notes about mental health

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Mental Health
 Mental health  Mental Health A state of emotional, psychological and social wellness evidenced by
satisfying interpersonal relationships, effective behavior and coping, positive self-concept and emotional
stability. (WHO).
 Mental illness  any disease or conditions that affect way a person, thinks, feels, behaves ability to
relate to others & to surroundings
Components of Mental Health
 The ability to accept self.
 The capacity to feel right towards others.
 The ability to fulfill life’s tasks.
Importance of mental health
 WHO suggests that half the world's populations are affected by mental illness with an impact on:
o Their self-esteem, Relationships and . Ability to function in everyday life.
 Good mental health can improve one’s life, poor mental health can prevent someone from living a
normal life.
Indicators of Mental Health
 A positive attitude towards self.
 Growth, development and the ability for self actualization.
 Integration. Autonomy
 Perception of Reality. Environmental Mastery.
Characteristics of Mentally Healthy Person
 An ability to make adjustments. Sense of personal worth, and importance.
 Own decision making and problem solving.
 Sense of personal security and feel secure in group, understand other people problems and motives.
 Sense of responsibility. Give and accept love. Shows emotional maturity and tolerate frustration.
 Have a philosophy of life and purpose to his daily activities.
 Has a variety of interests and well balanced with work, rest and recreation.
 Lives in the world of reality not fantasy.
Risk factors for mental health
 Genetic predisposition: vulnerability to most major psychiatric disorders
 Age: High prevalence in old ages e.g. Alzheimer's disease
 Sex: Anxiety & depression are more common among women, substance abuse is more common among
men.
 Infections: Parasites such as malaria & encephalitis →epilepsy - meningitis.
 Toxic substances: alcohol and opiates.
 Environmental exposure: lead in children → MR or ↓ intelligence.
 Homeless people: schizophrenia or substance abuse.
 Malnutrition: deficiency in vit. B & protein deficiency in Kwashiorkor 9. Living in high floors housing,
loneliness.
Interaction between physical and mental health problems
 Physical causes Mental disease Physical illness
 ↓ iodine during pregnancy & oxygen at birth, injuries & early childhood brain infections →MR.

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 Nutritional deficiencies such as PEM →MR.
 Depression interacts with cardiovascular illnesses &vice versa.
 Anxiety, depression & substance abuse can also complicate existing physical disorders.
Foundation
Central Nervous System
 Cerebrum
 Frontal lobe – control organization of thought, body movement, memories, emotions and moral
behavior.
o Associated with schizophrenia, attention deficit / hyperactive disorder and dementia
 Parietal lobe – interpret sensations of taste and touch and assist is spatial orientation .
 Temporal lobes – are centers for the sense of smell, hearing, memory, and expression of emotions.
 Occipital lobes – assist in coordinating language generation and visual interpretation, such as depth
perception.
Neurotransmitters
 Dopamine- controls complex movements, motivation, cognition, regulates emotional responses
 Serotonin- regulation of emotions, controls food intake, sleep and wakefulness, pain control, sexual
behaviors
 Acetylcholine- controls sleep and wakefulness cycle (decreased in Alzheimer’s)
 Histamine- controls alertness,peripheral allergic reactions, cardiac stimulations
 GABA- modulates other neurotransmitters
 Norepinephrine / Epinephrine- causes changes in attention, learning and memory, mood
Neurotransmitters
 Sympathetic - Increase v/s. Decrease GI motility. Decrease GU function. Moist mouth
 Parasympathetic - Decrease v/s . Increase GI motility . Increase GU function. Dry mouth
Types of mental disorders
 Impaired intelligence . Behavioral disorders as maladjustment & absenteeism.
 Psychosis & depression. Schizophrenia
 Psychopathic disorders: aggressive antisocial acts
Impact of mental disorders
Mental illness & poor mental health are public problems. Great impact on
 Individuals  Distressing symptoms. Unable to participate in work & leisure. Quality of life continues
to be poor: stigma & discrimination.
 Family  Economic burden. Disruption of house hold routine & restricted social activities. Lost
opportunities prevent them from achieving their full potential in work & social relations.
 Community  Cost of providing care. Loss of productivity. Legal problems including violence.
Prevention of mental illness
I. Primary prevention
1. Mental health promotion: improving ability of people to deal more effectively with everyday life
stresses. Mental health education to improve mental abilities through Mind's education with special
programs directed to vulnerable groups; children, adolescents, youth & elderly.
2. Genetic counseling, antenatal care: normal fetal development, no exposure to X ray & no self intake of
drugs. Natal care to prevent birth trauma can reduce occurrence of mental disorders (Down syndrome).

