According to Shives (2005) the factors that influence the development of mental health relate to three main areas: inherited characteristics, nurturing during childhood and life circumstances.

Different people will react to childhood experiences and life circumstances in different ways. Some, despite negative circumstances, will develop positive strategies for coping and will not become mentally ill. Generally it is people who have not achieved a strong sense of identity who are more prone to mental illness (Watkins 2001). Perhaps this is most clearly understood when considering the mental health of Indigenous populations. It is not difficult to imagine how the effects of colonisation, the removal of children from their families, the loss of traditional lifestyle and cultural practices and the resulting social disruption may impact negatively on mental wellbeing. It is generally understood that the difficulties involved in belonging and adjusting to two different cultural contexts can make it difficult to establish a strong sense of identity. The difficulties faced by Indigenous people have led to some serious mental health concerns. For example, there are worrying levels of depression, substance misuse, self-harm, harm to others and suicide in Aboriginal people in Australia that are at higher rates than in the non-Indigenous population (Australian Bureau of Statistics [ABS] and Australian Institute of Health and Welfare [AIHW] 2003).

Nurses working with Indigenous people can better empathise and not negatively judge behavioural signs of mental ill-health if they recognise that it often stems from deep mental anguish and spiritual sorrow relating to the effects of European invasion (Brown 2001).

WHAT IS MENTAL ILLNESS?

Just as it is difficult to arrive at a precise definition of mental health, so too is it difficult to succinctly define mental illness because it is often related to what a given society considers is normal or acceptable behaviour and, as with mental health, mental illness is a matter of degree.

What society considers is normal

People tend to evaluate the behaviour of others based on their own social, cultural, ethical and behavioural standards. Therefore, behaviour that is regarded by one person as acceptable and normal may be perceived by another person as totally unacceptable. In addition, what is accepted as normal in a society may change over time. For example, homosexuality was at one time considered a diagnosable clinical mental disorder (Stevens 2001). When a person’s behaviour is in question it is appropriate to ask ‘Who is qualified to decide whether this behaviour is acceptable or not?’ and ‘What is the meaning and relevance of this behaviour in relation to the context in which it is occurring and to the person’s society, religion and culture?’

In every society and cultural group there are different interpretations of certain behaviours and events. For example, in Western psychiatric terms, visual or auditory hallucination (people seeing or hearing things that no one else does) are viewed as abnormal and a sign of mental illness, whereas in some cultures these happenings are viewed as experiences of symbolic and spiritual importance and those experiencing them may be revered as visionaries as opposed to being perceived as mentally ill (Varcarolis 2006; Fontaine & Fletcher 1999).

A matter of degree

Anxiety, fear, anger, sadness and the need to be alone are feelings commonly identified in mental illness but they are normal feelings experienced at different levels of intensity by most people at various times. Depending on the intensity of the emotions, people may not feel as mentally healthy as they do at other times but will not necessarily be classified as mentally ill. It is when the feelings are exaggerated and extend over longer periods of time than deemed normal that the person is likely to seek professional help and be diagnosed as having a mental illness. For example, a diagnosis of a depressive disorder is likely when sadness or feelings of being ‘down in the dumps’ become deep, long-lasting feelings of despair that the person cannot escape from without professional help. Mental illness or mental disorder are therefore terms used to designate changes from normal mental functioning that are sufficient to become, and be diagnosed as, a clinical disorder (Weir & Oei 1996). Broadly, mental illness can be defined as a state in which an individual exhibits disturbances of emotions, thinking and/or action, but it can be defined in a multitude of ways. Clinical Interest Box 45.1 provides a range of definitions of mental illness.

CLINICAL INTEREST BOX 45.1 Definitions of mental illness

• Mental illness is a term that refers to all the different types of mental disorders. These include disorders of thought, mood or behaviour that cause distress and result in a reduced ability to function psychologically, socially, occupationally or interpersonally (Mayo Foundation for Medical Education and Research 2002)

• A disease that causes mild to severe disturbances in thought and/or behaviour, resulting in an inability to cope with life’s ordinary demands and routines (National Mental Health Association [USA] 2008)

• A disorder causing abnormal behaviour more often than in most people (Shives 2005)

• Psychopathology exhibiting frequent irresponsibility, the inability to cope, being at odds with society and an inaccurate perception of reality (Shives 2005)

• The absolute absence or constant presence of a specific behaviour that has social implications regarding its acceptance (Shives 2005)

• The American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM) is a classification system for mental illness. In the fourth edition (DSM-IV), mental illness is defined as being a clinically significant behaviour or psychological syndrome or pattern that occurs in an individual and that is associated with present distress (e.g. painful symptom) or disability (i.e. impairment in one or more areas of functioning) or with a significantly increased risk of suffering death, pain, disability, or an important loss of freedom. In addition, this syndrome or pattern must not be merely an expectable culturally sanctioned response to a particular event, for example, the death of a loved one. Whatever its original cause, it must currently be considered a manifestation of a behavioural, psychological or biological dysfunction in the individual. Neither deviant behaviour (e.g. political, religious or sexual) nor conflicts that are primarily between the individual and the society are mental disorders unless the deviance or conflict is a symptom of a dysfunction in the individual, as described above (American Psychiatric Association 2002)

There is no clear line that divides mental health from mental illness; the two grade into one another. Table 45.1 provides some areas of comparison between the two but it should be noted that, while these are general traits that mentally healthy or mentally ill people tend to share, different types of mental illness manifest with different effects and with different levels of intensity. In addition, mentally healthy people may experience more than one type of mental dysfunction at different periods in their lives.

