Serenity Daniels is a 28-year-old single woman with a long history of sexual and emotional abuse since her childhood. She has inflicted deliberate self-harm (DSH) on her body on numerous occasions. During these DSH episodes, Serenity usually cuts her wrists and uses alcohol as a way of numbing the pain. Besides, Serenity has problems with her self-image as she sees herself as “fat and ugly” and unloved. She also has frequent arguments with her co-workers and managers. As such, she does not hold job positions for long. This instability in moods, functioning, and self-image coupled with unstable relationships and episodes of depression and anger points towards a case of borderline personality disorder (BPD) (Johnson et al. 2010). This paper will discuss strategies that a Mental Health Nurse (MHN) might use to engage with Serenity. There are many strategies that can be used in this case but this paper will discuss dialectal behavior therapy, therapeutic alliance, mentalized-based therapy, and the dynamic deconstructive psychotherapy. Moreover, it will address relevant MHN management while she is admitted in the acute mental health setting as an informal client.
Strategies
One of the strategies that a Mental Health Nurse (MHN) can use to engage with Serenity is the dialectal behavior therapy (DBT). According to van Goethem et al. (2015), DBT is an effective method for preventing the occurrence of suicidal behavior of the patients. In this case, the DBT will be used to control the behavior of Serenity, since she is highly diagnosed of DSH. Moreover, the therapy involves commitment from both the patient and the MHN, and because of this, the patient will be given with greater attention. As a result, her condition will be attended carefully, and her emotions will be controlled. In this way, the MHN will be able to improve the stability of the mind of the patient through acceptance (Johnson et al. 2010). Through constant consultation, which lasts at least for a year, the improvement of Serenity’s condition can be seen depending on how the MHN will be able to convince Serenity to participate, as well as to how Serenity will respond to the MHN’s request (Kliem et al. 2010 ). Also, DBT requires collaboration among those who will administer this intervention, so it is a requirement that a team consisting of nurses and other practitioners should be built for the treatment of Serenity (van Goethem et al. 2015).
Another strategy that an MHN can use to engage with Serenity is therapeutic alliance. This strategy is important in a way that this will improve the compatibility between the patient, nurses, and physicians (Lieb et al. 2010). The success of the engagement with Serenity will largely depend on the type of relationship that an MHN forges with her. Various elements will contribute to the quality and strength of the therapeutic relationship that a nurse will establish with Serenity. The first component is the emotional bond and partnership that will arise between Serenity and the MHN. MHNs will need to put themselves in Serenity’s shoes to feel her emotional pain and physical condition. This kind of empathy will enable them to create a strong emotional bond with Serenity which will be crucial in engaging with her. Another component in this therapeutic alliance will be reaching a consensus with Serenity regarding the goals and tasks of her treatment program (Ardito & Rabellino, 2011). If Serenity and the nurses can come to an agreement about her treatment program, her outcome will most likely be positive.
An MHN might also use the mentalized-based therapy (MBT) strategy to engage with Serenity. This strategy is a psychodynamically-oriented psychotherapy that is used to assist people with BDH. Using MBT, a nurse will focus on helping Serenity to separate her feelings and thoughts from those around her. This mentalization strategy is based on the fact that Serenity tends to have intense and unstable relationships. As such, she usually manipulates or exploits others without her conscious knowledge. Moreover, she finds it difficult to discern the impact of her actions on others. Using mentalization, an MHN will be able to help Serenity understand her feelings and behavior and how they relate to particular mental states within herself and in others (Lieb et al. 2010). This strategy will help Serenity to have a better grasp of her feelings and emotions, hence, leading to more attachment (Olabi & Hall, 2010). In turn, she will be able to understand her emotional effect on others thereby leading to more positive interpersonal relationships.
Lastly, an MHN might consider using the schema-focused therapy (SFP) to engage with Serenity. This form of therapy combines the best aspects of interpersonal, experiental, psychoanalytic, and cognitive-behavioral therapies into one unified approach (Farrell et al. 2009). Using SFP, an MHN will focus on reframing the way Serenity views herself. This approach assumes that BPD is caused by a dysfunctional self-image that is primarily caused by traumatic childhood experiences (Farrell et al. 2009). In Serenity’s case, the MHN will try to shift Serenity’s long-standing pattern of thinking from from one of inferiority to one of significance. Instead of thinking about how ugly, fat, or unloved she is, Serenity will be influenced to think positively about herself. For instance, an MHN will encourage Serenity to think about loved or beautiful she really is. SFP will enable an MHN to change Serenity’s negative thinking thereby minimizing self-defeating patterns such as alcoholism and DSH.
Management
Serenity has a current behavioral plan that will need to be reviewed. It is important to review her plan since on a previous occasion, she overdosed on Paracetamol and had to be taken to the ICU. Moreover, her condition has not been improving under her current behavioral plan. Therefore, reviewing her plan by including new aspects such as collaborative care and counseling will go a long way in improving her outcome. Serenity’s condition makes it hard for her trust other people. In fact, she only has one close friend, Sarah, who once saved her life. To gain her confidence and trust, MHNs will begin by using the strategies mentioned above need to engage with Serenity. According to Beeney et al. (2016). MHNs should be aware that they are essential in the treatment of mental issues since they may provide empowerment and promote trust between the patients and the health care professionals. Also, according to the methods of cognitive behavioral therapy (CBT), Serenity’s condition only occurred due to the notion that she is not able to adapt to reality, as well as to changes happening around her. She was not able to accept what is in front of her, and as the result is that she tries to shove away the reality by focusing on the other things but in an extreme extent. Because of this, in the first days, a psychology expert will be the one to handle the situation, and nurses should take turns in assisting the psychologists so that they will be able to handle Serenity properly.
With this, Serenity will always be guided by her actions, and gradually, this will help her to interact properly with the people around her, and realize that she is not alone in her fight to become a better person again. For the nursing management, the use of reflective practice helps nurses understand the condition of Serenity, and helps them to become better at decision-making without the need for further instructions from the experts, as long as they learned how to administer the treatment, for Serenity. As such, the nursing management will make it sure that there is a sufficient time to focus the nurses’ attention to Serenity. It is important to maximize the time allocated for the treatment, as the behavior of Serenity is currently unpredictable and might only worsen if she will be neglected even for a short while.
Collaborative practice will enable MHNs to communicate with other nurses, professionals and to the relatives (Goodrich et al. 2013). Other professionals that may be consulted include counselors to help Serenity overcome her alcohol addiction, and dietitians to help her adopt healthy eating. This practice will be implemented more on managing Serenity as an informal patient. Since there is the need of reporting, there must be an assigned nurse who will write a journal on a daily basis that monitors the progress of Serenity’s condition. While at it, the other assigned nurses will have to perform the other necessary practices in conjunction with the collaborative practice, otherwise, Serenity reverts to the previous state before the next step commences (Schadewaldt et al. 2013). Also, the documentation will be based on this journal, to prevent too much time consumption.
There are two main challenges when using this particular approach for Serenity's long-term management. First, there can be problems with the team. There could be differences in assessment or difficulties with identifying authority (Howe, 2013). The goals and the methodologies of the people involved in a collaborative care may also be different or conflicting, thus making the approach ineffective. The second one is time management. Even with the idea of having a journal about Serenity’s condition, other methods are currently ongoing while the journal is being done (Lieb et al. 2010). As such, it is a challenge as to how to dedicate the time for this part, considering that the nurses are busy for tending Serenity and other patients. However, these problems may easily be overcome by a smooth and clear communication that can tackle the common goal and the appropriate methodologies to be used.
Counseling and rapport building is also a vital management regarding on how Serenity will be informed about her illness. Considering her condition, there are three important points to consider here. First, MHNs need to tell Serenity about the need to prevent suicide. The causes and impacts of suicide must be discussed in detail while maintaining the comprehension of Serenity (Howe, 2013). Next, MHNs need to discuss the importance of consultation with the physicians and the communication with nurses. Moreover, MHNs need to counsel her on alcohol cessation to reduce her alcohol dependency. Lastly, MHNs should build rapport between Serenity and people around her to prevent further depression, self-injury, and abusive relationships.
Using these approaches, Serenity must be able to be discharged from the mental health care facility, and return home while still being guided and rehabilitated (Saunders & Silk, 2009). Following her return to the community, she should be put under the care of community service providers who will make sure that she does not engage herself again in any forms of self-harm or make her condition affect her everyday life, including her friendship or work. The use of collaborative care has been proven to make health care professionals work better and provide a more holistic care. Moreover, these approaches can also help with her depression and alcoholism that stemmed from her low and negative self-image, and her experience of being abused (Olabi & Hall, 2010 ). This approach is especially useful for Serenity since this may allow her to be under a comprehensive care. Olabi & Hall (2010) also emphasized that this method may help one who refuse to seek professional overcome any stigma.
Conclusion
Serenity Daniels suffers from an extreme psychological condition and needs to be treated with the utmost care and attention. She might have the tendency to become unresponsive and distant, but this is the challenge for the physicians and mental health nurses. The need to determine the most suitable approach to alleviate her condition is one big challenge which will be faced by the mental health community. However, it is the duty of these individuals to serve as examples of people with a positive outlook, and to serve them with the most rightful intention of helping them become positive again, and to be back on the tracks of the world.
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