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Varcarolis’s Canadian Psychiatric Mental Health Nursing Chapter 34: Forensic Psychiatric Nursing Instructor’s Manual Thoughts About Teaching the Topic The faculty member may assign this chapter to students as required reading, whether or not there is a set lecture on the topic. Students may spend clinical time with a basic-level nurse in a correction facility or prison or may be assigned to spend clinical time in a program where offenders are receiving treatment for substance use problems or addiction rather than incarceration. Certainly, students will work with victims of crime in general mental health settings (acute or community). Chapter Outline Teaching Strategies Intersections of Mental Health and Forensics Forensics (an abbreviation derived from forensic science) is an umbrella term referring to legal issues or working with the courts. In recent years, nurses formalized a broad category called forensic nursing, which brings together components of traditional nursing care and legal issues to serve victims of violence and individuals who have committed acts that have brought them into contact with the criminal justice system. Individuals living with mental health challenges are overrepresented in the Canadian criminal justice system due to a number of factors, including the deinstitutionalization of people Psychiatric forensic nursing could be taught with other lecture topics such as community mental health nursing, sexual assault, alcohol and other drug addiction, or legal and ethical issues in nursing. Key Terms and Concepts correctional nursing forensic nursing forensic psychiatric mental health nurse Objectives Define forensic nursing, forensic psychiatric mental health nursing, and correctional nursing. Identify the functions of forensic nurses. Describe three subspecialties of forensic nursing. Identify three roles of psychiatric mental health nurses in the specialty of forensic nursing. Describe clinical competencies associated with forensic psychiatric mental health nursing. 6. Compare and contrast the roles of forensic psychiatric mental health nurses and correctional nurses. Describe the health care needs of incarcerated individuals. Discuss the challenges or issues associated with being a nurse in a correctional facility. challenged by mental illness without ensuring adequate community mental health services, a lack of affordable housing, and inadequate income support programs. These factors increase the vulnerability of individuals with mental illnesses, leading to greater victimization of this population. Without adequate services and a treatment plan in place, the likelihood of further victimization and recidivism among this population is high. Forensic Nursing Forensic nursing is defined as the application of nursing science to public or legal proceedings and the application of the forensic aspects of health care in combination with the biopsychosocial education in the scientific investigation and treatment of trauma or death of victims and perpetrators of abuse, violence, criminal activity, and traumatic accidents. Subspecialties include forensic nurse examiners (sexual assault survivors), forensic nurse death investigators (deceased), forensic psychiatric mental health nurses (mentally ill offenders), clinical forensic nursing (victims of interpersonal violence), forensic correctional nurses (offenders), and forensic geriatric or pediatric nurses (victims of abuse and neglect). Education In 2001, certification in forensic nursing became available for the subspecialty of sexual assault nurse examiners (SANEs) in Canada, and a call put forward by the International Association of Forensic Nurses for the incorporation of forensic content at all levels of nursing education. Many nurses are involved in forensic nursing without any specialized training. Canada was first in the world to offer a forensic studies certificate program online. Currently Canada does not have forensic nursing master’s or doctoral programs. Roles and Functions Roles centre on the identification of victims, creation of appropriate treatment plans, and collection, documentation, and preservation of potential evidence. The forensic nurse practises in assessment and treatment related to competency, risk, and danger. Forensic nurses may apply medical-surgical knowledge to the care of victims and offenders, and they may function in the legal role in the collection of evidence, or court testimony. Sexual Assault Nurse Examiner The SANE was the first specialized forensic role for nurses, and it represents the largest subspecialty in forensic nursing. They care for adult and pediatric victims of sexual assault. Along with SANEs, members of a Sexual Assault Response Team (SART) may include representatives from the health department, police services, advocacy groups, the local department of children and family services, crown attorneys’ offices, local hospitals, victim assistance programs, and other service areas, as pertinent. Nurse Coroner or Death Investigator This forensic nursing subspecialty is recognized internationally as having its historical roots in Alberta, Canada, where in 1977 the medical examiner system implemented a law to enable nurses to be hired as death investigators or medical examiner’s nurse Instructor’s Manual investigators for investigation of all deaths (unnatural, unexpected or unexplained). Forensic nurse death investigators are in charge of the body at a scene and works in collaboration with police services and other officials involved in the case. They interview witnesses, collect evidence, and document their findings. They may also notify the next of kin of the death. The Forensic Mental Health System in Canada An increasing number of individuals struggling with mental illness and living in the community without adequate mental health services and resources are coming into contact with the law. The Canadian forensic mental health system provides mental health services (inpatient and community) to individuals who have a mental illness and have come into contact with the law and are serving time in the federal system. The