Interpersonal and intrapersonal aspects of mental health nursing

Interpersonal / Intrapersonal Aspects of Mental Health Nursing

The following essay aims to examine and explore a ‘critical incident’, in which I was involved, which took place during a clinical placement. This assignment will discuss the use of both adaptive and maladaptive stress coping mechanisms displayed by the participants, evident during and after the incident; and will also attempt to explain them, using relevant psychological models. Before exploring the concept of stress coping mechanisms, it may be useful to define the term ‘stress’; Selye (1946) states that stress is "the non-specific response of the body to any demand for change". Lazarus and Folkman (1984, p.19) elaborate, referring to stress as a "relationship between the person and the environment that is appraised by the person as taxing or exceeding his or her resources and endangering his or her well-being". Stress affects everyone (D'Antuono and Reid, 1998), and is a normal part of everyday life; however, BUPA (2003) report that “stress-related medical problems are becoming increasingly common”, which carries clear implications for all healthcare professionals.

Chesney et al (2006) state that ‘adaptive coping’ refers to methods of coping, which lead to the successful management of a stressful situation; adding that the term ‘maladaptive coping’ describes coping techniques which do not adequately “regulate distress” (in the long-term) or fail to solve the original, underlying problem. These definitions are supported by Cincinnati Children's Hospital Medical Center (2006) who report that the term ‘adaptive coping’ pertains to dealing with stress effectively, and that the term ‘maladaptive coping’ refers to an “ineffective” response to stress, which can potentially lead to harm to the individual or others; maladaptive stress coping techniques can be utilised with relative success for short periods of time, but repeated use of these techniques over longer periods of time can potentially serve to ‘exacerbate’ the stress levels of the individual (Nagata et al, 2000). However, despite the clear distinctions made here between the terms ‘adaptive coping’ and ‘maladaptive coping’, it is interesting to note that Anderson and Arnoult (1985) suggest that behaviour, which is considered to be adaptive for one person, may be considered to be maladaptive for another; the issue of adaptive coping and maladaptive coping is one of “judgement” (Myors et al, 2001); which consequently creates “methodologic challenges in the study of coping” (Hopkins et al, 2005).

According to Fisher (2002) the term ‘critical incident’ pertains to a “snapshot”, “vignette”, or “brief episode” of interest from a significant personal experience. The incident, in which I was involved, took place whilst escorting a patient who had been admitted to and detained in hospital under Section 3 of the Mental Health Act (1983) following a deterioration in his mental state. In order to respect the confidentiality of the patient in question, and to conform to the code of conduct as outlined by the Nursing and Midwifery Council (2004), throughout this essay I will refer to the patient as Jeremy.

Jeremy had recently started to utilise periods of escorted leave within the local vicinity of the hospital, for up to an hour, with one healthcare professional. Jeremy had been receiving treatment for a number of weeks, and during this time his mental state had appeared to improve; Jeremy was no longer overtly expressing psychotic symptoms as he had previously done during his admission, and due to the successful and appropriate use of escorted leave preceding this incident, it was felt among the nursing team that on this occasion Jeremy could be escorted to the nearby supermarket.

He reported to staff that he intended to buy some toiletries and cigarettes, and appeared to be motivated by this. However, shortly after arrival at the supermarket, Jeremy began to appear increasingly uneasy and agitated, and was unable to concentrate on the task of purchasing his intended shopping. The supermarket was busy, and Jeremy became very distracted by the presence of other customers; therefore I suggested that if he preferred, we could leave and return at a time when the supermarket would be less busy and less crowded. However, Jeremy was adamant that he wanted to complete his shopping.

As we walked through the supermarket Jeremy became impulsive and began collecting unnecessary items, which were not on his shopping list. When I questioned Jeremy about this he responded in a very aggressive manner, immediately dismissing my query and suggestion to be mindful of his budget. Jeremy continued to impulsively select items, and failed to collect any items at all from his shopping list. When attempting to pay for the goods it became clear that Jeremy did not possess the necessary amount of money required; Jeremy then attempted to pay for the goods using his ‘library card’.

