COMMUNITY HEALTH NURSING

SEMINAR ON

COMMUNITY MENTAL
HEALTH

SUBMITTED TO SUBMITTED BY

Mrs. Remadevi PR Sameena V

Assistant Professor II MSc Nursing

Govt. College of Nursing Govt. College of Nursing

Thrissur Thrissur

SUBMITTED ON:
 "The difference between a healthy person and one who is mentally ill is the fact that
the healthy one has all the mental illness and the mentally ill person has only one"

(Robert Musil)

INTRODUCTION
Mental illness is an important constituent of optimum health. Mental health is
essential for a healthy and successful life. Mental and physical health is interrelated, and that
is the reason behind the popularity of saying 'healthy mind in healthy body'.

Burden of mental disorders had risen over last few decades. Mental health is a state of
well being in which the individual realizes his/her own abilities, can cope with the normal
stresses of life, can work productively and is able to make a contribution to his or her
community. WHO established that globally over 450 million people suffer from mental
disorders. Currently mental and behavioral disorders account for about 12% of the global
burden of diseases. This is likely to increase to 15% by 2020. Major proportions of mental
disorders come from low and middle income countries.

DEFINITION
The application of knowledge of psychiatric nursing in preventing, promoting and
maintaining mental health of people to help in early diagnosis and care and to rehabilitate the
clients after mental illness.

(B.
Kapoor)

The process of involving raising the level of mental health among people in a
community and reducing the number of cases suffering with mental illness.

(K. Lalitha, 2005)

CONCEPT
The community mental health services were focused to render the health care services
in familiar home environment, where the client will be at ease; stress elated to hospital
environment can be avoided. The client will develop adaptive coping strategies very easily to
overcome the stressors related to mental illness.
 The services will be provided to total population in geographical area rather than
specific client alone. Following services are provided in consultation with community mental
health nurse:

 Education
 Crisis intervention
 Family therapy
 Group therapy
 Psychotherapy
 Interaction skill training
 Promotive, preventive and rehabilitative services
 Follow up services.

MAGNITUDE OF MENTAL DISORDERS IN INDIA

Epidemiological studies are important in understanding the magnitude of the problem

in the community, the need for services, understand the historical trends, calculate morbid
risk and identify etiological factors in the causation and distribution of the mental disorders.
In India, during the period of 1964-1995, there were a large number of general population
epidemiological studies. Interestingly, during the last 15 years there have no similar studies
of the general population, except the one that is part of World Health Survey, which provides
new information about prevalence and treatment utilization with regard to psychosis from
World Health survey (WHO, 2006)

BURDEN OF THE DISEASE

(GBD - Global Burden of Diseases, DALY - disability-adjusted life years, YLL - years of life
lost, YLD - years lived with disability.)

GLOBALLY

In 2010, mental and substance use disorders accounted for 1839 million DALYs (95%
U1 153-5 million-216-7 million), or 7-4% of all DALYs worldwide. Such disorders
accounted for million Y LLs (6.5 million-12.1 million; 0.5% 0.4-0.71 of all YLLs) and 175.3
million YLDs (144.5 million-207.8 million of all YLDs). Mental and substance were the
leading cause Of YLDs worldwide. Depressive disorders accounted for (31.7-49.2) of
DALYs caused by mental and substance use disorders, with anxiety disorders accounting for
(11.2—18.4), illicit drug use disorders for alcohol use disorders for schizophrenia for7.4%
bipolar disorder for 7% developmental disorders for 4-2% ( 3.2-5.3), childhood behavioral
disorders for 3.4% (2.2-4.7), and eating disorders for 1.2% (0.9-1.5). DALYs varied by age
and sex, with the highest proportion of total DALYs occurring in people aged 10-29 years.
The burden of mental and substance use disorders increased by 37.6% between 1990 and
2010, which for most disorders was driven by population growth and ageing. (Global Burden
of Disease Study 2010).

 Nearly 1 million commit suicide every year

 5 to 10 million attempt to commit suicide every year
 In 2010, mental and substance use disorders accounted for 183.9 million Disability
Life Years of all DALYs.
 Mental and substance use disorders were the leading cause of Years Lived with
Disabilities (YLDs) worldwide. Among the DALYs
 Depressive disorders: 40.5%
 Anxiety disorders: 14.6%
 Illicit drug use disorders: 10.95
 Alcohol use disorders: 9.6%
 Schizophrenia: 7.4%
 Pervasive developmental disorders: 4.2%
 Childhood behavioral disorders: 3.4%
 Eating disorders: 1.2%

INDIA

The life time prevalence of mental disorders range from 12.2% to 48.6%. The
Ministry of Health and Family Welfare suggests that 6-7% of India's population suffers from
mental disorders with about 1% suffering from severe mental disorders. Mental illnesses like
Schizophrenia and Bipolar disorder are prevalent in about 200 cases per 10000 people. The
burden of these disorders is likely to increase to 15% by 2020. Burden of mental disorders
seen by the WHO is only a tip of iceberg. A study conducted in NIMHANS Bangalore shows
that, the burden of mental and behavioral disorders ranged from 9.5 to 102 per population. A
study conducted in Pune in 2012 reported the overall life time prevalence of mental disorders
to be nearly 5 percent. Males were reported to be at higher risk. Major cause was depression
followed by substance abuse and panic disorders and 25% of the mentally ill in India are
homeless.

Mental illness is definitely a burden to India, there remains to be a massive treatment

gap. A consultant with the National Institute of Mental Health and Neuro Sciences, in an
interview suggested that while it is desirable to have at least one psychiatrist per 100 people
in the general population, India has less than one psychiatrist for every people, most of whom
practice in urban areas where treatment costs are prohibitively high. With over 70 million
people mentally ill in India, there are approximately only 3000 psychiatrists, psychiatric beds
and only 43 mental health hospitals. The vast treatment gap is not about the numbers only;
the conditions of existing infrastructure are extremely poor.

TRENDS IN COMMUNITY MENTAL HEALTH

Trends British Era

Indian mental health is a child born to British parents and bred in Indian culture.

 The Indian Lunacy Act (1912) was based on the British legislation then in force. The
history of Indian psychiatry runs parallel to British psychiatry and the basic structure
remains the same even to this day.
 Creation of Asylums: To keep the dangerous lunatics and severely disturbed cases. or
when relatives were unable to manage them, owing to poverty or other constraints.
 European Mental later the Hospital for Mental Diseases and the Central Institute of
Psychiatry, Ranchi was meant almost entirely for European patients and was staffed
by British Army doctors.
 The treatment of lunatics was in the hands of church. This even accorded death as the
severest punishment for insanity and faith healers also treated mentally sick.
 In 1943, Dr. Fraser had written an article in the British Medical Journal on ganja
psychosis. The UK psychiatrists studied the cultural taboos in India about intoxicating
and showed great interest in this addiction.
 The birth of the Royal Medico Psychological Association, the precursor of the Royal
College of Psychiatrists in the 1960s, marks the of scientific psychiatry in England
and India.
  First Indian Psychiatrist to be recognized by the Royal College of Psychiatrists is
Professor Narendra Wig.