provincial and territorial forensic mental health systems address the care and treatment of patients in provincial and territorial systems. Forensic Psychiatric or Forensic Mental Health Nurse This specialty requires skills in psychiatric mental health nursing assessment, evaluation, and treatment of forensic clients diagnosed with a mental illness. Evidence collection is central to the role of the forensic psychiatric nurse. For example, evidence is collected by a careful evaluation of a forensic client’s mental status at the time of the offence. This evaluation aids in determining the individual’s fitness to stand trial and may later influence the sentence. Roles and Functions Roles of the forensic psychiatric nurse depend largely on the settings in which the nurse is employed. The forensic psychiatric nurse may work on a forensic assessment unit in a mental health facility, conducting court-ordered evaluations of criminal responsibility and court-ordered treatment to determine if individuals are fit to stand trial, or on a forensic rehabilitation unit providing treatment, care, and rehabilitation for clients who have been found to be unfit or not criminally responsible on account of a mental disorder (NCRMD). A person cannot be tried for a criminal offence if he or she is unable to provide a defence because of mental illness. “Unfit to stand trial” is defined as unable on account of mental disorder to: understand the nature or object of the proceedings, understand the possible consequences of the proceedings, or communicate with counsel. It is the accused individual’s capacity at the time of trial that is in question in determining fitness to stand trial. The court may decide that an individual found unfit to stand trial is to be treated for the purpose of making the individual fit to stand trial. Before rendering this decision, the court must be satisfied based on medical evidence that the proposed treatment is likely to make the individual fit to stand trial and that without treatment the individual is likely to remain unfit; that any potential harm associated with the treatment does not outweigh the anticipated benefits; and that the specified treatment is the least restrictive and least intrusive given the circumstances. Then every two years, until the person is either acquitted or tried, a review board holds a hearing to determine if the person has become fit to stand trial. Although there continues to be much debate, currently Canadian law requires only that individuals be able to provide a factual account to their lawyers but not necessarily an analytical or rational analysis. Criminal responsibility refers to the mental state of a defendant at the time of the offence. A person is not criminally responsible (NCR) under Canadian Criminal Code if he or she has a mental disorder that makes him or her unable to judge the nature or quality of the criminal act or to understand that the act was wrong at the time it was committed. Merely having a mental disorder does not automatically exempt a person from criminal responsibility. The courts make the decision based on a thorough legal and psychiatric review to determine the person’s state. A list of the important competencies of the forensic psychiatric mental health nurse in meeting these roles is presented in Box 342. Correctional Nursing in Canada Correctional nurses perform psychiatric mental health nursing role functions, including completing comprehensive mental status examinations and implementing psychiatric care plans. Varcarolis’s Canadian Psychiatric Mental Health Nursing Chapter 35: Therapeutic Groups Instructor’s Manual Thoughts About Teaching the Topic Although most nurses do not go into the field of psychiatric nursing, the importance of understanding group behaviour cannot be ignored. Nurses work in groups. Depending on the contexts and locations they are working in, nurses may lead more educational groups as ways of managing increased workloads, as well as advancing prevention and health promotion aspects of their mental health work. Helping students realize that concepts such as group roles and group process are applied similarly, whether in medical-surgical settings or psychiatric settings, increases the value of this learning for beginning students. Key Terms and Concepts Chapter Outline Teaching Strategies Group Concepts Definition of Group A group is defined as two or more people who develop a relationship that is interactive; these people share at least one issue or common goal. The specific characteristics of a group include the following: size, rules, boundaries, climate, defined purpose, apparent content, and underlying process. Therapeutic Factors Common to All Groups Irvin D. Yalom (2005) is credited with identifying the factors that make groups therapeutic (Box 35-2). These factors are conflict group group content group norms group process group psychotherapy group themes group work psychoeducational groups self-help groups support groups therapeutic factors Objectives Identify basic concepts related to group work. Describe the phases of group development. Define task and maintenance roles of group members. Discuss the therapeutic factors that operate in all groups. Discuss four types of groups commonly led by nurses. Describe a group intervention for (1) a member who is silent or (2) a member who is monopolizing the group. aspects of the group experience that leaders and members have identified as facilitating therapeutic change. They include imparting of information, instillation of hope, altruism, corrective recapitulation of the primary family group, development of socializing skills, imitative behaviour, interpersonal learning, group cohesiveness, catharsis, existential factors, and universality. Planning a Group Planning a group should include a description of specific characteristics, such as name and objectives of the group, types of patients or diagnoses of members, group schedule, description of leader and member responsibilities, and methods of evaluation. Phases of Group Development During the orientation phase, the leader’s role is to set the atmosphere of confidentiality and respect while members