovery. Early practitioners used various forms of talk therapy, formally known as psychotherapy, that focused on the complexity and inner workings of the mind. Freud claims that most psychological disturbances are the result of early trauma or incidents that are often not remembered or recognized. Freud identified three layers of mental activity: the conscious, the preconscious, and the unconscious mind. The conscious mind is your current awareness—thoughts, beliefs, and feelings. Expressing one’s beliefs about a subject would be demonstrating one’s conscious mind. Erikson’s development task, integrity vs. despair, stresses the need to feel satisfaction with one’s life and the resulting wisdom. Maslow was concerned with a person’s sense of esteem that includes feeling valued. It was Sullivan that introduced the concept of the good me vs. the bad me. The id is the primitive, pleasure-seeking, and impulsive part (according to Freud, predominantly sexual pleasure) of our personalities that lurks in the unconscious mind. The ego is the problem solver and reality tester that navigates in the outside world. It acts as an intermediary between the id and reality by using ego defense mechanisms, such as repression, denial, and rationalization. The ego is able to realistically evaluate situations, limit the id’s primitive impulses, and keep the superego from becoming too rigid and obsessive. The superego represents the moral component of the personality that Freud referred to as our conscience (our sense of what is right or wrong). The superego is greatly influenced by parents’ or caregivers’ moral and ethical stances. Psychoanalytic therapy was Freud’s answer for a scientific method to relieve emotional disturbances. Free association is used to search for forgotten and repressed memories. Psychodynamic therapy is theoretically related to psychoanalytic therapy and views the mind in essentially the same way. It tends to be shorter, about 10 to 12 sessions. The therapist takes a more active role because the therapeutic relationship is part of the healing process. Transference occurs as the patient projects intense feelings onto the therapist related to unfinished work from previous relationships. This countertransference must be scrutinized in order to prevent damage to the therapeutic relationship. Interpersonal theory focuses on what occurs between people, as opposed to psychoanalytic theory, which is rooted in what occurs in the mind. Herbert “Harry” Stack Sullivan (1892–1949), an American psychiatrist, believed that social forces and interpersonal problems were the cause of psychiatric alterations. Sullivan’s believed that personality is most influenced by the mother but that personality can be molded even in adulthood. Therapeutic Model Interpersonal therapy (IPT) is a hands-on system in which therapists actively guide and challenge maladaptive behaviors and distorted views. The premise for this work is that if people are aware of their dysfunctional patterns and unrealistic expectations, they can modify them. The focus is on the here and now, with an emphasis on the patient’s life and relationships at home, at work, and socially. The therapist becomes a “participant observer” and reflects on the patient’s interpersonal behavior, including responses to the therapist. Ivan Pavlov is famous for investigating classical conditioning, in which involuntary behavior or reflexes can be conditioned to respond to neutral stimuli. John B. Watson rejected psychoanalysis and sought an objective therapy that did not focus on unconscious motivations. He contended that personality traits and responses, adaptive and maladaptive, are learned. B. F. Skinner conducted research on operant conditioning in which voluntary behaviors are learned through consequences of positive reinforcement (a consequence that causes the behavior to occur more frequently) or negative reinforcement or punishment (a consequence that causes the behavior to occur less frequently). Behavioral therapy, or behavior modification, uses basic tenets from each of the behaviorists described previously. It attempts to correct or eliminate maladaptive behaviors or responses by rewarding and reinforcing adaptive behavior. Systematic desensitization is based on classical conditioning. The premise is that learned responses can be reversed by first promoting relaxation and then gradually facing a particular anxiety-provoking stimulus. This method has been particularly successful in extinguishing extreme fears, or phobias. Agoraphobia, the fear of open places, can be treated by initially visualizing trips outdoors while using relaxation techniques. Later, the individual can practice actual excursions that gradually increase in length, thereby eliminating or reducing agoraphobia. Aversion therapy is based on both classical and operant conditioning. It is used to eradicate unwanted habits by associating unpleasant consequences with them. One pharmacologically based aversion therapy is disulfiram (Antabuse). People who take this medication and then ingest alcohol become extremely ill, with nausea, vomiting, and dizziness. Aversion therapy has also been used with sex offenders, who may, for example, receive electric shocks in response to arousal from child pornography. Biofeedback is a technique in which individuals learn to control physiological responses