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3. Education, employment, social well-being, availability of food, housing - Important role in preventing
mental disorders & promoting mental health.
4. Raising public awareness about mental health disorders. Patients need kind care rather than punishment.
5. Awareness of psychological development: development of human being's cognitive, emotional,
intellectual, & social capabilities is functioning over course of life span from infancy through old age.
6. Life skills education: Interpersonal communication skills, Cooperation & teamwork. Decision-making.
Critical thinking skills. Skills for managing feelings. Skills for managing stress.
II. Secondary prevention
1. Detection of mental disorders/illness in PHC:
 Screening: for early detection of developmental delay at nursery, school, university, military and
work.
 Early diagnosis: progression from asymptomatic to symptomatic mental health disorder is subtle.
Mental disorder may exist for longer periods till recognized. Early diagnosis needs capacity building
of lay person, other professionals & general practitioners. 2ry It refers to intervention undertaken to
reduce complications & all specific treatment-related strategies.
2. Proper management and/or referral to psychiatrist: Complete psychiatric assessment. Detailed personal
history &diagnosis. Counseling, psychotherapy & medical treatment . Admission to psychiatric
word/hospital.
3. Crisis intervention: In wars, disasters, crisis situation - Mental health problems increase. Need
immediate intervention. Social support ↓ - Course of disease Duration intensity will increase
III. Tertiary prevention
Intervention that reduce disability and all forms of rehabilitation as well as prevention of relapse of illness. The
integration of needy groups in the society is needed. It can be achieved by:
 Increasing society understanding of causes of disabilities & abilities of needy/disabled group.
 Attempting to reverse peoples & children negative attitudes.
 Improving health-workers approach toward needy/disabled groups.
 Improving self-esteem & confidence of needy/disabled groups. 3ry Interventions that reduce disability
& all forms of rehabilitation as well as prevention of relapses of illness. The integration of needy groups
in the society is needed.
 Showing needy/disabled groups can take care of others, not just themselves.
 Increasing opportunities for physical & socio-economic integration of needy/disabled groups in daily
activities.
 Presenting abilities of needy/disabled groups through public information campaigns to reduce
stigmatization of mental problems.
 Training health workers about the needs of special groups.
 Providing facilities/ services-day care centers & counseling sites to families of needy/disabled.
 Orientation of children about disabilities in schools, helping regular schools integrates disabled children
& promotes inclusive education.
 Communicate to parents about disabilities of their disabled children.
 Improve physical accessibility to public places, like mosques, governmental offices and schools.
 Create incentives for employers to hire disabled people

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Sigmund Freud
 Father of Psychoanalysis
“Your behavior today is directly or indirectly affected by your childhood days or experiences.
Personality Structure
 ID ( 4-5months)
o Impulsive / Instinctual drive
 I want to… pleasure principle , I want to… physiologic needs, I want to… primary
process
 Superego
o Should not , Small voice of god , Set norms, standards and values
o Moral principle , Conscience
 Ego
o Executive , Reality principle , Conscious , Competencies
o Decision Maker; Problem-Solving; Critical and Creative thinking
Imbalances between Personality Elements
 ID high SE low  Manic Anti-social Narcissistic
 ID low SE high  Obsessive Compulsive, Anorexia nervosa
 EGO Schizophrenia
Psychosexual Theory of Freud - Libido
 Sexual energy responsible for survival of human beings
Oral stage - 18 months
 Cry, suck, mouth. Ego @ 6 months
o Child cries – fed – successful
o Child cries – ignored – unimportant - narcissistic
 fixation - occurs when a person is stuck in a certain developmental stage
 Regression - returning to an earlier developmental stage. infantile behavior
Anal stage -18 months – 3 years old
 Superego develops . Toilet training . Good Mother – Normal
 Bad Mother
o Clean, organized, obedient – OC (anal retentive)
o Dirty, disorganized – Anti-social (anal expulsive)
Phallic stage - Preschooler (3 – 6 years old)
Parent
 Oedipus Complex - Castration Fear
 Electra Complex - Penis Envy
o Repression - unconscious forgetting of an anxiety provoking concept
o Supression - conscious forgetting of an anxiety provoking situation
o Identification - attempts to resemble or pattern the personality of a person being admired of
o Introjection - acceptance of another values and opinion as one’s own
Latency stage - 6 to 12 years old
 School - Reading, writing, arithmetic
 Ability to care about and relate to others outside home