MENTAL HEALTH CARE IN INDEPENDENT INDIA

 Indian mental health professionals continued to care the mentally sick in asylums and
custodial in its outlook, which imposed limits on the number of patients who could
receive services.
 Non-specific psychotherapy and Western models of psycho analysis were practiced.
 Nursing care for patients was provided by general nurses.
 The research literature focused primarily on in depth psychological understanding of
mental disorders, focusing primarily on the individual.

MENTAL HEALTH CARE IN EVOLUTION INDIA

 Enhancing the capacity of the mental health infrastructure to serve a greater number
of services seekers.
 Improving the quality of services in custodial institutions and developing innovative
approaches in noncustodial settings.
 Increased the number of mental institutions: At the time of India had about
institutions for the mentally ill, with 10 of them having been built prior to the 20th
century.
 The concept of a day hospital is another important innovation in the 1960s.
Integrating mental health with general health -19.33 the 1st General psychiatric Unit
(GHPU).
 GHPU began its collaboration with department of neurology and were often termed as
neuropsychiatric clinics.
 In the 20 years that followed independence, 90 GHPU came into existence.
 It was a struggle to get a few beds allotted psychiatric patients in the general medical
psychiatric patients were shifted to OPD
 GHPUs became more accessible than the institutions. Comprehensive medical
psychiatric patients became easily available.
 In 1970s, slow and steady reduction beds custodial institution, growth in and Out
patient services were seen.
 Occupational therapy and recreational facilities were introduced.
 Between 1960-1972, the research focus was on the magnitude and nature Of mental
health problems in the community.
 Family intervention concept was introduced by Dr. Vidya Sagar at the Amritsar
Mental Hospital. At the same time Mental Health Centre, Christian Medical College
(CMC) Vellore also introduced family involvement in patient care. It was practiced at
NIMHANS in the 1960s and culminated in the opening of the family ward.

MENTAL HEALTH CARE SERVICES AS ON TODAY

 The development of disabilities as a consequence of social isolation and

institutional care in remote asylums led to the de-institutionalization movement.
 The focus shifted to community based care, which became the basis of the
National Mental Health Program (NMHP) that was launched in India in 1982.
 At present District Mental Health Program (DMHP) is under implementation in
25 districts, spread across 20 states/union territories (UTS).
 Hon'ble Supreme Court orders dated 15 October, 21m empowered the central
government to obtain necessary information from the states to project
comprehensive mental health services in the country.
 The Mental Health Act, 1987 and the State Mental Health Rules apvvar to have
made little impact were identified.
 The Hon'ble Supreme Court in CWIP NO. 334 of forced the state governments to
enforce licensing regulatory supervisions relating to private psychiatric clinics and
nursing homes.
 Custodial atmosphere in most mental hospitals has to be changed.
 Mapping of mental health
 Mental health resources were examined from all states/UT.s between May and
July 2002. The findings and suggestions are as follows:
 Severe manpower shortages in all categories of mental health personnel but are
more among clinical psychologists, psychiatric social workers and psychiatric
nurses.
 Uneven distribution of these scarce resources.
 Proposed mental health plan
 To relocate long stay patients into the community.
 Refractory patients (who cannot place back into their families) may be admitted as
paid patients in district/sub divisional hospital/Federal Government hospitals near
their hometown and maintenance therapy can be continued by physician.
 Legal steps under the provisions of the MEIA, sections 79 and 80, may be taken to
recover the cost of maintenance.
 With community based mental health care facilities in place through the DMHPs,
early identification and treatment of those suffering from mental disorders.
 Restrategized NMHP (2003) proposes to implement the DMHP in 2(K) districts
across the country, along with strengthening the departments of psychiatry in an
equal number of medical colleges and of 37 government mental hospitals.
 It is suggested to start crisis Intervention Units in at least one medical college in
each state and the unit will consist of one psychiatrist, one psychiatric social
worker, one psychiatric nurse and one psychiatric nursing orderly.
 The National Mental Health policy and The National Health (NHP.2002) covers
mental health.
 DMHP covers only 25 out of 593 districts across India.
 Uneven distribution of psychiatric services.
 Most of the mental hospitals are physically dilapidated, still gives custodial rather
than therapeutic
 Many psychiatric patients are in the hospital for more than 5 year.
 The observations are (NMHP2001).
 Teaching of psychiatry at the under graduate level remains inadequate
 The average doctors are ill equipped to deal with mental illness.
 Postgraduate training in medicine and allied specialties has no psychiatric
component taught, although 40% of population attending general hospital OPD
suffers from emotional rather than physical problems.
 Worthwhile research, especially in the field of community psychiatry is limited to
a few institutions such as NIMHANS, AIIMS, etc.
 Vision 2020 (NMHP) calls for an urgent, time-bound remedial action plan which
would ensure:
 Accessibility of at least basic psychiatric facilities within the community to as
large a section of the population as possible in all parts of the country.
  Affordability of the services with regard to initial capital cost as well as recurring
expenditure (including that on essential drugs) to accord with our limited
resources and low income level of the consumer population.
 Adaptability to the widely varying geographical, socio-cultural and economic
mosaic of our vast country.
 Acceptability of mental health care by the target population in the context of low
levels of literacy, ignorance, superstition, economic backwardness and lack of
empowerment of women, adolescents and children.
 Assessment of performance at the ground level through continuous monitoring

CHALLENGES AND ISSUES FOR MENTAL HEALTH

CARE INDIA

 Large "unmet need" for mental health care in the community

 Poor understanding of psychological distress as requiring medical intervention in
the general population
 Limited acceptance or modern medical care for mental disorders among the
general population
 Limitations in the available of health services (professionals and facilities) in the
public health services
 Poor utilization of available services by the ill and their families
 Problems in recovery and reintegration of persons with mental illness
 Lack of institutionalized mechanisms organization of mental health care

BARRIERS

 Funding in the initial period

 Limited undergraduate training in psychiatry
 Inadequate mental health of human resources
 Limited number of models and their evaluation
 Non-implementation of the MHA , 1987
 Privatization of health care in the 1990s
THE CHANGING FOCUS OF CARE
The Methods of treating mental illness have changed dramatically in the past century.
Community mental health as a treatment philosophy was mandated by the Community
Mental Health Act of 1963 thus bringing about the shift of mental health care from the
institution to the community, and heralding the era of deinstitutionalization.

Before 1840, there was no known treatment for individuals who were mentally ill.
Because mental illness was perceived as incurable, the only "reasonable" intervention was
thought to be removing these ill persons from the community to a place where they would do
no harm to themselves or others. Philippe Pinel, the Director of asylum of Bicetre in France,
William Tauke in England and Beniamin Rush in United States led a movement against the
ill treatment of mentally ill the asylums and started human care and removed physical
restraints.

