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UNIT 3 ■ Care of Patients With Psychiatric Disorders
Real People, Real Stories: Dr. Fred Frese
Author's review (if needed) Dr. frese: Like one time when they perceived I was spend- ing too much time interacting with patients, they assumed I was “going off again,” and next thing I knew, they called a “blue alert” and wanted to hospitalize me. But that time, the medical director just told me to take some time off. I never did find out why they called that blue alert. Initials Date OK Correx ISBN# 2/C Karyn: So you haven’t been hospitalized for a very long time, and you are internationally renowned for all of your work and advocacy in the field of mental health. What do you think has contributed most to your recovery? Date Check if revision 7678 11/19/18 Editor's review Initials Date OK Correx 2nd color PMS Dr. frese: Not always. It seemed like even among my cow- orkers, when something strange happened, they thought it was something wrong with me. Karyn: What do you mean by “something strange”? me. During the last attempt to hospitalize me, I actually escaped and ran away, even though I was in pretty bad shape. Karyn: So since you were knowledgeable about the laws, you could essentially be your own self-advocate and argue your case, so to speak? Dr. frese: Yes, and by that time, I was in grad school and had secured a job at what is now the Department of Men- tal Health and Addiction Services. I remember I was living in the hallway of some university housing, and one of the students, who saw me day after day just hanging around and not really doing anything, suggested that I might be eligible for a government job because of my military back- ground. When I applied, the receptionist saw my history of mental health commitments and said I would never get the job, but I did. The last time I went to the hospital, I went voluntarily because I knew I needed more medica- tion, but they thought I needed to be hospitalized and I didn’t; so I ran away. Karyn: Sounds like you were managing a lot of stuff—grad school, working—and, at the same time, episodically strug- gling with symptoms of illness. You were working in the field of mental health, too. Was the work environment supportive? Dr. frese: No, I haven’t been hospitalized since I got mar- ried. I think that has been central in my recovery: having a person who you trust to give you feedback and let me know when I need more medication. Karyn: What role do medications play in recovery? Dr. frese: It’s very individual. We need more research to identify who, among people with schizophrenia, will benefit most by continuous medication versus episodic, reduced doses, or no medication. Genetic research is hopeful, but we’re not there yet. It’s hard to advise any individual what to do without knowing their individual cir- cumstances, and even knowing, it can be very hard.
ectrum and Other Psychotic Disorders ndividual know where to seek assistance e hospital when suicidal thoughts occur? atient discussed the recent loss with staff y members? 356 ent able to verbalize feelings and behav- ated with each stage of the grieving pro- ecognize own position in the process? ession with and idealization of the lost sided? oward the lost object expressed appro- treatment, the patient will be able to differentiate between delusional thinking and reality. ent seeking interaction with others in an te manner? patient maintain reality orientation with ce of delusional thinking? ent able to concentrate and make deci- erning own self-care? patient set realistic goals for self? tient able to verbalize positive aspects past accomplishments, and future pros- uding a desire to live? atient identify areas of life situation that ollable? ent able to participate in usual religious and feel satisfaction and support from been successful in achieving the objec- . Evaluation of the nursing actions for d patient may be facilitated by gathering using the following types of questions: arm to the individual been avoided? dal ideations subsided?
Real People, Real Stories features interviews with patients and provides a model for effective therapeutic communication.
Author Dr. frese: I was 25 when I had my first episode. I was in the Marines and—I know I had seen the movie The Manchurian Candidate previously—and I began to think that the Vietnamese were using the same strategies from the movie to control us. When I let my commanding of- ficer know my theories, I was hospitalized involuntarily, and for the next 10 years I was in and out of hospitals— mostly involuntarily—taking various medications, living many different places, and not employed. Karyn: Were you getting any treatments or intervention that you thought were helpful to your recovery? Artist B /W 4/C Dr. frese: Well, at that time it was thought that schizophre- nia was not an illness from which one could recover. Even recently, I’ve heard some folks who have a family member with schizophrenia say, “There’s no way that anyone with this illness can get better.” But that’s starting to change, and now that the government, through SAMHSA (Sub- stance Abuse and Mental Health Services Administration) is backing the recovery model approach, I think healthcare will improve. I remember being told that my brain was going to progressively deteriorate and that I would never be able to function on my own. All in all, I probably spent about a year of my life in hospitalizations. Once the laws changed and I knew you had to be of imminent harm to yourself or others in order to be hospitalized involuntarily, I talked some of the health professionals out of admitting Townsend UF15_01 GW-CO X People with schizophrenia continue to be disenfranchised, misunderstood, and stigmatized. Even within healthcare, evidence has shown that some settings have been very hostile to people with severe mental illnesses. One way to begin combating stigmatization of people with mental illness is to get to know them personally. Dr. Fred Frese is a licensed psychologist and an internationally renowned speaker, writer, and advocate in the field of mental illness. Karyn: Could you share a little bit about your history with the illness of schizophrenia? 1. Patient must understand that you do not view the idea as real.