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 Sublimation - placing sexual energies toward more productive activities
 Substitution - replace a goal that can’t be achieved for another that is more realistic.
Genital stage - 12 years old and above
 Developing satisfying sexual and emotional relationships with members of the opposite sex
 Planning life’s goals
Ego defense mechanisms
 Function-To wards off anxiety. Without defense mechanisms, anxiety might overwhelm and paralyze us
and interfere with daily living
 2 Features:
1. they operate on an unconscious level (Except suppression)
2. they deny, falsify or distort reality to make it less threatening
Techniques
 Repression - unconscious forgetting of an anxiety provoking concept
 Supression - conscious forgetting of an anxiety provoking situation
 Regression - returning to an earlier developmental stage
 Fixation - occurs when a person is stuck in a certain developmental stage
 Rationalization - self-saving with incorrect illogical explanation
 Intellectualization - excessive use of abstract thinking; technical explanation
 Displacement – feelings are transferred or redirect to other person or object that is less threatening
 Projection - blaming; falsely attributing to another his/her own unacceptable feelings.
 Introjection - acceptance of another’s values and opinions as one’s own
 Sublimation - transfer of sexual energy to a more productive activity.
 Substitution - replaces a goal that can’t be achieved for another that is more realistic.
 Dissociation - separating and detaching idea, situation from its emotional significance.
 Isolation - individual strips emotion when talking or responding about it.
 Conversion - anxiety converted to physical symptoms
 Compensation- overachievement in one area to overpower weaknesses or defective area.
 Undoing - doing the opposite of what have done
 Denial - Failure to acknowledge an unacceptable trait or situation
 Fantasy - Magical thinking
 Reaction Formation - Opposite of intention
 Acting out - Deals with emotional conflict or stressors by ACTION rather than reflection or feelings.
 Symbolization - Creates a representation to an anxiety provoking thing or concept
 Splitting - Labile emotions; all bad – all good
Defense mechanisms commonly used in each respective disorders
 Paranoid – Projection
 Phobia – Displacement
 Amnesia – Dissociation
 Anorexia – Supression
 Bipolar Disorder – Reaction Formation
 Borderline – Splitting

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 Schizophrenia – Regression
 Substance Abuse – Denial
 Depression – Introjection
 OC – Undoing
 Catatonic - Repression
Erik Erickson Psychosocial Theory of Development
0-18 mos. T rust vs. M istrust
 attachment to mother which lays foundations for later trust in others
 conflict: general difficulties relating to others. suspicion, fear of the future
18 m0s – 3 yrs Autonomy vs. Shame/Doubt
 Gaining some basic control of self and environment
 Conflict: independence-fear conflict, severe feelings of self-doubt
3 yrs – 6 yrs Initiative vs. Guilt
 becoming purposeful and directive
 conflict: aggression-fear conflict; sense of inadequacy and guilt
6 yrs – 12 yrs Industry vs. Inferiority
 Developing social, physical and school skills, competence
 Conflict: sense of inferiority; difficulty learning and working
12 yrs – 20 yrs Identity vs. Role Diffusion
 Making transition from childhood to adulthood; developing a sense of identity
 Conflict: confusion of who one is, identity submerged in relationships or group memberships
21 yrs – 35 yrs Intimacy vs. Isolation
 establishing intimate bonds of love and friendship
 conflict: emotional isolation
35 yrs – 55 yrs Generativity vs. Stagnation
 fulfilling life’s goals that involve family, career and society, developing concerns that embrace future
generations
 Conflict: self-absorption. Inability to grow as a person
55 yrs – above Integrity vs. Despair
 Looking back into one’s life and accepting its meaning
 Conflict: dissatisfaction with life, denial of or despair over prospect of death
Jean Piaget Cognitive Theory of Development
 assimilation  people transform incoming information so that it fits within their existing schemes or
thought patterns
 accommodation  people adapt their schemes to include incoming information
Sensory motor stage - 0 to 18 months
 development proceeds from reflex activity to representation and sensorimotor solutions to problems
Pre-operational stage - 2 to 7 years
 development proceeds from sensorimotor representation to prelogical thought and solutions to problems.
can use these representational skills only to view the world from their own perspective. Understand the
meaning of symbolic gestures
Concrete operational - 7 to 12 years

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 development proceeds from prelogical thought to logical solutions to concrete problems. understand
concrete problems. cannot yet contemplate or solve abstract problems
Formal operational - 12 and above
 development proceeds from logical solutions to concrete problems to logical solutions to all classes of
problems. cannot yet contemplate or solve abstract problems. can also reason theoretically
Harry Stack Sullivan Interpersonal Theory
Infancy - 0 to 18 months
 anxiety develops as a result of unmet needs by the mother (bodily needs ); needs met, the child has sense
of well-being.
Childhood - 18 months to 6 years
 anxiety as a result of lack of praise/acceptance from parents. gratification leads to positive self-esteem.
moderate anxiety leads to uncertainty and insecurity; - severe anxiety results in self-defeating patterns of
behavior.
Juvenile - 6 to 9 years
 severe anxiety may result in a need to control or restrictive, prejudicial attitudes. learns to negotiate own
needs
Pre-adolescence - 9 to 12 years
 capacity to attachment, love and collaboration emerges or fails to develop. move to genuine intimacy
with friend of the same sex
Adolescence - 12 to adulthood
 if self-system is intact, areas of concern expand to include values, career decisions and social concerns.
lust is added to interpersonal equation. need for special sharing relationship shifts to opposite sex. new
opportunities for social experimentation lead to consolidation or self-ridicule.
Hildegard Peplau Nurse Patient Relationship
 Pre-interaction  Major task of nurse- to develop self-awareness
 Orientation  Major task of the nurse: to develop a mutual acceptable contract
 Working  Major task: identification and resolution of patient’s problem
 Termination  Major task: to assist the patient to review what he has learned and transfer his learning
to his relationship with others
Therapeutic communications
 Orientation
 Broad opening  recognition. Giving information. Silence. Offering self – “do you want me to sit
beside you?”
 Working
o focusing – “let us discuss this topic more.”.
o Exploring – “tell me more about it.” .
o Encourage evaluation – “is this what you want?”.
o Reflecting – same idea .
o Restating – same statement.
o Verbalizing implied – “are you going to kill yourself?”.
o Seeking clarification – “may you please repeat that statement”.
o General lead – “please continue.”; “and then?”.
o Limit setting – “stop.”.