In 1841, Dorothea Dix, a former schoolteacher, began a personal crusade across the
land on behalf of institutionalized mentally ill clients. The efforts of this "inspector" resulted
in more human treatment of persons with mental illness and the establishment of 32 hospitals
for the mentally ill. Most hospitals were built in the rural Thus the concept of community
mental health came in to practice. After the movement initiated by Dix, the number of
hospitals for persons with mental illness had increase although unfortunately not as rapidly as
did the population with mental illness. The demand soon outgrew the supply, and hospitals
overcrowded and understaffed, with conditions that would have sorely distressed Dorothea
Dix.

The book 'A Mind That Found Itself" written by an ex-psychiatric patient Clifford W
Beers (1908), exposed the awful conditions in the mental hospitals. This lead to the formation
of National Mental Health Association in USA to fight for better care to the mentally ill,
which in turn paved the way for Mental Hygiene movement. Adolf Mayer in 1909
management of mentally ill patients outside the institution and proposed a comprehensive
community mental health approach.

The community mental health movement had its impetus in the 1940s. With
establishment of the National Mental Health Act of 1946, the U.S. government awarded
grants to the states to develop mental health programs outside of state hospitals. Outpatient
clinics and psychiatric units in general hospitals were inaugurated. Then, in 1949, as an
outgrowth of the National Mental Health Act, the National Institute of Mental Health
(NIMH) was established. The U.S. government has charged this agency with the
responsibility for mental health in the United States.

In 1955, the Joint Commission on Mental Health and Illness was established by
Congress to identity the nation's mental health needs and to make recommendations for
improvement in psychiatric care. In 1961, the Joint Commission published the report, Action
for Mental Health, in which recommendations were made for treatment of clients with mental
,illness, training for caregivers and improvements in education and research of mental illness.
With consideration given to these recommendations. Congress passed the Mental Retardation
Facilities and Community Mental Health Centers Construction Act (Often called the
Community Mental Health Centers Act) of 1963. This act called for the construction of
comprehensive community health centers, the cost of would be shared by federal and state
governments. The deinstitutionalization movement ( the closing of state mental hospitals and
discharging of individuals with mental illness) had begun. Unfortunately, many state
governments did not have the capability to match the federal founds required for the
establishment of these mental health centers. Some communities found it difficult to follow
the rigid requirements for the eservices required by the legislation that provided the grant.

In 1980 the Community Mental Health Systems Act. which was to have played a
major role in renovation of mental health care, was established. Funding was authorized for
community mental health centers, services to high-risk populations. and for rape research and
services. Approval was also granted for the appointment of an associate director for minority
concerns at NIMH. administration set forth its intention to diminish federal involvement.
Budget cuts reduced the number of mandated services, and federal funding for community
mental health centers was terminated in 1984.

Meanwhile, costs of care for hospitalized psychiatric clients continued to rise. The
problem of the "revolving door" began to intensify. Individuals with severe and persistent
mental illness had no place to go when their symptoms exacerbated, except back to the
hospital. Individuals without support systems remained in the hospital for extended periods
because of lack of appropriate community services. Hospital services were paid for by cost
based, retrospective reimbursement: Medicaid, Medicare, and private health insurance.
Retrospective reimbursement encouraged hospital expenditure; the more services provided,
as the more payment received.
 Deinstitutionalization continues to be the changing focus of mental health care in the
United States. Care for the client in the hospital has become cost prohibitive, whereas care for
the client in the community is cost effective. The reality of the provision of health care
services today is often more of a political and funding issue than providers would care to
admit. Decisions about how to treat are rarely made without consideration of cost and method
of payment.

MODELS OF COMMUNITY HEALTH NURSING

Four models have dominated the community mental health movement since 1963.
Each one has been influenced by the political. Social and economic climate of that period.
Individually and together they have contributed much to the field and the best part of each
model continued to be used today. They are

1. Public health model

2. Biological- medical model
3. Systems model
4. Patient centered model

PUBLIC HEALTH MODEL

In this model patient' is the community rather than the individual and the focus is on
the amount of mental health or illness in the community as a whole including the factors that
promote or inhibit mental health. The emphasis in this model is reducing the risk of mental
illness of an entire population by providing services to high risk groups. Use of this model by
a mental health professional required a wide range of skills by the mental health professionals
which includes community need assessment, identifying or prioritizing the target or high risk
groups and intervening with new treatment modalities such as consultation, education and
crisis intervention.

1. COMMUNITYNEEDSASSESSMEVT

In the public health model services are developed and delivered based on a culturally
sensitive assessment of community needs. Since it is not possible to interview each person in
the community to determine mental health needs four techniques are used to estimate service
needs.
Social indicators: It infers needs for service from descriptive statistics found in public
records and reports, especially those statistics that are highly correlated with poor mental
health outcomes. Examples of statistics most commonly used as social indicators are income,
race, marital status, population density, crime and substance abuse.

Key informants: Key informants are people knowledgeable about the community needs.
Typical key informants are public officials, clergy, social service personnel, nurses and
primary care physicians.)

Community forums: in a community forum members or the community are invited to a

series of public meetings were they can express their ideas and beliefs about mental health
needs in their community.

Epidemiological studies: epidemiological studies examine the incidence and prevalence or

mental disorders in a defined population. Because they are expensive to carry out most
community need assessment results from previously published studies and apply these
findings in their community.

2. IDENTIFYING AND PRIORITIZING TARGET GROUPS

When the data from the various community needs assessment are analyzed, specific
high risk groups begin to emerge. For example socio-economic data might show that a large
number of elderly widows live in the community. Community forums and surveys of key
informants may find there are few services and programmes for the elderly and
epidemiological studies might suggest that elderly widows living alone are at high risk tor
depression. Therefore elderly widows might become a target group for programme
development and intervention. Intervening with high risk group in the community can include
primary, secondary or tertiary prevention activities.

Primary prevention - target people are at risk for developing psychiatric illness and promote
their adaptive coping mechanisms.

Secondary prevention: target people who show early symptoms of an emotional disorder
but regain level of functioning through aggressive case finding and treatment.

Tertiary prevention: targets those who are mentally ill and helps to reduce the severity,
discomfort and disability associated with their illness.
3. INTERVENTION STRATEGIES

Before the community mental health movement of the 1960s, most mental health
outpatient services consisted of office- based, individual psychotherapy sessions. Although
this may have been a good secondary prevention strategy, it did not promote mental health or
prevent emotional problems on a community wide basis. New treatment strategies that were
developed to fulfill the goals of community mental health included mental health education,
crisis intervention and mental health consultation.

4. ROLE OF NURSE

Public health nurses were closely seen allied with secondary and tertiary prevention
activities, the medical model and the care of the sick. Therefore the chronically mentally ill
patients were referred to the public health nurse; few nurses were invited to join psychiatry,
psychology and social work as professional staff in most community mental health services.
In addition nursing education was slow to curricula and change clinical practice to reflect this
shift in care to the hospital to the community. As a result, most nurses felt unprepared to
function in the community and were unable to create a role for themselves. With few
expectations, the nurse's role in community mental health centres was limited to traditional
nursing tasks such as monitoring and caring for the chronically mentally ill.