such as breathing rates, heart rates, blood pressure, brain waves, and skin temperature. This control is achieved by providing visual or auditory biofeedback of the physiological response and then using relaxation techniques such as slow, deep breathing or meditation. There is a recent emergence of smartphone apps and wearable devices that provide this immediate physiological feedback. Behavioral therapy, or behavior modification, uses basic tenets from each of the behaviorists described previously. It attempts to correct or eliminate maladaptive behaviors or responses by rewarding and reinforcing adaptive behavior. The snack is such a reward. Aversion therapy introduces unpleasant consequences for a behavior while systematic desensitization promotes relaxation. The anger management group is likely to introduce techniques from various theories. Humanistic Theory The humanists developed a psychological science concerned with the human potential for development, knowledge attainment, motivation, and understanding. Maslow’s hierarchy of needs theory placed conceptually on a pyramid, with the most basic and important needs on the lower level. The higher levels, the more distinctly human needs, occupy the top sections of the pyramid. According to Maslow, when deficiencies at the lower levels are fulfilled, higher-level needs can emerge. Therapeutic Model Carl Rogers, an American psychologist, popularized person-centered therapy in the 1940s. Rogers, unlike Freud, saw people as basically healthy and good. He identified people and all living organisms as having innate self- actualizing tendencies to grow, develop, and realize their full potential. Patient-centered therapy is an existentially based therapy. The emphasis is on self-awareness and the present because the past has already happened, and the future has not yet occurred. The role of the therapist is that of a nondirective facilitator who seeks clarification and provides encouragement in this process. Three essential qualities in the therapist are congruence (genuineness), empathy, and respect. Cognitive Theory Aaron T. Beck was convinced that depressed people generally have standard patterns of negative and self-critical thinking. He believed that cognitive appraisals of events lead to emotional responses; it is not the event itself that causes the response but, instead, one’s evaluation of the event Cognitive-behavioral therapy (CBT) is a popular, effective, and well-researched therapeutic tool. It is based on both cognitive and behavioral theory and seeks to modify negative thoughts that lead to dysfunctional emotions and actions. Several concepts underlie this therapy. One is that we all have schemata, or unique assumptions about ourselves, others, and the world around us. Rapid, unthinking responses based on these schemata are known as automatic thoughts. These responses are particularly intense and frequent in psychiatric disorders such as depression and anxiety. Often these automatic thoughts, or cognitive distortions, are irrational because people make false assumptions and misinterpretations. The goal of CBT is to identify the negative patterns of thought that lead to negative emotions. Once the maladaptive patterns are identified, they can be replaced with rational thoughts. A particularly useful technique in CBT is to use a four-column format to record the precipitating event or situation, the resulting automatic thought, the ensuing feeling(s) and behavior(s), and finally, a challenge to the negative thoughts based on rational evidence and thoughts. This is sometimes referred to as the ABCs of irrational beliefs and is a good exercise. Biological Theory In the 1950s a surgeon noticed that surgical patients were calmed by the administration of chlorpromazine (Thorazine) as a preanesthetic agent. It soon became widely used for the treatment of schizophrenia and dramatically reduced the use of restraint and seclusion. This discovery spurred the development of other drug- based treatments and the adoption of a chemical-imbalance theory of psychiatric disorders. Research has proposed toxins, viruses, hostile environments, and brain trauma as possible catalysts for the development of psychiatric disorders. Biological Therapy Major classifications of medications are antidepressants, antipsychotics, antianxiety agents, mood stabilizers, and psychostimulants. Clinicians recognize the importance of optimizing other biological variables, such as correcting hormone levels (as in hypothyroidism), regulating nutritionally deficient diets, and balancing inadequate sleep patterns. Electroconvulsive therapy (ECT) has proven to be an effective treatment for severe depression and other psychiatric conditions. ECT is a procedure that uses electrical current to induce a seizure and is thought to work by affecting neurotransmitters and neuroreceptors. Other types of therapy transcranial magnetic stimulation and vagus nerve stimulation improves levels of neurotransmitters. Numerous studies have indicated that all mental processes are derived from the brain. Therefore psychotherapeutic outcomes, such as changes in symptoms, psychological abilities, personality, or social functioning, are generally accepted to be attributed to brain changes brought about either by medication or psychotherapy. Numerous studies compiled by Karlsson (2011) substantiate