Nursing Archive

Mental health and mental illness

I write this editorial as a follow-up to the most recent editorial in Archives (“Promises, Promises”) by our Editor, Judith Krauss (2004). Judy’s previous editorial focused on “recovery” as it is outlined in The New Freedom Commission on Mental Health and the role that relationships play in the generation of hope in the pathway to healing and recovery. My emphasis in the present editorial is on “advocacy” and the need for us, as mental health providers, to ensure that the “transformation of the mental health system”—as recommended by the Commission—be heard this time. Judy requested that all of our readers go to the web site to download the full report and read it if you have not already done so. I second this request.

During his 2000 presidential campaign, George W. Bush pledged that if he were elected, he would create a commission to conduct a comprehensive review of the care of people with mental illness. Such an examination would be the first to be undertaken in almost 25 years—which was during the Carter Administration. In April of 2002, in fulfillment of this pledge, Bush announced the creation of the President’s New Commission on Mental Health. The goal of the Commission was to “recommend improvements to enable adults with serious mental illness and children with serious emotional disturbances to live, work, learn, and participate fully in their communities.” (Executive Order, 2002). Dr. Michael Hogan, Ohio’s mental health director, chaired the Commission and issued the final report. Important here is that, in the final report, the Commission did not explicitly recommend the investment of any new moneys to finance the transformation for which it called.

The Commission put forth 19 recommendations linked to six goals as already outlined by Krauss (2004). In his report Dr. Hogan (2003) emphasized that the United States should fundamentally transform its system for treating people with mental illness. The report described the present mental health system as being fragmented and currently insufficient for delivery of mental health services. Such information is not news to those of us who are mental health providers; however it is more than significant that this information was requested and supported by the President of the United States.

The six goals of the Commission describe an ideal mental health system that is a far cry from the current system as we know it. However, Washington, D.C. is driven by priorities that are deemed more pressing than the Hogan report. It is not surprising, therefore, that the report has generated only limited interest outside the field of mental health care. And we must remember what happened with the last Commission on Mental Health created by President Jimmy Carter in 1977 (1978). The Carter Commission on Mental Health had proposed an ambitious agenda for reform, but before its major recommendations could be implemented, they fell victim to the dramatically different attitude toward the role of government in the provision of human services that Ronald Reagan brought to the White House in 1981. The Mental Health Systems Act of 1978, the centerpiece of the recommendations of the Carter Commission, was repealed by the Omnibus Budget Reconciliation Act of 1981, which contained the first round of budget reductions proposed by the Reagan administration and enacted by Congress (Iglehart, 2004).

The good news is that the mental health community mobilized quickly after the release of Dr. Hogan’s report. Putting aside parochial interests that have often divided advocates for people with mental illness, four organizations—The Bazelon Center for Mental Health Law, the National Alliance for the Mentally III, the National Association of State Mental Health Program Directors, and the National Mental Health Association—came together to create the Campaign for Mental Health Reform. Nine other organizations quickly joined the campaign.

Bottom line is that it is now up to us, the mental health providers. The specific findings of this landmark report strongly resonate many of the themes that consumers, families, and mental health providers have been advocating for the past several years. The report gives us a platform to drive a public policy advocacy message through to audiences in the legislature and media. We are at a convergence of opportunity. We have need and we have the most potent advocacy document since the Surgeon General’s Report on Mental Health released in 1999. These documents provide us with the tools to take the next critical step as the most influential mental health care provider, i.e., nurses, in contact with individuals with mental illness. We can assure that the call for transformation of the mental health system is heard this time. Be sure to telephone, write, or email your political representatives about this issue.

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Effect of physical health

RESEARCHERS HAVE recently begun to examine the impact of psychological responses to trauma, specifically, posttraumatic stress disorder (PTSD) symptomatology, on health. For women, a significant positive correlation has been reported between the severity of PTSD symptoms and physical health problems in victims of sexual assault and veterans of war (Kimerling et al 2000 and Zoellner et al 2000). However, there is a paucity of research examining the relationship between PTSD, PTSD symptom clusters, and physical health in women who have left an intimate abusive relationship. Moreover, although there is some research that examines the physical and psychological effects of lifetime trauma, seldom do these investigations separate violent from nonviolent trauma. The purposes of this research were to examine the relationships between violent and nonviolent trauma, posttraumatic stress disorder and its symptom clusters of avoidance, intrusion/re-experiencing, and hyperarousal, and self-reported physical health symptoms in postabused women.

Review of literature

Research has shown that intimately abused women experience serious physical health problems requiring medical, trauma, or gynecologic treatment (Campbell and Alford 1989; Follingstad et al 1991; Golding et al 1997 and Tollestrup et al 1999), and psychological/emotional health problems, including depression (Campbell 1989; Dienemann et al 2000 and Jack and Dill 1992), substance abuse (Curry 1998 and McFarlane et al 1996), and PTSD (Astin et al 1995; Houskamp and Foy 1991; Kemp et al 1995; Saunders 1994 and Woods 2000). Battered women experience both acute physical injuries and long-term health problems (Bergman and Brismar 1991; Eby et al 1995 and Plichta 1996). Campbell, J.C. and Soeken, K.L., 1999. Women’s responses to battering: A test of the model. Research in Nursing & Health 22, pp. 49–58. View Record in Scopus | Cited By in Scopus (29)Campbell and Soeken (1999a) found both direct and indirect effects of intimate abuse on women’s health. Additional research has shown that these physical health symptoms and problems remained significant even after controlling for age, ethnicity, and stress (Campbell & Soeken, 1999b). Although this previous research extends knowledge about intimate partner violence and physical health problems in women, it is not known whether all types of trauma have a similar impact on physical health symptoms or whether trauma has a cumulative effect on health outcomes over the life course.