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o Interpreting – “maybe that thing is very significant to you.”
 Termination  summarizing – “let us now sum up. You have stated earlier…etc.”. “ do you have any
questions?”. “ our next therapy…”. Look for changes in behavior . Resistance is a common problem
Therapeutic Communication Techniques
 Accepting-indicating reception. Eg.”Yes” “ I follow what you said” Nodding..
Broad Openings
 Allowing the client to take the initiative in introducing the topic
 Eg. “is there something you’d like to talk about?” “ Where would you like to begin?”
Consensual Validation
 Searching for mutual understanding, for accord in the meaning of the words
 Eg. “Tell me whether my understanding of it agrees with yours” “ Are you using this word to convey
that. . .?”
Encouraging Comparison
 Asking that similarities and differences be noted
 Eg. “was it something like..?” “ Have you had similar experiences?”
Encouraging Description of Perceptions
 Asking the client to verbalize what he or perceives
 Eg.”Tell me when you feel anxious” “ What is happening?” ‘ What does the voice seem to be saying?”
Encouraging Expression
 Asking client to appraise the quality of his or her experience
 Eg. “what are your feelings in regard to..?” “ Does this contribute to your distress?”
Exploring
 Delving further into a subject or idea
 Eg. “Tell me more about that.” “ Would you describe it more fully?” “ What kind of work?”
Focusing
 Concentrating on a single point
 Eg. “This point seems worth looking at more closely” “ Of all the concerns you’ve mentioned, which is
most troublesome?”
Formulating a Plan of Action
 Asking the client to consider kinds of behavior likely to be appropriate in future situations
 Eg. “What could you do to let your anger out harmlessly?” “ Next time this comes up, what might you
do to handle it?”
General Leads
 Giving encouragement to continue
 Eg. “Go on” “ And then?” “ Tell me about it”
Giving Information
 Making available the facts that the client needs
 Eg. “My name is…” “ Visiting hours are…” “ My purpose in being here is… “
Giving Recognition
 Acknowledging, indicating awareness
 Eg. “Good morning, Mr. S…” “ You’ve finished your list of things to do.” “ I noticed that you’ve
combed your hair”

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Making Observations
 Verbalizing what the nurse perceives
 Eg. “You appear tense..” “ I notice that your biting your lips”
Offering Self
 Making oneself available
 Eg. “I’ll sit with you awhile” “ I’ll stay here with you” “ I’m interested in what you think”
Placing Event in Time or Sequence
 Clarifying the relationship of events in time
 Eg. “what seemed to lead up to…? “ Was this before or after?”
Presenting Reality
 Offering for consideration that which is real
 Eg. “I see no one else in the room.” “ Your mother is not here; I am a nurse.”
Reflecting
 Directing client actions, thoughts, and feelings back to client
 Eg. Client: “Do you think I should tell the doctor…? Nurse: “Do you think you should?”
Restating
 Repeating the main idea expressed
 Eg. Client: I can’t sleep. I stay awake all night.” Nurse:You have difficulty sleeping.” Client:”I’m really
mad, and upset” Nurse: You’re really mad and upset.”
Seeking Information
 Seeking to make clear that which is not meaningful or that which is vague
 “ I’m not sure that I follow.” “ Have I heard you correctly?”
Silence
 Absence of verbal communication, which provides time for for the client to put thoughts or feelings into
words, regain composure, or continue talking
 Eg. Nurses says nothing but continues to maintain eye contact and conveys interest.
Suggesting Collaboration
 Offering to share , to strive, to work with the client for his or her benefit
 Eg. Perhaps you and I can discuss and discover the triggers for your anxiety
Summarizing
 Organizing and summing up that which has gone before
 Eg. “Have I got this straight?”
Translating into Feelings
 seeking to verbalize client’s feelings that he or she expresses only indirectly
 Eg. Client: “I’m dead”. Nurse: “Are you suggesting that you feel lifeless?”
Verbalizing the Implied
 Voicing what the client has hinted at or suggested
 Eg. Client: I cant’ talk to you or anyone. It’s a waste of time.” Nurse: “Do you feel that no one
understands”
Voicing Doubt
 Expressing uncertainty about the reality of the client’s perceptions “ Isn’t that unusual?” “ Really?” “
That’s hard to believe.”