TABLE 45.1 AREAS OF COMPARISON BETWEEN MENTAL HEALTH AND MENTAL ILLNESS ^*

Attribute	The mentally healthy person	The mentally ill person
Self-concept	Accepting of self and others. Able to develop talents and potential to fullest extent Adequately in touch with self and able to use the personal resources identified Acknowledges personal strengths and limitations	Poor self-image, low sense of self-worth and unable to recognise talents, so cannot achieve personal potential Lacks confidence and feels inadequate Tends not to recognise personal strengths and limitations
Relationships	Able to form close, meaningful and lasting relationships. Can communicate emotions and can give and receive Can accept authority Can share with people and grow from the experiences These factors often mean the presence of a strong social support network that aids coping in times of stress	Inability to cope with stress can result in disruption, disorganisation, inappropriate responses and unacceptable behaviour that make it difficult to meet the expectations of others in work or social environments. This means that there may be an inability to establish or maintain meaningful relationships. These factors may result in a limited social support network
Outlook on life	Optimistic and positive view, sense of purpose and satisfaction	Tends to a pessimistic negative view of present and future
Coping and adaptation	Able to tolerate stress and return to normal functioning after stressful events. Can cope with feelings such as frustration and aggression without becoming overwhelmed	Can feel overwhelmed by even minor levels of stress and may react with maladaptive behaviour
Judgment/decision making	Uses sound judgment to make decisions and is able to problem solve	May display poor judgment and avoid problems rather than attempting to solve them
Characteristics/traits	Can delay gratification	May feel an urgency to have personal wants and needs met immediately and may demand immediate gratification
Level of functioning	Accepts responsibility for own actions Can function effectively and independently	May act irresponsibly, be unable to accept responsibility for own actions and may blame others for outcomes May exhibit dependency needs because of feeling inadequate
Perceptions	Able to differentiate between what is imagined and what is real because can test assumptions by considered thought. Can change perceptions in light of new information	May be unable to perceive reality

* It should be noted that these are general points only. Different types of mental illness manifest with different effects and, while there are traits that mentally healthy people tend to share, many mentally healthy people may experience several areas of dysfunction at different periods in their lives. Mental illness may occur as a temporary inability to cope; it may occur episodically with long periods of mental health in between; or it may occur as a chronic condition that is constantly present.

(Shives 2005; Stuart & Laraia 2001; Varcarolis 2006)

Symptoms of mental illness occur on a continuum and range from minimal to severe. A person usually receives a diagnosis of having a mental illness when the level of mental distress causes them to seek professional help or when others in society perceive that they need professional psychiatric help. It is important to recognise that, in relation to the differences between mental health and mental illness, there is a ‘grey’ area into which all individuals may enter from time to time. Those with a severe and long-term psychiatric disorder may dip back into relative mental health and reality-based living for a while and, similarly, sometimes the stresses of everyday living are so overwhelming that the most well-adjusted ‘normal’ person may experience marked irrational thoughts, feelings and actions. Therefore, as in the case of physical illness such as diabetes, heart disease or cancer, anyone can develop a mental illness. A mental illness is not the fault of the person affected, and the cause may be related to a combination of biological, psychological and sociocultural factors.

SIGNS AND SYMPTOMS OF MENTAL ILLNESS

Symptoms of mental illness include changes in personal habits, social withdrawal and changes in mood and thinking. While particular symptoms occur with specific disorders, there are warning signs that indicate the presence of a mental health problem. Clinical Interest Box 45.2 provides examples of early warning symptoms of mental illness that may occur in children, adolescents and adults. (For details concerning the symptoms associated with specific disorders, refer to texts dedicated to mental health or psychiatric nursing such as those listed at the end of this chapter.)

CLINICAL INTEREST BOX 45.2 Warning signs and symptoms of mental illness

People may have one or two of these or other symptoms at any one time. This does not necessarily mean there is cause for alarm, but it is advisable they be assessed professionally. A combination of multiple symptoms is a strong signal that professional assessment and help should be sought as soon as possible.

