The client can make mistakes, survive them, and learn from them. Mistakes are a part of normal life for everyone, and it is not the nurse’s role to protect clients from such experiences.
The nurse will not always have the answer to solve a client’s problems or resolve a difficult situation.
As clients move toward recovery, they need support to make decisions and follow a course of action, even if the nurse thinks the client is making decisions that are unlikely to be successful.
Working with clients in community settings is a more collaborative relationship than the traditional role of
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caring for the client. The nurse may be more familiar and comfortable with the latter.
How should consumers be selected to be peer counselors? What selection criteria should be used? Who should make the selection?
How much input should the residents in a neighborhood have about the location of a group home or halfway house in their area?
People with mental illness are treated in a variety of settings, and some are not in touch with needed services at all.
Shortened inpatient hospital stays necessitate changes in the ways hospitals deliver services to clients.
Adequate discharge planning is a good indicator of how successful the client’s community placement will be.
Impediments to successful discharge planning include alcohol and drug abuse, criminal or violent behavior, noncompliance with medications, and suicidal ideation.
Partial hospitalization programs usually address the client’s psychiatric symptoms, medication use, living environment, activities of daily living, leisure time, social skills, work, and health concerns.
Community residential settings vary in terms of structure, level of supervision, and services provided.
Some residential settings are transitional, with the expectation that clients will progress to independent living; others serve the client for as long as he or she needs.
Types of residential settings include board and care homes, adult foster homes, halfway houses, group homes, assisted living and independent living programs.
A client’s ability to remain in the community is closely related to the quality and adequacy of his or her living environment.
Poverty among persons with mental illness is a significant barrier to maintaining housing in the community and is seldom addressed in psychiatric rehabilitation.
Psychiatric rehabilitation refers to services designed to promote the recovery process for clients with mental illness. This recovery goes beyond symptom control and medication management to include personal growth, reintegration into the community, empowerment, increased independence, and improved quality of life.
The clubhouse model of psychosocial rehabilitation is an intentional community based on the belief that men and women with mental illness can and will achieve normal life goals when provided time, opportunity, support, and fellowship.
Assertive community treatment is one of the most effective approaches to community-based treatment.
It includes 24-hour-a-day services, low staff-to-client ratios, in-home or community services, intense and frequent contact, and unlimited length of service.
Psychiatric rehabilitation services such as ACT must be provided along with stable housing to produce positive outcomes for mentally ill adults who are homeless.
Adults with mental illness may be placed in the criminal justice system more frequently because of deinstitutionalization, rigid criteria for civil commitment, lack of adequate community support, economizing on treatment for mental illness, and the attitudes of police and society.
Barriers to community reintegration for mentally ill persons who have been incarcerated include poverty, homelessness, substance abuse, violence, victimization, rape, trauma, and self-harm.
The multidisciplinary team includes the psychiatrist, psychologist, psychiatric nurse, psychiatric social worker, occupational therapist, recreation therapist, vocational rehabilitation specialist, and sometimes pharmacist.
The psychiatric nurse is in an ideal position to fulfill the role of case manager. The nurse can assess, monitor, and refer clients for general medical and psychiatric problems; administer drugs; monitor for drug side effects; provide patient and family health education; and monitor for general medical disorders that have psychological and physiologic components.
Empowering clients to pursue full recovery requires collaborative working relationships with clients rather than the traditional approach of caring for clients.
REFERENCES
Babalola, O., Gormez, V., Alwan, N. A., et al. (2014). Length of hospitalization for people with severe mental illness. The Cochrane Database of Systematic Reviews, 1, CD000384.
Carras, M. C., Mojtabai, R., Furr-Holden., C. D., et al. (2014). Use of mobile phones, computers, and internet among clients of an inner-city community psychiatric clinic. Journal of Psychiatric Practice, 20(2), 94–103.
Chinman, M., George, P., Dougherty, R. H., et al. (2014). Peer support services for individuals with serious mental illnesses: Assessing the evidence. Psychiatric Services, 65(4), 429–441.
Clubhouse International. (2015). Mission. Retrieved from http://www.iccd.org/mission.html
Finnerty, M. T., Manuel, J. I., Tochterman, A. Z., et al. (2015). Clinicians’ perceptions of challenges and strategies of transition from assertive community treatment to less intensive services. Community Mental Health Journal, 51(1), 85–95.