positive treatment responses with various psychotherapies resulting in brain changes for the following disorders: major depressive disorder (MDD), anxiety disorders (panic disorder, social anxiety disorder, specific phobias), posttraumatic stress disorder (PTSD), borderline personality disorder, and obsessive-compulsive disorder (OCD). These studies suggest that currently, the most effective therapies for treating the aforementioned disorders resulting in brain changes are CBT, dialectic behavior therapy (DBT), psychodynamic psychotherapy, and interpersonal psychotherapy (IP). Other Major Theories Jean Piaget concluded that cognitive development was a progression from primitive awareness to complex thought and responses. Erik Erikson was a child psychoanalyst who described development as occurring in eight predetermined life stages, whose levels of success are related to the preceding stage. The theory of object relations was developed by interpersonal theorists who emphasize past relationships in influencing a person’s sense of self as well as the nature and quality of relationships in the present. The term object refers to another person, particularly a significant person. Hildegard Peplau’s (1909–1999) seminal work Interpersonal Relations in Nursing was first published in 1952 and has served as a foundation for understanding and conducting therapeutic nursing relationships ever since. Peplau based her work on Sullivan’s interpersonal theory and emphasized that the nature of the nurse–patient relationship strongly influenced the outcome for the patient. Peplau made an extremely useful contribution to understanding anxiety by conceptualizing the four levels still in use today: 1. Mild anxiety is a day-to-day alertness (e.g., “I’m awake and taking care of business”). Stimuli in the environment are perceived and understood, and learning can easily take place. 2. 2. Moderate anxiety is felt as a heightened sense of awareness, such as when you are about to take an exam. The perceptual field is narrowed, and an individual hears, sees, and understands less. Learning can still take place, although it may require more direction. 3. 3. Severe anxiety interferes with clear thinking, and the perceptual field is greatly diminished. Nearly all behavior is directed at reducing the anxiety. An example of this is your response to your car skidding on wet pavement. 4. 4. Panic anxiety is overwhelming and results in either paralysis or dangerous hyperactivity. An individual cannot communicate, function, or follow directions. This is the sort of anxiety that is associated with the terror of panic attacks. Behavioral: Promoting adaptive behaviors through reinforcement can be valuable and important in working with patients, especially when working with a pediatric population. These patients look forward to positive reinforcement for good behavior and will work hard for gold stars or other privileges. Cognitive: Helping patients identify negative thought patterns is a worthwhile intervention in promoting healthy functioning and improving neurochemistry. Workbooks are available to aid in the process of identifying these cognitive distortions. Psychosocial development: Erikson’s theory provides a structure for understanding critical junctures in development. The older adult who has suffered a stroke may be depressed and despairing because he can no longer take care of his house. In this case, the nurse and patient could explore ways of optimizing the patient’s  remaining strengths and talents, such as by nurturing and tutoring young people or by developing attainable goals such as getting the mail, taking out the trash, and so forth. Hierarchy of needs: Maslow’s theory is useful in prioritizing nursing care. When working with actively suicidal patients, students sometimes think it is rude to ask if the patients are thinking about killing themselves. However, safety supersedes this potential threat to self-esteem. Although the “must-dos” in nursing begin with physical care (e.g., providing medication and hydration through intravenous [IV] fluids), the goal should also include higher-level needs, which can be obtained by listening, observing, and collaborating with the patient in the development of the plan of care The mental health recovery model is not a focus on a cure but, instead, emphasizes living adaptively with chronic mental illness. It is viewed as both an overarching philosophy of life for people with mental illness and an approach to care for use by those who treat, finance, and support mental health care. It is also an effective approach to dealing with substance abuse. This model emphasizes hope, social connection, empowerment, coping strategies, and meaning in life. Group Therapy This therapeutic method is commonly derived from interpersonal theory. It operates under the assumption that interaction within the group can provide support or bring about desired change among individual participants of two or more individuals who influence one another who share a degree of cohesiveness and shared goals. Groups possess both content and process dimensions. Group content refers to the actual dialogue between members or the type of information that can be transcribed (written or recorded) in minutes of meetings. Group process includes all the other elements of human interaction, such as nonverbal