In younger children

• Decline in standard of performance in school work or activities that does not pick up again over time

• The child is not managing or coping with tasks as expected at their developmental age

• Suggestions from teachers that there may be a learning difficulty, a behavioural problem or a problem making friends

• Hyperactivity

• Persistent crying, waking at night, or nightmares

• Persistent disobedience or aggression

• Frequent temper tantrums

• Excessive anxiety (e.g. preoccupation with fears of burglars, barking dogs, parents getting killed)

• Constant fighting with other children, and reports from school of the child being ‘angry or disruptive’

• Refusal to go to school

• Refusal to go to bed, inability to sleep, or a need to sleep with, or close to, parents

• Decreased interest in playing

• The child tries to stimulate themself in various ways (e.g. hair pulling, rocking of the body, head banging)

• The child constantly says things that indicate low self-esteem (e.g. ‘I’m dumb’, ‘I never do anything right’, ‘No one likes me’, ‘I’m too skinny’, or too fat, too tall, too ugly, etc)

• The child is preoccupied with fire, or sets fires

In older children and adolescents

• Frequently asks or hints at the need for help

• Fears or phobias that interfere with normal activities

• Substance misuse

• Change in sleeping/eating/hygiene habits

• Isolating self from others excessively

• Involved in beating up others

• Inability to cope with problems and usual daily activities

• Excessive complaints about physical aches and pains

• Defiance of authority, truancy, theft and/or acts of vandalism

• Intense fear of weight gain

• Frequent outbursts of anger

• Demonstrates ritualistic behaviours (e.g. preparing for bed, a meal, or going out) using routines that are exact, precise and never vary

• Provocatively sexual behaviour that is not appropriate

• Participates in mutilating or killing animals

• Persistent and prolonged low mood (a major concern, especially if accompanied by poor appetite or thoughts and talk of death or signs of self-mutilation)

WHO IS MOST AT RISK OF DEVELOPING A MENTAL ILLNESS?

Anyone can develop a mental illness but some groups of people in society are particularly at risk. Clinical Interest Box 45.3 identifies groups of people at greater risk of mental illness.

CLINICAL INTEREST BOX 45.3 People at risk of mental illness

Anyone can develop a mental illness, but people at particular risk include:

• Adolescents: adolescents face a period of enormous physical, psychological and social change. Some adolescents may not have sufficient resources to cope with the demands placed on them at this challenging stage of life and to complete the developmental tasks necessary to move successfully from adolescence to adulthood. Erik Erikson’s theory of personality development (Erikson & Erikson 1997) is one that is useful to explore in relation to life stages and developmental tasks

• New parents: new parents face a multitude of stressors (things that trigger a stress response) as well as many pleasures connected with a new baby. Stressors may include conflict over the acceptance of the pregnancy, transition from being a couple to being parents, loss of financial income, a baby’s constant demands, and anxiety about the infant’s welfare

• Women: women face factors such as a disadvantaged status in society, internal conflict arising from decisions about whether to pursue a career, become a home-maker or try to achieve both, or being subjected to domestic violence or abuse. These are social factors that may possibly predispose some women to mental illness

• Older adults (male and female): older adults may face many stressors, including loss of work role status because of retirement, reduced income, fear of declining physical and mental abilities, relocation, death of a partner and/or friends and siblings of similar age. The effect of these multiple losses may accumulate and leave some older adults at risk of mental illness

• Refugees and migrants: these people may experience a grief reaction on leaving their homeland, friends and family to live in a country where the cultural practices, values and beliefs are different and where they may be considered of low status and worth. It may be difficult for some migrants to work successfully through their grief because of language barriers, the stress from job and financial uncertainty, and lack of support from relatives and friends left behind. Some refugees and migrants may experience problems of adjustment, isolation and loneliness, each of which may contribute to mental illness. In some cases refugees have experienced torture and trauma in their country of origin, which creates a high risk of developing a post-traumatic stress disorder (Griffiths et al 2003)

• Physically or intellectually impaired persons: factors such as isolation, lack of meaningful relationships, social restrictions caused by disabilities, poor self-esteem, and negative stigmatising community attitudes towards people with disabilities are all aspects of experience that can elevate the risk of mental illness, particularly anxiety and depression (Dewer & Barr 1996)

Many people from all age groups and of different social, educational and cultural backgrounds cope with highly stressful events and accumulative stressors. (Factors relating to the ability to cope with stress are described and discussed in Chapter 13.)

CLASSIFICATION OF MENTAL DISORDERS

There are more than 200 classified forms of mental illness. These include:

• Cognitive disorders (e.g. dementia, delirium)

• Anxiety disorders (e.g. phobias, panic disorder, obsessive disorder)

• Schizophrenia and other psychotic disorders (e.g. paranoid or catatonic-type schizophrenia)

• Mood disorders (e.g. depression, bipolar disorder [mixed mood])

• Personality disorders (e.g. antisocial personality disorder, dependent personality disorder)

• Sexual and gender identity disorders

• Eating disorders

• Sleep disorders

• Impulse-control disorders.

(Refer to mental health, psychiatric nursing texts for more information concerning specific psychiatric disorders.)

