NATIONAL OPEN UNIVERSITY OF NIGERIA

COURSE CODE: NSC503

COURSE TITLE: MENTAL HEALTH AND PSYCHIATRIC NURSING III

COURSE CODE: NSC503 (4 CREDIT UNIT)

COURSE TITLE: MENTAL HEALTH AND PSYCHIATRIC NURSING III

Course Writers: Dr. J A Afolayan

COURSE REVIEWER: DR E C Ndie

Programme Co-ordinator: DR E C NDIE (H O D)

COURSE GUIDE

Contents

Introduction

The Course
Course Aims
Course Objectives
 Working through the course
Course Material
Study Units
Text Books

Assessment
Tutor Marked Assignment
Pen- On- Paper end of Course
Examination

Summary References/Further

Readings

1.0 Introduction

This course focuses on building on knowledge of psychosocial development

from childhood to adulthood and the understanding of human behavior in
health and illness and the knowledge acquired from NSC 314 (Mental
Health Nursing and Psychiatric Nursing I) and NSC 412 (mental health and
psychiatric nursing II) It is designed to equip the students to completely
employ nursing process and evidence base nursing practice in the
development of nursing care of Psychiatric clients. The course will expose
the students to specific mental health issues related to substance abuse,
therapeutic modalities in dynamics of human behaviours in the application
of interventions and the concept and practice of community mental health
nursing.
2.0 What you will learn in this course
The overall aim of NSC 503: Mental Health and Psychiatric Nursing III is
to enable you build on what you have learnt in Mental Health and
Psychiatric Nursing I and II as this course advanced on the previous one.
Some of the topics covered in this unit includes Substance Abuse,
Alcoholism, Epilepsy, Therapeutic Modalities in Psychiatry, Crisis
Intervention, Community Mental Health Nursing, Legal Aspects of Mental
Health Nursing, History Taking of Psychiatric Patients, Electro-Convulsive
Therapy, Occupational and Recreational Therapies, Rehabilitation and
Psychiatric Pharmacology.

3.0 Course aims

The aim of this course can be achieved by adequate response to the
following :
- .
- Outline the substances commonly abused.
- Explain the concept of alcoholism.
- Discuss various therapeutic modalities in psychiatry.
- Explain the concept of crisis intervention.
- Describe community mental health nursing.
- Discuss the legal aspects of mental health.
- Explain how history taking of psychiatric patients is carried out.
- Describe Electro-convulsive therapy.
- Discuss occupational and recreational therapy with the concept
of rehabilitation.
- Outline the various drugs used in psychiatry.

4.0 Course objectives

Each unit also has specific objectives which you need to read carefully and
you can always refer to them in the course of your reading to aid your self-
evaluation.
On successful completion of the course, you should be able to:
- Out-line the characteristics of substance abuses.
- Define alcoholism
- Discuss various therapeutic modalities in psychiatry.
- Discuss legal aspects of mental health nursing.
- Discuss crisis intervention.
- Correctly take history of psychiatric patients.
- Apply electroconvulsive therapy.
- Describe occupational and recreational therapies.
- Outline drugs used in psychiatry.

5.0 Working through this course

In order to successfully complete this course you are required to read the
study units, read reference books and other materials provided by the
university.

6.0 Course materials

Major components of the course are:
- Course Guide
- Study Units
- References/ Further Readings

7.0 Assessment
There are two aspects of the assessment of the course. Firstly, the tutor
marked assessment and secondly, there will be a written examination (final).
In dealing with the assignments, you are expected to apply information,
knowledge and strategies gathered during the course. The tutor marked
assignments are expected to be submitted to your study centre in accordance
with the directives of the university.

8.0 Tutor marked assignment

Each unit has tutor marked assignment questions at the end of the units.

9.0 References/Further Readings

 Table of Content

Module 1: Drug Abuse and Crisis Intervention

Unit 1: Substance Abuse

Unit 2: Alcoholism
Unit 3: Crisis intervention

Module 2: Therapeutic modalities in psychiatry

Unit 1: Somatic Therapy
Unit 2: Psychological Therapy
Unit 3: Therapeutic Milieu

Module 3: Community Mental Health Nursing

Unit 1: Community Mental Health Nursing

Unit 2: Legal aspects of Mental Health Nursing

Module 1: Substance Abuse and Crisis

Intervention

Unit 1: Substance Abuse

Table of Contents

1.0 Introduction
2.0 Objectives
Main Content
Introduction
Effects of drug abuse
Examples of drugs commonly abused
Causes of drug abuse
Principles of diagnosis
Underlying psychopathologic substances
Guide to management of substance abuse crisis
Methods of combating drug abuse and addiction
Socio-economic and psychological problems of drug abuse and
addiction
4.0 Conclusion
5.0 Summary
6.0 Tutor Marked Assignment
7.0 References

1.0 Introduction

Please recall that in the last unit, we examined organic mental disorders and
the effect of drugs on mental health, in this unit the learners will be exposed
to substance abuse (drug abuse and drug addiction).
2.0 Objectives

At the end of this unit, the learners should be able to:

- Define drug abuse and addiction
- Differentiate between drug abuse and addiction
- List five drugs commonly abused
- Enumerate some causes of drug abuse
- State the principles of diagnosis
- Describe the guide to the management of substance abuse crisis
- Methods of combating drug abuse and drug addiction
 - list four socio-economic and psychological problems of drug abuse
and addiction

Main content
Introduction
Drug abuse as defined by WHO has to be a persistent or sporadic excessive
use of a drug and that use of drug is inconsistent with or unrelated to
acceptable medical practice. With this definition, it shows that any drug can
be abused. Drug abuse itself is not an illness but it may and usually leads to
an illness. Although marijuana is the drug most extensively resorted to, the
sedatives, stimulants and hallucinogens are widely abused and addiction to
the “hard” narcotics has increased considerably. The variety of drug effects
and the constant introduction of new drugs and agents and rediscovery of old
ones have led to some confusion in the terminology of inappropriate or
inadvisable drug use.
DEFINITIONS OF TERMS; These are common terms used in substance
abuse
Misuse implies overzealous or indiscreet administration of drugs by
physicians. To misuse a drug might be to take it for the wrong indication, in
the wrong dosage, or for too long a period, to mention only a few obvious
examples.
Abuse implies the use of drugs for other legitimate medical purposes.
That is, abuse might be construed as any use of a drug for nonmedical
purposes, almost always for altering consciousness.
Drug dependence: Dependence is a biologic phenomenon. Psychic
Dependence is manifested by compulsive drug-seeking behaviour in which
the individual uses the drug repetitively for personal satisfaction. Heavy
cigarette smoking is an example. Physical Dependence is present when the
withdrawal of the drug produces symptoms that are frequently the opposite
of those sought by the user. It has been suggested that the body adjusts to a
new level of homoeostasis during the period of drug use and reacts in
opposite fashion when the new equilibrium is disturbed.
Addiction is usually taken to mean a state of physical and psychic
dependence, but the word is too precise to be useful.
Addiction as defined by „WHO‟ is a “behavioral pattern of drug use
characterized by overwhelming involvement with the use of a drug,
compulsive drug-seeking behaviour, and a high tendency to relapse after
withdrawal”. The W.H.O. stresses that “addiction should be viewed on a
continuum relative to the degree where drug use affects the total life quality
of the drug use and to the range of circumstances in which it controls his
behaviour”.
Effects of drug abuse
Some drugs when abused produce dependence with the following
characteristics:
(i) Compulsion to take the drug on a continuous or sporadic basis in
order to experience its psychic effects (psychological dependence).
(ii) Presence of physical symptoms when the drug is suddenly withdrawn
(withdrawal symptom).
(iii) Tolerance.
(iv) Detrimental effect on the individual and the society.

Substances commonly abused

(a) Common analgesics – e.g. aspirin
(b) Stimulants e.g. kolanuts, coffee
(c) Alcohol
(d) Sedatives e.g. barbiturates
(e) Amphetamine
(f) Cannabis (Indian hemp).

Causes of drug abuse

1. Habit formation
2. Peer group
3. Self-medication
4. Over-prescription of drugs by some doctors
5. Environment
6. Illnesses particularly emotional disorders.
7. Stress in homes and places of work

Principles of diagnosis
Substance abuse
Abuse is characterized by a pattern of pathologic use lasting for at least a
month and causing impairment in social and occupational functioning.
Pattern of Pathologic Use: Although the pattern varies depending
upon the substance used, it may be characterized by
(i) intoxication throughout the day”,
(ii) inability to cut down or stop use,
(iii) repeated efforts to control use through periods of temporary
abstinence or restriction of use to certain times of the day
(iv) continuation of substance use despite a serious physical disorder that
the individual knows is exacerbated by use of the substance,
(v) need for daily use of the substance for adequate functioning and
episodes of a complication of the substance intoxication
 (vi) Impairment in Social or Occupational-functioning: Behaviour may
include erratic, impulsive, or aggressive actions and failure to meet
important obligations to friends and family. Disturbed social
interaction is a consequence of intoxicated behaviour and personality
changes that may be produced by the psychoactive drug. There may
also be legal difficulties associated with behaviour during the
intoxicated state (e.g. car accidents) or criminal behaviour to obtain
money to purchase the substance. It is important to distinguish
criminal activity (e.g. theft) to perpetuate drug intoxication from
recreational drug use in conflict with local customs and laws.
(vii) Impairment in occupational functioning may include missing work or
school and inability to function effectively because of intoxication.

Substance Dependence
Substance dependence is a more severe form of substance abuse and it is
characterized by the following;
(i) Tolerance: Tolerance means markedly increased amounts of the
substance are required to achieve the desired effect, or there is
markedly diminished effect with regular use of the same dose.
(ii) Withdrawal: “In withdrawal, a substance specific syndrome follows
cessation of or reduction in intake of a substance that was previously
regularly used by the individual to induce a physiologic state of
intoxication”. Characteristics of the withdrawal syndrome vary with
the substance used. Frequently observed symptoms are anxiety,
restlessness, irritability, insomnia and impaired attention.
Multiple Drug Abuse
When the history includes use of more than one substance, multiple
diagnosis of substance use disorders should be made, except under the
following conditions:
1. when the specific substances cannot be identified;
2. when the substances used are from different (non-alcoholic)
categories or
3. when the substances abused cannot be classified – it is thus designated
as “unspecified, mixed, or other substances abuse” respectively.
Multiple drug abuse is common among drug abusers, and the resulting
 spectrum of symptoms often makes diagnosis and treatment difficult.
Drug tolerance is associated with some (but not all) patterns of drug abuse.
This diagnosis is complicated when multiple drugs are used, some of which
(e.g. sedative-hypnotics) may manifest cross-tolerance. An abuser of a
sedative-hypnotic such as a short-acting barbiturate or benzodiazepine may
combine use of drugs and alcohol, producing mixed addiction. Individuals
who abuse various drugs in the same group may develop substantial
tolerance but are not immune to the life-threatening consequences of the
drugs – e.g. they are often seen in emergency room after overdose or
associated dysfunction such as having a blackout while driving. These
serious consequences of substance abuse may be the first symptom of
addictive disease seen by the physician.

Underlying Psychopathologic Disorders

Individuals with primary substance use disorders should be evaluated for
underlying psychopathologic conditions such as an affective disorder or
thought disorder (or both problems such as medical diseases or
complications). Following detoxification from drug dependence, individuals
whose only problem is the primary addictive disease are better managed in
an abstinence-oriented treatment approach. Individuals who have both an
addictive disease and an underlying psychopathologic disorder may require
psychotropic medication following detoxification and are less well suited to
abstinence-oriented treatment.
Guide to management of substance abuse crisis
A. Assessment
This should include the following:
(1) Substance Used:
- Type of substance (or availability of sample for identification or
testing if the patient does not know the type).
- Route of administration (inhaled, ingested, injected etc.)
(2) Pattern and circumstances of substance use
- self-medication because of physical, mental or emotional problem
- concomitant use of prescription or over-the-counter medications
- Alternating or concomitant use of other drugs in the same drug
group.
- Identifiable events, such as loss or celebration, precipitating the
substance abuse crisis.
- If the drug is used habitually, pattern of development and method of
maintenance of habit.
(3) Extent of potential support system
- Family or friends available to help the patient follow through on
 treatment
- Community groups or agencies specifically addressing the patient‟s
abuse pattern.
(4) History of previous treatment
- Type and duration of treatment
- Results
(5) Other
- Effects of drug use on the patient‟s life (e.g. financial problems,
changes in physical appearance).
- Physical infirmity that could exacerbate the problem
- Willingness to change abuse habits.
B. Initial Management of the Crisis
Before treatment is begun, it is important to assure the patient of
confidentiality and explain the rationale for treatment and what to expect.
The patient‟s behaviour is observed carefully; vital signs are monitored, and
the patient is given only symptomatic treatment before the substance is
identified. No medication should be given if there is any question about
identification of the drug.
The goal of the 3 approaches listed is to achieve an alteration in the
patient‟s status or a favorable resolution of the crisis. Judgment must be used
in selecting the most appropriate approach in the circumstances.
(i) Assistance: The involvement of another individual or authority in
the substance abuse crisis often helps patients endure the crisis and workout
a personal solution. This gives them an opportunity for growth through
mastery of the crisis. Psychiatric emergency clinicians often directly involve
others or ask patients to recommend someone with whom they are
comfortable to reassure and guide them during the crisis.
(ii) Complete Management: Some cases require complete
management of the crisis by the clinician, as in the active treatment of drug
over-does.
(iii) Patient Education: In some instances, clinicians provide
additional information or resources so that patient can resolve their own
substance abuse crisis.
C. Follow-up Strategies
After crisis intervention for the drug overdose, medical management of the
complications and appropriate detoxification procedures, the physician
should evaluate the patient to determine if there are any associated physical
problems, persistent organic mental disorder or major underlying
psychopathological conditions. In most cases, the substance use disorder
must be viewed as the primary disease process. Fewer than 10% of patients
who have addictive disease have a major underlying psychopathologic
 condition.
However, if an underlying problem exists it is difficult to follow a drug-free-
abstinence-oriented approach to treatment, since the patient will often
require psychotropic medication for management of the psychopathologic
disorder. Antidepressants may be prescribed for a major depressive episode,
or an antipsychotic drug may be given for an underlying thought disorder.
For some patients with primary addictive disease, a drug maintenance
programmes (e.g. with methadone) may be implemented, but abstinence-
based recovery-oriented strategies should be tried first.
Most follow-up strategies are psychosocial in nature and include family
therapy and individual psychotherapy. Successful strategies include
participation in non-medical self-help groups, such as Alcoholics
Anonymous (A.A.) and Narcotics Anonymous. These programmes focus on
abstinence and emphasize the principles of recovery, with the group process
supporting and maintaining recovery. On occasion, the addict will require
residential therapy, typically in a highly structured behaviour modification
self-help community.
Follow-up care must be tailored to the individual‟s addictive disease process
and must be flexible enough to change as the patient‟s needs change. The
physician should recognize that addiction is a chronic, relapsing disease with
potentially fatal and consequences but that recovery is possible.

Methods of combating drug abuse and drug addiction

1. Legal Penalties: The government should make provision for penalties
that await offenders. Those who sell out dangerous drugs should be
adequately punished. There should be legal codes controlling buying
and selling of drugs. The Ports and Customs should be adequately
controlled. Adequate laws should be enacted.
2. Law Enforcement Agents: The Police together with the Pharmacists
should inspect shops, chemist shops and see to adequate storage and
dispensing of drugs. Offenders should be planned.
3. Health Education: The public should be educated regarding the use of
certain drugs especially without valid Doctor‟s prescription. The
public could be educated via Radio, Television, Public lectures and
mounting of Posters.
4. Provision of Effective and Efficient Health Care Delivery: There is no
doubt that if effective and efficient Health Care delivery is provided
by the Government, it will go a long way to reduce or discourage self-
medication and minimize risk of drug abuse and drug dependence.
 Socio-economic and psychological problems of drug abuse and
drug addiction
(i) Deviant Behaviours: Some people abuse drug in order to carry out
some deviant activities to the detriment of the health of the other
members of the society. For example, most of the vices are committed
under the influence of drug. Some people break into some houses after
taking some drugs.
(ii) Mental Illness: Some of the mentally sick in our society today have
abused drugs – sometimes in their life. Drug abuse and drug
dependence may result in any form of mental illness; and the more
mentally sick we have in the society, the more dangerous the society
will be for the rest of the populace.
(iii) Broken Homes: Experiences have shown that drug abuse and drug
dependence could result in broken homes.
(iv) Low Productivity: When many people who could have been engaged
in meaningful production are mentally sick, there will be a generally
low productivity output.
(v) Late Diagnosis of Disease: Some people treat themselves at home,
ignorantly and later come to the hospital when the disease would have
gone in an advanced stage. Some of them end up staying in the
hospital for a very long time while others die.
(vi) Death: Intake of an overdose of some drugs could easily lead to death.

4.0 Conclusion

The effects of drug abuse and drug addiction are preventable in any society.
In Nigeria, the Federal Government set up agencies in this direction like
NAFDAC so as to curb the incidence of substance abuse and its menace but
the success depends on every member of the society. Drugs have also played
a role in political history. For example, the opium wars of the nineteenth
century between China and Britain and the drug movement of the 1970s in
the United States changed the course of history. Even today, we are
struggling with political and social events that relate to drugs and other illicit
substances.
5.0 Summary

In this unit, the learner has gone through lecture on substance abuse (what,
how, who, where, when of substance abuse and its effects). The devastating
effects of substance abuse are alarming in our society, the prevention
requires the concerted efforts of all and sundry as the world of substance use
and abuse is always changing. As health care providers become more
familiar with current chemical fads, new and more potent drugs are
introduced.

7.0 References / Further Readings

Adedotun, A. 2000. Basic Psychiatry and Psychiatric Nursing, Ile-Ife:
Basag (Nig) Enterprises.
Olatawura, M. O. 2002. Psychology and Psychiatry Lecture Series
from Ibadan, Ibadan: Spectrum Books Ltd.
Morrison-Valfre, M. 2005. Foundations of Mental Care Missouri:
Mosby.
Staurt, G. W. and Laraia, M. T. 2001. Principles and Practice of
Psychiatric Nursing. 7th Ed. Missouri: Mosby. Inc.
Stellenberg, E. L. and Bruce, J. C. 2007. Nursing Practice Medical-
Surgical Nursing for Hospital and Community 2nd Ed.
London: Churchill Livingstone.
 Unit2: Alcoholism

Table of Contents

1.0 Introduction
2.0 Objectives
Main Content
Introduction
Types of alcoholism
Causes of alcoholism
Effects of alcoholism
Stages of alcoholism
Complications
Treatment
4.0 Conclusion
5.0 Summary
6.0 Tutor Marked Assignment
7.0 References/Further readings

1.0 Introduction

Alcohol is brewed in all cultures from time immemorial and is known to

have high abuse potential in all cultures so it should be considered with rapt
attention. This unit will expose you to the subject matter of alcoholism, its
meaning, types, causes, effects, stages, complication and treatment of
alcoholism.
2.0 Objectives

At the end of this unit, you should be able to:

- describe what alcoholism is
- state the types of alcoholism
- list the cause of alcoholism
- explain the effects of alcoholism
- enumerate the stages of alcoholism
- describe the complications and treatment of alcoholism
Main content
Introduction
Alcoholism is a syndrome consisting of 2 phases:
Problem drinking and alcohol addiction. Problem drinking is the repetitive
use of alcohol often to alleviate tension or solve other emotional problems.
Alcohol addiction similar to that which occurs following the repeated use of
barbiturates or similar drugs.
 Definition: The term „Alcoholism’ is a very general one and is used to
describe a state in which excessive indulgence in alcohol has become
harmful to the individual‟s physical or mental health, to his inter-personal
relations, or to his social or economic functioning. An „alcoholic‟ is a person
whose drinking pattern is having these consequences or beginning to show
the signs of their development. In contrast to the self-indulgent the heavy
drinker who drinks because he likes it, while the alcoholic is dependent on
alcohol and drinks because he must. Alcoholism is a major problem world-
wide.
Diagnostic Criteria for disorders associated with alcohol abuse and
dependence is stated below.
Alcohol abuse: is characterized by 3 criteria.

(1) A pattern of pathologic alcohol use, such as the need for daily drinks
or the presence of binges or blackouts.
(2) Impairment in social or occupational functioning due to alcohol use,
such as loss of a job or legal difficulties; and
(3) Duration of disturbance of at least one month.
Alcohol dependence: is characterized by 2 criteria.