are helped to relax and feel comfortable. The group task is for members to get to know one another and begin to take steps toward the working phase. In the working phase, members are involved in working toward the group’s goals, while the leader ties together common themes, encourages expression, and prevents hostile attacks. Also, the leader keeps the group focused on therapeutic goals of the individual members; members accept each other’s differences. During the termination stage, the group members prepare for separation and help each other prepare for the future. Group Member Roles Growth-producing roles adopted by group members include opinion giver, opinion seeker, information giver, information seeker, initiator, elaborator, coordinator, orienter, evaluator, clarifier, recorder, and summarizer. A member may adopt more than one role. Group Leadership Responsibilities A group leader has multiple responsibilities in starting, maintaining, and terminating a group. Cultural considerations must be taken into consideration as well. Communication techniques frequently utilized by the group leader include seeking clarification, encouraging description, presenting reality, focusing, reframing, providing feedback, and promoting the development of insight. Styles of Leadership There are three main styles of leadership—autocratic, democratic, and laissez-faire. Table 35-2 describes communication techniques used by leaders. Clinical Supervision Transference and counter-transference issues occur in groups just as in individual treatment, and a more objective input supports a focus on therapeutic goals. Nurse as Group Leader Nurses with basic preparation may lead activity, educational, task, and support groups. Basic Groups Psychoeducational Groups Psychiatric nurses, with their biopsychosocial and spiritual approach, are the ideal professionals to teach a variety of health subjects. These groups include a variety of specific somatic or psychological subjects, which also allow members to • communicate about emotional concerns. Some of the psychoeducational groups include the following: Medication education groups are designed to teach patients about their medications, answer their questions, prepare them for discharge, and foster medication adherence after discharge. Patients should be taught the name of the medication, reasons for taking the medication, exact dose, time to take the medication, common adverse effects, ways to remember to take each dose, foods or OTC medications to avoid, what to do if they wish to change the regimen, and the importance of informing other health care providers of the medication being used (to prevent adverse medication interactions). Health education groups work with topics such as AIDS education, STD education, sexuality and psychotropic medication, and effects of antidepressants on sexuality. Concurrent disorders groups work with such topics as psychiatric illness and substance use. The RN may co-lead this group with another concurrent disorders specialist (master’s level clinician). Symptom management groups concentrate on a topic such as anger or psychosis. The focus is on sharing positive and negative experiences so that members learn coping skills from each other. Stress management groups teach members various relaxation techniques to reduce stress. They are usually time limited. Self-help groups are designed to serve people who have a common problem; they are led by a member rather than a professional. Strategies include promoting dialogue, selfdisclosure, and encouragement. Concepts: psychoeducation, self-disclosure, mutual support. Characteristics: peer support, group teaching, counselling, using shared experiences. Advanced-Practice Nurse or Nurse Therapist Groups Group Psychotherapy This is a specialized treatment intervention in which a leader(s) establishes a group for the purpose of treating patients with psychiatric disorders. Psychodrama Groups These are specialized groups in which members are encouraged to act out life experiences or situations for the purpose of learning and insight. Dialectical Behaviour Treatment Dialectal behaviour treatment (DBT) groups are a type of group psychotherapy where patients are seen each week with the goal of improving interpersonal, behavioural, cognitive, and emotional skills and for reducing self-destructive behaviours (Sadock and Sadock, 2008). Dealing With Challenging Member Behaviours Group therapy is about working through problem behaviours, but some can be especially disruptive to the group process and difficult for the leader to manage. Monopolizing Member Compulsive speech by a patient is an attempt to deal with anxiety. Intervention: Ask group why they have permitted the monopolizer to go on and on. This helps the group to recognize the role of their own passivity and to disclose their own feelings. Therapist helps group use “I” statements rather than “you” statements. Complaining Member Who Rejects Help This type of patient takes pride in believing that his or her problem is insoluble. The group becomes concerned initially, and then frustrated and angry with the patient. Intervention: The therapist agrees with the content of the patient’s pessimism and maintains detached affect. With group cohesion, a therapist can help such a patient recognize the pattern of his or her relationships. Demoralizing Member Those who tend to challenge the group leader and demoralize the group are self-centred, lack empathy, are depressive or angry, and refuse to take personal responsibility. Narcissistic individuals have problems in group therapy because they are defensive and have a grandiose sense of self-importance. They may initially be charming and then demanding; may devalue the therapist and then feel elated; or may monopolize the group. Intervention: The therapist must listen to the content that is being avoided and stay therapeutically objective. Only then can the therapist be empathetic in a matter-of-fact way. Silent Member This person may be silent for various reasons: because he or she is observing intently, trying to decide whether the group is safe, concerned that he or she may not be as competent as