MEDICAL DIAGNOSES

The American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM) is a respected and influential classification system under which a mental illness is determined according to the symptoms experienced and the clinical features of the illness. There are many categories of classification but mental illness is mainly classified within the following areas:

• Thought disorders, such as schizophrenia, which disrupt the ability to think and perceive things clearly and logically and can impair a person’s perception of reality

• Mood disorders, which affect how a person feels and can result in persistent low mood (depression) or cycles of low mood and euphoria (bipolar disorder)

• Behavioural disorders, which involve people acting in potentially destructive ways, including eating disorders such as anorexia nervosa and bulimia

• Mixed disorders, which have components of two or more of the other categories (Mayo Foundation for Medical Education and Research 2002).

Diagnosis according to the DSM (4th edition) has the benefit that clients may feel great relief when they have a diagnosis that helps them make sense of what is happening to them, and a medical diagnosis can guide clinical treatment. But this diagnostic system has a disadvantage in that a diagnosis can also be a label that has negative connotations; for example, a label of schizophrenia or a personality disorder is associated with significant social stigma. Diagnostic labels describe certain types of behaviour but they indicate very little about the nature or causes of the experience.

NURSING DIAGNOSES

Mental health nurses develop nursing diagnoses in response to the client’s experience, emotions and behaviours. Nursing care responds holistically to the client’s biological, psycho-social, spiritual and environmental needs and specifically addresses the client’s feelings and behavioural responses to those feelings, many of which are common across several different medically classified conditions. Examples of some nursing diagnoses commonly used in mental health nursing are provided in Clinical Interest Box 45.4.

CLINICAL INTEREST BOX 45.4 Examples of nursing diagnoses used in mental health nursing

• Impaired social interaction: insufficient or excess quantity or ineffective quality of social interactions

• Ineffective coping: inability to form a valid appraisal of the stressors, inability to use available resources

• Chronic low self-esteem: long-standing negative feelings about self or own capabilities

• Self-care deficit: impaired ability to perform or complete activities of daily living (e.g. hygiene, toileting, nutrition)

• Imbalanced nutrition, less than body requirements: intake of nourishment insufficient to meet the body’s metabolic needs

• Powerlessness: perception that one’s own actions will not significantly affect an outcome; a perceived lack of control over a current situation

• Disturbed thought processes: disruption in cognitive abilities and activities

• Disturbed sensory perceptions: alteration in the amount or patterning of incoming stimuli accompanied by a diminished/exaggerated/distorted/impaired response to the stimuli (often used for clients who are experiencing delusions, hallucinations, or illusions or have impaired awareness of self/environment)

• Impaired verbal communication: diminished, delayed or impaired ability to understand or transmit verbal messages

• Dysfunctional grieving: prolonged unsuccessful use of strategies and responses by which people attempt to work through the process of grieving (see Chapter 14 for information concerning the grieving process)

• Risk for injury: potential for injury as a result of environmental conditions interacting with the client’s adaptive and defensive resources

• Risk for self-directed violence; risk for other-directed violence; existence of the potential for an individual to be physically, emotionally or sexually harmful to self or others

• Risk for suicide: potential for self-inflicted life-threatening injury

(Fortinash & Holoday Worret 2003; Varcarolis 2006)

A mental disorder can be categorised as temporary, episodic or chronic, according to the way it manifests:

• Temporary: a temporary inability to cope; for example, a single experience of depression. The vague definition of ‘a nervous breakdown’ is a common non-medical term for this kind of isolated non-recurring illness

• Episodic: an illness that occurs episodically; for example, recurrent episodes of a disabling condition such as bipolar disorder (once known as manic depression) or schizophrenia. While the condition is disabling when it occurs, the person affected can often enjoy a comparatively normal life for much, if not most, of the time

• Chronic: a constant disabling and unrelenting illness that is extremely challenging for the affected person and their families to deal with; for example, a chronic type of schizophrenia or bipolar disorder or irreversible dementia.

Although the use of the terms psychosis and neurosis to describe particular illnesses is no longer favoured, nurses need to be aware of the meanings associated with each as the terms are still used in some contexts. The terms are out of favour because symptoms ascribed to each condition can occur in the other, and this causes confusion. The term psychosis refers to disorders that are so marked and incapacitating that the person who is afflicted is out of touch with reality and lacks insight into the illness and the associated behaviours, which may be unusual or bizarre. Psychosis was the term traditionally used to describe disorders such as schizophrenia and bipolar disorder, in which the symptoms experienced were quite different to those experienced by other people and included delusions and hallucinations (Gibb & Macpherson 2000). (Clinical Interest Box 45.5 provides explanations and examples of delusions and hallucinations.)