(1) Either a pattern of pathologic alcohol use or impairment in social or

occupational functioning due to alcohol; and
(2) Either tolerance or withdrawal
Tolerance: is defined as a need for increased amount of alcohol to achieve a
desired effect or as a markedly diminished effect with regular use of the
same amount of alcohol.
Withdrawal: is defined as the development of alcohol withdrawal (certain
characteristic sign and symptoms, such as tremor, tachycardia, and
restlessness) after cessation of or reduction in drinking.
Types of alcoholism
Alcoholism is not a uniform disorder, and a number of different types
may be recognized.
Various methods of classification are known, but the following
represent the main groups.
(a) Habitual Excessive Drinkers: These people drink for pleasure or
social reasons and become habituated to it. They grow tolerance and no
physical or mental complications except that in some people, there may be
outbursts of disturbed behaviour loss of employment, financial difficulties
and disruption of family relationship.
(b) Habitual Symptomatic Excessive Drinkers: There is a
psychological dependence o alcohol which is needed to relieve physical or
 emotional discomfort. The drinking is thus a symptom of a disturbance in
another field.
(c) Periodic Excessive Drinkers: Some alcoholics are subject to
periodic bouts of heavy drinking (sometimes called “dipsomania”) but in
the intervals can often abstain or drink only moderately. Severe recurrent
anxiety or depression is sometimes the basis of such drinking.
(d) Alcohol Addiction: In the fully established addict, the bodily
metabolism has become adapted to the presence of alcohol. Physical
dependency has developed and sudden interruption of alcohol consumption
may lead to severe physical withdrawal symptoms. At first there may be
weakness, sweating, anorexia, nausea, irritability and restlessness; later
tremors, severe apprehension, hallucinations and convulsions may occur.
Causes of alcoholism
There is no single cause of alcoholism. Biomedical, psychologic and social
factors all play a role in its development and stressful events; sometimes
serve as catalysts of drinking behaviour.
The following factors contribute:
(i) National differences in drinking habits cost of alcohol, licensing laws and
wine production.
(ii) Social factors – probably make it more common in men than women.
(iii) It sometimes run in family but definitely not inherited.
(iv) The predisposing unstable personality may have some genetic basis; the
influence of the parental example is probably an important factor.
(v) Some shy and oversensitive individuals drink to be able to mix more
freely.
(vi) Some use as a sedative to reduce tension. It is also used to reduce
various mental conflicts or to escape from difficult life situations.
Effects of alcoholism
Increased alcohol use can lead to both physical and psychologic dependence,
which result in a number of important biomedical, psychological, and social
sequelae such as cirrhosis, depression, marital problems and occupational
problems. These sequelae themselves are stressful and lead to more
drinking, further dependence and additional sequelae - and the cycle
continues.
Other effects of alcoholism are classified into two:
Physical: Diminishing appetite with nausea and vomiting, especially in the
morning is commonly present and is due to “chronic gastritis”. This is to
some extent responsible for the vitamin B deficiency.
Mental: The alcoholic eventually may become selfish, inconsiderate,
deceitful and unrealiable in his behaviour. His mood may vary between self-
 pity, remorse and outbursts of violence. He‟s often suspicious of the wife
and accuses her of infidelity.
Stages of alcoholism
1. Pre-alcoholic: It is characterized by a gradual change in socially
motivated drinking to a means of relieving personal tension.
2. Prodomal phase: Begins when the need for alcohol is no more social,
rather it is psychological. It is characterized by sudden onset of black-
outs. They have guilty feelings and avoid reference to alcohol in
social gatherings.
3. The Crucial Phase: There is loss of behavioural control, drinking
become conspicuous. He tries to stop, but cannot stop. He is critical of
others; he does not like correction and becomes aggressive. He may
loose his job, friends and there is a decrease in sexual drive and
malnutrition sets in.
4. The Chronic Phase: There is marked ethical deterioration, impairment
of thinking and can drink with anyone regardless of status. He has lost
complete control and he gets hopelessly and helplessly drunk. He
starts to loose tolerance for alcohol because of Liver damage. He now
accepts defeat and is ready for treatment.
Complications
(1) Alcoholic Hallucinosis: This syndrome occurs either during
heavy drinking or on withdrawal and is characterized by a
paranoid psychosis without the tremulousness, confusion and
clouded sensorium seen in withdrawal syndromes. The patient
appears normal except for the auditory hallucinations, which
are frequently persecutory and may cause the patient to behave
aggressively.
(2) Delirium Tremens: It is an acute organic psychosis that is
usually manifest within 24-72 hours after the last drink (but
may occur up to 7-10 days later). It is characterized by mental
confusion tremor, sensory hyperactivity, visual hallucinations
(often of snakes, bugs etc), automatic hyperactivity,
diaphoresis, dehydration, electrolyte disturbances
(hypokalemia, hypomagnesemia), seizures and cardiovascular
abnormalities.
Delirium tremens is therefore a toxic state that occurs in response to
withdrawal or diminution of alcoholic intake. It is particularly common in
patients who are withdrawn from alcohol when admitted to the hospital for
treatment of phenmonia or fractures. Patient can be treated with sedation,
such as chlorpromazine, 100 mg 4 times daily orally; and paraldehyde
 12-16mls orally, in cold fruit juice or cracked ice. The duration of delirium
tremens is 2-7 days.
If patient is dehydrated, dehydrate with oral fluids or give dextrose and
saline solution intravenously; add Vit. Bco. intramuscularly. Because of the
frequency of convulsions, diphenylhydantoin (Dilantin), 100mg 3 times a
day orally, should be considered.
It has been suggested that the mental symptoms in alcoholic illnesses are not
due to poisoning by the alcohol but to vitamin B deficiency as a result of
faulty absorption from the stomach due to the alcoholic, gastritis usually
present.
Note: If alcohol is taken over long periods in large quantities permanent
structural damage may be done to the central nervous system resulting in
some permanent intellectual reduction and probably other mental symptoms.
Large quantities take over short periods, on the other hand, produce
symptoms of acute intoxication or poisoning which tend to clear-up fairly
rapidly and completely.
(3) Withdrawal Syndrome: When an alcoholic suddenly stops
drinking (especially the addicts) withdrawal syndrome results,
acute withdrawal syndrome results/occurs when the patient has
been hospitalized for some unrelated problem and presents as a
diagnostic problem.
(4) Korsakoff Psychosis: It‟s an organic brain damage that is
irreversible. It consists of marked loss of memory for recent
events, disorientation, confabulations.
(5) Wernicke’s Encephalopathy: There is disorientation,
associated with paralysis of ocular muscles, nystagmus, ataxia.
It is due to acute deficiency of vitamin B1.
Other complications are:
Liver Cirrhosis
Gastritis

Peripheral Neuritis
Cardiomyopathy
Chronic Brain Syndromes; Cerebellar degeneration; and Peripheral
neuropathies.
Treatment
Treatment should be directed first at the stage of dependence on drinking
and finally should attempt to explore and modify predisposing causes.
(i) Acute Stage: Unless the patient is in a very poor stage of health, alcohol
is usually withdrawn abruptly.
In heavy drinkers – prevent risk of fits and delirium tremens with
anticonvulsant drug and tranquilizers.
Presence of weight loss, salt depletion and malnutrition necessitates liberal
administration of fluids, salts, vitamins (often given parenterally in very
large doses) and glucose with small doses of insulin.
Tension and restlessness are controlled by tranquilizers of the Phenothiazine
group e.g. Largactil (given by injection). Large doses of Chlormethiazole 1-
2g in divided doses is given for delirium in heavy drinkers.
(ii) Long Term Treatment
(a) Apomorphine
This therapy attempts to induce a conditioned aversion to alcohol by
associating drinking with repeated nausea and vomiting. This treatment is
carried out in hospital and only if patient‟s condition is alright.
Patient is given in the morning 1/10gr. apomorphine injection (or Emetine)
at the same time 4 oz of 50% alcohol by mouth. Apomorphine is a powerful
emetic and induces nausea and vomiting.
Apomorphine injection and alcohol by mouth are repeated 2 hourly until the
evening of the third day. During this time, the patient is given injections of
vitamin B but is allowed no food and no fluids except alcohol.
On the evening of the 3rd day he has a normal meal and thereafter is given a
full diet and if necessary a course of modified insulin. He is given no more
alcohol and injections of apomorphine are tapered off by giving him 1/40gr
4 hourly for 24 hours and 1/80gr 6 hourly for 24 hours. The treatment
requires skilled nursing and vital signs are monitored regularly and charted.
(b) Antabuse (Disulfiram)
This is a drug which interferes with the breakdown of alcohol in the body so
that the toxic substance acetaldehyde accumulates in the blood and causes
unpleasant side effects. The effects of alcohol on a patient taking Antabuse
is usually dramatic.
Within a few minutes, his face becomes very flushed, his pulse rate rises and
he usually complains of headache, palpitation and breathlessness. The
patient having had this experience develops a negative attitude to alcohol
intake.
(c) Psychotherapy: Patient benefits from individual and group
psychotherapy. Either method aims at discouraging patient in drinking (i.e.
Apomorphine and Antabuse).
(d) Alcoholics Anonymous (A.A.)
The alcoholics, who generally feel misunderstood, rejected and ostracized by
society finds in this fellowship a body of people who have undergone
experiences very similar to his own. He feels understood, accepted and
achieves a feeling of belonging. He assists other alcoholics and in so doing
helps himself, gradually regarding his self-respect and self-confidence.
Alcoholic Anonymous (A.A.) is therefore a directive and inspirational form
of group therapy for Alcoholics.
(e) Other cares:
Nurses roles include: Psychological care, physical care, diet general
observations of rehabilitation of patient.

4.0 Conclusion

The practice of using substances to make one feel better is as old as humans
themselves. Even animals have been seen eating certain plants that change
their behaviours. Alcohol has played a role in many cultures throughout
recorded time. Many people think of alcohol as a stimulant because they feel
relaxation, alertness and pleasure when they drink. Actually these feelings
are caused by the depressant effects of alcohol on the central nervous
system. Once swallowed, alcohol is rapidly diffused to all the body‟s organs.

5.0 Summary

With continued use of alcohol, tolerance develops and individuals become

dependent on alcohol. If drinking does not stop, death from multiple organ
failure (especially the liver) results, usually after a series of assorted chronic
health problems.

6.0 Tutor Marked Assignment

What are the effects of alcoholism on the development of the nation?

7.0 References / Further Readings

Olatawura, M. O. 2002. Psychology and Psychiatry Lecture Series
from Ibadan, Ibadan: Spectrum Books Ltd.
Morrison-Valfre, M. 2005. Foundations of Mental Care Missouri:
Mosby.
Staurt, G. W. and Lavaia, M. T. 2001. Principles and Practice of
Psychiatric Nursing. 7th Ed. Missouri: Mosby. Inc.
Stellenberg, E. L. and Bruce, J. C. 2007. Nursing Practice Medical-
Surgical Nursing for Hospital and Community 2 nd Ed.
London: Churchill Livingstone.
 Unit 3: Crisis Intervention

Table of Contents

1.0 Introduction
2.0 Objectives
Main Content
Crisis
Grief
4.0 Conclusion
5.0 Summary
6.0 Tutor Marked Assignments
7.0 References

1.0 Introduction

Mental health clients may be labeled with one or more psychiatric diagnosis,
but all have one thing in common i.e. unsuccessful coping behaviours. The
very nature of mental illness is characterized by actions that are not in
keeping with society‟s definitions of appropriate behaviours. Mental health
caregivers provide clients with education about and opportunities to engage
in more effective behaviours. When experiencing stress, people use their
resources to decrease the discomfort. These efforts called coping
mechanisms used as the tools that help us work through the ups and downs
of daily living. A crisis is an upset in the homeostasis of an individual. A
crisis has several characteristics that separate it from other stressful
situations. For example, a crisis occurs when an individual‟s usual coping
mechanisms are ineffective so the crisis demands new solutions with new
coping strategies. Crisis is self-hinting because human beings can not endure
high levels of continued stress, crisis are usually resolved within a short time
and because a crisis usually affects more than one person, for everyone
within the person‟s support system is affected by the crisis.
2.0 Objectives

At the end of this unit, the learners should be able to:

- define what crisis is
- define grief crisis is
- list the characteristics of individuals prone to crisis
- enumerate the types of crisis
- describe the resolution of crisis
- describe the stages of grief
- explain how grief is resolved
Main content
Crisis
Crisis can be viewed as an integral component of everyday life
situations. A crisis may influence people‟s lives in different ways. As a
consequence of a crisis experience, the individual may go down to a lower
or less healthy level of functioning than what was before the crisis, or he
may resume the same level of functioning by repressing the crisis and the
related emotions. On the other hand, he may function at a healthier level
than prior to the crisis, because the challenge of a crisis can bring out new
strengths, skills and coping mechanisms.
Intervention at a crisis is extremely important to prevent mental
illness, because long-standing problems make the person totally incapable of
handling the situation. If proper guidance is provided at the correct time, the
victim will come out of it better equipped to handle future problems in life.
Definition
Crisis is a state of disequilibrium resulting from the interaction of an
event with the individual‟s or family‟s coping mechanisms, which are
inadequate to meet the demands of the situation, combined with the
individual‟s or family‟s perception of the meaning of the event (Taylor
1982)
Crisis Proneness
Hendricks (1985) suggests that certain individuals are more prone to
crisis than others. The following are characteristics often found in
individuals who are regarded as being more susceptible to crisis:
 Dissatisfaction with employment or lack of employment.
 History of unresolved crisis.
 History of substance abuse.
 Poor self-esteem, unworthiness.
 Superficial relationships with others.
 Difficulty in coping with everyday situations.
 Under utilization of resources and support systems.
 Aloofness and lack of caring.
It is important to note that individual personality traits must also be
considered in conjunction with these characteristics. Crisis is defined by the
individual; what is a crisis for one is merely an occurrence for another. This
factor is a critical component that must be evaluated in relation to crisis
prone characteristics as well as personality traits.

Types of Crisis
Maturational Crisis
Maturational crisis can be defined as the predicable processes of
growth and development that evolve over a period of time, the ultimate goal
of these processes is maturity.
The transition points where individuals move into successive stage
often generate disequilibrium. Individuals are required to make cognitive
and behavioural changes and to integrate those physical changes that
accompany development.
The extent to which individuals experience success in the mastery of
these tasks depends on previous successes, availability of support systems,
influence of role models and acceptability of the new role by others.
The transitional periods or events that are most commonly identified
as having increased crisis potential are adolescence, marriage, parenthood,
midlife and retirement.
Situational Crisis
A situational crisis is one that is precipitated by an unanticipated
stressful event that creates disequilibrium by threatening one‟s sense of
biological, social or psychological integrity.
Examples of events that can precipitate situational crises are
premature birth, status and role changes, death of a loved one, physical or
mental illness, divorce, change in geographic location and poor performance
in school.
Social Crisis
Social crisis is accidental, uncommon and unanticipated and results in
multiple losses and radical environmental changes. Social crisis include
natural disasters like flood, earthquakes, violence, nuclear accidents, mass
killings, contamination of large areas by toxic wastes, wars etc. This type of
crisis is unlike maturational and situational crisis because it does not occur
in the lives of all people.
Because of the severity of the effects of social crisis coping strategies
may not be effective. Individuals confronted with social crisis usually do not
have previous experience from which to draw expertise. Support systems
may be unavailable because they may also be involved in similar situations.
Mental health professionals are called upon to act quickly and provide
services to large numbers of people and in some cases, the whole
community.
 Phases of Crisis
Caplan (1964) has described four phases of crisis as described below:
Phase I
Perceived threat acts as a precipitant that generates increased anxiety.
Normal coping strategies are activated, and if unsuccessful, the individual
moves into Phase II.
Phase II
The ineffectiveness of the Phase I coping mechanisms leads to further
disorganization. The individual experiences a sense of vulnerability. The
individual may attempt to cope with the situation in a random fashion. If the
anxiety continues and there is reduction, the individual enters Phase III.
Phase III
Redefinition of the crisis is attempted and the individual is most
amenable to assistance in this phase. New problem solving measures may
also affect a solution. Return to pre-crisis level of functioning may occur. If
problem solving is unsuccessful, further disorganization occurs and the
individual is said to have entered Phase IV.
Phase IV
Severe to panic levels of anxiety with profound, cognitive, emotional
and physiological changes may occur. Referral to further treatment resources
is necessary.
Signs and Symptoms of Crisis
 The major feeling in a crisis situation is anxiety. The individual
experiences a heavy burden of free-floating anxiety.
 The anxiety may be manifested through depression, anger and guilt.
The victim will attempt to get rid of the anxiety using various coping
mechanisms, healthy or unhealthy.
 The individual may become incapable of even taking care of his daily
needs and may neglect his responsibilities.
 The individual may become irrational and blame others for what has
happened to him.
Resolution of Crisis
Healthy resolution of a crisis depends upon the following three
factors:
1. Realistic appraisal of the precipitating event, i.e. recognition of the
relationship between the event and feelings of anxiety id necessary for
effective problem-solving to occur.
2. Availability of support systems.
3. Availability of coping measures over a life-time: A person develops a
repertoire of successful coping strategies that enable him to identify
and resolve stressful situations.
There are three ways by which the individual may resolve the crisis:

Pseudo-resolution
In this, the individual uses repression and pushes out of consciousness
the incident and the intense emotions associated with it, so there will not be
any change in the level of functioning of the individual. But in future, if and
when a crisis occurs, the repressed feelings may come to surface and
influence the feelings aroused by the new crisis. In such a situation, the
particular crisis may be more difficult to resolve because the feelings
associated with the earlier crisis are neither expressed nor handled at that
time.
Unsuccessful Resolution
In this, the victim uses pathological adaptation at any phase of crisis,
resulting in a lower level of functioning. The victim, rather than accepting
the loss and reorganizing his life, keeps ruminating over the loss. An
example is prolonged grief reaction, which results in depression.
Successful Resolution
In this, the victim may go through the various phases of crisis, but
reaches Phase III where various coping measures are utilized to resolve the
crisis situation. The individual develops better skills and problem solving
ability, which can be and will be used in various situations in future.
Crisis Intervention
Crisis intervention is a technique used to help an individual or family
to understand and cope with the intense feelings that are typical of a crisis.
Nurses function as part of the interdisciplinary team in the use of crisis
intervention as a therapeutic modality. Nurses may employ crisis techniques
in their work with high-risk groups such as clients with chronic diseases,
new parents and bereaved persons.
Nurses may also use crisis intervention in dealing with intra-group
staff issues and client management issues.
Aims of Crisis Intervention Technique
 To improve a correct cognitive perception of the situation.
 To assist the individual in managing the intense and overwhelming
feelings associated with the crisis.
Intervention
A. Steps to provide a correct cognitive perception
Assessment of the situation
 This may be achieved by direct questioning with the purpose of
identification of the problem and the people involved.
 It is necessary to identify the support systems available and to know
the depth in which the individual‟s feelings are affected.
 Assessment should also be done to identify the strengths and
limitation of the victim.
Defining the event
 The victim at times may not be able to identify the precipitating even
because of possible denial, or due to reluctance to talk about it.
 It may be necessary for the therapist to review the details of the
incidents in the past 2 to 4 weeks in order to identify the event that
precipitated the crisis. Such a review will also help to bring the
precipitating even to the awareness of the victim.
Develop a plan of action
 The victim and the people closely associated with him should have
actual involvement in developing the plan of action.
 The therapist must be aware that the victim may not be in a condition
mentally to comprehend complicated information due to the
overwhelming anxiety experienced by him. The instructions given by
the therapist must be simple and clear, and too much information
should not be given at a time. The instructions may have to be written
down, as the victim may not be able to retain all the information.
B. Steps to assist the victim in managing the intense feelings
Helping the individual to be aware of the feelings
 The victim needs help in identifying his own feelings, which is the
first step in handling them.
 The therapist should use appropriate communication technique so that
the victim will feel comfortable to express his feelings without the
fear of being judged or criticized.
 The therapist also should be efficient in observing the non-verbal and
verbal behaviour of the victim, so that he will be able to make a
careful assessment of his feelings.
Helping the individual to attain mastery over the feelings
 The individual should be given adequate support and guidance
through the therapeutic process in order to handle the feelings
associated with the crisis but special care should be taken not to give
any false reassurance.
  He should not in any way be encouraged to blame others, as this will
only let him escape from taking any responsibility.
 Care must be taken that the individual may not develop too much
dependency on the therapist, which is unhealthy.
 After the victim and the support groups make the plan of action under
the guidance of the therapist, this should be discussed with the victim
and the concerned others, so that they will have a clear understanding
of the methods of implementation of the plan.
 To improve coping with the situation necessary environmental
manipulation must be done in physical or interpersonal areas.
 It is advisable to have another appointment for the victim to visit the
therapist within a week, in order to assess how the plan is working
out, and if needed, to revise and modify the plan.
Grief
Grief is a subjective state of emotional, physical and social responses
to the loss of a valued entity. The loss may be real, in which case, it can be
substantiated by others (e.g. death of a loved one) or perceived by the
individual alone, in which case, it can not be perceived or shared by others
(e.g. loss of feeling of femininity following mastectomy).
Stages of Grief
Kubler-Ross (1969) having done extensive research with terminally ill
patients identified five stages of feelings and behaviours that individuals
experience in response to a real, perceived or anticipated loss:
Stage I-Denial: This is a stage of shock and disbelief. The response may be
one of “No, it can‟t be true!” Denial is a protective mechanism that allows
the individual to cope within an immediate time-frame while organizing
more effective defense strategies.
Stage II-Anger: “Why me?” and “It is not fair!” are comments often
expressed during the anger stage. Anger may be directed at self or displaced
on loved ones, caregivers and even God. There may be a preoccupation with
an idealized image of the lost entity.
Stage III-Bargaining: “If God will help me through this, I promise I will go
to church every Sunday and volunteer my time to help others”. During this
stage, which is generally not visible or evident to others, a bargain is made
with God in an attempt to reverse or postpone the loss.
Stage IV-Depression: During this stage, the full impact of the loss is
experienced. This is a time of quiet desperation and disengagement from all
associations with the lost entity.
Stage V-Acceptance: The final stage brings a feeling of peace regarding the
loss that has occurred. Focus is on the reality of the loss and its meaning for
the individuals affected by it.
All individuals do not experience each of these stages in response to a
loss, nor do they necessarily experience them in this order. some individuals
grieving behaviour may fluctuate and even overlap between stages.
Resolution of Grief
Resolution of the process of mourning is thought to have occurred when an
individual can look back on the relationship with the lost entity and accept
both the pleasure and the disappointments (both the positive and negative
aspects) of the association. Pre-occupation with the lost entity is replaced
with energy and desire to pursue new situations and relationships.
The length of the grief process may be prolonged by a number of
factors:
 If the relationship with the lost entity had been marked with
ambivalence, reaction to the loss may be burdened with guilt, which
lengthens the grief reaction.
 In anticipatory grief where a loss is anticipated, individuals often
begin the work of grieving before the actual loss occurs. Most people
experience the grieving behaviour once the actual loss occurs, but
having this time to prepare for the loss can facilitate the process of
mourning, actually decreasing the length and intensity of the response.
 The number of recent losses experienced by an individual also affects
the length of the grieving process and whether he is able to complete
one grieving process before another loss occurs.
Maladaptive Grief Responses
Maladaptive grief responses to loss occur when an individual is not able to
satisfactorily progress through the stages of grieving to achieve resolution.
Several types of grief responses have been identified as pathological
[Lindemann (1944), Parkes (1972)].
These are prolonged, delayed/inhibited and distorted responses.
Prolonged Response
It is characterized by an intense preoccupation with memories of the lost
entity for many years after the loss has occurred.
Delayed or Inhibited Response
The individual becomes fixed in the denial stage of the grieving process. The
emotional pain associated with loss is not experienced, but there may be
evidence of anxiety disorders or sleeping disorders. The individual may
remain in denial for many years until the grief response is triggered by a
remainder of the loss or even by another unrelated loss.
Distorted Response
The individual who experiences a distorted response is fixed in the anger
stage of grieving. The normal behaviour associated with grieving, such as
helplessness, hopelessness, sadness, anger and guilt are exaggerated out of
proportion to the situation. The individual turns the anger inward on the self
and is unable to function in normal activities of daily living. Pathological
depression is a distorted grief response.