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Nontherapeutic Communication Techniques
 Advising-telling the client what to do Agreeing- indicating accord with the client
 Eg. “I think you should….” “ That’s right”
Agreeing
 Indicating accord with the client “ that’s right.” “I agree”
Belittling Feelings expressed
 Misjudging the degree of the client’s comfort
 Client: “I have nothing to live for..I wish I was dead” Nurse: “Everybody gets down in the dumps.”
Challenging
 Demanding proof from the client
 “ But how can you be President of the Philippines?”
Defending
 Attempting to protect someone or something from verbal attack
 “ This hospital has a fine reputation.”
Disagreeing
 Opposing the client’s ideas Eg. “That’s wrong”
Disapproving
 Denouncing the client’s behavior or ideas
 “ That’s bad” “ I’d rather you wouldn’t”
Giving approval
 Sanctioning the client’s behavior or ideas “ That’s good.” “I’m glad that..”
Giving Literal Responses
 Responding to a figurative comment as though it were a statement of fact
 Client: “They’re looking in my head with television camera.” Nurse: “Try not to watch television.”
Indicating the existence of an external source
 “ What makes you say that?”
Interpreting
 Asking to make conscious that which is unconscious “ What you really mean is..”
Introducing an unrelated topic
 Changing the subject
 Client: “I’d like to die.” Nurse: “did you have visitors last night?”
Making stereotyped comments
 Offering meaningless cliches or trite comments
 “ Keep your chin up.” “ Just have a positive outlook.”
Probing
 Persistent questioning of the client “ Now tell me about this problem. I need to know.”
Reassuring
 Indicating there is no reason for anxiety
 “ Everything will be alright.”
Rejecting
 Refusing to consider or showing contempt for the client’s behavior, ideas “ Let’s not discuss..”
Requesting an explanation

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 Asking the client to provide reasons for thoughts, feelings, behaviors, events ‘ Why do you think that?”
Testing
 Appraising the client’s degree of insight “ Do you know what kind of hospital this is?”
Using Denial
 Refusing to admit that a problem exists
 Client: “I am nothing.” Nurse: “Of course, you’re something.”
Principles of Mental Health Nursing
1. Accept the patient exactly as he is.
 Acceptance conveys the feelings of being loved and care: it provides the patient with an experience,
which is emotionally neutral, where he finds unlearning of his sick behavior is less threatening before he
can relearn the art of living with himself with others.
 Acceptance does not mean complete permissiveness, but setting of positive behavior to convey to him
the respect as an individual human being acceptance is expressed in the following ways:
Acceptance is expressed in following ways:
A. Being non judgemental & non punitive
 We don’t judge patient’s behavior as right or wrong, good or bad. Patient is not punished for his
undesired behavior.
 All direct and indirect methods of punishing must be avoided.
 Chaining, restraining, putting him in a separate room are some of the direct punishment.
 Ignoring his presence or withdrawing his importance is few ways of giving indirect punishment.
B. Being sincerely interested in the patient.
This can be demonstrated by:
 Studying patient’s behavior pattern.
 Making the patient aware in a in a manner that you are interested in him.
 Seeking out a patient.
 Using time spent with him on these things he is interested in.
 Being aware of his likes and dislikes.
 Explains when his demands can not be met.
 Dealing with his comments, complaints, and expressions of approval realistically.
 Accepting his fears as real to him.
 Avoiding subjects on which he feels sensitive.
 Listening to him.
C. Recognizing & reflecting on feeling which patient may express.
 The nurse acts as a sounding board for patients strong or negative feelings.
 The nurse develops skill identifying the feelings actually expressed for e.g. When a patients says ‘I
would like to break someone’s neck; we understand that he is angry at somebody and is expressing
the anger.
D. Talking with a purpose.
 Nurse’s conversation with a patient must resolve around his needs, wants and interest.
 Direct approaches like reflection , open – end question, focusing on a point, presenting reality is
more effective when the problems are not obvious
 Avoid evaluative, hostile, probing responses, which

