NU673 Psychiatric Mental Healthcare

You have created 4 entries for your previous Reflective Journal about a patient encounter this semester. Each reflective journal is shown below.

Create a 5th journal. For this 5th entry, you will review the previous 4 entries below and evaluate your progress in reflective practice over the course of the term.

The purpose of this reflective journal is self-reflection regarding the role in the process of self-reflection as a PMHNP provider. Through reflective practice, the student will evaluate their own emotional health and recognize one’s own feelings as well as one’s ability to monitor and manage those feelings. The point of the exercise is to learn yourself, your triggers, the types of cases you end up getting overly involved with, and those you’d rather refer to someone else. The idea is to be able to personally reflect on your behaviors/thoughts/decisions and how those impact you in the role of PMHNP.

The ability to analyze one’s self and be aware of how one’s emotions and responses affect others is a crucial component to developing a therapeutic relationship with patients. During this clinical/course and particularly through this exercise it is expected that the student develops recognition of their own feelings, prejudices, biases, triggers, anxieties, limitations, and of course strengths while developing the ability to appropriately manage these issues as they arise and how to best align your strengths to overcome your limitations. In this final journal entry, review your previous journal entries and reflect upon your success in achieving this as well as the goals you stated in your first journal.

Questions to address in your final reflective essay include:

1. What goals did you set for yourself at the beginning of the semester?

2. Did you meet these?

3. What feelings, prejudices, and biases did you experience during your clinical experience and how did you manage them?

4. How did you manage your anxiety, self-doubt, and/or uncertainty?

5. What understanding or insights did you develop during your clinical experience?

6. Has reflective practice impacted you as a person, student, and/or provider?

7. If so, how?

8. Will you continue to use reflection in your future practice?

9. If so why and how?

Resource to use

Course Description

This course prepares students to assess, diagnose, and manage mental health care needs across the lifespan. Emphasis will be placed on underlying acute and chronic psychiatric/mental health diagnoses. Clinical opportunities will be utilized for all PMHNP to apply concepts in primary and acute care settings with adults and families.

Program: Graduate Nursing

Resources

Carlat, D. J. (2023). The psychiatric interview (4th ed.). Philadelphia, PA: Wolters Kluwer. ISBN: 9781975212971

American Nurses Association & American Psychiatric Nurse Association. (2015). Psychiatric–mental health nursing: Scope and standards of practice (2nd ed.). Silver Spring, MD: American Nurses Credentialing. ISBN-13: 978-1558105553 ISBN-10: 1558105557

American Psychiatric Association. (2022). Diagnostic and Statistical Manual of Mental Disorders, Text Revision Dsm-5-tr (5th ed.) (DSM-5). Washington DC: APA Press. ISBN: 978-0890425763

Johnson, K., & Vanderhoef, D. (2016). Psychiatric mental health nurse practitioner review manual (4th ed.). Silver Spring, MD: American Nurses Association. ISBN: 978-1-935213-79-6

Robert Joseph Boland, Verduin, M. L., Ruiz, P., Arya Shah, & Sadock, B. J. (2021). Kaplan and Sadock’s synopsis of psychiatry: Behavioral sciences/clinical psychiatry (12th ed.). Philadelphia, PA: Lippincott Williams, and Wilkins. 9781975145569

Recommended

Bickley, L. (2016). Bates’ Guide to Physical Examination and History-Taking [VitalSouce bookshelf version]. https://batesvisualguide.com/. Eleventh, North American Edition; Lippincott Williams & Wilkins: ISBN 1609137620

Corey, G. (2016). Theory and practice of counseling and psychotherapy (10th ed.). Boston, MA:Cengage. ISBN: 9781305263727

Heldt, J. P., MD. (2017). Memorable psychopharmacology. Create Space Independent Publishing Platform. ISBN-13: 978-1-535-28034-1

Shea, S. C. (2017). Psychiatric interviewing: The art of understanding (3rd ed.) Elsevier.