Exercise 1: What can prolong the grief process?

Treatment
Normal grief does not require any treatment while complicated grief
requires medication depending on the prevailing behaviour responses.
Nursing Intervention
 Provide an open accepting environment.
 Encourage ventilation of feelings and listen actively.
 Provide various diversional activities.
 Provide teaching about common symptoms of grief.
 Reinforce of goal-directed activities.
 Bring together similar aggrieved persons, to encourage
communication, share experiences of the loss and to offer
companionship, social and emotional support.
4.0 Conclusion
Griefs and crises can be successfully managed with adequate
adaptation, social support from significant individuals in the society as
unresolved griefs and crises may result in major health and psychological
problems. Emotional support and referral to various community resources
should be offered promptly.
5.0 Summary

You have gone through this unit on griefs and crisis management, the
knowledge is to assist you as learners for better adaptation and for you to
assist you clients.
Tutor Marked Assignments
Describe how you will assist a teenager that drops out of school as a
result of loss of her parents in air crash that recently happened
Answer to Exercise 1
 ambivalence, reaction to the loss may be burdened with guilt, which
lengthens the grief reaction.
 In anticipatory grief grieving starts before the actual loss occurs.
 The number of recent losses experienced by an individual.

7.0 References / Further Readings

Morrison-Valfre, M. 2005. Foundations of Mental Health Care,
Missouri: Mosby Inc.
Olatawura, M. O. 2002. Psychology and Psychiatry Lecture Series
from Ibadan, Ibadan: Spectrum Books Ltd.
Sreevani, R. 2004. A Guide to Mental Health and Psychiatric Nursing,
New Delhi: Jaypee Brothers Medical Publishers (P) Ltd.
Module 2: Therapeutic Modalities in Psychiatry

Unit 1: Somatic therapies

Table of Contents

1.0 Introduction
2.0 Objectives
Main Content
Introduction
Somatic therapies
4.0 Conclusion
5.0 Summary
6.0 Tutor Marked Assignment
7.0 References

1.0 Introduction

Patients suffering from physical illnesses are given specific treatment

because the causes are specific and the signs and symptoms are specific. In a
psychiatric setting, the treatment may not be so specific and most patients
are given more than one treatment. Some patients do not want treatment and
may not cooperate with the doctors and nurses. Some do not realize that they
are ill and may actively resist all forms of treatment.
2.0 Objectives

At the end of this unit, the learners should be able to:

- list the examples of psychopharmacology
- describe electroconvulsive therapy
- state the indications and contra-indications of ECT
- discuss the management of a patient undergoing ECT.
Main content
Introduction
The nurse has an extremely important role to play in the treatment of
the mentally ill. She is the one who has closer contact with the patient than
any other members of the hospital team. She also has a greater opportunity
to get to know him and report on his improvement.
The various treatment modalities in psychiatry are broadly divided as:
 Somatic (physical) therapies
 Psychological therapies
Other therapies are:
 Milieu therapy

 Therapeutic community
 Activity therapy
Somatic (Physical) Therapies
Psychopharmacology
The understanding of the biological regulation of thought, behaviour and
mood is the basis of all somatic therapies used in modern psychiatry.
Psychopharmacology agents are now the first-line treatment for almost every
psychiatric ailment. With the growing availability of a wide range of drugs
to treat mental illness, the nurse practicing in modern psychiatric settings
needs to have a sound knowledge of the pharmacokinetics involved, the
benefits and potential risks of pharmacotherapy, as well as her own roles and
responsibilities.
The various drugs used in psychiatry are called psychotropic (or
psychoactive) drugs. They are so called because of their significant effect on
higher mental functions. There are about seven classes of psychotropic
drugs. Before going into a detailed description of each, a few guidelines are
given below regarding the administration of drugs in psychiatry in general.
The specific responsibilities are mentioned separately under each case.
General Guidelines Regarding Drug Administration in Psychiatry
 The nurse should not administer any drug unless there is a written
order. Do not hesitate to consult the doctor when in doubt about any
medication.
 All medications given must be charted on the patient‟s case record
sheet.
 In giving medication:
o always address the patient by name and make certain of his
identification.
 o do not leave the patient until the drug is swallowed
o do not permit the patient to go to the bathroom to take the
medication
o do not allow one patient to carry medicine to another.
 If it is necessary to leave the patient to get water, do not leave the tray
within the reach of the patient.
 Do not force oral medication because of the danger of aspiration. This
is especially important in stuporous patients.
 Check drugs daily for any change in colour, odour and number
 Bottles should be tightly closed and labeled. Labels should be written
legibly and in bold lettering. Poison drugs are to be legibly labeled
and to be kept in separate cupboard.
 Make sure that an adequate supply of drugs is on hand, but do not
overstock.
 Make sure no patient has access to the drug cupboard.
 Drug cupboards should always be kept locked when not in use. Never
allow a patient or worker to clean the drug cupboard. The drug
cupboard keys should not be given to patients.
Classification of Psychotic Drugs
 Antipsychotics
 Antidepressants
 Mood stabilizing drugs
 Anxiolytics and hypnosedatives
 Antiepileptic drugs
 Antiparkinsonian drugs
 Miscellaneous drugs which include stimulants, drugs used in eating
disorders, drugs used in deaddiction, drugs used in child psychiatry,
vitamins, calcium channel blockers etc.
Antipsychotics
Antipsychotic are those psychotropic drugs, which are used for the treatment
of psychotic symptoms. These are also known as narcoleptics (as they
produce neurological side-effects), major tranquilizers, D2-receptor blockers
and anti-schizophrenic drugs.
Indications
Organic psychiatric disorders
 Delirium
 Dementia
 Delirium tremens
 Drug-induced psychosis and other organic mental disorders
Functional disorders
 Schizophrenia
 Schizoaffective disorder
 Paranoid disorders
Mood disorders
 Mania
 Major depression with psychotic symptoms
Childhood disorders
 Attention-deficit hyperactivity disorder
 Autism
  Enuresis
 Conduct disorder
Neurotic and other psychiatric disorders
 Anorexia nervosa
 Intractable obsessive-compulsive disorder
 Severe, intractable and disabling anxiety
Medical disorders
 Huntington‟s chorea
 Intractable hiccough
 Nausea and vomiting
 Tic disorder
 Eclampsia
 Heat stroke
 Severe pain in malignancy
 Tetanus
Pharmacokinetics
Antipsychotic when administered orally are absorbed variably from the
gastrointestinal tract, with uneven blood vessels. They are highly bound to
plasma as well as tissue proteins. Brain concentration is higher than plasma
concentration. They are metabolized in the liver, and excreted mainly
through the kidneys. The elimination half-life varies from 10 to 24 hours.
Most of the antipsychotics tend to have a therapeutic window. If the blood
level is below this window, the drug is ineffective. If the blood level is
higher than the upper limit of the window, there is toxicity or the drug is
again ineffective.
Mechanism of Action
Antipsychotics drugs block D2 receptors in the mesobimbic and mesofrontal
systems (concerned with emotional reactions). Sedation is caused by alpha-
adrenergic blockade. Anti dopaminergic actions on basal ganglia are
responsible for causing EPS (extrapyramidal symptoms).
Atypical antipsychotic have antiserotonergic (5-hydroxytryptamine or 5-HT)
antiadrenergic and antihistaminergic actions. These are therefore called
serotonin-dopamine antagonists.
Adverse Effects of Antipsychotic Drugs
I. Extrapyramidal symptoms (EPS)
1. Neuroleptic-induced Parkinsonism: Symptoms include rigidity,
tremors, bradykinesia, stooped posture, drooling, akinesia, and ataxia
etc. the disorder can be treated with anticholinergic agents.
2. Acute dystopia: Diatonic movements results from a slow sustained
muscular spasm that lead to an involuntary movement. Dystonia can
involve the neck, jaw, tongue and the entire body (opisthotonos).
There is also involvement of eyes leading to upward lateral movement
of the eye known as oculogyric crisis. Dystonias can be prevented by
anticholinergics, antihistaminergics, dopamine agonists, beta-
adrenergic antagonists, benzodiazepines etc.
3. Akathisia: Akathisia is a subjective feeling of muscular discomfort
that can cause patients to be agitated, restless and feel generally
dysphonic. Akathisia can be treated with propranolo, benzodiazepines
and clonidine.
4. Tardive dyskinesia: It is a delayed adverse effect of antipsychotics. It
consists of abnormal, irregular choreoathetoid movements of the
muscles of the head, limbs and trunk. It is characterized by chewing,
sucking, grimacing and peri-oral movements.
5. Neuroleptic malignant syndrome: This is a rare but serious disorder
occurring in a small minority of patients taking neuroleptics,
especially high-potency compounds.
The onset is often, but not invariably, in the first 10 days of treatment.
The clinical picture includes the rapid onset (usually over 24-72
hours) of severe motor, mental and autonomic disorders. The
prominent motor symptom is generalized muscular hypertonicity.
Stiffness of the muscles in the throat and chest may cause dysphasia
and dyspnea. The mental symptoms include akinetic mutism, stupor
or impaired consciousness. Hyperpyrexia develops with evidence of
autonomic disturbances in the form of unstable blood pressure,
tachycardia, excessive sweating, salivation and urinary incontinence.
In the blood, creatinine phosphokinase (CPK) levels may be raised to
very high levels, and the white cell count may be increased.
Secondary features may include pneumonia, thromboembolism,
cardiovascular collapse and renal failure.
The syndrome lasts for one or two weeks after stopping the drug.
II. Autonomic side-effects: Dry mouth, constipation, cycloplegia,
mydriasis, urinary retention, orthostatic hypotension, impotence and
impaired ejaculation.
III. Seizures
IV. Sedation
V. Other effects
 Agranulocytosis (especially for clozapine)
 Sialorrhoea or increased salivation (especially for clozapine)
  Weight gain
 Jaundice
 Dermatological effects (contact dermatitis, photosensitive reaction)
Nurse‟s Responsibility for a Patient Receiving Antipsychotics
 Instruct the patient to take sips of water frequently to relieve dryness
of mouth. Frequent mouth washes, use of chewing gum, applying
glycerine on the lips are also helpful.
 A high-fiber diet, increased fluid intake and laxatives if needed, help
to reduce constipation.
 Advise the patient to get up from the bed or chair very slowly. Patient
should sit on the edge of the bed for one full minute dangling his feet,
before standing up. Check BP before and after medication is given.
This is an important measure to prevent falls and other complications
resulting from orthostatic hypotension.
 Differentiate between akathisia and agitation and inform the
physician. A change of drug may be necessary if side-effects are
severe. Administer antiparkinsonian drugs as prescribed.
 Observe the patient regularly for abnormal movements.
 Take all seizure precautions.
 Patient should be warned about driving a car or operating machinery
when first treated with antipsychotics. Giving the entire dose at
bedtime usually eliminates any problem from sedation.
 Advise the patient to use sunscreen measures (use of full sleeves, dark
glasses etc) for photosensitive reactions.
 Teach the importance of drug compliance, side-effects of drugs and
reporting if too severe, regular follow-ups. Give reassurance and
reduce unfounded fears and anxieties.
 A patient receiving clozapine is at risk for developing agranulocytosis.
Monitor TC, DC essentially in the first few weeks of treatment. Stop
the drug if the WBC count drops to less than 3000/mm3 of blood. The
patient should also be told to report if sore throat or fever develops,
which might indicate infection.
 Seizure precautions should also be taken as clozapine reduces seizure
threshold. The dose should be regulated carefully and the patient may
also be put on anticonvulsants such as eptoin.

Antidepressants
Antidepressants are those drugs, which are used for the treatment of
depressive illness. These are also called mood elevators or thymoleptics.
 Indications
Depression
 Depressive episode
 Dysthymia
 Reactive depression
 Secondary depression
 Abnormal grief reaction
Childhood psychiatric disorders
 Enuresis
 Separation anxiety disorder
 Somnambulism
 School phobia
 Night terrors
Other psychiatric disorders
 Panic attacks
 Generalized anxiety disorder
 Agoraphobia, social phobia
 OCD with or without depression
 Eating disorder
 Borderline personality disorder
 Post-traumatic stress disorder
Depersonalization syndrome
 Medical disorders
 Chronic pain
 Migraine
 Peptic ulcer disease
Pharmacokinetics
Antidepressants are highly lipophilic and protein-bound. The half-life
is long and usually more than 24 hours. It is predominantly metabolized in
the liver.
Mechanism of Action
The exact mechanism is unknown. The predominant action is by
increasing catecholamine levels in the brain.
TCAs are also called monoamine reuptake inhibitors (MARIs). The
main mode of action is by blocking the reuptake of norepinephrine (NE)
and/or serotonin (5-HT) at the nerve terminals, thus increasing the NE and 5-
HT levels at the receptor site.
MAOIs instead act on MAO (monoamine oxidase), which is responsible for
the degradation of catecholamines after re-uptake. The final effect is the
same, a functional increase in the NE and 5-HT levels at the receptor site.
The increase in brain amine levels is probably responsible for the
antidepressants action. It takes about 5 to 10 days for MAOIs and 2 to 3
weeks for TCAs to bring down depressive symptoms.
SSRIs act by inhibiting the re-uptake of serotonin and increasing its levels at
the receptor site.
Side Effects
1. Autonomic side effects: Dry mouth, constipation, cycloplegia,
mydriasis, urinary retention, orthostatic hypotension, impotence,
impaired ejaculation, delirium, and aggravation of glaucoma.
2. CNS effects: Sedation, tremor and other extra-pyramidal symptoms,
withdrawal syndrome, seizures, jitteriness syndrome, precipitation of
mania.
3. Cardiac side effects: Tachycardia, ECG changes, arrhythmias, direct
myocardial depression, quinidine-like action (decreased conduction
time).
4. Allergic side-effect: Agranulocytosis, cholestatic jaundice, skin
rashes, systemic vasculities.
5. Metabolic and endocrine side-effects: Weight gain.
6. Special effects of MAOI drugs: Hypertensive crisis, severe hepatic
necrosis, hyperpyrexia.
Nurse’s Responsibility for a Patient Receiving Antidepressants
Most of the nurse‟s responsibilities for a patient on antidepressants are the
same as for a patient receiving antipsychotics. In addition:
 Patients on MAOIs should be warned against the danger of ingesting
tyramine-rich foods which can result in hypertensive crisis. Some of
these foods are beef liver, chicken liver, fermented sausages, dried
fish, overriped fruits, chocolate and beverages like wine, beer and
coffee.
 Report promptly if occipital headache, nausea, vomiting, chest pain or
other unusual symptoms occur; these can herald the onset of
hypertensive crisis.
 Instruct the patient not to take any medication without prescription.
 Caution the patient to change his position slowly to minimize
orthostatic hypotension.
 Strict monitoring of vitals, especially blood pressure is essential.
Lithium and other mood stabilizing drugs
Mood stabilizers are used for the treatment of bipolar affective
disorders. Some commonly used mood stabilizers are:
 Lithium
 Carbamazepine
 Sodium valproate
Lithium
Lithium is an element with atomic number 3 and atomic weight 7. it
was discovered by FJ Cade in 1949 and is a most effective and commonly
used drug in the treatment of mania.
Indications
 Acute mania
 Prophylaxis for bipolar and unipolar mood disorder.
 Schizoaffective disorder
 Cyclothymia
 Impulsivity and aggression
 Other disorders
o premenstrual dysphoric disorder
o bulimia nervosa
o borderline personality disorder
o episodes of binge drinking
o trichotillomania
o cluster headaches
Pharmacokinetics
Lithium is readily absorbed with peak plasma levels occurring 2-4
hours after a single oral dose of lithium carbonate. Lithium is distributed
rapidly in liver and kidney and more slowly in muscle, brain and bone.
Steady state levels are achieved in about 7 days. Elimination is
predominantly via kidneys. Lithium is reabsorbed in the proximal tubules
and is influenced by sodium balance. Depletion of sodium can precipitate
lithium toxicity.
Mechanism of Action
The probable mechanisms of action can be:
 It accelerates presynaptic re-uptake and destruction of catecholamines
like norepinephrine
 It inhibits the release of catecholamines at the synapse.
 It decreases postsynaptic serotonin receptor sensitivity.
 Also these actions result in decreased catecholamine activity, thus
ameliorating mania.