Abused and postabused women, that is, those who have left an intimately abusive relationship, have been shown to experience PTSD. In a meta-analysis of 11 studies Golding (1999) reported that 31% to 84.4% of women who experienced intimate partner violence met PTSD criteria. In a study of 52 postabused women, 44% to 66% of the women were experiencing PTSD symptoms depending on measure, even though they had been out of the intimately abusive relationship approximately nine years (Woods, 2000).

Research with predominately male combat veterans has found that persons with PTSD are at increased risk of morbidity and mortality (Beckman et al 1998; Boscarino 1997 and Schnurr and Spiro 1999). Moreover, the more severe the PTSD symptoms, the greater the physical health problems experienced by trauma survivors (Kimerling et al 2000 and Zoellner et al 2000). Although combat exposure had an indirect effect on the physical health of an aging population of male combat veterans, PTSD had a direct effect on the respondent’s self-report of poor health status (Schnurr & Spiro, 1999). Similarly, Taft, Stern, King, and King (1999) found that PTSD had a direct effect on the physical health of 1,632 male and female Vietnam veterans. Wagner, Wolfe, Rotnitsky, and colleagues (2000) reported that the degree of PTSD symptoms at initial assessment was predictive of health problems over time in 2,301 male and female Gulf War veterans. Although these research finding support relationships between PTSD and physical health, other empirical evidence suggests that specific PTSD symptom clusters have differential relationships with health outcomes.

In a study of 52 female war veterans, Kimerling, Clum, and Wolfe (2000) reported that the hyperarousal cluster was a significant predictor of variance in physical health complaints (beta = .73). Zoellner, Goodwin, and Foa (2000) theorized that chronic hyperarousal may be related to physical symptoms in 76 female victims of sexual assault. However, Zoellner et al.’s results only supported that re-experiencing (intrusion) explained a significant portion of the variance in physical health when negative life events and depression were statistically controlled. These mixed findings suggest that research should examine the effect of the PTSD symptom clusters on physical health across all trauma survivor populations.

Multiple factors have been identified as influencing the development of PTSD in trauma survivor groups, including the magnitude and duration of the traumatic event and a history of multiple traumas. Zaidi and Foy (1994) found a significant correlation between childhood physical abuse and combat-related PTSD. These results are consistent with Bremner, J.D., Southwick, S.M., Johnson, D.R., Yehuda, R. and Chaney, D.S., 1993. Childhood physical abuse and combat-related posttraumatic stress disorder in Vietnam veterans. American Journal of Psychiatry 150, pp. 235–239. View Record in Scopus | Cited By in Scopus (216)Bremner, Southwick, Johnson et al.’s (1993) findings that history of childhood physical and/or sexual assault was associated with combat-related PTSD after controlling for level of combat exposure in male veterans. Bremner et al. (1993) theorized that exposure to trauma during childhood may increase vulnerability to future stress and result in long-term neurobiological changes in the stress response.

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Mental health for family members

ALTHOUGH THE CONCEPT of recovery from mental illness is not a new development, the introduction of a second generation of neuroleptic medications has resulted in increased reporting of this phenomenon in the literature. The opportunity for recovery may become more of a reality for many. However, Metlzer, (1998) and Sheitman and Lieberman, (1998) reported that 20% of consumers with schizophrenia are estimated to be nonresponders even to the new generation of medications.

Recovery not only implies alleviation of the influence of psychotic symptoms but reengaging in seeking a meaningful life. Recovery is often a complex, time consuming process. In 1993, Anthony, from his work with consumers of mental health services offered, a definition of recovery as “ …a deeply personal, unique process of changing ones’ attitudes, values, feelings, goals, skills and/or roles. It is a way of living a satisfying, hopeful and contributing life even with limitations caused by illness. Recovery involves the development of new meaning and purpose in ones’ life as one grows beyond the catastrophic effects of mental illness”. (p. 15). From a consumer’s perspective, Patricia Deegan (1996) eloquently suggested that “recovery does not mean cure. Rather recovery is an attitude, a stance and a way of approaching the day’s challenges. It is not a perfectly linear journey. There are times of rapid gains and disappointing relapses. There are times of just living, just staying quiet, resting and regrouping. Each person’s journey of recovery is unique.” (pp. 96–97).

Although families are often the greatest source of support for their relative who suffers from severe mental illness, their perspective on the recovery process is less known. This qualitative study sought to examine the role that medication played in the families’ subjective experience of improvement of psychosis as a step in the recovery process. Parallel research examined the consumers’ experience (Forchuk et al. in press) and the staff experience (Forchuk et al 2003a and Forchuk et al 2003b).

Literature review

For several decades there has been considerable literature describing the burden that a relative with severe mental illness places on the family. More recently, families have begun to share with researchers their experiences of a relative’s recovery from psychosis after the introduction of a second generation neuroleptic medication. These studies have shown that both the illness and changes in the illness have an impact not only on the patient but also on the family.

Several early qualitative studies looked at families’ experiences as family members with schizophrenia started taking the second generation neuroleptics. The earliest was Conley and Baker (1990) who described three families who experienced difficulties when their relative began to show improvement. Their relative became angry with them and this resulted in mutual withdrawal as they were not used to their relative’s more demonstrative expression of emotion. Mason, Gingerich, and Siris (1990) also reported on the stress experienced by care providers when new medications produced improvement in psychotic, depressive, or negative symptoms. This altered the status quo and called for changes in interactive processes. Both these early studies called for increased psychosocial interventions and support to assist all parties to successfully manage this phase of their relative’s improvement.