Stahl, S. M. (2013). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (4th ed.). Cambridge University Press. ISBN 978-1-107-68646-5

Stahl, S. M. (2020). Prescriber’s guide: Stahl’s essential psychopharmacology (7th ed.). Cambridge University Press. ISBN 978-1108926010

Journal 1

Describe your past experience in mental health or with someone with mental health.

My experience was in a clinic with a patient who had substance use and depressive mood disorder. The patient had been brought to the clinic after she had tried to commit suicide. The patient could not eat or sleep well at home, isolated herself from others, and had selective mutism, and with the few words she spoke, she could express suicidal ideation (Park, S. C., & Kim, D. 2020). The psychiatrist and Nurse Practitioner started a treatment plan that included antidepressants. The patient was encouraged to attend three group therapy per day. A therapist would hold therapy sessions on alternate days. I encouraged her to express her emotions by providing her the opportunity to express her frustrations, educated her family on how to assess for suicidal tendencies and employ safety measures at home, and promote sleep and food intake by encouraging her to eat and avoid sleeping during the day to promote rest at night. The patient improved as days passed; she was happier, could interact with everyone, express her feelings, and had positive thoughts about herself and the world. The sleeping patterns improved, and food intake increased.

What are the reasons you have chosen to work with this population?

I have a lot of empathy for people suffering from depression and substance addiction. Family neglects them, and some end up in the street, and some even die. I want to reduce the stigma associated with mental illness (Peter, L. J et al., 2021). By helping people understand that it is a disease like any other; they need care and acceptance to have a better life. It is fulfilling when a patient with depressive disorder and mental illness gets better and goes back to everyday life (Avena, N. M et al., 2021). Create awareness about mental health to increase acceptance of such patients.

Discuss any concerns you have regarding this specific clinical course and population.

A concern of this clinical course is that a lot of emphasis and resources should be put on mental conditions in schools because one in every eight people in the world has a mental condition (Melamed, O. C et al., 2020). Students should be well equipped before graduation to be able to detect and handle mental illness. Another concern is stigma and discrimination against the mentally sick, and awareness should be created about mental illness and there is the lack of resources in the community to handle this population.

Identify personal academic/professional goals for the clinical course and population.

My goal is to work with underserved populations suffering from mental illness to increase access to these population groups; I would also like to reduce the negative stigma associated with mental illness.

Acquire more knowledge and skills on substance use disorder and mental health illness to be able to recognize and handle mental and substance use disorders comfortably.

References

Avena, N. M., Simkus, J., Lewandowski, A., Gold, M. S., & Potenza, M. N. (2021). Substance use disorders and behavioral addictions during the COVID-19 pandemic and COVID-19-related restrictions. Frontiers in Psychiatry, 12, 653674.

Melamed, O. C., Hauck, T. S., Buckley, L., Selby, P., & Mulsant, B. H. (2020). Article commentary: Covid-19 and persons with substance use disorders: Inequities and mitigation strategies. Substance abuse, 41(3), 286-291.

Park, S. C., & Kim, D. (2020). The centrality of depression and anxiety symptoms in major depressive disorder determined using a network analysis. Journal of affective disorders, 271, 19-26.

Peter, L. J., Schindler, S., Sander, C., Schmidt, S., Muehlan, H., McLaren, T., … & Schomerus, G. (2021). Continuum beliefs and mental illness stigma: a systematic review and meta-analysis of correlation and intervention studies. Psychological Medicine, 51(5), 716-726.

Journal 2

transference, countertransference, prejudice/biases, & judgments

Transference is a situation where a client in therapy projects feelings that were meant for someone else in a past relationship, such as feelings towards a parent, onto their therapist, and it usually happens unconsciously. Countertransference is a phenomenon where the therapist unconsciously redirects their own emotions onto a client from unresolved past emotions. Prejudice or biases are opinions and generalized beliefs about someone that are not true and are not from experience. They can be positive or negative, conscious or unconscious, and affect decisions and perceptions. Judgment is the ability to objectively assess, manage, and evaluate a client’s situation and treatment plans without personal influences or prejudice, thus making a sound judgment (de León de Bernardi, B. 2023).