communication, adaptive and maladaptive roles, energy flow, power plays, conflict, hidden agendas, and silence. Although the content is essential to the group’s work, it is the process that becomes the real challenge for leaders as well as participants. Group development tends to follow a sequential pattern of growth and requires less leadership with time. Understanding this pattern is especially helpful to the leader in order to anticipate distinct phases and provide guidance and interventions that are most effective. Tuckman’s (1965) model of group development has four stages: forming, storming, norming, and performing. A fifth stage, adjourning (mourning), was later added (Tuckman & Jensen, 1977). These stages are comparable to human development from infancy into old age, accompanied by varying levels of maturity, confidence, and need for direction (Table 3.7). Studies of group dynamics have identified informal roles of members that are necessary to develop a successful group. The most common descriptive categories for these roles are task, maintenance, and individual roles. Task roles serve to keep the group focused and attend to the business at hand. Maintenance roles function to keep the group together and provide interpersonal support. Individual roles are not related to group goals but, rather, to specific personalities. Leadership style depends on group type. A leader should select the style that is best suited to the needs of a particular group. The autocratic leader exerts control over the group and does not encourage much interaction among members. In contrast, the democratic leader supports extensive group interaction in the process of problem solving. A laissez-faire leader allows the group members to behave in any way they choose and does not attempt to control the direction of the group. For example, the staff leading a community meeting with a fixed, time-limited agenda may tend to be more autocratic. In an educational group, the leader may be more democratic to encourage members to share their experiences. In a creative group, such as an art or horticulture group, the leader may choose a laissez-faire style, giving minimal direction to allow for a variety of responses. Psychiatric-mental health nurses are involved in a variety of therapeutic groups in acute care and long-term treatment settings. For all group leaders, a clear theoretical framework provides a structure for understanding group interaction. Coleadership of groups is a common practice and has several benefits:  Provides training for less experienced staff Allows for immediate feedback between the leaders after each session Gives two role models for teaching communication skills to members A therapeutic milieu (mil-yoo), or healthy environment, combined with a healthy social structure within an inpatient setting or structured outpatient clinic, is essential to supporting and treating those with mental illness. Within these small versions of society, people are safe to test new behaviors and increase their ability to interact adaptively with the outside community. Community mental health nurses need to be very knowledgeable about community resources such as shelters for abused women, food banks for people with severe financial limitations, and agencies that can provide various other forms of support. Prescriptive privileges are not required. Advocacy is a generalized nursing responsibility while spiritual counseling is not viewed as within the scope of general nursing practice. Obtaining treatment for mental health problems is also complicated by the nature of mental illness. At the most extreme, disorders with a psychotic component, such as schizophrenia, may disorganize thoughts and impair a person’s ability to recognize the need for care. There is a word for this inability: anosognosia (uh-no-sog-NOH-zee- uh). Major depressive disorder, a common psychiatric condition, may interfere with the motivation to seek care because the illness often causes feelings of apathy, hopelessness, and anergia (lack of energy). Although people with financial resources have a variety of psychiatric treatment options, state or county governments coordinate a separate care system for uninsured individuals, often for those with the most serious and persistent illnesses. This separate system of care has its roots in asylums that were created in most existing states before the Civil War. These asylums were created with good intentions in an environment of optimism about recovery. The dominant belief was that states had a special responsibility to care for people who were then called “insane” (Latin insanus, from in- “not” + sanus “healthy”). Effective treatments were not yet developed, and community care was virtually nonexistent. By the early 1950s there were only two real options for psychiatric care: a private psychiatrist’s office or a mental hospital. At that time, there were 550,000 patients in state hospitals. A majority were individuals with disabling conditions who had become institutionalized in the asylums. The number of people in state-managed psychiatric hospitals began to decrease with the creation of Medicare and Medicaid during the 1960s Great Society reform period. Medicaid had an especially potent effect because it paid for short-term hospitalization in general hospitals and medical centers and for long-term