Counselling In Mental Health Nursing Practice

Description of Incidence

Discuss about the Counselling in Mental Health Nursing Practice.

A clinical reflection is a positive attempt by healthcare professional describing their clinical investigation, assessment, practice and applied skills. This clinical reflection works as a tool for development of critical clinical skills, thinking power, professional role, active learning and personal potential in clinical practice. In reflective writing, the professional try to evaluate their own practice determining the pros and cons of their healthcare practice. This self-assessment enables them to explore their strengths as well as weaknesses that help further to initiate improvements in practice (Stuart, 2014).

These clinical reflections are performed with the use of reflection models that help to describe the professional and personal competencies developed after any incidence or helps to process thought after any clinical incidence (Lees, 2014). In the present clinical reflection paper, a critical incidence is described that is judged on the basis of ethical, racial, religious and gender sensitivity required in counselling practice. As a professional counsellor or therapist working in mental health services, learner implements suitable clinical interventions using clinical decision-making framework to treat the on-going mental health issues of the patient. This reflective clinical paper will help the learner for professional and personal development in the field of mental healthcare. Beddoe (2010) indicated that clinical reflective writing has now become an important part of contemporary nursing and counselling practice to manage diversified clinical situations, incidences and scenario. 

The patient named Liliana is an old lady, 62 years of age was admitted to mental health services on 2-oct-2016 having referrals from NEMHS following referral from MHT. Liliana is a divorcee living with her only daughter Maria and three grandchildren at Sheidow Park. She was presented to the clinical department with daughter Maria. Liliana is having a long history of clinical conditions that involves physical impairment includes bursitis of L shoulder, high cholesterol, osteoarthritis and fibromyalgia, further, mental impairment or conditions includes bipolar disorder (diagnosed in 1996), stress, anxiety, depression, mood, eating and sleep disorder.

The referral received from NEMHS and MHT indicated that Liliana is at the critical stage of distress, unwilling to take medication and no locomotion or movement and lacking of interest in personal coping activities. On analysing the clinical history of Liliana it was identified that she had multiple admission to psychiatric units from 2006 for managing her bipolar disorder. She confronted the depressed and manic phases of bipolar disorder till 2010. In total, she had nine referrals to acute mental health services having a persistent history of lacking engagement in clinical processes, aggressive behaviour and poor insight of her mental health condition. Liliana is right now on medication for bipolar disorder (Sodium valproate), anxiety (venlafaxine) along with cholesterol medication to manage high cholesterol level. She is having panic attacks and lacking psychological support.

Demonstrating Ethical, Racial, Religious and Gender Sensitivity in Counselling

On performing a Mental Health Examination of Liliana present medical condition indicates that she is an old woman having an exceptional appearance with anxious behaviour in initial stages followed by the calm, friendly and cooperative behaviour in the interview session. The mood rate obtained was 10/10 (bad mood) having normal flow if speech and no evidence of formal thought disorder. Further, perception analysis indicated no fluctuation and denied the thought of suicide intent. The cognitive functionality was TPP oriented and judgement was impaired in distress. The sleep, energy and appetite were poor with weight loss.

The risk assessment of Liliana indicated that although she is not having thoughts if suicide but she wants to end up with her psychological pain. She is also having a historical attempt of anti-depressant overdose and DSH. However, history of the suicidal attempt was unknown. Further, presently Liliana is willing to get engaged with mental health services although she was showing a lack of personal engagement in her previous admissions to mental health services. As per this assessment, Liliana is having a critical condition of bipolar disorder as a sufferer from last 20 years. Liliana denies the intent of risk behaviour like suicide but still she requires observations and monitoring, further, her physical pain (osteoarthritis) and psychological pain (hurt, misery, anguish) are reason hindering the pathway of recovery and self-management. Her anxiety, mood disorder, stress and depression are outcomes of lifelong unmanaged bipolar disorder.