A patient interaction that had transference, countertransference, prejudice/biases, or judgment occurred when I encountered a patient who was suffering from depression from abandonment by his parents at a young age. He expressed feelings of loneliness, being unwanted and unworthy in life, stating that he fears engaging in relationships as he feels he will still be unwanted. I had empathy for him, was compassionate towards him, and was so protective of his feelings that he became very attached and developed strong affection towards me, seeing me as a supportive figure indicating transference. I developed countertransference in this situation by being overly protective and compassionate because as the patient expressed his feelings, my unresolved conflicts with my mother were triggered. Prejudice occurred in that I took my patient’s side, became sympathetic, and validated their feelings, forming an opinion that the parents abandoned him, without understanding the complexity of their relationship. I became judgmental towards my patient’s parents, labeling them unloving, uncaring, and neglectful, being biased toward my client’s feelings.

I have experienced prejudice/biases, judgments, and countertransference in my prior patient encounters. These occurrences are frequent in clinical practice and can take on different shapes that affect treatment outcomes and the therapeutic relationship. I have experienced transference and countertransference, especially with those with comparable experiences or histories. It has also happened when patients’ resistance or lack of development incited skepticism or dissatisfaction in me. One continuous component of my self-reflective practice as a psychiatric mental health nurse practitioner provider has been recognizing these dynamics (Mann, D. 2021). Reflecting on these encounters, I see how crucial it is to acknowledge and deal with transference and countertransference dynamics to preserve therapeutic rapport and prevent detrimental effects on patient care.

The situation arises from the patient or therapist projecting their own emotions from the past onto other people. Various factors, such as individual experiences, cultural background, societal influences, and professional training, combine to produce these phenomena. In contexts involving patient care, discrimination, transference, countertransference, and judgments can all be influenced by our unresolved issues, biases, and stereotypes. Furthermore, how patients and clinicians view each other may be influenced by society’s ideas around stigmatization and mental health. These dynamics are rooted in the intricate interactions between responsibilities in the workplace, emotional weaknesses, and personal experiences (Velarde, C et al., 2024). Unresolved issues or past traumas may influence my perception and response to patients and patients may feel transference when similar memories are evoked in a therapy situation.

It would be inappropriate for me to continue caring for that patient as I may not provide objective judgment in that particular case and the patient will not get adequate treatment. I will prevent these issues from affecting patient care by becoming better at controlling my emotional responses and keeping a more detached perspective when providing patient care through self-reflection and supervision and attending ongoing education to address any prejudices or stereotypes that might affect my practice—practicing mindfulness techniques to improve self-awareness, and getting supervision or consultation to examine my emotional reactions enabling me to get important insights and support in handling complex therapeutic issues. To minimize the impact of transference and countertransference and to preserve professionalism, I will always set clear boundaries within the therapeutic alliance. This entails abstaining from behaving based on preconceived notions or biases, keeping the proper emotional and physical distance, and abiding by ethical standards. Collaborating with the patient in developing treatment goals and interventions fosters empowerment and mutual respect in the therapeutic relationship. By actively involving the patient in decision-making processes, we can address any concerns or misunderstandings that may arise due to transference or countertransference. I will keep developing my self-awareness and improving my ability to handle the challenges of the therapeutic alliance going forward. From my previous entries, I see the importance of maintaining constant self-awareness and watchfulness when controlling prejudice, biases, transference, and judgments in patient care (Jenks, D. B., & Oka, M. 2021). Even though it can be challenging to eliminate these problems, it is essential to recognize that they exist and take proactive steps to lessen their influence on the therapeutic relationship.

References

de León de Bernardi, B. (2023). Field theory: The transference-countertransference relationship and second look. The International Journal of Psychoanalysis, 104(4), 737-754.

Jenks, D. B., & Oka, M. (2021). Breaking hearts: Ethically handling transference and countertransference in therapy. The American Journal of Family Therapy, 49(5), 443-460.

Mann, D. (2021). Psychotherapy: An erotic relationship: Transference and countertransference passions. Routledge.