the others, or hoping to avoid conflict. Intervention: The leader should exhibit patience but encourage each member to offer comments to the group. Expected Outcomes Expected outcomes of group participation will vary, depending on the type and purpose of the group. Varcarolis’s Canadian Psychiatric Mental Health Nursing Chapter 36: Family Interventions Instructor’s Manual Thoughts About Teaching the Topic This chapter includes a wealth of information about families. There is good clarification of the differing roles of the basic-level nurse and the advanced-practice nurse. Although the basic-level student needs to understand the complexity of family therapy, the focus of instruction should be on use of the nursing process in situations commonly seen at their introductory level of practice: assessment of family structure and function, often-used nursing diagnoses, examples of outcome criteria, and strategies for intervention. Key Terms and Concepts behavioural family therapy boundaries clear boundaries enmeshed boundaries family systems theory family triangle flexibility genogram insight-oriented family therapy intergenerational issues nuclear family psychoeducational family therapy rigid boundaries sociocultural context Objectives Define the concept of family. Differentiate between functional and dysfunctional family patterns of behaviour as they relate to the five family functions. Compare and contrast insight-oriented family therapy and behavioural family therapy. Identify family theorists and their contributions to the family therapy movement. Incorporate the family’s sociocultural context when assessing and planning intervention strategies. Construct a genogram using a three-generation approach. Formulate outcome criteria that a nurse counsellor and family might develop together. Identify strategies for family intervention in specific psychiatric clinical situations. Distinguish between the nursing intervention strategies of a basic-level nurse and those of an advanced-practice nurse with regard to counselling and psychotherapy and psychobiological issues. Explain the importance of the nurse’s role in psychoeducational family therapy. Chapter Outline Teaching Strategies Family Families are self-defined—in other words, the family is made up of the people the patient identifies as family and can include neighbours and significant people in the community. The family can be the source of love or hate, pride or shame, security or insecurity. Family Functions The family serves to provide love and nurturance, socialization of children, and social control of members, production, and consumption of goods and services, addition of new family members through birth or adoption, and physical care and maintenance of family members. These functions take place within a societal context that also influences family members. Families and Mental Health and Illness A history of parental blame in mental health theory and practice has propelled families to advocate for health care services, acknowledgement of their knowledge, and research in mental health. Families play a significant and often underacknowledged role as caregivers. Family situations also play a role in the environmental stressors that may trigger crises and mental health problems. Family Therapy Family therapy is defined as a psychotherapeutic process that focuses on modifying and improving the interactions among the people who make up the family or marital unit. It focuses on evaluating these relationships and the communication patterns, structure, and rules that govern the family interactions. While novice nurses do not take a lead role in family therapy, they support the interventions and goals put forward in family therapy. It is important for nurses to be aware of the terms (to follow) associated with family therapy. Boundaries Boundaries maintain a distinction between individuals in the family. Ideally, there will be clear individual boundaries, clear generational boundaries, and clear family boundaries. Diffused or enmeshed boundaries refer to a blending together of the roles, thoughts, and feelings of the individuals so that clear distinctions fail to emerge. Families with diffused boundaries are more prone to psychological or psychosomatic symptoms. Rigid or disengaged boundaries are those in which the rules and roles are adhered to no matter what. This prevents trying new roles or taking on different functions. Isolation may be marked. Communication Healthy communication uses clear, direct messages, asking for what one wants and openly expressing both positive and negative feelings. Family members get the attention they need without resorting to manipulation. Emotional Support Affection is uppermost, and anger and conflict do not dominate interactions. Healthy families give mutual positive regard, resolve conflicts, use resources for all family members, and promote growth in all family members. Socialization The healthy family develops in a healthy pattern, using mutual negotiation of roles by age and ability. Parents feel good about parenting, and spouses are happy with each other’s role behaviour. Family Life Cycle 1. A family is a system moving through time, with each stage having tasks. Family stress is often greatest at transition points from one stage to another. Symptoms are likely to appear when there is an interruption in the unfolding of the family life cycle (illness, death, divorce). Six main stages exist in the changing family life cycle: Launching the single young adult Joining families: the couple forms Becoming parents—families with young children Families with adolescents Launching children and moving on The family in later life Theory Family systems perspective is rooted in observing the patient in terms of social systems and has an interactive, interpersonal context rather than an intrapsychic focus. Jay Haley describes double-bind theory, a situation in which two conflicting messages are given simultaneously on two levels— verbal and nonverbal. The individual is placed in a position in which no acceptable response exists. Virginia Satir became interested in the patient’s position and relationships within