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other psychotic disorders has been identified. e include (on a gradient of psychopathology least to most severe): schizotypal personal- sorder, delusional disorder, brief psychotic der, substance-induced psychotic disorder, hotic disorder associated with another medi- ondition, catatonic disorder associated with her medical condition, schizophreniform dis- , schizoaffective disorder, and schizophrenia. ng care of the patient with schizophrenia is ac- lished using the six steps of the nursing process. ing assessment is based on knowledge of tomatology related to thought content and esses, perception, affect, volition, interper- functioning and relationship to the external d, and psychomotor behavior. toms of schizophrenia are categorized as posi- an excess or distortion of normal functions) or ve (a diminution or loss of normal functions). sychotic medications remain the mainstay of ment for psychotic disorders. Atypical antipsy- cs have become the first line of therapy and both positive and negative symptoms of schizo- nia. They have a more favorable side-effect pro- han the conventional (typical) antipsychotics. iduals with schizophrenia require long-term rated treatment with pharmacological and interventions. Some of these include indi- l psychotherapy, group therapy, behavior py, social skills training, milieu therapy, fam- erapy, and assertive community treatment. he majority of clients, the most effective treat- appears to be a combination of psychotropic cation and psychosocial therapy. e clinicians are choosing a course of therapy d on a model of recovery, somewhat like that h has been used for many years with prob- of addiction. The basic premise of a recovery el is empowerment of the consumer. The re- ■■ By the end of 2 weeks, patient will recognize and verbalize that false ideas occur at times of in- creased anxiety. Long-Term Goals ■■ By time of discharge from treatment, patient’s verbaliza- tions will reflect reality-based thinking with no evidence of delusional ideation. ■■ By time of discharge from Movie Connections list films that demonstrate conditions and behaviors you may not encounter in clinical. ent selecting and consuming foods suffi- gh in nutrients and calories to maintain d nutritional status? patient sleep without difficulty and wake sted? patient attend to personal hygiene and ? atic complaints subsided? Modalities nal Psychotherapy s documented the importance of close, ttachments in the prevention of depres- ver double the risk among those with uality of social relationships (Teo et al., this concept in mind, interpersonal psy- focuses on the client’s current interper- ns. Interpersonal psychotherapy with the erson proceeds through three phases. Text continued on page 428
UNIT 3 ■ Care of Patients With Psychiatric Disorders
TABLE 15–2 | CARE PLAN FOR THE PATIENT WITH SCHIZOPHRENIA—cont’d
Fig. # NURSING DIAGNOSIS: DIsTuRbED THOugHT PROCEssEs RELATED TO: Inability to trust, panic anxiety, possible hereditary or biochemical factors EVIDENCED BY: Delusional thinking; inability to concentrate; impaired volition; inability to problem solve, abstract, or conceptualize; extreme suspiciousness of others OuTCOME CRITERIa NuRsINg INTERVENTIONs RaTIONaLE Short-Term Goal
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1. Convey acceptance of patient’s need for the false belief but indicate that you do not share the belief. 2. Do not argue or deny the belief.
2. Arguing with the patient or denying the belief serves no useful purpose, because delusional ideas are not eliminated by this approach, and the development of a trusting relationship may be impeded. 3. Discussions that focus on the false ideas are purposeless and useless and may even aggravate the psychosis.
Use “reasonable doubt” as a thera- peutic technique: “I understand that you believe this is true, but I person- ally find it hard to accept.”
3. Reinforce and focus on reality. Discourage long ruminations about the irrational thinking. Talk about real events and real people. 4. If patient is highly suspicious, the following interventions may be helpful: a. Use same staff as much as possible; be honest and keep all promises. b. Avoid physical contact; ask the pa- tient before touching to perform a procedure, such as taking a blood pressure. c. Avoid laughing, whispering, or talk- ing quietly where patient can see but cannot hear what is being said. d. Provide canned food with can opener or serve food family style.
4. To decrease patient’s suspiciousness:
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a. Familiar staff and honesty pro- motes trust.
b. Patients with suspicious ideation often perceive touch as threatening and may respond in an aggressive or defensive manner.
Therapeutic Communication Icon identifies helpful interventions and guidance on how to speak with your patients. Look for this icon in Care Plan sections. c. Patient may have ideas of refer- ence and believe he or she is being talked about.
d. Suspicious patients may believe they are being poisoned and re- fuse to eat food from an individu- ally prepared tray. e. Suspicious patients may believe they are being poisoned with their medication and attempt to discard the tablets or capsules. f. Competitive activities are very threatening to suspicious patients. g. Patients with suspicious ideation are prone to distrust and are hypervigi- lant of peoples’ behavior and com- munication. Approaches that are overly directive or cheerful may in- crease the patient’s suspiciousness.
e. Mouth checks may be necessary following medication administration to verify whether the patient is actually swallowing the pills. f. Provide activities that encourage a one-to-one relationship with the nurse or therapist. g. Maintain an assertive, matter-of- fact, yet genuine approach.
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