Forchuk, C., Martin, M. L., Jensen, E., et al. (2013). Integrating an evidence-based intervention into clinical practice: Transitional relationship model. Journal of Psychiatric and Mental Health Nursing, 20(970), 584–594.
Gros, D. F., Magruder, K. M., & Frueh, B. C. (2013). Obsessive-compulsive disorder in veterans in primary care: Prevalence and impairment.
General Hospital Psychiatry, 35(1), 71–73.
International Center for Clubhouse Development. (2015). Retrieved from http://www.iccd.org
Kripalani, S., Theobald, C. N., Anctil, B., et al. (2014). Reducing hospital readmission rates: Current strategies and future directions. Annual Review of Medicine, 65, 471–485.
Lamb, H. R., & Weinberger, L. E. (2013). Some perspectives on criminalization. The Journal of the American Academy of Psychiatry and the Law, 41(2), 287–293.
Lamb, H. R., & Weinberger, L. E. (2014). Decarceration of U. S. jails and prisons: Where will persons with serious mental illness go? The Journal of the American Academy of Psychiatry and the Law, 42(4), 489–494.
Lazar, S. G. (2014). The mental health needs of military service members and veterans. Psychodynamic Psychiatry, 42(3), 459–478.
Loader, K. (2014). Resolving the psychiatric bed crisis: A critical analysis of policy. British Journal of Nursing, 23(3), 150–152.
Malhotra, S., Chakrabarti, S., & Shah, R. (2013). Telepsychiatry: Promises, potential, and challenges. Indian Journal of Psychiatry, 55(1), 3–11.
Martin, M. S., Colman, I., Simpson, A. I., et al. (2013). Mental health screening tools in correctional institutions: A systematic review. BMC Psychiatry, 13, 275.
Marx, A. J., Test, M. A., & Stein, L. I. (1973). Extrohospital management of severe mental illness: Feasibility and effects of social functioning.
Archives of General Psychiatry, 29(4), 505–511.
Mathewson, K. (2014). Creating a learning culture. Psychiatric Rehabilitation Journal, 37(1), 71–72.
Myers, K. M., & Lieberman, D. (2013). Telemental health: Responding to mandates for reform in primary health care. Telemedicine Journal and e-Health, 19(6), 438–443.
Naslund, J. A., Grande, S. W., Aschbrenner, K. A., et al. (2014). Naturally occurring peer support through social media: The experiences of individuals with severe mental illness using YouTube. PloS One, 9(10):e110171.
O’Brien, B. S., & Sher, L. (2013). Military sexual trauma as a determinant in the development of mental and physical illness in male and female veterans. International Journal of Adolescent Medicine and Health, 25(3), 269–274.
Reid, S. C., Kauer, C. D., Hearps, S. J., et al. (2013). A mobile phone application for the assessment and management of youth mental health problems in primary care: Health service outcomes from a randomized controlled trial of mobile type. BMC Family Practice, 14:84.
Roy, L., Crocker, A. G., Nicholls, T. L., et al. (2014). Criminal behavior and victimization among homeless individuals with severe mental illness: A systematic review. Psychiatric Services, 65(6), 739–750.
Santucci, K. (2012). Psychiatric disease and drug abuse. Current Opinion in Pediatrics, 24(2), 233–237.
Skosireva, A., O’Campo, P., Zerger, S., et al. (2014). Different faces of discrimination: Perceived discrimination among homeless adults with mental illness in healthcare settings. BMC Health Services Research, 14, 376.
Substance Abuse and Mental Health Services Administration. (2015). Retrieved from http://samhsa.gov
Sweeney, A., Fahmy, S., Nolan, F., et al. (2014). The relationship between therapeutic alliance and service user satisfaction in mental health inpatient wards and crisis house alternatives: A cross-sectional study. PloS One, 9(7), e100153.
Tsai, J., Mares, A. S., & Rosenheck, R. A. (2012). Does housing chronically homeless adults lead to social integration? Psychiatric Services, 63(5), 427–434.