Several studies described family changes. Meltzer, H., 1992. Dimensions of outcome with clozapine. British Journal of Psychiatry 160 Suppl 17, pp. 46–53. View Record in Scopus | Cited By in Scopus (144)Meltzer in 1992, reported outcome measures for 54 patients following one year of clozapine treatment. Families reported feeling less anxious, greater social freedom and lesser financial demands. Kotcher and Smith (1993), in a nonexperimental report of their experience of treating over 40 patients, described phase-specific reactions of patients and their families and suggested phase-specific interventions to maintain collaborative working relationships. Stebbin, in her 1995 exploratory descriptive study with a convenience sample of 10 Michigan families reported that while some families were pleased with the clinical outcomes they anguished over the balance of benefits and limiting side effects of clozapine. Their expectations became more realistic as time passed during the course of treatment. Families expressed a need for an informal or formal source of emotional support to cope effectively with their family member’s clozapine therapies.

A few qualitative studies described the positive changes that occurred for family members as their relative improved from psychosis (Dickson et al 1995 and Najarian 1995). These highlighted improved family functioning and needs for support.

Recent studies have looked at the experience of family members throughout the illness trajectory. Karp and Tanarugsachock (2000) interviewed 50 family members in an ethnographic study. Family members were found to go through predictable phases. The early frustration, as the family member was diagnosed, evolved into grief and sadness. As the lack of control over the illness was recognized, family members reached a stage of acceptance, but also a withdrawal that included respect for the family member’s struggle.

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Mental health on this study

RESEARCHERS, EDUCATORS, and clinicians have long acknowledged the transformative impact of the mid-20th century focus on interpersonal relations and relationships on nursing, in general, and psychiatric nursing, in particular (Lego 1999 and Reed, 1995). Today, the work of nursing is inextricably relationship-centered (Duffy and Hoskins (2003). Some of the most compelling theoretical and methodological work in the discipline encourages practitioners in current practice to consider ways in which biases from ethnocultural variations (Choi, 2002) or racism (Kendall and Hatton (2002), to name but a few, affect the construction and experience of therapeutic relationships.

But relationships are themselves embedded in particular environments. The construction of safe, healing environments has, of course, long been a benchmark of expert psychiatric nursing practice. In addition, psychiatric nurses have been remarkably adept at adapting such environments to meet the needs of cognitively impaired patients or the demands of insurance companies for the rapid assessment, stabilization, and discharge of individual patients. Still, such adaptations assume the stability of supportive, empathic, and therapeutic relationships. Little attention has been paid to wondering if such an assumption is valid, or to understanding the longer-term implications of the reciprocity between such relationships and the immediate, structural, and demand-laden context in which they occur.

This historical case study of the work of those involved in the day-to-day care of patients at the Friends Asylum in early 19th century Philadelphia suggests that the implications may be quite profound. The historical case study methods applied in this research uses the distance of time to enable a more analytic focus on the nature of complex changes not immediately apparent to contemporary historical actors (Gaddis, J.L., 2002. The Landscape of History: How Historians Map the Past, Oxford University Press, London and New York.Gaddis, 2002). This method requires that background exposition, historical data, and analytic arguments form a reasoned narrative that addresses and advances different aspects of the study’s central thesis (Iacovetta & Mitchinson, 1998).

This study draws its data from the daily diaries kept by the lay superintendents of the Asylum from 1814–1840 (hereafter SD). At the end of each day, these men wrote about their, their patients’, and their attendant staff’s work: that was done about the house and in the “family’s” farm and gardens. More importantly, they wrote, with unusual candor and extraordinary detail, about their patients and their patients’ actual words and behaviors. The Asylum’s lay superintendents also wrote about their and their attendant staff’s feelings: about the joys and the frustrations of working, day-to-day, with insane patients. These patients’ names have been changed in this study to protect their confidentiality. Still, both their words and that of their staff tell a story about how the small, incremental changes made to a therapeutic environment fundamentally changed the way staff thought about and implemented therapeutic relationships.

The friends asylum

The Friends Asylum, founded in Philadelphia in 1817, was the first institution in the United States solely for insane men and women, and was the model for many similar institutions established later in the 19th century (Grob, 1973). The Asylum practiced a then-innovative and new treatment: the “moral treatment” of the insane. Moral treatment held out to families the bold and very real promise of a cure if only they consigned their insane kin to the care and treatment of a new institution (Evans, 1839). There, a new kind of moral and disciplined environment, created by lay men and women, would stand in sharp contrast to the debilitating (although, moral treatment’s adherents were quick to state, not necessarily deliberate) associations of home that had first given rise to and then supported the insane’s deranged symptomatology (D’Antonio, 2001). Theoretically, an asylum’s quiet, secluded, and healthy country setting, its diverting opportunities, the soothing associations of gardens and walkways, and the “judicious kindness of others” would gently appeal to both the insane individual’s latent rationality and to his inherent capacity to find the road to his recovery and eventual cure (Tuke, 1813).