Cannon (1932) describes the psycho-physiological response to stress as one of ‘fight or flight’; Cannon (1932) suggests that the body responds to stressful or threatening situations in one of two ways; either attempting to overcome the situation (fight), or attempting to escape the situation (flight). Jeremy later revealed to a staff nurse of the ward that he had been experiencing auditory hallucinations whilst in the supermarket. One might argue that the excessive noise and crowds of the supermarket may have been a contributory factor to the high levels of stress and the symptoms experienced here by Jeremy; Eysenck and Flanagan (2001) support this notion, reporting that stress can ‘trigger’ the appearance of symptoms (for example, hallucinations) for people with a predisposition to mental illness.

The ‘fight or flight’ model would suggest that Jeremy was attempting to cope with the stressful situation of being in the busy supermarket by using a ‘fight’ response; this notion is reinforced by the fact that Jeremy declined the offer to leave the supermarket and return at a less busy time, which one may have considered to be a response of ‘flight’.

However, one may also argue that Jeremy was, in fact experiencing a response of ‘flight’, due to the impulsivity he displayed when he was collecting his shopping, as if in a rush to get out of the supermarket. Jeremy may have impulsively selected items because he was unable to concentrate, and therefore unable to collect his intended shopping; Jeremy may also have felt unable to explain how he was feeling to me, as I was a relatively new member of staff and he may have done this in attempt to retain some dignity by disguising how he was feeling. This view is supported by Nagata et al (2000) who report that the impulsive behaviours exhibited here by Jeremy are maladaptive, and may have been the “consequences” of his attempt to cope with the stress of the incident. Furthermore, one may argue, that my initial response to Jeremy may have also been maladaptive. Jeremy did not appear to feel safe enough to disclose his feelings and anxieties to me; this may suggest that my response was not as therapeutic as it could have been, causing Jeremy to disguise his feelings and therefore contributing to his increasing stress levels.

Whilst in the supermarket I began to feel inadequate, as my interventions did not appear to help Jeremy and seemed to increase or add to his stress. I felt unable to cope on my own and was torn between a desire to escape the situation, and my professional obligation to stay with and help Jeremy. Welker-Hood (2006) reports that for nurses, “job stress” can potentially create a stress response “in which neither fight nor flight is perceived to be possible”. Despite my inability to help Jeremy and my feelings of inadequacy I decided to adhere to my duty of care and responsibility for Jeremy. Stuart and Sundeen (1995, p.13) suggest that the stress of the incident and “inadequate staff support” may have led to the “depletion” of my “personal resources”, and therefore caused me to doubt or question my “clinical competence” and “professional initiative”. The Nursing Standard (2001, p.17) supports this, reporting that “inadequate preparation to deal with the emotional needs” of Jeremy, and a “lack of staff support” could have contributed to my feelings of “isolation”, “inadequacy” and “helplessness”; adding that this is likely to lead to “poor job performance” and also lowers “work productivity”; therefore one can assume that my response was maladaptive.

The limitations of the ‘fight or flight’ model are highlighted by Bracha et al (2004) who argue that since the model was first presented, more than seventy years ago, “important advances” have been made in our understanding of the response of the body to stress, suggesting that the model may need “updating”. It is also interesting to note that Gross (2001, p.175) states that the psycho-physiological changes that take place within the body during a stressful experience, which are described in the ‘fight or flight’ model are “irrelevant to most of the stressors we face in modern life”. Gross (2001) suggests that these changes are intended to help the individual cope with potentially dangerous and life-threatening situations, which are not usually encountered nowadays in the modern world. Furthermore, Gross (2001) emphasises the impact of this, adding that whilst these responses may have been considered to be adaptive responses to stress for our ancestors, in the context of the modern world, they may even be considered to be maladaptive responses.