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E. Listening
 Listening is an active process. Two ears required for what the patient says verbally and
 Third ear’ is required for what patient is otherwise none verbally saying.
F. Permitting patient to express strongly held feelings
 Strong emotions bottled up are potentially explosive and dangerous .it is better to permit the patient
to express his strong feelings without disposal or punishment.
 Feeling of anxiety, fear, hostility hatred or anger should be expected, tolerated and allowed to
express.
 The nurse must accept the expression of patient negative feeling quietly and calmly.
2) Use self understanding as a therapeutic tool
 Self understanding leads to understanding to others.
 Patient’s behavior can produce lot of anxiety or fear in the nurse, and she ought to understand why she
is anxious or frightened.
 We can understand ourselves better by
 Exchanging personnel experience freely with our colleagues
 Discussing our personal reaction with an experienced
 Participating in group conference regarding our patient care.
3) Use consistent behavior to increase patient’s emotional security.
 Patient to be consistently and continuously exposed to an atmosphere of quiet acceptance.
 Permissiveness to be limited e.g. with homicidal, suicidal, hyperactive and suspicious patients.
 Patient is allowed to feel as he does but limitations are put on his behavior.
 Attempt to win patient’s liking is most
4) Give reassurance to patients in acceptable manner
 Reassurance is building patient’s confidence or restoring his confidence. While giving reassurance , we
must avoid saying to the patient ‘you will get well, “nothing to worry”
Reassurance can be given in following manner :
 Be truly interested in patient’s problem.
 Pay attention to the patient matter however significantly it may be.
 Allow him to be as sick as needs to be.
 Be aware how the patient actually feels.
 Sit beside patient when he does not want to talk.
 Accept patient’s silence.
 Listen to problem without showing surprise.
 Agree with his problem and think with him to solve the problem.
5) Change patient’s behavior through emotional experience and not by rational interpretation.
 Major focus in psychiatry is on feeling aspect and not on intellectual aspect. Telling and advising the
patient is not effective in changing behavior.
 Role play and emotional drama and transactional analysis are few ways of creating emotional experience
in a patient.
 When an alcoholic is told that his drunkard behavior is more hurting to his wife and children he does not
agree to our interpretation. What the same acted by a role of his wife, children and alcoholic, he gains
more understanding.

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 Understanding cannot be forced as insight and understanding one’s own behavior is painful.
Interpretation is only done when patient is ready.
6) Avoid unnecessary increase in patient’s anxiety
Anxiety is a feeling of fear for an unknown object or event. It is a threat to biological integrity of a
person. Psychiatric patients have already some amount of anxiety so psychiatric nurses should not further
increase their anxiety by:
 Contradicting his psychotic ideas.
 Demanding the patient to complete set task.
 Making him to face repeated failure.
 Using big sentences, professional terms while talking with him.
 Care less conversation with patient
 Calling attention to patient’s defect.
 Being insincere
 Giving no orientation to ward co-patient’s staff policies routine and procedures.
 Treats passing sharp commands and showing in difference.
 Asking questions about family, friends, and home in first meeting.
 Showing nurses own anxiety.
7) Demonstrate objective observation to understand and interpret the meaning of patient’s behavior
 We need to observe the patient when he says or does.
 Analysis of the observation should be done to draw thaw the motivation or purpose behind his talk or
action.
 While working with patient learn his basic problems guess what he will do. Keep asking yourself what is
the goal of patient and why he behaves like this.
 Be objective. Objectivity is not coldness but it is indifference and absence of feelings and ability not to
let your own judgment confused
The indications for lack of objectivity in nurse’s observation are:
 Nurse is critical of patient
 Defending or justifying herself
 Demanding that the patient should her in a certain way
 Evaluating the patient’s behavior right or wrong
8) Maintain realistic nurse patient relationship
 Realistic and professional relationship focuses on the personal and emotional needs of patient.
 It is therapeutically oriented and planned
 It is always based on patient’s needs
 Nurse differentiate between patient’s demands and actual needs
 It is for purpose or bringing adaptive ness, integration and maturity in relations.
9) Avoid physical and verbal force as much as possible
Any kind of force results in psychological trauma in patient. Restraining the violent patient is an e.g. of
physical restrain. If all needs to be use the following points to be kept in mind:
 Carry out procedure quickly , firmly and effectively
 Do not show anger while tying
 Tell him the reason and tell that he will be allowed to mix with others when he get the control on him.