Exercise 1: List the roles of a nurse to a depressive patient

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Dosage
Lithium is available in the market in the form of the following preparations:
 Lithium carbonate: 300mg tablets (e.g. Licab); 400mg sustained
release tablets (e.g. Lithosun-SR)
 Lithium citrate: 300mg/5ml liquid.
The usual range of dose per day in acute mania is 900-2100mg given
in 2-3 divided doses. The treatment is started after serial lithium estimation
is done after a loading dose of 600mg or 900mg of lithium to determine the
pharmacokinetics.
Blood Lithium Levels
 Therapeutic levels = 0.8 – 1.2 mEq/L (for treatment of acute mania)
 Prophylactic levels = 0.6 – 1.2 mEq/L (for prevention of relapse in
bipolar disorder)
 Toxic lithium levels > 2.0 mEq/L
Side Effects
1. Neurological: Tremors, motor hyperactivity, muscular weakness,
cogwheel rigidity, seizures, neurotoxicity (delirium, abnormal
involuntary movements, seizures, coma).
2. Renal: Polydipsia, polyuria, tubular enlargement, nephrotic syndrome.
3. Cardiovascular: T-wave depression
4. Gastrointestinal: Nausea, vomiting, diarrhoea, abdominal pain and
metallic taste.
5. Endocrine: Abnormal thyroid function, goiter and weight gain.
6. Dermatological: Acne form eruptions, popular eruptions and
exacerbation of psoriasis.
7. Side-effects during pregnancy and lactation: Teratogenic possibility,
increased incidence of Ebstein‟s anomaly (distortion and downward
displacement of tricuspid valve in right ventricle) when taken in first
trimester. Secreted in milk and can cause toxicity in infant.
8. Signs and symptoms of lithium toxicity (serum lithim level > 2.0
mEq/L):
 ataxia
 course tremor (hand)
 nausea and vomiting
 impaired memory
 impaired concentration
 nephrotoxicity
 muscle weakness
 convulsions
 muscle twitching
 dysarthria
 lethargy
 confusion
 coma
 hyperreflexia
 nystagmus
Management of Lithium Toxicity
 Discontinue the drug immediately
 For significant short-term ingestions, residual gastric content should
be removed by induction of emesis, gastric lavage and adsorption with
activated charcoal.
 If possible instruct the patient to ingest fluids
 Assess serum lithium levels, serum electrolytes, renal functions, ECG
as soon as possible.
 Maintenance of fluid and electrolyte balance
 In a patient with serious manifestations of lithium toxicity,
hemodialysis should be initiated.
Contraindications of Lithium Use
 Cardiac, renal, thyroid or neurological dysfunctions
 Presence of blood dyscrasias
 During first trimester of pregnancy and lactation
 Severe dehydration
 Hypothyroidism
 History of seizures
Nurse’s Responsibility for a Patient Receiving Lithium
The pre-lithium work up: A complete physical history, ECG, blood studies
(TC, DC, FBS, BUN, creatinine, electrolysis) urine examination (routine and
microscopic) must be carried out. It is important to assess renal function as
renal side effects are common and the drug can be dangerous in an
individual with compromised kidney function. Thyroid functions should also
be assessed as the drug is known to depress the thyroid gland.
To achieve therapeutic effect and prevent lithium toxicity, the following
precautions should be taken:
 Lithium must be taken on a regular basis, preferably at the same time
daily (for example, a client taking lithium on TID schedule, who
forgets a dose should wait until the next scheduled time to take
lithium and not take twice the amount at one time because lithium
toxicity can occur).
 When lithium therapy is initiated, mild side effects such as fine hand
tremors, increased thirst and urination, nausea, anorexia etc may
develop. Most of them are transient and do not represent lithium
toxicity.
 Serious side-effects of lithium that necessitate its discontinuance
include vomiting, extreme hand tremors, sedation, muscle weakness
and vertigo. The psychiatrist should be notified immediately if any of
these effects occur.
 Since polyuria can lead to dehydration with the risk of lithium
intoxication, patients should be advised to drink enough water to
compensate for the fluid loss.
 Various situations can require an adjustment in the amount of lithium
administered to a client, such as the addition of a new medicine to the
client‟s drug regimen, a new diet or an illness with fever or excessive
sweating. In this connection, people involved in heavy outdoor labour
are prone to excessive sodium loss through sweating. They must be
advised to consume large quantities of water with salt, to prevent
lithium toxicity due to decreased sodium levels. If severe vomiting or
gastroenteritis develops, the patient should be told to report
immediately to the doctor. These are the conditions that have a high
potential for causing lithium toxicity by lowering serum sodium
levels.
 Frequent serum lithium level evaluation is important. Blood for
determination of lithium levels should be drawn in the morning
approximately 12-14 hours after the last dose was taken.
 The patient should be told about the importance of regular follow-up.
In every six months, blood sample should be taken for estimation of
 electrolytes, urea, creatinine, a full blood count and thyroid function
test.
Carbamazepine
It is available in the market under different trade names like Tegretol,
Mazetol, Zeptol and Zen Retard.
Indications
 Seizures-complex partial seizures, GTCS, seizures due to alcohol
withdrawal
 Psychiatric disorders: rapid cycling bipolar disorder, acute depression,
impulse control disorder, aggression, psychosis with epilepsy,
schizoaffective disorders, borderline personality disorder, cocaine
withdrawal syndrome.
 Paroxysmal pain syndrome – trigeminal neuralgia and phantom limb
pain.
Dosage
The average daily dose is 600-800mg orally, in divided doses. The
therapeutic blood levels are 6-12µg/ml. Toxic blood levels are reached at
more than 15µg/ml.
Mechanism of Action
Its mood stabilizing mechanism is not clearly established. Its anticonvulsant
action may however be by decreasing synaptic transmission in the CNS.
Side Effects
Drowsiness, confusion, headache, ataxia, hypertension, arrhythmias,
skin rashes, Steven-Johnson syndrome, nausea, vomiting, diarrhoea, dry
mouth, abdominal pain, jaundice, hepatitis, oliguria, leucopenia,
thrombocytopenia, bone marrow depression leading to aplastic anemia.
Nurse‟s Responsibilities
 Since the drug may cause dizziness and drowsiness advise him to
avoid driving and other activities requiring alertness.
 Advise patient not to consume alcohol when he is on the drug.
 Emphasize the importance of regular follow-up visits and periodic
examination of blood count and monitoring of cardiac, renal, hepatic
and bone marrow functions.
Sodium Valproate (Encorate chrono, valparin, Epilex, Epival)
Indications
 Acute mania, prophylactic treatment of bipolar I disorder, rapid
cycling bipolar disorder.
 Schizoaffective disorder.
 Seizures
  Other disorders like bulimia nervosa, obsessive-compulsive disorder,
agitation and PTSD
Mechanism of Action
The drug acts of gamma-amino butyric acid (GABA) an inhibitory amino
acid neurotransmitter. GABA receptor activation serves to reduce neuronal
excitability.
Dosage
The usual dose is 15mg/kg/day with a maximum of 60mg/kg/day orally.
Side effects
Nausea, vomiting, diarrhoea, sedation, ataxia, dysarthria, tremor, weight
gain, loss of hair, thrombocytopenia, platelet dysfunction.
Nurse’s Responsibilities
 Explain to the patient to take the drug immediately after food to
reduce GT irritation
 Advise to come for regular follow-up and periodic examination of
blood count, hepatic function and thyroid function. Therapeutic serum
level of valproic acid is 50-100 micrograms/ml.
Anxiolytics (Anti-anxiety drugs) and Hypnosedatives
These are also called minor tranquillizers. Most of them belong to the
benzodiazepine group of drugs.
Classification
1. Barbiturates: Example, Phenobarbital, pentobarbital, secobarbital and
thiopentone.
2. Non-barbiturates non-benzodiazepine anti-anxiety agents: Example,
Meprobamate glutethimide, ethanol, diphenhydramine and
methaqualon.
3. Benzodiazepines: Presently benzodiazepines are the drugs of first
choice in the treatment of anxiety and for the treatment of insomnia.
 Very short-acting: Example, Triazolam, Midazolam.
 Short-acting: Example, Oxazepam (Serepax), Lorazepam (Ativan,
Trapex, Larpose), Alprazolam (Restyl, Trika, Alzolam, Quiet, Anxit).
 Long-acting: Example, Chlordiazepoxide (Librium), Diazepam
(Valium, Calmpose), Clonazepam (Lonazep), Flurazepam (Nindral),
Nitrazepam (Dormin).
Indications for Benzodiazepines
 Anxiety disorders
 Insomnia
 Depression
 Panic disorder and social phobia
  Obsessive-compulsive disorder
 Post-traumatic stress disorder
 Bipolar I disorder
 Other psychiatric indications include alcohol withdrawal, substance-
induced and psychotic agitation
Dosage (mg/day)
Alprazolam: 0.5-6 PO
Oxazepam: 15-120 PO
Lorazepam: 2-6 PO/IV/IM
Diazepam: 2-10 PO/IM/slow IV
Clonazepam: 0.5-20 PO/IM
Chlordiazepoxide: 15-100 PO; 50-100 slow IV
Nitrazepam: 5-20 PO
Mechanism of Action
Benzodiazepines bind to specific sites on the GABA receptors and increase
GABA level. Since GABA is an inhibitory neurotransmitter, it has a calming
effect on the central nervous system, thus reducing anxiety.
Side Effects
Nausea, vomiting, weakness, vertigo, blurring of vision, body aches,
epigastric pain, diarrhoea, impotence, sedation, increased reaction time,
ataxia, dry mouth, retrograde amnesia, impairment of driving skills,
dependence and withdrawal symptoms (the drug should be withdrawn
slowly, as a result).
Nurse’s Responsibility in the Administration of Benzodiazepines
 Administer with food to minimize gastric irritation.
 Advise the patient to take medication exactly as directed. Abrupt
withdrawal may cause insomnia, irritability and sometimes even
seizures.
 Explain about adverse effects and advise him to avoid activities that
require alertness.
 Caution the patient to avoid alcohol or any other CNS depressants
along with benzodiazepines; also instruct him not to take any over-
the-counter (OTC) medications.
 If IM administration is preferred give deep IM.
 For IV administration do not mix with any other drug. Give slow IV
as respiratory or cardiac arrest can occur; monitor vital signs during
IV administration. Prevent extravasations since it can cause phlebitis
and venous thrombosis.
Antiparkinsoninan agents
In clinical practice anticholinergic drugs, amantadine and the antihistamines
have their primary use as treatments for medication-induced movement
disorders, particularly neuroleptic-induced parkinsonism, acute dystonia and
medication-induced tremor.
Anticholinergics
 Trihexyphenidyl
 Benztropine
 Biperiden
Dopaminergic Agents
 Bromocriptine
 Carbidopa/Levodopa
Monoamine Oxidase Type B Inhibitors
 Selegiline
Trihexyphenidyl (Artane, Trihexane, Trihexy, Pacitane)
Indications
 Drug-induced parkinsonism
 Adjunct in the management of parkinsonism
Mechanism of Action
It acts by increasing the release of dopamine from presynaptic
vesicles, blocking the re-uptake of dopamine into presynaptic nerve
terminals or by exerting an agonist effect on postsynaptic dopamine
receptors.
Trihexyphenidyl reaches peak plasma concentrations in 2-3 hours
after oral administration and has a duration of action of up to 12 hours.
Dosage
1-2mg per day orally initially. Maximum dose up to 15 mg/day in
divided doses.
Side Effects
Dizziness, nervousness, drowsiness, weakness, headache, confusion,
blurred vision, mydriasis, tachycardia, orthostatic hypotension, dry mouth,
nausea, constipation, vomiting, urinary retention and decreased sweating.
Nurse‟s Responsibilities
 Assess parkinsonian and extrapyramidal symptoms. Medication
should be tapered gradually.
 Caution patient to make position changes slowly to minimize
orthostatic hypotension.
 Instruct the patient about frequent rinsing of mouth and good oral
hygiene.
  Caution patient that this medication decreases perspiration, and over-
heating may occur during hot weather.
Antabase drugs
Disulfiram is an important drug in this class and is used to ensure
abstinence in the treatment of alcohol dependence. Its main effect is to
produce a rapid and violently unpleasant reaction in a person who ingests
even a small amount of alcohol while taking disulfiram.

Clonidine
Indications
 Control of withdrawal symptoms from opioids
 Tourette‟s disorder
 Control of aggressive or hyperactive behaviour in children
 Autism
Mechanism of Action
 Alpha 2- adrenergic receptor agonist.
 The agonist effects of clonidine on presynaptic alpha 2- adrenergic
receptors result in a decrease in the amount of neurotransmitter
released from the presynaptic nerve terminals. This decrease serves
generally to reset the sympathetic tone at a lower level and to decrease
arousal.
Dosage
Usual starting dosage is 0.1mg orally twice a day; the dosage can be
raised by 0.3mg a day to an appropriate level.
Side Effects
Dry mouth, dryness of eyes, fatigue, irritability, sedation, dizziness, nausea,
vomiting, hypotension and constipation.
Nurse’s Responsibility
 Monitor BP, the drug should be withheld if the patient becomes
hypotensive.
 Advice frequent mouth rinses and good oral hygiene for dry mouth.
Methylphenidate (Ritalin)
Methylphenidate, dextroamphetamine and pemoline are sympathomimetics.
Indications
 Attention-deficit hyperactivity disorder
 Narcolepsy
 Depressive disorders
 Obesity
Mechanism of Action
Sympathomimetics cause the stimulation of alpha and beta-adrenergic
receptors directly, as agonists and indirectly by stimulating the release of
dopamine and norepinephrine from presynaptic terminals.
Dextroamphetamine and methylphenidate are also inhibitors of
catecholamine reuptake, especially dopamine re-uptake and inhibitors of
monoamino oxidase. The net result of these activities is believed to be the
stimulation of several brain regions.
Dosage
Starting dose is 5-10mg per day orally; maximum daily dose is 80 mg/day.
Side Effects
Anorexia or dyspepsia, weight loss, slowed growth, dizziness, insomnia or
nightmares, dysphoric mood, tics and psychosis.
Nurse’s Responsibilities
 Assess mental status for change in mood, level of activity, degree of
stimulation and aggressiveness.
 Ensure that patient is protected from injury.
 Keep stimuli low and environment as quiet as possible to discourage
over stimulation.
 To decrease anorexia, the medication may be administered
immediately after meals. The patient should be weighed regularly (at
least weekly) during hospitalization and at home while on therapy
with CNS stimulants, due to the potential for anorexia/weight loss and
temporary interruptions of growth and development.
 To prevent insomnia administer last dose at least 6 hours before
bedtime.
 In children with behavioural disorders a drug „holiday‟ should be
attempted periodically under the direction of the physician to
determine effectiveness of the medication and the need for
continuation.
 Ensure that parents are aware of the delayed effects of Ritalin.
Therapeutic response may not be seen for 2-4 weeks; the drug should
not be discontinued for lack of immediate results.
 Inform parents that OTC (over-the-counter) medications should be
avoided while the child is on stimulant medication. Some OTC
medications, particularly cold and hay fever preparations contain
certain sympathomimetic agents that could compound the effects of
the stimulated and create drug interactions that may be toxic to the
child.
  Ensure that parents are aware that the drug should not be withdrawn
abruptly. Withdrawal should be gradual and under the direction of the
physician.

Electroconvulsive therapy
Electroconvulsive therapy is a type of somatic treatment first introduced by
Bini and Cerletti in April 1938. From 1980 onwards ECT is being
considered as a unique psychiatric treatment.
Electroconvulsive therapy is the artificial induction of a grandmal seizure
through the application of electrical current to the brain. The stimulus is
applied through electrodes that are placed either bilaterally in the fronto-
temporal region, or unilaterally on the non-dominant side (right side of head
in a right-handed individual).
Parameters of Electrical Current Applied
Standard dose according to American Psychiatric Association, 1978:
 Voltage – 70-120 volts
 Duration – 0.7-1.5 seconds
Type of Seizure Produced
 grandmal seizure – tonic phase lasting for 10-15 seconds
 clonic phase lasting for 30-60 seconds
Mechanism of Action
The exact mechanism of action is not known. One hypothesis states that
ECT possibly affects the catecholamine pathways between diencephalons
(from where seizure generalization occurs) and limbic system (which may
be responsible for mood disorders), also involving the hypothalamus.
Types of ECT
Direct ECT: In this, ECT is given in the absence of anaesthesia and
muscular relaxation. This is not a commonly used method now.
Modified ECT: Here ECT is modified by drug-induced muscular relaxation
and general anaesthesia.
Frequency and Total Number of ECT
Frequency: Three times per week or as indicated.
Total number: 6 to 10; up to 25 may be preferred as indicated.
Application of Electrodes
Bilateral ECT: Each electrode is placed 2.5-4cm above the midpoint, on a
line joining the tragus of the ear and the lateral canthus of the eye.
Unilateral ECT: Electrodes are placed only on one side of head, usually non-
dominant side (right side of head in a right-handed individual).
Unilateral ECT is safer, with much fewer side effects particularly those of
memory impairment.
Indications
a. Major depression: With suicidal risk; with stupor; with poor intake of
food and fluids; melancholia with psychotic features with
unsatisfactory response to drugs or where drugs are contraindicated or
have serious side-effects.
b. Severe catatonia (functional): With stupor; with poor intake of food
and fluids; with unsatisfactory response to drug therapy, or when
drugs are contraindicated or have serious side-effects.
c. Severe psychosis (schizophrenia or mania): With risk of suicide,
homicide or danger of physical assault; with depressive features; with
unsatisfactory response to drug therapy, or when drugs are
contraindicated or have serious side-effects.
d. Organic mental disorders:
 organic mood disorders
 organic psychosis
e. Other indications: ECT is preferred to antidepressants therapy in some
cases, such as for clients with cardiac disease; when tricyclics are
contraindicated because of the potential for dysrhythmia and
congestive heart failure; and for pregnant women, in whom
antidepressants place the foetus at risk for congenital defects.
Contraindications
A. Absolute:
 Raised ICP (intracranial pressure)
B. Relative:
 cerebral aneurysm
 cerebral hemorrhage
 brain tumour
 acute myocardial infarction
 congestive heart failure
 pneumonia or aortic aneurysm
 retinal detachment
Complications of ECT
Life-threatening complications of ECT are rare. ECT does not cause any
brain damage.
Fractures can sometimes occur in elderly patients with osteoporosis. In
patients with a history of heart disease, dysrhythmias and respiratory arrest
may occur.
Side effects of ECT
 Memory impairment
 Drowsiness, confusion and restlessness
 Poor concentration, anxiety
 Headache, weakness/fatigue, backache, muscle aches
 Dryness of mouth, palpitations, nausea, vomiting
 Unsteady gait
 Tongue bite and incontinence.
ECT Team
Psychiatrist, anesthesiologist, trained nurses and aides should be involved in
the administration of ECT
Treatment Facilities
There should be a suite of three rooms:
1. A pleasant, comfortable waiting room (pre-ECT room).
2. ECT room, which should be equipped with ECT machine and
accessories, an anesthetic appliance, suction apparatus, face masks,
oxygen cylinders with adjustable flow valves, curved tongue
depressors, mouth gags, resuscitation apparatus and emergency drugs.
There should be immediate access to a defibrillator.
3. A well equipped recovery room.
Role of the Nurses
a. Pre-treatment evaluation
 Detailed medical and psychiatric history, including history of
allergies.
 Assessment of patient‟s and family‟s knowledge of indicators, side-
effects, therapeutic effects and risks associated with ECT.
 An informed consent should be taken. Allay any unfounded fears and
anxieties regarding the procedure.
 Assess baseline vital signs.
 Patient should be on empty stomach for 4-6 hours prior to ECT.
 Withhold night doses of drugs, which increase seizure threshold like
diazepam, barbiturates and anticonvulsants.
 Withhold oral medications in the morning.
 Head shampooing in the morning since oil causes impedance of
passage of electricity to brain
 Any jewellery, prosthesis, dentures, contact lens, metallic objects and
tight clothing should be removed from the patient‟s body.
 Empty bladder and bowel just before ECT.
  Administration of 0.6mg atropine IM or SC 30 minutes before ECT,
or IV just before ECT.
b. Intra-procedure care
 Place the patient comfortably on the ECT table in supine position.
 Stay with the patient to allay anxiety or fear.
 Assist in administering the anesthetic agent (thiopental sodium 3-5mg/
kg body weight) and muscle relaxant (1mg/kg body weight of
succynylcholine).
 Since the muscle relaxant paralyzes all muscles including respiratory
muscles, patent airway should be ensured and ventilatory support
should be started.
 Mouth gag should be inserted to prevent possible tongue bit.
 The place(s) of electrode placement should be cleaned with normal
saline or 25 percent bicarbonate solution, or a conducting gel applied.
 Monitor voltage, intensity and duration of electrical stimulus given.
 Monitor seizure activity using cuff method.
 100 percent oxygen should be provided.
 During seizure monitor vital signs, ECG, oxygen saturation, EEG etc.
 Record the findings and medicines given in the patient‟s chart.
c. Post-procedure care.
 Monitor vital signs
 Continue oxygenation till spontaneous respiration starts.
 Assess for post-ictal confusion and restlessness.
 Take safety precautions to prevent injury (side-lying position and
suctioning to prevent aspiration of secretions, use of side rails to
prevent falls).
 If there is severe post-ictal confusion and restlessness, I.V. diazepam
may be administered.
 Reorient the patient after recovery and stay with him until fully
oriented.
 Document any findings as relevant in the patient‟s record.
Psychosurgery
Psychosurgery is defined by APA‟s Task Force as “a surgical
intervention, to sever fibres connecting one part of the brain with another, or
to remove, destroy, or stimulate brain tissue, with the intent of modifying
behaviour, thought or mood disturbances, for which there is no underlying
organic pathology”.
Indications
 Severe psychiatric illness.
  Chronic duration of illness of about 10 years.
 Persistent emotional disorders.
 Failure to respond to all other therapies.
 High risk of suicide.
Major Surgical Procedures
 Stereotactic subcaudate tractotomy.
 Stereotactic limbic leucotomy.
 Stereotactic bilateral amygdalotomy
Nursing care for a patient undergoing psychosurgery is the same as
for any neurosurgical procedure.

4.0 Conclusion

The essence of this unit is to expose the learners to different

pharmacological treatment of psychiatric patients. You must have gone
through some therapeutic modalities in this unit. Electroconvulsive therapy
was also discussed in the unit, the mechanism of action, indications,
contraindications, complications, side-effects and the role of the nurse in the
management of a patient undergoing ECT.
5.0 Summary

You have acquired knowledge on therapeutic modalities in psychiatry

with particular reference to somatic therapies and I hope your exposure has
enriched you greatly.
Tutor Marked Assignment
(1) Explain the meaning of Electroconvulsive therapy.
(2) Describe your role as a nurse in the management of a patient
undergoing ECT.
Answer to Exercise

 Warn patients on the danger of ingesting tyramine-rich foods.

 Report promptly if occipital headache, nausea, vomiting, chest pain
or other unusual symptoms occur
 Instruct the patient not to take any medication without prescription.
 Caution the patient to change his position slowly to minimize
orthostatic hypotension
 Strict monitoring of vital signs especially blood pressure
7.0 References / Further Readings
Olatawura, M. O. 2002. Psychology and Psychiatry Lecture Series
from Ibadan, Ibadan: Spectrum Books Ltd.
Staurt, W. G. and Sundeen, J. S. 1995. Principles and Practice of
Psychiatric Nursing. 5th Ed. London: C. V. Mosby Company.
Staurt, W. G. and Lavaia, M. T. 2001. Principles and Practice of
Psychiatric Nursing. 7th Ed. Missouri: Mosby. Inc.
Ahuja, N. A. 1999. Short Text Book of Psychiatry 3rd Ed. New Delhi:
Jaypee Brothers.
Sreevani, R. 2004. A Guide to Mental Health and Psychiatric Nursing,
New Delhi: Jaypee Brothers Medical Publishers (P) Ltd.
 Unit 2: Psychological Therapy

Table of Contents

1.0 Introduction
2.0 Objectives
Main Content
Psychoanalytic therapy
Behaviour therapy
Cognitive therapy
Hypnosis therapy
Abreaction therapy
Relaxation therapy
Individual therapy
Supportive therapy
Group therapy
Family and marital therapy
4.0 Conclusion
5.0 Summary
6.0 Tutor Marked Assignment
7.0 References

1.0 Introduction

This unit is on psychological therapies as part of the therapeutic modalities

in psychiatry. The psychological therapies to be discussed shall include
psychoanalytic, behaviour, cognitive therapies, hypnosis, abreaction,
relaxation, individual, supportive, group, family and marital therapies.
2.0 Objectives

At the end of this unit, you should be able to:

- describe psychoanalytic therapy
- explain behavioural therapy
- describe cognitive therapy
- discuss relaxation therapies
- differentiate between individual, group, family and marital therapies

Main content
Psychological therapies
 There are several kinds of psychological therapies:
- Psychoanalytic therapy - Behaviour therapy
- Cognitive therapy - Hypnosis
- Abreaction therapy - Relaxation therapies
- Individual therapy - Supportive therapy
- Group therapy - Family and marital therapy

Psychoanalytic therapy
 Psychoanalysis was first developed by Sigmund Freud at the end of
the 19th century. The most important indication for psychoanalytical
therapy is the presence of long-standing mental conflicts, which may
be unconscious but produce symptoms. The aim of therapy is to bring
all repressed material to conscious awareness so that the patient can
work towards a healthy resolution of his problems, which are causing
the symptoms.
 Psychoanalysis makes use of free association and dream analysis to
affect reconstruction of personality. Free association refers to the
verbalization of thoughts as they occur, without any conscious
screening. The psychoanalyst searches for patterns in the material that
is verbalized and in the areas that are unconsciously avoided (such
areas are identified as resistances).
 Analysis of the patient‟s dreams helps to gain additional insight into
his problems and the resistances. Thus dreams symbolically
communicate areas of intrapsychic conflict.
 The therapist then attempts to assist the patient to recognize his
intrapsychic conflicts through the use of interpretation.
 The process is complicated by the occurrence of transference
reactions. This refers to the patient‟s development of strong positive
or negative feelings towards the analyst and they represent the
patient‟s past response to a significant other, usually a parent. The
therapist‟s reciprocal response to the patient is called
countertransference. Such reactions must be handled appropriately
before progress can be made.
 The roles of the patient and psychoanalyst are explicitly defined by
Freud. The patient is an active participant, freely revealing all
thoughts exactly as they occur and describing all dreams. He is
frequently in a recumbent position on a couch during therapy to
induce relaxation, which facilitates free association. The
psychoanalyst is a shadow-person. He reveals nothing personal, nor
does he give any directions to the patient. His verbal responses are for
the most part brief and noncommittal, so as not to interfere with the
 associative flow. He departs from this style of communication when
an interpretation of behaviour is made to the patient.
 By termination of therapy, the patient is able to conduct his life
according to an accurate assessment of external reality and is also able
to relate to others uninhibited by neurotic conflicts.
 Psychoanalytical therapy is a long-term proposition. The patient is
seen frequently, usually five times a week. It is therefore time
consuming and expensive.
Behaviour therapy
It is a form of treatment for problems in which a trained person deliberately
establishes a professional relationship with the client, with the objective of
removing or modifying existing symptoms and promoting positive
personality, growth and development.
Behaviour therapy involves identifying maladaptive behaviours and seeking
to correct these by applying the principles of learning derived from the
following theories:
 Classical conditioning model by Ivan Pavlov (1936)
 Operant conditioning model by BF Skinner (1953)
Major Assumptions of Behaviour Therapy
Based on the above-mentioned theories, the following are the
assumptions of behaviour therapy:
 All behaviour is learned (adaptive and maladaptive).
 Human beings are passive organisms that can be conditioned or
shaped to do anything if correct responses are rewarded or reinforced.
 Maladaptive behaviour can be unlearned and replaced by adaptive
behaviour if the person receives exposure to specific stimuli and
reinforcement for the desired adaptive behaviour.
 Behavioural assessment is focused more on the current behaviour
rather than on historical antecedents.
 Treatment strategies are individually tailored. Behaviour therapy is a
short duration therapy.
Behaviour therapy is a short duration therapy, therapists are easy to train and
it is cost-effective. The total duration of therapy is usually 6-8 weeks. Initial
sessions are given daily but the later sessions are spaced out. Unlike
psychoanalysis where the therapist is a shadow person, in behaviour therapy
both the patient and therapist are equal participants. There is no attempt to
unearth an underlying conflict and the patient is not encouraged to explore
his past.
Behaviour Techniques
(A) Systematic desensitization: It was developed by Joseph Wolpe, based on
the behavioural principle of counter conditioning. In this patients attain a
state of complete relaxation and are then exposed to the stimulus that elicits
the anxiety response. The negative reaction of anxiety is inhibited by the
relaxed state, a process called reciprocal inhibition.
It consists of three main steps:
1. Relaxation training
2. Hierarchy construction
3. Desensitization of the stimulus.