Velarde, C., Johnson, M. C., Hayes, J. A., & Villarán, V. (2024). Identifying the origins of countertransference using the Core Conflictual Relationship Theme method: A multiple case study approach. Psychotherapy Research, 34(3), 366-378.

Journal 3

Schizophrenia

Schizophrenia is one of the most exciting cases in mental health. Schizophrenia is a mental disorder that affects the ability to behave and think clearly. There are numerous symptoms of schizophrenia which include; isolation, hostility, delusion, hallucination, anxiety, elevated moods, paranoia, fatigue, anosognosia and incoherent speech. The most critical and yet interesting symptom of schizophrenia I have met in the field while interacting with a mental health patient is Anosognosia, especially among patients who are on the early stages of schizophrenia. This week in the clinical setting, I met a forty-three-year-old male patient who had been diagnosed with schizophrenia. The patient kept on denying having a mental problem even though the relatives reported unusual behaviors at home. After interacting with the patient, I realized that he was unaware of his illness and believed that his delusions and hallucinations were real. The relatives reported that he has been struggling with coping with the severe consequences of a lack of social skills, initiative, and motivation, and his ability to live independently. After closely interacting with the patient, I realized that he has difficulty with his manic behavior and elevated moods. The relatives also reported that the patient has a problem engaging in promiscuous sex and spending money he does not have, even though he claims to be aware of and comfortable with what he does in his life. After doing more research on Anosognosia, more than fifty percent of patients with schizophrenia are suffering from Anosognosia (Bickley, L. (2016). The damage to the frontal lobe and right side of the brain brings Anosognosia. Anosognosia is different from denial in that, in Anosognosia, the patient is unaware of his condition, while denial is psychological, where the patient does not want to face the seriousness of his condition because it is painful.

The treatment of schizophrenia involves cognitive therapy, rehabilitative therapy, family therapy and psychotherapy. The differential diagnosis of schizophrenia includes; autism, dementia and communication disorders. Medications used for schizophrenia are classified as Typical and Atypical. Typical/Standard antipsychotics: chlorpromazine (Thorazine), haloperidol (Haldol), fluphenazine Atypical antipsychotics: clozapine (Clozaril), risperidone (Risperidal), olanzapine (Zyprexa), quetiapine (Seroquel), ziprasidone (Geodon), aripiprazole (Abilify), paliperidone.

The encounter with the above patient aided in improving my knowledge of the role of a psychiatric mental health nurse practitioner on Anosognosia in schizophrenic patients. Understanding the signs and symptoms and the causes of Anosognosia in mental health patients will help me make diagnoses easily in such patients. For example, the knowledge that the damage to the frontal lobe of the brain, which controls one’s self-image and mental health, will enable me to make an easy diagnosis. The frontal lobe of the brain is damaged by medical conditions such as schizophrenia, bipolar disorders, and dementia. Other causes include traumatic injury to the brain and stroke. The signs and symptoms of these conditions include stubbornness, anger, frustration, and lack of knowledge of their mental health condition. To make a diagnosis of Anosognosia, assessing the level of awareness is the gold standard. Encountering the above patient enabled me to understand how to treat Anosognosia. Treatment of Anosognosia involves stimulating the vestibular system, which creates a sense of balance in the brain. An electrode must be placed on the skull behind the ears to stimulate the vestibular system. This stimulation helps improve self-awareness in the affected areas of the brain (Hallam et al.,2020).

Understanding Anosognosia in schizophrenia also helped me learn how to interact with patients. As a psychiatric mental health nurse practitioner, maintaining a positive attitude is crucial when helping a patient with Anosognosia. When interacting with them, I am supposed to show empathy, listen to them as they express their concerns, and provide a well-structured environment. This will help minimize homelessness, arrest, suicide, and violence among these patients.