Work and the practice of moral treatment

In actual practice, moral treatment at the Friends Asylum in the early 19th century took the familiar and reframed it as therapeutic (D’Antonio, 1990). Every normal aspect of a sane person’s life became part of the armantarium of an insane patient’s treatment. The structured times an individual arose in the morning, took meals, and retired at night was at once a disciplined therapeutic strategy consciously planned to the instill the habits of orderliness and control lost to the ravages of insanity and a familiar routine harkening back to the idyllic rhythms of a domestic farm economy. During the longer, more productive, days of summer, staff and their patients arose at five, and enjoyed their supper at seven. In winter, they arose at seven and took supper at five. Dinner was always at noon, with a trumpet summoning men from the fields or workshops (The Friends Asylum, 1913).

Insane patients worked side-by-side with their attendant staff and the institution’s farmer, gardener, and domestic help within this routine to attend to the seemingly never ending cycle of daily, weekly, and seasonal chores both within and outside the house. The tenets of moral treatment cast this work as therapeutic. Cultivating potatoes or making new bed sheets, for example, distracted the morbidly preoccupied, soothed the violently agitated, and stimulated the dangerously depressed. This work was both meaningful and productive. It was also critically important. The Asylum’s domestic economy, in fact, depended upon the labor of both staff and patients together to care for sick patients, to put food on the table, and to cover chronic shortfalls on its shoestring budget (see especially SD 26 May 1823, 19 April 1827, and 29 April 1830).

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Role functioning of Depression

DEPRESSION DURING THE perinatal period is a major public health concern. Approximately 13% of women experience postpartum depression (PPD; [O’Hara and Swain 1996]). Up to half of these women have episodes that last 7 months or longer [England et al 1994]. The most significant factor in the duration of the PPD is delay in seeking treatment [England et al 1994]. As with other cases of major depression, PPD is characterized by mood alterations, disturbed cognitive processes, and physical symptoms which result in poor role functioning at work, school, in social, family and personal relationships, and in less satisfaction in the role of mother ( [Beck 1999]; Table 1). Although most postpartum women experience a delay of 3–6 months after childbirth before they resume usual household, social, community, self-care, and occupational roles [Fishbein et al 1998, Gennaro and Fehder 2000, McVeigh 1998, McVeigh 2000, Tulman and Fawcett 1990, Tulman et al 1990 and Waters and Lee 1996], women with postpartum depression have prolonged difficulties with functioning.

Symptoms of Major Depression With Postpartum Onset

Data from the [American Psychiatric Association 1994]

Postpartum depression can be successfully treated with antidepressants [Appleby et al 1997] and/or psychotherapy [O’Hara et al 2000]. Remission of symptoms defines successful treatment of depression but current treatment goals also include return of the patient to the desired level of functioning in all of their life roles [Sederer et al 1996 and Stahl 1999].

Relationship between depression symptoms and role functioning

Although not specifically studied in women with postpartum depression, high levels of role functioning impairment have been shown in individuals with depression in both clinical [Brent et al 1998, Mauskopf et al 1996 and Wells et al 1989] and community [McKee et al 2001] samples. For example, in patients with major depression (n = 95) who were administered the Sickness Impact Profile, [Goethe and Fischer 1995] reported role functioning impairment in the areas of work, alertness, emotional behavior, social interaction, and recreation. There was only minimal impairment in ambulation, mobility and body care. The psychosocial functioning scores were most highly correlated with level of depression (r = 0.64, p < .001), similar to that reported in previous studies [Leader and Klein 1996].

Interestingly, role functioning impairment does not always parallel symptom severity. In samples of clinically depressed patients, both [Lyness et al 1993] and [Goethe and Fischer 1995] found that some individuals with mild symptoms of depression had severely impaired role functioning, whereas some individuals with severe symptoms of depression were able to function successfully in occupational and social roles. The investigators were unable to explain this perplexing finding. However, even mild symptoms of depression may impact role functioning. [Mintz et al 1992] showed that minor depression (Hamilton Rating Scale for Depression [HRSD] score < 10) was associated with loss of interest and negative self-evaluation. These scores increased dramatically with each elevation of HRSD score.

Role functioning after treatment for depression

As would be expected, role functioning impairment tends to improve with treatment as the depression remits [Coulehan et al 1997. J.L. Coulehan, H.C. Schulberg, M.R. Block, M.J. Madonia and E. Rodriguez, Treating depressed primary care patients improves their physical, mental, and social functioning. Archives of Internal Medicine 157 (1997), pp. 1113–1120. View Record in Scopus | Cited By in Scopus (126)Coulehan et al 1997]. For example, [Mintz et al 1992] used data from 10 published studies to evaluate the impact of symptoms of depression on work impairment. They found that affective work impairment (feeling of distress, shame, or lack of interest) was associated with mild depression and functional impairment (absenteeism, performance adequacy, or interpersonal conflict) was associated with more profound depression. With treatment, work improvement and symptom improvement were correlated, but work improvement took longer. It is not known how treatment of depression might impact role functioning in the postpartum period, leading to the need for the present study.

The purpose of this study was to describe any improvement in symptoms of depression and role functioning of women with PPD after 8 weeks of antidepressant treatment. A second purpose was to determine the relationship between measures of depression and role functioning of women with PPD after 8 weeks of antidepressant treatment. The study comprehensively measured numerous domains of role functioning, as well as symptoms of depression, to inform researchers and clinicians of outcomes that can be expected from antidepressant treatment.

Theoretical framework

A Stress and Coping framework [Lazarus 1999] was used to guide the study. In this theoretical framework symptoms of depression and impaired role functioning lead to increased stress. Remission of symptoms with antidepressant treatment, especially improvement in mood and increased energy, leads to the perception of decreased stress and having adequate resources to deal with challenges. The improvement in mood and energy also make use of social support more probable. This leads to improved role functioning, our definition of coping.