CLINICAL INTEREST BOX 45.5 Delusions and hallucinations *^*

Delusion: a fixed thought or belief that is not reality based or true, is not consistent with the person’s level of education and development or cultural background, and is not amenable to reason. It is categorised as a thought disorder

Type	Example
Somatic delusions (a false belief involving a body part or function)	A young woman believes her body is rotting away from the inside, her heart is made of ice and is gradually melting because she doesn’t deserve to live
Nihilistic delusions (false feeling that the self, others or the world is non-existent)	A client refuses to eat, saying there is no need for him to eat because he has no body
Delusions of persecution (oversuspiciousness: the person falsely believes themself to be the object of harassment)	A client believes the staff belong to a cult, are watching his every move and are out to get him. He is afraid to go to sleep for fear of what the staff might do to him
Delusions of control (false belief that one is being controlled by an external source)	A client believes her feelings, thoughts and actions are being controlled by aliens who send messages to her via the television, instructing her on what to do
Delusions of grandeur (exaggerated beliefs about personal importance or powers)	A client believes he is God and controls the universe
Delusions of self-depreciation (beliefs of unworthiness)	A client believes she is ugly and sinful, saying, ‘I don’t deserve to be loved — look at me — it shows that I am full of sin’

Hallucinations: sensory perceptions that are not founded on any external stimuli. They may involve any of the five senses. They are most commonly visual or auditory

Type	Example
Visual hallucination	A client tells you that he sees his deceased wife in different areas of his home
Auditory hallucination	A 16-year-old client tells you she hears voices in her head saying derogatory things such as, ‘You are worthless, you don’t deserve to live’
Gustatory (taste) hallucination	A middle-aged client with organic brain syndrome complains of a constant metallic taste in his mouth
Olfactory hallucination	A 30-year-old client states that she smells ‘rottenrotten garbage’ in her bedroom although no one else can smell anything unusual or unpleasant
Tactile hallucination	A middle-aged woman undergoing symptoms of alcohol withdrawal reports feeling ants crawling all over her body although no ants are present

^* Clients can experience delusions and hallucinations together. For example, a client may hear her dead daughter’s voice, see her standing close by and be convinced that she caused her daughter’s death despite of evidence to the contrary that her daughter died as a result of injuries received in a car accident when on holiday with a friend.

(Shives 2005; Fortinash & Holoday Worret 2003)

Unlike people suffering from a psychotic disorder, those with what used to be termed a neurosis have insight into their condition. For example, a person who has an obsessive-compulsive disorder may experience persistent and intrusive thoughts (obsessions) about personal cleanliness. To decrease the level of anxiety the person may wash his hands hundreds of times a day, even if his hands become red and raw (compulsion to act). When they are extreme, such thoughts and acts may be so unusual and disrupt the person’s life to the degree that to the observer the person is mentally ill. Unlike those experiencing a psychotic disorder, the affected person is aware that the behaviour is abnormal (there is insight into the behaviour and the illness). Despite their condition, people who have what was once classified as a neurosis can often continue to function in society, whereas a person who is psychotic cannot function effectively (Gibb & Macpherson 2000).

THEORETICAL MODELS AND CAUSATION OF MENTAL ILLNESS

Historically the medical profession was prominent in the care of people with mental illness and as a result there has been, and still is, a strong focus on identifying physical causes of mental illness. However, others have looked at psychological, sociocultural, interpersonal and human development factors and there are now many theoretical models used to explain the presence of a mental disorder. Mental health nurses select concepts from the various relevant models that best explain the client’s behaviours, problems and needs. They then draw on these concepts as a basis for client assessment and then for planning, conducting and evaluating care (Varcarolis 2006). The following provide very basic examples of a small selection of theoretical models. To work effectively in the area of mental health, however, nurses need a deep and sound understanding of a wide range of models.

THE MEDICAL, OR BIOLOGICAL, MODEL

This model explains mental illness as being caused by physiological malfunction in the body. Physical causes can be separated into acquired and non-acquired factors. Acquired causes include head injury, cerebral infection and substance misuse. Non-acquired causes include genetic transmission, electrical conductivity changes in the brain, or alterations to the production and/or activity of neurotransmitters (Gibb & Macpherson 2000). There is evidence to support biological explanations. For example, studies indicate that depression and schizophrenia may be linked to abnormal neurotransmitter function, and that genetic factors may be linked to both (Kennedy & Mitzeliotis 1999; Varcarolis 2006). A medical approach to treating mental illness tends to focus primarily on medication and sometimes includes electroconvulsive therapy (ECT), both of which aim to correct chemical imbalance in the body believed to be caused by abnormal neurotransmitter function in the brain. Emil Kraepelin (1856–1926) is a theorist associated with the origins of the medical model.

PSYCHOLOGICAL AND PSYCHODYNAMIC MODELS

The psychoanalytical model, first conceptualised by Sigmund Freud (1856–1939), is possibly the most well-known model in this group. Freud’s model viewed human personality as developing predominantly within the first 5 years of life and focused mostly on unconscious, non-rational and instinctual parts of human behaviour (Varcarolis 2006). Freud attributed disrupted behaviour in the adult to developmental tasks that were not accomplished successfully at earlier developmental stages. For example, within this theoretical framework a mental illness may be linked to a failure during adolescence to move successfully from dependence on parents to independence. Freud’s mode of treatment was psychoanalysis, which aimed to bring unconscious problems to conscious awareness.

