Mental Health: Clinical case presentation

Presenting Factors:

• Current Unemployment.
• Thoughts of self harm/suicide (by running car off the road).
• Living with parents.
• Social Isolation.
• Confusion with regard to time.

Precipitating Factors:

• Loss of job (approx. 3-4 weeks ago) due to client committing stealing offences.
• Loss of independence (re. living arrangements).
• Relationship problems with parents and lack of emotional support.

Predisposing Factors:

• Living in a rural community.
• Social isolation.
• Limited exhibited ability to solve problems while under stress.

Perpetuating Factors:

• Lack of insight to services and assistance available.
• Financial hardship.
• Negative self image will hamper necessary outward steps required to solve problems.

Protective Factors:

• Eagerness to move into a metropolitan setting.
• Eager for reemployment.
• Family support.
• Help seeking behaviour, openness about problems with interviewer.

• Tom has mentioned he has been feeling low because he has recently been dismissed from work due to the misappropriation of funds. Tom admits taking the money and takes responsibility for his actions.
• There was no obvious inability to independently manage activity of daily living.
• Tom’s current state of mind was expressed through fidgeting with his hands, constantly learning forward and by displaying poor eye contact.
• Tom was cooperative and calm and mentioned he felt ashamed and expressed a negative self-image.
• Tom stated he’s low mood was triggered by the events of the last couple of weeks.
• The loss of work, loss of social relationships, lack of finances and consequently loss of independence with now living in an isolated location have are all key factors in his current psycho-emotional state.
• He has mentioned his only social relationship now is with his parents.
• Tom appears to be angered in particular by his father.
• Tom has expressed suicidal ideation with the idea of running the car of the road in response to this current situation, but has never acted on them.
• This has placed him as a high risk of self harm and also medium risk of hurting others given his aggression towards his father.
• Tom has moved into his parent’s garage which is unsuitable but provides a sense of separation between Tom and his parents.
• Tom is aware he needs to find a new job but has expressed no interest of looking and feels limited.
• His form of thought become disjointed when he discussing how long since he has lost his job and there was evidence of slowing and mental confusion.
• Tom’s insight is partial as he is aware of his personal difficulties.
• He appears to be open to assistance and support but he appears unclear where to begin.

Mental Health: Clinical case presentation

Tom is a 44 year old man who has been referred by his GP to Mental Health Services following being dismissed from work.

2.Clinical Formulation

Tepou (2015)

5 P's

Handover

1. Mental Status Examination

3. Identifying Needs

Form of Thought

Mood and Affect

Appearance and Behaviour

Speech Form and Speech Content

• Client stated feelings of stress, being unhappy, mood as low, confused and down – “I’ve only got myself to blame”.
• Client demonstrates a ‘Restricted’ affect.
• Appropriate
• Stable
• Cooperative
• Congruent mood and affect.

• Rate variable but not to an extreme – easily understandable
• Regular volume, no raised voices.
• Good quantity and detailed information provided
• Speech is intense at times.
• No evident disturbance of meaning.
• No disturbance of language

• Descriptive explanations of events conversed.
• Thoughts not evident to be excessive or absent.
• Thought is mildly disjointed.
• Appears to jump from thought to thought within a topic, it’s mild but noticeable.
• Recognizes irrationality / inappropriateness of behaviour to father.
• Not recognizing own 'wishful' thinking re-moving out (e.g. lack of strategy to support desires).
• Recognizing some level of confusion related to stress.
• Not formulating strategies to solve life problems but has attended session gives no indication of hostility to assistance.

• Shook hands with interviewer, firm grip.
• Wearing glasses and green long sleeved t-shirt and jeans.
• Tom presented casually with no definitive evidence of self care deficit.
• Slight stubble on chin.
• Looking down – displaying minimal eye contact
• Wide eyes and facial expression showing signs of tension.
• Leaning forward slightly and engaged.
• Fidgeting and restless with his hands on multiple occasions
• No obvious motor abnormalities that might be physiologically based.
• Did not appear more than slightly reluctant to share current issues even though shame and negative self image was expressed.

Thank you for enjoying our presentation!

Safety and security:

• Social Stability
• Employment/Financial Security
• Own Home (independent dwelling)

Love and belonging:

• Friends/Social Circle
• Intimacy
• Sense of connection
• Sense of belonging in the community

Self esteem:

• Confidence/Self Esteem
• Achievement
• Respect of others
• Independence

Self actualisation:

• Purpose and meaning
• Recognize potential at new job
• Acceptance of his current situation
• Acceptance of self

Perception

Insight & Judgement

Sensorium and Cognition

Content of Thought

• Client stated that he feels like his father is staring at him. - “He’s thinking I’m a bludger, a slacker, and he’s right.”
• Client is ‘perceiving’ judgement from his father without providing any overt evidence for this judgement.
• External expression of self judgement?
• Displacing to Father?
• No evidence suggesting hallucinations.
• No evidence suggesting Illusions.
• No evidence suggesting depersonalisation/derealisation.

