CRIS LUTHER'S TRENDS AND ISSUES IN PSYCHIATRIC MENTAL HEALTH NURSING

CURRENT TRENDS & ISSUES IN PSYCHIATRIC AND MENTAL HEALTH NURSING
Prepared by CHRISTIAN LUTHER FABIA, R.N.,
Professor: DR. EMILIO ALVAREZ, Philippine Colleges of Health & Sciences, Inc., School of Graduate Studies | 1
Current Trends and Issues in Psychiatric
& Mental Health Nursing
Prepared by
CHRISTIAN LUTHER FABIA, B.S.N.,R.N.
Master of Arts in Nursing
Major in Psychiatric and Mental Health Nursing
DR. EMILIO ALVAREZ
Professor
Philippine Colleges of Health Sciences, Inc., Manila
School of Graduate Studies
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About the cover:
Philippe Pinel, (1745-1826), French physician demanding the removal of chains from the insane at the Bicetre Hospital in Paris.
“I cannot here avoid giving my most decided sufferage in favour of the moral
qualities of maniacs. I have no where met, excepting in romances, with fonder
husbands, more affectionate parents, more impassioned . . . than in the lunatic
asylum, during their intervals of calmness and reason.”
(A quote by Philippe Pinel on decisions, giving, husbands, parenthood, and reason)
________________________________________
Looking at the past gives a vivid understanding of the present. It is a means of
defining and building a future of better, if not the best practices.
(THE RATIONALE FOR CHOOSING THE COVER)
A painting by Charles Muller;
source: http://ec-dejavu.ru/b/bezumie_7.html).

- Rationale for Selection of Topics and Organization of Text –
The course title is: Current Trends and Issues in Psychiatric and Mental Health Nursing. My professor at the
PCHS- Graduate School, DR. EMILIO ALVAREZ provided me with a course syllabus with the course description written
as: “The course deals with the journey of nursing toward its current state of professionalism. It
provides a forum for knowledgeable discussion on the logically significant trends and problem that
concern all of today’s nurses so that intelligent decision making can occur.” He also advised me that topics
in this subject should be specific to psychiatric and mental health nursing in lieu with the major I am pursuing.
There were two challenges- first, I am the lone enrollee in this track (Psychiatric and Mental Health Nursing), so that
how can a series of fora be possible as the course description suggests? Second, the need to modify the course
syllabus parallel to this major.
This compilation is the answer to the first challenge. And, for the latter, I made a thorough research on the
inclusion of topics utilizing various resources- textbooks, journals, updates from PMH Nurses Association of the
Philippines and consultation at Philippine Mental Health Association. I underwent various modification of the final
content and, guided by the course syllabus, I came up with the concepts I believe to be essential and consistent with
the course title: TRENDS AND ISSUES IN PSYCHIATRIC MENTAL HEALTH NURSING.
________________________________________
The text is organized in four parts. A review of basic concepts progressing to more advanced and updated contents
with emphases on the current trends and issues. Literature search were conducted in an attempt to present the most
current information available.
Part 1, The Development and Evolution of Psychiatric Mental Health Nursing, discusses the benchmarks of psychiatric
mental health nursing history from the time of Philippe Pinel who introduced the concept of Asylum to present. It aims to guide
appreciation on the journey, evolution and complexes that shaped the current practice of Psychiatric and Mental Health Nursing.
Part 2, The Challenges of Psychiatry and Mental Health Today, presents vital issues that confront psychiatric professionals
to include nurses in this specialty field. The WHO-AIMS Report on the current situation of psychiatric care delivery in the country
present challenges to the government, concerned professionals and to the nation as a whole. Paradigm shift and homelessness are
universal issues that are seen to be contributory factors in the increasing number of mentally ill population.
Part 3, The Current Bases of Psychiatric Mental Health Nursing, consists of topics that are essential to the practice of the
field specialty. The ANA provides both the Standards of Care and Performance of a PMH Nurse which is adapted in most countries
to include the Philippines. The NEW approach in the continuum of care is an important guide for a nurse in the classification of
clients. It also answers to the problems of role ambiguity and confusion as it directs when to intervene collaboratively or
independently. The development of theories and the use of models (which are vital foundations of every profession) are
thoroughly discussed and their relation and application to the current practice. Cultural competence has been a dormant issue in
the past and is now an emerging discussion in both the practice and the academe. Several researches were done not only in the
traditional ethnographic concept but to include ethnopharmacology.
The old paradigm of psychiatric care urged nurses to be “caring and more caring” ; the modern paradigm suggests that “caring is
most essential but not enough- psychiatric nurses must understand principles, theories and models (eg.: psychoanalysis,
psychobiology and psychopharmacology).” Hence, it is a must for a psychiatric nurse to comprehend the vital concepts of theories
and models as these are the very bases of his competency.
Part 4, Empowerment through Awareness on Legal and Commitment Issues, Advanced Directives and Forensic
Nursing (Trends and Issues), explores ethical and legal issues related to psychiatric-mental health nursing. It is through
awareness on these issues that nurses in this field become more confident to render their job. Forensic nursing has become one
of the fastest growing nursing specialty of today, nurses in this field focus on advocacy for and ministration to offenders and
victims of violent crime and the families of both. It is also recognized as a significant resource in the treatment of incarcerated
persons. Psychiatric nurses are empowered when they are well informed on vital and current issues and the career path to an
expanded role in the arena of psychiatric care. Hence awareness is empowerment.
TRENDS AND ISSUES IN PSYCHIATRIC MENTAL HEALTH NURSING, perhaps the greatest challenge to nursing lies in
the future, as we identify and develop clinical provider performance measures that are relevant to the care and the
people we nurses serve!
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- Introduction -
Psychiatric-mental health nursing involves the diagnosis and treatment of human responses to actual or
potential mental health problems. It is a specialized area of nursing practice that uses theories of human
behavior as its scientific framework and requires the purposeful use of self as its art of expression. It is
concerned with promoting optimum health for society. Comprehensive services focus on prevention of
mental illness, health maintenance, management of and referral for mental and physical health problems,
diagnosis and treatment of mental disorders (Haber & Billings, 1993).
Psychiatric nurses must be able to make rapid comprehensive assessments; use effective problem-solving
skills in making complex, clinical decisions; act autonomously as well as collaboratively with other
professionals; be sensitive to issues such as ethical dilemmas, cultural diversity, and access to psychiatric
care for undeserved population; be comfortable working in decentralized settings ; and be sophisticated
about the costs and benefits of providing care within fiscal constraints (ANA, Statement on Psychiatric-Mental
Health Clinical Nursing Practice, 1994,p7).
My definition of psychiatric-mental health nursing is based on my personal experience- which is: “A
detour from the ordinary; a specialty field for nurses who have discovered that they are by
nature empathic. Nurses in this specialty field are professionals who understand the
complexes of human behavior that guides them to respect the uniqueness of every individual.
Their ability to maintain composure in trying situations is almost infinite!”
When I applied at the PCHS Graduate School enrolling in M.A. with Tracks in Psychiatric Mental Health
Nursing- I was asked about my option to pursue the major since I was a lone enrollee in this track. I have
long contemplated pursuing this major considering that this is my area of interest and is consistent with
my professional and academic performances.
With the guidance of my chosen institution to pursue my degree- the PCHS Graduate School, ultimately, I
envision myself as a Forensic Nurse in the future.
The Student
About the Compilation
This material is a compilation of various information on generally acceptable knowledge, concepts, principles, theories and
practices in PSYCHIATRIC AND MENTAL HEALTH NURSING. It adapts contents from various publicly acknowledged publications,
authors, theorists, authorities and practitioners whose works are commonly utilized in the academe and practice, and are frequently-tested
competencies locally and abroad. The works of these authors, theorists, authorities and practitioners are indispensable in learning
PSYCHIATRIC AND MENTAL HEALTH NURSING as they are indispensable in the completeness of this compilation.
Care has been taken to confirm accuracy of the information presented and describes generally accepted practices. However the
student who prepared this material is not responsible for errors or omissions or for any consequences from application of the information in this
compilation.
The primary goal of the student is to familiarize concepts in the subject CURRENT TRENDS AND ISSUES IN PSYCHIATRIC AND
MENTAL HEALTH NURSING based on the COURSE DESCRIPTION provided by the PCHS-Graduate School with the guidance of
his Graduate School Professor DR. EMILIO ALVAREZ.
This material is not intended for commercial publication and resources were acquired legally. It is his great pleasure that this compilation be
reproduced for reference of other students aiming to thoroughly understand CURRENT TRENDS AND ISSUES IN PSYCHIATRIC AND
MENTAL HEALTH NURSING.