Carl Jung (1875–1961), Melanie Klein (1882–1960) and Erik Erikson (1902–1994) are some of the theorists that have expanded on Freud’s thinking about the nature of human development and behaviour. Erikson’s theory has provided nurses with a developmental model that encompasses the entire life span. Erikson studied healthy personalities and focused on human strengths as well as weaknesses, emphasising how people who failed to achieve developmental milestones at various life stages could rectify these failures at later stages (Varcarolis 2006).

It was Freud who identified the manner in which humans develop and used defence mechanisms to ward off anxiety that might otherwise be overwhelming and incapacitating (Varcarolis 2006). Defence mechanisms prevent conscious awareness of threatening feelings and can be a helpful response in adapting to stress, but their overuse can be a sign of maladaptation to stress and an indicator of mental ill-health. They are particularly relevant in understanding stress-vulnerability and stress-adaptation models of health and illness. Stress-vulnerability/adaptation models recognise that throughout life there is a need for everyone to adapt to change, for example, to adjust to school and then work life, to living with a partner, or to becoming a parent or a grandparent and then to retirement and perhaps the death of a spouse. The model views that some people find it more difficult than others to adapt to life’s changes and to cope effectively with the stressors that change can bring. When life results in a stressful situation or there is an accumulation of multiple stressors, people who have been unable to develop and establish adequate coping skills and coping resources are at the highest risk of developing a mental illness. (See Chapter 13 for further information concerning these two theoretical models, the use of defence mechanisms and adaptation to stress.)

SOCIAL AND INTERPERSONAL MODELS

Social/interpersonal models draw attention to the impact of factors within a person’s social environment on mental wellbeing. The basic concept is that negative social factors such as low status, low levels of support, isolation and poverty contribute to and increase the risk of developing mental illness such as depression (Gibb & Macpherson 2000).

Interpersonal models encompass the premise that internal conflict within one’s personality and particular behaviours may be derived from unresolved conflicts within personal relationships, sometimes during early life experiences. This model also encompasses the premise that an individual’s wellbeing is dependent on the amount of stress experienced and the effectiveness of personal coping strategies in dealing with that stress. Karen Horney (1885–1952), Harry Stack Sullivan (1892–1949) and Hildegard Peplau (1909–1999), a nurse theorist, are some of the important theorists who have conducted work related to social and interpersonal factors and mental health.

COGNITIVE BEHAVIOUR MODELS

Cognitive behaviour models stem from the assumption that behavioural responses are learned. Ivan Pavlov (1849–1936) developed the understanding of learned behaviours when he found that when a bell was repeatedly rung each time dogs were given food the dogs began to salivate just at the sound of the bell. This conditioned reflex was termed classic conditioning and is acknowledged as a form of learning that applies to humans, learning in which a previously neutral stimulus comes to elicit a given response through association. For example behavioural theorists would suggest that children who observe parents responding to every minor stress with anxiety would soon learn the response and would develop a similar pattern of behaviour (Stuart & Laraia 2001). According to the behavioural model, this early learning experience would be considered a significant factor in the cause of an anxiety disorder and limited constructive coping strategies in later life.

BF Skinner (1904–1990) added to behavioural theory by introducing the concept of operant conditioning. Operant conditioning refers to the use of reinforcers to motivate the repetition of particular behaviours. The use of positive reinforcement (the continual rewarding of desired behaviours) forms the basis of behaviour modification therapy used to help motivate clients to change undesirable behaviours. It has been effective for clients with phobias, alcohol addiction and a variety of other conditions (Varcarolis 2006).

Aaron Beck was one of the early founders of cognitive behaviour therapy (CBT), now a common and often very successful form of psychological treatment. It is based on the view that dysfunctional behaviour is linked to dysfunctional thinking, and that thinking processes are shaped by underlying beliefs. For example, the client with depression believes, ‘I am no good at anything, I’m worthless, and nobody likes me’. Cognitive behaviour therapy is based on helping clients recognise, challenge and change dysfunctional thinking. (Chapter 13 provides further information about CBT.) Beck’s work has primarily focused on helping people with depression but he has expanded the use of CBT to include working with people who have complex disorders such as borderline personality disorder and schizophrenia, and there are distinct signs of success (Fenichel 2000).

Mental health, like physical health, is clearly affected by a multitude of factors. Consequently, mental health nurses and psychiatrists are concerned with all the aspects of people’s lives that distinguish them as human beings. The mental health nurse uses knowledge from the psychosocial and biophysical sciences, and theories of stress vulnerability, personality and behaviour, to develop a framework on which to base the art of nursing. The mental health nurse is an integral part of the interdisciplinary team required to meet the needs of clients who have a mental illness.

THE PROVISION OF CARE

THE MULTIDISCIPLINARY TEAM

Many people may be involved in assisting a person who is experiencing a disruption or potential disruption to their mental health. Mental health care commonly employs an interdisciplinary team approach to care management. The client’s care, according to individual needs, is planned and implemented by a team composed of mental health nurses, psychiatric social workers, counsellors, clinical psychologists, general or specialist medical officers (depending on the client’s physical status) and pharmacists. Additional team members may be required and, depending on individual needs, these may include: a dietitian; an occupational therapist; a recreational, art, music or dance therapist; complementary health care therapist; and a chaplain or other spiritual support person (Clinical Interest Box 45.6).