As a professional counsellor for providing therapeutic services and counselling there is a critical requirement to follow certain ethics, regulations, laws and regulation to address aspects of race, religion, gender and diversity in the clinical scenario. According to Laszloffy and Habekost (2010) the ethical principles that counsellor needs to follow involves respecting humanity and dignity if people surrounding the practice. Counsellor needs to respect the religion, colour and race of every individual involved in the clinical process. They further, need to provide the right of informed consent to the patient further following other laws of their working zone. The protection of patient autonomy, restrictions, rights and the decision is also a part of counselling practice. Lastly, the counsellor needs to maintain professional boundaries as well as relationships as a part of ethical practice.

The race, religion, gender and age are some of the critically sensitive factors that disturb the pathway of ethical practice especially while handling trauma and mental disorder (Cooper et al. 2013). Any therapeutic practice for mental illness requires modifications in attitude, behaviour, spirituality, conscious; values and beliefs of the patient, which are, develop as per the cultural and religious principle of society. Therefore, these factors create complexity and sensitivity in counselling practice (Collins and Arthur, 2010). According to Boyd-Franklin (2010), a counsellor needs to develop a multicultural approach to address the sensitive issues related to race, colour and religion. A multicultural competency helps in better communication, understanding others perceptions and better therapist-client relationship. In the present incidence, race or religion is not an issue in counselling performance, however, to address the requirement of informed consent, however, to address this issue, consent from Liliana has already been provided with referrals. The only need is to develop interventions that involve patient autonomy and beneficence a primary part of counselling practice.

Articulating about Clinical Interventions and Clinical Decision Making for Provided Incidence

London et al. (2012) studied that counselling practice should involve gender aware counselling goals that work to provide stability on controversial issues related to gender sensitivity. In the present incidence, as Liliana is a female it is appropriate to involve feminist counselling practice where women issues are handled with their gender sensitivity. This counselling process works to provide respect, empathy and dignity to female patients. Further, as Liliana is an old lady of 62 years, therefore, age can be a major issue while developing effective intervention because she is already confronting physical and psychological pain that can hinder her recovery process. Therefore, the age factor should be a major consideration while developing interventions for Liliana. Collins and Arthur (2010) indicated that proper counselling practice should involve aspects like ethical stability, the value of individuality, respecting autonomy and democratic relationship.

As a counsellor, in the case of Liliana, the interventions were planned to address the most dynamic issues hindering the recovery process related to bipolar disorder. The dynamics like physical pain (osteoarthritis) and psychological pain, mood disorder, physical immobility, anxiety and stress. The interventions developed for these issue help to accelerate the recovery from bipolar disorder and provide an effective quality of life to the patient. As a professional practitioner, the National Framework of clinical decision-making was implemented to develop these counselling interventions. This framework provided principles, skills and processes to make an effective clinical decision (Curran et al. 2012).

I implemented the skills of critical thinking, pattern recognition, communication skills, sharing information and reflection while performing my counselling practice. All the clinical decisions are as per evidence-based approaches as guided in the framework (Lees, 2014). For the purpose of reflection, the client feedback was considered as an effective strategy to evaluate the clinical practice (Curran et al. 2012). The decision-making process involves four steps, firstly gathering and analysing patient data, secondly making judgements as per the collected information. Further, making the decision for clinical interventions for which I took advice and support from other team members as well and lastly, evaluating the outcomes of feedback collection process (Lyons, 2010).

Starting from the very first and most effective intervention developed to cure the bipolar disorder of Liliana is Cognitive Behaviour Therapy (CBT) a monitoring mental state intervention. According to Bauer et al. (2012), this therapy works to modify negative thought process and behaviour patterns that place difficulty in recovery from bipolar disorder. Liliana is facing mood swings (depression episodes) involving aggressive behaviour and unintentional risk of relapse. Therefore, to address these issue CBT works as a complete package because mood swings are under the influence of thought process, further, mood determines the behaviour of the individual. Therefore, by implementing CBT as an intervention, the negative thought process and behaviour patterns will get modify to control moods swings and aggressive behaviour of the patient.