- Table of Contents -
Part 1: The Development and Evolution of Psychiatric Mental Health Nursing
Benchmarks in Psychiatric Nursing History,p.6
Historical Development of Psychiatry in the Philippines, p.9
Development of Psychiatric Education in the Philippines, p.12
Part 2: The Challenges of Psychiatry and Mental Health Today
WHO- Assessment Instrument for Mental Health Systems (AIMS):
Report on Mental Health System in the Philippines, 2006, p.13
Paradigm Shift and Homelessness: Two Vital Issues in Today’s Psychiatric Care Delivery, p.15
Part 3: The Current Bases of Psychiatric Mental Health Nursing
Competencies of a PMHN Nurse, p.16
The Nurses’ Role in the New Continuum of Care, p.17
The Influences of Theories to Current Practice, p.20
Integrating Models in the Current Psychiatric Care, p.21
The Need for Cultural Competence in the Current Practice of Psychiatric Nursing, p.24
Part 4:
Empowerment through Awareness on Legal and Commitment Issues,
Advanced Directives and Forensic Nursing
(Trends and Issues)
Legal Issues, p.29
Commitment Issues, p.32
Psychiatric Advance Directives, p.34
General Legislation/ Regulation Pertinent to Mental Health, p.35
Forensic Psychiatry & Forensic Nursing, p.36
Post Script, p.38
SUICIDE: An Alarming Malady
Delivered by Christian Luther Fabia, R.N.
During the 2010 Scientific Fora, Continuing Education for Health Care Professionals
December 10, 2011, Top Plaza Hotel, Dipolog City, Zamboanga del Norte

Part 1: The Development of Psychiatric Mental Health Nursing
Benchmarks in Psychiatric Nursing History
Benchmark I: Period of Enlightenment
The modern age of psychiatric care began with Philippe
Pinel in France and another visionary, William Tuke in
England. In 1793, Pinel became the superintendent of the
institution, Bicerre (for men) and, later, the Salpetririe (for
women). Pinel was dismayed by the conditions he found and
wrote of the patients, “They were abandoned to the
incompetence of a callous director and to the cold brutality
of servants…” (Weiner, 1992). Soon after assuming
leadership Pinel unchained the shackled, clothed the naked,
fed the hungry, and abolished the whips and other tools of
abuse. Simultaneously, in England, William Tuke was
planning a private facility that would ensure moral treatment
for the mentally ill after he witnessed the deplorable
condition in public facilities.
In 1796, based on Quaker teachings, his York Retreat
opened for patients, providing “a place in which the unhappy
might obtain refuge- a quiet haven in which the shattered
bark might find a means of reparation or safety”
(Charland,2007; Gollaher, 1995). Pinel and Tuke crafted this
first benchmark of modern psychiatric care.
DR. PHILIPPE PINEL
FRENCH PHYSICIAN & PSYCHIATRIST
BORN APRIL 20, 1745, SAINT-ANDRE, DEPARTEMENT TARN
DIED OCTOBER 25, 1826, PARIS
He is known to be the instrumental in the development
of a more humane psychological approach to the
custody and care of psychiatric patients, referred to
today as moral therapy.
Asylum
The first definition of Asylum (sanctuary) had materialized in
the form of hospitals built in rural areas. Patients were
isolated geographically, socially, and, after release, from
follow up care. Patients were also isolated from public
scrutiny, which enabled many large institutions to become
closed systems. As might be guessed, the beneficence of the
reformers was not shared by many of the caretakers who
followed. Within a relatively brief period, the meaning of the
term asylum changed; it evolved from a place of refuge to a
place of torment.
Early reformers were driven by a desire to improve the lot of
abandoned, mentally-ill persons and to provide asylum for
sanctuary.
Dorothea Dix (1802 to 1887), one of the first major reformers in the United States, was instrumental in developing the concept of
asylum; she played a direct role in opening 32 state hospitals. She visited Tuke’s York Retreat wherein Tuke’s moral treatment
influenced her to confront the pain and suffering she had witnessed in her native land. Dix came to believe that the people of the
United States had an obligation for their mentally-ill brothers and sisters. She proposed to alleviate suffering with adequate shelter,
nutritious food and warm clothing. In Gollaher’s biography of Dix (1995), he quotes from one of her memorials the documents she
wrote to expose the terrible plight of the insane. From her Massachusetts memorial, he notes:
Concord: A woman from the (Worcester) hospital in a cage in the almshouse.
Lincoln: A woman in a cage.
Medford: One idiotic subject chained, and one in a close (or narrow) stall for 17 years…

Granville: One often closely confined …now losing the use of his limbs from want of exercise…
The period of Enlightenment was short-lived. Within 100 years of the establishment of the first asylum, known as the Eastern
Lunatic Asylum, the lunatics were being charged with misuse and abuse of their charges. State hospitals were beset with
problems.
Today, however, a renewed interest in asylum as a place of rest and restoration exists. This concept can be considered in terms of
the four Ps: parents, professionals, patients, and public, each of which has a stake in the discussion of asylum.
Benchmark II: Period of Scientific Study
The shift in focus from sanctuary to treatment is linked to
the second benchmark in psychiatric care, personified by
Sigmund Freud (1856-1939). Toward the last third of the
nineteenth century, several scientists devoted themselves to
understanding the mind and mental illness. Nonetheless, the
efforts forever changed the world’s view: mental illness need
not be suffered (however humanely patients were treated)
but might be alleviated. In a sense, psychiatric care was
popularized.
Early Scientists
Although Freud had the greatest impact on the world’ view of mental illness, He neither thought nor worked in a vacuum. Other
men and women had tremendous influence on this newly enthusiastic and optimistic approach to mental illness. Emil Kraeplin
(1856-1926) made tremendous contributions to the classification of mental disorders. He was a true scientist whose classic
descriptions of schizophrenia are valuable reading. Eugene Bleuler (1857-1939) coined the term schizophrenia and added a note of
optimism to its treatment. Still others, many of whom were colleagues or disciples of Freud, made significant contributions to the
merging field of psychiatry.
Freud’s contributions still influence psychiatric care although, for a number of years, belittling his thinking was popular.
Freud described human behavior in psychological terms. He developed a theory
of motivation, established the usefulness of talking (catharsis), explained the
importance of dreams and proposed to unlock the hidden parts of the mind. He
discussed sex openly and remains surprisingly relevant today (Hartmann,
2009). He introduced terms which have become parts of our language-
psychoanalysis, id, ego, superego, and free association. He feel free to study
human beings as he would with any other animal because of Charles Darwin’s
work. The work of others evolved from Freud’s studies. Alfred Adler, Carl Jung,
Ernest Jones, Otto Rank, Helen Deutsch, Karen Horney, and Anna Freud
(Freud’s youngest child) all made significant, and in most cases, lasting
contributions to the field of dynamic psychiatry.
Freud’s inspiration, however, reached far beyond those with whom he worked
personally. Freud challenged the society to look at human beings objectively
and fostered a milieu of thinking about the mind and mental disorders. The
nurse-patient relationship is built on this concept and is devoted to the
implementation of strategies for working with psychiatric patients.

Benchmark III: Period of Psychotropic Drugs
From this milieu of theory and scientific thought came the third benchmark, which began
around 1950 with the discovery of scientific drugs. Chlorpromazine (Thorazine), an anti-
psychotic drug, and lithium (antimanic agent), were introduced first, and imipramine
(Tofranil) an antidepressant, was introduced a few years later.
The impact of these drugs have been powerful. Patients who appeared beyond reached
became less agitated and experienced a reduction in psychotic thinking. Depressed
patients regained normal feelings. Hospital stays were shortened, and hospital
environments improved. However,although psychotropic drugs have allowed manypatients
to be treated in less restrictive environments, ethical, moral and legal questions have
arisen with this treatment modality.
Benchmark IV: Period of Community Mental Health
In the foregoing suggests the notion that one benchmark period entirely before the next
one began, then we will clarify the misunderstanding. Trends tend to overlap as
advocates of one view struggle to defend existing strategies while more dynamic forces
emerge elsewhere. As the various treatment approaches were being developed in the
milieu derived from Freud’s theories, criticism grew and the state hospital system
continued its “plunge” into “psychiatric Siberia”.
In the U.S., legislations were passed that would change the approach of psychiatric care.
In 1946, President Truman signed the National Mental Health Act, enabling the
establishment of the National Mental Health Act. In 1947, the Hill-Burton Act legislated
funds to build general hospitals that included psychiatric units. This initiative began the
effort for early intervention and helped shorten the length of hospitalization for psychiatric
patients.
In 1961, the Joint Commission on Mental Illness and Health published a report entitled Action for Mental Health. It urged increased
support for the state hospital system in recognition for improved treatment of the mentally-ill population.
Rather than increasing monetary support for the state hospital system, a convergence of forces set the stage for this hospital
benchmark period in psychiatric history:
1. The public’s declining confidence in the state hospital system
2. The failure of various treatment approaches to eradicate mental illness.
3. The legislative climate that had begun in the 1940s, emphasizing the civil rights of the mentally ill.
4. The newfound faith in psychotropic drugs.
These factors led to the enactment of the Community Mental Health Centers (CMHC) Act in 1963. The goal was
deinstitutionalization of the state hospital system population. The problem of geographic isolation was addressed with the
establishment of community treatment centers and community living arrangements (eg.: halfway houses). Keeping the individual
closer to the family addressed issues of isolation from family members. Isolation form follow up care was remedied because of
various levels of care were available locally.
Eventually, community mental health programs were developed to meet the needs of all those living within the boundaries of a
designated (eg.: catchment) area. These programs had the following goals:
 Emergency Care
 24-hour inpatient care
 Partial hospitalization care
 Outpatient care
 Consultation and education for the population
served by the center
 Screening services
Deinstitutionalization
Deinstitutionalization refers to the depopulating of state mental hospitals. Nurses and doctors gravitated toward people with whom
they can identify. It is much easier to counsel and medicate a woman going through the crisis of divorce than to attempt to
understand the babblings of a person with disorganized schizophrenia.