care in nursing homes. However, it did not cover care for most patients in psychiatric hospitals. These incentives stimulated the development of general hospital psychiatric units and also led states to transfer geriatric patients from 100% state- paid psychiatric hospitals to Medicaid-reimbursed nursing facilities. In the 1999 Olmstead decision, the Supreme Court decreed that institutionalizing people in psychiatric hospitals was considered unjustified isolation. The opinion of the court was that mental illness is a disability, that institutionalization is in violation of the Americans with Disabilities Act, and that all people with disabilities have a right to live in the community. These forces combined to lead to the gradual and incomplete creation of state- and county-financed community care systems. These systems served to complement, and largely replace, the functions of state hospitals. The number of state psychiatric hospitals continues to be cut and has been reduced from 322 in 1950 to 188 in 2015. Patient-centered medical homes (PCMHs) received strong support from the Affordable Care Act (ACA) of 2010. These health homes were developed in response to fragmented care that resulted in some services never being delivered while others were duplicated. The focus of care is patient centered and provides access to physical health, behavioral health, and supportive community and social services. Services range from preventive care and acute medical problems to chronic conditions and end-of-life issues. CMHCs are regulated through state mental health departments and funded by the state. Some areas may provide local funding. Because of this limited government funding, financial support services may be restricted to those whose income and medical expenses make them eligible. Typically, fees are determined using a sliding scale based on income and ability to pay. Community-based facilities provide comprehensive services to prevent and treat mental illness. These services include assessment, diagnosis, individual and group counseling, case management, medication management, education, rehabilitation, and vocational or employment services. Some centers may provide an array of services across the life span, whereas others may be population specific, such as adult, geriatric, or children. People with serious mental illness are often isolated, impoverished, and regressed. They may benefit from psychiatric rehabilitation services that are provided through the community mental health system or other organizations. Psychiatric rehabilitation is a social model that emphasizes and supports recovery and integration into society rather than accepting a medical model of dysfunction. The development of social skills; the ability to access resources; and the acquisition of optimal social, working, living, and learning environments are the focus of this treatment method. The therapeutic milieu is essential to successful inpatient treatment. Milieu refers to the environment in which holistic treatment occurs and includes all members of the treatment team in a positive physical setting, with interactions among those who are hospitalized and activities that promote recovery. Teamwork and collaboration are essential elements of interprofessional teams in acute care inpatient settings. Teamwork refers to a group of people working together to improve patient health, with each member of the team performing specialized functions. Inpatient care begins with a medical assessment to rule out or consider comorbid conditions, which are one or more disorders that occur along with another condition in the same person at the same time Group therapy is an important facet of inpatient care. Coping skills are taught and enhanced through cognitive- behavioral groups. Occupational therapy provides an opportunity to practice life skills that have been delayed, hampered, or eroded. Psychoeducational groups focus on specific psychiatric disorders, medication, symptom management, goal setting, life planning, and recovery. The length of stay varies depending on the severity of the illness and symptoms. Nationwide, the mental health average length of stay is 8 days, and for substance use, the average length of stay is 4.8 days If we accept the notion that psychiatric disorders are usually a combination of biochemical interactions, genetics, and environment, then it stands to reason that by providing a healthy living situation, we are likely to fare better. If, for example, a person has a family history of anxiety and has demonstrated symptoms of anxiety, then a good first step (or an adjunct to psychiatric treatment) could be to learn yoga and balance the amounts of life’s obligations with relaxation A goal of psychiatric care is to balance the rights of the individual patient and the rights of society at large. An ethical dilemma results when there is a moral conflict between two or more courses of action, with each potential choice carrying similarly favorable and unfavorable consequences Ethics is the study of philosophical beliefs about what is considered right or wrong in a society. Bioethics is a more specific term that refers to the ethical questions that arise in health care. The five basic principles of bioethics. Law and ethics may be closely related because laws tend to reflect the ethical values of society. Legal