2. BIOLOGICAL - MEDICAL MODEL

In the mid 1970's several events turned public attention to the second mission of the
community mental health movement- the care of the diagnosed mentally ill. A new political
administration, the waging of an expensive war in Vietnam, and a general economic down
turn stimulated a national discussion regarding the best use of scarce health care resources. At
the same time public disillusionment with the deinstitutionalization of the chronically
mentally ill lead to questions about the cost of community mental health centres with their
focus on prevention rather than care of those who were already ill.

Families of the mentally ill had also become a force in the late 1970's. Their agenda
was at least two fold- l) to force as many resources as possible toward the care of those with
severe and persistent mental illness and 2) to use their political strength to direct federal
research dollars toward finding a biological basis for the major mental illness. Psychiatrists
with their new on the biological model of psychiatry and family groups thus became allies
and thus formed a coalition that put biological psychiatry in a strong leadership position in
the mental health field.

Financial pressure also brought about a change in the focus of mental health centres.
As the beginning of the community mental health movement the federal government has
promised to of the cost of each centre. Regulations stated that federal support would decrease
by 15% each year until by the eighth year of their existence the centres were expected to self-
supporting through a combination of state funds and third party reimbursement. By the early
1970's many of the centres faced the end of federal funding and state governments were
unable or unwilling to take on the burden of funding these centres. The centres then had to
rely heavily on the third party reimbursement through fee for service mechanisms which were
typically physician and illness oriented. Centres thus began to focus on the diagnosis and
treatment of the deinstitutionalized severe and mentally ill primarily through the reimbursable
services of medication management and psychotherapy.

Since centres were not allowed to reduce the five original essential services and were
not given sufficient funds to add these new services, decisions about priorities had to be
made. Because of the political and social pressure to care for the mentally ill who were
discharged in to the community in large numbers, the community mental health centres
reluctantly decreased their preventive efforts and moved toward the increased use of medical
model and the care of the diagnosed mentally ill.

DEINSTITUTIONALIZATION

Between 1965 and 1 975 nearly 500000 patients were either discharged or diverted
from state hospitals to care in the community. It was hoped that psychiatric treatment in the
community centres combined with living arrangements by family or board and care homes
would allow these mentally ill patients to live more human lives in their own communities. It
rapidly became clear however the policy makers had seriously miscalculated both the service
need of this population and the ability of community to accommodate the large number of
mentally ill that had been discharged from the state hospitals. Frequently these former
patients had to be readmitted within one year. Others who could not meet the increasingly
strict admission criteria of the state hospitals drifted into the criminal justice system or in to
homelessness. Many who were elderly were admitted to nursing homes. In reviewing the
failures of this early attempt to move mentally ill patients in to community care mental health
experts agree that the following problems contributed to the lack of success.

 Poor coordination between the state hospitals and the community mental
health centers.
 Underestimation of the support systems that was necessary to allow mentally
ill persons to live in the community.
 Lack of knowledge about mental health rehabilitation.
 Underestimation of community resistance of deinstitutionalization.
 Shortage of professionals trained to work with this population in the
community.
 Reimbursement systems that rewarded hospitalization.

It was apparent by the 1980's that the biological medical model of community mental
health may not be able to provide the psychological and social supports that were needed to
allow the severe and persistently mentally ill to live successfully in the community.
Professionals began to search for a more comprehensive model of care that would take into
account all aspects of a person's life.

ROLE OF NURSE

Nurses began to play a more important role in community mental health care during
the 1970's and 1980's. Initially nurses worked in aftercare programmes providing support
coordination of care and health teaching. Gradually those responsibilities grew to those of
nurse therapist in individual, group and family therapies with a variety of community mental
health patients, not only the chronically mentally ill. In 1975 a NIMH task force examined
the staffing needs in mental health and existing training programmes. The result was a new
NIMH policy mandating that to be eligible for NIMH training grants, educational
programmes had to address the needs of unserved and underserved populations including
children. the chronically mentally ill, minorities and women.

The outcome of this mandate was the nursing school faculty began to reach out to
community mental health centres to develop clinical placements for nursing students In this
process, faculty were able to educate central administrators about the scope of nursing
practice and variety of skills, in addition to medication administration and monitoring, that
nurse could bring to the community setting. At the same time, curricula in nursing school
were revised to reflect this new practice setting. Crisis intervention, brief therapy,
counselling, assessment and diagnosis skills were emphasized as nurses began to take their
place as members of the interdisciplinary team in community mental health centres while
struggling to keep their unique identity.

3. SYSTEMS MODEL
The systems model of community mental health emerged in the 1980's and operated
on the philosophy that all aspects of an individual's life needed to be cared for - basic human
needs, as well as need for psychiatric treatment and rehabilitation.) The focus of this model
was on developing a comprehensive system of care and co coordinating needed services into
an integrated package. This model of community mental health emerged as it became
apparent that mental health treatment would not allow people with severe and disabling
mental illness to live successfully in the community. Special federal initiative was launched
in 1977 to assist state and communities to develop comprehensive services for this
population. This initiative was lead by NIMH, which began to fund demonstration
programme for community support systems in many ways.

COMMUNITY SUPPORT SYSTEMS

Community mental health centres were given primary responsibility the development
and implementation of community support systems for individuals in their service areas.
These systems were to be guided by certain principles. In implementing these systems, case
management became the primary means for ensuring that the components of the service
system were available to every person with a chronic mental illness who need them. These
components included client identification and outreach mental health treatment, crisis
response services, health and dental care, housing, support and entitlement, peer support,
family and community support, rehabilitation services and protection and advocacy

PRINCIPLES OF COMMUNITY SUPPORT SYSTEM

 Persons with long term mental illness should have access to specialized mental health
services and the support needed the individuals.
 Services should be consumer centered and based on the needs of the individual rather
than the needs of the system or provider.
 Services should empower people.
  Services should be racially and culturally appropriate.
 Services should be flexible.
 Services should focus on strength.
 Services should be offered in the least restrictive and most natural setting.
 Services should meet special needs.
 Service systems should be accountable.
 Services should be coordinated.

CASE MANAGEMENT

Case management services are aimed at linking the service system to the individual
and coordinating the service components so that the individual can achieve successful
community living. It include problem solving to provide continuity of services and overcome
problems of rigid systems, fragmented services, poor utilization of resources and problems of
inaccessibility. The 6 activities that form the core of case management are the following

Identification and outreach- to encourage states to provide case management services, the
federal government passed the State Comprehensive Mental Health Service Plan, which
required that case management services be provided to every mentally ill individual in a state
that requires a significant amount of public funds or services. A comprehensive mental health
service plan must have strategies to locate potential individuals, inform them of available
services and ensure their access to these services.

