Mental Health T1 - Overview of Mental Illnesses, Diagnosis, Treatment | PDF

**Mental Health T1** **Week 1** **What is mental health versus mental illness** Mental Health - WHO definition: 1. The who defines **mental health** as "a state of well-being in which each individual is able to realize his or her own potential, cope with the normal stress...

**Mental Health T1** **Week 1** **What is mental health versus mental illness** Mental Health - WHO definition: 1. The who defines **mental health** as "a state of well-being in which each individual is able to realize his or her own potential, cope with the normal stresses of life, work productively and fruitfully, and make a contribution to the community". - Public Health Agency of Canada definition: 2. "the capacity of each and all of us to feel, think, and act in ways that enhance our ability to enjoy life and deal with the challenges we face. It is a positive sense of emotional and spiritual well-being that respects the importance of culture, equity, social justice, interconnections and personal dignity" - Psychiatry's definition: 3. Continually evolving 4. It is shaped by the prevailing culture and societal values, and it reflects changes in cultural norms, society's expectations, and political climates. 5. In the past it was described as "strange or different" which is inadequate and puts people in a box. Mental Illness - Alteration in cognition, mood, behaviour that are coupled with significant distress and impaired functioning characteristic - Refers to all mental disorders with definable diagnoses 6. Cognition may be impaired like in Alzheimer's disease 7. Mood may be affected like in major depression 8. Behavior may be changed like in schizophrenia 9. Combination of the three **What is the mental health continuum?** The mental health continuum by Epp Report has 4 possible outcomes - Severe mental health disorder with optimal mental health 10. A person with schizophrenia who is stable on their meds, visits the doctor, has a social life, takes care of themselves. - No mental health disorder with optimal mental health 11. Where everyone wants to be at - No mental health disorder with poor mental health 12. Somone who doesn't have diagnosis of mental health illness/disorder, yet this person has poor coping skills against stressors - Severe mental health disorder with poor mental health 13. Somone who is diagnosed with a mental health illness/disorder and they aren't able to cope with it. **Influences that can have an impact on an individual's Mental Health (Contributing Factors)** - Support system (friends, family, community) - Religious influence - Developmental events - Personality traits and states - Demographic and geographic locations - Negative influences (psychosocial stressors, poverty, impaired parenting) - Beliefs and values - Hormonal influences, - Biological influences - Inherited factors - Environmental influences **Resilience** - Micheal Ungar defines it as: 14. A process and outcome of complex, cultural systems, rather than as an individual capacity to overcome adversity - Accessing and developing resilience assists people to recover from painful experiences and difficult events - Characterized by optimism and a sense of mastery and competence **Mental Health and Culture** Culture - Comprises the shared beliefs, values, and practices that guide a group\'s members in\ patterned ways of thinking and acting, and includes factors such as religion,\ geography, socioeconomic status, occupation, ability or disability, and sexual\ orientation - Culture can also be viewed as a blueprint for guiding actions that affect care, health,\ and well-being - How group members make sense of the world and make decisions about how to relate and behave - What is normal or abnormal? Influences the development of mental health and illness concepts 15. Western: hearing voices, seeing visions is viewed as deviation from reality 16. Indigenous: hearing voices or seeing visions is viewed as honour and value **Social Determinants of Health (WHO definitions)** - Income and social protection - Education - Unemployment and job insecurity - Working life conditions - Food insecurity - Housing, basic amenities and the environment - Early childhood development - Social inclusion and non-discrimination - Structural conflicts - Access to affordable health services of decent quality **How are mental disorders diagnosed? DSM5** Diagnostic and Statistical Manual of Mental Disorders (DSM) was published by the American Psychiatric Association in 1952. Its purpose is to provide clinicians, educators, and researchers with a common framework to understand and communicate about mental disorders. With a common understanding about theses disorders, researchers and clinicians could work together to improve care for these patients. - Now use the 5^th^ edition of DSM - Has over 350 diagnoses - Influenced by psychiatrists, psychologists, licensed clinical social workers, licensed counsellors, licensed marriage and family therapists, and advanced-practice psychiatric mental health nurses - DSM-5 classifies disorders that people have. It does not classify people. Organizes diagnoses for psychiatric disorders on a developmental hierarchy, meaning that disorders that are usually seen in infancy, childhood, and adolescence are listed in the first chapter and neurodevelopmental disorders and disorders that occur later in life, such as the neurocognitive disorders, are further down the list. Diagnostic groups that are related to one another have been closely situated (for example, schizophrenia spectrum disorders are next to bipolar-related disorders, and feeding and eating disorders are next to elimination disorders). Diagnosis is based on presenting symptoms and the impact of symptoms on the patient's life. Examples - Neurodevelopmental disorder - Schizophrenia spectrum disorder - Bipolar and related disorders - Depressive disorders - Anxiety disorders - Obsessive-compulsive disorders - Trauma and stressor disorders - Dissociative disorders - Somatic symptom disorders - Feeding and eating disorders - Elimination disorders - Sleep--wake disorders - Sexual dysfunctions - Gender dysphoria - Disruptive, impulse control, and conduct disorders - Substance and addictive disorders - Neurocognitive disorders - Personality disorders - Paraphilias - Other disorders **What are things we can do to stop stigma? (9 things)** What is stigma? - Negative, unfavorable attitudes and the behaviour they produce - Form of prejudice that spreads fear and misinformation, labels individuals and perpetuates stereotypes - Stigma against people with mental illnesses is oppressive and alienating - It prevents many from seeking help, denying them access to support networks and treatment they need to recover Effects of Stigma - Creates a greater negative impact on their health than the actual illness itself - Social isolation and restricts social support network - Poverty - Depression and loss of hope - Suicide - One of the main reasons that many people don't consider it a real health issue 9 Ways to Reduce Stigma 1. Educate yourself on mental illness 2. Be aware of your attitudes and behaviours 3. Choose your words carefully 4. Educate others on myths and stereotypes 5. Focus on positives 6. Support and encourage people 7. Include everyone **Week 2**\ **What are the TEN Basic Principles of Mental** Developed from a comparative analysis of national mental health laws in 45 countries worldwide conducted by the World Health Organization 1. Promotion of mental health and prevention of mental disorders a. Everyone should benefit from the best possible measure to promote their mental well-being and to prevent mental disorders. 2. Access to basic mental health care b. Everyone needs access to basic mental health care 3. Mental health assessments in accordance with internationally accepted principles 4. Provision of the least restrictive type of mental health care c. Persons with mental health disorders should be provided with health care which is the least restrictive 5. Self-determination d. Consent is required 6. Right to be assisted in the exercise of self-determination e. If unable to make decisions, consent from third parties of his or her choice 7. Availability of review procedure f. As the right to review by an official, SDM or other providers 8. Automatic periodical review mechanism g. When a decision is affecting treatment or requires hospitalization, there should be a review mechanism 9. Qualified decision-maker h. Can be judge or SDM. Needs to be competent, knowledgeable, and independent. Impartial if its judge 10. Respect of the rule of law i. Should be in accordance with law of the land **Health Care Law?** Ontario Mental Health Act (MHA) - The Mental Health Act sets out the powers and obligations of psychiatric facilities in Ontario - It governs the admission process, categories of patient admission (ie: voluntary vs involuntary admission), and sets directives around assessment, care and treatment. - MHA can temporarily take away a person's rights under the Canadian Charter of Rights and Freedoms 17. Rights information: patients under the MHA must be informed of their rights, including access to a rights advisor and ability to appeal to the Consent and Capacity Board 18. Forms and procedures: specifies various forms (ie: form 1, form 3) that professionals must complete for actions such as temporary detention - It also outlines the powers of police officers and Justices of the Peace to make orders for an individual who meets certain criteria, to undergo psychiatric examination by a physician Criminal Code of Canada - Mental Disorder is a part of the Criminal Code which addresses the criminal liability of accused persons affected by a mental disorder - It describes a court's powers to order assessments and determine fitness to stand trial, and rendering a verdict of "not criminally responsible" Assessment and Hospitalization under MHA Categories of patient admission - Voluntary Patient 19. a person who has voluntarily agreed to be admitted to a psychiatric facility for care - Involuntary Patient (Form 3 and 4) 20. a person who has been assessed by a psychiatrist and meets the set criteria in section 20 of the MHA, following which the person is admitted and detained. - Informal Patient 21. a person who has been admitted with the consent of their SDM because they are found incapable of consenting to their own admission, but do not meet criteria for involuntary admission. 22. Informal patients usually include minors (\7 days pass, a new assessment must be conducted. 28. If a patient is assessed and discharged or they have left. The doctor can sign the Form 1 from the time of assessment to up to 7 days. - The physician must have reasonable grounds to believe the individual meets one or more of the following criteria: 29. Risk of harm to self 30. Risk of harm to others 31. Unable to care for self due to a mental illness - Form 1 is valid for up 72 hours. 32. Time is legally started when the patient arrives at a Schedule 1 facility and has obtain a copy of the Form 42. 33. A psychiatrist must assess the patient in the 72 hours and decide - Discharged by the psychiatrist - Admitted as involuntary patient under Form 3 - Admitted as voluntary or an informal patient Form 42: Notice to person of Application for Psychiatric Assessment (Form 1). - Companion document to Form 1. It is a safeguard to ensure patients are aware of their rights. - Form 42 informs the patient that they have been detained under the MHA for up to 72 hours. The patient has the right to know the reason for detention, the right to consult a lawyer, or consult a rights advisor - Form 42 must be given the patient immediately upon their detention to psychiatric facility. Failure to provide Form 42 can nullify the legal authority to detain even if the Form 1 has been signed. Form 3: Certificate of Involuntary Admission (2 weeks) - After or during the 72-hour period, if the patient still falls under the criteria for admission, the psychiatrist will complete a Form 3. 