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psychiatric patients in mental health

EDUCATING PSYCHIATRIC patients about their illness and treatment for the purpose of increasing compliance with therapy, decreasing illness relapses and hospitalizations, strengthening social adaptation, and increasing quality of life is growing in importance. However, many studies reveal that patients do not have enough information about their medications and other therapy and they are noncompliant with therapy [Brown et al 1987, Schaub et al 2001 and Kelly et al 1990]. Researchers emphasize that the basic reason for lack of success in therapy is patients’ failure to take medications in the prescribed manner [Clary et al 1992, Seltzer et al 1980 and Eckman et al 1990].

Lithium is the medication used in the treatment and prevention of repetitive mood disorders and has side effects and danger of toxicity [Kearney and Meadows 1993, Lee et al 1992 and Mander 1988]. Despite this only a few studies were found related to medication compliance in patients who take lithium and in these studies they report that patients who take lithium have limited information about their medication [Lee et al 1992 and Dubyna and Quinn 1996] and emphasize the need for intensive patient education for patients who take lithium, in particular regarding side effects [Schaub et al 2001 and Lee et al 1992].

Recently psychoeducation therapy, which includes education about disorders and medications, has been increasing for psychiatric patients. There are many studies in the literature, which show the effect of informing psychiatric patients about their illness, treatment and medications on ensuring their compliance with therapy [Brown et al 1987, Kelly et al 1990, Seltzer et al 1980, Pollack 1995, Goulet et al 1993, Halford et al 1995, Harter et al 2002, Bruseker and O’Halloran 1999, van Gent and Zwart 1991 and Goldman and Quinn 1988]. However there are insufficient studies, which bring to light the effect of informing patients who take lithium about their treatment and medication on their adaptation to their illness and quality of life.

Psychiatric nurses have primary responsibility for patients’ attaining optimal living conditions after discharge, in their taking individual responsibility for their care and in using psychoeducational approaches. Psychotropic medications have an important contribution to psychiatric patients being able to attain independent living conditions. In medication therapy nurses are not just responsible for giving the medication, they are also responsible for evaluating the medication’s effect and side effects, increasing patients’ knowledge about the medication, and ensuring and supporting compliance [Dubyna and Quinn 1996, William 1989, Grimm 1986 and Farkas 1990].

The purpose of this study was to investigate the effects of disorder and medication education on patients’ compliance with the medication, symptom level, and quality of life in outpatients who have bipolar disorder and take lithium.

Method

Setting and subjects

The research was performed in Sivas, a province in Central Anatolia, Turkey in a psychiatric department of a university hospital. Patients who were diagnosed with bipolar disorder according to DSM-IV diagnostic criteria and who had taken lithium for a long time (1992–2002) were included in the study. Thirty-two patients who met the criteria were identified. These patients were set up in order, then they were selected according to order numbers, for example those with odd numbers constituted the study group and the others the control group. The purpose of the research was explained to all of the patients and informed consent was obtained. Six patients who had medication and address change during the implementation period were removed from the study and the study was performed with the remaining 26 patients, 14 in the study group and 12 in the control group.

Instruments

Data were obtained in the research using Personal and Disease Characteristics Information Form, Brief Symptom Inventory, Quality of Life Assessment, and Medication Information Questionnaire.

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Mental health with Online courses

TRADITIONAL CLINICAL conferences with psychiatric nursing students are designed to help students integrate theoretical concepts and knowledge with clinical practice. An effective clinical conference has three important goals: the experience of being a member of a group, mastery of the course objectives, and exploration of personal feelings and attitudes about their work with individuals who have psychiatric disorders (Wink, 1995). These goals reflect cognitive, behavioral, and affective domains of learning. Since psychiatric care is delivered interpersonally, clinical conferences are especially valued by faculty because they foster self-reflection and sensitivity to others. It is not clear if these goals can be realized in clinical conferences conducted online using an asynchronous threaded discussion. The present study describes the group process and content topics of five online clinical conferences to evaluate if they meet course objectives.

Review of the literature

Most research on Web-based courses has examined student satisfaction and perceptions (Conrad 2002; Haythornthwaite et al 2000 and Thurmond et al 2002), while some researchers have compared face-to-face courses with online courses (Herod 2000 and Thornam, C.L. and Phillips, S., 2001. Interactivity in online and face-to-face sections of a graduate nursing course. TechTrends 45 1, p. 34. Full Text via CrossRefThornam and Phillips 2001). Fewer researchers, however, have examined the interactions in online course discussions, though measures are available (Li 2001–2002 and McKlin et al 2002). Analyzing real time or synchronous interactions, Lobel and colleagues (2002) developed a program to evaluate participation by undergraduate student groups during an online class session. Tu (2002) reviewed student ratings of social presence, the degree of salience of another person in an interaction. He reported students perceived that email communications have more social presence than bulletin board communications indicating that the type of computer mediated communications may influence interaction. Examining the amount of structure needed for interaction, (Land and Dornisch (2001) found students required guidelines and strategies about how to respond to others online.

Kanuka and Anderson (1998) using a constructivist learning theory, examined transcripts generated by 25 managers participating in a 3-week discussion on creating online workplace learning centers. Using Gunawardena, Lowe and Anderson’s (1997) five-phase model to analyze the construction of knowledge, they found that most interactions involved sharing and/or comparing information; phase-one of knowledge construction. Interactions about differences and inconsistencies, a higher phase of knowledge construction, were infrequent. The investigators conjectured that it may be easier for participants to ignore differences in online discussions than in face-to-face interactions.