Personal strengths may positively affect my relationship with patients. My first strength is open-mindedness. Being open-minded enables me to deal with patients with different medical and mental Conditions, patients from different social classes, patients from other ethnic groups, and different places. My patients tend to express themselves without fear of being judged or fear of being criticized. How I frame my questions and direct them to my patients will show that, as a PMHNP, I am invested in their needs, well-being, and feelings. Being compassionate is another strength that positively affects my service delivery as a psychiatric mental health nurse practitioner. Being empathetic helps my patients feel respected during their medical care. I receive comments from my patients on how quickly I address their concerns. A sense of curiosity is another strength I have when dealing with patients. My professional curiosity helps me determine my nursing goals, estimate treatment concerns, and answer frequently asked questions.

After reflecting on this event of anosognosia in schizophrenic patients and interacting with the patient and the family members, I learned that the condition is common and more than fifty percent of patients with schizophrenia and bipolar disorders are suffering from Anosognosia (Kletenik et al.,2023). After doing more research on this topic, I learned that Anosognosia is not only found in these conditions but can also affect people who have dementia and those who are recovering from traumatic brain injury. This case has helped me improve my knowledge, and I will implement my findings in my future practice.

References

Bickley, L. (2016). Bates’ Guide to Physical Examination and History-Taking [VitalSouce bookshelf version]. https://batesvisualguide.com/. Eleventh, North American Edition; Lippincott Williams & Wilkins

Hallam, B., Chan, J., Costafreda, S. G., Bhome, R., & Huntley, J. (2020). What are the neural correlates of meta-cognition and Anosognosia in Alzheimer’s disease? A systematic review. Neurobiology of aging, 94, 250-264.

Kletenik, I., Gaudet, K., Prasad, S., Cohen, A. L., & Fox, M. D. (2023). Network localization of awareness in visual and motor Anosognosia. Annals of Neurology, 94(3), 434-441.

Journal 4

generalized anxiety disorder.

For this encounter I met a female patient, thirty-two years old, who has been diagnosed with generalized anxiety disorder. Her presenting complaints included; generalized body fatigue, restlessness, poor concentration, excessive worries, and muscle tension. My role in this patient as her nurse was first to emphasize and establish rapport and gain trust from the patient. My role involves listening actively to the patient’s history, considering the patient’s experience, and collaborating with relatives, elatives, and other medical practitioners on her treatment plan.

Psychiatric Screening Measures for this patient included GAD-7 (Generalized Anxiety Disorder-7): Score 18 (indicating severe anxiety). PHQ-9 (Patient Health Questionnaire-9): Score 10 (indicating moderate depression) and DASS-21 (Depression Anxiety Stress Scales): Anxiety subscale score 12 (severe), Stress subscale score 14 (severe), Depression subscale score 8 (mild). Differential Diagnoses include Major Depressive Disorder, Panic Disorder, Social Anxiety Disorder and Adjustment Disorder with Anxiety.

My preceptor assisted me in gaining insights on this patient’s encounter and to gain a deeper understanding of generalized anxiety disorder signs and symptoms and how the patients present. The persuasive nature of generalized anxiety disorder was based on persistent worries. This led me to conduct a thorough examination and assessment to identify any negative impact of generalized anxiety disorder on her life. To strengthen my provider-patient relationship, I created a safe environment for my patient to express her symptoms without fear of judgment. Interacting with this patient led to my personal realization of my strengths as I empathized deeply with her, which helped me gain her trust. However, as a nurse, I realized I tend to be overly involved emotionally, which limits my professional practice. From this patient, I learned the importance of creating a therapeutic alliance from the first time I met a patient. I will prioritize this in my future practice.

References

Garakani, A., Murrough, J. W., Freire, R. C., Thom, R. P., Larkin, K., Buono, F. D., & Iosifescu, D. V. (2020). Pharmacotherapy of anxiety disorders: current and emerging treatment options. Frontiers in psychiatry, p. 11, 595584.

Sapra, A., Bhandari, P., Sharma, S., Chanpura, T., & Lopp, L. (2020). Using generalized anxiety disorder-2 (GAD-2) and GAD-7 in a primary care setting. Cureus, 12(5).

Taylor, S. (2020). Anxiety disorders, climate change, and the challenges ahead: Introduction to the special issue. Journal of anxiety disorders, p. 76, 102313.

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