Jeremy and I returned to the hospital without the shopping, as Jeremy was unable to pay. Whilst walking from the supermarket back to the hospital, Jeremy presented as quiet and would not initiate or participate in conversation. After the incident and our return to the ward Jeremy continued to present as verbally uncommunicative, and then isolated himself in his bedroom.

Selye (1956) describes the response of the body to stress in the ‘general adaptation syndrome’ model. Selye (1956) states that there are three stages in the response; the ‘alarm stage’; the ‘adaptation stage’; and the ‘exhaustion stage’. The ‘alarm stage’ is experienced in the form of “anxiety”, which Selye (1956) would suggest corresponds with the agitated and uneasy behaviour exhibited by Jeremy in the supermarket, and also with his distraction and lack of concentration. The ‘adaptation stage’ can be described using the term “homeostasis” (Selye, 1956) or the term “coping” (Lazarus, 1966). The ‘alarm stage’ and the ‘adaptation stage’ are often associated with the ‘fight or flight’ model (Stuart and Sundeen, 1995). The ‘exhaustion stage’ occurs when it is not possible to overcome the stressful or threatening situation, and Selye (1956) would argue that this stage of the model corresponds with the withdrawn and isolative behaviour displayed by Jeremy after the incident. Altschul and Sinclair (1986, p.15) report that this stage can be potentially harmful, “as the physiological changes aroused in the first stage can become intensified and permanent pathological states can develop”; Stuart and Sundeen (1995) reiterate the dangers presented by the ‘exhaustion stage’, reporting that excessive stress, if not overcome or neutralised can ultimately lead to death.

Following the incident, it transpired that Jeremy had attempted to obtain alcohol and cannabis from a visitor to the hospital. This clearly illustrates that Jeremy was attempting to cope with the stress of the incident; Blanchard et al (1999) suggest that “expectancies of tension reduction, negative emotions, and avoidance coping” may have catalysed the attempt made by Jeremy to use alcohol and drugs. However Brady and Sinha (2005) report that the use of alcohol and drugs are widely viewed as methods of maladaptive coping. Despite this, Solomon (2001) suggests that the use of alcohol may be considered to be an adaptive method of coping if used only in the short-term; which one might argue suggests that Jeremy may have attempted to use alcohol and drugs as a method of coping with the stress of the incident because it had worked for him with relative success previously. This is reinforced by Hopkins et al (2005) who report that certain stress coping strategies may be adaptive on one occasion, but maladaptive on another (for example, during periods of illness).

The impact of changes to the health or illness status of an individual on the appropriate use of coping strategies is further emphasised by Myors et al (2001) with reference to pregnant women; stating that the changes in health status inherent in becoming or being pregnant then cause certain coping strategies to switch from adaptive coping techniques to maladaptive coping techniques. Myors et al (2001) report that although excessive eating, smoking and the use of alcohol, are all commonly used coping strategies, which can be considered to be adaptive if used only in the short-term; in the “context” of a pregnant woman these behaviours are viewed increasingly as maladaptive. This reinforces that health and illness can impact upon which coping techniques are to be viewed as adaptive or maladaptive; suggesting that the use of alcohol and drugs would have been a maladaptive method of coping for Jeremy, especially in the context of his mental illness.

Blanchard et al (1999) report that substance abuse occurs “frequently” alongside mental illness as a maladaptive method of coping, “with significant detrimental effects to clinical outcome”. However, Blanchard et al (1999) also report that high stress levels are “thought to elicit substance abuse” as a method of coping; a view supported by Brady and Sinha (2005) who suggest that repeated and chronic stress may lead to the progressive use of more maladaptive coping strategies over time, suggesting that the stress experienced preceding and during the incident may have influenced the choice of coping strategy employed by Jeremy.