Although participants may not have the same experience as found in face-to-face groups, a sense of community still appeared to exist in online courses. Fahy (2003) examined peer-to-peer support in three online courses using the Transcript Analysis Tool. Although there was no difference in supportive interactions by gender, wide variation occurred across individuals. The most frequent type of support was in the form of referential statements, i.e., direct answers or reference to specific preceding statement of other participants. Likewise McDonald (1998) found the majority of speech segments, i.e., messages with single themes, were initially directed to the group. However, with time a greater proportion of messages were directed at specific individuals. Though the content of segments was cognitive in nature; participants interacted in an interpersonal level sharing personal thoughts and experiences. The online groups appeared to progress through similar stages of development as occur in face-to-face groups.

The present study differs from previous research by examining online interactions in an established group; a cohort of graduate nursing students who had been together in three previous online courses and met face-to-face on several occasions. The online clinical conference replaced a bimonthly telephone clinical conference for the students’ final practicum course in advance practice psychiatric mental health nursing. The purpose of the present study was to examine the range of topics and quality of interactions in an online clinical conference. Specific questions addressed were:

1. What topics were discussed in an online clinical conference and did they meet objectives of the conference?
2. What were the characteristics of the interactions among students in the online conference?

Methodology

Sample

Ten students enrolled in the course, nine of which comprised a group who had taken the previous three psychiatric nursing courses and two practicum courses together online. The tenth person was a doctoral student in nursing and new to the group. Students’ practicum settings were in outpatient community mental health agencies, private psychiatric offices and inpatient units. All but one of the preceptors was an advance practice psychiatric nurse.

Setting

The School of Nursing at the University of Kansas Medical Center under the direction of Dr. Helen Connors has a history of distance learning, first with telecommunication and more recently with the Internet. The goal of the distance education program is to prepare advance practice nurses who will work in rural underserved areas. In spring 2000, the School of Nursing faculty made a commitment to put the graduate psychiatric nursing courses online. Psychiatric nursing faculty partnering with the second author of this paper, an expert in learning technology from the Department of NetLearning at the University of Kansas Medical Center, designed the online courses. Students taking online courses are supported by a number of services including a Help Section and Tip sheets and an extended hour call in help line for trouble shooting problems.

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Posttraumatic stress for Women

THE PURPOSE OF this investigation was to test a short-term, cognitive group therapy intervention method to reduce or resolve ongoing psychological disruption and/or trauma among women who experienced traumatizing provider interactions (TPI) in their childbearing experience. The specific research question addressed in this quasiexperimental investigation was: What are the differences in patterns of psychological disruption between entry into the investigation and completion of short-term, cognitive group therapy among women who identified traumatizing provider interactions during their childbearing experience?

Background/significance

Psychological and emotional disruptions during the perinatal period have become so culturally commonplace that “experiential normalization” by the health care community has occurred [Sorenson 1990b]. Through normalization indifference, clinicians fail to recognize potential correlates of these disruptions and therefore do not implement strategies preventing their occurrence or mitigating their detrimental effects. Indeed, provider indifference to the negative effects of postpartum psychological disruptions is so pervasive that a United States House Resolution (HRES 163 IH) was proposed to address provider responsibilities to detect and treat these disruptions.

Compounding normalization, detectable psychological illnesses often go unidentified and/or untreated because sequela primarily occurs after hospital discharge [Cox et al 1982]. Rates of psychological disruption are estimated at 80% of all newly delivered women; 3% to 20% report overt psychiatric symptoms; and 1 in 10 report severe forms of psychological impairment [Hansen 1990, Horowitz et al 1995 and Jacobson et al 1965]. About 4% of cases persist for as long as a year, with an estimated 10% to 35% rate of recurrence. Recent research by [Righetti-Veltema et al 1998] and [Whitton et al 1996]) claim the incidence of overt postpartum depression in its nonpsychotic forms is approximately 10% to 15% for primiparas.

Posttraumatic stress disorder (PTSD), a specific subset of postpartal psychological impairment, has only recently become identified and explored due to its perceived rarity among uncomplicated deliveries and outcomes. However, recent findings from England indicate that posttraumatic stress among normal deliveries was fully experienced among 3% of the population and 24% met two of three criteria for posttraumatic stress. These findings indicate that posttraumatic stress is broader-based than previously considered [Czarnocka and Slade 2000]. A critical feature across studies of postpartum women who exhibit PTSD is relational difficulties with providers [Allen 1998, Ballard et al 1995, Beech and Robinson 1985 and Menage 1993].

Although psychological and emotional disruptions are multidimensional in origin, this investigation focused on the psychosocial/relational dimension. Interpersonal interactions are basic relational expressions defined as an existential, dynamic communication process between two or more human beings that involves the exchange of facts, feelings, and perceptions to which meaning is ascribed [Duldt et al 1984]. During affirmatory interactions, relational needs are met and perceptions are validated, thus promoting individual worth, self-esteem, positive regard, adaptation to life experiences, and actualization of the human potential [Peplau 1952].