Assessment - a thorough assessment of individual's strengths and deficits is required for an

effective service plan. Assessments addressed all aspects o a person's life including
psychological, physical, financial, medical, educational, vocational, social and housing needs
Particular emphasis is placed on identifying that can be compensate for weakness and
understanding patients cultural and health related values and beliefs

Service planning- a comprehensive service plan guides all case management activities and
must be carefully formulated with individual and family involvement. The goal of the service
is to assist the person to live in the community successfully. Since many of these people have
histories of numerous psychiatric hospitalizations, the service plan should include new
approaches that might interrupt the chain of events that previously led to rehospitalization.
Treatment objectives and specific actions that will be taken should also be clearly stated.
Linkage with needed services- a major component of case management is linking the
mentally ill with the various social, medical and rehabilitative services that they need to live
successfully in the community. Once again, this activity often requires a team approach, since
the services needed are often diverse and span a broad range of the agencies. Various services
includes mental health treatment, crisis response services, health and dental care, housing etc.

Monitoring the service delivery- monitoring is an important part of service delivery and is
often difficult to implement successfully. The monitoring function of case management
serves two basic purposes

1. It ensures that the objectives of the service plan are being met,

2. It provides the information necessary for an ongoing reevaluation of the plan.

The case manager assist the individual in obtaining the services identified in the
service plan. Since the needs of the mentally ill are unusually complex and require the
services of multiple agencies, the case manager must develop coordinating and facilitating
skills. Periodic review of the individual's progress with each of these service providers is part
of the case manager's duties. Information obtained from these contacts should also be used in
regular reviews of the overall service plan.

Advocacy - assisting people to the available services and influencing providers to improve
existing services and develop new ones are also important roles of the case manager.
Psychiatric patient and their families struggle with issues of discrimination, stigma, rights and
inadequate resources on a daily basis. Advocacy activities are sensitive to this injustice and
are proactive in nature. They include political negotiation as well as consumer and
professional collaboration. Finally it is essential to advocacy efforts to be sensitive to the
cultural background of the individual and the norms and the values of the community.

ROLE OF NURSE

The systems model of community mental was based on a holistic approach that
focused on the caring and the curative aspects or service delivery. Case management, in
particular allowed nurses to assume direct care, supervisory and consulting roles while
working with patients and families by

 Serving as their gate keepers and in accessing the health care system.
 Assisting them in making informed decisions about their health care needs
  Monitoring their health and human service plan of care
 Educating them to enhance their self care ability

4. PATIENT- CENTERED MODEL

Although the system model of community mental health contributed to an improved
and more coherent service delivery system for the mentally ill, new problems and population
began to emerge.

DUAL- DIAGNOSIS PATIENT

Individuals with dual diagnosis have a substance abuse problem and a psychiatric disorder.
Unfortunately mental health and substance abuse services have traditionally been funded and
staffed separately, and the substance abuse problems of patients treated in the mental health
system have often received little attention. Mental health providers tend to treat the
psychiatric condition and then refer the patient elsewhere for substance abuse treatment.

YOUNG SERIOUSLY MENTALLY ILL

Young individuals with serious mental illness Often do not fit into current programmes and
use the mental health system sporadically, primarily in times of crisis.

HOMELESS MENTALLY ILL

Mentally ill patients who are homeless reflect the tension between a mental health
system that views housing as a social welfare problem and public housing agencies that
believe that this population needs specialized residential programme provided by mental
health agencies. This results in the needs of this population being underserved.

INDIVIDUALS WITH AIDS/ HIV

Those with AIDS/HIV requires an intense service from the general health sector for
their many life threatening physical problems, but they also need psychiatric services to cope
with the emotional impact of physical deterioration and impending death. In addition 28% of
men and 52% of women with AIDS are intravenous drug users, thus they need to enter a
system of care that of substance abuse treatment. According to Mechanic. a viable frame
work for organizing effective delivery of mental health service must include provision of
assertive community treatment, use of capitation and managed care and appointment of local
health authorities.

ROLE OF NURSE

Current trends of shortened length of stay in psychiatric hospitals, use of alternatives

for hospitalization whenever possible, increased focus on patients with complex treatment
problems and the growth of community and family movements have had major impacts on
the ways in which mental health care is delivered in this country. A number of new
approaches are being implemented to overcome the clinical and system problems that have
interfered with providing patient centred care for the mentally ill. These represent unique
opportunities and challenges for nurses for nursing.

On one hand psychiatric nurses continue to struggle with their involvement in

community psychiatric care. Many community mental health centres are reluctant to hire
psychiatric nurse because they are too expensive compare with other mental health workers,
psychiatric nurses are also slow been slow to articulate the range and quality of services they
can provide in community setting thus demonstrating their cost effectiveness as health care
providers.

CASE MANAGEMENT- COLLABORATIVE CARE

CASE MANAGEMENT - DEFINITION

Case management is the coordination of community-based services by a professional

or team to provide people the quality mental health care that is customized accordingly to an
individual's setbacks or persistent challenges and aid them to their recovery.

FUNCTIONS

Case management is about engaging the clients in a process, not processing clients.
Hence, Rose and Moore in 1995 defined the following as case management functions:

1. Outreach or identification of clients

2. Assessment of individual needs
3. Service or Care planning
4. Plan implementation
 5. Progress monitoring
6. Regular review and Termination
The key issue for the service planners is to determine the optimal mix of services and
the level of provision of particular service delivery channels. The absolute need for various
services differs greatly between countries but the relative needs for different services, i.e. the
proportions of different services as parts of the total mental health service provision, are
broadly the same in many countries. Services should be planned in a holistic fashion so as to
create an optimal mix.

Figure shows the relationship between the different service components. It is clear
that the most numerous services ought to be self-care management, informal community
mental health services and community mental health services provided by the primary health
care staff, followed by psychiatric services based in general hospitals and formal community
mental health services, and lastly by specialist mental health services. The emphasis placed
on delivering mental health treatment and care through services based in general hospitals or
community mental health services should be determined by the strengths of the current
mental health or general health system. as well as by cultural and socioeconomic variables.
In a country like India, where majority of the mentally ill persons are living in the community
and where there are vast amount of unmet mental health service needs, it would be prudent to
utilize the approaches of self care and informal care. It is to be recognized as of date, efforts
in this direction has been limited. Most of the past quarter century of mental health planning
has been on integration of mental health with general health services. However, there are
pockets of self-care, informal care by the families (eg. mental handicap, schizophrenia) and
patient groups (eg. drug dependence) to point to the value of this approach to mental health
care. In order for this to become a reality, there has to be a paradigm shift in the organization
of knowledge, dissemination of information and skills and greater efforts towards
empowerment of the community. This is both a challenge and an opportunity for India. Self
care and informal care has a special relevance. Some of the issues related to functions and
competencies required are outlined in a recent document and summarized as follows.
 CRISIS INTERVENTION

INTRODUCTION
Stressful situations are a part of everyday life. Any stressful situation can give rise to
crisis. It is a kind of disequilibrium which requires problem solving approach in order to
preserve self esteem and promote growth. Crisis comes originally from Greek word 'Krises'
which means, 'separate' or 'divide'. Crisis can occur with any age and to anyone. It does not
respect age, socioeconomic or socio cultural difference. Crisis is a term commonly used in
own society for instances in which circumstances are suddenly altered.