Magalhaes et al. (2012) provided six strategies to practice CBT for bipolar disorder, As a professional consultant, I provided this six-step CBT therapy that involves accepting your (patient) condition, monitoring mood, cognitive restructure, frequent problem-solving approach, encouraging social engagement and stabilising routine. This six-step CBT was considered to be perfect for addressing bipolar disorder of Liliana. In the first step, Liliana was allowed to understand and acknowledge about her condition, however, Liliana already had a good insight perception that helped to develop the base of CBT. Further, in next step, Liliana was told to rate her mood daily on the scale of 0-10 making her more aware of fluctuations and triggers. In the third step of CBT, detecting the problems and correcting them for balanced thinking modified thought process.

In the fourth step, the patient was allowed to detect problems in therapy, predict solution and implement an effective solution to solve their problem. Further, for enhancing social skills, assertiveness helped to manage interpersonal relationships in a better manner. Lastly, the routine was stabilised using morning exercise, relaxation, proper meals, sleep and social plans to improve the quality of life (Pfennig et al. 2014). Further, Bonsall et al. (2012) provided some techniques to maximise CBT treatment for bipolar disorder that involves listening carefully to the doctor, completing CBT homework and gathering knowledge about your disorder. These techniques were also provided as consultation advice for Liliana to cope up with bipolar disorder.

Now, another intervention described in studies of Parikh et al. (2012) is providing regular medication as prescribed by the professional doctor to manage the clinical conditions hindering therapeutic intervention because bipolar disorder recovery is critically affected by other clinical conditions. In the case of Liliana, her high cholesterol and osteoarthritis can hinder the bipolar recovery process. Therefore, it is essential to monitor medication and provide regular medication to the patient. As Liliana was detected with the unwillingness to take medication this intervention will help to overcome this psychological issue. Further, supporting and monitoring medication compliance will help to evaluate the effectiveness of this intervention.

World Health Organization (2016) recommended in their study the intervention to provide sleep hygiene to control the sleeplessness disorder developed as a symptom of bipolar disorder. This intervention involves light exercise before sleep, natural light exposure and regular relaxation. Liliana facing sleeplessness can recovery her sleep with the help of this intervention. Further, Somers et al. (2012) studied the use of Family-focussed counselling approach as liaise with the family of the patient to increase support in the treatment process. In this intervention, the family members are provided with consultation regarding managing medications, providing mood stabilisers, identification of manic and depression in their family member suffering bipolar disorder. In the case of Liliana, this intervention is very important to overcome her psychological pain along with bipolar disorder where her daughter will be guided by the professional consultant.

Bonsall et al. (2012) indicated the Assist and support with transition home intervention that involves different strategies practised by caregiver handling patient at home. The strategies are talk therapy, relaxation training, self-management training, walking aids, stress management and pain coping techniques. This intervention can work to overcome the symptoms and side effects of bipolar disorder in the case of Liliana. These techniques help to control stress, pain, anxiety and maintains the quality of life. The guidance and practice provided under this intervention will help to overcome the issue of lacking self-engagement in the case of Liliana.

Somers et al. (2012) studied about psychoeducation that is provided by counsellors to BD patient that was observed to be effective in controlling relapse and overall functionality of the patient. Under psychoeducation a complete awareness about the disorder, avoiding substance abuse, adherence treatment and early identification of new episode is provided to the patient. As Liliana is facing episodes of the relapse this psychoeducation will work to control this situation. A 21-session group-psychoeducation helps to develop social skills, education and knowledge about once condition.

Further, for the management of osteoporosis (physical pain), Liliana was advised to take Pain Coping Skills Training for the management of her pain. Magalhaes et al. (2012) studies about this intervention where behavioural modifications are made in lifestyles using coping technique that patient learn through this training. The pain coping skills training involves three-component approach where in the first component is educational rationale where the patient is trained to better understand their feelings, thoughts and behaviours In the second component, therapist teach the patient about coping strategies and the third component involves home practice and lifestyle modification training for painful situations confronted by the patient. These were the counselling advices and interventions provided to Liliana as per her identified issues and illnesses. 