In contrast to affirmatory interactions, disaffirming and traumatizing interactions create psychological disruption and trauma by negatively affecting relational trust, creating uncertainty, and disrupting psychological functioning and developmental processes [Kendall-Tackett 1993, Machnowski 1997, Rubin 1984, Sorenson 1990b and Spinda 1997]. Entrusted with women’s care, providers who engage in disaffirming, traumatizing interactions have a profoundly unique impact on a clinically vulnerable population of women undergoing biological, psychological, social, spiritual, and developmental changes during the perinatal period [Machnowski 1997]. Indeed, multiple studies indicate that disaffirming, traumatizing relationships with providers are associated with higher PTSD symptoms among postpartum women and their families [Ballard et al 1995, Beech and Robinson 1985, Lyons 1998 and Menage 1993. J. Menage, Posttraumatic stress disorder in women who have undergone obstetric and/or gynaecological procedures. Journal of Reproductive and Infant Psychology 11 (1993), pp. 221–228. Full Text via CrossRef | View Record in Scopus | Cited By in Scopus (54)Menage 1993].

Disaffirming and traumatizing provider interactions (TPIs) are vitally important to recognize and address because they impact the individual mother, her child, family, and ultimately the community. Long-term maternal outcomes associated with TPIs have been theoretically depicted by Finkelhor’s Traumagenics Model ([Kendall-Tackett 1993] and [Ralph and Alexander 1994]) Postnatal Stress Disorder. Consistent with DSM-IV’s [American Psychiatric Association 1994] classification of post traumatic stress, TPIs: (1) leave women feeling sad, depressed, angry, anxious, or otherwise psychologically/emotionally distressed; (2) evoke prolonged, recurrent troublesome memories or repetitive negative thought patterns, and (3) severely tax women’s coping resources. Feelings associated with TPIs include: grief, loss, ambivalence, fear, anger, vulnerability, fatalism, panic, guilt, betrayal, defeat, helplessness, violation, resentment, denial, demoralization, isolation, confusion, uncertainty, inconfidence, failure, incompetence, loneliness, emptiness and depression (Alexander, 1994; [Allen 1998, Baldwin and Palmarini 1986, Cohen 1979, Glazer 1980, Kendall-Tackett 1993, Leifer 1977, O’Hara 1986 and Ralph and Alexander 1994]). Despite its long-term importance, little research addresses the assisted or unassisted resolution of TPI.

Tags: Posttraumatic Stress

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African Americans of the Mental health

IN GENERAL, HEALTH status in the United States has continually improved throughout the last century. However, tremendous disparities in health status exist across various segments of the population [Sebastian 1999, Wallace 1999 and Williams et al 1997]. African Americans have higher rates of death, disease, and disability than Caucasians, including higher rates for 13 of the 15 leading causes of death in the U.S. [Williams et al 1997].

Results from studies comparing mental health status of African Americans and Caucasians vary. Some researchers found that African Americans have higher levels of psychological distress [Fiscella and Franks 1997, Snowden 2003, Thompson 2002 and Vega et al 1997]. However, results from the Epidemiological Catchment Area Study [Robins and Regier 1991. L.N. Robins and D.A. Regier. Psychiatric disorders in America: The Epidimiologic Catchment Area Study, Free Press, New York (1991).Robins and Regier 1991] and the National Comorbidity Study [Kessler et al 2002] found that African Americans have lower or equivalent rates of psychiatric disorder. On the other hand, when gender was examined in the ECA study, African American women had higher rates of anxiety disorders than Caucasian women [Robins and Regier 1991]. The purpose of this manuscript is to compare rural African American and Caucasian women on alcohol and other drug use (AOD), comorbid Axis I psychiatric disorders, and experiences with violence.

Review of the literature

Researchers have shown that race is not the primary contributor to health disparities, but socioeconomic status (SES) [Sebastian 1999 and Williams et al 1997]. Compared with Caucasians, African Americans have a median income that is 63% less and are more than twice as likely to be unemployed, three times more likely to be poor, and twice as likely not to have graduated from college [Williams et al 1997]. Also contributing to disparities in SES, African American families are more likely to be headed by a single parent, to lack health insurance, and to live in segregated, impoverished housing [Wallace 1999]. More than one-third of all African American women live in poverty, placing them at a tremendous disadvantage [Davis 1997]. Disparities in health care may exist because people with higher SES status have more resources (money, education, prestige, power, social support and social connections) that can be used to prevent risk and to promote health. [Buka 2002 and Galea and Vlahov 2002]. Studies of racial differences in health that control for SES often find that racial disparities are reduced and sometimes eliminated [Williams et al 1997]. However, importantly, race is often a determinant of SES in that many African Americans face economic discrimination [Williams et al 1997].

Rural women are at particular risk for health disparities. Rural women often live in poverty, are unemployed, lack health insurance, and face environmental and geographic constraints that limit access to what limited health care exists [Gaston 2001]. Lack of personal transportation and unreliable public transportation compounds geographic separation and further limits access to health care for rural women. Many rural areas are characterized by conditions that plague poor, inner-city neighborhoods such as poverty, high crime rates, alcohol and other drug (AOD) use, domestic violence, and few opportunities for entertainment that are not centered around AOD use [Boyd and Mackey 2000, National Institute on Drug Abuse [NIDA] 1997 and Rural Women’s Work Group 2000]. In addition to increasing risk for AOD use and relapse after treatment, these conditions are associated with increased risk for stress-related mental disorders such as anxiety disorders and major depression.

Prevalence rates for use of illicit drugs vary across studies and according to time frame (i.e., lifetime, 1 month, 1 year). According to the latest National Household Survey on Drug Abuse [Substance Abuse and Mental Health Services Administration [SAMSA] 2002], for persons 12 years old or older, more Caucasians use illicit drugs than do African Americans for lifetime use (44.5% vs. 38.6%) and past year use (12.9 vs. 12.2). Past month use of illicit drugs was slightly higher for African Americans (7.4%) than for Caucasians (7.2%). In the age range of 12 to 17, which is the only age range reported by race and gender, more Caucasian women used illicit drugs than African American women for lifetime use (28.5% vs. 27.5%), past year use (21.4% vs. 18.0%), and past month use (10.8% vs. 8.7%).