Depopulation of State Hospitals (U.S.A.)
The state hospitals reached its peak in 1955, with 558,922 patients. Today, the state hospital population is about 70,000 patients,
a decline of over 85%. Almost 1,000,000 people would be in state hospitals today if the same proportion were in effect. Thus over
900,000 individuals who might have been hospitalized years ago are currently living outside institutions. This decline has resulted
in the closing of many state hospitals. Patients hospitalized today require a high level of care, have few social relationships, and
are psychotic and atypically acutely ill young men.
In the Philippines, the following facilities provide treatment for mentally-ill children and adolescents:
 Mental Hospital
 Out-patient facilities
 Day treatment facilities
 Community-based in-patient facilities
 Community Residential Facilities
(WHO-AIMS Report, 2006)
Benchmark V: Decade of the Brain
The 1990s were declared the Decade of the Brain by Congress. During this decade, a steep increase in brain research occurred
that coincided with an increased interest in biologic explanations for mental disorders. The immediate impetus for this benchmark
was the significant changes in the diagnostic manual published in 1980. However, in many ways, the emphasis on brain biology
represented a completion of the circle started by Kraeplin 100 years before. Kraeplin believed brain pathology was at the root of
serious mental disorders.
Significant changes in public awareness occurred which enabled clinicians o address relatively complex topics with patients and
families. Nursing responded to this challenged with a significant augmentation of psychobiologic content in academic nursing
programs and continuing education programs.
The Decade of the Brain brought many challenges but the benefits have been tremendous in terms of making psychiatric nursing a
more viable specialty. It crystallized the fact that some behaviors are caused by biologic irregularities and not willful contrariness,
or worse. It also enabled individuals to move beyond blaming toward a focus on what could be done. This benchmark brought
nursing back into the mainstream of psychiatric care.
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Historical Development of Psychiatry in the Philippines
The history of Philippine psychiatry reflects the convergence of mind, body and spirit
in the interpretation of wellness and illness to explain common symptoms of
mental illness. Mental health workers to include nurses who have been trained in the
Western biomedical model must be able to connect the gap what people believe and what
they should be made to know. The approach in which psychiatric nurses deal with their
patients and their families and attempts at health promotion and the destigmatization of
mental illness is greatly affected by these realities.
Thus, redefining the perspective of mental health nursing using vocabulary and experience is necessary. Connecting these to the
disease diagnostic criteria as people have learned about them should follow (Casimiro-Querubin and Castro-Rodriguez, 2002).
In order to understand the history of treatment of the treatment of mental illness in the Philippines, it is deemed necessary to
comprehend the history of psycvhiatry in general, without overlooking the fact that this understanding can never be complete
without an appreciation of the system of knowledge or treatment that is essentially Filipino or Asian in character.
Reyes and Della (2002) identified the six major periods in the history of mental illness treatment marked by great historical events:
1. Pre-Spanish Regime
During this period the Filipinos believed in a world that was equally material and spiritual. The concept of illness was based on the
belief in such material and spiritual worlds, thus the treatment of both physical and mental illness depended heavily on the valid
and authentic rituals and ceremonies aimed at converting the punishment and at the same time maintaining and protecting the
psychological well-being and survival of the people involved. The Filipinos also relied on healers called babaylan (shaman) and

sorcerer healing, through which the spirits communicated with people or healed the sick individual. This cause of healing involved
the temporary possession of the medium’s body.
2. Spanish Rule
Under the Spanish era, the Filipinos accepted that mental illness was caused by an act of
sorcery . As it was written, the mangkukulam (witches) pricked the heads of their magic
dolls with their magic pins while the mangaaaway (devil men) solicited satanic powers
that can cause individuals to become mentally-ill (Santiago, 1995).
Herbolarios (herbsmen) intervene for treatment or “victims” are brought to the church for
exorcism or ritual cleaning. Herbolarios are said to have an understanding of the
mentally-ill persons. Through their own ability to get rid of the individual’s malady or
ailment, they may have been using psychotherapy in a much different and ancient form.
Therefore, it goes without saying that the procedures or religious rites have represented
the means for the patient’s healing.
Early Nineteenth Century
The organized care and treatment for individuals with mental illness was established at the Hospicio de San Jose in the early 19th
century. This historical event was made possible when the Spanish naval authorities requested for a place of confinement for their
mentally-ill sailors. Medical doctors and nuns from the hospicio composed the treatment staff. Carcel de Bilibid served as the place
for patients who committed criminal acts and those who are dangerous ones.
3. The American Era
In 1904, The Insane Department was opened at San Lazaro Hospital for use by mentally ill patients who were transferred from the
Hospicio de San Jose. Dr. Elias Domingo who headed the unit was the first physician to obtain formal training in psychiatry in the
U.S. He was assisted by Filipino and American nurses who were also trained in psychiatric nursing care.
In 1918, the city sanitarium was constructed to provide a place for treatment solely for patients residing in Manila. Consequently,
the insane department in San Lazaro Hospital provided services for patients residing outside Manila.
4. Japanese Occupation
The WWII broke out on 8 December 1941 and the Japanese occupation began.
Meanwhile the National Psychopathic Hospital continued to operate without regard of the
danger and fear that the war was bringing. Many of the patients were fetched by their
families while those left in the hospital died due to starvation and lack of medicine. The
remaining patients and employees were executed for alleged anti-Japanese activities.
The Japanese Imperial Army donated and electroshock apparatus to the hospital. It was a
big help to the patients and represented a breakthrough in the treatment of hospital
patients. Since then, the electroshock therapy became the principal and famous treatment
modality of the time due to the scarcity of medicine. The war was definitely an
unprecedented obstacle in the progress of psychiatry and psychiatric treatment.
5. The Liberation Period and the Era of the Republic
At the end of WWII and the Japanese Rule, the hospital was liberated by the American Army of Liberation in 1945. With the return
of the American to the Philippines, the development and growth in the treatment of mentally-ill patients began. Rehabilitation and
expansion of facilities, training of medical staff and improvement in the management of hospitalized patients were immediate. This
cooperative effort was in keeping with the general adoption of the concept of “mental health” in the U.S.
It was during this period when the National Psychopathic Hospital was renamed National Mental Hospital, with Dr. Jose Fernandez
designated as officer-in-charge from October 1946 to April 1961. Additional infirmary buildings for non-paying and paying patients,
additional infrastructures and the improvement of basic services were accomplished.
Other Psychiatric Services
V.Luna General Hospital (AFP Hospital)
 In 1946, the hospital established a neuropsychiatric service. The initial modes of treatment were ECT, insulin therapy and
narcoanalysis.

 In 1947, hypnosis and group therapy were added; First prefrontal lobotomy (destruction of the white matter of the frontal
lobe of the brain) was performed by Mjr. Romero Gustillo using an improvised leucotome. It successfully performed to a
violent patient who did not respond to ECT and pharmacotherapy.
 In 1949, Mjr. Jaime Zaguirre performed the first transorbital lobotomy on another patient with schizophrenia.
 In 1953, carbon dioxide and oxygen therapies were initiated.
 In 1954, integration hibernation psychotherapy was introduced.
University of Sto. Tomas
 In 1947, the UST Neuropsychiatry Section was opened with Dr. Leopoldo Pardo as its chief.
 In 1986, the section was developed as a separate department from the Medicine Department which was headed by Dr.
Gilberto Gimenez.
The Philippine Mental Health Association
 Was founded by Dr. Eduardo Krapf, Toribio Joson, and Manuel Arguelles in 1949. It is a private organization established
purposely to support the mental health services of the government.
University of the East Ramon Magsaysay Memorial Medical Center
 Established a department of psychiatry in 1956
Philippine General Hospital (UPGH)
 Opened its own neuropsychiatric unit headed by Dr. Baltazar Reyes, Jr. in 1958
 In 1964, the unit was separated to become a department.
In the Philippines, the emphasis of the treatment of mentally-ill patients was psychotherapy and chemotherapy, which were
usually based on the development and progress in the U.S.
The end of WWII marked the continued interest and expansion of psychoanalysis abroad. Because of its popularity, psychoanalysis
was equated often with psychiatry by the general public. However, despite this seeming dominance of the psychoanalytic
treatment during this period, the biological orientation as demonstrated by the use of insulin coma in schizophrenia and electric
shock in depression were still commonly used.
In 1953, this situation was radically changed with the dramatic discoveries in psychopharmacology. Consequently, these
developments proved favorable and were largely responsible for the changes in the practice of psychiatry in the country. Soon
drugs known to be helpful and beneficial with schizophrenia, depression, and anxiety disorders were being used. In the Philippines
the use of chlorpromazine has apparently shortened the hospital stay of psychotic patients. Most importantly, its use facilitated the
early discharge of these patients and early reintegration into the community.
6. Present-day Psychiatry
In the Philippines, the use of somatic
therapies became most popular in this
period. In the early 1960s the following
drugs were introduced:
 Lithium- used specifically for the treatment of mania
 Benzodiazepines- usually prescribed for non-psychotic anxiety
 Imipramine-like drugs and MAOIs0 commonly prescribed for the treatment of
depression and for patients with severe state of anxiety.
 Serotonin specific reupateke inhibitors and serotonin-norephineophrine reupatake
inhibitors were included in the treatment of depression during the last decades
on the 20th
century.
 Atypical antispsychotics were also introduced in the treatment of mental
disorders and they have the advantage of causing few side effects.
 Some somatic therapies become obsolete except for ECT.
 Collaboration among different professionals- psychologists, social workers,
nurses and occupational therapists further enhanced the delivery of care.
 Hospitalizations were apparently shortened.
 The thrust in the psychiatry movement and attention has now focused on
interventions for people who are not necessarily suffering from mental illness.
 The growing interest is geared towards assisting individuals who are vulnerable
to develop mental health disturbances- these people are who are victims of
either domestic or non-domestic violence, victims of disaster, abandoned
children, overseas workers, and others.
_______________________________________

Development of Psychiatric Education in the Philippines
 In 1973, Jesusa Bagan Lara wrote the first textbook entitled
An Outline of Psychiatric Nursing.
 The Board Examiners for Nurses in 1967 announced that all
nursing students must have at least 4 units of Mental Health
Psychiatric Nursing to complete the G.N. or B.S.N. programs
(Sand and Robles, 1972).
 Mental Health Psychiatric Nursing were included as a
separate subject in the Nurses Board Exam in 1978 (Lara,
1978).
 Nenita Yasay-Davadilla was the first psychiatric nurse to be
sent abroad (University of Maryland) to obtain M.S. in
Psychiatric Nursing under the WHO scholarship program.
 Magda Carolina Go Vera Llamanzares was the first
independent nurse practitioner in child psychiatric nursing.
 In 1968, the UP College of Nursing offered M.N. program
with specialization in psychiatric nursing.
 Sotera V. Capellan was the first G.N. to head the psychiatric
nursing service at the National Psychopathic Hospitan (now
NCMH), 1928-1957.
 The National Center for Mental Health with an authorized
bed capacity of 4,200 and a daily average of 3,400 in-
patients is the only mental hospital in the Philippines and is
the main center for clinical practice by nursing students for
most colleges in Metro Manila. A good number of students
from provincial colleges of nursing also choose to go to
NCMH during the summer period for practicum
(http://www.doh.gov.ph//ncmh2).

Part 2: The Challenges of Psychiatry and Mental Health Today
Assessment Instrument for Mental Health Systems (AIMS):
Report on Mental Health System in the Philippines, 2006
- Summary of the Report-
The Philippines have a National Mental Health Policy since 2001, which addresses the main issues of mental health
in the country. There is no mental health legislation, but different stakeholders are currently working towards the passage of a
mental health act. A regular budget allocation exists for mental health. In 2005, over 10 million US dollars (five percent of
the total health budget) was directed towards mental health. There is a Commission on Human Rights mandated to
review/inspect human rights protection of patients.
The Philippines has all types of mental health facilities. At present, there are 2 mental hospitals, 46 outpatient
facilities, 4 day treatment facilities, 19 community-based psychiatric inpatient facilities and 15 community
residential (custodial home-care) facilities. The only mental hospital in the National Capital Region houses 4,200 beds, while
almost all mental health facilities are located in major cities.
The total number of human resources working in mental health facilities or private practice is 2,900, including 353 psychiatrists,
141 other doctors not specialized in psychiatry, and 769 nurses. Coordinated and sustained efforts are needed to
strengthen the mental health system in the Philippines.
____________________________________________________________
Strengths and Weaknesses of the Mental Health System in the Philippines
It is apparent that the elements necessary for pursuing an effective mental health program in the Philippines are in place. The
major resource in the Philippines is its highly literate population who also values education and professional development.
Academic institutions and training centers have in the last 4 decades developed good programs to educate and develop the mental
health human resources, specifically psychiatrists, psychologists, social workers, nurses and allied mental health professionals.
These have developed a multidisciplinary group of professionals to address the mental health needs in the country, and have
broadened the scope of the national mental health program. In some ways these changes have advanced the understanding of
mental health disorders so that other agencies have initiated mental health programs relevant to their special needs. The challenge
is motivating these professionals to stay in the country and sustain their involvement, especially in the community setting, because
the country is continuing to lose this valuable and crucial resource to overseas employment.
The Philippines has a constitutionally created Human Rights Commission, but the body should have the authority to oversee
regular inspections and provide sanctions. The majority of mental health facilities are still located in the National Capital Region.
Hence, access to mental health facilities is uneven across the country, favoring those living near the main cities. In the mid 1990’s,
the Mental Health Program made some efforts to strengthen services in the community through trainings of local health
professionals. Essential psychotropic medications are available in all the facilities. In terms of support for child and adolescent
health, a psychosocial care system in schools has been established through collaboration with the Department of Health and
different government agencies and NGOs. However, psychosocial support in schools is mainly delivered by teachers and only a few
schools have part-time or full-time mental health professionals.
____________________________________________________________
Organization of Mental Health Services
The Department of Health institutionalizes the National Mental Health Program through organization of functional management
structures that groups mental health stakeholders into different committees. The national program management committee acts as
the main authority and facilitates the overall implementation of priority targets and strategies aligned to health systems goals of
improving the health status in the country. They are composed of mental health advocates from

central and regional units of the Department of Health, the Director of the National Center for Mental Health, mental health
experts from the medical centers, academe, consumer groups and professional organizations as well as representatives from other
government agencies.
a. Mental health outpatient facilities
There are 46 outpatient mental health facilities available in the country, of which 28% allocate units that are for children and
adolescents only. These facilities treat 124.3 users per 100,000 general population. Of all users treated in mental health outpatient
facilities 43% are female and 8% of all contacts were children or adolescents. The leading diagnoses of users treated in outpatient
facilities are mainly schizophrenia and related disorders (57%) and mood disorders (19%). Information on diagnosis is based on
number of users treated. The average number of contacts per user is 1.87. Twenty four percent of outpatient facilities provide
follow-up care in the community, while 11% have mental health mobile teams. In terms of available treatments, a majority (51-
80%) of the patients received psychosocial treatments. All (100%) mental health outpatient facilities have at least one
psychotropic medicine of each therapeutic class (anti-psychotic, antidepressant, mood stabilizer, anxiolytic, and antiepileptic
medicines) available in the facility or a near-by pharmacy all year round.
b. Day-treatment facilities
There are four day-treatment facilities available in the country, which treat 4.42 users per 100,000 general population. Of all users
treated in day-treatment facilities, 44% of them are female and 7% are children or adolescents. There is one day-treatment facility
(25%) that devotes a unit for children and adolescents only. On average, users spent 2.59 days per year in day treatment
facilities.
c. Community-based psychiatric inpatient units
There are 19 community-based psychiatric inpatient units available in the country for a total of 1.58 beds per 100,000 general
population. Only 1% of beds are reserved solely for children and adolescents. Thirty seven percent of admissions are female, while
6% of admissions are children/adolescents. The diagnoses of admissions to community-based psychiatric inpatient are primarily
from the following two diagnostic groups: schizophrenia and related disorders (63%) and
mood disorders (24%). On average patients spend 69.65 days per admission. The majority (51-80%) of patients in community-
based psychiatric inpatient units received one or more psychosocial interventions in the last year. All of community-based
psychiatric inpatient units have at least one psychotropic medicine of each therapeutic class (anti-psychotic, antidepressant, mood
stabilizer, anxiolytic, and antiepileptic medicines) available in the facility.
d. Community residential facilities
There are fifteen community residential facilities, or what is casually referred to in the Philippines as “home-care facility”. They are
mostly available in urban areas. They provide for a total of .61 beds/places per 100,000 general population. About 3% of the beds
in community residential facilities are reserved for children and adolescents only. Thirty three percent of users treated in
community residential facilities are female and only 2% are children and adolescents. The number of users in community
residential facilities is 1.09 per 100,000 general population.
e. Mental hospitals
There are two mental hospitals available in the country for a total of 5.57 beds per 100,000 general population. Two percent of
these beds are reserved for children and adolescents only. Thirty eight percent of admissions in mental hospitals are female. The
two hospitals are organizationally integrated with mental health outpatient facilities. The patients admitted to mental hospitals
belong primarily to the following two diagnostic groups: schizophrenia and related disorders (71%) and
mood disorders (18%). The number of patients in mental hospitals is 8.97 per 100,000 general population. The average number of
days spent in mental hospitals is 209. Sixty-four percent of patients spend less than one year, 18% of patients spend 1-4 years,
13% of patients spend 5-10 years, and 5% of patients spend more than 10 years in mental hospitals. Some (21-50%) patients in
mental hospitals received one or more psychosocial interventions in the last year. One hundred percent of mental hospitals have at
least one psychotropic medicine of each therapeutic class (anti-psychotic antidepressant, mood stabilizer, anxiolytic, and
antiepileptic medicines) available in the facility. There has been neither an increase nor a decrease of number of beds in the last
five years. The occupancy rate is about 92%.
f. Forensic and other residential facilities
In addition to beds in mental health facilities, there are also 400 beds (0.47 per 100,000 general population) for people committed
by courts for confinement in forensic inpatient units. All forensic beds are located at the National Center for Mental Health. Thirty
three percent of patients spend less than one year, 38% of patients spend 1-4 years, 25% of patients spend 5-10 years, and 4%
of patients
spend more than 10 years. There is only one residential facility (with 540 beds) specifically for people (of any age) with mental
retardation. This facility is managed by the government social welfare service, which now operates beyond its bed capacity. There
are six facilities (250 beds - private and public combined) specifically for people with substance abuse problems. There is one
facility that cares for senior citizens aged 60 and above, both male and female, who are abandoned, neglected and mostly
suffering from dementia.
________________________________________

Paradigm Shift and Homelessness
Two Vital Issues in Today’s Psychiatric Care Delivery
Paradigm Shift in Psychiatric Care
“Asylum psychiatry, and the Kraeplinian model on which it was based, fell into relative decline” (Wilson 1993)
Psychiatry in general lost interest in the severe mental illness (SMI) as a result of the
influx of psychoanalysts in the 1930s and 1940s (Miller, 1984). As Freud himself had
discovered, his analytic approach was most helpful to persons with less severe problems
and was not particularly helpful to psychotic patients. Thus, as Freudian thinking
influenced more psychiatrists and psychiatric nurses, a natural withdrawal from the SMI
and refocusing on individual’s more amenable to treatment occurred.
Public mental hospitals lost prestige, as did the physicians and nurses working in them. Within the psychiatric nursing fraternity,
staff nurses were not as highly valued as those who worked in the role of therapist. The devalued inpatient psychiatric nurses were
referred to as either lazy or crazy.
The mainstream of psychiatry and psychiatric nursing turned from chronically disturbed patients to individuals with lowered self-
esteem, those who were striving to reach their potential, and those who were existentially unhappy (Detre, 1987). Psychiatry
changed its focus from one extreme of the psychiatric care continuum (the SMI) to the other (the worried well) over a few
decades.
Psychiatry and psychiatric nursing became interested in issues such as poverty, racism, alternate lifestyle, sexism at the
professional level. Some clinicians believe that this process of enlightenment and social relevance further distanced the mainstream
of psychiatric care from persons most in need of that care.
Psychiatry returned to its roots with the birth of the Diagnostic and Statistic Manual-III in 1980. That edition has been described by
Wilson (1993) as the “remedicalization of psychiatry”. Psychiatric nursing was much slower to embtrace research (eg.: evidence-
based diagnosis) and the biologic underpinnings of the more severely mentally ill. But as the Decade of the Brain (1990s)
progressed, psychiatric nursing and psychiatric nursing textbooks reflected the new understandings.
____________________________________________________________
Homelessness
People who are homeless and mentally ill present a challenge to the political
systems in the society. These individuals are usually single or separated from
loved ones, and have a weak social support system. The homeless SMI are found
in parks, transport terminals, jails, and general hospitals among others. They
often present a troubling appearance and many of them have become bold in
their efforts to survive, assaulting the sensitivities of passersby. From aggressive
panhandling to embarrassing public elimination of body wastes, societal standards
are being affronted.
Homeless people may live exclusively in the streets, or they may live in community shelters. A possible third group includes
individuals who are able to stay in cheap hotels, alternating between this and nights in less accommodating surroundings. Still
another significant group moves among homeless shelters, rehabilitation programs, jails, and prisons.
In the U.S. many psychiatric professionals directly linked to deinstitutionalization of state hospitals. About 800,000 people
are homeless each night (SAMSHA, 2005). Homeless population includes people and their families who have been displaced by
social policies over which they have no control. Perhaps 25% are children, and another 25% are employed in low-paying jobs. The
consensus of opinion is that between 20-25% of the adult homeless population has SMI, and that 50-70% suffer from alcohol or
drug abuse (SAMSHA, 2005). Many suffer from both.
In the Philippines, The National Statistics Office defines homeless as “households living in parks, along sidewalks and all
those without any form of shelter”, it is estimated that 4.5 million Filipinos are in this situation. Seventy five percent of which
is believed to be squatters or illegal settlers in the main urban centers.

In Quezon City alone —the largest city in the National
Capital Region (NCR) that is greater Manila—200,000
families are described as ‘informal settlers.’ Data gathered
from the Quezon City Urban Poor Affairs Office (QC-UPAO)
records showed that that 47.6 percent or 95,188 of these
poor families occupy private land. More than 84,000 others
reside in areas covered by government-owned and
controlled corporations. The top five places occupied by the
homeless in Quezon City are sidewalks and open spaces (7,
852 families); areas under the Pasig River Rehabilitation
Program (4,117); and properties owned by the Metropolitan
Waterworks and Sewerage System (2,342). The rest of the
urban poor live along creeks and rivers; transmission and old
railway lines, bridges and various sites owned by electricity
distributor Manila Electric Company (MERALCO) and the
National Power Corporation. Others squat in and live off the
city’s garbage dumps.
People often become homeless when their housing and economic issues collide with other crisis such as domestic violence,
physical or mental illness, addiction, transition into adulthood, and relational strains. Up to half of homeless women and children
are victims of domestic violence. Just recently, the number of Filipinos with no health insurance has been reported at over 50
million. About 26% of people who experience homelessness nationwide are mentally ill (Department of Housing and Urban
Development). This compares to 6% of the country’s general population (Substance Abuse and Mental Health Services Administration).
Homelessness is and end product of chronic mental illness and probably exacerbates it as well. Stated another way,
many chronically ill persons end up on the streets because of their inability to succeed in a competitive society and, once they are
on the streets, the stresses of the homeless life compound their mental health problems; they are in a no-win situation.
________________________________________

Part 3: Part 3: The Current Bases of Psychiatric Mental Health Nursing
Competencies of a PMHN Nurse
A. Standards of Psychiatric-Mental Health Nursing Practice
Standards of practice are authoritative statements used by nursing profession to
describe the responsibilities for which nurses are accountable. They provide
direction for professional nursing practice and a framework for evaluation of
practice. They also define the nursing profession’s accountability to the public
and the client’s outcomes for which nurses are accountable.
Below is the current revision of Scope and Standards of Psychiatric-Mental Health
Nursing Practice (ANA, 2000).
Standards of Care
Standard I. Assessment (collection of client health data).
Standard II. Diagnosis (analysis of collected data in determining diagnosis)
Standard III. Outcome Identification (identification of expected outcomes individualized to the client)
Standard IV. Planning (develops plan of care that is negotiated among the client, nurse, family and healthcare team and
prescribes evidence-based interventions to attain expected outcomes.
Standard V. Implementation of interventions identified in the Plan of Care:
 Standard Va. Counseling- to improve or regain previous coping abilities, fostering mental health, and preventing mental illness and
disability.
 Standard Vb. Milieu Therapy- provides structures and maintains a therapeutic environment in collaboration with the client and other
healthcare providers.
 Standard Vc. Promotion of Self-Care Activities- structuring interventions around the client’s activities of daily living to foster self-care
and mental and physical well-being.
 Standard Vd. Psychobiologic Interventions- the use of knowledge of psychobiologic interventions and the application of clinical skills
to restore the client’s health and prevent future disability.
 Standard Ve. Health Teaching- through which, the nurses assists the client in achieving satisfying, productive and healthy patterns of
living.
 Standard Vf. Case Management- coordination of comprehensive health services and ensure continuity of care.
 Standard Vg. Health Promotion and Maintenance- employment of strategies and interventions to promote and maintain mental health
and prevent mental illness.
Standard of Professional Performance
Standard I. Quality of Care
Systematic evaluation of the quality of care and the effectiveness of nursing practice
Standard II. Performance Appraisal
Evaluation of one’s own psychiatric-mental health nursing practice in relation to professional practice standards and relevant
regulations.
Standard III. Education
Acquisition and maintaining current knowledge in nursing practice
Standard IV. Collegiality
Interaction and contribution to the professional development of peers, healthcare clinicians and others as colleagues.
Standard V. Ethics
Assessment, actions and recommendations on behalf of clients are determined and implemented in an ethical manner.
Standard VI. Collaboration
Collaboration with the client, significant others, and healthcare providers in giving care.

Standard VII. Research
Contribution to nursing and mental health through the use of research methods and findings.
Standard VIII. Resource Utilization
Considering factors related to safety, effectiveness, and cost in planning nd delivering client care.
________________________________________
The Nurses’ Role in the New Continuum of Care
Continuum of Care
The continuum of care provides individuals with a wide range of treatment options. Obviously, not everyone needs admission to
the hospital nor our economy can afford this level of care for the large number of people who are said to be suffering from mental
health problems. The hope then is to have effective alternatives within a context of a seamless continuum.
The role of nurses and other professionals is to assess the individual’s current level of functioning and then direct
or escort the person to appropriate resources. Coordination of services for the individual necessitates multidisciplinary
collaboration. Without this coordination, the continuum of care will not be seamless and, in fact, may hinder the very thing it
purports to help. Multidiscplinary care has been expanded to include not only professional staff, but also noprofessionals, patients,
family and various nonpsychiatric resources (nursing homes, medicare representative, medical clinics, etc.).
The seamless continuum:
SUSPECTED MENTAL HEALTH PROBLEM
Leave the system
NO
Problem Confirmation
YES
RISK ASSESSMENT:
 Dangerous to self and others?
 Gravely disabled?
 Acutely psychotic?
 Suicidal or homicidal?
NO YES
Treatment options:
 Residential services
 Outpatient services
 Self-help resources
 Other
Community-based care,
consider:
 Severity of patient’s
illness
 Amount of
supervision required
by the patient
Hospital-based care
Discharge
Planning
Examples:
1. An individual with auditory hallucinations telling her to kill her newborn infant needs inpatient hospitalization with 24-hour
nursing care and supervision in a safe environment.
2. An individual with thoughts of suicide but without a plan might be managed effectively by attending a day treatment
program 5 days a week for 2 weeks.

3. An individual with a history of medication noncompliance who needs a place to live might be appropriately placed in a
group home with a 24-hour supervision.
4. An individual with alcoholism who has completed acute detoxification might need referral to outpatient counseling or self-
help groups such as Al-Anon.
For any individual, additional referrals along the continuum of care can be made if needs change. An individual might be referred
to mental health services at any suggestions of family physicians, police officer, family member or nursing staff from the any of the
programs within the continuum. Self-referral is also a means whereby individuals can gain entry into the mental health system.
Continuum of Care Treatment Options
Hospital-Based Care
Historically, hospitals were the point of entry into the health care system, whereas the point of entry now can be anywhere along
the continuum of care. Patients admitted for psychiatric hospitalization stayed about 4-6 weeks. Today, length of stay (LOS) is
typically 3-5 days. Current issues include:
 Economic decisions
 Decreased reimbursement
 Goals, staffing patterns, acuity of patients, and discharge planning of hospitalization have changed as well:
- Goals of crisis intervention is safety
- Staffing must be cost-effective while maintaining quality of service
- Acuity of patients has increased
- Discharge planning begins immediately
The highest priority for admission to hospital-based care is safety for self and others. Hospitalization provides thorough
psychiatric evaluation to identify the underlying cause of their symptoms in addition to safety and protection.
 When a patient is deemed a danger to self (suicidal) and others (homicidal), a 24-hour supervision in a secure
environment is required.
 Individuals who are acutely psychotic or those who are confused and disoriented might not function well enough to meet
their basic needs including physical safety.
 Individuals with toxic reactions to medications or other substances and who need medical intervention when withdrawal
from substances might produce life-threatening conditions.
 Some patients are admitted for a medical evaluation or because the medical illness produces or complicates a psychiatric
disorder.
Types of Hospital-based care include:
- Locked units
- Open or unlocked units
- Psychiatric Intensive Care Units (PICUs) for high-acuity patients
- Specialty units (eg: edults, geriatric, child and adolescent, substance abuse)
Traditional Outpatient Services (TOS)
 Outpatient treatment that are conducted in mental health clinics and private offices.
 Psychiatrist, Psychologist, Social Worker of a Psychiatric Nurse Specialist provide counseling
 The typical pattern for a patient with chronic mental illness might be a visit with a counselor or case manager, and
periodic appointments with a psychiatrist for medication review.
 Counseling should determine the need for additional or more intense service/s.
TOS Who may benefit? Essential to program
Partial Programs and
Day Treatment
Individuals who need some
supervision, structured
activities, ongoing treatment
and nursing care.
 Performed 4-8 hours/ day and 1-5 days/ week
 Programming can occur during the day or nighttime
 Specific populations or type of problem are considered when
group or community treatment is conducted
Psychiatric Home
Care
Patients who are
homebound because their
illness or disability inhibits
their ability to leave home
and obtain services.
 Home visit occur in conjunction with other community-based
services
 Home care for patients with severe and persistent mental
illness
Community Outreach
Programs
Developed to reach
individuals in areas in which
lack of traditional medical
and social services exists.
 Mobile crisis teams reaching out to homeless population,
migrant workers and their families
 Mobile programs that serve the needs of mentally-ill
individuals on the streets, under bridges, in parks, etc.
 Physicians and nurse volunteers work hand in hand in
operating neighborhood clinics

Residential Services Available to help individuals
who need temporary or long
term housing needing 24-
hour supervision. The LOS
might be 3-6 months or
longer
 Extended care facilities (eg.: nursing homes) are available for
people who require 24-hour supervision and medical nursing
care; people with severe developmental disabilities such as
dementia or acute and chronic medical illnesses benefit most
 Group homes may provide temporary or permanent housing
for individuals with chronic mental disorders (staff might be
present for 24 hours/day or less); group therapies and
structured activities are done in some group homes whereas in
some, they only provide meals, bed and laundry services.
 Halfway houses are commonly for individuals with chemical
dependency; residents are expected to seek employment and
participate in cooking and cleaning chores; self-help groups
(eg.: Al Anon) in which meetings are conducted by members
and not professionals and can take place on a weekly basis;
Today, halfway houses are also open for individuals with other
problems
Primary Care
Individuals with mental health problems such as anxiety, depression and sleep disturbances sometimes seek help for these
problems in primary care offices and clinics. Reasons include:
 Stigma of mental health care (no one will know)
 Lack of knowledge about who o see and where to get help
 Reduced access to care
Psychopharmacologic medications are prescribed at times by primary care providers without a comprehensive history and
assessment of the patient. The patient’s immediate need might be addressed, but other modes of treatment that could benefit the
patient might not be provided. The nurse working in primary care areas provides those interventions (self, drugs, milieu) that
benefit individuals with mental health needs. Thus, psychotherapeutic management is relevant in the primary care setting as well.
______________________________________________________________________________
Current Trend: Assertive Community Treatment (ACT), an Evidence-based Practice
ACT is a comprehensive community-based service delivery model in which a
team of professionals assumes direct responsibility for providing services needed by the
client 24 hours a day, 7 days a week. The multidisciplinary team members compose of a
nurse, psychiatrist, social worker, and substance abuse counselor work together and
share responsibility for providing comprehensive treatment and support for a specified
number of clients.
It is an evidence-based practice model of community treatment that has reduced hospital
admissions and improved social functioning and quality of life for individuals with severe
mental illness (Marshall et al, 2005; Marshall and Lockwood, 2005)
Treatment and services include:
 Assistance with shopping
 Laundry
 Transportation
 Housing
 Healthcare and Medication monitoring; Emergency response
______________________________________________________________________________
________________________________________
The Influences of Theories to Current Practice
Prior to 1950s, the medical dominated psychiatric-mental health nursing practice.
Physicians and psychiatrists assessed diagnosed and planned care for individuals
with psychiatric disorders. Nurse practitioners were supervised mainly by
physicians and psychiatrists who incorporated the theories of individuals such as
Freud, Sullivan, Skinner, Bowen or Erikson in their practice. However, during this
same period, nursing leaders began to emerge to provide impetus for the
development of psychiatric nursing as an independent discipline.

Theorist Theory Impact on Nursing Theory
Sigmund Freud Psychoanalytic Nurses began to focus on human behavior, early stages of sexual development,
and the use of maladaptive defense mechanisms.
Harry Stack Sullivan Interpersonal Nurses recognized that humans are social beings who develop personal
relationships that could result in stress or anxiety, the use of maladaptive
behaviors, or alteration of the development of one’s personality.
B.F. Skinner Behavior Nurses recognized that interventions could be used to bring about change in
thoughts, feelings, and observed behavior.
Murray Bowen Family Systems Nurses developed an understanding of individual and family behaviors and their
relationship to each other.
Erik Erikson Developmental Nurses recognized that personality development begins at birth and continues
across the lifespan until death.
Significant Nursing Theories to Psychiatric and Mental Health Nursing
a. Peplau’s Interpersonal Theory
Hildegard Peplau was responsible in part for the emergence of theory-based psychiatric nursing practice. She believed that the
nurse served as therapist, counselor, socializing agent, manager, technical nurse, mother, surrogate and teacher. He also
incorporated communication and relationship concepts and identified the four phases during the interactive processes- orientation,
identification, exploitation, and resolution (Meleis, 1997). Analysis of this theory (Johnson 1997) reveals that it is effective in long-term
care facility which allows for the development of nurse-client relationship.
b. Orem’s Behavioral Nursing Theory
The theory focuses on self-care deficit- it proposes that recipient of nursing care are persons who are incapable of continuous self-
care or independent care because of health-related or health-derived limitations (Johnson, 1997). Because of the individual’s self-care
deficit, a nurse, family member or friend may educate or consult with the individual to improve the deficit. This is utilized in
psychiatric setting where individuals may neglect needs such as eating, drinking, rest, personal hygiene, and safety because of
their underlying disorder.
c. Roy’s Theory of Adaptation
Human beings are use coping mechanisms to adapt to both internal and external stimuli. Two major internal coping mechanisms
are the regulator and cognator. The regulator mechanism refers to an individual’s physiologic responses to stress, whereas the
cognator mechanism pertains to perceptual, social and information-processing factors. Coping behaviors occur in four modes-
physiologic, self-concept, role function and interdependence. This theory is important in psychiatric setting as the nurse assesses
client behavior and stimuli and develops a plan of care to assist the client in adaptation in the four modes- contributing to health,
quality of life, and dying with dignity (Johnson, 1997).
Application of theories to Practice (Meleis, 1997)
a. Needs-Oriented Approach suggests active doing and functioning. Nurses problem-solve, perform physiologic and
psychosocial activities for the client, supplement knowledge, and may become temporary self-care agents for clients with
self-care deficits.
b. Interaction-Oriented Approach is used by nurses who rely on interactions and include themselves as therapeutic tool
and evaluate their actions according to the client’s response. They counsel, guide and teach clients, helping them to find
meaning in their situations. Nurses appear to be process-oriented.
c. Outcome-Oriented Approach is used by nurses who are viewed as goal setters. They are referred to as controllers,
conservators, and healers without touch. They focus on maintaining and promoting energy and harmony with the
environment. They do not view themselves as therapeutic agents as they focus on enhancing the development of health
environments.
d. Eclectic Approach is an individualized style that incorporates the client’s own resources as a unique person with the
most suitable theoretical model. The therapist realizes that there is no one way to deal with all of life’s stresses or
problems of living and is open to new ideas and approaches as the need arises.
________________________________________

Integrating Models in the Current Psychiatric Care
Psychoanalytic Model
This model is a theory of personality originated by Sigmund Freud that emphasized unconscious processes or psychodynamic
factors as the basis for motivation and behavior. The theorist believed that an individual’s drives, instincts, libido, and psychosexual
attitude are formed early in life and are crucial to understanding of the personality.
Key Concepts
a. Personality Processes consists of id, ego and superego- that function as a whole to bring about behavior. When these
processes function in harmony, the individual experiences stability; when disharmony occurs, the individual is in conflict.
 The individual is all Id at birth wanting to experience only pleasure principle; it involves immediate gratification,
enabling the individual to strive for pleasure through the use of fantasies and images; it is compulsive without
morals; the ego controls id impulses and mediate between reality and fantasy.
 The ego focuses on reality principle and strives to meet the demands of the id while maintaining by maintaining
the well-being of the individual by distinguishing fantasy from environmental reality. Secondary process thinking
comprises rational, logical thinking and intelligence. It is the part of personality that experiences anxiety and
uses defense mechanisms for protection; heredity, environmental factors, and maturation influence the
formation of the ego.
 The superego is concerned with right and wrong- that is the conscience. It provides the ego with an inner
control to help cope with id; it is formed from the internalization of what parents teach their children about right
and wrong through rewards and punishment. Self-esteem is affected by the perception of a person’s actions as
good or right. The theorist proposed that guilt and inferiority are experienced when the individual cannot live up
to parental standards. Inner conflicts result when the id, the ego, and the superego are striving for different
goals.
b. Consciousness concept of Freud is central to understanding problem of personality and behavior:
 Consciousness or material within an individual’s awareness is only a small part of the mind.
 Unconscious is a larger area and consists of memories, conflicts, experiences and materials that have been repressed
and cannot be recalled at will.
 Precocious refers to memories that can be recalled to consciousness with some effort.
The theorist believed that uncovering unconscious material generates an understanding of behavior that enables individuals to
make choices about behavior and thus improve their mental health. Insight into the meaning of the symptom facilitates change.
c. Defense Mechanisms
The ego usually copes with anxiety through rational means. But when anxiety is too painful, the individual copes with
using defense mechanisms to protect the ego and diminish anxiety. When these mechanisms are used excessively,
individuals are unable to face reality and do not solve their problems. Defense mechanisms are primary unconscious
behaviors; however, some are within voluntary control.
Painful feelings connected with childhood conflict are often repressed. Later in life, as similar conflicts are experienced
once again, repression fails, and these feelings emerge, causing anxiety and discomfort.
Freud defined three types of anxiety that form the basis of mental disorder:
 Reality anxiety stemming from an external real threat
 Neurotic anxiety, dealing with the fear that instincts will cause the person to do something to invite
punishment, such as being promiscuous
 Moral anxiety, such as guilt experienced when an individual acts contrary to his or her conscience
Relevance to Current Practice
The goals of Freudian psychoanalytic therapy and other psychodynamic therapies are to
bring the unconscious into consciousness, enabling the individual to work through the
past and understand their past and current behaviors. By overcoming repression and
resistance to exploring feelings and thoughts, childhood experiences can be analyzed.
Uncovering the causes of current behavior leads to insight (Miller, 2004). Only then
individuals decrease their self-defeating behaviors and improve their mental health.
In traditional long-term psychoanalysis, the therapist uses free association (allowing the
patient to say everything that comes to mind) so that repressed material can be identified
and interpreted for patients.

Dream analysis helps patients uncover the meaning of their dreams, which also increases awareness about present behavior.
Patient’s inconsistencies and resistance to therapy are confronted.
Transference (an unconscious emotional reaction based on past experience) that occurs in the current relationship with the
therapist is used to encourage working through feelings that would otherwise remain unconscious.
Supportive therapy was developed for ill patients who were unable to tolerate intense probing of intrapsychic conflict, defenses
and transference issues. It involves interaction with the patient (not silent listening) and emphasizes focus on the present (not on
the past). Questioning is less challenging and critical, and the approach conveys empathy and understanding (Miller, 2004).
In brief therapeutic encounters, the nurse must recognize and understand the maladaptive defense mechanisms that patient’s use.
The nurse assesses the client’s behaviors and other relevant data gathered to formulate a nursing diagnosis. The nurse carefully
shares these observations regarding these mechanisms with patients to increase awareness with these behaviors to increase
adaptive behavior.
Example: An individual who denies a problem with alcohol must recognize that an arrest for public intoxication, a pending divorce,
and three job losses are in fact, related to drinking and that abstinence from alcohol is the major adaptive coping mechanism
needed.
In long-term relationships, patients can be assisted with learning to think, feel and behave according to their own individual
values, beliefs and needs, not according to someone else’s.
Example: A college student who is pursuing Fine Arts at the insistence of a domineering parent can be assisted in deciding his
career goals, while developing ego strength to withstand parental pressures.
Patients might also need assistance with accepting their desires and drives as normal, for which they need not feel guilt or shame,
and with choosing acceptable ways of expressing their desires and drives.
______________________________________________
Developmental Model
Erik Erikson (1963, 1968) built on Freud’s psychoanalytic model by including psychosocial
and environmental influences along with the Freudian psychosexual concepts. This model
spans the total life cycle from birth to death. The theorist believed that each of the eight
stages of development afforded opportunities for growth, even to the acceptance of the
person’s own death.
Key Concepts
Each Eriksonian stage is comprised of a developmental crisis involving positive and
negative experiences. Mastery of critical tasks is the result of having more positive than
negative experiences. Nonmastery of tasks inhibits movement to the next stage. Erikson
believed that the drive of humans to earlier states and behaviors; therefore, he saw
regression as a possibility. Regression often occurs as a result of trauma, prolonged or
severe stress, and physiologic or psychiatric illnesses.
Implied but not clearly described in Erikson’s model is the concept of partial mastery of critical tasks in development. The
degree of mastery of each stage is related to the degree of maturity that the adult attains. Deficits in development carried from
one stage to the next progressively interfere with functioning, until the individual is no longer capable of growing without returning
emotionally to an earlier stage to resolve the crisis.
Examples: A person might develop enough trust in others to engage in superficial relationship but might not be able to develop
intimacy with a spouse;
A person might have enough initiative to accept job but might have lack the industry to stay with it.
An environmental or social tragedy can shake the early foundations of development, such as when divorce from a spouse
threatens the individual’s sense of trust in others and results in self-doubt.
An individual can skip developmental stage because of life circumstances, but might have to return to that stage later to master
those critical tasks:
Example: A young teenager mother might skip the stages of identity and intimacy as a result of the responsibilities of caring for a
child (genarativity). However, this new mother will probably be drawn back to the issues of identity and intimacy, often before her
child enters school. This creates an inherent conflict in roles, feelings, and behaviors.

Mastery of the critical tasks of each stage occurs more easily when it is chronologically appropriate. Overcoming delayed or
incomplete development is difficult but possible.
Relevance to Current Practice
Most patients with psychiatric disorders demonstrate partial mastery of the developmental
stages preceding the stage for their chronologic age. The nurse conducts an assessment
of the patient’s level of functioning through the interpretation of verbal and nonverbal
behaviors and identifies the degree of mastery of each stage up to the patient’s
chronologic age.
The behavioral manifestations of problems are clues to issues to be addressed in working with the patient.
Example: An adolescent is overwhelmed with shame about being sexually abused as a child. Mature relationship will not be
achievable until the shame and doubt are solved through dealing more effectively with the memories and emotions related to the
abuse.
Patients diagnosed with schizophrenia are often struggling with trust issues because of suspiciousness and fear of closeness. The
nurse must concentrate on trust-building strategies with these patients. Although Erikson focused on the polarity of each
developmental stage (Eg.: trust vs. mistrust) as if the positive pole were the desirable task to be accomplished, it is now
recognized that the extremes of either pole produce problems in functioning:
Examples: Being overly trusting can result in being repeatedly taken advantage by others; Having too much industry will result in
working beyond working hours without any time for recreation.
The Need for Cultural Competence in Today’s Psychiatric Nursing
Culture is critical component of patient’s lives that affects their health care
attitudes and actions as well as their ability to understand and use the
interventions that psychiatric nurses develop (Campinha-Bacote, 2005, 2007; Warren,
2000, 2007). Culture is the internal and external manifestation of a person’s
group’s, or community’s learned and shared values, beliefs, and norms used to
help individuals function in life and understand and interpret life occurrences
(Leininger and McFarland, 2006). The cultural perspectives and patterns of both the
nurse and patient influence the nurse-patient interaction. These perspectives and
patterns also affect a patient’s level of mental health.
For example, a patient’s behaviors might be labeled as pathologic if a nurse
misinterprets the patient’s normal or culturally relevant beliefs and health care
actions (Warren, 2000, 2007). Furthermore, a patient labeled as noncompliant might
not be receiving culturally competent care (Purnll, 2009; Purnell and Paulanka, 2003).
Culture and Psychiatric Nursing
The U.S. Surgeon General’s report on mental health has emphasized the need for culturally competent mental health care (U.S.
Surgeon General, 2001). Nurses provide services to a multitude of patients from diverse cultures. The term cultural diversity might
encompass areas such as age, gender, socioeconomic status, religion, race, ethnicity, mental illness, and physically challenging
conditions (Andrews and Boyle, 2007; Campinha-BAcote, 2005, 2007; Comas-Diaz and Green, 1994; giger and Davidhizar, 2008; Institute of Medicine [IOM],
2003 Leininger and McFarland, 2006;Spector,2004). The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision
(DSM-IV-TR) has incorporated additional information regarding specific cultural features for each diagnostic category and includes
an appendix, Outline for Cultural Formulation, and a Glossary of Culture-Bound Syndromes (American Psychiatric Association [APA], 200).
Barriers to Culturally Competent Care
A growing knowledge and research base has indicated that patient’s adherence to treatment increases when cultural needs are
incorporated into health care planning (APA, 2000; U.S. Surgeon General, 2001; Warren, 2001). Because nurses are often the
gatekeepers for health care systems, knowledge of cultural factors related to psychiatric care is important.

The most common barrier to the delivery of culturally competent nursing care involves miscommunication between
nurses and patients. A nurse might lack knowledge and sensitivity regarding a patient’s cultural beliefs and practices hence, the
nurse might not recognize the importance and value of these beliefs to the patient as they relate to health care practices. Similarly,
patients might be unaware of the nurse’s cultural perspectives and misinterpret health care recommendations from the nurse (Diala
et al., 2001).
It is true to the Philippines society that miscommunication between the nurse and the patient might occur. Being an
archipelago and acculturated by different races, the Philippines has many local languages and beliefs (Jacano, 1998). Consequently, to
facilitate successful relationships with their patients, the nurse must understand his or her own cultural beliefs and values and how
these beliefs and values influence patient care. This cultural awareness facilities the psychotherapeutic relationship and the nursing
process (Quander, 2001; Warren, 2008a).
Cultural Etiology of Illness and Disease
Nurse’s and patient’s health care actions and beliefs are generally formulated by
three factors: (1) their definition of health; (2) their perception of the
way in which illness occurs; and (3) their cultural worldview (Carter, 1995;
Chong, 2002; Diala et al.,2001; Herrera et al., 1999). Nurses and patients might define
health quite differently.
Closely connected to a nurse or patient’s definition of health is his or
her belief of how illness and disease occur. The nurse or patient might
believe that illness and disease are created by natural, unnatural, or scientific
causes. For example, a person who believes in the concept of natural cause of
illness or disease believes that everyone and everything in the world is
interrelated and that a disruption of this connectedness (e.g. a tornado) causes
an illness or disease (Giger and David bizar, 2008; Spector, 2004).
Conversely, nurses or patients might believe that unnatural or outside forces create illness and disease. An individual might believe that another
person enlists the services of a magician, witch, ghost, or supernatural being to cast a spell or hex on him or her. Finally, nurses or patients might
believe in the scientific cause of illness—specific, concrete explanations exist for every illness and disease (i.e, the entrance of pathogens such as
viruses, bacteria, and germs into the body) (Campinha-Bacote, 2005, 2007; Warren, 2007). The scientific model is the typical model taught in most
Western culture schools of nursing. However, many non-Western culture acknowledge and teach health care providers the
importance of the natural and unnatural causes of illness.
Patient’s health care beliefs and actions are related not only to the way in which health, illness, and the cause of illness are defined but also to
individual worldviews. There are four primary worldviews: (1) analytic, (2) relational, (3) community, and (4) ecologic. This primary
worldview is often the one that individuals express or are comfortable with when they are with family or significant others, or during stressful
times. Many individuals use a mixture of the four worldviews or adopt another worldview when they are in another environment, such as a work or
business setting. The nurse’s failure to understand the patient’s primary worldview might negatively affect the nurse-patient relationship and
impede successful interventions and mental health outcomes.
THE
FOUR
WORLDVIEW
Analytic
A person who experiences the analytic worldview values detail to time, individuality and possessions. A person with this
view also prefers to learn through written hands on, and visual resources the relational worldview is grounded in a belief
in spiritually and the significance of relationships and interactions between and among individuals. The preferred learning
style is through verbal communication. And individual who expresses the community worldview believes that community
needs and concerns are more important than individual ones. Quiet, respectful communication, as well as meditation and
reading, are valued as a learning style. The ecologic worldview is based on a belief that a form of interconnectedness
exists between human beings and the earth, and that individuals have a responsibility to take care of the earth. Learning
is accomplished through quiet observation and contemplation, and verbal communication is minimized.
Worldviews form a basis for the expression of culturally bound mental health and wellness issues. For example, a patient
or nurse using an analytic worldview perspective might espouse specific detail to time, calculations, individuality, and the
importance of acquiring material objects. Being on time for appointments, immediately getting to the purpose of a health
visit, and using printed pamphlets and books for health education are valued. Nurses and other health care professionals
must be extremely accurate and precise when providing care for these patients. The example of individuality and valuing
material goods is often embodied in traditional American society’s values, beliefs, and actions.
Relational
The individual with a relational worldview values the development of interactions and relationships, usually prefers
learning through verbal communication, and views spirituality as an important context for living life. These individuals
might want to chat for a moment before getting to the heart of the health visit. They might desire the involvement of
relatives, friends, or spiritual and religious advisors during the health visit or during the nurse’s development of the

nursing process. The relational worldview might be noted in certain individuals from African-American, Latino (Latina) or
Hispanic cultures (Plummer, 1996; Warren, 2007).
Community
Individuals with a community worldview value the importance and needs of the community over the individual. People
with this perspective often use meditation and contemplation techniques. A patient with this view is respectful and polite
regarding health care advice and might not want to question a nurse or physician. This reticence might occur even if the
patient does not understand the nurse’s recommendation. People from some Asian cultural groups often embody these
philosophers (Warren, 2007).
Ecologic
A patient or nurse with an ecologic worldview values interconnectedness with other people and the universe takes
responsibility for others and the world, and feels a need to maintain peace and tranquility. These individuals prefer a
quiet, restful approach in interactions with others. Conversation is respectful, concise, and often kept to a minimum.
Individuals from some of the indigenous or Native-American cultures might embrace this worldview.
EUROPEAN-AMERICAN WORLDVIEW
Component Perspective
Cultural value Value is placed on the member or object or on the attainment of the object.
Knowledge Knowledge is acquired according to proof of the existence of anything- that is, the ability of an
individual to see, hear, touch, taste or smell it.
Logic Dichotomous mode of reasoning is used.
Relationship Relationships are developed based on the perceived need for them.
AFRICAN, AFRICAN-AMERICAN, HISPANIC, AND ARABIC WORLDVIEW
Cultural value Value is placed on the maintenance and development of interpersonal relationships.
Knowledge Knowledge bases are developed through the use of affective or feeling senses.
Logic Reasoning ability is based on the union of opposites.
Relationship Development of interpersonal relationships is based on the fact that all relationships are
interrelated across all continua.
ASIAN, ASIAN-AMERICAN AND POLYNESIAN WORLDVIEW
Cultural value Value is placed on the balance between member and group interactions
Knowledge Knowledge bases are developed in striving for transcendence of the mind and body.
Logic Reasoning ability is based on the belief that the mind and body can exist independently of the
physical world.
Relationship Development of relationships is grounded in the belief that everyone and everything in the
physical and physical worlds are related.
NATIVE-AMERICAN WORLDVIEW
Cultural value Value is placed on the context of a person’s relationship to a Greater or Supreme Being.
Knowledge Knowledge bases are developed on the basis of a person’s understanding of an individual’s
relationship with the Greater or Supreme Being.
Logic Reasoning ability is grounded on the belief that every person is innately good and has no evil
within.
Relationship Development of relationships with another person, group or community is grounded on the idea
that the Greater or Supreme Being is in every person; hence all persons should be valued.
Culture-Bound Mental Health Issues
Culture-bound syndromes are recurring patterns of behavior that create disturbing experiences for individuals
(APA, 2000). These behaviors might or might not be congruent with symptomatology presented in the DSM-IV-TR for various
diagnostic categories. However, because these behaviors can be culture-based, nurses must be aware of the symptoms to assess
patients who are from racially and ethnically diverse cultures accurately.
People from racially and ethnically diverse cultures often use culturally specific language to describe mental distress that they
experience (Munoz and Luckmann, 2005; Ross, 2001; Taylor, 2003). One example involves the description of depressive symptoms and the
actual symptomatology (Baker, 2001; Delahanty et el., 2001; Pouissaint and Alexander, 2000).
 Native Americans might state that they are “having heart pain” or are “heartbroken” when they experience depressive
symptomatology (Warren, 2007).

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