1. Relaxation training: there are many methods which can be used to

induce relaxation, some of them are:
 Jacobson‟s progressive muscle relaxation
 Hypnosis
 Meditation or yoga
 Mental imagery
 Biofeedback
2. Hierarchy construction: Here the patient is asked to list all the
conditions which provoke anxiety. Then he is asked to list them in a
descending order of anxiety provocation.
3. Desensitization of the stimulus: This can be done either through
imaginary or in reality. At first, the lowest item in hierarchy is confronted.
The patient is advised to signal whenever anxiety is produced. With each
signal he is asked to relax. After a few trials, patient is able to control his
anxiety gradually.
Indications:
Phobias
Obsessions
Compulsions
Certain sexual disorders
(B) Flooding: The patient is directly exposed to the phobic stimulus, but
escape is made impossible. By prolonged contact with the phobic stimulus,
the therapist‟s guidance and encouragement and his modeling behaviour
reduce anxiety.
Indication: Specific phobias
(C) Aversion therapy: Pairing of the pleasant stimulus with an unpleasant
response, so that even in absence of the unpleasant response the pleasant
stimulus becomes unpleasant by association. Punishment is presented
immediately after a specific behavioural response and the response is
eventually inhibited.
Unpleasant response is produced by electric stimulus, drugs, social
disapproval or even fantasy.
Indications:
Alcohol abuse
Paraphilias
Homosexuality
Transvestism
(D) Operant conditioning procedures for increasing adaptive behaviour
1. Positive reinforcement: When a behavioural response is followed by a
generally rewarding event such as food, praise or gifts, it tends to be
strengthened and to occur more frequently than before the reward.
This technique is used to increase desired behaviour.
2. Token economy: This programme involves giving token rewards for
appropriate or desired target behaviours performed by the patient. The
token can be later exchanged for other rewards. For example, on
inpatient hospital wards, patients receive a reward for performing
desired behaviour, such as tokens which they may use to purchase
luxury items or certain privileges.
(E) Operant conditioning procedures to teach new behaviour
1. Modeling: Modeling is a method of teaching by demonstration,
wherein the therapist shows how a specific behaviour is to be
performed. In modeling the patient observes other patients indulging
in target behaviours and getting rewards for those behaviours. This
will make the patient to repeat the same behaviour and earn rewards in
the same manner.
2. Shaping: In shaping the components of a particular skill, the
behaviour is reinforced step by step. The therapist starts shaping by
reinforcing the existing behaviour. Once it is established he reinforces
the responses which are closest to the desired behaviour and ignores
the other responses.
For example, to establish eye-to-eye contact, the therapist sits
opposite the patient and reinforces him even if he moves his upper
body towards him. Once this is established, he reinforces the person‟s
head movement in his direction and this procedure continues till eye-
to-eye contact is established.
3. Chaining: Chaining is used when a person fails to perform a complex
task. The complete task is broken into a number of small steps and
each step is taught to the patient. In forward chaining one starts with
 the first step, goes on to the second step, then to the third and so on. In
backward chaining, one starts with the last step and goes on to the
next step in a backward fashion. Backward chaining is found to be
more effective in training the mentally disabled.
(F) Operant conditioning procedures for decreasing maladaptive behaviour
1. Extinction/Ignoring: Extinction means removal of attention rewards
permanently, following a problem behaviour. This includes actions
like not looking at the patient, not talking to the patient, or having no
physical contact with the patient etc., following the problem
behaviour.
This is commonly used when patient exhibits odd behaviour.
2. Punishment: Aversive stimulus (punishment) is presented contingent
upon the undesirable response. The punishment procedure should be
administered immediately and consistently following the undesirable
behaviour with clear explanation.
Differential reinforcement of an adaptive or desirable behaviour
should always be added when a punishment is being used for
decreasing an undesirable behaviour. Otherwise the problem
behaviours tend to get maintained because of the lack of adaptive
behaviours and skill defect.
3. Timeout: Timeout method includes removing the patient from the
reward or the reward from the patient for a particular period of time
following a problem behaviour. This is often used in the treatment of
childhood disorders. For example, the child is not allowed to go out of
the ward to play if he fails to complete the given work.
4. Restitution (Over-correction): Restitution means restoring the
disturbed situation to a state that is much better than what it was
before the occurrence of the problem behaviour. For example, if a
patient passes urine in the ward he would be required to not only clean
the dirty area but also mop the entire/largest area of the floor in the
ward.
5. Response cost: This procedure is used with individuals who are on
token programmes for teaching adaptive behaviour. When undesirable
behaviour occurs, a fixed number of tokens or points are deducted
from what the individual has already earned.
(G) Assertiveness and social skill training: Assertive training is a behaviour
therapy technique in which the patient is given training to bring about
change in emotional and other behavioural pattern by being assertive. Client
is encouraged not to be afraid of showing an appropriate response, negative
or positive, to an idea or suggestion. Assertive behaviour training is given by
 the therapist, first by role playing and then by practice in a real life situation.
Attention is focused on more effective interpersonal skills.
Social skills training helps to improve social manners like encouraging eye
contact, speaking appropriately, observing simple etiquette and relating to
people.
Cognitive therapy
Cognitive therapy is a psychotherapeutic approach based on the idea
that behaviour is secondary to thinking. Our moods and feelings are
influenced by our thoughts. Self-defeating and self-depreciating patterns of
thinking result in depressed mood. The therapist helps the patient by
correcting this distorted way of thinking, feelings and behaviour.
The cognitive model of depression includes the cognitive triad:
1. A negative view about self
2. A negative view about the environment and
3. A negative view about the future
These negative thoughts are modified to improve the depressive
mood. Cognitive therapy is used for the treatment of depression, anxiety
disorder, panic disorder, phobic disorder and eating disorders.
Hypnosis therapy
The word „hypnotism‟ was first used by James Briad in the 19th
century. Hypnosis is an artificially induced state in which the person is
relaxed and unusually suggestible. Hypnosis can be induced in many ways,
such as by using a fixed point for attention, rhythmic monotonous
instructions etc.

Changes that occur during Hypnosis

 The person becomes highly suggestible to the commands of the
hypnotist.
 There is an ability to produce or remove symptoms or perceptions.
 Dissociation of a part of body or emotions.
 Amnesia for the events that occurred during the hypnotic state.
Techniques
Patient is either made to lie down on a bed or sit in a chair. He is
asked to gaze fixedly on a spot. Therapist makes monotonous suggestions of
relaxation and sleep. The patient however is not asleep and can hear what is
being said, answer questions and obey instructions.
This therapy is useful in:
 Abreaction of past experiences.
 Psychosomatic disorders.
  Conversion and dissociative disorders.
 Eating disorders.
 Habit disorders and anxiety disorders.
Abreaction therapy
Abreaction is a process by which repressed material, particularly a painful
experience or conflict, is brought back to consciousness. The person not only
recalls but also relives the material, which is accompanied by the appropriate
emotional response. It is most useful in acute neurotic conditions caused by
exreme stress (Post-traumatic stress disorder, hysteria etc).
Although abreaction is an integral part of psychoanalysis and hypnosis, it
can also be used independently.

Method
Abreaction can be brought about be strong encouragement to relieve the
stressful events. The procedure is begun with neutral topics at first, and
gradually approaches areas of conflict. Although abreaction can be done
with or without the use of medication, the procedure can be facilitated by
giving a sedative drug intravenously. A safe method is the use of
thiopentone sodium i.e. 500mg dissolved in 10 c.c. of normal saline. It is
infused at a rate no faster than 1 cc/minute to prevent sleep as well as
respiratory depression.
Ralaxation therapy
Relaxation produces physiological effects opposite those of anxiety:
slowed heart rate, increased peripheral blood flow and neuromuscular
stability.
There are many methods which can be used to induce relaxation.
Jacobson‟s Progressive Muscle Relaxation
Patients relax major muscle groups in fixed order, beginning with the small
muscle groups of the feet and working cephalad or vice versa.
Mental Imagery
It is a relaxation method in which patients are instructed to imagine
themselves in a place associated with pleasant relaxed memories. Such
images allow patients to enter a relaxed state or experience a feeling of
calmness and tranquility.

Use of Tape-recorded Exercises or Instructions

This allows patients to practice relaxation on their own.
 Meditation or Yoga
It is concentrating on the spirit by using certain postures to prepare the body
to sit motionless, remain alert and focus on one particular point.Yoga is
highly useful in reducing stress and treating anxiety.
Bio-feedback
Bio-feedback is based on the idea that the autonomic nervous system can
come under voluntary control through operant conditioning. Thus it helps
people to control usually involuntary physiological functions so as to change
them, for instance, by relaxing. People learn to control these functions by
hearing or seeing signals from instruments that produce information about
various measures such as muscle tension, blood pressure, etc. This feedback
helps the patient to control such responses.
Uses of bio-feedback include treatment of enuresis, and treatment of a
host of ailments brought on by stress such as migraine headaches, tension
headaches, idiopathic hypertension, cardiac problems etc.
Individual therapy
Psychotherapy can be defined as the treatment of problems of an emotional
nature, in which a trained person deliberately establishes a professional
relationship with the patient to remove, modify or retard existing symptoms,
mediate disturbed patterns of behaviour and promote positive personality
growth and development.
Individual psychotherapy is conducted on a one-to-one basis, i.e. The
therapist treats one client at a time. The patient is encouraged to discover for
himself the reasons for his behaviour. The therapist listens to the patient and
offers explanation and advice when necessary. By this he helps the patient to
come to a greater understanding of himself and to find a way of dealing with
his problems.
Indications: Stress-related disorders, alcohol and drug dependence, sexual
disorders and marital disharmony.

Supportive therapy
In this, the therapist helps the patient to relieve emotional distress and
symptoms without probing into the past and changing the personality. He
uses various techniques such as:
 Ventilation: It is a free expression of feelings or emotions. Patient is
encouraged to talk freely whatever comes to his mind.
 Environmental modification/manipulation: Improving the well-being
of mental patients by changing their living condition.
  Persuasion: Here the therapist attempts to modify the patient‟s
behaviour by reasoning.
 Re-education: Education to the patient regarding his problems, ways
of coping etc.
 Reassurance
Group therapy
Group psychotherapy is a treatment in which carefully selected people
who are emotionally ill meet in a group guided by a trained therapist, and
help one another effect personality change.
Selection
 Homogeneous groups.
 Adolescents and patients with personality disorders.
 Families and couples where the system needs change.
Advantages
Group therapy gives an opportunity for immediate feedback from a
patient‟s peers and a chance for both patient and therapist to observe the
patient‟s psychological, emotional and behavioural responses towards a
variety of people.
Contraindications
 Antisocial patients.
 Actively suicidal or severely depressed patients.
 Patients who are delusional and who may incorporate the group into
their delusional system.
Size
Optimal size for group therapy is 8 to 10 members.
Frequency and Length of Sessions
Most group psychotherapists conduct group sessions once a week.
Length of session is 45 minute/hour.
Approaches to Group Therapy
 The therapist role is primary facilitator; he should provide a safe,
comfortable atmosphere for self-disclosure.
 Focus on the “here and now”.
 Use any transference situations to develop insight into their problems.
 Protect members from verbal abuse or from scapegoating.
 Whenever appropriate provide positive reinforcement, this gives ego
support and encourages future growth.
 Handle circumstantial patients, hallucinating and delusional patients
in a manner that protects the self-esteem of the individual and also
sets limits on the behaviours to protect the other group members.
  Develop ability to recognize when a group member is “fragile”; he
should be approached in a gentle, supportive and non-threatening
manner.
 Use silence effectively to encourage introspection and facilitate
insight.
 Laughter and a moderate amount of joking can act as a safety valve,
and at times can contribute to group cohesiveness.
 Role playing may help a member develop insight into the ways in
which he relates to others.
Some Techniques Useful in Group Therapy
 Reflecting or rewording comments of group members.
 Asking for group reaction to one member‟s statement.
 Asking for individual reaction to one member‟s statement.
 Pointing out any shared feelings within group.
 Summarizing various points at the end of the session.
Psychodrama is a method of group psychotherapy in which
personality makeup, interpersonal relationships, conflicts and emotional
problems are explored by means of special dramatic methods. Psychodrama
may focus on any special area of functioning (a dream, a family or a
community situation), a symbolic role, an unconscious attitude or an
imagined future situation.
Family and marital therapy
In family and marital therapy the focus of intervention is not on the
individual but on the family unit. The family therapist works towards
improving group interactions and helping each member to function better.
Indications
Family therapy is indicated whenever there are relational problems within a
family or marital unit, which can occur in almost all types of psychiatric
problems including the psychoses, reactive depression, anxiety disorders,
psychosomatic disorders, substance abuse and various childhood psychiatric
problems.
Components of Therapy
 Assessment of family structure, roles, boundaries, resources,
communication patterns and problem solving skills.
 Teaching communication skills.
 Teaching problem solving skills.
 Writing a behavioural marital contract.
 Homework assignments.
 4.0 Conclusion

Management of psychiatric patients is multidimensional, so this unit has

looked into psychological therapies in the care of disorders of mental health
individuals.

5.0 Summary

This unit has taken the learners through various psychological therapies like
psychoanalytic therapy, behaviour therapy, cognitive, relaxation, individual
therapies to mention but a few. The knowledge acquired in this unit will
assist you in the management of psychiatric patients in your day to day
professional activities.

Tutor Marked Assignment

(1) List five ways of psychological therapies
(2) Discuss any two of the five psychological therapies mentioned
above.

7.0 References / Further Readings

Olatawura, M. O. 2002. Psychology and Psychiatry Lecture Series
from Ibadan, Ibadan: Spectrum Books Ltd.
Staurt, W. G. and Sundeen, J. S. 1995. Principles and Practice of
Psychiatric Nursing. 5th Ed. London: C. V. Mosby Company.
Staurt, W. G. and Lavaia, M. T. 2001. Principles and Practice of
Psychiatric Nursing. 7th Ed. Missouri: Mosby. Inc.
Ahuja, N. A. 1999. Short Text Book of Psychiatry 3rd Ed. New Delhi:
Jaypee Brothers.
Sreevani, R. 2004. A Guide to Mental Health and Psychiatric Nursing,
New Delhi: Jaypee Brothers Medical Publishers (P) Ltd.
 Unit 3: Therapeautic Mileu

Table of Contents

1.0 Introduction
2.0 Objectives
Main Content
Mileu therapy
Therapeutic community
Activity therapy
4.0 Conclusion
5.0 Summary
6.0 Tutor Marked Assignment
7.0 References

1.0 Introduction

In continuation of the therapeutic modalities, this unit will look into

therapeutic mileu, therapeutic community and activity therapy in the
management of mentally ill individuals. Therapeutic mileu is an
environment that is structured and maintained as an ideal, dynamic setting in
which to work with clients.
2.0 Objectives

At the end of this unit, the learners should be able to:

- describe mileu therapy.
- explain how to maintain a milieu therapy
- state the components of a milieu therapy
- list the aims of activity therapy
- enumerate the components of activity therapy
- describe the implications of activity therapies for nursing practice.
Main content
Milieu therapy
The therapeutic milieu is an environment that is structured and maintained
as an ideal, dynamic setting in which to work with clients. This milieu
includes safe physical surroundings, all the treatment team members, and
other clients. It is supported by clear and consistently maintained limits and
behavioural expectations.
A therapeutic setting should minimize environmental stress such as noise
and confusion, and physical stress. It provides a chance for rest and
nurturance of self, a time to focus on the development of strengths, and an
opportunity to learn to identify alternatives or solutions to problems and to
learn about the psychodynamics of those problems.
A therapeutic milieu is a “safe space”, a non-punitive atmosphere in which
caring is a basic factor. In this environment, confrontation may be a positive
therapeutic tool that can be tolerated by the client. Nurses and treatment
team members should be aware of their own roles in this environment,
maintaining stability and safety, but minimizing authoritarian behaviour.
Clients are expected to assume responsibility for themselves within the
structure of the milieu as much as possible. Feedback from other clients and
the sharing of tasks or duties within the treatment programme facilitate the
client‟s growth.
The various components of the therapeutic Milieu include:
Maintaining Safe Environment
The nursing staff should follow the facility‟s policies with regard to
prevention of routine safety hazards and supplement these policies as
necessary. For example:
 Dispose of all needles safely and out of reach of clients.
 Restrict or monitor the use of matches and lighters.
 Do not allow smoking.
 Remove mouthwash, aftershave lotions and so forth, if substance
abuse is suspected.
 Listed below are the most restrictive measures to be used on a unit on
which clients who are exhibiting behaviour directly threatening or
harmful to themselves or others may be present. These measures may
be modified based on the assessment of the client‟s behaviour:
o immediately on the client‟s admission, search the client and all
of the client‟s belongings and remove potentially dangerous
items, such as wire, clothes hangers, ropes, belts, safety pins,
scissors and other sharp objects, weapons, and medications;
keep these belongings in a designated place inaccessible to the
client.
o be sure mirrors, if glass, are securely fastened and not easily
broken.
o keep sharp objects (e.g scissors, pocket knives, knitting
needles) out of reach of clients and allow their use only with
supervisors; use electric shavers when possible (disposable
razors are easily broken to access blades).
o identify potential weapons (e.g. mop handles, hammers) and
dangerous equipment (e.g. electrical cords, scalpels), and keep
them out of the client‟s reach.
o do not leave cleaning fluids, bleach, mops and tools, unattended
 in client care areas.
o do not leave medicines unattended or unlocked.
o keep keys (to unit door, medicines) on your person at all times.
o be aware of items that are harmful if ingested, for example,
mercury in manometers.
o search packages brought in by visitors, explain the reason for
such rules briefly and do not make any exceptions.
The Trust Relationship
One of the keys to a therapeutic environment is the establishment of trust.
Both the client and the nurse must trust that treatment is desirable and
productive. Trust is the foundation of a therapeutic relationship, and limit-
setting and consistency are its building blocks.