family. She saw poor self-esteem and symptoms as expressions of family pain. The Milan group used paradox to challenge the family about present situations as a way of delivering therapy. Minuchin looked at organizational patterns and boundaries. Murray Bowen used the family systems model. Frameworks for family therapy include the strategic model, which assumes that changing any element in the family system brings change to the entire system, and the structural model, which emphasizes the boundaries between family subsystems and the establishment and maintenance of a clear hierarchy based on parental competence. Further, two basic forms of marital family therapy exist: (1) insight-oriented marital and family therapy and (2) behavioural marital and family therapy. Working With the Family Many concepts are used in working with families. The concepts of the identified patient, the family triangle, and the nuclear family emotional system are discussed. Other concepts are explained in Box 35-2. The Family as a System All families can be viewed as unique systems, each with its own structure, rules, and history of handling problems and crises. In marital and family therapy, the focus is not on the individual but on family patterns and interactions. The Identified Patient The identified patient is the individual regarded by others as having the problem. He or she is usually responding to problems within the family system. The presenting problem should be assessed by looking at circular causality (i.e., viewing it from many different perspectives). Family Triangles Interlocking triangles occur within families. When major tension is experienced between two people, the tension is relieved by bringing in a third person to help lower the tension. In triangles, there is a close side, a distant side, and a side where tension exists. Differentiation refers to the ability of the individual to establish a unique identity while still remaining emotionally connected to the family of origin: the lower the differentiation, the higher the tension and the greater the need for triangles. Triangles become active in the event of any change. A nurse’s task is to calm down the system and help the family explore alternative ways of dealing with change while avoiding being “triangled in.” The Nuclear Family Emotional System Nuclear family refers to parent(s) and children under the parents’ care. A nuclear family emotional system is the flow of emotional processes within the nuclear family; symptoms belong to the family rather than to the identified patient. Application of the Nursing Process Assessment Assessment is typically intermixed with treatment and has multiple foci, including the family system, the subsystems, and the individuals. Nichols suggests three areas of consideration: stage of the family life cycle, multigenerational issues, and sociocultural context. Sociocultural Context This context considers issues of gender, race, ethnicity, class, sexual orientation, and religion as each affects values, norms, traditions, roles, and rules. The nurse will seek to understand how the family’s beliefs affect the presenting problem and impact the family’s options. Intergenerational Issues Three to four previous generations influence a family. The patterns, histories and contexts over many years will continue to hold influence over new generations. The nurse will seek to understand how the messages and legacies relate to the presenting problem. Constructing a Genogram A genogram is one format for summarizing information and relationships across three or more generations. It incorporates the stage of the family life cycle, multigenerational issues, and sociocultural context. The genogram provides a graphic display of complex patterns and becomes a source of hypotheses that indicate how the presenting problem connects to the family over time. CFAM and CFIM, and McGill Model Focused interviews and family assessment devices can be of help to the nurse. These models can provide positive approaches that are of particular use within illness situations—including mental illness. Self-Awareness Owing to the potential for multiple transferences and triangulations, self-assessment is vital when working with families. Nurses must become aware of their own potential for forming triangles when anxious, becoming defensive when personal family anxieties are aroused, and experiencing role blurring when sensitive personal issues and conflicts are triggered. Nurses must understand how their own views were formed, consider their position in society and privilege associated with that position, and then begin to understand how other people may be in alternate positions. Diagnosis Box 36-3 identifies a number of nursing diagnoses that may be useful when working with families: Impaired parenting, Sexual dysfunction, Interrupted family processes, Caregiver role strain, Risk for caregiver role strain, Parental role conflict, Spiritual distress, Impaired adjustment, Ineffective denial, Compromised family coping, Ineffective family therapeutic regimen management, Deficient knowledge, Impaired verbal communication, and Defensive coping. In addition, the DSM-5 heading “Other Conditions That May Be a Focus of Clinical Attention” contains the following categories: Relational problems, Problems related to abuse or neglect, Bereavement, Identity problems, Religious or spiritual problems, Age-related decline, and Acculturation problems. Outcomes Identification Useful goals include reducing dysfunctional behaviour of individual family members; reducing intra-family relationship conflicts; mobilizing family resources and encouraging adaptive family problem solving; improving family communication skills; increasing awareness and sensitivity of other family members’ emotional needs; helping family members meet needs of their members; strengthening families’ ability to cope with major life stressors and traumatic events; and improving integration of family system into societal system. Other goals related to psychoeducational interventions, self-help groups, or professional counselling are learning to accept illness of a family member; learning to deal effectively