Due to industrial development and industrial technology, people are more aware of
things and computerized technology, due to which lifestyle is also changed. Everywhere we
are finding competition through which tension and stress occur to the individual and which
create crisis. Sudden death, divorce and separation are other causes of crisis. Crisis is a
turning point resulting from a stressful event or threat to one's well-being.

DEFINITION

Crisis is a sudden event in one's life that disturbs homeostasis, during which usual
coping mechanisms cannot resolve the problem

(Lagerquist,
2001).

Caplan (1964) defines the crisis as psychological disequilibrium in a person who confronts a
hazardous circumstance that for him constitutes an important Problem which he can for the
time being neither escape nor solve with his customary problem-solving resources.

According to Rapport (1965), an essential property of crisis is the potential for promoting
growth. Crises Present challenges and call for new responses.

CHARACTERISTICS OF CRISIS

According to Kaplan and Sadak, the characteristics of crisis may be:

 It is precipitated by specific identifiable events.

  It is personal by nature.
 It is acute and not chronic.
 It has potential for psychological growth or deterioration.

Other characteristics includes

 Presence of both danger and opportunity

 A crisis is dangerous because the related stress may result in pathological behavior
such as injury to self or others.
 A crisis can be an opportunity because it may be the catalyst for the individual to seek
help.
 Crisis can provide the seeds of growth and change
 Many times a person will not seek help until they can admit that they do not have
control of the problem.
 No panaceas or quick fixes
 It is common that the failure of a quick fix to a problem may actually lead to a crisis
situation.
 The Necessity of Choice
 Choosing is proactive and deciding not to choose is actually a choice that typically
has negative results.
 Universality and Idiosyncrasy
 Crises are universal because no one is immune to them.
 Crises are idiosyncratic because individuals may react differently to the same
situation.
 Resiliency
 Perception
 It is the perception, not the event, that causes distress.
 Complicated symptomology
 Crisis is complex and defies linear causality.

TYPES OF CRISIS

Crisis can occur in a person by three ways:

 Individual crisis
 Family crisis
  Community crisis.

INDIVIDUAL CRISIS

MATURATIONAL CRISIS

It is also called the expected crisis. The expected ones are those periods that occur with some
degree of predictability as the result of maturation, e.g. stage of growth and development of
an Individual. It occurs during transition from phase of life to the next, such as from
childhood to adolescence and from adolescence to adulthood. For example, adolescent issues,
such as dating, sexual activity, career choice, etc.

SITUATIONAL CRISIS (UNEXPECTED CRISIS)

The unexpected is an accidental occurrence called situational crisis. These crises

follow anticipated sudden events over when no control can be exerted. For example divorce,
death, etc.

FAMILY CRISIS

MATURATIONAL CRISIS

Duvall and Miller developed a right stage family cycle based on variety of family pattern.
Age and child family function.

Stage l: Married couples

 Allocation of responsibilities
 New residence
 Learning how to live together on daily basis.

Stage II: Child-bearing

 New role of the parents

 Develop a patterning skill which includes money, energy, etc.

Stage Ill: Families with preschool parents

 First child between 21/2 and 6 years, when second child is born
  Need demand for adequate space and equipment.

Stage IV: Families with school children

 Children independence
 Parents must establish relationship.

Stage V: Families with teenagers

 Rapid physiological and psychological changes and bring a distinct set of problems
 Parents should limit and protect adolescents simultaneously allowing freedom.

Stage VI: Families launching young adults

 Marriage problem
 Family shrinking to the original pair, parents may in-laws and grandparents.

Stage VII: Families with middle-aged parents

 Children may leave the home

 Placement of members in the larger society
 Family members establish roots in society through relationships in church, school,
political and other organization which will protect the family members from
undesirable outside influences

Stage VIII: Families with aging members

 Retirement or ends with the death of both spouses

 Children may not meet the needs of elderly couple.

Situational crisis

Stressful, unanticipated events that may precipitate a family crisis include the birth of
a premature infant, death of family members, and diagnosis of serious illness.

COMMUNITY CRISIS

Maturational Crisis
Growth demands in health care services through government as education, safe water supply,
sewage utilities, and public safety. Fire protection. etc.

Situational Crisis

Situational crisis in a community can result from events, such as natural disasters or
the sudden influx of a large of refugees. Baldwin identified six classes of emotional crisis
which progress by degree of severity.

Dispositional Crisis

An acute response to an external situational stressor,

e.g. husband bit her wife due to stress at work place.

Crisis of Anticipated Life Transition

Normal life cycle transition that may anticipate but over which the individual may
feel a lack of control.

 Crisis resulting from traumatic stress

 Maturational crisis
 Crisis reflecting psychopathology.

PHASES OF CRISIS

The development of a crisis situation follows a relatively predictable Caplan (1964)

has outlines four specific phases through which individual progress in response to
precipitating stressor and which culminate in the state of acute crisis. During crisis the
anxiety increases, coping skill less available and less effective.

Phase I

The individual is exposed to a precipitating stressor. There is rise in tension. People

commonly experience feelings of discomfort and bewilderment from the impact of the
stimulus demands the habitat solving responses. Previous problems solving technique are
employed to a precipitating situation. Anxiety increases, previous problem solving technique
employed.
Phase 11

Previous problem solving technique does not relieve the stress, anxiety further. Coping
technique that helped in past are attempted. Individual begins to feel large deal of discomfort
and confusion. There is rise in tension produces lack of success and continuation of stimulus
due to failure of previous problem-solving technique.

Phase III

All possible resources (Internal/external) are used to resolve the problem and
discomfort. Individual tries to view the problem in different perspective and tries new
problem solving technique. The individual may try to view the problem from different
perspective or even to overlook certain aspect of new problem resolution may occur at this
phase.

Phase IV

If the problem continues and unable to solve because of its tension is beyond a further
threshold or its breaking point as a result it converts drastic results. Anxiety reach to panic
state, cognitive disorder, labile emotion and psychotic thinking may appear. In this stage the
person mobilizes internal and external resources and tries out new problem solving methods
or redefines the threat. So that the old methods can work. Resolution may occur in this phase.
If new or old problem solving methods are put into action and are effective.

CRISIS REFLECTING PSYCHOPATHOLOGY

Motional crisis in which preexisting psychopathology has instrumental or in which

psychopathology significantly impairs or implicates adaptive resolution. Examples Of
psychopathology that may precipitates crisis include border line personality, severe neuroses,
character logical disorder or schizophrenia (Baldwin 1978).

PSYCHIATRIC EMERGENCIES

Crisis situation in which general functioning has been severely impaired. The
individual rendered in competent or unable to assume personal responsibility. Example
actually suicidal individual, drug overdoses, reaction to hallucinogenic drugs, acute
psychoses, anger and alcohol intoxication.
SETTING FOR CRISIS INTERVENTION

Nurses works in many setting in which they see people in crisis:

 Hospitalization are often stressful for patient and their families and are precipitating
causes of crisis
 Nurses in community mental health center
 Department of psychiatry
 Schools
 Occupational health centers.