obligations can be found in federal or state statutes, Board of Nursing (“Board”) regulations, or administrative code. You should familiarize yourself with all sources of nursing law relating to both patient care and record keeping in your state because they vary depending on the jurisdiction. Although they come from a variety of sources, we refer to them collectively as “laws” because there are legal consequences for violating them. Guidelines should never override law. The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act (MHPAEA) states that if mental health or substance abuse care is covered by a private insurance plan, then these conditions must receive coverage equitable to other physical medical conditions. People with mental illness are guaranteed the same rights under federal and state laws as any other citizen. Most states specifically prohibit any person from depriving an individual receiving mental health services of his or her civil rights, including the right to vote; the right to civil service ranking; the rights related to granting, forfeit, or denial of a driver’s license; the right to make purchases and to enter contractual relationships, including marriage (unless the patient has lost legal capacity by being deemed legally incompetent); the right to press charges against another person; and the right to personal and religious expression. The patient’s rights also include the right to humane care and treatment. The medical, dental, and psychiatric needs of the patient must be met in accordance with the prevailing standards accepted in these professions. Individuals in prisons and jails are afforded the same protections. Due process is a legal term referring to the requirement of state and federal governments to follow fair procedures before depriving someone of “life, liberty, or property.” The right to due process derives from the Fifth and Fourteenth Amendments of the US Constitution. The Fifth Amendment applies exclusively to actions of the federal government; the Fourteenth Amendment extends due process to state actors. In 2001 the Supreme Court extended those rights to non citizens. Voluntary Admission Generally, voluntary admission is sought by a patient or a patient’s guardian through a written application to the facility. Voluntarily admitted patients have the right to demand and obtain release at any time. However, few states require voluntarily admitted patients to be notified of the rights associated with their status. In addition, many states require that a patient submit a written release notice to the facility staff, who then reevaluate the patient’s condition for possible conversion to involuntary status according to criteria established by state law. Involuntary Admission (Commitment) Involuntary admission is made without the patient’s consent. Generally, involuntary admission is necessary when a person is in need of psychiatric treatment, presents a danger to self or others, or is unable to meet his or her own basic needs due to mental illness. Involuntary commitment requires that the patient retain freedom from unreasonable bodily restraints as well as the right to informed consent and the right to refuse medications, including psychotropic or antipsychotic medications. Three different commitment procedures are commonly available: judicial determination, administrative determination, and agency determination. In addition, a specified number and type of physicians must certify that a person’s mental health status justifies detention and treatment. Involuntary hospitalization can be further categorized by the nature and purpose of the involuntary admission: emergency hospitalization, observational or temporary hospitalization, long-term or formal commitment, or outpatient commitment. Recently, states have begun using involuntary outpatient commitment as a preventive measure, allowing a court order before the onset of a psychiatric crisis that would result in an inpatient commitment. The order for involuntary outpatient commitment is usually tied to the receipt of goods and services provided by social welfare agencies, including disability benefits and housing. The use of the least restrictive means of restraint for the shortest duration is always the general rule and even the law. Verbal interventions or enlisting the cooperation of patients are examples of first-line interventions. Recent changes in state laws regarding the use of restraints and seclusion have prompted agencies to revise their policies and procedures, further limiting these practices. The current trend is toward “restraint-free” environments and alternative methods of therapy and cooperation with the patient, which is proving successful. Typically, medication is considered if verbal or environmental interventions fail. Chemical interventions are usually considered less restrictive than mechanical, but they can have a greater effect on the patient’s ability to relate to the environment. When used judiciously, psychopharmacology is extremely effective and helpful as an alternative to other physical methods of restraint. The history of mechanical restraint and seclusion is one that is marked by abuses and overuse. This was especially true before the 1950s, when there were no effective chemical treatments. Legislation has dramatically reduced this problem by mandating strict guidelines.