34. Only a psychiatrist can sign a Form 3 35. If a psychiatrist was the MD who signed Form 1 then a different psychiatrist will need to assess and sign Form 3. - The form 3 is valid for up to 14 calendar days, including the day it was signed 36. If a Form 3 is signed on January 16^th^, it would expire on January 29^th^ at midnight - January 29^th^, 0001hr it would not be valid Form 4: Certificate of Renewal - At the end of 14 days of the Form 3, a psychiatrist will reassess a patient and determine if they still meet the criteria for admission - if they do, a psychiatrist will complete a Form 4 37. The 1st Form 4, the patient is involuntarily admitted for up to 1 month 38. The 2nd Form 4, the patient is involuntarily admitted for up to 2 months 39. The 3rd Form 4, the patient is involuntarily admitted for up to 3 months - Each Form 4 must be accompanied by a Form 30 - With each Form 4, the patient is to be informed of their right to appeal the decision by the Consent and Capacity Board 40. After the 3^rd^ Form 4 as been issued, an automatic review is conducted by the CCB - Patient can contest or request an appeal at any time during their detainment/stay Form 30: Notice to Patient Under Certificate of Involuntary Admission/Cert of Renewal - Companion with Form 3 and each Form 4 - Given promptly to the patient and inform them the reason for detainment and informs them of their rights - After Form 30 as been issued 41. The clerk or nurse must contact the Patient Advocate Officer/Patient Rights Advisor. The officer-in-charge of the hospital also needs to be notified. 42. Within 24 hours, the advisor must meet with the patient to ensure that they understand their rights. - The patient must be informed that they can agree to the detention or contest their involuntary status to the CCB - If the patient wishes to appeal, the advisor directs them to the CCB, and they will set up a tribunal. The courts will ask another psychiatrist to review the plan. - A lawyer, judge, mental health expert, a sonographer, and the patient must be present. - A Form 50 is used for appeals Form 5: Change to Informal or Voluntary Status - When a patient is Certified on Form 3 or 4 and no longer meet the criteria of the MHA, the psychiatrist will sign a Form 5 to terminate the involuntary status of a patient and change the status to an informal or voluntary patient - Must include the reason for terminating involuntary status and must be completed by the psychiatrist documenting the patient's improvement. - Clerk or nursing staff must fax Form 5 to the CCB before patient is discharged or going out for a privilege Form 9: Order for Return → for Police - Issued by the Officer-in-Charge of the hospital when an involuntary patient leaves the facility without permission - Form 9 authorizes the police to apprehend and return the patient to the nearest Schedule 1 facility - Form 9 is valid for one month from the date of issue **Legal & Ethical Considerations** - MHA forms suspend an individual\'s civil liberties. - MHA forms detain people--but do not force them to adhere to treatment. Treatment can only be administered if: 43. The patient is capable and has given informed voluntary consent 44. The patient is found incapable and a legally valid SDM has given consent **What is Autonomy** - According to law, all individuals have the right to decide whether to accept or reject treatment - It is important that psychiatric mental health nurses know that the presence of psychotic thinking does not mean that the patient is mentally incompetent or incapable of understanding; he or she is still able to provide or deny consent - A health care provider can be charged with assault and battery for providing life sustaining treatment to a client when the client has not agreed to it - The client should receive information such as what treatment alternatives are available; why the most responsible practitioner believes this treatment is the most appropriate; outcomes; risks and adverse effects - There are some conditions under which treatment may be performed without obtaining informed consent. A client's refusal to accept treatment may be challenged under the following circumstance 45. When a client is mentally incompetent to make a decision and treatment is necessary to preserve life or avoid serious harm 46. When refusing treatment endangers the life or health of another 47. During an emergency in which a client is in no condition to exercise judgement 48. When the client is a child (consent is obtained from parent or surrogate) **What is informed consent?** - The principle of informed consent is based on a person\'s right to self-determination and the ethical principle of autonomy - Consent for surgery, electroconvulsive treatment, or the use of experimental drugs or procedures must be obtained - Patients have the right to refuse participation in experimental treatments or research - For consent to be effective, it must be informed - Informed consent includes 49. The nature of their problem or condition 50. The nature and purpose of a proposed treatment 51. The risks and benefits of that treatment 52. The alternative treatment options 53. The probability of success of the proposed treatment 54. The risks of not consenting to treatment - A nurse may sign as a witness on a consent form, however, legal liability for informed consent lies with the physician 55. Three elements of Informed Consent - Knowledge: the client has received adequate information on which to base his or her decision - Competency: the individual's cognition is not impaired to an extent that would interfere with decision making or, if so, that the individual has legal representation - Free will: the individual has given consent voluntarily without pressure or coercion from others **Competency** - The capacity to understand the consequences of one\'s decisions - Patients must be considered legally competent until they have been declared incompetent through a legal proceeding - If found incompetent, the patient may be appointed a legal guardian or representative, who is legally responsible for giving or refusing consent for the patient while always considering the patient\'s wishes - Can be family members (order of selection) 56. Spouse 57. Adult children or grandchildren 58. Parents 59. Adult siblings 60. Adult nieces and nephews **Week 3** **Concepts of the therapeutic nurse-client relationship** The first connection is about understanding that the nurse is safe, discreet, reliable, and consistent and that the relationship will be conducted within appropriate and clear boundaries.  - Therapeutic relationship has specific goals and functions - Facilitating verbal expression of distressing thoughts and feelings - Assisting the patient to develop self-awareness and insight into their thoughts, feelings, and behaviours, for them to better manage the activities of daily living - Helping patients examine self-defeating behaviours and test alternatives  - Promoting self-care and independence **\ What is therapeutic use of self? Why is it important?