Building Self-esteem
Strategies to help build or enhance self-esteem must be individualized and
built on honesty and on the client‟s strengths. Some general suggestions are:
 Set and maintain limits
 Accept the client as a person
 Be non-judgmental at all times
 Structure the client‟s time and activities
 Have realistic expectations of the client and make them clear to the
client
 Initially provide the client with tasks, responsibilities and activities
that can be easily accomplished; advance the client to more difficult
tasks as he progresses
 Praise the client for his accomplishments, however small, giving
sincere appropriate feedback for meeting expectations, completing
tasks, fulfilling responsibilities and so on.
 Never flatter the client
 Use confrontation judiciously and in a supportive manner; use it only
when the client can tolerate it.
 Allow the client to make his own decisions whenever possible. If the
client is pleased with the outcome of his decision, point out that he
was responsible for the decision and give positive feedback.
 If the client is not pleased with the outcome, point out that the client,
like everyone, can make and survive mistakes, then help the client
identify alternative approaches to the problem; give positive feedback
for the client‟s taking responsibility for problem solving and for his
efforts.
Limit-setting
 Setting and maintaining limits are integral to a trust relationship and to a
therapeutic milieu. Before starting a limit explain the reasons for limit-
setting. Some basic guidelines for effectively using limits are:
 State the expectations or the limit as clearly, directly and simple as
possible.
 The consequence that will follow the client‟s exceeding the limit also
must be clearly stated at the outset.
 The consequences should immediately follow the client‟s exceeding
the limit and must be consistent, both over time (each time the limit is
exceeded) and among staff (each staff member must enforce the
limit).
 Consequences are essential to setting and maintaining limits, they are
not an opportunity to be punitive to a client.
In conclusion, the nurse works with other health professionals in an
interdisciplinary team; the interdisciplinary team works within a milieu
that is constructed as a therapeutic environment, with the aim of
developing a holistic view of the client and providing effective treatment.
Therapeutic community
The concept of therapeutic community was first developed by Maxwell
Jones in 1953. He wrote a book entitled “Social Psychiatry” which was first
published in England. Later on when it was published in the United States,
its title was changed to “Therapeutic Community”.
Definition
Stuart and Sundeen defined therapeutic community as “a therapy in which
patient‟s social environment would be used to provide a therapeutic
experience for the patient by involving him as an active participant in his
own care and the daily problems of his community.
Objectives
 To use the patient‟s social environment to provide a therapeutic
experience for him.
 To enable the patient to be an active participant in his own care and
become involved in daily activities of his community.
 To help patients to solve problems, plan activities and to develop the
necessary rules and regulations for the community.
 To increase their independence and gain control over many of their
own personal activities.
 To enable the patients to become aware of how their behaviour affects
others.
Elements of Therapeutic Community
  Free communication.
 Shared responsibilities.
 Active participation.
 Involvement in decision making.
 Understanding of roles, responsibilities, limitations and authorities.
Components of Therapeutic Community
Daily Community Meetings

 These meetings are composed of 60-90 patients. All levels of unit

staff are involved, including administrative personnel. Acute patients
are not involved in the meetings.
 Meetings should be held regularly for 60 minutes
 Discussion should focus mainly on day-to-day life in the unit.
 During discussions patients‟ feelings and behaviours are examined by
other members.
 Frank discussions are encouraged, these may take place with much
outpouring of emotions and anger.
Patient Government or Ward Council
 The purpose of patient government is to deal with practical unit
details such as house-keeping functions, activity planning and
privileges.
 A group of 5-6 patients will have specific responsibilities, such as
house keeping, physical exercise, personal hygiene, meal distribution,
a group to observe suicidal patients etc. Staff members should be
available always.
 All decisions should be feedback to the community through the
community meetings.
Staff Meetings or Review

A staff meeting should be held following each community meeting

(Patients are excluded and only staff are present). In this meeting the staff
would examine their own responses, expectations and prejudices.
Living and Learning Opportunities
Learning opportunities are to be provided within the social milieu, which
should provide realistic learning experiences for the patients.
Advantages of Therapeutic Community
 Patients develop harmonious relationships with other members of the
community.
 Gains self-confidence.
 Develops leadership skills.
  Learns to understand and solve problems of self and others.
 Becomes socio-centric.
 Learns to live and think collectively with the members of the
community.
 Lasting therapeutic community provides opportunities to participate in
the formulation of hospital rules and regulations that affect patient‟s
personal liberties like bedtime, meal time, weekend permission, and
control of radio or T.V., social activities, late night privileges.
Disadvantages of Therapeutic Community
 Role blurring between staff and patient
 Group responsibility can easily become nobody‟s responsibility.
 Individual needs and concerns may not be met.
 Patient may find the transition to community difficult.
Role of the Nurse
 Providing and maintaining a safe and conflict free environment
through role modeling and group leadership.
 Sharing of responsibilities with patients.
 Encouraging the patient to participate in decision-making functions.
 Assisting patients to assume leadership roles.
 Giving feedback.
 Carrying out supervisory functions.
In conclusion, therapeutic community is an approach which is:
 Democratic as opposed to hierarchical.
 Rehabilitative rather than custodial.
 Permissive instead of limited and controlled.
Activity therapy
Activity therapies include occupational therapy, recreational therapy,
educational therapy, play therapy, music therapy, dance therapy, and art
therapy.

Aims
 To assist the client in making the transition from the sick role to
becoming a contributing member of society.
 To assist in diagnostic and personality evaluation.
  To enhance psychotherapy and other psychotherapeutic measures (the
activity prescribed for the client often provides a nonverbal means for
the client to express and resolve his feelings).

Occupational therapy
Occupational therapy is the application of goal-oriented, purposeful
activity in the assessment and treatment of individuals with psychological,
physical or developmental disabilities.
Goal
The main goal is to enable the patient to achieve a healthy balance of
occupations through the development of skills that will allow him to
function at a level satisfactory to himself and others.
Settings
Occupational therapy is provided to children, adolescents, adults and
elderly parents. These programmes are offered in psychiatric hospitals,
nursing homes, rehabilitation centres, special schools, community group
homes, community mental health centres, daycare centres, half-way homes
and deaddiction centres.
Advantages
 Helps to develop social skills and provide an outlet for self
expressions.
 Strengthens ego defenses.
 Develops a more realistic view of the self in relation to others.
Points to be kept in mind
 The client should be involved as much as possible in selecting the
activity.
 Select an activity that interests or has the potential to interest him.
 The activity should utilize the client‟s strengths and abilities.
 The activity should be of short duration to foster a feeling of
accomplishment.
 If possible, the selected activity should provide some new experience
for the client.
Process of Intervention
It consists of six stages:
1. Initial evolution of what patient can do and cannot do in a variety of
situations over a period of time.
2. Development of immediate and long-term goals by the patient and
therapist together. Goals should be concrete and measurable so that it
is easy to see when they have been attained.
3. Development of therapy plan with planned intervention.
4. Implementation of the plan and monitoring the progress. The plan is
followed until the first evaluation. If satisfactory, it is continued, or
altered if not.
5. Review meetings with patient and all the staff involved in treatment.
6. Setting further goals when immediate goals have been achieved;
modifying the treatment programme as relevant.

Exercise 1: Highlight the components of therapeutic milieu

Types of Activities
Diversional activities: These activities are used to divert one‟s thoughts from
life stresses or to fill time. E.g. organized games.
Therapeutic activities: These activities are used to attain a specific care plan
or goal. E.g. basket making, carpentry etc.
Suggested Occupational Activities for Psychiatric Disorders
Anxiety disorder: Simple concrete tasks with no more than 3 or 4 steps that
can be learnt quickly. E.g. kitchen tasks, washing, sweeping, mopping,
mowing lawns and weeding gardens.
Depressive disorder: Simple concrete tasks which are achievable; it is
important for the client to experience success. Provide positive
reinforcement after each achievement. E.g. crafts, mowing lawns and
weeding gardens.
Manic disorder: Non-competitive activities that allow the use of energy and
expression of feelings. Activities should be limited and changed frequently.
Client needs to work in an area away from distractions. E.g. raking grass,
sweeping etc.
Schizophrenia (paranoid): Non-competitive, solitary, meaningful tasks that
require some degree of concentration so that less time is available to focus
on delusions. E.g. puzzles, scrabble.
 Schizophrenia (catatonic): Simple concrete tasks in which client is actively
involved. Client needs continuous supervision and at first works best on a
one-to-one basis. E.g. metal work, moulding clay.
Antisocial personality: Activities that enhance self-esteem and are
expressive and creative, but not too complicated. Client needs supervision to
make sure each task is completed.
Dementia: Group activities to increase feelings of belonging and self-worth
provide those activities which promotes familial individual hobbies.
Activities need to be structured, requiring little time for completion and not
too much concentration. Explain and demonstrate each task, then have client
repeat the demonstration.
Substance Abuse: Group activities in which clients uses his talents. E.g.
involving client in planning social activities, encouraging interaction with
others etc.
Childhood and adolescent disorders:
Children: Playing, story telling, painting, poetry, music etc.
Adolescents: Creative activities such as leather work, drawing, painting.
Mental retardation: Repetitive work assignments are ideal; provide positive
reinforcement after each achievement. E.g. cover making, candle making,
packaging goods.
Recreational Therapy
Recreation is a form of activity therapy used in most psychiatric settings. It
is planned therapeutic activity that enables people with limitations to engage
in recreational experiences.
Aims
 To encourage social interaction.
 To decrease withdrawal tendencies.
 To provide outlet for feelings.
 To promote socially acceptable behaviour.
 To develop skills, talents and abilities.
 To increase physical confidence and a feeling of self-worth.

Points to be kept in mind

 Provide a non-threatening and non-demanding environment.
 Provide activities that are relaxing and without rigid guidelines and
time-frames.
 Provide activities that are enjoyable and self-satisfying.
 Types of Recreational Activities
Motor forms: These can be further divided into fundamental and accessory;
among the fundamental forms are such games as hockey and football, while
the accessory forms are exemplified by play activity and dancing.
Sensory forms: These can be either visual e.g. looking at motion pictures,
play etc., or auditory such as listening to a concert.
Intellectual forms: These include reading, debating and so on.
Suggested Recreational Activities for Psychiatric Disorders
Anxiety disorder: Aerobic activities like walking, jogging etc.
Depressive disorder: Non-competitive sports, which provide outlet for anger,
like jogging, walking, running etc.
Manic disorder: One-to-one basis individual games like chess, puzzles.
Schizophrenia (paranoid): Concentrative activities like chess, puzzles.
Schizophrenia (catatonic): Social activities to give client contact with reality,
like dancing, athletics.
Dementia: Concrete, repetitious crafts and projects breed familiarization and
comfort.
Childhood and adolescent disorders: It is better to work with the child on a
one-to-one basis and give him a feeling of importance. Some activities
include playing, story telling and painting.
Adolescents fare better in groups; provide gross motor activities like
sports and games to use up excess energy.
Mental retardation: Activities should be according to the client‟s level of
functioning such as walking, dancing, swimming, ball playing etc.
Educational Therapy
Educational therapy is used when the client has problems which result from
a great deal of misconception. The educational therapist provides reading
and learning experiences that can do a great deal to eliminate his
misconceptions and anxiety.
Biblio Therapy
It is described as the prescription of reading materials that will help to
develop emotional maturity and sustain mental health. Some emotionally
disturbed individuals are able to relate therapeutically to the experiences of
others when they read about them, rather than experiencing them directly. It
also provides a medium for discussions with others.
Play Therapy
Play is a natural mode of growth and development in children.
Through play a child learns to express his emotions and it serves as a tool in
the development of the child.
Curative functions
  It releases tension and pent-up emotions.
 It allows compensation for loss and failures.
 It improves emotional growth through his relationship with other
children.
 It provides opportunity to the child to act out his fantasies and
conflicts, to get rid of aggression and to learn positive qualities from
the other children.

Diagnostic functions
 Play therapy gives the therapist a chance to explore the family
relationships of the child and discover what difficulties are
contributing to the child‟s problems.
 Play therapy allows to study hidden aspects of the child‟s personality.
 It is possible to obtain a good idea of the intelligence level of the
child.
 Through play inter-sibling relationships can be adequately studied.
Types of Play Therapy
Individual vs. group play therapy: In individual therapy, the child is allowed
to play by himself and the therapist‟s attention is focused on this one child
alone.
In group play therapy other children are involved.
Free play vs. controlled play therapy: In free play the child is given freedom
in deciding with what toys he wants to play.
In controlled play therapy, the child is introduced into a scene where
the situation or setting is already established.
Structured vs. unstructured play therapy: Structured play therapy involves
organizing the situation in such a way so as to obtain more information.
In unstructured play therapy no situation is set and no plans are
followed.
Directive vs. non-directive play therapy: In directive play therapy, the
therapist totally sets the directions, whereas in non-directive play therapy,
the child receives no directions.
Play therapy is generally conducted in a play room. The play room
should be suitably stocked with adequate play material depending upon the
problem of the child.
Music Therapy
Music therapy is the functional application of music towards the
attainment of specific therapeutic goals.
Advantages
  Facilitates emotional expressions.
 Improves cognitive skills like learning, listening and attention span.
 Exercise through body movement maintains good circulation and
muscle tone.
 Social interaction is stimulated.
Dance Therapy
It is a psychotherapeutic use of movements, which furthers the
emotional and physical integration of the individual.
Advantages
 Helps to develop body awareness.
 Facilitates expression of feelings.
 Improves interaction and communication.
 Fosters integration of physical, emotional and social experiences that
result in a sense of increased self-confidence and contentment.
Art Therapy
The goal of art therapy is to help the patient express his thoughts,
emotions and feelings through his drawings.
Importance of art therapy
 It is used as a diagnostic and therapeutic tool.
 It provides socially acceptable outlets for fantasy and wish fulfillment.
 It helps the patient to gain relief from anxiety by graphically
representing conflicts and aggressive and traumatic material without
guilt.
Implications of Activity Therapies for Nursing Practice
The nurse has an important role in enhancing the therapeutic effects of
activity therapies. Some points to be kept in mind are:
 Close coordination between the nursing staff and the activity therapy
department is essential.
 By engaging in these activities, the nurse not only has an opportunity
to support the therapeutic efforts of the recreational therapist, but also
has an invaluable opportunity to observe the client in different
settings.
 Through her observations of the client‟s behaviour during these
activities, the nurse will gain valuable information that she can
subsequently utilize to therapeutic advantage in the working phase of
the nurse-client relationship.
4.0 Conclusion
The needs of mentally ill individual are numerous as the illness may
affect both the body and the mind of the patient, so meeting the needs can be
approached from somatic, psychological and activities point of the view, so
this unit dealt with the use of milieu therapy, therapeutic community and
activity in meeting the needs of psychiatric patients in our communities.
5.0 Summary

This unit looked into the use of environment in meeting the needs of
individuals with disorders of mental health. I hope the knowledge gained
from the unit can now assist you to answer the following tutor marked
assignments.
Tutor Marked Assignments
(1) Discuss how a milieu therapy can be attained by you as a nurse
to meet the needs of your clients.

Answer to Exercise
 maintain safe environment - Trust relationship
 Build self esteem - Limit setting

7.0 References / Further Readings

Olatawura, M. O. 2002. Psychology and Psychiatry Lecture Series
from Ibadan, Ibadan: Spectrum Books Ltd.
Staurt, W. G. and Sundeen, J. S. 1995. Principles and Practice of
Psychiatric Nursing. 5th Ed. London: C. V. Mosby Company.
Staurt, W. G. and Lavaia, M. T. 2001. Principles and Practice of
Psychiatric Nursing. 7th Ed. Missouri: Mosby. Inc.
Ahuja, N. A. 1999. Short Text Book of Psychiatry 3rd Ed. New Delhi:
Jaypee Brothers.
Sreevani, R. 2004. A Guide to Mental Health and Psychiatric Nursing,
New Delhi: Jaypee Brothers Medical Publishers (P) Ltd.

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MODULE 2

Unit 1: Community Mental Health Nursing

Table of Contents

1.0 Introduction
2.0 Objectives
Main Content
Introduction
Community Mental Health-Psychiatric Nurse Attributes
Goals of Community Mental Health Nursing
Psychiatric Services in Community Psychiatry
Role of the Community Psychiatric Nurse
Levels of Prevention
4.0 Conclusion
5.0 Summary
6.0 Tutor Marked Assignments
7.0 References/Future Readings

1.0 Introduction

This unit will introduce the learners to community mental health nursing.
Community mental health has developed a response to the realization that
much of the effort expended in the past as treatment for mentally ill
individuals encouraged chronicity rather than a return to a productive life.
Thus, the current trend is to treat the individual immediately in the
community, no matter how disturbed his behaviours may be. In this way, it
is hoped that the development of chronic symptomatology and the rupturing
of community ties through institutionalization can be avoided.

2.0 Objectives

At the end of this unit, the learner should be able to:

- describe the aims of community mental health nursing
- list the methods used in practicing community psychiatry
- discuss the roles of community psychiatric nurse.
Main content
Introduction
The term community can be defined either as a political (geographic) unit or
as a functional unit. People qualify as members of a geographic or political
unit by holding rights of citizenship within the boundaries of specified
territory or merely by living there.
Community Psychiatry is a new speciality- though a widely embracing one-
within the field of psychiatry. It consists of the acceptance of responsibility
by one or more Psychiatrists and others working with them for the
prevention, early detection, and short-terms and long-term (including
rehabilitative) treatment of metal disorders in a circumscribed population.
Community care consists of medical and social services provided by four
main groups, namely, department of Health and Social Security Area Health
Authorities, Local Authorities and Voluntary Organisations.
Community mental health is essentially a synonym for community
psychiatry. The aim is to provide care for patients at centres located near
their homes as at a stage when their disorder have not yet becomes severe or
chronic , so that disruption of their lives is minimized. In most cases these
are patients these prognosis is good. Both rehabilitative and primary
preventive efforts are also emphasized; the latter through education and
consultation.
Thus, the Community Mental Health was a revolutionary idea when it was
introduced in the early 1960‟s. Its overall goal was helping people in their
own community or neighbourhood to reach and maintain more satisfactory
levels of functioning. It also aims to use the support of patient‟s relatives
(family) and friends where possible and to put them in touch with the
psychiatric services which exist for guidance and treatment of such patients.
The family is the principal “medium” by which the Community‟s “message”
is transmitted. While acknowledging the importance of biological and others
influences, the Community Psychiatrist place special emphasis on the fact
that the emotional health of the individual and families depends on the
healthy development and functioning of human communities.
Since the patient receives treatment within his own environment, the
possibility of “lengthy rehabilitation” as in the case of patient admitted in a
comprehensive psychiatric setting (Psychiatric Hospital) is reduced.
Community Mental care prevents unnecessary boredom often experienced
by hospitalised patients. It is also worth mentioning that the social stigma
attached to people with mental disorders is considerably reduced.
Attributes of a Community Mental Health/Psychiatric Nurse
 Awareness of self, personal and cultural values
 Non-judgmental attitude
 Problem solving skills
 Ability to cross service system (e.g. to work with school, other health
care providers, employers, etc).
 Knowledge of community resources
 Willingness to work with the family or significant other identified by
the client as support people.
 Understanding of the social, cultural and political issues that affect
mental health and illness
 Knowledge of political activism

Goals of Community Mental Health Nursing

 To provide prevention activities to populations for the purpose of
promoting mental health.
 To provide interventions as early as possible.
 To provide corrective learning experiences for client-groups who have
deficits and disabilities in the basic competencies needed to cope in
society, and to help individuals develops a sense of self-worth and
independence.
 To anticipate when populations become at risk for particular
emotional problems and to identify and change social and
physiological factors that diversely affect people‟s interaction with
their environments.
 To develop innovative approaches to primary prevention activities.
 To assist in providing mental health education to populations about
mental health and illness and to teach people how to assess their
mental health.

Community Mental Health Nursing Process

The key aspects of the assistance include:
 Impairments directly due to psychiatric disorder such as persistent
hallucinations, negatively symptoms, social withdrawal, under-
activity and slowness.
 Secondary social disadvantages such as unemployment, poverty
and homelessness, as well as the stigma attached to psychiatric
illness.
  Personal reactions to illness and social disadvantage such as low
self-esteem and hopelessness, poor motivation and capacity for
self-management and performance of social roles.
 Unpredictable behaviour, risk of harm to self and others, and
liability to relapse.
 Financial circumstance of the client.
 Availability of community resources.
 Social circumstances to which the patient is likely to return.
The expected outcome of the assessment is a detailed outline of the person‟s
present functioning highest level of functioning, highest level functioning
and the needed services.

Intervention
Community psychiatric nurse must approach innervations with inflexibility
and resourcefulness to need the broad range of needs of the patients with
continued mental deficits. Interventions cannot be direct only towards
discrete psychiatric symptoms, but must also facilitate client‟s access to
various community resources providing for basic needs such as housing
nutrition, etc. Since people suffering from mental illness often remain in or
return to the community following treatment, nurses mist be able to the
assess the presence of continued mental health problems and plan and
implementation interventions within the confines of the resources available
in the community.
Carr et al. (1984) have identified the following roles for nurses working in
community mental health services:
Consultative roles: This means giving advice to other professionals in the
community about the type and level of nursing care required for a given
client group.
Clinician role: Providing direct nursing care to the patient in the community.
Therapeutic role: Employing psychotherapeutic and behavioural methods for
management of patients.
Assessor/researcher role: The nurse assesses the care given to the client
group, and may also assess the outcome ongoing care programs.
Educator: Creating awareness in the community about mental health and
metal illness with special focus on vulnerable groups.
Trainer/Manpower facilitators: Training of paraprofessionals, community
leaders, school-teachers and other care-giving professionals in the
community.
Manager/Administrator: Management or resources, planning and
coordination.
Domiciliary care: Services are provided to the client by visiting their homes.
Services like administration of medications, assessment of the level of
functioning and improvement of patient, monitoring of side-effects of drug,
counselling of patients and family members are offered at the client‟s home
setting.
Liaison role: Nursing working in the community help the clients and the
family members by bridging the gap between the client and the hospital,
client and the employers and also by networking in the community for
resources development.
Preventive roles: These preventive roles are under primary, secondary, and
tertiary levels.
Other areas of community health psychiatric nursing
 Social skills training
 Assertive management and relaxation
 Bereavement counselling
 Group meetings
 Community out-reach work services
 Child care services
 Adult care and elderly care services

Some Tips to be kept in mind when working in the Community

1. Identification of Patient in the Community: Talk to important people
like, village panchayat members, local leader, teachers, and educated youth
members of services agencies like angawadi mahila mandals, etc. and
request them to tell you about individuals:
 Who talk nonsense and act in manner considered stranger or
abnormal.
 Who have becomes very quiet and do not talk or mix with other
people
 Who claim to hear voice or see things that others cannot hear or see.
 Who are suspicious and claim that others are trying to harm them.
 Who have become unusually cheerful, crack jokes and say that they
are very wealthy and superior to others when it is not really so.
 Who have become very sad lately and cry without reason.
 Who talk about suicide or have made an attempt at suicide.
 Who get processed by god or spirit or who are said to be the victims
of black magic or evil power
  Who are dull, mentally not grown up like other of their age and slow
since birth.
When you visit homes, enquire about members suffering form mental
illness. Ask the above mentioned questions tactful without offending them
and obtain information about the existence of a patient in them in that
family, neighbourhood or among their relatives.
When you go to school, enquire from teachers and students about
children who suffer from fits, behavioural and learning problems.
2. Refer the immediately in the following conditions
 The patients is severely ill, violent or unmanageable at home
 History of recent head injury
 Repeated convulsions (continuous or more than 3 times a day)
 Distributed behaviour after delivery
 The client has attempted suicide or is threatening to commit suicide
 Distributed behaviour in people with known diabetes or hypertensions
 People who show abnormal behaviour after taking alcohol or may
other intoxicating substance.