INDICATION FOR CRISIS THERAPY:

 The anxious mother

 The acting out adolescent
 Newly retired depressed attempt
 People with suicidal attempt
 Psychosomatic patients
 Survivors of sudden cardiac arrest
 Crime
 Accident victims
 Any death occurs in the family
 Persons with marital conflict
 Persons with drug abuse
 Persons with depression and anxiety.

CRISIS INTERVENTION

INDIVIDUAL CRISIS

 Eliminate hazardous situations which may produces crisis, e.g. ensure that work in a
safety guidelines are follows to prevent situational crisis.
 Identify vulnerable groups (Police, members of military) before exposure to stressful
situation.
  Provide anticipatory education about stress reduction and coping strategies.
 Advice those exposed to crisis producing situation about coping alternation and
available resources.
 Provide the knowledge about effectiveness of coping strategies through health
education.
 Provide additional, physical, social and informational resources to individual under
stress.

FAMILY CRISIS
Intervention for family crisis are:

• Provide information that is brief, consist and concrete family to record

• Ascertain comprehension by asking family to repeat to you to what information they
given
• Provide for or allow ventilation of feeling
• Maintain a nonanxious pressure in the face of family
• Inform family as to range of behaviors within the norm for crisis.

Denial

• Identify what denial is serving for family

• Evaluate appropriateness of use of denial in terms of time
• Do not actively support denial but neither hopes for the future
• If denial is prolonged and dysfunctional none direct and specific factual
representation may be essential.

Anger, Hostility, Distrust

• Allow for ventilation of angry feelings, clarifying thoughts, fears and beliefs
• Do not personalize family's expressions of these strong emotions
• Institute family control within the hospital environment when possible
• Remain available to families during their ventring of these emotions.

Grief and Depression

• Acknowledge family's grief and depression

 • Encourage them to be precise about what it is they are grieving about
• Allow the family appropriate link for grief
• Remain sensitive to your own unfinished business and hence, comfort or discomfort
with family's grieving.

Hope

• Clarify with families their hopes, individually and with one another
• Clarify with families their worst fear in reference to the situation
• Support realistic hope
• Offer gentle factual information to reframe unrealistic hope
• Assist families in reframing unrealistic hope in other fashion.

COMMUNITY CRISIS INTERVENTION

DISASTER SITUATIONS

The community response on disaster characteristically of four phases:

Heroic Phase

The heroic phase typically lasts through at least the first week post disaster. Of the
disaster pulls people together and emotions are strong. Large amounts of energy are expended
in rescue efforts, providing shelter and emergency stabilization. Emergency medical teams,
neighbors and friends rally around the survivors, offering emotional support and tangible
supplied needed for recovery.

Honeymoon Phase (Bowenkamp, 2000)

Honeymoon phase occurs when the commonly pulls together and outside resources
are brought in' after initial search and recovery phase. The honeymoon phase typically lasts
up to six months post-disaster. During this phase, survivors rely on the fact that different
agencies have made promises of aid and they trust that these will be fulfilled. Sharing the
experience of the trauma with others and tangible evidence of continuing support are crucial.
Emergency resource may start to withdrawn towards the end of the honeymoon phase and
this can increase survivor anxiety.
Disillusionment Phase

• This phase usually as the initial emergency response starts to subside. This phase can
last up to a year or more post disaster.
• People start to realize the extent of their losses. Survivors can experience anger, and
bitterness at the loss of support, particularly, if it is sudden and complete.
• It can feel like a double when, the previously felt of community investment in their
cause begins to fall apart.
• Kaplan, and Bodwer (2000) suggest that opportunities for psychological debriefing
sessions should continue for a period well the initial disaster for victims of extreme
Stress.

Reconstruction Phase

• The final phase reconstruction, occurs with the realization that the survivor will used
to bear the primary responsibility for rebuilding his or her life.
• Ongoing support is required as the survivor learns to cope with new roles and
responsibilities and to develop new alternatives to living a full life post trauma.
• This phase can last for several years with the individual gradually getting back to full
normal functioning after a disaster.
• Although the disaster experience records in memory, it is never lose and the person
never again fully trusts in the continuity of life.

Violence

Violence is a special form of crisis in that it involves the use of physical force and
demands and immediate response for the client's protection as well as that of others in the
client’s path (Cahill et al 1991).

It is a psychosocial emergency that can be just as critical as a life-threatening

medical emergency. Violence is associated with power and control, usually the perpetrator
feels powerless or out control and the behavior is a maladaptive attempt to restore emotional
balance. The cause of violent behavior is organic and the nurse should assure these in an
organic component until otherwise indicated, drugs and alcohol often are implicated. The
violent client must be stabilized immediately for the protection of self and others.
INDICATORS OF POTENTIAL VIOLANCE

Behavioral categories Suggested indicators

Mental status Confused
Mental status Paranoid ideation
Evidence of drug involvement
Organic impairment
Motor behavior Agilated
Pacing
Body language Eyes dazing
Spitting
Menacing posture
Speech pattern Rapid
Incoherent
Menacing tones
Verbal threats
These characteristic indications of increasing tension leading to violence.

Treatment of Violence Clients

• Providing a safe, non stimulating environment.

• The client should be checked thoroughly for potential weapons. Prevention of violent
behavior is best.
• The nurse can use simple strategies, such as calling the client by name, using a low,
tone of voice, or presenting a show of force if necessary to help the client defuse
tension.
• Encouraging the client to physically walk and to vent emotions verbally can be
helpful.
• Sometimes the environment is overstimulation and the client clause down if taken to
an area that provides less sensory input.
 PHASES OF CRISIS INTERVENTION BASED ON NURSING
PROCESS

Guilera and Messick (1982) have described four Specific phases in the technique of
crisis intervention. These phases are clearly comparable to the step of the nursing process.

PHASE 1 ASSESSMENT

In this phase the nurse gathers information regarding the precipitating stressor and the
resulting crisis. A nurse in crisis intervention might some of the following assessment. In this
phase the crisis helper collect data regarding the precipitating factor which causes stress. The
crisis helpers:

• Ask the client to explain the event and when it occurred

• Assess physical and mental status
• Whether previous coping mechanism tried and what is the result and also new one has
tried or not
• Assess for support system
• Assess individual's perception, strength, limitation etc.

CLIENT'S FEELINGS

• The nurse asks clients to the feelings they experience

• By accepting the feelings without judgment, the nurse assists clients to accept their
own feelings
• The nurse naturally will feel some discomfort in the presence of a in pain
• The human inclination is to stop the person from crying and to stop talking about
what is horrible and upsetting
• By avoiding the topic of distress, the client at least appears to be in less pain
• Nevertheless, it is beneficial for the person in crisis to express feelings and experience
the pain or frustration
• Therefore, the nurse must learn to tolerate these feelings of discomfort
• The nurse must understand cognitively and emotionally that ultimately Clients make
their own decisions.

Client's Perception of the Event

 • The nurse first determines the client's perception of the stressful event
• How threatened is the client
• Is the client realistic or distorting the meaning of event?