CLINICAL INTEREST BOX 45.6 Some members of the health care team

• The psychiatrist: a physician whose specialty is mental disorders and who is responsible for diagnosis and treatment. A psychiatrist has the legal power to prescribe and to write treatment orders and, as such, is often the team leader

• The mental health nurse: a nurse with experience and expertise in clinical psychiatry, who promotes a holistic approach to care

• The clinical psychologist: a psychologist who has undertaken specialised education in the area of mental health and whose function includes applying and interpreting psychological tests and the implementation of specific therapies such as behaviour modification programs and sexual, marital or family therapy

• The psychiatric social worker: a social worker in the field of mental health, whose function includes assisting the client to prepare a support system that will help maintain their mental health on discharge into the community from an inpatient facility. A social worker may liase with employers, contacts in day-treatment centres, and those providing training and educational programs. The social worker may also assist the client to locate and access sources of financial aid and accommodation

• Occupational, recreational, art, music and dance therapists: according to their specialist areas of expertise, these various therapists assist clients to gain skills that assist them to cope more effectively, to gain or retain employment, to use leisure time in a way that promotes their mental wellbeing and to express their emotions in healthy ways

(Varcarolis 2006; Stuart & Laraia 2001)

It should never be forgotten that the most important member of the team is the client, and often clients know what they need to promote their own recovery. Some clients have reflected on the times when they have been at their most vulnerable. For example, some clients who have experienced admissions to acute-care settings have identified that what they need most at times of severe mental distress is somewhere they can feel safe and supported, somewhere they can relax and calm down, and someone to be with them who will listen and really hear them (Watkins 2001). While the client may feel the need for medication, it is not appropriate or helpful to implement other therapeutic interventions, such as group therapy, recreational therapy or family therapy, until the client is feeling less distressed and can collaborate in decisions about what sort of interventions will be most helpful. Skilled helping involves actively listening to the client and working collaboratively with the client to achieve a process of recovery. (See Chapter 29 for information concerning active listening as a therapeutic measure.) The therapeutic process involves health professionals, including nurses, as facilitators who use their knowledge to help the client become more resourceful and self-reliant. This helping relationship needs to be a participative but never a directive process (Watkins 2001). The model of helping relationships established by Carl Rogers (1961) and the model of skilled helping established by Gerard Egan (1994) are client-centred models of caring on which many mental health nurses can reliably base their therapeutic interactions with clients.

RESPONSIBILITIES OF THE MENTAL HEALTH NURSE

Mental health nursing may be described as an interpersonal process in which the nurse uses the presence of self, interpersonal communication skills and a knowledge of physiology, psychology and sociology to help clients in mental distress. A combined understanding of biological processes and psychodynamic processes is essential for the mental health nurse because many people with mental illness have a concurrent physical problem, and the two are often interconnected (Stuart 2001a).

Mental health nurses are very involved in psychiatric inpatient services and in community mental health services. They play a major role in education and health promotion, as well as in the provision of continuing care and counselling for people with mental health problems. For some experienced mental health nurses the role may include conducting specific psychological therapies such as cognitive behaviour therapy.

Nursing care aims to help clients cope with the experience of mental illness, prevent relapse and to promote a return to mental health through a successful rehabilitation program. The primary aims of mental health nursing (Watkins 2001) are to help individual clients to:

• Identify and clarify their needs and problems

• Create a better future for themselves (e.g. empower clients by developing self-help strategies)

• Create strategies to enable them to move forward (e.g. clients can become stuck in a particular way of responding to situations).

Rehabilitation is important for people who have been discharged from a psychiatric ward or unit. Some of these people need minimal support but others represent a population of chronically ill clients who return to hospital periodically over many years and require support in several different areas of their lives. The community mental health nurse and other members of the community mental health team may be involved in:

• Monitoring medication

• Individual and family therapy

• Crisis intervention

• Social skills training

• Medical care for concurrent physical problems

• Vocational training and support (Shives 2005).

FACILITATING DEVELOPMENT OF CONSTRUCTIVE COPING MECHANISMS

While the nurse’s role in stress and stress management is explained in Chapter 13, some specific points need to be highlighted here. To recognise and deal with stress, individuals need to be provided with information about, and helped to recognise:

• Issues and events related to health and illness, and the importance of adhering to sound health practices (e.g. adequate nutrition, sleep, exercise and relaxation) as a way of promoting mental wellbeing

• The dimensions of potential stressors, possible outcomes, and their own established positive and negative coping mechanisms and their coping resources

• How to recognise their existing strengths and develop and maximise their abilities in problem solving, tolerating stress and dealing effectively with interpersonal relationships

• Where and how to gain access to additional coping resources (e.g. vocational training, support groups and counselling).