with ill member’s symptoms; understanding what medications can and cannot do and when to seek medical advice; and assisting in locating community resources. Planning Careful analysis of a sound assessment helps identify the most appropriate interventions. Factors to be considered include immediate and long-term needs of the family, crisis at a family developmental stage, coping mechanisms being used, and identification of new skills family members need, such as conflict management, parenting, limit setting, or need for psychoeducational family interventions. Implementation • Outcome research has shown that family therapy is effective for the following situations: The child is the patient, and the disorder is one of conduct. The wife of the couple is depressive. A substance-abusing person enters treatment and then is maintained after treatment. An individual with schizophrenia is the patient, and family therapy is used to reduce relapse. Counselling and Communication Techniques 1. A nonblaming manner promotes open and flexible communication among all professionals and family members in the caregiving system. Imparting information should be clear and understandable to all family members and allow them to choose and decide what to do with the information. The perspective of each family member must be elicited and heard. Family Therapy The advanced-practice nurse with graduate or postgraduate training in family therapy may conduct private family therapy sessions. Family therapy is appropriate for most situations. Exceptions are (1) when there is an unsafe environment in which someone will be harmed by information, uncontrolled anxiety, or hostility; (2) when there is lack of willingness to be honest; and (3) when there is unwillingness to maintain confidentiality. Traditional Family Therapy Some therapists focus on here-and-now interactions, others on family history and what happened between sessions; still others are eclectic in choice of techniques. Families with a hospitalized member may benefit from multiple-family therapy for help gaining insight and support. Psychoeducational Family Therapy The goal, through sharing of mental health care information, is to help members understand their family member’s illness, prodromal symptoms, medication needed to reduce symptoms, and more. Painful issues and feelings can be shared and put in perspective. Self-Help Groups There are two types of self-help groups: one for people suffering from a personal problem or social deprivation (e.g., AA), the other for families with a member with a specific problem or condition (e.g., Al-Anon). Case Management Case management involves teaching, giving appropriate referrals, offering emotional support, and making ongoing assessments of family strengths and weaknesses. Pharmacological Interventions Nurses explain to the family the purpose for a prescribed medication, the desired effects, and the potential adverse reactions. Evaluation The nursing process is not concluded until members of the family are demonstrating changes in behaviours, communication, coping skills, and conflict resolution, and the family is more integrated into the societal system. Varcarolis’s Canadian Psychiatric Mental Health Nursing Chapter 37: Integrative Care Instructor’s Manual Thoughts About Teaching the Topic Instructors may be inclined to avoid this topic, since there is such a dearth of research-based evidence of effectiveness. However, since so many people are choosing to use or at least investigate complementary and alternative medicine, students should be made as knowledgeable as possible, since their patients will be using them as sources of information. In lieu of a separate lecture on the topic of integrative care, the information about herbal supplements might be included as a topic when psychopharmacology is taught, and the other modalities might be integrated when traditional treatments are discussed as part of lectures on the psychobiological disorders and nursing interventions. This topic could also be a focus of discussion in a Web site, providing a variety of links and critical thinking questions to students, or as part of a clinical postconference learning activity. If the instructor knows a nurse practitioner or clinician with TCAM expertise, such a guest could be invited for a postconference to share knowledge and experiences of integrative care and how it is used in mental health practice. Key Terms and Concepts acupuncture aromatherapy chiropractic medicine conventional health care healing touch holistic nurse homeopathy integrative health care natural health products (NHP) naturopathy reflexology Reiki therapeutic touch traditional, complementary, and alternative medicine (TCAM) Objectives Define the terms integrative, traditional, complementary, and alternative health care. Identify trends in integrative health care. Discuss how to help educate the public in the safe use of integrative modalities. Explore information resources available through literature and online sources. Explore five aspects of integrative care: whole medical systems, mind–body–spirit Instructor’s Manual 37-2 approaches, biologically based interventions, manipulative approaches, and energy therapies. Discuss the techniques used in major traditional, complementary, and alternative modalities and potential applications to psychiatric mental health nursing practice. Chapter Outline Teaching Strategies Integrative Health Care in Canada Overview of Complementary and Alternative Medicine Complementary and Alternative Medicine Defined Traditional, complementary, and alternative medicine (TCAM) is being sought by individuals to help manage or sometimes prevent the onset of chronic illness, increase longevity, improve cognitive function, or increase feelings of well-being. Caution is advised, since sources of information about TCAM, often friends or the Internet, may not be entirely reliable. The dominant health care system of biomedicine in Canada (allopathy) is research based, whereas TCAM is based on cultural or historical beliefs that do not necessarily have scientific underpinnings. Conventional medicine often focuses on treating a