3. Follow-up care with special emphasis on medication regimen,

improvement made, and side effects, patient‟s occupational function
4. Be prepared to answer certain common questions asked regarding
mental illness.
 Is mental illness hereditary?
 Is mental illness contagious?
 Do ghosts, black magic, curse cause mental-illness?
 Is mental illness treatable?
 Can patients take up responsibilities after recovery?
 Can marriage cure mental illness?
5 Remember
 Do not give false assurance or make false promises, just tell them you
will do your best to help them.
 Do not make any decisions for the family.
 Do not criticize or blame
 See that they develop confidence in their abilities.
 Do not make them dependent on you
 Avoid half-heated attempts; hard work yields good results.
Psychiatric Services In Community Psychiatry
Various ways (methods) are used in practising community psychiatry:
(a) Psychiatric service in General Hospital: They furnish strategic
application of community psychiatry. Here, the hospital serves as the
community psychiatry. In this setting, psychiatric staff members can interact
closely with their medical and paramedical colleges. People turn more
readily to non-Psychiatrist physicians for help with their physiologic
difference than to anyone else. Furthermore, any illness is psychologically
stressful both to the patient and to his family; and many physical illnesses
are provoked at least in part by emotional tension. As in other psychiatric
treatment setting, continuity of care can be maintained as people are
transferred form outpatient to impatient to artificial hospitalization (night or
day hospital) and then back to outpatient
(b) Day Hospital (in the Hospital or on separate premises): Day hospital may
be provided within the community. They are either attached to an hospital or
stand on their own. Patients are brought by their relations to receive
psychiatric treatment, depending on patient‟s condition; HW stays in the say
hospitals for example morning till evening with relatives.
Patient may even be admitted for a short-term treatment with the
relative in attendance.
(c) The field of child and family psychiatry serve as models for much of
what takes place in community psychiatry. The therapist treating an
emotionally disturbed child recognizes that other members of the family
play a part in his patient‟s disturbance. Parents may be urged to obtain
individuals therapy, or they may be regarded essentially as consultees. The
child‟s problems are then discussed with the parents in such a way as to ease
the parent‟s tensions and enlist them as colleagues in treating the child.
(d) Psychiatric Social workers form the hospital do follow-up of patients in
assessing situations in the environment, treating and advising the community
on health grounds.
(e) Day centres are also established for care of the elderly, for chronic
Schizophrenia, for the mentally handicapped.
(f) Child Guidance Clinics are established in the community to take care of
physical, emotional and psychological cares of children. The psychiatrist pay
visit to the institutions.
(g) Social clubs in the Community aid treatment and prevention of
psychiatric conditions. The alcoholics for example form themselves into
clubs, they sheer opinions and receive advice form medical team.
(h) Village system care-neighbouring villages are used in some cases.
Patients and relatives say there and receive treatment in the hospital.
Role Of The Community Psychiatric Nurse
 In community Mental Health today, Psychiatric nurse with a
generalist background are prepared to attempt to meet the needs of
“total patient”. Their flexibility enhances the developmental nature of
this growing specialty. Community mental nurses are action oriented.
As in all Community health, the focus is one primary prevention. The
nurse does not wait for the patient to become “ill” first, rather, the
emphasis on prevention. Problems are dealt with in the setting where
they began; an attempt is made not to remove the person from the
community.
 Among other things, the nurse who is a clinical specialist in
Psychiatric nursing serves as an individual and group therapist and
consultation and liaison person to community agencies and hospital
units.
 The community Psychiatric nurse makes home visits and serves as a
resources person, educator, administrator and researchers.
 The community Psychiatric nurse communicates clearly with other
health members to maintain their significant professional
contributions.
 She assists the relatives in the management of the patient by helping
them to prepare for the patient‟s return to the community, - providing
support for the family, noting signs of stress within the family and
taking appropriate remedial action.
 She is also concerned with giving health education within the
community
 The nurse is concerned with the administration and supervision of
drugs at home or health centre, and recognition of side-effects.
 She plays a role in running groups/social clubs which provide
support after patient‟s discharged home.
 The community Psychiatric nurse is also concerned with provision of
community of hospital in-patient or outpatient treatment.
 At times she runs a “supportive”, and works with outpatient.

Levels Of Prevention
In the 1960s, psychiatric Gerald Caplan described levels of prevention
specific to psychiatry. He defined primary prevention as an effort directed
towards reducing the incidence of mental disorders in a community.
Secondary prevention refers to decreasing the duration of disorder while
tertiary prevention refers to reducing the levels of impairment.
 Primary Prevention
Primary prevention seeks to prevent the occurrence of mental disorders by
strengthening individual, family and groups coping abilities.

Role of a nurse in primary prevention

Community mental health nurse are in a key position to identify individual,
family and group needs, conflicts and stressors. Thus, they play a level of
prevention

Health Maintenance
MENTAL HEALTH
PRIMARY
Ability to cope with activities of daily Specific protection of
PREVENTION
living in an adaptive manner
vulnerable population
PRIMARY
Health Maintenance
MENTAL HEALTH PREVENTION

Ability to cope with activities of daily living PRIMARY Specific protection of

in an adaptive manner PREVENTION vulnerable population
Fig. 1: Levels of prevention (This paradigm was developed by Bloom,
1979)

Major role in identifying high-risk groups and preventing the occurrence of

mental illness include:
 Antenatal care to the mother an educating her regarding the
adverse effects of irradiation, certain drugs and prematurely.
 Ensuring timely and efficient obstetrical assistance to guard
against the ill effects of anoxia an injury to the newborn at birth.
 Dietary corrections of those infants suffering from metabolic
disorders.
 Fostering bonding behaviours
 Teaching growth the and development to parents and teachers.
 Correction of endocrinal disorders.
 Consulting with parents about appropriate disciplinary measures
 Promoting open health communication in families.
  Rendering crisis counselling to the parents of physically and
mentally handicapped children.
 Identifying the problems of scholastics performance and emotional
disturbances among school children and going timely intervention.
School teachers can be taught to recognize the beginning
symptoms of problems.
 Ensuring harmonious relationship among the members of the
family and teaching healthy adaptive techniques at the time of
stress-producing events.
 Extending mental health education services at Child Guidance
Clinics about child rearing practice; at parent-teachers association
regarding the triad relationship between teacher, child and parent;
and at various extramural health agencies regarding integration of
mental health into general health practice.
 Strengthening social support for the frustrated ages and helping
them to retain their usefulness.

Secondary Prevention
Secondary prevention targets people who show early symptoms of mental
health disruption but regain premorbid level of functioning through
aggressive treatment.

Role of a Nurse in Secondary Prevention

 Case finding through screening and periodic examination of
population at risk, monitoring of client etc. thus in clinics, schools,
home health care and the work place community mental health nurse
detect early sign of increase level of anxiety, decreased ability to
cope with stress and failure to perceive self, the environment and/or
reality accurately and provide direct service appropriate
 Consultation and referral services.
 Early and effective treatment for patient, and if necessary, to family
members as relevant; providing counselling services to caregivers of
mentally ill patients.

Tertiary Prevention
Tertiary Prevention targets those with metal illness and helps to
reduce the severity, discomfort and disability associated with their illness. In
these terms community mental health nurses play a vital role in monitoring
the progress of discharged patients in halfway homes, houses, etc.,
especially with regard to their medication regimen, coordination of care, and
so on.

Exercise 1:
Summarize the Secondary level and the nurse‟s role

Roles of a nurse in tertiary prevention

 There are wide range of service that needs to be provided to patient as
part of the tertiary prevention program. Nurses need to be familiar
with the agencies in the community that provide these services.
Collaborative relationship between mental health care providers and
community agencies are absolutely essentially if rehabilitation is to
succeed.
 An important intervention in the maintenance of patient in their own
homes in the community is the Training in Community Living (TCL)
program, designed by „Stein‟ and „Test‟. In this model when a person
is referred for a hospital admission the staff goes to the community
with him rather than his going to the hospital to be with the staff. This
real world experience with the patent enables the nurse to assess
accurately the skills that the person breeds to learn and to mutually
agree on realistic goals.

 Another aspect of community life that is more difficult to assess

accurately and deal with effectively, is the stigma attached to mental
illness. Many patient and their families try to avoid stigma by keeping
the nature of the person‟s illness secret. The need for secrecy place
additional stress on the family system because there us always the fear
that the truth will be revealed. Nurses in the community are in a key
position to monitor community attitudes and help in fostering a
realistic attitude towards the mentally ill.
 For some patents, the emotional climate of the family to which they
return can have a significant effect on their adjustment, and
eventually, recovery from the debilitating effects off chronic metal
illness. Families sometimes view mental illness as a weakness of
 character that can be overcome by exertion of moral effort. This type
of familial attitude may result in guilt on the part of the patient who
believes that he has disappointed his significant other. Guilt leads to
increase anxiety and decrease self-esteem. These are the conditions
that interface with a high level of functioning. Therefore nursing
working with families need to foster health attitudes towards the
mentally ill member.

4.0 Conclusion

Community mental heath-psychiatric nursing which is the application

of specialized knowledge to populations and communities to promote and
maintain mental health, and to rehabilitate populations at risk that continue
to have residual effects of mental illness. Psychiatric nursing in the
community setting differs markedly from its hospital counterparts. The
community setting requires that the psychiatric nurse posses knowledge
about a broad array of community resources and be flexible in approaching
problems related to individual psychiatric symptoms, family and support
systems and basic livings needs such as housing and financial support.
5.0 Summary

You will agree with me that the method of treating mental illness have
changed dramatically in the past century thus bringing about the shift in
mental health care from the institution to the community and heralding the
era of deinstitutionalization. This unit has taken you through these changes
which make you more relevant in the management of mental disorders as a
professional nurse.

Tutor Marked Assignments

Differentiate between institutionalized and deinstitutionalized
management of mental health nursing in Nigeria

Answer to Exercise
Targets people who show early symptoms of mental health disruption but
regain premorbid level of functioning through aggressive treatment.

Roles are:
 Case finding through screening and periodic examination of
population at risk.
 Consultation and referral services.
 Early and effective treatment for patient,
7.0 References / Further Readings
Adedotun, A. 2000. Basic Psychiatry and Psychiatric Nursing. Ile-Ife:
Basag (Nig) Enterprises.
Olatawura, M. O. 2002. Psychology and Psychiatry Lecture Series
from Ibadan, Ibadan: Spectrum Books Ltd.
Sreevani, R. 2004. A Guide to Mental Health and Psychiatric Nursing,
New Delhi: Jaypee Brothers Medical Publishers (P) Ltd.
Unit 2: Legal Aspects of Mental Health Nursing

Table of Contents

1.0 Introduction
2.0 Objectives
Main Content
Trends in Patients‟ Care and the Law
Essence of Law in Psychiatry
The Law and the mentally ill in Nigeria I
The Law and the mentally ill in Nigeria II
4.0 Conclusion
5.0 Summary
6.0 Tutor Marked Assignments
7.0 References

1.0 Introduction

In one of your previous courses, you studied nursing ethics and

jurisprudence, the course reflected on legal aspects of nursing profession. In
this unit, you will also be taken through the legal aspects of psychiatry and
psychiatric nursing, so the need to reflect and go back to the previous course
on nursing ethics and jurisprudence.
The practice of psychiatric nursing is influenced by the law particularly in
concern for rights of patients and the quality of care they are receiving. The
relationship between psychiatric and law reflects on tension between
individual rights and social needs, and the two areas have many similarities.
Both psychiatric and law deals with human behaviours, the interrelationships
between people and the responsibilities people assume based on these
relationships. Both also have a role in society‟s desire for control of
undesirable behaviours. Together, they mutually analyse when psychiatric
treatment is therapeautic, custodial or incarceration.
2.0 Objectives

At the end of this unit, the learners should be able to:

- state the similarities and dissimilarities between psychiatry and law
- explain the essence of law in psychiatry
- explain when and why the patient must be compulsorily admitted to
hospital, detention for care and discharge
- state the legal and criminal responsibilities of mentally ill in Nigeria
- explain the concept of criminal responsibility
- discuss the concept of diminished responsibility
 - state the role of psychiatrist and the law
- enumerate the rights of patients

Main content
Trends in Patients’ Care and the Law
Mental (psychiatric) hospitals have ceased to be generally regarded merely
as places of care and custody and their ability to treat and cure patients has
been widely recognised. Unlocking of doors, removal of railings and
reduction of other restrictions on personal liberty have become the common
practice, and in this the mental hospitals have met with public support.
An increasing number of general hospitals provide accommodation for
psychiatric patients for it is now recognised that they do not always need to
be treated in special hospitals. This change of attitude to the mentally ill,
which came about concurrently with rapid advances in treatment and new
methods of hospital administration called for revision of outworn laws and
statutory regulations.
In Britain, the repeal of section 315 of the lunacy Act made possible the
admission of patients to mental hospitals without any formalities as
„informal‟ patients. The new Act removed the magistrate form any part in
the legal detention of patients. Furthermore, it decreed that a patients
suffering from a mental disorder, even if detained against his will, could be
treated in a general hospital and do not only in a mental hospital as was
previously the case.
Formerly, even a voluntary patient could not be admitted to a
psychiatric hospital unless he was suffering from a „psychiatric illness‟,
although the latter term was not clearly defined in the regulations. There is
now complete freedom to admit patients to any kind of hospital according to
their clinical needs and the facilities available. There is no legal bar to a
psychiatric hospital reserving wards for, say, maternity or general surgical
cases, in the same way as there is no bar to a general hospital reserving
wards or beds for psychiatric patients.
Of course this legal freedom is not likely to cause any great change in
the function of hospitals, other than to bring more psychiatric patients into
general hospitals. Patients with different kinds of psychiatric illness will
continue to be treated in different clinics or hospitals, because those with
mental illness need different treatment from those with mental subnormality.
Essence of Law in Psychiatry
It seems rather convenient to start by explaining why the law is so
necessarily important in psychiatric. The answer lies partly in the nature of
psychiatric illness itself, partly in the concept of responsibility and
 accountability, and partly in the acceptance of the principle of the
fundamental human right of freedom of movement of the individual.
Firstly, psychiatric illness, unlike other illness, is not always referable to a
deviation from biological norms. Rather it may manifest in a behavioural
pattern that constitute a deviation that is so gross and so bizarre that there is
no difficulty among all and sundry in saying that the person involved must
be mentally ill. In others, it requires the opinion of experts before any
pronouncement of illness can be made.
Secondly, an individual with the types of behaviour specified above,
attribute to illness, cannot be expected to be accountable for his own actions.
In order to avoid incidents of this type, there should exist in each society
laws to provide for the hospitalization (compulsory if necessary) of mentally
disordered persons, and to ensure that they are not allowed to roam at large
in the community. This is not to say that every mentally disordered persons,
and to ensure that they are not allowed to roam at large in the community.
This is not to say that every mentally disordered person must be
hospitalized. The types of person that are of particular concern here are those
who are unable to recognise or accept that they are ill and in need of
treatment, those unable to look after themselves and at the same time do not
have anybody to take responsibility for their welfare those with overt or
potential destructiveness either to themselves or to others, or to property,
and those with inability to control their behaviour especially when such
behaviour is of a destructive.
An acceptable law must make provisions for the hospitalisation of the types
of persons described above whilst at the same time taking into account the
principle of the fundamental human right of freedom of movement. In
addition, the law must ensure that, though certain personal and civil right of
persons suffering from some types of illness may have to be curtailed, other
rights are not unduly restricted. And it must make allowance for the effects
of mental illness on a person‟s sense of responsibilities and accountability
especially with respect to criminal behaviour. From these points of view, the
law may be divisible into two groups. The first group, describe as
“humanitarian” would consist of rules intended to protect the mentally ill
person himself; whilst the second group, intended to protect the public, may
be described as „self-preservatory‟.

Humanitarian
Thus the humanitarian rules would be concerned with:
1. Care or treatment of the individual:
a. Getting him, if necessary against his will to a place where he can be
looked after and keeping him there until he is well enough to be
released.
b. Protecting those who have to carry out (a) above; so that they are not
deemed to be violating his fundamental human rights.
c. Ensuring that he is not deprived of his liberty for an unnecessarily
long time.
2. Protection from undue criminal conviction.
3. Protection of his property and affairs whilst ill.
Self-Preservatory Rules
These rules would be concerned with the protection of the public
form:
1. Mentally disordered persons who may find themselves in position of
power in the governmental machinery. For example:
a. Kings, Emperors, Presidents, Prime Ministers, Ministers and/or
state Secretary (ies):
b. Judges and Magistrates
c. Other High government officials.
2. Mentally disordered persons who are not in crucial positions in the
government but by virtue of their being loose in the society, are
capable of inflicting harm on other people either by:
a. direct/indirect assault on person;
b. damage to property; or
c. entering into marriage contract with unsuspecting persons.
The Law and the Mentally Ill in Nigeria (Compulsory Admission
to Hospital, Detention for Care and Discharge)
The law which provided for the custody and removal of the mentally ill in
Nigeria used to be called the Lunacy Ordinance.
(1) This law, which was first commenced on 21st December 1916, was a
transcription of the English law, which was over 100years old and
which was repealed and replaced by an Act of Parliament known as
the Mental Act of 1959.
(2) At about this time, with the creation of self-governing regions in
Nigeria, the Lunacy Ordinance was revised and incorporated into the
Laws of each region as the Lunacy Law.
(3) And in Eastern and Northern Nigeria in 1963, (4, 5) The Law. In all
three regions are similarly worded except in a few minor details. The
description which follows therefore, applies to all of them although
the Lunacy Law of Western Nigeria is used as an example.
The sections of the Lunacy Law which are of relevance for discussion here
are sections 10-18. only these will be discussed. Section 10 of the Lunacy
Law in Western Nigeria States that, “whenever a Medical Officer has cause
to suspect that any person is a lunatic and considers it expedient that such
person should be placed forthwith under observation in an asylum, he may
grant a certificate of emergency, and shall cause such a person to be taken to
an asylum and it shall be lawful for such a person to the asylum specified,
and for the superintended of the asylum to receive and detain such a person
in the asylum: „Provided that no such person shall be detained in an asylum
under any such certificate for a longer period than (7) seven days except
with the authority of a magistrate‟
Section 11-16 requires that an information be given on oath to a magistrate
who may then examine the person suspected to be mentally disordered, and
hold an inquiry as to this person‟s state of mind. There are regulations
governing the conduct of such an inquiry. The magistrate may issue a
warrant of arrest of the suspected persons. He should appoint a qualified
medical practitioner to examine the patient, and complete a statutory
certificate. Depending on the opinion of the magistrate may then complete
another certificate authorising the compulsory admission of the patient.
Where there is no qualified medical practitioner within the magisterial
district the magistrate must be complete a warrant in term of form F (see
Appendix) to a magistrate in a district where there is a qualified medical
practitioner.
The latter magistrate must then go through the procedure of conducting an
inquiry into the state of mind of the suspected person all over again. But he
will be required to complete a different compulsory admission of the patient
into the asylum.
The Discharge Procedure under the Lunacy Law (Sections 17 and 18)
provides for only two people who may order the discharge of only two
people who may order the discharge of a compulsorily admitted patient.
These are magistrate and the governor of the state. But the magistrate can
only order the discharge of a patient „has been granted by the superintendent
of the asylum in which the person is detained, or by any two qualified
medical practitioners of whom one at least shall be a Medical Officer‟.
The governor, on the other hand, „may order the discharge from any asylum
of any person detained therein under this law whether recovered or not and
may allow any lunatic to be absent on trial for such period as he thinks fit,
and may at any time grant an extension of such period‟. And „In respect of
any lunatic absence on trial, the governor may order the payment out of the
revenue of any sum not exceeding the sum of two pounds per month (or
about N 300.00) to the person taking charge of such lunatic‟.

Observations
In spite of its revision in 1959, the Lunacy Law remains couched in a
language which reminiscent of Pre-Renaissance concepts of mental
disorders and which must militate against the willingness of mental health
personnel in this country to apply the law. It is therefore not surprising that it
is difficult to find any psychiatric establishment in this country where the
law is put into practice.
While the majority of patients can be treated informally, there will always be
a group of patients whose illness makes them a potential source of danger to
themselves or to others but who are so lacking in insight that they will not
voluntarily seek the care, protection and treatment they require. This group
includes, among others, the severely mentally disordered persons who live
on and roam the streets, the streets of our towns and cities i.e. vagrant
psychoses. For this category of patients the law must evolve a system that
will facilitate a smooth and speedy admission procedure so that the
treatment which these patients‟ need may be promptly instituted. That the
personal liberty of the individual is not unduly jeopardized is safeguarded in
the fundamental human right of Freedom of Movement in the constitution of
the Federal Republic of Nigeria (6). Section 21 (i.e.) provides that no person
shall be deprived of his personal liberty save in certain circumstances which
involve persons suffering from infectious diseases, persons of unsound
mind, persons addicted to drugs or alcohol or vagrants. And in these cases,
deprivation of personal liberty must be for the purpose of their care or
treatment or the protection of the community.
In terms of smoothness of practice for mental health personnel, the early
institution of badly needed treatment and the convenience of the mentally
disordered patient, section 10 (cited above) is about the only satisfactory
provision available in this law. In order to detain a patient for longer than
seven days, one must go through a legal procedure (Sections 11-16) which,
in the light of Nigeria judicial system, may be very cumbersome and
discouraging.
Perhaps such a cumbersome procedure as is demanded by Sections 11-16
above may help to safeguard the personal liberty of the suspected patient as
envisaged by the provisions of the constitution of the federation by ensuring
that he may never be compulsorily admitted until a detailed inquiry has been
conducted to confirm a disordered mental state. It is, however, obvious that
the advantages associated with such a procedure far outweigh any advantage
it may possess.