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 Attend his needs as usual never show him that he is being punished
 After he becomes controlled never remind him again about the incidence.
10) Nursing care is centers on the patient as a person and not on control of symptoms
 Every is caused, understand the meaning behind the behavior.
 Two patients showing the same symptoms may have different needs .e.g. one may have headache due to
sleeplessness and other may have due to hypoglycemia
 Analysis and study of symptoms is necessary to reveal their meaning and their significant to patient
11) Explain routine procedure at patient’s understanding level
 Every patient has right to know what is being done and why it is being done on him
 Every procedure should be explained at his understanding level to reduce his anxiety
 Character of explanation depends on: patient’s attention, level of anxiety, and level of ability to decide.
12) Many procedures are modified but basic remains unaltered
The nursing principles remain same such as:
 Safety
 Comfort
 Individuality and privacy
 Maintain therapeutic effectiveness , workmanship during procedure
 Economy of time, energy and material
Mental health act India
Mental Health Act 1987
Historical context
 Mental health act was drafted by parliament in 1987. This Act come into effect in April 1993. “ An act
to consolidate and amend the law relating to the treatment and care of mentally ill person. Make better
treatment with respect to their property and affair matter connected therewith and incidental thereto.
Objectives
 To establish central and state authorities for licensing and supervising psychiatric hospitals.
 To establish such psychiatric hospitals and nursing homes.
 To provides a check on working of these hospitals
 To provides a custody of mentally ill person who are unable to look after themselves and dangerous for
themselves
 To establish central and state authorities for licensing and supervising psychiatric hospitals.
 To establish such psychiatric hospitals and nursing homes.
 To provides a check on working of these hospitals
 To provides a custody of mentally ill person who are unable to look after themselves and dangerous for
themselves
Chapters of MHA 1987
 Chapter 1: deals with preliminaries
 Chapter 2:deal with the establishment of mental health authorities at central and state
 Chapter 3: deals with the establishment and maintenance of psychiatric hospitals and nursing homes
 Chapter 4: deals with the procedure of admission and detentions of mentally ill in psychiatric hospitals
 Chapter 5: deals with the inspection, discharge, leave of absence and removal of mentally ill persons

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 Chapter 6: deals with the judicial inquisitions regarding alleged mentally ill person possessing property
and its management
 Chapter 7: deals with the maintenance of mentally ill in psychiatric hospitals or psychiatric nursing
home
 Chapter 8: deals with the protection of human rights of mentally ill persons
 Chapter 9: deals with the penalties and procedures for infringement of guidelines of the act
 Chapter 10: deals with the miscellaneous matters not covered in the other chapters of the act
Chapter 1
 District court civil court or any other civil component to deal with any of the matter specified in this act
 Inspecting court means a person authorities by the state govt to inspect any psychiatric hospital and
license means a licenses under section 8
 Medical officer in gazette medical officer in the service of the government
 Mentally ill person: a person who is in need of treatment by any person of mental disorder other than
mental retardation
 Mentally ill prisoner is mentally ill person ordered for detention in the psychiatric hospital, jail and any
other place for safety custody
Chapter 2: mental health authorities
 Central authority - Shall be subjected to the direction and control of central government Shall be in
charge of regulation, development, direction and co ordination with respect to mental health services
under the central government Advice the central on all matters relating to mental health.
 State authority - shall be subject to the superintendence, direction and control of the State Government.
Shall be in charge of regulation, development and co-ordination with respect to Mental Health Services
under the State Government and all other matters which, under this Act, Advise the State Government
on all matters relating to mental health
Chapter 3: psychiatric hospital or psychiatric nursing home
 Establishment or maintenance of psychiatric hospitals and psychiatric nursing homes.
 Establishment or maintenance of psychiatric hospitals or psychiatric nursing homes only with licence.
 Application for licence.
 Grant or refusal of licence.
 Duration and renewal of licence.
 Psychiatric hospital and psychiatric nursing home to be maintained in accordance with prescribed
conditions.
 Revocation of licence.
Chapter 4: admission and detention in psychiatric hospital or psychiatric nursing home
 Part 1: admission on voluntary basis
 Part 2:admission under special circumstances
 Part 3:reception order
Chapter 5: inspection, discharge, leave of absence and removal of mentally ill persons
 Part i inspection
 Part ii discharge
 Part iii leave of absence
 Part iv removal

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Chapter 6: judicial inquisition regarding alleged mentally ill person possessing property, custody of his
person and management of his property
 Appointment of manager by Collector.
 Appointment and remuneration of guardians and managers.
 Duties of guardian and manager. Powers of manager.
 Manager to furnish inventory and annual accounts.
 Manager’s power to execute conveyances under orders of District Court.
 Manager to perform contracts directed by District Court.
 Disposal of business premises. 64. Manager may dispose of leases.
 Manager may dispose of leases.
Chapter 7: liability to meet cost of maintenance of mentally ill persons detained in psychiatric hospital or
psychiatric nursing home
 Cost of maintenance to be borne by Government in certain cases.
 Application to District Court for payment of cost of maintenance out of estate of mentally ill person or
from a person legally bound to maintain him.
 Persons legally bound to maintain mentally ill person not absolved from such liability.
Chapter 8: protection of human rights of mentally ill persons
 Mentally ill persons to be treated without violation of human rights
 No mentally ill person shall be subjected during treatment to any indignity (whether physical or mental)
or cruelty.
 No mentally ill person under treatment shall be used for purposes of research.
Chapter 9: penalties and procedure
 Penalty for establishment or maintenance of psychiatric hospital or psychiatric nursing home in
contravention of Chapter 3rd
 Penalty for improper reception of mentally ill person
 Penalty for contravention of sections 60 and 69 Offences by companies
Chapter 10: miscellaneous
 Provision as to bonds
 Report by medical officer
 Pension etc, of mentally ill person payable by Government
 Legal aid to mentally ill person at State expense in certain cases
 Protection of action taken in good faith.
 Effect of Act on other laws
 Power to remove difficulty
 Repeal and saving
Mental health care act 2017
An Act to provide for mental healthcare and services for persons with mental illness and to protect,
promote and fulfill the rights of such persons during delivery of mental healthcare and services and for matters
connected therewith or incidental thereto.
Chapters MHCA 2017
 Chapter 1:preliminary
 Chapter 2:mental illness and capacity to make mental healthcare and treatment decisions