ADDITIONAL READINGS
Becker, M., Boaz, T., Andel, R., et al. (2012). Predictors of avoidable hospitalizations among assisted living residents. Journal of the American Medical Directors Association, 13(4), 355–359.
Murthy, P., & Chand, P. (2012). Treatment of dual diagnosis disorders. Current Opinion in Psychiatry, 25(3), 194–200.
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MULTIPLE-CHOICE QUESTIONS
Select the best answer for each of the following questions.
All are characteristics of ACT except which of the following?
Services are provided in the home or community.
Services are provided by the client’s case manager.
There are no time limitations on ACT services.
All needed support systems are involved in ACT.
Research shows that scheduled intermittent hospital admissions result in which of the following?
Fewer inpatient hospital stays
Increased sense of control for the client Feelings of failure when hospitalized Shorter hospital stays
Inpatient psychiatric care focuses on all the following, except brief interventions.
discharge planning.
independent living skills.
symptom management.
Which of the following interventions is an example of primary prevention implemented by a public health nurse?
Reporting suspected child abuse
Monitoring compliance with medications for a client with schizophrenia Teaching effective problem-solving skills to high school students Helping a client to apply for disability benefits
The primary purpose of psychiatric rehabilitation is to control psychiatric symptoms.
manage clients’ medications.
promote the recovery process.
reduce hospital readmissions.
Managed care provides funding for psychiatric rehabilitation programs to develop vocational skills.
improve medication compliance.
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provide community skills training.
teach social skills.
The mentally ill homeless population benefits most from case management services.
outpatient psychiatric care to manage psychiatric symptoms.
stable housing in a residential neighborhood.
a combination of housing, rehabilitation services, and community support.
FILL-IN-THE-BLANK QUESTIONS
Identify the interdisciplinary team member responsible for the functions listed below.
_________________________________ Works with families, community supports, and referrals _________________________________ Focuses on functional abilities and work using arts and crafts
_________________________________ Makes diagnoses and prescribes treatment _________________________________ Emphasizes job-seeking and job-retention skills
SHORT-ANSWER QUESTIONS
Identify three barriers to community reintegration faced by mentally ill offenders.
Discuss the concept of evolving consumer households.
List factors that have caused an increased number of persons with mental illness to be detained in jails.
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Key Terms acceptance advocacy attitudes beliefs
compassion fatigue confidentiality congruence countertransference duty to warn empathy exploitation genuine interest intimate relationship orientation phase patterns of knowing positive regard preconceptions problem identification
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self-awareness self-disclosure social relationship
termination or resolution phase therapeutic relationship therapeutic use of self transference
unknowing values
working phase
Learning Objectives
After reading this chapter, you should be able to:
Describe how the nurse uses the necessary components involved in building and enhancing the nurse–client relationship (trust, genuine interest, empathy, acceptance, and positive regard).
Explain the importance of values, beliefs, and attitudes in the development of the nurse–client relationship.
Describe the importance of self-awareness and therapeutic use of self in the nurse–client relationship.
Identify self-awareness issues that can enhance or hinder the nurse–client relationship.
Define Carper’s four patterns of knowing, and give examples of each.
Describe the differences between social, intimate, and therapeutic relationships.
Describe and implement the phases of the nurse–client relationship as outlined by Hildegard Peplau.
Explain the negative behaviors that can hinder or diminish the nurse–client relationship.
Explain the various possible roles of the nurse (teacher, caregiver, advocate, and parent surrogate) in the nurse–client relationship.
THE ABILITY TO ESTABLISH THERAPEUTIC relationships with clients is one of the most important skills a nurse can develop. Although important in all nursing specialties, the therapeutic relationship is especially crucial to the success of interventions with clients requiring psychiatric care because the therapeutic relationship and the communication within it serve as the underpinning for treatment and success.
This chapter examines the crucial components involved in establishing appropriate therapeutic nurse–client relationships: trust, genuine interest, acceptance, positive regard, self-awareness, and therapeutic use of self. It explores the tasks that should be accomplished in each phase of the nurse–client relationship and the techniques the nurse can use to help do so. It also discusses each of the therapeutic roles of the nurse: teacher, caregiver, advocate, and parent surrogate.
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