disease, whereas TCAM focuses on healing the whole person. Complementary and alternative medicine covers a broad range of healing philosophies that are not widely taught in medical schools, not generally used in hospitals, and usually not reimbursed by insurance companies. Such therapies used alone are called alternative therapies, whereas those used with conventional treatments are called complementary. Consumers of traditional health care practices are requesting information about complementary and alternative medical treatments from their health care practitioners. Some question TCAM, and others who are actually using medicinal herbs are seeking advice regarding their use. Practitioners must expand their understandings of TCAM. Internet sites developed by individual organizations may present biased information; therefore, practitioners are referred to the United States government’s National Institute of Health (NIH) site for unbiased information. Research Although research on the efficacy of TCAM is increasing, studies in the field are minimal when compared to conventional medicine. Patients and Integrative Care Reasons patients are attracted to TCAM include a desire to be an active participant in health care and engage in holistic practices; find lower-risk therapeutic approaches; and find less expensive health care than conventional health care. Additional reasons include dissatisfaction with the practice style of conventional medicine and positive experiences with TCAM practitioners. Safety and Efficacy A number of patients do not inform their health practitioners or other practitioners they are seeing about TCAM products they are using— this can complicate treatment with drug interactions and possible delays in diagnosis. Also important to note is that patients have been injured by a uncaring conventional medical system or suffered consequences from the use of conventional pharmaceuticals—for many, despite unknown efficacy or safety, the TCAM alternative is their preferred option. Trial and error is common. Cost The growth in the use of TCAM therapies is linked to the rising cost of conventional health care, the long wait-lists in many communities to access mental health programs, and slow or poor responses to conventional treatments. Though many TCAM therapies are less expensive, before we can adopt them, health care workers must support the pursuit of safe, reliable, and effective alternatives. Reimbursement Payment for TCAM services comes from a wide array of sources, although third-party coverage is still the exception rather than the rule. Placebo Effect Research continues to both refute and support this claim. Integrative Nursing Care The Canadian Holistic Nurses Association (CHNA) recognizes holistic nursing as a specialty, with a philosophy of holistic nursing including the following three characteristics: self-care, humanizing health care, and promoting wellness. Classification of Integrative Medicine There are five major domains of TCAM therapies: (1) whole medical systems, (2) mind–body–spirit approaches, (3) biologically based practices, (4) manipulative approaches, and (5) energy therapies. Whole Medical Systems What we consider alternative medical systems are often traditional systems of medicine in other cultures (e.g., traditional Chinese medicine, which emphasizes the proper balance or disturbances of qi, or vital energy). Therapeutic techniques include acupuncture, herbal medicine, and massage. Other examples of alternative medical systems are homeopathy, which uses small doses of specially prepared plant extracts and minerals to stimulate the body’s defences, and naturopathy, which emphasizes health restoration rather than disease treatment. Naturopathy uses diet, homeopathy, acupuncture, herbal medicine, hydrotherapy, spinal and soft tissue manipulation, physical therapies, and counselling. Traditional Aboriginal Medicine While traditional Aboriginal teachings vary, depending on the affiliation of Aboriginal peoples, the overall medicine wheel concepts and traditional knowledge of healing is increasingly applied in a number of settings. Traditional Aboriginal elders and healers incorporate a variety of spiritual and healing practices such as ceremonies (e.g., sweat lodges), vibrational medicine (e.g., chanting and drumming), and use of traditional medicines (e.g., native herbs) to restore balance and harmony. Ayurvedic Medicine Ayurveda means “the science of life” and is a philosophy that emphasizes individual responsibility for health. It is holistic, promotes prevention, recognizes the individual as unique, and offers natural treatments. Traditional Chinese Medicine Traditional Chinese medicine includes acupuncture, acupressure, herbs, transcendental meditation, tai chi, and qigong. Acupuncture Acupuncture consists of placement of needles into the skin at certain points to modulate the flow of energy (qi) through pathways called meridians. Acupressure consists of the use of pressure instead of needles. There is interest in acupuncture to treat alcoholism and other substance abuse. Research is currently being conducted into the effectiveness of acupuncture in emotional disorders. Homeopathy and Naturopathy Homeopathy is based on the Law of Similars (“like cures like”). Small doses of diluted preparations that mimic an illness are used to heal. Treatments are individualized according to the patient’s symptoms, so generalization is impossible. Naturopathy emphasizes health restoration and combines nutrition, homeopathy, herbal medicine, hydrotherapy, light therapy, counselling, and other therapies. Mind–Body Approaches Mind–body approaches include meditation, spiritual healing, and some therapies classified as alternative and complementary, such as hypnosis, dance, and music and art therapy, as well as prayer. Guided Imagery “Imagery is not only visual pictures but also remembrance of situations and experiences such as sound, smell, touch, movement and taste” (Zahourek, 2002, p. 113). Biofeedback Biofeedback is the use of external equipment or a method of feedback that informs a person about his or her psychophysiological processes and state of arousal (Anselmo, 