** **Therapeutic vs social relationship** Social Relationships - Defined as a relationship that is initiated primarily for friendship, socialization, enjoyment, or accomplishment of a task.  - Mutual needs are met during social interaction. - Communication skills may include giving advice, such as relationship advice, and sometimes meeting basic dependency needs during a stressful time. Therapeutic Relationship - The psychiatric nurse maximizes his or her communication skills, understanding of human behaviours, and personal strengths to enhance the patient's growth. - The focus of the relationship is on the patient's ideas, experiences, feelings, and personal issues introduced during the clinical interview, with the development of personal insight as a desired outcome. - The nurse and the patient identify areas that need exploration periodically evaluate the degree of change in the patient's understanding of the stressors and pinpoint strategies to manage them differently. - Focused on the patient's problem and needs. - Working under clinical supervision (i.e., being evaluated, receiving feedback, and gradually gaining autonomy and responsibility) is an excellent way for a psychiatric nurse's focus and boundaries to remain clear.  - Summary  61. The needs of the patient are identified and explored. 62. Clear boundaries are established. 63. Alternative problem-solving approaches are taken. 64. New coping skills may be developed. 65. Insight is developed, and behavioural change is encouraged. **Goals and concepts of relationship** Relationship boundaries - Physical boundaries: general environment, office space, treatment room, conference room - The contract: set time, confidentiality, and agreement between nurse and patient as to roles and responsibilities of all involved in the therapeutic relationship (nurse, patient, and family) - Personal space: physical space, emotional space, and space set by roles Blurring of boundaries - When the relationship is allowed to slip into a social context - When the psychiatric nurse's needs (for attention, affection, or emotional or spiritual support) are met at the expense of the patient's needs - Boundaries are necessary primarily to protect the patient. The most egregious boundary violations are those of a sexual nature. Blurring of roles - The blurring of roles in the psychiatric nurse-patient relationship is often a result of unrecognized transference or counter-transference. - Transference and counter-transference are psychological concepts that often come up in therapeutic and healthcare settings because of the close relationships formed between patients and caregivers. - Can influence communication, trust, and the therapeutic relationship between nurses and patients. Awareness of these phenomena is essential for maintaining professionalism and ensuring patient-centered care. 5 Steps Approach to Setting Limits 1. Explain which behaviour is inappropriate 2. Explain why the behaviour is inappropriate 3. Give reasonable choices with consequences 4. Allow time 5. Be prepared to enforce your consequence **Peplau' Model of the nurse-patient relationship** Pre-Orientation phase Orientation phase - Establishing rapport  66. Build trust and create a safe environment where the patient feels respected and understood - Parameters of the relationships  67. Roles and responsibilities of both the nurse and the patient - Formal or informal contact  68. A contract emphasizes the patient's participation and responsibility because it shows that the psychiatric nurse does something **with** the patient rather than **for** the patient. 69. Mutual agreement about those goals is also part of the contract - Confidentiality 70. The patient has a right to know  - That specific information may be shared with others on the treatment team - Who else will be given the information (e.g., a clinical supervisor, the physician, the staff, or, if the nurse is in training, other students in conference) 71. The patient also needs to know that the information will not be shared with relatives, friends, or others outside the treatment team, except in extreme situations. - Extreme situations include - child or elder abuse - threats of self-harm or harm to others - intention not to follow through with the treatment plan. - Planning for terms of termination 72. Planning for termination begins in the orientation phase 73. Can also be mentioned during the working phase if appropriate 74. The date of the termination should be clear from the beginning Working phase - Maintain therapeutic relationship - Gather further data - Promote patient's  75. Problem-solving 76. Self-esteem 77. Use of language - Facilitate behavioural change - Overcome resistance behaviours - Evaluate problems and goals, and redefine them as necessary - Promote practice and expression of alternative adaptive behaviours.\\ Termination phase - The tasks of termination are as follows: 78. Summarizing the goals and objectives achieved in the relationship 79. Discussing ways for the patient to incorporate into daily life any new coping strategies learned 80. Reviewing situations that occurred during the nurse-patient relationship 81. Exchanging memories, which can help validate the experience for both the nurse and the patient and facilitate the closure of the relationship - Important reasons for the nurse to engage consciously in the termination phase of the therapeutic relationship include the following: 82. Feelings are aroused in both the patient and the nurse about the experience they have had when these feelings are recognized and shared, patients learn that it is acceptable to feel sadness and loss when someone they care about leaves. 83. Termination can be a learning experience; patients can learn that they are important to at least one person, and psychiatric nurses learn continually from each clinical experience and patient encounter. 84. By sharing the termination experience with the patient, the psychiatric nurse demonstrates genuineness and caring for the patient.  