There is a wide variety of activities that clients may find helpful in promoting coping, but there is no one right or best activity. What works for one person may not work for another. Nurses have a responsibility to provide clients with information and options, but only the client can know what feels appropriate, so the choice of what activities to attempt or to become involved with should ultimately rest with the client. Clinical Interest Box 45.7 provides examples of positive constructive coping strategies, coping resources and negative destructive coping mechanisms.

CLINICAL INTEREST BOX 45.7 Examples of positive constructive coping strategies, coping resources and negative destructive coping mechanisms

Positive constructive coping strategies

• Use of complementary therapies

• Leisure and recreational activities

• Yoga

• Physical activity

• Art and music

• Relaxation techniques

• Reading

• Adult education classes

• Walks in the countryside

• Prayer and religious contemplation

• Medication

• Slowing down

• Expressing feelings

• Keeping pets

• Keeping busy

• Disputing worrying thoughts

• Positive affirmation

• Talking with friends and family and/or mental health professionals

• Joining a self-help or service user group

• Keeping a journal

• Listening to talking books

• Finding out about my mental health problem

• Contacting the crisis team

• Helping others

• Having a socially valued occupation

• Taking respite breaks

• Getting enough rest

• Being listened to

• Understanding my symptoms

• Motivating myself

• Taking one day at a time

• Having a routine

• Having achievable goals

• Monitoring my symptoms

• Avoiding overloading myself

(Mental Health Foundation 1997)

Examples of negative destructive coping strategies

• Always being submissive to others and so failing to get own needs met

• Excessive use of alcohol and/or other drugs or overeating (seeking comfort in substances)

• Promiscuity (seeking love and acceptance in a way that does not improve self-esteem)

THE NURSE’S ROLE IN EDUCATING THE PUBLIC AND REDUCING STIGMA

One particularly important facet of the community mental health nurse’s role is educating the public about mental illness to reduce the stigma that for many mentally ill people is the biggest hurdle to overcome (Watkins 2001). There is a general lack of knowledge in the community about what constitutes mental illness and about the prognoses of mental disorders, which ensures that mental illnesses are often surrounded by mystery, misinformation and stigma (Weir & Oei 1996). Despite positive interventions in recent years, people suffering from mental illness remain among the most stigmatised, discriminated against, marginalised, disadvantaged and vulnerable members of society (Johnstone 2001). Clinical Interest Box 45.8 illustrates one person’s experience of stigma.

CLINICAL INTEREST BOX 45.8 The stigma of mental illness

John was diagnosed with schizophrenia 2 years ago. Getting a diagnosis was such a relief, because then we knew what had caused such a big change in him. The nurses taught us about the illness and now, because we know what to look for, we pick up the early warning signs. He knows where to get help and most of the time he avoids a relapse.

John’s pretty much in control of his illness now, but the thing that’s upset him and us most is the way some people have treated him. He lost his part-time job in the supermarket and even one of his lecturers at college told him he should consider leaving his engineering course because of it. Even my own sister won’t have him baby-sit his young cousins anymore. John now feels it is not safe to tell anyone about it. How do you think that makes him feel? If it was diabetes that made him ill I wonder if people would have reacted the same.

(Marjorie, mother of John, age 21)

Several myths about mental illness create fear of those affected and this fear serves to increase stigmatising behaviours and attitudes. For example, there is a widely held perception that people with mental illness are often out of control, unpredictable and may pose a threat. The truth is that most people with mental illness do not behave in this way; however, severe mental distress is often highlighted in the media, and this links images of dangerous behaviour with mental illness in the minds of the public (Watkins 2001). In addition, single, isolated and often very minor criminal acts committed by mentally ill people tend to be sensationalised by the media, contributing to negative stereotypes (Jewell & Posner 1996).

The lack of accurate knowledge about mental illness that leads to fear, mistrust and sometimes violence against people living with mental illness and their families can also serve to:

• Lower the morale and self-esteem of people living with mental illness

• Prevent people with mental illness from admitting the problem and seeking professional help

• Prevent people with mental illness from gaining paid employment

• Limit the participation of people with mental illness in community activities and force them into a reclusive lifestyle

• Cause families and friends to turn their backs on the mentally ill person when support is most needed.

The picture is not always as dismal as this. Many mental health care users are themselves excellent ambassadors for people with mental illness. By calling themselves consumers or clients they have empowered themselves to become advocates for other people experiencing mental health disorders. Mental health care users or consumers now have a vital role to play in participating and planning the delivery of mental health services (Happell & Roper 2003). Consumer advocacy groups now exist in every state and territory of Australia to promote participation of consumers in planning, implementation and evaluation of mental health services. Accordingly, many consumers live and work within a local community, use the same facilities (e.g. shops, library, cinema, sports centres) as everyone else, are accepted by the people within the community and experience no harassment and attract no hostility from the local residents (Repper et al 1997). All nurses can play a part in highlighting and reducing stigma by: