Chapter 5: Settings for Psychiatric Care

Um, welcome back to the deep dive today.

We are uh, we're doing something a little specialized Yeah, a bit of a targeted session today, right?

This one is specifically for the last minute lecture team So if you are a nursing student, you know prepping for your first psych rotation or trying to cram for an exam This is for you.

We are tackling a subject that um

Well on the surface it sounds incredibly administrative it really does it sounds it sounds dry Yeah, like a like a list of dresses or zoning laws But if you actually look at the table of contents It is the bedrock of how mental health treatment happens in the real world We're diving into settings for psychiatric care exactly and I know I know it sounds like a lot of logistics But if you're trying to understand how the mental health system works, you have to know this stuff It's about understanding the where and the how of treatment and we're working directly from chapter five of essentials of psychiatric mental health nursing

The fourth edition the fourth edition right and to kick this off There's an analogy in the text that I think I mean it just perfectly nails the problem right out of the gate It starts with a sore throat.

It's a great comparison it is so You know picture a typical tuesday morning you wake up you swallow And it just feels like you gulp down a handful of razor blades.

Your throat is completely on fire You check the mirror you see those little white spots.

What is your immediate next move?

Well, I mean for most people the script is just automatic you call your primary care doctor and you say I think I have strep right you get an appointment you walk in you tell the receptionist what's wrong You aren't whispering.

You aren't looking over your shoulder.

You probably even uh, You probably texted your boss on the way and just said hey running late stopping at the doctor first sore throat It's a completely neutral transaction.

It is it's a biological problem with a logistical solution You have a map for it society have a map everyone agrees on the map exactly But now I want you to rewind that tuesday morning You wake up, but your throat is totally fine.

Instead you feel this This crushing weight on your chest.

You literally can't summon the will to lift the covers or uh Maybe your thoughts are just racing at a thousand miles an hour, right?

Bounding around your scalp bouncing off the walls of your skull exactly and you are convinced genuinely convinced that your neighbor is recording your thoughts That is a very very different tuesday.

It is so Do you text your boss?

Do you know exactly which phone number to call?

Do you walk into a clinic and announce it to the receptionist in a normal voice for the vast majority of people?

The answer is a hard no no and that hesitation that confusion is exactly where we're starting today Unlike physical medicine the entry into the psychiatric care system is often hidden.

It's confusing.

It's steeped in stigma Yeah, the text actually points out that we don't have the same frame of reference for it You know, you know your grandmother had bypass surgery But you probably have no idea if she was ever treated for a nervous breakdown because people hide it they bury it and before you tune out thinking this is just a Geography lesson of hospital wings.

Let's be super clear.

This is about the hidden architecture of our society It's about where we put people when they are at their absolute most vulnerable and why the system is designed or frankly Misdesigned the way it is.

It's the stark difference between physical medicine and mental health care as that sore throat analogy highlights Physical care has a clear front door Psychiatric care is often just a maze.

So our mission today is to act as the guides through that maze We are breaking this down specifically for the last minute lecture team So if you are a nursing student, this is your road map for the exams But for everyone else listening, this is a look at a system that

Statistically speaking you or someone you love will eventually have to navigate We really do have a lot of ground to cover We need to talk about the history how we went from literally chaining people in basements to the modern hospital We need to talk about the different settings everything from a therapist couch to a high security forensic unit And we really need to talk about the nurse's role in all of this, which is way more complex than just handing out pills Oh, absolutely.

Let's start with that friction.

We just identified Why is the entry into the mental health system?

So incredibly difficult the text mentions health disparities right up front It does and in a medical context a disparity isn't just a difference.

It's an inequity It means that if you are poor or you live in a rural area or you belong to a racial minority Your access to care and the actual quality of that care is objectively worse But isn't that kind of true for regular medicine too?

I mean if i'm out in a rural farming town i'm farther away from a top -tier heart surgeon That is true, but in mental health there's an added layer and that layer is attitude The text is very specific about this a provider's bias Whether they are conscious of it or not can fundamentally alter the treatment Yeah If a doctor sees a patient as difficult or flawed rather than ill the outcomes just tank both implicit and explicit bias Shade how a patient is treated.

So if a provider has a negative view of mental illness that actually changes the clinical outcome It absolutely can it guides their expectations.

It dictates how hard they are willing to fight for resources for that specific patient That's rough.

It is but they're also

Biological and psychological barriers that are internal to the patient that make entering the system so hard The text defines two terms that every single nursing student needs to memorize

Anasognosia and inertia Okay, let's hit those.

Let's really break these down because they sound like harry potter spells, but they are they're devastating clinical realities Let's do anasognosia first.

So anasognosia and it's pronounced Uh nosog n -o -h -z -u is very often mistaken for denial, but denial is a psychological defense mechanism It's you lying to yourself to protect your feelings like saying I don't have a drinking problem.

I just like to unwind Exactly, but anasognosia is biological It stems from physical anatomical changes in the brain often seen in schizophrenia

The brain is literally unable to process the fact that it is sick So the patient isn't just being stubborn not at all Yeah, imagine if you were colorblind and I kept screaming at you to pick up the red ball You aren't refusing to see red.

You physically cannot see red Oh, wow, right a patient with anasognosia looks at their hallucinations or their delusions and they see absolute reality Their brain cannot perceive the illness.

So in their mind, why on earth would they go to a doctor?

That is a terrifying thought you're sick, but the sickness actively hides itself from you It just completely severs the feedback loop of I feel bad.

I should seek help It does it breaks the alarm system and then on top of that you have energosia, which is incredibly common in major depression Which just sounds like no energy that is the literal greek translation But clinically it's not just oh i'm feeling a bit tired today It is a profound crushing paralysis of the will right think about it Navigating the american health care system requires a tremendous amount of executive function You have to make phone calls.

You have to verify insurance.

You have to drive to appointments If you have energy, you might logically know you need help But the physical act of picking up the phone feels like trying to deadlift a car So between the societal stigma the brain literally not knowing it's sick and the body having zero energy to move The deck is completely stacked against getting care.

Exactly Plus the text mentions that mental health issues often don't even look like mental health issues at first.

They look physical.

Yes somatic symptoms Anxiety might present as a racing heart sweaty palms or severe dizziness.

So they go straight to a cardiologist They go to the er they get a full ekg.

They get a complete workup for a myocardial infarction A heart attack and when it comes back totally clear they're sent home They might bounce around a different specialist for years treating stomach issues or heart palpitations before any doctor finally asks How is your mood and that leads to massive delays in getting actual psychiatric treatment huge delays years sometimes So our mission today is to demystify this whole system We want to understand the different settings from outpatient to inpatient And specifically what a nurse is doing in each one because it seems like the landscape has changed a lot over the years It has changed dramatically.

I mean to really understand where we are right now We have to look at the history We have to look at the massive shift from the asylum era to modern care Right when we say asylums I think most people have a pretty grim cinematic picture in their heads horror movies lightning storms crashing rusty iron gates And sadly that picture is often pretty accurate when you look at the later years of those institutions But the text notes something surprising

Before the civil war when asylums were first created there was actually a ton of optimism Optimism really for an asylum.

Yes, think about the word itself asylum implies a sanctuary a safe place before the civil war the prevailing idea was that the Remember that word comes through the latin for not healthy needed protection from a very cool chaotic world Okay, I can see that the state felt this moral duty To house them feed them and protect them It was actually spearheaded as a major reform movement by people like dorothea dix But it went wrong.

It went horribly wrong.

It became a massive warehousing operation The system just collapsed under its own weight by the 1950s.

We had over half a million people locked in state hospitals they were essentially institutionalized for life because Frankly, there were no effective treatment.

They just stayed there.

They stayed there.

They were incredibly overcrowded severely underfunded and the conditions were just They were deplorable.

It was a holding pen and then the 1950s happened The text calls this the turning point two massive things happened that basically cracked the asylum walls wide open science and money Or more specifically in nursing terms Medication and policy.

Okay, let's start with the science what changed

1952 Chlorpromazine most people know it by its brand name thorazine.

This was the very first anti -psychotic medication That must have been an absolute game changer.

It was revolutionary.

It was viewed as a miracle drug at the time Before thorazine if a patient was severely violent or manic The only options a nurse had were physical restraints

Hydrotherapy,

which was basically wrapping them in cold wet sheets or total isolation.

Wow Thorazine calmed the central nervous system.

It quieted the auditory hallucinations

Suddenly patients who had been screaming in wards for years could actually sit down in a chair and have a coherent conversation And if they can have a conversation, they don't necessarily need to be locked in a ward Exactly.

It opened the door to the real possibility of living outside the hospital But scientific possibility isn't enough on its own.

You need policy to fund it.

That's where the 1960s come in Right the great society reforms.

Yes, specifically the creation of medicare and medicaid.

Ah the money piece always follow the money Before this the individual states paid for the massive asylums out of their own budgets

But then medicaid came along and offered federal money for care But only if that care happened in the community or in general hospitals Medicaid explicitly stopped paying for long -term custodial care in those old state psychiatric hospitals So the states looked at their budgets and said great Let's move all these patients out of our facilities and get the federal government to pick up the tab That was the massive catalyst for deinstitutionalization the widespread emptying of the state hospitals

But there is one more pillar a legal pillar that we have to discuss The olmstead decision this was much later, right like 1999.

Yes, the supreme court case olmstead vlc in 1999

This is absolutely crucial for nursing students to remember because it fundamentally frames mental health as a civil right a civil right Yes, the supreme court ruled that keeping someone in a psychiatric institution when they're perfectly capable of living in the community Is unjustified isolation.

So it's legally a civil rights violation to keep them locked up It is a direct violation of the americans with disabilities act The court effectively said people with mental illness have a right to live in the community

You cannot just lock people up because it's administratively convenient for the state if they can survive outside They have a legal right to be outside and this solidified the massive decline of state hospital beds completely We went from about 322 state hospitals in 1950 Down to about 188 by 2015 which brings us to what I think is the golden rule of psychiatric nursing settings The least restrictive environment.

Yes.

This is a concept.

You simply must memorize The primary goal is always to treat the patient in a setting that provides the necessary level of safety But allows for the greatest possible personal freedom, right?

You don't put someone in a straight jacket if talk therapy works You don't put them in a locked inpatient unit if they can manage their symptoms at home with outpatient support Okay, so let's follow that exact path Let's start with the least restrictive settings the outpatient care settings This is arguably the absolute front line of mental health in this country It really is and as we mentioned with the sore throat analogy, the first stop for most people isn't a psychiatrist It's their primary care provider their pcp.

Why is the pcp the go -to for mental health too?

Just habit familiarity is a huge part of it.

You already know you're a doctor And there is significantly less stigma walking into a regular family practice waiting room Than walking into a building that says mental health clinic on the side Plus as we discussed so many patients present with those physical somatic symptoms first But there's a pretty severe downside to the pcp model, right?

Time time is the enemy here.

A standard pcp appointment is what 15 minutes?

Maybe 20 if you're really lucky, right?

It's usually just take a deep breath cough.

You're good to go.

Exactly Now imagine a provider trying to unravel a complex

Layered case of bipolar disorder or passive suicidal ideation in 12 minutes While they're also supposed to be checking your blood pressure and refilling your cholesterol prescription.

It's impossible.

It is PCPs are brilliant generalists, but they often lack the highly specialized psychiatric training for deep assessment And they definitely lack the time so to bridge that gap the text talks about pcmh's

Patient -centered medical homes now this sounds like an actual building, but it's more of a a concept, right?

It's a model of care It was very strongly supported and incentivized by the affordable care act The whole idea is to stop fragmented care fragmented meaning meaning your heart doctor has no idea What your psychiatrist is doing and neither of them are talking to your therapist a pcmh acts as a central health home The text lists five key characteristics for these let's run through them quickly So students know exactly what makes a medical home a home.

Sure.

Number one is comprehensive care They handle absolutely everything preventive care acute issues chronic disease management and mental and physical health It's all managed under one virtual or physical roof.

Okay.

Number two patient -centered I know this sounds like total corporate buzzword soup, but clinically it means the relationship is the primary focus The patient isn't just a chart number they are an active partner in the care team got it number three coordinated care The home communicates with the broader health care system.

They talk to the hospitals the specialized surgeons the home health aides They connect all the dots so the patient doesn't have to the home is the quarterback number four is accessible service This simply means they're actually available to the patient not just monday through friday 9 to 5.

We're talking secure email support

247 triage phone lines significantly shorter wait times for appointments Because as we know mental health crises absolutely do not respect business hours.

Very true.

And finally number five quality and safety They rely strictly on evidence -based care and they use continuous data tracking to keep improving their outcomes It's really about treating the entire whole person in one continuous coordinated loop.

That sounds like the ideal setup But let's look at the more traditional specialized outpatient settings The text mentions community mental health centers

Cmhcs, right?

These were essentially born out of jfk's 1963 community mental health act the massive policy goal was to replace those crumbling state asylums With local community -based care.

They are heavily regulated by the states and they usually offer a sliding scale fees Based on a patient's income.

So they're affordable.

What do they actually do?

They provide the absolute basics of psychiatric survival Assessment individual counseling intensive case management and medication prescription and monitoring And for people who need more than just a weekly visit, but still don't need a locked hospital ward There is a psychiatric rehabilitation Now how is that different from just regular treatment?

That is a really great distinction to make traditional treatment usually follows a medical model You have a dysfunction.

We apply a treatment to fix the dysfunction

Psychiatric rehabilitation, however follows a social model a social model.

Yes The focus shifts entirely to recovery social integration and vocational training It helps people with severe Persistent mental illness learn how to actually function in the world How to hold down a job how to live independently in an apartment how to socialize without severe anxiety It's less about curing the disease and more about teaching life skills.

Exactly Now here is one that I think definitely trips nursing students up on exams Psychiatric home care It's a nurse coming directly to your house, but you can't just call it medicare and order this like a pizza What are the strict criteria medicare is incredibly incredibly strict about this to get reimbursed for psychiatric home care You absolutely must meet three specific criteria One you must have a documented psychiatric diagnosis Two you must be under the active care of a pcp

And three and this is the massive hurdle You must be homebound and homebound doesn't just mean you work from home and prefer to stay in your pajamas No, not at all It legally means you cannot safely leave your home or that leaving causes severe undue psychological or physical stress Or you physically cannot leave without the aid of another person or a device It has to be a genuinely taxing effort to get out the front door.

Can you give an example of that?

Sure think of an elderly patient with severe agoraphobia a paralyzing fear of open spaces

Just the thought of walking to the mailbox at the end of the driveway induces a full -blown panic attack Or think of someone with severe advanced dementia who wanders off and gets lost the second they step outside.

They're considered homebound But and this is a big but the text notes two very specific somewhat quirky exceptions You are allowed to leave the house for two things without losing your official homebound status.

Yes I always call these the dignity clauses.

Yeah, this is a classic classic nursing exam detail You can leave your house once a week for religious services and you can leave once a week for hair care Hair care and church the absolute essentials of life.

It sounds trivial when you first hear it, but it really speaks to human dignity For a severely homebound senior citizen going to the salon or going to sunday service Might be the only tethers to their past identity that they have left That makes a lot of sense.

So moving up the ladder of intensity We have iop's and php's

Now these just sound like government alphabet soup.

What is the actual difference between them?

They are intermediate steps Think of them as the vital bridge between outpatient care and inpatient hospitalization

Iop stands for intensive outpatient program.

These are usually half -day programs half -day.

So like a morning session Yeah, you go for maybe three to four hours a few days a week you do intensive group therapy Maybe you see the prescriber to adjust meds and then you go to work or you go home You still have a life outside the program and php's

Partial hospitalization programs the name really gives it away You are partially hospitalized you're there for about six hours a day usually five days a week Wow, so that's basically a full -time job.

It is a full -time job.

You have highly structured activities constant nursing supervision and deep therapy The clinical goal is twofold

either to aggressively prevent you from needing full inpatient admission Or to act as a step -down unit to help you transition back to the real world After you've been in an inpatient ward and nurses obviously play a huge huge role in all of these outpatient settings They do especially pmhrn's which are psychiatric mental health registered nurses.

They're the ones developing the complex care plans But beyond clinical skills, they absolutely need to know the community like knowing the bus routes Exactly knowing the bus routes knowing where the food banks are Knowing the intake rules for the local domestic violence shelters The text explicitly says a community psychiatric nurse views the entire community as a patient And we also see aprn's in these settings advanced practice registered nurses, right?

These are masters or doctoral level nurses and this is a huge shift in modern care in many community mental health centers today Aprn's actually outnumber psychiatrists.

Yes, they have the authority to deeply assess Formally diagnose and prescribe medication They are very often the primary psychiatric provider for these outpatient populations Okay, so that covers the community the least restrictive side of things, but sometimes Despite everyone's best efforts that just isn't enough.

Sometimes a patient is in a severe crisis So let's move to section three of our outline Inpatient care settings.

This is acute stabilization.

Yes, this is the absolute most restrictive level of care It provides 24 hour round the clock nursing supervision It is reserved for when a patient's safety simply cannot be guaranteed on the outside What are the specific criteria for being admitted here because I know you can't just walk in and say you're stressed It is a very high bar Insurance companies will absolutely not pay for an inpatient bed just because you're having a hard week It usually requires imminent documented danger like suicidal ideation Suicidal ideation with a specific viable plan

Or homicidal intent Severe aggressive impulses that can't be controlled a profound need for crisis stabilization where the patient has lost touch with reality Or and this is very common substance detoxification that requires intensive medical monitoring because the withdrawal process could be literally lethal We should probably touch on the legal status of admission briefly, too The text mentions voluntary versus involuntary Right and we will dive much deeper into the complex legalities of that in a future episode on chapter six but briefly for now Voluntary means the patient agrees they need help and signs themselves in involuntary means they are legally committed against their will because a doctor And a judge have determined they pose a clear and present danger to themselves or others Okay, so walk us through the actual environment if I if I unlock the heavy doors and walk onto an inpatient psych unit What do I actually see you see what the text calls a therapeutic milieu milieu?

That is such a fancy academic word.

It is it just comes from the french for middle or environment But in psychiatry the concept is profound The milieu is the treatment wait the environment itself is the treatment.

Yes, think about a regular medical floor The treatment is the ivy antibiotics or the surgical procedure

But in psych the treatment is the structured interactions you have with the other patients It's the highly predictable structure of the day It's the rules the boundary setting and the overwhelming sense of safety The entire holistic environment is designed to be a healing space But it's also designed to be a rigorously safe space, right?

The text goes into some really intense detail about the physical room design It's not just about making it look nice.

It's hardcore suicide prevention.

Absolutely.

It is grim, but it is necessary architectural engineering Statistically hanging is the most common method of inpatient suicide So every square into the room is designed to minimize ligature points ligature points meaning places where a desperate patient could tie a rope A bed sheet or shoelace.

What specifically do they do to the rooms?

Well, you'll see closet rods and bathroom hooks that are breakaway meaning they snap off Exactly if you put more than say five or ten pounds of downward weight on them, they instantly collapse You physically cannot hang yourself from them

What else what about the windows and beds?

The windows are heavily locked obviously and they're usually made of shatterproof safety glass or thick polycarbonate The beds are very often solid platform beds.

Why platform beds?

So a patient can't crawl underneath them to hide and so they can't get crushed by any Moving mechanical parts like you'd find in a standard hospital bed All the furniture is incredibly heavy so it can't be thrown and it has rounded corners to prevent head injuries

Even the fire sprinklers, especially flush mounted tight against the ceiling so you can't tie anything around the nozzle It is a very very carefully engineered environment.

Wow It really shows how much thought goes into safety.

There is another term used here regarding safety that students need to know elopement Yes Now in the general outside world elopement means running off secretly to get married but in psychiatric nursing elopement means a patient leaving the hospital Before they are formally discharged basically going AWOL Locked units with their double door sally ports are specifically designed to prevent elopement So a patient is admitted the heavy doors lock behind them.

What happens next?

What is the actual process of care?

The very first step might actually surprise you.

It's a comprehensive medical assessment.

Why medical?

They're on a psych ward.

You have to do it to rule out co -morbid conditions Remember physical biological illness can severely mimic psychiatric symptoms like what?

Well, an undiagnosed brain tumor in the frontal lobe can look exactly like a sudden severe personality change A severe thyroid issue can look identical to major clinical depression a bad reaction to a street drug can look like primary schizophrenia You absolutely have to rule those physical issues out or begin treating them alongside the psych issue You simply cannot treat the mind until you've cleared the body That makes total sense and then once the medical side is clear the psychiatric activities start yes The schedule kicks in group therapy Intensive psychoeducation where they learn about their specific medications and symptom triggers and occupational therapy now How long do people usually stay in these units?

It's remarkably short the average length of stay for mental health is only about eight days eight days Yeah, and for substance use detox.

It's even shorter about 4 .8 days on average only eight days I mean that doesn't seem anywhere near long enough to cure a severe mental illness It's not and that is a massive public misconception.

We need to clear up right now

Acute inpatient care is not about a cure It is strictly about stabilization just stopping the bleeding essentially exactly getting them out of immediate crisis That is exactly why discharge planning starts on day one the minute they walk in the door You have to figure out exactly where they're going next so they don't just bounce right back into the hospital a week later We call that the revolving door syndrome or recidivism It is a huge huge failure point in the modern system to make all this complex care happen in just eight days You need a village the text has a great breakdown in box 5 .1 of the interprofessional team I want to play a quick game with this.

Okay.

I'm going to introduce a hypothetical patient We'll call her mrs.

G and I want you to tell me exactly what each team member is doing for her on the unit Let's do it.

I love a case study.

Okay, mrs.

G is 65 years old.

She has bipolar disorder She is currently in a severe manic episode She hasn't slept a wink in three days and she is actively refusing to take any of her normal medication first up on the team The psychiatrist, okay The psychiatrist is the head of the medical model.

They are a medical doctor an md or do They are formally diagnosing the severity of her mania and they are the ones ordering the heavy mood stabilizers or Antipsychotics.

Yeah, she desperately needs to break the mania and induce sleep.

They're looking purely at the brain chemistry next The psychologist now note the key difference here.

This is usually a phd or a cid not a medical doctor They aren't writing the prescriptions for the pills.

So what are they doing for mrs.

G?

They might be conducting in -depth cognitive testing to see if there's early onset dementia complicating her bipolar disorder Or they might be doing specialized psychotherapy once she calms down to understand the psychological reasons Why she stopped taking her meds in the first place got it Next the social worker crucial absolutely crucial role.

The social worker is on the phone They're calling mrs.

G's family to get collateral history They are checking if she has a safe calm environment to return to They are fighting with her insurance company and they're setting up that vital outpatient appointment for the day after she leaves They are the bridge connecting the locked unit to the outside world next up occupational therapist or ot In psych ot is heavily focused on functional real world skills The ot is watching mrs.

G function on the unit Can she safely dress herself is her mania so severe that she's too distracted to use a fork at dinner They focus heavily on adl's activities of daily living before discharge They might work with her on physically organizing a weekly pill box So she doesn't forget her meds when she gets home and quickly the recreation therapist They use structured activity board games art projects gentle movement to improve her emotional and physical well -being It's essentially Therapeutic play to ground her back in reality.

What about the pharmacist?

They are carefully monitoring her complex drug regimens behind the scenes Checking for dangerous interactions with any blood pressure or cholesterol meds She might also be taking and finally the center of the wheel the person tying it all together the pmhrn The nurse the absolute backbone of the unit They are the only professionals on that entire lift who are physically present two or four seven The doctor sees mrs.

G for maybe 15 minutes during morning rounds, right?

The nurse is with her for an eight or 12 hour shift.

The nurse physically administers the medication Ensured she actually swallows it instead of hiding it in her cheek Constantly monitors her sleep patterns verbally de -escalates her when she starts yelling at the wall in the hallway And rigorously documents every single thing she does it really is a massive coordinated team effort But I want to circle back specifically to the nurse Section five of our outline is entirely dedicated to the nurse's role in inpatient care And there is a persistent annoying myth that the text explicitly busts here Oh, I know exactly which myth you mean the myth that psych nurses just sit around and talk exactly Oh, you don't do real medical stuff.

You just chat with patients and drink coffee.

It is so incredibly far from the truth If I had a nickel for every time I heard that in nursing school It is arguably one of the absolute most difficult nursing specialties in the entire profession.

Why is that?

Because you don't have an ekg machine or a blood lab doing the monitoring for you.

You are the primary diagnostic tool First of all talking in this context is therapeutic communication.

It is a highly learned heavily practiced technical skill It is not just chatting about the weather It's knowing exactly how to frame a question that opens a psychological door Rather than saying the wrong thing and slamming it shut but beyond the communication the actual physical care is incredibly medically complex The text gives a very specific example of this complexity.

It does imagine you have an older male patient He has severe diabetes.

He just had a recent leg amputation and he is admitted to your psych unit Because he is acutely suicidal that is an incredibly heavy complex case It is an everyday reality on these units Now the nurse isn't just sitting in a chair watching him for suicide risk They're actively monitoring his fluctuating blood glucose levels.

They're carefully managing his sliding scale insulin And they're performing sterile wound care on his amputation stump to prevent sepsis Right because the body is still sick exactly if you ignore the diabetes because you are focused on the depression He slips into a diabetic coma if you only focus on the wound care and ignore the suicide risk He takes his own life You have to aggressively manage both the medical and the psychiatric crisis simultaneously all shift long It's intense medical nursing fully layered with intense psychiatric nursing exactly.

They're constantly collecting vital data Managing the overall physical safety of the milieu and they are incredibly involved in medication management And meditation management and psych isn't just handing out pills on a schedule.

Not at all Psychiatric medications are notoriously trial and error The doctor writes the prescription but the nurse is the one who observes the real -time effects Right because the doctor left 11 hours ago exactly the nurse charts patient is excessively drooling and shuffling their feet a sign of extra pyramidal symptoms Or patient is still actively responding to internal auditory voices Those critical nursing observations are what dictate the doctor's next dose adjustment the nurse's eyes completely drive the medical management So that paints a very clear picture of the general inpatient world But there are specialized settings designed for very specific situations section six covers these let's start with the fastest one

crisis intervention crisis intervention is all about speed It's usually located in busy hospital er's or dedicated community crisis centers The sole goal is to rapidly stabilize the person within 24 hours from there They either deescalate enough to go home without patient support or they are formally transferred to an inpatient unit Then there are the state acute care hospitals Now these are the modern descendants of those old massive state asylums We talked about who actually goes to a state hospital today today.

They serve primarily as the ultimate safety net They're for the severely uninsured or those who have exhausted absolutely all their private insurance benefits and are still incredibly sick But they also have a massive massive role in forensic care forensic So this is where the psychiatric system violently intersects with the legal system Yes, they securely house patients who have been found not guilty by reason of insanity or ngri The text used the incredibly tragic case of andrea yates as the primary example here He was the mother in texas who drowned her children, right?

Yes back in 2001 She drowned her five young children in the bathtub

The jury ultimately found her ngri because expert testimony shows she was suffering from profound severe postpartum psychosis She had deeply entrenched delusional beliefs that she was actually saving her children's souls from eternal damnation by killing them It's just horrifying, but she wasn't sent to a maximum security prison No, she was committed to a secure state psychiatric facility because the legal logic is You cannot morally punish someone for a horrific act if their diseased brain literally compelled them to do it without their rational consent Correct.

The legal goal in an ngri case is psychiatric treatment of public safety.

Yeah, not purely punitive retribution However, this perfectly segues into the absolute darkest side of the forensic system the prisons themselves Yeah, the text drops a statistic here.

I mean it literally stops you in your tracks when you read it It is shameful in 44 out of the 50 us states the largest provider mental health care is not a hospital It is the state prison system.

Wait, I really want to make sure everyone heard that The prisons hold more mentally ill people than the actual hospitals.

Yes We have effectively criminalized the visible symptoms of severe mental illness.

Think about it A homeless man with unmedicated schizophrenia is hallucinating and shouts aggressively at a police officer on the street That's disorderly conduct or assaulting an officer.

Exactly.

He gets arrested He goes to county jail then maybe prison and once he is locked inside that system.

He does not get better He gets markedly worse.

He is subjected to punitive segregation Constant extreme noise and physical violence.

It is the exact polar opposite of a therapeutic healing milieu It exacerbates the illness that is just a profoundly heavy reality We will definitely come back to that in the outro, but let's keep moving through the specialized populations quickly pediatrics, right?

Children are always treated completely separate from adults for obvious safety reasons a key difference in a pediatric unit is that daily school attendance is usually required during this day and Intense family involvement in therapy is absolutely critical for discharge geriatrics.

This obviously focuses on the older adult population The complex interplay between mind and body is the main focus here Physical illness like a stroke or a severe uti Very often precipitates deep psychiatric symptoms like depression or delirium And managing progressive dementia is a major major component and veterans the va system The text gives a really fascinating mini history of how we as a society Label military trauma over time.

It's a great illustration of how our clinical understanding has evolved Back in the civil war they called severe combat trauma soldier's heart Which sounds almost poetic or romantic?

Yeah in world war one it became shell shock in world war two It was battle fatigue and now of course we clinically know it as post -traumatic stress disorder or ptsd The statistics the text gives here for veterans are sobering.

They are heartbreaking The text notes that anywhere from nine percent to 31 percent of deployed soldiers experience severe ptsd

The va hospital system has to be a highly specialized Massive machine just to handle that sheer volume of complex trauma and the accompanying high suicide risk Finally in this section alcohol and drug treatment facilities This is very often treated as an entirely separate track from the mental health system, though.

They frequently overlap You have acute medical detox, which is strictly inpatient because withdrawing from alcohol or benzodiazepines can literally cause fatal seizures And then you have rehab which is often long -term residential or intensive outpatient and relies incredibly heavily on 12 -step peer models like aa Speaking of aa that perfectly brings us to section seven self -help financing and the future Because not all effective care actually comes from a doctor or a nurse.

No, not at all Self -help is a massive component of recovery basic lifestyle changes rigorous sleep hygiene daily exercise yoga Meditation these are completely valid evidence -based adjuncts to formal medical treatment and peer groups like aa or nami The national alliance on mental illness provide crucial lived experience peer support And nami is more than just a support group.

They are a massive political force Yes, the text identifies them as consumer advocates.

They don't just sit in circles and talk They actively fight societal stigma and aggressively lobby congress for better mental health laws and funding Let's talk about that funding.

Let's follow the money financing care

The text talks heavily about the aca the affordable care act and this concept of parity What exactly is mental health parity parity simply means equal?

The legal concept is that insurance companies must cover mental illness at a level comparable to how they cover physical illness So they can't discriminate right before parity laws an insurance company could legally say We will pay for unlimited million dollar chemotherapy treatments if you get cancer But we will only cover a maximum of five psychiatrist visits a year if you get schizophrenia Parity makes that kind of blatant discrimination illegal and the aca the affordable care act really helped enforce this It supercharged it it strictly prevented insurance companies from denying coverage for pre -existing conditions Which is absolutely life -saving for anyone with a chronic lifelong mental illness It allowed young adults to stay on their parents insurance plans until age 26 Which is crucial because that is exactly the age range when severe illnesses like schizophrenia typically first emerge Oh, that makes sense and it mandated full coverage for preventive care like routine depression screenings at the primary care office Now for those without private corporate insurance we rely on the public safety nets Medicare and medicaid let's clearly distinguish those for the students quick and dirty distinction for the exam Medicare is a federal program and it is mostly for people over age 65 Or those with specific severe long -term disabilities Medicaid is a joint state and federal program and it is strictly need -based.

It is for people with very low income And what about actual income replacement if you are too mentally ill to work The text mentions ssdi versus ssi.

This is alphabet soup again.

It is but you have to know it.

Let's clarify it SSDI is social security disability insurance You only get this if you have actively worked for years and paid taxes into the system But then became severely disabled you are effectively making a claim against your own insurance policy that you bought with your taxes Okay, and ssi ssi Is supplemental security income This is funded by general tax revenues And it is strictly for people who have zero income or older adults who didn't work long enough to pay into the ssdi system It is the absolute baseline financial safety net got it So looking forward after all this what is the textbook's vision for the future of psychiatric care?

The text outlines a much more hopeful future of truly integrated care A system where mental health isn't isolated in a separate stigmatized building But is just seen as a routine part of overall health a system where care is heavily consumer driven Where racial and economic disparities are actively eliminated and where telehealth technology vastly improves access for rural patients It's a really hopeful vision.

It feels like we are slowly moving that way.

We are slowly but we are okay We have covered a massive amount of ground today We have thoroughly covered the map from the sore throat of the outpatient system to the highly engineered ligature points of the inpatient unit To the prisons to the insurance office Now it is time to formally test our knowledge time for the pop quiz Exactly.

This is section eight of our outline review and critical thinking

I'm going to play the nervous nursing student.

You play the strict professor Based directly on the text chapter review questions.

I want you to quiz me.

All right student sharpen your pencil.

Let's go scenario one

You're working as a nurse in the community mental health center.

You have a male patient diagnosed with major depressive disorder He's visibly apathetic hunched over withdrawn He looks at you and says I usually just spend all day staring at the tv If there's nothing on I just sleep or sit there thinking about how bad things are.

Okay classic Energia and depression exactly now you need to respond.

Do you choose?

Option a refer him immediately to a recreational therapist to get him moving Option b tell him firmly, you know sitting around watching tv and sleeping is just making your depression significantly worse Or option c ask him.

What kinds of tv programs do you usually like to watch?

Okay, let's think this throughout loud option b telling him it makes his depression worse I mean medically speaking that is a true statement, isn't it?

Energia feeds the depression cycle.

It is a 100 factually true statement But the clinical question is is it therapeutic no, no, it sounds incredibly judgmental It sounds like a parent schooling a lazy teenager If I say that he'll just shut down completely right option a the referral to rec therapy that just feels Like i'm passing the buck I haven't even done a basic nursing assessment yet and i'm already turfing him to another department.

Correct You haven't established any connection.

So by process of elimination.

It has to be option c

What kinds of tv programs do you like to watch?

But honestly that feels so

Passive like i'm just making small talk while he's suffering.

It's not passive at all.

It's highly strategic You are actively building therapeutic rapport.

You are taking a genuine non -judgmental interest in his current very limited world Once he opens up and tells you he likes a nature documentaries, then you have a hook then you can say oh, that's cool I love those too Have you ever thought about maybe sitting on the park bench outside for 10 minutes to see some nature?

You use the assessment to gently build the intervention

Connect before you correct connect before you correct.

I like that a lot.

Okay next scenario scenario two You are the charge nurse on a highly acute inpatient unit specifically for adolescents enagers The floor staff comes to you complaining that the kids are practically vibrating with pent -up energy and starting to act out The staff wants to organize a physical activity in the courtyard as the charge nurse Which of the following do you officially approve option a a highly competitive soccer match?

Option b a badminton tournament or option c line dancing to popular music Okay teenagers Surging hormones a lock psych unit.

Let's look at a soccer involves heavy physical contact Someone gets slide tackled.

Someone gets shoved pride gets hurt and suddenly we have a massive fistfight on the unit Soccer is a terrible idea.

I completely agree highly volatile badminton no contact But you have to hand them rackets rackets are solid metal or carbon fiber sticks rackets are basically weapons A manic teen could swing it out of here or snap it in half and use the sharp edge Exactly way too high risk for an acute unit.

So Line dancing honestly, that sounds so cheesy.

They're gonna roll their eyes at me.

They probably will roll their eyes Yeah, it might be cheesy, but look at the underlying structure.

It is highly organized Everyone faces the same direction and moves in unison.

There's absolutely zero physical contact There is no winner or loser so it doesn't spark competitive aggression It safely burns off that pent -up physical energy without introducing weapons or contact The correct answer is strictly c safety always always trumps coolness on a psych unit Okay, that makes sense safety first bring on the final hard one The clinical judgment scenario scenario three you are an outpatient case manager Your new patient is a 45 year old male currently homeless He is highly agitated pacing the room and keeps mentioning that his thoughts are tangled up During the intake he casually reveals that he recently tested positive for hiv But he is absolutely not taking any antiretroviral medications However, because of his severe paranoia He flat -out refuses to sign any legal release forms so you can legally get his medical records from the free clinic Okay, that's a mess it is What is your absolute number one priority as his nurse option a?

aggressively addressing his physical health and hiv status immediately because it's a fatal disease or Option b focusing solely on establishing baseline trust and rapport

Man, this feels like a trap the hiv is a biologically life -threatening condition If he's unmedicated and homeless his viral load is probably spiking He could progress to aids and die my nursing instinct screams option a Fix the failing body but walk that out practically play the tape forward.

He is actively paranoid He told you his thoughts are tangled He doesn't even trust you enough to sign a single piece of paper If you aggressively push the medical issue right now If you say you just take these pills today or you will die.

What is he going to miss in a bolt?

He's going to run right out the clinic door and i'll never see him again Exactly, and if he runs you can't treat the hiv anyway So I have to suppress my medical panic and choose option b establish trust you absolutely nailed it This right here is the true art of psychiatric nursing.

You have to play the long game You have to actively lower his severe anxiety Maybe you don't talk about the hiv at all today Maybe you just get him a warm turkey sandwich and a cup of coffee Maybe you just sit quietly and listen to him talk about his tangled thoughts Once he slowly realizes over a few visits that you are a safe person and not a threat Then he might sign the form you simply cannot medically treat a patient who isn't physically in the room Wow, such a delicate high stakes balance It's really knowing when to push and knowing when to just wait It is and that is exactly why this job is so incredibly important.

It's so incredibly difficult Well, we have covered an enormous amount of ground today We have traced the entire map from the simple sore throat at the primary care office to the highly engineered Anti -ligature doors of the locked unit to the intricate life -saving dance of trust in a homeless clinic The overarching takeaway from chapter five is that the setting truly matters The environment whether it's a supportive home a heavily structured hospital or a chaotic prison Entirely dictates the quality of the care and as future psychiatric nurses You are the ultimate guardians of that environment.

You dictate the milieu.

Absolutely now before we sign off I want to leave everyone with that one lingering really uncomfortable thought we touched on earlier the prison statistic Yeah If society closed down the massive terrifying state asylums in the 1960s to be more humane and integrate people into the community But we ultimately ended up just filling the concrete cells of the state penitentiaries with the exact same mentally ill patients 50 years later Have we really progressed as a society?

Or did we just change the mailing address of the institution?

It is a chilling question I think it's the defining question of our generation in mental health.

It's something to mull over Thank you to everyone for taking this incredibly detailed deep dive with us today Good luck with your clinical rotations and good luck on those exams study hard everyone You've got this.

This has been a presentation by the last minute lecture team.

We will see you next time