85. This encounter may be the first successful termination experience for the patient. **What hinders and what helps the nurse-patient relationships** The following factors enhanced the nurse-patient relationship, allowing it to progress in a mutually satisfying manner: - Consistency 86. Ensures that a nurse is always assigned to the same patient and that the patient has a routine for activities.  87. Interactions are facilitated when they are frequent and regular in duration, format, and location.  88. The importance of consistency extends to the nurse's being honest and consistent (congruent) in what is said to the patient. - Pacing 89. Letting the patient set the pace and letting the pace be adjusted to fit the patient's moods.  90. A slow approach helps reduce pressure; at times, it is necessary to step back and realize that developing a strong relationship may take a long time. - Listening 91. Letting the patient talk when needed. The nurse becomes a sounding board for the patient's concerns and issues. - Initial impressions 92. Positive initial attitudes and preconceptions are significant considerations in how the relationship will progress. 93. Preconceived negative impressions and feelings such as the patient is interesting or challenging can lead to poor outcomes. - Promoting patient comfort and balancing control usually reflect caring behaviours. Control refers to keeping a balance in the relationship: not too strict and not too lenient. **Transference and Counter-transference** Transference Definition - Transference occurs when a patient unconsciously redirects feelings, emotions, or attitudes from a past relationship (often with a parent, caregiver, or authority figure) onto a current healthcare provider, therapist, or nurse. Examples - A patient views a nurse as a parental figure and behaves overly dependent or rebellious. - A patient develops strong, emotional feelings (positive or negative) toward a nurse based on past unresolved experiences. Counter-Transference Definition - Counter-transference occurs when the caregiver, nurse, or therapist unconsciously redirects their feelings or past experiences onto the patient. This can arise from personal triggers, unresolved conflicts, or emotions tied to the caregiver's life. Examples - A nurse becomes overly attached to a patient who reminds them of a family member. - A nurse feels irritated or avoids a patient because it reminds them of someone who caused them distress in the past. **Factors that encourage and promote patients' growth** Genuineness Empathy - Empathy versus sympathy 94. Empathy: we understand the feelings of others 95. Sympathy: we feel the feelings of others Positive regard - Attitudes - Action 96. Attending 97. Suspending values judgement 98. Helping patients develop resources **Communication and the Clinical Interview** **Factors that affect communication** Personal factors - Emotional factors (mood, responses to stress, personal bias) - Social factors (previous experience, cultural differences, language differences) - Cognitive factors (problem-solving ability, knowledge level, language use) Environmental factors - Physical factors (background noise, lack of privacy, uncomfortable accommodations) - Societal determinants (sociopolitical, historical, and economic factors; the presence of others; expectations of others) Relationship factors - Status of individuals in terms of social standing, power, roles, responsibilities, and age. **Verbal and nonverbal communication** Verbal communication - Communicate our beliefs and values - Communicate perceptions and meanings - Communicate what may be considered insults or judgement - Convey messages clearly to avoid conflicting or implied messages - Convey clear and honest feelings - Words are culturally perceived and therefore clarifying the intent of certain words is very important. Nonverbal communication - Communication is 90% nonverbal - Are messages expressed through directly observable behaviors  99. Tone of voice 100. Certain words 101. Physical appearance 102. Facial expression 103. Body posture 104. Amount of eye contact 105. Hand gestures - Sometimes these behaviours operate outside the awareness of the person exhibiting the behaviours or unconsciously. - Nonverbal behaviours must be observed and interpreted in light of a person's culture, class, gender, age, sexual orientation, and spiritual beliefs.  Interaction of verbal and nonverbal communication - Interpretation of feelings and attitudes **Communication skills for nurses** Therapeutic communication strategies - Silence - Active listening 106. Observing the patient's nonverbal behaviors 107. Understanding and reflecting on the patient's verbal message 108. Detecting inconsistencies or things that the patient said that require clarification - Clarifying techniques 109. **Paraphrasing** is to clarify using different words or fewer words. Use simple, precise terms to confirm the message before moving forward in the conversation.  110. **Restating** means saying the same keywords that the patient just said 111. **Reflecting** means to assist the person to better understand their thoughts and feelings. May take the form of a question or simple statement.  112. **Exploring** enables the nurse to examine important ideas, experiences, or relationships more fully. - Asking questions and eliciting patient responses 113. Open-ended questions 114. Close-ended questions Nontherapeutic communication techniques - Excessive questioning 115. Multiple questions 116. Consecutively or very rapidly 117. This approach lacks respect and is not sensitive to patient's needs - Giving approval or disapproval  - Giving advice 118. Prevents the patient's from making their personal decisions 119. Patient may believe that they are incapable of making their own decisions - Asking "why" questions 120. Implies criticism 121. Can be perceived as intrusive or judgemental Cultural consideration - Communication styles - Eye contact  - Cultural filters - Touch  **The Clinical Interview** Preparing for the Interview - Pace - Setting 122. Can be anywhere 123. The purpose is to make the patient feel safe and secure - Seating 124. Same height 125. Avoid a face-to-face stance 126. Avoiding a desk barrier 127. Don't make the patient feel trapped in a room Introduction - Introduce yourself to the patient - Describe the purpose of the meeting - Issues of confidentiality should be addressed - Ask them how they would like to be addressed