However, according to both D'Antuono and Reid (1998) and Hodapp et al (1998) even very young children experience regular stresses, and both also report that from a young age children begin to develop both adaptive and maladaptive methods of coping. This is important, as it suggests that the methods of coping, which are learned during these key developmental stages “may be precursors of patterns of coping throughout adulthood” (Gould et al, 2004), which implies that Jeremy may have learned such maladaptive coping techniques during his childhood. McGovern and Whitcher (1994, p.220) support this notion, reporting that “early experiences affect the way we behave in adulthood”, adding that methods of coping “can be handed down from parent to child, thus perpetuating possible poor ways of coping with difficulties faced throughout life”. Furthermore, it is reported by Nagata et al (2000) that the use of one maladaptive coping method may induce the use of another maladaptive coping method, suggesting that a “chain reaction” of maladaptive coping can be induced; Parle et al (1996) support this view, describing a “maladaptive cycle of coping”.

However, it is interesting to note that patterns of adaptive coping can also become obsessive, and over time can develop into maladaptive coping patterns (Albucher et al, 1998). Furthermore, the repeated use or reliance of the same coping method may lower its ability to “reduce threats, fears, and anxiety” (Khouzam, 1999). Psych Central (2006) suggest that this may be promoted by “a need for sameness and consistency” and an expected “sense of security”; adding that this can potentially cause adaptive coping techniques to become maladaptive methods of coping, through becoming “time-consuming”, ritualistic or “distressing”.

Holmes and Rahe (1967) report that the ability of an individual to cope with stress and recover from illness can decrease following a significant or stressful life change. Wilson and Kneisl (1996) state that this may be because the occurrence of stressful life events places an increased demand on the ability of an individual to cope; furthermore, Gross (2001) reports that the occurrence of a stressful life event may also increase the susceptibility of the individual to mental illness. Jeremy had experienced a number of stressful events as outlined by Holmes and Rahe (1967) preceding the incident, including personal illness (leading to his admission to hospital), a change in his financial state, a change in his living conditions and a temporary change in his residence; and one might argue that these events could therefore be contributory factors towards the high levels of stress experienced by Jeremy, and indeed his mental illness. Altman et al (2006) reinforce this argument, reporting that stressful life events are strong “predictors” for “episodes” and “relapse” of mental illness; adding that “minimal stress can cause a subsequent episode” of illness, or increase the period of recovery for the individual.

Hodapp et al (1998) report that the repeated use of maladaptive coping methods by an individual can consequently create an increase in the stress levels of those around them, emphasising the impact of maladaptive coping on others. Furthermore, according to the Nursing Standard (2001) the use of maladaptive coping techniques, and the poor management of stress are detrimental for both “employers” and the “healthcare system”, as they can potentially lead to an increase in sickness and “absenteeism”, and as a result, an increase in “costs”; one may argue that this adds significant weight to the case for healthcare professionals to promote the use of adaptive methods of coping among patients and users of the healthcare service.

However, according to the Nursing Standard (2001, p.17) “a certain amount of stress is required to live and enjoy life”; a view reinforced by Welker-Hood (2006) who reports that “a certain amount of positive stress” can be useful, adding that it can help to increase performance and focus “attention and mental acuity”, referring to this as “eustress”. Despite this, the potential effects of stress cannot be denied, and it is highlighted by Ewles and Simnett (1992) that there is a need for healthcare professionals to promote the use of adaptive coping strategies. Myors et al (2001) suggest that there is a need for “educational programs” with a placed emphasis on the use of adaptive coping methods, and limiting or “reducing” the use of maladaptive coping techniques. “Coping skills are potentially modifiable” (Pilowsky et al, 2004) and furthermore, Myors et al (2001) report that there is a continual need throughout life to “create new ways of coping” due to the demands and changes which are encountered. Furthermore, Hopkins et al (2005) state that the “identification” of both adaptive and maladaptive coping methods which are employed by patients, “may contribute to improvements in support and quality of care”, through creating “a better understanding of coping” and allowing greater scope to “teach” methods of adaptive coping.

This essay has discussed the stress responses evoked in the participants of a ‘critical incident’, and the use of both adaptive and maladaptive coping strategies that followed. This assignment illustrates the relevance and importance of psychology in the study of coping, and demonstrates the need for mental health professionals to reflect on such ‘critical incidents’ involving their patients.

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