Clinical supervision is considered to be the most important and essential competency for healthcare professional practice that promotes effective treatment (Stuart, 2014). As a mental health counsellor for the provided incidence, the overall clinical supervision was an effective attempt to understand the patient situation and provide workable counselling and therapy.  According to Lam et al. (2010), clinical supervision involves the model of practice, strategic implementation and systematic evaluation of applied strategies by professionals. It is also consolidated as a reflection of personal performance and case review to achieve the best care process.

The present clinical supervision involves effective management, positive support, effective recommendations and workable professional supervision as benefits for current incidence. The case of Liliana was properly handled in a manner of initial assessment of Mental Health Status (MHS), stressors, medical history followed by determination of risk summary and dynamics of incidence. Further, recommendations or plan were provided that involves counselling and therapeutic approaches that can benefit the patient to overcome serious dynamics. This highlights the positive support provided by clinicians in this incidence. The recommendations are effective enough to cover all the serious health issues identified for Liliana. Further, MSE assessment in clinical supervision provided a complete detailed identification of patient current status and health.

For reflecting on the feeling and learning I gained from the present incidence of clinical supervision I used Gibb’s reflection cycle that helped me to evaluate the six stages of clinical reflection. According to Beddoe (2010), Gibb’s reflection cycle helps to understand learning from experience by describing incidence as a six-stage process that involves description, feelings, evaluation, analysis, conclusion and action plan.

The description of incidence indicates that Liliana case is a critical and serious case of bipolar disorder that requires workable counselling and therapy for her survival. She has already referred to various mental health services previously but yet not accommodated effective recovery. Further, her unwillingness to take medications and engagement in care process is also creating major drawbacks in the recovery process. I realised that recovery in such attitude and behaviour will be a tough process to deal with, therefore, along with other stakeholders decisions about interventions were developed to provide an improvement in these hurdles of the recovery process.

Further, describing my feelings as second stage of Gibb’s cycle, I felt this situation as an alarming one for my professional career because I haven’t faced any such complex situation before where it is critically essential to manage the mental issues (bipolar disorder, anxiety, stress), physical issue (osteoporosis) and psychological issues (unwilling attitude and behaviour) with one stage therapeutic practice. I didn’t want the patient to feel threatened or serious about their present situation and used talk therapy as a part of consolidation in the counselling process. I took advice from my mentor and seniors regarding the case history and developing appropriate interventions for Liliana.  My mentor suggested me to have patients and carefully handle the critical aspects of incidence.

When evaluating this incidence at the third stage of Gibb’s cycle, I realised that the incidence was extremely and exceptionally challenging one for me. However, I tried my best to develop the most workable advice and interventions for Liliana. I got a positive response from my mentors for my planning, practice and management. I took the help of other stakeholders as well for implementing the interventions into practice. The interventions developed can work in a multidimensional manner to cure the mental as well as physical issues of Liliana. The cognitive behavioural therapy, pain coping training, family-focussed counselling and psychoeducation are some of the most incredible interventions that assure positive response.

On further, analysing the situation, I can predict that these clinical interventions will surely work to improve the on-going issues of Liliana resulting in better quality of life for this aged women. For further analysing the effectiveness of intervention a feedback collection strategy can be adopted where Liliana will provide her feedback on the effectiveness created by these interventions. However, I would establish some more strategies to analyse the effectiveness of interventions and develop a more versatile plan for nursing care if provided with other chance to re-examine this incidence.

Conclusion

The study on clinical reflection about provided incidence indicates that counselling practice is highly dependent on clinical experiences gained from the new incidence of complex health issue that helps to elaborate and amend the defects in caring practice. Each and every incidence is a new experience for learning in the life of healthcare professionals. This clinical reflection provides a deep inside of one such clinically complex incidence of Liliana patient suffering from mental, physical and psychological disturbances in life. As a healthcare professional, learner worked to analyse her condition, detect the defects and provide appropriate interventions. A clear reflection on complete incidence followed by demonstrating ethical, racial, religious and gender sensitivity in counselling is described in the study. Further, a detailed elaboration on the development and importance clinical interventions for Liliana conditions is provided in the study. The complete reflection on learning, thinking, experience and feelings is provided using Gibb’s reflection cycle also describing benefits of this clinical supervision. This clinical reflection will help me in the detection of the defects and develop lacking competencies in my clinical practice. Further, the work can also be useful for other professionals to enhance their clinical knowledge and skills.