Similarly, more Caucasians (aged 12 or older) used alcohol than African Americans in three types of alcohol use categories: any use (52.7% vs. 35.1%); binge alcohol use (21.5% vs. 16.8%); and heavy alcohol use (6.4% vs. 4.1%). In the only age range reported by race and gender (12–17 year old), Caucasian women reported higher use than African American women: Any use (19.7% vs. 11.2%) binge alcohol use (11.5% vs. 5.9%); and heavy alcohol use (2.4% vs. .5%) [Substance Abuse and Mental Health Services Administration [SAMSA] 2002]. Earlier studies of alcohol use found that more African American women abstain from alcohol use than do Caucasians (64% vs. 48%) [Jones-Webb 1998].

Although AOD use among African Americans is lower than or equal to that of Caucasians, African Americans disproportionately experience negative health and social consequences of AOD use [D’Avanzo et al 2000, John et al 1997 and Rouse et al 1995]. African Americans have higher incidences of alcohol related illness such as cirrhosis, cancer, pulmonary disease, malnutrition, and birth defects than do Caucasians [D’Avanzo et al 2000 and Jones-Webb 1998]. African Americans suffer disproportionately from many AOD related adverse effects: unemployment, substandard housing, homelessness, poor educational outcome, and inadequate health care [Woods 1998]. However, these same conditions are risk factors for AOD disorders, thus creating a vicious circle [Galea and Vlahov 2002]. African Americans also are at greater risk of being victims of alcohol or illicit drug-related homicides, being arrested for drunkenness or possession of a controlled substance, and being sent to prison rather than to treatment [D’Avanzo et al 2000].

Tags: mental health

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Consciousness of the Substance abuse

PSYCHOACTIVE DRUGS alter perceptions, feelings, and thoughts of the individual consumer [Mangini 1998, Weil 1996, Weil and Rosen 1983 and Zinberg 1976. N.E. Zinberg, Observations on the phenomenology of consciousness change. Journal of Psychedelic Drugs 8 1 (1976), pp. 59–76. View Record in Scopus | Cited By in Scopus (6)Zinberg 1976]. Individuals who compulsively abuse psychoactive drugs experience these alterations in consciousness. [James 1890/1981] concept of the fringe of consciousness sheds light on how these changes in consciousness feel and what meaning emerges for the individual in that feeling. The emphasis on feelings in James’s concept of the fringe offers a deeper understanding of the immediate experience of addictive drugs; this emphasis on feelings also has import for the relationship between client and nurse.

William James, a philosopher and psychologist at the turn of the 20th century, developed a model of consciousness that theorized how changes in consciousness occur, and how these changes modify ordinary manifestations of consciousness. [James 1912/1976] conceived consciousness not as an entity but as a function. That function was knowing. The active nature of the verb symbolizes the ongoing process of the activity. It symbolizes a particular relationship between the individual and the world. How this knowing occurs has implications for the changes in consciousness that nurses observe and clients experience under the influence of psychoactive drugs. The paramount significance of this kind of knowing is its relationship to feelings and their intense counterparts, emotions.

Feelings and thought

Feelings are a biological expression of the body: the afferent impulses of the nervous system. Feelings are also a manifestation of the response of the whole person to life’s experiences. In James’s model of consciousness [James 1912/1976], whether one examines feelings as biological sensations or psychosocial-spiritual responses depends on the individual’s interest and the immediate context. Interest in this sense is what captures the individual’s attention. Biology, habit, culture, and the unique processes by which the individual synthesizes those components and acts on them shape this interest. Consciousness in this sense of action is selective [Taylor 1981].

[James 1890/1981] described feelings as the germ (as in a germinating seed), and the thought that emerges from and surrounds that feeling as the developed tree. This metaphor describes the relationship between feeling and knowing. It also describes two types of knowing: that of direct experience and that arrived at by thought and analysis. “Through feelings we become acquainted with things, but only by our thoughts do we know about them. Feelings are the germ and starting point of cognition, thoughts the developed tree.” (p. 218). This metaphor of germ and tree is particularly important when describing states of consciousness altered by psychoactive drugs: when selective awareness deviates from the ordinary waking consciousness of most people’s everyday experience.

The substrate of feelings is critical to all states of consciousness and helps to differentiate among them ([James 1884 and James 1890/1981]). This is true for the subjective experience of the client as well as the feeling response of the observer or nurse. But these feelings, because they are feelings, are not mature, developed, and orderly thoughts. They are therefore difficult to describe, conceptualize, and articulate. Our perception of feelings is an awareness of a change at the organic level of the body ( [James 1890/1981 and James 1894]). Whether we conceptualize those feelings as physical processes or psychological needs reflects a selected point of view; how the individual experiences those feelings at the time of the changes, however, might be difficult to articulate, particularly when the feelings are intense. The intense feelings ascribed to addiction [Khantzian 1985 and Khantzian 1997] might in the subjective experience of the individual preclude conceptualization. James noted that in emotional experiences, the undifferentiated organic response persists longer before distinction between feeling and thought or self and not self occurs ( [James 1912/1976], p. 73). Yet that subjective experience reflects the unique response of that individual. This dynamic nature of feelings is what brings them to the focus of the individual’s attention.

Tags: Consciousness Abuse

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