Client's Support Systems

After determining the client's perception of the event, the nurse focuses on who will
be available to support the client. Questions such as the following can help identify the
client's support systems: 'Whom do you trust?' , 'Who is your best friend?' , 'Is there a
member of your family with whom you are particularly close?

• The nurse also should inquire to the client's religious beliefs. For many families, god
is a source of comfort and strength.
• It is best to have people involved with the client.
• Because a crisis period lasts for a brief time and the nurse will be involved only
temporarily, the client needs others on whom to rely for continued support.

Client's Coping Skills

• The nurse must encourage the client to describe coping methods as possible.
• Then the nurse should determine whether the client's coping mechanisms are adaptive
or maladaptive.

Client's Potential for Self-Harm

• Assessment of clients in crisis is not complete without asking if they are having
thoughts of hurting themselves.
• Clients who have attempted suicide before or have attempted suicide before or have
decided how, when and where to kill they need protection.
• The suicidal clients should not be left alone.

NURSING DIAGNOSIS

Information from the comprehensive assessment is then analyzed and appropriate

nursing diagnoses reflecting the immediacy of the crisis situation are identified. Possible
nursing diagnosis for the client in crisis may include following:
 • Anxiety related to situation and maturational crisis, threat of self-concept, unmet
needs, and traumatic event. as evidenced by restlessness, insomnia, verbalizations, of
fear of going crazy, feelings of inadequacy, fearlessness and focus on self.
• Ineffective individual coping related to inadequate coping and personal vulnerability
as evidenced by inability to problem solves, altered participation, inappropriate use of
mechanisms in ability to meet role expectations and anxious mood.
• Altered thought process related to situational and maturational crisis, threat to self-
concept and high anxiety level, as evidenced by inability to problem solve or make
decisions, inaccurate interpretation of the environment, easy distractibility and
inappropriate affect or thinking.
• Impaired social interaction related to self-concept disturbance and unmet dependency
needs as evidenced by verbalized or observed discomfort in social situations,
verbalized or observed inability to receive or communicate a satisfying sense of
belonging and caring and dysfunctional interaction with peers, family and others.
• Social isolation related to high level of anxiety and possible regression, evidenced by
absence of supportive significant others (family, friends, and group) uncommunicated
and withdrawn behavior and preoccupation with own thoughts.
• Self esteem disturbance, altered role related to of overwhelming problem lack of
support systems and high anxiety level as evidenced by self destructive behavior, lack
of for self care, verbalization of worthlessness, inability to recognize own
accomplishments and lack of appropriate behavior

Planning

In the planning phase of nursing process, the nurse selected the appropriate nursing
activities for the identified nursing diagnosis. In planning intervention the type of crisis as
well as the individual strength and available resources for support are taken into
consideration. Goals are established for intervention.

Goal

The minimum therapeutic goals of crisis intervention are psychological resolution of

the individual's immediate crisis. To reach that end the following goals are set.

• Establishing a working relationship with the client

• Identifying the specific problem
 • Reducing the distortion of the clients perception of the event
• Improving the client's self esteem
• Decreasing the client's anxiety
• Promoting involvement of family and friends
• Reinforcing healthy coping mechanisms
• Validating the client's ability to solve the problem.

INTERVENTION

• Use a realty oriented approach

• Remain with individual who is experiencing panic anxiety
• Establishing a working relationship by showing unconditional acceptance, by active
listening or by attending the immediate needs
• Discuss lengthy explanation or rationalization of the situation
• Set firm limits on aggressive destructive behavior
• Clarify the problem that the individual is facing
• Help the individual determine what he or she believes precipited crisis
• Acknowledge feeling of angry, helplessness or any other
• Nursing intervention may take places in different level using a variety of technique in
a classic model shield described like a hierarchy from the most basic to most
complex.

EVALUATION

The last phase is evaluation when the evaluate the patient whether the intervention resulted a
positive resolution or not. If the goals have not been met she should be return to first step and
assessment continues again. It is the phase to evaluate the outcome of crisis intervention, i.e.
whether the stated objective has achieved or not. The resolution stage is often neglected as
once the level of the crisis is reduced teams often strive to pass people onto other services as
quickly as possible. The consequence of doing this is often a fairly rapid return to a crisis
situation.
CRISIS INTERVENTION MODEL
These include intervention that directly change the patient's physical or interpersonal
situation. These intervention provides situational support or remove stress.
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General Support

General support includes interventions that convey the feeling that the nurse is on the
patients side and ready to help the person.

Generic Approach

The generic approach is designed to reach rich individuals and large groups as quickly
as possible. It applies a specific method to all people faced with a similar type of crisis. The
expected course of the particular type of crisis is studied and mapped out. The intervention is
set up.

Individual Approach

The individual approach is a type of crisis intervention similar to the diagnosis and
treatment of a specific problem in a specific patient. The nurse must understand the specific
patient characteristics that lead to the present crisis and must use the intervention that is most
likely to help the patient develop an adaptive response to the crisis. It is particularly useful in
combined situational and maturational crisis. The introduced approach is also helpful when
symptoms include homicidal and suicidal risk. In these instances the nurse should make a
formal safety contract in which the patient agrees not to harm himself/herself or others.

CONCLUSION
Crisis is a sudden event in one's life that disturbs homeostasis, during which usual
coping mechanisms cannot resolve the problem. Stressful situations are a part of everyday
life. Any stressful situation can give rise to crisis. Types of crisis includes individual crisis,
family crisis and community crisis.

RESEARCH ARTICLES

Community mental health in India: A rethink

Rangawsamy Thara, Ramachandran Padmavati, Jothy R Aynkran & Sujit

John

Abstract

Background

Community care of the chronic mentally ill has always been prevalent in India,
largely due to family involvement and unavailability of institutions. In the 80s, a few mental
health clinics became operational in some parts of the country. The Schizophrenia Research
Foundation (SCARF), an NGO in Chennai had established a community clinic in 1989 in
Thiruporur, which was functional till 1999. During this period various programmes such as
training of the primary health center staff, setting up a referral system, setting up of a
Citizen's Group, and self-employment schemes were initiated. It was decided to begin a
follow up in 2005 to determine the present status of the schemes as well as the current status
of the patients registered at the clinic. This we believed would lead to pointers to help evolve
future community based programmes.

Methods

One hundred and eighty five patients with chronic mental illness were followed up
and their present treatment status determined using a modified version of the Psychiatric and
Personal History Schedule (PPHS). The resources created earlier were assessed and
qualitative information was gathered during interviews with patient and families and other
stakeholders to identify the reasons behind the sustenance or failure of these initiatives.

Results

185 patients followed up, 15% had continued treatment, 35% had stopped treatment,
21% had died, 12% had wandered away from home and 17% were untraceable. Of the
patients who had discontinued treatment 25% were asymptomatic while 75% were acutely
psychotic.

BIBLIOGRAPHY
1. Suryakantha A H. community medicine with recent advances:fourth editionjaypee
brothers medical publishers:New Delhi:2017
2. Dash Bijayalaskhmi. A comprehensive textbook of community health nursing:, jaypee
brothers medical publishers:New Delhi:2017