References

Books

Cooper, M., O’Hara, M., Schmid, P.F. and Bohart, A. eds., 2013. The handbook of person-centred psychotherapy and counselling. Palgrave Macmillan. 

Lees, J., 2014. Clinical counselling in context: an introduction. Routledge. 

Lyons, N. ed., 2010. Handbook of reflection and reflective inquiry. Springer US. 

Stuart, G.W., 2014. Principles and practice of psychiatric nursing. Elsevier Health Sciences. 

Journals 

Bauer, M., Ritter, P., Grunze, H. and Pfennig, A., 2012. Treatment options for acute depression in bipolar disorder. Bipolar disorders, 14(s2), pp.37-50. 

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Bonsall, M.B., Wallace-Hadrill, S.M., Geddes, J.R., Goodwin, G.M. and Holmes, E.A., 2012. Nonlinear time-series approaches in characterizing mood stability and mood instability in bipolar disorder. Proceedings of the Royal Society of London B: Biological Sciences, 279(1730), pp.916-924.

 Boyd-Franklin, N., 2010. Incorporating spirituality and religion into the treatment of African American clients. The Counseling Psychologist. 

Collins, S. and Arthur, N., 2010. Culture-infused counselling: A model for developing multicultural competence. Counselling Psychology Quarterly,23(2), pp.217-233. 

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Lam, C.S., Tsang, H.W., Corrigan, P.W., Lee, Y.T., Angell, B., Shi, K., Jin, S. and Larson, J.E., 2010. Chinese lay theory and mental illness stigma: implications for research and practices. Journal of Rehabilitation, 76(1), p.35. 

Laszloffy, T. and Habekost, J., 2010. Using experiential tasks to enhance cultural sensitivity among MFT trainees. Journal of marital and family therapy,36(3), pp.333-346. 

London, B., Downey, G., Romero-Canyas, R., Rattan, A. and Tyson, D., 2012. Gender-based rejection sensitivity and academic self-silencing in women. Journal of personality and social psychology, 102(5), p.961. 

Magalhaes, P.V., Dodd, S., Nierenberg, A.A. and Berk, M., 2012. Cumulative morbidity and prognostic staging of illness in the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD). Australian and New Zealand journal of psychiatry, p.0004867412460593. 

Parikh, S.V., Zaretsky, A., Beaulieu, S., Yatham, L.N., Young, L.T., Patelis-Siotis, I., MacQueen, G.M., Levitt, A., Arenovich, T. and Cervantes, P., 2012. A randomized controlled trial of psychoeducation or cognitive-behavioral therapy in bipolar disorder: a Canadian Network for Mood and Anxiety treatments (CANMAT) study [CME]. The Journal of clinical psychiatry, 73(6), pp.803-810. 

Pfennig, A., Correll, C.U., Marx, C., Rottmann?Wolf, M., Meyer, T.D., Bauer, M. and Leopold, K., 2014. Psychotherapeutic interventions in individuals at risk of developing bipolar disorder: a systematic review. Early intervention in psychiatry, 8(1), pp.3-11. 

Somers, T.J., Blumenthal, J.A., Guilak, F., Kraus, V.B., Schmitt, D.O., Babyak, M.A., Craighead, L.W., Caldwell, D.S., Rice, J.R., McKee, D.C. and Shelby, R.A., 2012. Pain coping skills training and lifestyle behavioral weight management in patients with knee osteoarthritis: a randomized controlled study. Pain, 153(6), pp.1199-1209. 

World Health Organization, 2016. mhGAP intervention guide for mental, neurological and substance use disorders in non-specialized health settings.Lancet.