Suggested Modifications
Modification of the Law, both in terms of its language and the procedure
laid down for the compulsory admission of the psychiatric patient seems
long overdue. The need for change is buttressed by the fact that a
considerable advancement in psychiatric knowledge has taken place, and
progress made in the provision of mental health care in Nigeria since the
Lunacy Ordinance was introduced in 1916.
Firstly, there is a need for an overhaul of the terminology. The terms
“lunacy”, “lunatic”, “asylum”, “insanity” should be replaced. These words
not only reflect an antiquated notion of the nature of mental illnesses, they
also carry with them negative social values. A considerable proportion of the
unfavorable attitudes the public manifests towards the mentally ill originate
from fears of mental illness as a terrible and shameful social condition.
The procedure stipulated in Sections 11-16 which necessitates in the issue of
warrant for the arrest of the patient the holding of a summary trial involving
his exposure to public spectacle detention in prison pending decision on his
state of mind is distastefully stigmatizing to the patient as well as to his
family. These sections of the law need to be abolished and be replaced by
more enlightened and humanitarian ones. The 1957 Report of the Royal
Commission on the Law relating to Mental Illness and Mental Deficiency
which sat under the chairmanship of Lord Percy of Newcastle stated inter
alia, „mental disorders of all kinds must be viewed primarily as a matter of
protecting society‟. In other words, it is largely a medical rather than a legal
concern. The English Mental Health Act 1959 is based on this commission‟s
report.
Dr. Issac Ray, an American Psychiatrist who lived in the 19th century, has
enumerated the essential and basic components of enlightened and
humanitarian laws governing the involuntary hospitalization of the mentally
ill (7). He stated these components as follows:
“In the first place” – the law should put no hindrance in the way of prompt
use of those instrumentalities which are regarded as most effectual in
promoting the comfort and restoration of the patient”.
Secondly, it should avoid all unnecessary exposure of private trouble, and all
unnecessary conflict with popular prejudices. Thirdly, it should protect
individuals from wrongful imprisonment. It would be objective enough to
any legal provision that it failed to secure these objectives in the completes
possible manner.
The Law and the mentally ill in Nigeria II
Introduction
When a mentally ill individual first manifests an act that will later be
perceived as psychiatric symptom, the act is not always recognized as a
symptom of illness but rather as a deviation from social norms. (1) This is
particularly so with major mental illnesses. It follows, therefore that in order
to avoid imposing punishment for an offence committed by a mentally
disordered person, the society must formulate laws to guide those who
administer justice in our law courts.
The Nigerian Criminal Code Ordinance
The law which provides for the determination of legal and criminal
responsibility of the mentally ill in Nigeria is embodied in the Nigerian
Criminal Code Ordinance. (2) which is based on a Criminal Code drafted by
the renowned English criminal lawyer, Sir Fitzjames Stephens, in 1878 it
was proposed to replace the Common Law in England but was never enacted
by the British Parliament. It was instead introduced into Queensland in
Australia in 1899 and into Nigeria in 1916 following the unification of the
north and south. (3) With the creation of self-governing regions around
1959, the Criminal Code Ordinance was revised and incorporated into the
laws of the Western and Eastern Regions as “Criminal Code Law”. In
Northern Nigeria, due to the prevailing Moslem religion there, the Criminal
Code Ordinance redrafted and brought into operation in September, 1960 as
the Penal Code Law. (4) According to Richardson (5); the Northern Nigeria
Penal Codes were based on the equivalent Sudan Codes which were in turn
modelled upon the Indian Penal Codes.
The sections of the Nigerian Criminal Code Ordinance which are of
relevance to the theme of this discussion here are Sections 27, 28 and 327.
„Section 27
Every person is presumed to be of sound mind and to have been of sound
mind at any time which comes in question until the contrary is proved.
„Section 28
A person is not criminally responsible for an act or omission if at the time of
doing the act or making the omission he is in such a state of mental disease
or natural mental infirmity as to deprive him of capacity to control his
actions, or capacity to know that he ought not to do the act or make the
omission.
A person whose mind, at the time of his doing or omitting to do an act is
affected by delusions on some specific matter or matters, but who is not
otherwise entitled to the benefit of the foregoing provisions of this section, is
criminally responsible for the act or omission to the same extent as if the real
state of things had been such as he was induced by the delusions to believe
to exist.
„Section 327
Any person who attempts to kill himself is guilty of a misdemeanour and is
liable to imprisonment for one year.
Despite its intention to avoid conflict with the Holy Qu‟ran and Sunna, the
Northern Nigerian Penal Code has retained a number of offences contained
in the Nigerian Criminal Code Ordinance so that nothing which is an offence
under the Criminal Code ceases to be an offence in Northern Nigeria. Thus,
Section 231, which deals with „attempting to commit suicide‟, is essentially
the same as Section 327 of the Nigerian Criminal Code. Similarly, Section
51 in the Penal Code, which gives the legal definition of insanity, contains
almost all the elements of Section 28 of the Nigerian Criminal Code.
Observations
The above Laws are of concern to the medical profession from certain points
of view:
(a) The desire of the physician to ensure that his mentally abnormal
patient is not unjustly convicted for an offence of which he is accused.
(b) The compatibility of the Laws with the modern trend in psychiatric
knowledge.
In order to examine the Law from these points of view it would be
fruitful, at this stage, to examine the meaning of „criminal responsibility‟.
The Concept of Criminal Responsibility
According to Jacobs (1971), „a person is responsible for something if he can
be called upon to answer questions about it‟. Thus responsibility, either in
law or morals, constitutes an instrument of social control. In criminal law,
the general rule is that liability requires “mens rea”, lawyers Latin for a
guilty mind, and “actus reus” – wrongful intention. The interpretation of
these requirements usually involves a subjective inquiry into the actual state
of mind of the accused at the time of offence committed. Since the criminal
law seeks to punish the offender for the offence committed. It is absolutely
important that the law lays down criteria for distinguishing, on ground of
supposed mental abnormality, between those who are, and those who are
not, responsible for their actions.
Mental Illness and Criminal Responsibility in the Nigerian
Criminal Code
Section 28 of the Nigerian Criminal Code gives the legal definition of
insanity but it places the onus of proof of mental abnormality on the
accused, through Section 27. Such a proof is based on informed advice from
the medical profession by the production of medical evidence and/or cross-
examination of a medical witness. The onus however, is not as great as that
placed on the prosecution to prove its case beyond all reasonable doubts.
Sometimes a positive family history of mental abnormality may constitute
sufficient admission. For example, in the case of Rex. vs Edem Ugo Inyang
the judges ruled that, “Evidence of insanity of ancestors or blood relations is
admissible. Medical evidence is not essential”.
Section 28 of the law emphasizes that the mental abnormalities should have
existed at the material time when the offence was committed. It does not
matter if such abnormality was temporarily or permanently although the
former may be difficult to establish. For example, in Rex. vs. Edem Ugo
Inyang the high court judge had ruled that the accused as sane at the time he
committed the offence. At the Appeal Court, J.I.C Taylor, in arguing on
behalf of the appellant, distinguished between „partial insanity‟ and „total
insanity‟. By „partial insanity‟, he meant that the appellant was subject to
periods of insanity, during one of which he killed the deceases. „Total
insanity‟ meant permanent insanity. But the Appeal Judges in disagreeing
with Taylor‟s submission, stated: “It is clear that the learned Judges‟
summing up of the appellant when he struck the deceased, no matter whether
that state of mind was a temporary or permanent one”.
The principle followed in most English speaking countries was laid
down in 1843 in the McNaughten Rules Walker (1968). McNaughten was a
paranoid who attempted to assassinate the British Prime Minister, Sir Robert
Peel, being under the delusion that only by shooting the Prime Minister
could he escape from the persecution, which had been dogging him for many
years. He shot and killed the Prime Minister‟s Private Secretary, apparently
mistaking him for Peel. The argument of McNaughten‟s lawyer, Cockburn,
sought to rely on lack of control and the jury had no hesitation in acquiring
his client. The public reaction to the case led the House of Lords to pose five
questions to the judges in Britain on the question of insanity. The judges‟
answer to the third and fourth questions embody the McNaughten Rule as
follows:
“The jurors ought to be told in all cases that every man is to presumed
to be sane, and to possess a sufficient degree of reason to be responsible for
his crimes, until the contrary be proved to their satisfaction and that to
establish a defense on the grounds of insanity, it must be clearly proved that,
at the time of committing the act, the party accused was labouring under
such a defect of reason, from disease of the mind, as not to know the nature
and quality of the act he was doing; or if he did know it, that he did not
know he was doing what was wrong”.
Thus the McNaughten Rules take into consideration only the cognitive
aspects of the individual‟s behaviour and ignores the emotional and
volitional aspects. The accused person must be suffering from a defect of
reason… so as to know… if he did not know that he was doing what was
wrong. If it were strictly applied, it would be almost impossible to find
anyone to whom the Rules would apply. The Nigerian Criminal Code whilst
incorporating the McNaughten Rules in its Sections 27 and 28 has gone far
further in taking cognizance of the individual‟s volitional state. Thus, the
capacity to control his actions… which is in Section 28 is not found in the
McNaughten‟s Rules.
There has been one instance in Nigerian medico legal history in which the
Nigerian Criminal Code (Section 28) was compared with the McNaughten
Rules. This was in the case of Rex. vs. Omoni which is regarded as the
standard case on our law of insanity. This comparison shows that the
Nigerian Legislature had not only departed from the phraseology of the
English Judges 1845 but had also introduced two entirely new factors:
“natural mental infirmity” and “capacity to control his actions”. In trying to
elicit the exact meaning of the phrase “natural mental infirmity”, the West
African Court of Appeal (WACA) Judges Rex. vs. Omoni stated, “We must
ascribe to them (i.e. the words “natural mental infirmity” an intention to
distinguish between „mental disease‟ and „natural mental infirmity‟, for
otherwise the last words would be redundant. The words „natural mental
infirmity‟ mean, therefore, in one‟s opinion, „a defect in mental power
neither produced by own default nor the result of disease of the mind‟.
The only category of mental abnormality which falls into this class is
that group known as mental subnormality or mental retardation. Thus, it
would seem that a mentally retarded person cannot be held to be criminally
responsible for his offences. In Britain, on the other hand, a mental defective
would still be found guilty although, under the Mental Deficency Acts of
1913 and 1927, the courts would be empowered to place him under
guardianship or to send him to an institution for mental defectives instead of
passing sentence on him.
Let us examine the phrase „to deprive him of capacity to control his
actions‟. The W.A.C.A. Judges observed that these words not only departed
from the Rules in McNaughten‟s case, but were in direct conflict with the
line of English decisions subsequent thereto, in which the Judges of England
have declined to accept the defense of irresistible impulse‟ which these
words appear to have introduced into the laws of Nigeria. The Judges further
observed, „As to the wisdom of introducing or maintaining this departure
from English Law, it is one for the legislature to judge; this court can only
apply this law as one finds it‟. They went on to quote Hewart in the case of
Rex. vs. Kopach, where the learned Lord Chief Justice said, „The complaint
against the Judge is that he did not tell the jury that something was the law
which was not the law. It is the fantastic theory of uncontrollable impulse
which if it were to become part of our criminal law, would be merely
subversive. It is not yet part of the Criminal Law and it is to be hoped that
the time is far distant when it will be made so.
Obviously these judges were averse to the concept of “uncontrollable
impulse”. It is notable that in this respect the Nigerian Law has been ahead
of the British Law which places emphasis on the cognitive aspects of the
individual‟s behaviours only, and refuses explicitly to recognize the
importance of volitional factors. Thus the Nigerian Criminal Code, by virtue
of the clause „incapacity to control his actions‟, seem to exonerate persons
suffering from disorders like kleptomania states of epilepsy associated with
automatism or certain abnormal metabolic states in which the individual
may behave in an uncontrollable manner e.g. hypoglycemic states.
It appears however that the judges in Nigerian Courts have been reluctant to
give recognition to the full meaning of this phrase. Although a plea of
„uncontrollable impulse‟ may be made, it is not considered as sufficient
proof of insanity. In the case of Rex. vs. Ashigifuwo (11), the judges ruled
that „mere absence of any evidence of motive for a crime is not a sufficient
ground upon which to infer mania‟. In Rex. vs Inyang (1) they stated „where
there was sufficient evidence indicative of insanity rather than the opposite,
the absence of any evidence of motive may become relevant to the point at
issue and material to it‟.
The inclusion of the second part of Section 28 may represent a setback in the
Nigerian Law. The interpretation of this paragraph seems to be that the mere
presence, per se, of delusion in the accused person is sufficient ground to
absolve him from the offence charged. Aguda (1965) has attempted to
clarify this paragraph by giving the following example as an illustration:
A sees Z and Z‟s wife in his house and A, under the insane delusion that the
woman was his wife and that Z was committing adultery with her, kills Z.
The rule says that A‟s criminal responsibility should be considered on the
basis of the fact as he supposed them to be. If the facts would have
amounted to a killing as a result of provocation, then he will be convicted of
manslaughter. Although it is arguable whether A, in the above example,
would be said to be suffering from a delusion or an illusion, we could agree
for the purposes of this discussion that he was in fact suffering from a
delusion. The argument that A would be liable to conviction for
manslaughter seems to indicate that the law makers have definitely failed to
be guided by informed psychiatric knowledge on this issue. According to
Jaspers (1959), „since time immemorial, delusion has been taken as the basic
characteristic of madness‟. To be mad was to be deluded. Delusion manifests
itself in judgements; delusions can only arise in the process of thinking and
judging. To this extent, pathologically falsified arguments are termed
delusions, it is, therefore, apparent that the person who is deluded (whether
„on some specific matter or matters‟) cannot but be entitled to the benefit of
the first paragraph of Section 28. fortunately, the practical application of this
part of Section 28 is strictly limited. Aguda (1965) pointed out that most
cases could be disposed off under the first part of this section. The inclusion
of the second paragraph is thus unnecessary.

The Concept of ‘Diminished Responsibility’

The Nigerian Law does not recognize the concept of „diminished
responsibility‟, which became incorporated in the English Law in the
Homicide Act of 1957 (14). This concept dates back to 835 Walker (1968).
In the case of William Braid who pleaded guilty to some unrecorded
offence, Dr. Trail was examined, after the accuser‟s mind had diminished his
responsibility, although it did not take it away entirely. “It seems to have
been based on the concept of „partial insanity‟ put forward in Scotland by Sir
George Mackenzie who lived between 1636-91 Walker (1968). He argued
that since the law granted total immunity to those who were shown to suffer
from total insanity, it should by rule of proportions, moderate the
punishment if those with partial insanity. Although partial insanity was not
usually recognized as a defense, it was taken into account after conviction,
by the practice of allowing, or advising, the jury to recommend a pardon.
One wonders if this was what Taylor was trying to achieve when he tried to
distinguish between „partial insanity‟ and „total insanity‟ in the appeal of this
client (Rex. vs. Inyang spurs).
Regular use of the concept of „diminished responsibilities‟ did not, occur
until 1867 in Aberdeen, when Lord Dees tried Dingwall, a 45-year-old
chronic alcoholic, who stabbed his wife to death after a drinking bout. Lord
Dees, in directing the jury, ask the jury to consider, among other factors that
the prisoner appeared to have been peculiar in his mental constitution and to
have had his mind weakened by successive attacks of disease (he had had
repeated attacks of delirium tremens). Lord Dees was of the opinion that the
weakness of his mind was not inadmissible in deciding whether the offence
should be classed as murder or culpable homicide. The state of mind of a
prisoner, he thought, might be an extenuating circumstance, although not
such as to warrant an acquittal on grounds of insanity. The result was the
substitution of a lesser penalty than death. Lord Dees and his fellow judges
in Scotland continued to steer juries into similar verdicts and by 1909, the
phrase „diminished responsibility‟ was actually being used by judges.
It is arguable that the development of the concept of „diminished
responsibility‟ in Scottish Courts was the result of accident of history. The
McNaughten Rules which were in force in England at that time were not
applicable to Scotland. Thus the boundary between murder and culpable
homicide was less clearly defined in Scotland. However, the advantages of
this concept are obvious:
1. A greater number and types or degrees of mental abnormality could
be taken into account.
2. Whereas English Law allowed only two possibilities that the prisoner
was or was not so insane as not to be accountable for his act or
omission, Scots law allowed a third; that he was sufficiently
disordered to deserve mitigation of the usual punishment though not
complete exemption. That is, he was not in complete control of his
own mind.
3. The effect enabled the judge to pronounce either a sentence of life-
imprisonment, imprisonment for a specified term, a fine, a probation
order, or an absolute or conditional discharge.
In Nigeria, where the death penalty is still in force, the inclusion of
„diminished responsibility‟ would no doubt prevent the execution of a
sizeable number of convicted persons who could only be classified as
„partially insane‟ thus not qualifying for acquittal under Section 28, for
example, Lambo (1962) made a study of persons convicted for criminal
offences which included murder or multiple murders by members of the
prescribed Odozi Obodo and Leopard Men societies. He found that the
criminal behaviour by such persons could be regarded as one of the
components of a psychiatric syndrome which he termed “Malignant
Anxiety”.
Aguda (1965), thinks that the defence of irresistible impulse covers
„diminished responsibility‟ and even more. This is doubtful. He argues that
whereas the defense of diminished responsibility is restricted to cases of
homicide the defense of irresistible impulse under the Nigerian Criminal
Code is applicable to all offences. It is true that for example, the
kleptomaniac in Nigeria may be able to obtain an acquittal with a defense of
irresistible impulse, but this does not necessarily mean that all or majority of
mentally ill persons accused of a criminal offence suffer from irresistible
impulse. There is still a considerable class of persons who commit homicide
while suffering from some form of mental illness which is significant in the
 commitment of the offence but the nature of which does not entitle them to
total acquittal under Section 28 of the Criminal Code. The provision of a
defense of diminished responsibility would enable such persons to be given
a lesser penalty than death. The Northern Nigeria Penal Code does not
recognize the defense of irresistible impulse, or that of diminished
responsibility.
Attempting to Commit Suicide
Section 327 of the Criminal Code which deals with attempted suicide is
overdue for abrogation. Persons who commit suicide or attempt suicide are
usually mentally ill, some of them severely so. In a study of 38 patients with
self-poisoning and self-injury admitted to University College Hospital,
Ibadan, only 21 percent were found to have no evidence of psychiatric
illness (Ebie, 1972). If a person succeeds in committing suicide the law
cannot reach him to try him. But if he fails to die, then he may be sent to jail
for one year. It is thus arguable whether such a person is being tried because
he failed or because he ever attempted suicide in the first place. Section 327
is that it seems to be imposing a moral judgment on the individual. Suicide
used to be a crime in England but this is no longer so since the passing of the
Suicide Act of 1961.
It cannot be argued that the imposition of a penalty for attempted suicide is
based on the rationale that it would help to deter people from committing
this act. There is evidence to suggest that Nigeria has one of the lowest
suicide rates in the world. Asuni (1961) found an incidence of less than 1 in
every 100,000 in Western Region Nigeria (now Ondo, Ekiti, Osun, Oyo,
Ogun, Edo and Delta states). This was lower than the lowest figure recorded
anywhere else in the world. There are reasons to believe that this rate is due,
not to the punitive intent of Section 327, but to other factors. Imposition of a
penalty is more likely to make people conceal the fact of an attempted
suicide or increase their determination to ensure that they successfully carry
out the act. Hence people in need of care would be reluctant to come forward
for the help they badly need.
The Role of Psychiatrists and the Law
In the course of all these, I have often wondered whether a psychiatrist is the
most qualified person to deal with this sort of subject or whether it does not
actually belong in the territory of legal practitioners. The law is,
fundamentally a complete artefact – a collection of man made rules enacted
by legislators or rulers of a country with or without taking into account the
predominant current social feelings at the time each rule becomes enacted.
The people who administer the law (lawyers, police, magistrates, judges) are
therefore interested in medical aspects only to enable them ensure that
 justice (as in implicit in the Law) is done. Thus they are more interested in
say for example, the time of death in the case of a murder, the state of mind
of the accused at the time of offence alleged etc. There is little interest in
aetiological factors or pathogenesis or the phenomenology of the illness or
disease in question. And they tend to expect accurate, unambiguous answers
from medical witnesses. Unfortunately in the area of psychiatry, such clear
cut answer cannot always be offered. This is a situation that has tended to
make the law courts cautious with psychiatric testimonies.
This subject of law and psychiatry is an interdisciplinary one in which both
psychiatry and law overlaps and should ideally involves the corroborative
effort of both the lawyer and the psychiatrist. Otherwise a person seeking to
tackle such a subject single-handedly should, ideally be both a lawyer and a
psychiatrist rolled into one person. Doctors, on the other hand tend to be
interested in the Law, only when they find themselves confronted with
certain problems in medical practice. For example, the legal definition of
death, or performing a life saving surgical procedure on a patient or his
relatives. And the interest ceases once the problem has been solved.

The medical profession as a body has a duty in educating the community

and advising the lawmakers on these aspects of the Law relating to health.
And there is a need for the lawmakers to acknowledge this. In playing these
educational and advisory roles, objectives and scientific facts based on
research should be placed above the personal beliefs of the doctor so that a
Roman Catholic doctor faced with say, a move to liberate the law on
abortion does not allow his religious beliefs to becloud his objectivity and
scientific attitude.
Rights of Patients
Patient‟s Rights, generally include:
1. Right to keep personal effects (not harmful).
2. Right to independent psychiatric examinations.
3. Right to get his consent (or be informed) pre-procedure or any
operation.
4. Right to treatment – to refuse or accept – Consider his mental state.
5. Right to marry and divorce.
6. Right to be employed, if possible.
7. Right to education.
8. Right to fair hearing in the court.
9. Right to periodic review.
10. Right to referral or discharge.
11. Right to compensation.
 12. Right to contractual relationship.
13. Right to freedom from mechanical restraints or seclusion.
14. Right to request (and sign) for discharge – if he‟s not too psychotic.

4.0 Conclusion

It should be noted that despite the similarities in

psychiatry and law, there existed some dissimilarities which
include, that psychiatry is concerned with the meaning of
behaviour and personal life satisfaction, law addresses the
outcome of behaviour and has developed a system of rules and
regulations to facilitate orderly social functioning. These
differences are not the same in terminology when it is
recognized that insane and legal- commitments are
predominantly legal, not psychiatric terms.

5.0 Summary

You will agree with me that sound understanding of this

unit will assist you in your professional services to humanity
wherever you service is needed. Now you can attempt the
following tutor marked assignments.

Tutor Marked Assignment

(1) Account for the similarities and
dissimilarities between
psychiatry and the law.
(2) What is the relevance of this unit to the
development of nursing profession in Nigeria?
7.0 References / Further Readings
Adedotun, A. 2000. Basic Psychiatry and Psychiatric
Nursing. Ile-Ife: Basag (Nig) Enterprises.
Olatawura, M. O. 2002. Psychology and Psychiatry
Lecture Series from Ibadan, Ibadan: Spectrum
Books Ltd.
Fish, F. J. 1967. An outline of Psychiatry, Bristol: John
Wright & Sons Ltd.
Henderson, D. and Gillespie, R. D. A. 1950. A textbook in
Psychiatry.
7th Ed. New York: Oxford University Press.