• Client is completely conscious, aware and engaged in conversation.
• Some evidence of clouding and slowing
• Client admits to experiencing confusion of late - “Forgetful and confused due to stress”.
• Was unable to specify specific time - “not sure if three or four weeks ago.”
• Evidence of blocking as it is unlikely he really has ‘forgotten’ such a momentous change in his life.
• Client experienced some confusion regarding moving
• Recalls memories of himself and his friends

• Delusions not evidenced.
• Suicidal/Self harm thoughts reported “Sometimes I think it might be worth driving car off the road then I can relax”.
• Mentions that “thinking about it is a way to cope”.
• Thoughts appear to be affected very negative.
• Driven by shame (reported) and negative self image(reported in self description).
• Ideation relates to being a failure responsible for own situation, accepting responsibility (reported) but no evidence of constructive strategy to solve problems.
• Recurring themes.

• Clients insight is ‘Partial’
• Client is aware of personal difficulty with stress, client has formulated no strategy for self to current difficulty.
• Client is aware of own role in predicament.
• Client has presented to clinic to discuss situation appears to be open to support.
• Client is aware of potential implications with friends (former colleagues) since incident.
• “I can’t see them again, I’d feel so ashamed. I’m that loser that stole your money.”
• Client may require some assistance to make rational decisions. Formulates desire to move out states intended date but has no plan to enact decision and when put on the spot defers action.
• Does not verbalise reason to defer action.
• Client does not exhibit appropriate independent problem solving considering gravity of situation and current stress level.

Ejolt (2012)

Risk Assessment

• Risk of self harm (Medium) (New South Wales Department of Health, 2004).
• Risk of harm to others (re. driving car off the road (Medium), Harm to Father (medium).
• Risk of social isolation (High).
• Risk of [further] impairment of current relationships (e.g parent and former colleagues)
• Risk of financial difficulty due to current unemployment and potential future moving expenses (High).

4. Nursing Care based

on the Therapeutic Relationship, Cultural Safety and The

Recovery Model

References -

Nursing Care and Recovery Model

Recovery Model

Solution Focused Therapy

Cognitive Behavour Therapy

The focal point of this therapy is that client’s difficulties and its causes are not discussed but rather exploring their strengths and resources that they hold which may help them.

Cognitive therapy is a treatment type, exploring a vast number of interventions to treat psychological disorders (Hofmann et al., 2014) and may benefit Tom by assisting to reconstruct his social environment.

Although cognitive therapy is a collaborative intervention, and is likely to be enforced by a psychologist, it is still important that we as nurses are able to follow up and encourage commitment to the therapy.

Overall, cognitive therapy involves regular correspondence between the client and the collaborative team. It involves constant reflection of his feelings and beliefs and to touch base with his current situation and whether the interventions are proving successful or not.

pinterest (2015)

"Imagine that tonight you go to bed and while you're asleep a miracle happens.The result of this miracle is that you wake up tomorrow morning and all the problems you've come here to talk about are solved. How would you know, or what would be the first thing you notice that tell you this miracle has happened?"

‘On a scale of zero to ten, where zero is ‘I can’t do this’ and ten is ‘I am employed’ where do you think you sit right now?’

The five principles at the core of the recovery model are Hope, Personal responsibility, Connectedness, Discovery and Active sense of self (Queensland Health, 2005).

huffingtonpost (2015)

Therapeutic Relationship

A therapeutic relationship will be established from the very first meeting but a real therapeutic alliance will take some effort, skill and time to establish. Nine key components have been validated by the Dziopa and Ahern (2009) literature review that encompass the competencies needed to achieve this, and all of these are relevant for Tom.

These competencies are:

• Understanding and empathy
• Individuality
• Providing support
• Being there/Being available
• Being Genuine
• Promoting Equality
• Demonstrating Respect
• Demonstrating clear boundaries
• Demonstrating self awareness

Cultural Safety

Cox, L., & Taua, C. (2013). Sociological Considerations and Nursing Practice. In P.