as (name) Initialing the Interview - "Where should we start?" - "Tell me a little about what has been going on with you." - "What are some of the stresses you have been coping with recently?" - "Tell me a little about what has been happening in the past couple of weeks." - "Perhaps you can begin by letting me know what some of your concerns have been recently." - "Tell me about your difficulties." Tactics to avoid - Do Not 128. Give false reassurance 129. Argue or minimize 130. Interpret situations for the patient 131. Probe about sensitive topics which they do not wish to discuss 132. Participate in criticism of another staff member - Try To 133. Keep the focus on facts 134. Make observations of the behaviours 135. Listen attentively 136. Pay attention to nonverbal cues 137. Encourage the patient to look at the pros and cons Helpful Guidelines - Speak briefly - When you do not know what to say, say nothing - When in doubt, focus on feelings - Avoid giving advice - Avoid relying on questions - Pay attention to nonverbal cues Attending behaviour  - Eye contact - Body language - Vocal quality - Verbal tracking Clinical Supervision Process Recordings **Group therapy** What is it? - Group therapy is a form of psychotherapy in which one or two therapists work with a number of clients simultaneously. The aims include relieving distress through discussing and expressing feelings; helping to change attitudes, behaviour and habits that may be unhelpful; and promoting more constructive and adaptive ways of coping. Some groups may focus on providing members with information about specific issues or teaching them coping skills (CAMH, 2023). Who can attend - Anyone can attend a group therapy session. However, group therapy can be especially helpful for people with limited access to mental healthcare, such as those living in rural or low-income areas where healthcare clinics are understaffed or scarce. One of the goals of group therapy is to bring people who share similar experiences together. Group therapy usually focuses on a specific mental health concern, such as social anxiety or depression. Some other examples of conditions a group may focus on include: - Generalized anxiety disorder - Post-traumatic stress disorder - Panic disorder - Phobias - Depression - Attention deficit hyperactivity disorder - Substance use disorder - Can also help people with - Grief - Eating Disorders - Chronic pain - Anger management - Intimate Partner Violence - Cultural/Intergenerational Trauma - Chronic illness (Medical News Today, 2023).  How does Group Therapy​ work? - Therapy groups typically meet for one to two hours, usually weekly. The group members and leaders sit in a way that allows each person to see everyone else. The therapists guide the group process and provide structure. - Groups may be open or closed. In an open group, members may join at any time, while a closed group has a set start and end date. - Groups are often formed around a shared issue. For example, group members may be living with a particular mental health concern (e.g., social anxiety, an eating disorder, an addiction), or dealing with a loss or other challenge (e.g., parenting difficulties, the mental illness or suicide of a family member). - As with other forms of psychotherapy, what is said in group therapy remains confidential, with certain exceptions. Group members are expected to respect other participants\' privacy by not disclosing their identity or discussing the content of sessions outside the therapy room. It is also often an expectation that members will not socialize or contact one another outside the group (CAMH, 2023). What are the different types of group therapy? - There are many different forms of group therapy. The way a group works depends on its goals. The two main types are process-oriented groups and psychoeducational groups. - In process-oriented groups, the interpersonal experience between the members of the group is a major focus. Opening up in front of others can be challenging, but it also may lead to major growth and change when a person experiences a sense of belonging and acceptance from their peers. Process groups are based on working through these challenges and changes. - A process group may be based on a shared issue in members\' lives outside the group, or it may focus purely on the interactions that arise within the group itself. - This type of group tends to be flexible in structure, and the agenda each week is typically set by the group members themselves. The therapists facilitate the discussion when needed, but they are not the centre of attention. Process groups may be open-ended or time-limited but generally run for at least six months. - Psychoeducational groups are more focused on sharing information on a particular topic or teaching skills (e.g., anger management, cognitive-behavioural therapy). The relationship between members is not so important in this kind of group, though people may still benefit from connecting with others who are struggling with similar issues. - In psychoeducational groups, the therapist is more active and has the role of an instructor. These groups are more likely to be time-limited and relatively short-term (CAMH, 2023). What are some benefits of group therapy?  - The group dynamic allows members to feel supported and accepted, and it can reduce stigma and isolation. - The similarities among members can provide a sense of community, while the diversity of experience can spark ideas for new ways of coping with challenges. - The group provides a safe environment in which to take social risks and experiment with new ways of interacting and behaving. - Members can gain hope and learn from the strategies of those in the group who are \"further ahead\" than they currently are. - Group therapy allows members to better understand how they relate to others and to make positive changes in their relationships. - Observing the group in action gives the therapists a window into how each member functions in a social situation, which can result in valuable feedback (CAMH, 2023). **Week 4\ What are the two types of assessments? Comprehensive vs Focus** Comprehensive A comprehensive assessment includes a complete health history and physical examination; considers the psychological, emotional, social, spiritual, ethnic, and cultural dimensions of health; attends to the meaning of the client's health--illness experience; and evaluates how all of this affects the individual's daily living Focused A focused assessment is the collection of specific information about a particular need, problem, or situation and may involve evaluation of such things as medication effects, risk for self-harm, knowledge deficits, or the adequacy of supports and resources - As the name suggests, focused assessments are briefer, narrower in scope, and more present oriented than are comprehensive assessments - Nurses often employ standardized assessment tools (e.g., Glasgow Coma Scale \[GCS\], Mini-Mental Status Examination, or Hamilton Depression Inventory). **What type of assessment is the Mental Status Assessment?