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 Chapter 3:advance directive
 Chapter 4 :nominated representative
 Chapter 5:rights of persons with mental illness
 Chapter 6:duties of appropriate government
 Chapter 7:central mental health authority
 Chapter 8:state mental health authority
 Chapter 9:mental health establishments
 Chapter 10 :finance, accounts and audit
 chapter 11:mental health review boards
 chapter 12:admission, treatment and discharge
 chapter 13:responsibilities of other agencies
 chapter 14:restriction to discharge functions by professionals not covered by profession
 chapter 15:offences and penalties
 chapter 16:miscellaneous
Chapter 1:Definition of mental illness as per MHCA 2017
This act defines “mental illness” as a substantial disorder of thinking, mood, perception, orientation or memory
that grossly impairs judgment, behaviour, capacity to recognise reality or ability to meet the ordinary demands
of life, mental conditions associated with the abuse of alcohol and drugs, but does not include mental
retardation which is a condition of arrested or incomplete development of mind of a person, specially
characterised by sub normality of intelligence.
Chapter 2
 Determination of Mental Illness
 Capacity to make mental healthcare and treatment decisions
Chapter 3: Advance Directive
 A person with mental illness shall have the right to make an advance directive that states how he/she
wants to be treated for the illness and who his/her nominated representative shall be. The advance
directive should be certified by a medical practitioner or registered with the Mental Health Board.
 If a mental health professional/ relative/care-giver does not wish to follow the directive while treating
the person, he can make an application to the Mental Health Board to review/alter/cancel the advance
directive.
Chapter 4
 Appointment and revocation of nominated representative
 Nominated representative of minor
 Revocation, alteration, etc of nominated representative by board17.
 Duties of nominated representative
Chapter 5: Rights
 Right to access mental health care
 Right to community living
 Right to protection from cruel , inhuman and degrading treatment
 Right to equality and non discrimination
 Right to information
 Right to confidentiality

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 Right on release of information in respect of mental illness
 Right to access medical records Right to personal contacts and communication
 Right to legal aid
Chapter 6: Duties of Appropriate government
 Promotion of mental health and preventive programs
 Creating awareness about mental health and illness and reducing stigma associated with mental illness
 Appropriate government to take measures as regard to human resource development and training, etc.
 Co-ordination within appropriate government.
Chapter 7: Central Mental Health Authority
 Establishment of central authority and composition of central authority
 Members not to participate in meeting in certain cases
 Functions of chief executive officer of central authority
 Functions of central authority
Chapter 8: State mental Health Authority
 Establishment of state authority and composition of state authority
 Member not to participate in meetings in certain cases
 Officers and other employees of state authority
Chapter 9: Finance accounts and audit
 Grants by central government to central authority
 Central Mental health authority fund
 Accounts and audit of central authority
 Annual report of central authority
 Grants by state government
 State mental health authority fund
 Accounts and audit of state authority
 Annual report of state authority
Chapter 10: Mental Health Establishment
 Registration of mental health establishment
 Procedure for registration inspection and enquiry of mental health establishment
 Maintenance of register of mental health establishment in digital format.
 Duty of mental health establishment to display information.
Chapter 11: Mental Health Review Board
 Constitution of Mental Health Review Boards.
 Composition of Board.
 Decisions of Authority and Board.
 Application to board. Meetings.
 Central Authority to appoint expert committee to prepare guidance document.
 Powers and functions of Board.
 Appeal to High Court against order of Authority or Board.
 Grants by Central Government.
Chapter 12: Admission, Treatment And Discharge

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 Admission of person with mental illness as independent patient in mental health establishment.
 Admission of minor.
 Admission and treatment of persons with mental illness, with high support needs, mental health
establishment, beyond thirty days(supported admission beyond thirty days).
 Leave of absence and Absence without leave or discharge.
 Transfer of persons with mental illness from one mental health establishment to another mental health
establishment. Emergency treatment.
 Prohibited procedure
Chandni
3.8.2020