Potter, A. Perry, J. Crisp, & C. Taylor. (Eds.). Fundamentals of nursing, (pp. 321 - 345) (4th ed.). Chatswood, NSW: Elsevier Australia

De Oliveira, I. (2014). Trial-Based Cognitive Therapy [EBL version]. Rourledge: NY. Retrieved from http://www.tandfebooks.com.ezp01.library.qut.edu.au/doi/view/10.4324/9781315754918

Dziopa, F., & Ahern, K. (2009). What makes a quality therapeutic relationship in psychiatric/mental health nursing: a review of the research literature. Internet Journal Of Advanced Nursing Practice, 10 (1), 1-19. Retrieved from

http://sf5mc5tj5v.search.serialssolutions.com.ezp01.library.qut.edu.au/?genre=article&issn=15236064&title=Internet%20Journal%20of%20Advanced%20Nursing%20Practice&volume=10&date=20090528&atitle=What%20makes%20a%20quality%20therapeutic%20relationship%20in%20psychiatric%2Fmental%20health%20nursing%3A%20a%20review%20of%20the%20research%20literature.&spage=1&pages=1-19&sid=EBSCO:CINAHL%20with%20Full%20Text&aulast=Dziopa%20F

Eisendrath, S.J., Gilung, E.P., Delucchi, K.L., Chartier, M., Mathalon, D.H., Sullivan, J.C., Segal, Z.V., & Feldman, M.D. (2014). Mindful-based cognitive therapy (MBCT) versus the health-enhancement program (HEP) for adults with treatment-resistant depression: a randomized control trial study protocol. BMC Complementary and Alternative Medicine, 14 (95). Retrieved from http://go.galegroup.com.ezp01.library.qut.edu.au/ps/i.do?id=GALE%7CA362091957&v=2.1&u=qut&it=r&p=HRCA&sw=w&asid=ff895fec0d361e05f66b13cd57962ff6

Evans, N., & Evans, A. (2013). Solution-focused approach therapy for mental health nursing students. British Journal of Nursing, 22 (21), 1222-1226. doi: http://dx.doi.org/10.12968/bjon.2013.22.21.1222

Ferraz, H., & Wellman, N. (2008). The integration of solution‐focused brief therapy principles in nursing: A literature review. Journal of Psychiatric and Mental Health Nursing, 15 (1), 37-44. doi:10.1111/j.1365-2850.2007.01204.x

Fowler, J. (2007). Using solution-focused techniques in clinical supervision. Nursing Times, 103 (22), 30-31.Retrieved from http://www.nursingtimes.net/using-solution-focused-techniques-in-clinical-supervision/199240.article

Happel, B., Cowin, L., Roper, C., Lakeman, R., Cox, L. (2013). Introducing mental Health Nursing: A service user-oriented approach. (2nd Ed.). Crows Nest, NSW: Allen & Unwin.

Hofmann, S.G., Asmundson, G.J.G., & Beck, A.T. (2014). The Science of Cognitive Therapy. Behaviour Therapy, 44 (2), 199-212. doi: 10.1016/j.beth.2009.01.007

Hus, V., Gotham, K., & Lord, C. (2012). Standardizing ADOS Domain Scores: Separating Severity of Social Affect and Restricted and Repetitive Behaviors. Journal Of Autism And Developmental Disorders, 44 (10), 1-6. doi:10.1007/s10803-012-1719-1

Iveson, C. (2002). Solution-focused brief therapy. Advances in Psychiatric Treatment, 8 (2), 149-156. doi:10.1192/apt.8.2.149

New South Wales Department of Health. (2004). Framework for Suicide Risk Assessment and Management for NSW Health Staff [Booklet]. North Sydney, NSW: Author.

Queensland Health (2005). Sharing Responsibility for Recovery: Creating and sustaining recovery oriented systems of care for mental health [Booklet]. Queensland Government, Brisbane. Retrieved from http://www.health.qld.gov.au/mentalhealth/docs/Recovery_Paper_2005.pdf

Strazdins, L. (2007). The mental health costs and benefits of giving social support. International Journal of Stress Management, 14 (4), 370-385. doi: 10.1037/1072-5245.14.4.370

Thomas, A., & O'brien, J. (2008). Depression and cognition in older adults. Current Opinion In Psychiatry, 21 (1), 1. doi:10.1097/YCO.0b013e3282f2139b

Wand, T. (2010). Mental health nursing from a solution focused perspective: Solution focused mental health nursing. International Journal of Mental Health Nursing, 19 (3), 210-219. doi:10.1111/j.1447-0349.2009.00659.x

• It is impossible to truly know the culture of all service users but what we can do is to know one's own culture.
• So the first step to delivering culturally safe care is that of self reflection and self awareness by looking carefully at ourselves before we look at Tom in detail (Happel, Cowin, Roper, Lakeman, Cox, 2013, p. 351).
• As the nurse patient relationship is inherently bicultural and our culture will impact the client in some way.
• This will require compassion and sensitivity and exemplifies the use of the nurse as a therapeutic instrument (Happel et al., 2013, p. 297).
• A culturally safe nurse will also recognize the importance of power in the delivery of care and will focus on making Tom a partner in care thus enhancing trust, building rapport and promoting equality as part of the therapeutic alliance (Happel et al., 2013, p. 357).