** Assessment of the patient's behavioral and cognitive function - Description of - Patient's appearance - General behaviour - Level of consciousness and attentiveness - Motor speech activity - Mood and affect - Thought and perception - Attitudes and insights - Higher cognitive abilities - Appearance - Grooming and dress - Level of hygiene - Pupil dilation or constriction - Facial expression - Height, weight, nutritional status - Presence of body piercing or tattoos, scars, etc. - Relationship between appearance and age  - Alertness - Behaviour - Excessive or reduced body movements - Peculiar body movements (e.g., scanning of the environment, odd or repetitive gestures, level of consciousness, balance and gait) - Abnormal movements (e.g., tardive dyskinesia, tremors) - Level of eye contact (keep cultural differences in mind) - Speech - Rate: slow, rapid, normal - Volume: loud, soft, normal - Disturbances (e.g., articulation problems, slurring, stuttering, mumbling)  - Cluttering (e.g., rapid, disorganized, tongue-tied speech)  - Mood - Affect: flat, bland, animated, angry, withdrawn, appropriate to context, lability. - Mood: sad, euphoric, duration, degree, stability  - Disorders of the Form of Thought - Thought process (e.g., disorganized, coherent, flight of ideas, neologisms, thought blocking, circumstantiality) - Thought content (e.g., delusions, obsessions) - Perceptual Disturbances - Hallucinations (e.g., auditory, visual, tactile) - Illusions - Cognition - Orientation: time, place, person - Level of consciousness (e.g., alert, confused, clouded, stuporous, unconscious, comatose) Memory: remote, recent, immediate - Fund of knowledge (general knowledge as compared to the average person in a given society) - Attention: performance on serial sevens (counting down from 100 by 7s), serial threes (counting down from 20 by 3s), digit span tests (recalling in order a series of digits)  - Abstraction: performance on tests involving similarities, proverbs - Insight - Judgement - Ideas of Harming Self or Others - Suicidal or homicidal thoughts: - Presence of a plan - Lethality of means - Means to carry out the plan - Opportunity to carry out the plan **When is assessment done with patients?\ **A mental status assessment is typically performed when a healthcare provider suspects a change in a patient\'s mental state, including situations like: a patient presenting with altered mental status, concerns about cognitive impairment, unusual behavior, suspected psychiatric illness, or when monitoring the progression of a known neurological condition; it can also be included as part of a routine physical examination, especially if there are any concerns raised during the patient history.** ** **Assessment and the nursing process\ **Begins with the initial encounter, continues through the duration of caring for patient - Conducted interprofessional - Standardized nursing assessments - Age considerations - Assessment of children - Assessment of adolescents - Assessment of older adults - Language barriers Gathering data - Review of systems - Laboratory data - Mental status examination (MSE) - Psychosocial assessment - Trauma and violence informed approaches - Spiritual or religious assessment - Cultural and social assessment - Validating the assessment - Using rating scales **What is considered the 7th step in the nursing process?\ **Considered a 7th step in the process (Documentation) - Changes in patient condition - Informed consents (for medications and treatments) - Reaction to medication - Documentation of symptoms (verbatim when appropriate) - Concerns of the patient - Safety concerns (thoughts of harm to self or others) - Incidents of mandatory reporting (children's protective services, police) - Any untoward incidents in the health care setting **What is risk assessment?** The assessment of suicide risk is commonly based on the identification and appraisal of warning signs as well as risk and protective factors that are present. Information relevant to the person's history, chronic experience, acute condition, present plans, current ideation, and available support networks can be used to understand the degree of risk. **When should risk assessments be completed?** Warning Signs - Threatening to harm or end one's life - Seeking or access to means: seeking pills, weapons, or other means - Evidence or expression of suicide plan - Expressing ideation about suicide or wish to die - Hopelessness - Rage, anger, seeking revenge - Acting reckless, engaging impulsively in risky behaviours - Expressing feeling trapped - Increase or excessive substance use - Withdrawing from family, friends, and society - Dramatic changes in mood - Express no reason for living, no sense of purpose in life Risk Factors - Unemployed or financial difficulties - Divorced, separated, widowed - Social isolation - Prior traumatic life events or abuse - Previous suicide behaviour - Chronic mental illness - Chronic or deliberate physical illness **Week 5** **What is trauma?** - Trauma results from exposure to an incident or series of events that are emotionally disturbing or life-threatening with lasting adverse effects on the individual's functioning and mental, physical, social, emotional, and/or spiritual well-being. - Trauma can come in many forms, and whether caused by a single event or by repeated exposure, the way a person feels, thinks, and behaves is shaped by that experience. As health care professionals, you may encounter both patients and colleagues that have been impacted. - In the context of violence, trauma can be acute (resulting from a single event) or complex (resulting from repeated experiences of interpersonal and/or systemic violence) - An emotional response to a terrible event like an accident, rape or natural disaster. Immediately after the event, shock and denial are typical. Longer-term reactions include unpredictable emotions, flashbacks, strained relationships and even physical symptoms like headaches or nausea. **What are the 3 things that we must provide our patients who have experienced trauma?