2009). Hypnosis and Therapeutic Suggestion Hypnosis is a natural focusing of attention that varies from mild to greater susceptibility to suggestion. Meditation Meditation practices include consciously breathing and focusing attention. Transcendental meditation and mindfulness meditation are two approaches. Rhythmic Breathing Rhythmic breathing focuses on purposeful breathing to enhance the relaxation response. Spirituality Historically, spiritual care was very much a part of the psychiatric care that patients received. Today, there is an increasing interest in the importance of spiritual interventions for some psychiatric patients. The challenge in meeting these spiritual needs of the patient occurs with respecting boundary issues. There is abundant research demonstrating the positive relationship between religion and measures of well-being. Therefore, asking patients about issues such as prayer, sources of hope and strength, and the patient’s preferred spiritual practices allows us to know how we can provide spiritual support for the patient. Biologically Based Therapies Biologically based therapies may overlap with conventional medicine’s use of dietary supplements such as vitamins and minerals. Diet and Nutrition Many dietary supplements are sold without premarketing safety evaluations. Nutritional therapies used for addictions have typically not been subjected to the rigors of scientific research. If standardized through research trials, they may eventually have a significant impact on the treatment of addiction. Individuals who experienced major depression were found to be twice as likely to be taking nonprescription dietary supplements as were individuals without depression, suggesting that such individuals may seek self-medication for depression rather than seek traditional treatment. Of additional concern to health care providers is the fact that many nutritional supplements may have problematic interactions with prescription medications. Patients should be encouraged to discuss intake of supplements with health care practitioners. Herbal Therapy There is a need for standardization and regulation of herbal products, for these psychoactive substances are neither benign nor without potential for drug–drug interactions. St. John’s wort is used for depression and ginkgo biloba for dementia. Serotonin syndrome has been noted in the elderly who combine use of St. John’s wort and other antidepressants. Warnings have been published about interactions with drugs used to treat HIV infections and with immunosuppressant drugs. Side effects of St. John’s wort include dry mouth, dizziness, fatigue, constipation, nausea, and photosensitivity. Ginkgo biloba has been used for cerebral insufficiency. One research study suggests that individuals with mild to severe dementia may see improvement with 4 to 6 weeks of therapy. Of concern is the fact that ginkgo interacts with anticoagulants and antiplatelet agents to cause spontaneous bleeding. Ginkgo must also be used with caution by those who consume alcohol or who have other risk factors for hemorrhagic stroke. Other herbs: Black cohosh is said to have a calming effect but is toxic in high doses and should be avoided by individuals with hypertension or heart disease. Kava kava is used for analgesic antianxiety effect, but it may potentiate the action of other tranquilizing agents, especially benzodiazepines and alcohol. Valerian is used as a treatment for insomnia. It may potentiate the effects of other CNS depressants and may cause headache and upset stomach. Herbal teas are said to have a sedative–hypnotic effect. The most studied is chamomile, which has been found to bind with GABA receptors. Aromatherapy Aromatherapy employs the use of essential oils for inhalation or skin application to reduce stress, regulate emotions, relieve anxiety, and reduce insomnia by stimulating the olfactory nerve to send messages to the limbic area. Manipulative Practices This group of treatments is based on physically touching another person and employing manipulation or movement of the body. Chiropractic Medicine Chiropractic is the most widely used complementary or alternative therapy. It is practised for relief of musculoskeletal pain and involves manipulation of the spinal column, called adjustment. Massage Therapy Massage therapy includes a broad group of medically valid therapies that involve rubbing or moving the skin (effleurage), kneading the muscles (petrissage), vibration and percussion, and friction. Reflexology Reflexology is another type of massage that focuses on the feet, hands, or ears. Energy Therapies Energy therapies focus on energy fields. They are based on the belief that nonphysical bioenergy forces pervade the universe and people. Therapeutic Touch In therapeutic touch, healing is promoted when the body’s energies are in balance; therapists pass their hands over the person, and the healer can feel the body’s imbalances. Practitioners centre themselves before they begin a treatment session so that they can focus on helping the client without any preoccupation. After a session, many individuals express a sense of deep relaxation. Healing Touch This involves gentle “laying on of hands” on a clothed body or moving over the body in the energy field. Reiki In Reiki, the belief is that the practitioner’s energy is connected to a universal source and is transferred to a recipient for physical or spiritual healing. Thought Field Therapy and Emotional Freedom Technique This type of therapy is based on the idea that negative emotions are the result of energy imbalances and blocks in the body. The goal is to release these blocks and view the problem with less distress by tapping specific acupuncture points and meridians and repeating a positive mantra. BioelectromagneticBased Therapies Transcranial magnetic stimulation and vagus nerve stimulation treatments for depression are in this category. Instructor Manual for Varcaroliss Canadian Psychiatric Mental Health Nursing Margaret J. Halter, Cheryl L. Pollard, Susan L. Ray, Mary Haase, Sonya Jakubec, Elizabeth M. Varcarolis 9781926648330, 9781771721400

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