John, a 26-year-old man, presented at the local A & E department and has now been referred to the mental health liaison team after drinking a large amount of alcohol and taking 100 paracetamol tablets. He woke up the next morning surprised that he was alive but also concerned about his actions. On this basis he asked his next-door neighbour to take him to hospital.
Over the last year John has been experiencing symptoms of anxiety; John describes himself as a constant worrier but recently he has felt "more panicky", to the point that he finds it more and more difficult to engage in everyday activities such as talking to other people. The impact of these distressing symptoms is that John has now been off sick from work for the last three months.
John indicates that he now has significant difficulty in controlling his "worrying", he constantly feels restless and irritable, is physically tense, has difficulty concentrating on everyday tasks, and has difficulty sleeping. John also mentions that to help him sleep he has been drinking four to five cans of strong lager every night.
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(a) How would the mental health nurse build a therapeutic relationship with John?
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Correct answer: The nurse would use a range of communication strategies in the process of building a therapeutic relationship with John. These strategies would include:
- selecting the right words to use;
- knowing when to talk and when to be silent;
- using the right verbal and non-verbal responses;
- adapting non-verbal communication to suit the situation.
To use these strategies the nurse needs to be aware of the impact their self has upon others, they need to be aware of their own thoughts and feelings, and they also need to be able to use this knowledge in a positive way when working with John. It is essential within the therapeutic relationship that the nurse is empathetic through being:
- an active listener;
- genuinely interested;
- accepting the person;
- caring and compassionate.
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(b) How should the nurse mange the risk element when building a therapeutic relationship with John?
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Correct answer: It is quite common for a therapeutic relationship within the mental health field to have a "risk element". Where risk is present the intention of being collaborative and person-centred has to be balanced against minimising and containing this risk. That said, the nurse should look to build a therapeutic relationship with John that is based on true partnership working and values both John and his experiences. To balance these considerations the nurse should take a values-based approach that moves the therapeutic relationship forwards by:
- considering John's perspective;
- balancing the "rules" against this perspective;
- preserving the person-centred element of this perspective;
- fully representing this perspective in the decision-making process.
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(c) How would the nurse formally describe John's drinking?
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Correct answer: Alcohol use is usually described in terms of safe limits: 21 units of alcohol per week for men and 14 units for women (a unit of alcohol is approximately a small glass of wine or half a pint of beer). In John's case his alcohol use can be described as harmful drinking, which in men is consuming over 50 units weekly.
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(d) What negative impact could John's alcohol intake have upon his health?
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Correct answer: Generally John's alcohol misuse could lead to:
- disturbances of consciousness and perception;
- damage to John's health and social functioning;
- neglect;
- physical and psychological withdrawal;
- hallucinations and delusions;
- memory and cognitive impairments.
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(e) What other symptoms of anxiety might John be experiencing?
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Correct answer: John could experience other symptoms of anxiety such as:
- increased vigilance;
- hyperactivity;
- palpitations;
- abdominal discomfort and nausea;
- hot flushes;
- outbursts of anger;
- ruminating thoughts and compulsions.
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(f) What types of psychological interventions would the nurse consider delivering, bearing in mind John's alcohol consumption?
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Correct answer: After the detoxification phase (if required) the nurse could deliver the following psychological interventions:
- build a collaborative and therapeutic relationship;
- motivational and brief intervention work;
- guided self-help ;
- breathing and relaxation exercises;
- identifying, challenging and replacing negative thoughts;
- harm reduction;
- coping strategy work;
- health promotion;
- contingency approaches – using incentives to change behaviour.
Consider Chapters 2, 3, 18 and 25.
John is progressing well; he feels that he has recovered and has now returned to work; subsequently John has been discharged from the community mental health nurse's case load.
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(a) What potential conflict could there possibly be between John's and the nurse's understanding of recovery, and what would be the best way forward?
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Correct answer: Utilising a recovery-based approach presents a significant challenge for mental health nurses especially where there are professional and policy drivers that require mental health nurses to utilise such an approach but there is no single agreed definition of recovery. On this basis recovery should be seen as being relative to the individual and their circumstances meaning that the recovery process for that individual is being constantly redefined by their ever-changing needs. The challenge for the mental health nurse in these circumstances is that they need to be both receptive and responsive to John's ever-evolving needs in a way that their practice is positively redefined by these experiences. Even though recovery as a process is relative in nature it can be seen to have aims, which include:
- promoting wellbeing;
- maximising opportunity;
- empowering individuals to take control;
- facilitating and supporting the individual in finding meaning and purpose.
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(b) John returning to work can be viewed as a factor that positively influences the recovery process. What other factors are there?
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Correct answer:
- positive and sustainable relationships;
- meaningful activity;
- autonomy;
- resilience;
- personal growth;
- a healthy living environment;
- a supportive social network.
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(c) How should the nurse use their experiences of working with John in their journey towards being a clinical expert?
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Correct answer: Key to being an expert is the use of reflection; this process enables the nurse to develop their self-awareness to a level where they are able to clearly identify their strengths and also the areas that they need to develop further. It is important to recognise that knowledge accrued through the reflective process is useful knowledge especially as it is experience-based knowledge. Like scientific knowledge this form of knowledge should not be used in isolation; rather it should be used to complement scientific knowledge in a way that anchors both forms of knowledge to the nurse's ongoing practice experiences.
Consider Chapters 27 and 38.