\ **Safety, trust and choice **Types of Trauma** Acute Definitions -  Results from exposure to a single overwhelming event Examples - Rape, death of loved one, natural disaster, war Characteristics - Detailed memories, omens, hyper-vigilance, exaggerated startle response, misperceptions or overreactions Chronic Definitions - Results from extended exposure to traumatizing situations Examples - Prolonged exposure to violence or bullying, profound neglect, home environment, or abrupt removal from an environment with friends or colleagues, poverty, racism, oppression Characteristics - Denial and psychological numbing, dissociation, rage, social withdrawal, sense of foreshortened future Complex Definitions - Results from a single traumatic event that is devastating enough to have long-lasting effects Examples - Mass casualties, car accidents with fatalities, shootings, war, refugees dislocations Characteristics - Perpetual mourning or depression, chronic pain, concentration problems, sleep disturbances, irritability Other Types of Trauma - Historical (political and systemic, like slavery) - Intergenerational (multiple generations impact which is passed onto upcoming generation) - Physical (bodily injury or harm) - Psychological (Emotional changes from an incident) - Social (oppression, hate crimes, discrimination in school or environment, poverty, addiction) - Ongoing (Instead of being identified with a single event, continuous day after day) - Vicarious (Experienced by helpers from caring for survivors of trauma) **Triggers** - Signals that act as signs of possible danger, based on historical traumatic experiences lead to a set of emotional, physiological, and behavioural responses that arise in the service of survival and safety (e.g., sights, sounds, smells, touch). - Triggers are all about a person's perceptions experienced as reality. The mind/body connection sets in motion a fight, flight, or freeze response. A patient or colleague who is triggered will experience fear, panic, upset, and agitation. **Process of trauma** \ **Long-term effects of trauma** - Smoking - STI - COPD - Alcoholism - Illicit drugs - Suicide attempts **TIC Principles/Approaches** - Safety (physical environment and interactions) - Trustworthiness and transparency (decisions and confidentiality) - Peer support  - Collaboration and Mutuality (mutual decision-making and sharing of power) - Empowerment and choice  - Cultural, historical and gender issues (effort to move past cultural stereotypes and biases) **Healthcare Workers\' Impact by Trauma** Signs of compassion fatigue - Decrease in work production - Decrease in concentration and focus - Apathy and emotional numbness - Isolation and withdrawal - Exhaustion - Addictions and self-medicating  Risk Factors for Compassion Fatigue - Being new to the field - Having a prior history of trauma - Working long hours and sleep deprivation - Not have a good support system - Difficulty communicating emotions **TVIC principles/care** Principles 1. Understand trauma, violence and ites impacts on people's lives and behavour 2. Create emotional and physically safe environment for all clients and providers 3. Foster opportunities for choice, collaboration and connection 4. Use a strengths-based and capacity building approach to support clients Reasons to implement TVIC - To increase attention on the impact of violence on people\'s lives & well-being - Understand violence and its relationship to\ trauma - Recognize that, like past violence, ongoing violence may be a primary cause of trauma responses - Reduce the tendency to blame/judge people for their psychological or behavioural reactions to experiences of violence, and recognize that these responses may be a result of trauma - Distinguish how trauma that results from violence is different from trauma caused by other negative events, such as natural disasters - Connect to broader systems - Draw attention to the cumulative effects of multiple forms of violence including systemic violence, such as racism or discrimination - Direct attention to the importance of organizational-level actions, such as changes to policies that take clients\' safety and experiences of violence into account and that recognize how broader conditions of people\'s lives (e.g. poverty or unstable housing) increase risk of multiple forms of violence - To reduce harm - Service providers can inadvertently re-traumatize or trigger their clients when they - Touch without warning or permission - speak in a way that conveys negative judgement or blame, such as, \"Oh, you\'re back again\", or, \"Why don\'t you just leave your partner?\" - interpret a reaction or behaviour as being out of proportion or unwarranted without considering the experiences which may have contributed to the reaction or behaviour - use forceful or demanding language to tell a client to complete a task---such as fill out a medical history form or remove clothing for an examination - To improve system response for everyone - Trauma and violence-informed approaches can help make systems and organizations more responsive to the needs of all people and provide opportunities for practitioners to provide the most effective support to their clients. - These approaches aim to increase the safety, control and resilience of all clients, regardless of whether or not they have experienced violence or trauma sometime in their lives - Disclosure of violence and trauma is not the goal in trauma and violence-informed approaches - Here are some of the many reasons why individuals may choose not to disclose: - it is unsafe to disclose - the history is not central to the immediate service being provided - a client has limited or no memory of their history - the client finds it too distressing to disclose How to Implement Trauma and Violence Informed Approaches