10.4 Caring for Clients With Mental Health or Substance Use Disorders

Nursing assistants provide care for individuals with mental health disorders in many settings. According to the National Alliance on Mental Illness (NAMI), approximately 1 in 5 adults in the United States experiences some type of mental health disorder. In the United States, this means that over 43 million people experience a mental health disorder within any given year. Among individuals who experience a mental health disorder, 9.8 million experience a severe mental health disorder, meaning it dramatically interferes or limits their ability to function in everyday life. However, of all the adults in the United States with a mental health disorder, research shows that only 41% received mental health services in the past year, and for those diagnosed with a severe mental health disorder, only 63% received treatment or services. These numbers demonstrate the need to identify and provide effective treatment to individuals living with these disorders.^[1]

Just as there are various physical illnesses with varying degrees of severity, there are also various mental health illnesses with varying degrees of severity. Symptoms of mental health disorders can often be managed with medications, in a similar way that physical illnesses like diabetes are managed with insulin and other medications. By helping individuals with mental health disorders manage their medications and attend psychotherapy and/or counseling sessions, caregivers can help individuals with mental health disorders stabilize their emotions and behaviors and reach their greatest potential in their life.

Being aware of common mental health disorders will allow you, as a caregiver, to understand what the person is experiencing and how to help them meet their needs in the best possible way. While every case is different, it is important to be aware of how individuals with mental health disorders may present themselves and start thinking about how you will help manage related symptoms and behaviors.^[2]

There are several categories of mental health disorders diagnosed by mental health providers such as a psychiatrist, psychologist, or advanced practice nurse practitioner. This section will further describe these common mental health disorders:

• Anxiety Disorders
• Psychotic Disorders
• Bipolar Disorder
• Depressive Disorders
• Trauma Disorders
• Personality Disorders
• Substance Use Disorder

Anxiety Disorders

Anxiety is a universal human experience that includes feelings of apprehension, uneasiness, uncertainty, or dread resulting from a real or perceived threat. Fear is a reaction to a specific danger, whereas anxiety is a vague sense of dread to specific or unknown danger.^[3] Everyone experiences feelings of mild anxiety due to situations that occur in their daily lives, such as an upcoming exam, job interview, sports competition, or other type of performance. However, individuals with anxiety disorders experience more than temporary worry or fear. The anxiety can worsen over time, and symptoms interfere with their daily functioning. People experiencing moderate to severe anxiety may also have objective symptoms such as an elevated heart rate, respiratory rate, or blood pressure.

There are several types of anxiety disorders, including generalized anxiety disorder, panic disorder, and phobia-related disorders^[4],[5]:

• Generalized Anxiety Disorder (GAD): People with GAD have excessive anxiety and worry about numerous events or activities (such as work or school performance). The individual finds it difficult to control their anxiety and worry, and it is associated with symptoms such as restlessness, becoming easily fatigued, difficulty concentrating, irritability, muscle tension, and sleep disturbances. These symptoms impact daily functioning.
• Panic Disorder: People with panic disorder have recurrent panic attacks. Panic attacks are sudden periods of intense fear that come on quickly and reach their peak within minutes. Attacks can occur unexpectedly or can be brought on by a trigger, such as a feared object or situation. People experiencing a panic attack may exhibit symptoms such as sweating, trembling, shortness of breath, chest pain, nausea, increased heart rate, or feelings of losing control.
• Phobia: A phobia is an intense fear of specific objects or situations (such as flying, heights, or spiders).
  • Arachnophobia (fear of spiders) is a common phobia.
  • Agoraphobia is an intense fear of being in open spaces, a crowd, or outside of one’s home alone. People with agoraphobia often avoid these situations because they fear having a panic attack and, as a result, may become homebound.
  • Social anxiety disorder is a type of phobia that includes fear or anxiety about social situations where there is possible scrutiny by others.

Psychotic Disorders

The term psychosis describes conditions when a person experiences a loss of contact with reality and has difficulty understanding what is real and what is not real. Symptoms of psychosis include hallucinations and delusions. Hallucinations are false sensory perceptions not associated with real external stimuli and can include any of the five senses (seeing, hearing, feeling, tasting, or smelling). For example, individuals may experience hallucinations of seeing someone in the room when no one is there, hearing voices when alone, or smelling something cooking when nothing is being prepared. Some people are aware that their hallucinations are not real while others cannot separate their hallucinations from reality. Delusions are fixed, false beliefs held by a person even though there is concrete evidence they are not true. Examples of delusions may include believing that spies can hear your thoughts, people are poisoning your food, or a celebrity is in love with you. Symptoms of a psychotic episode include delusions, hallucinations, incoherent speech, and purposeless excessive movement.^[6],[7]

Psychosis is a symptom of several mental illnesses, including schizophrenia, bipolar disorder, severe depression, or severe anxiety, but there are also potential medical causes. Sleep deprivation, medical conditions like hyperglycemia, side effects of certain prescription medications, and use of alcohol or other drugs can cause psychotic symptoms. Psychosis caused by medical conditions or substance use is referred to as delirium. It starts suddenly and can cause hallucinations, but it is reversible by treating the cause of the delirium.

Nursing assistants can help manage patients’ symptoms of psychosis with the following interventions^[8],[9]:

• Making sure the room is quiet and well-lit
• Having clocks and calendars within view
• Inviting family members to spend time in the room
• Ensuring hearing aids and glasses are worn
• Promoting undisrupted sleep when possible
• Getting patients up and out of bed when possible

Schizophrenia is a type of mental illness with symptoms of psychosis that last for at least six months. In addition to symptoms of psychosis, it also affects how a person feels, with reduced motivation, difficulty concentrating, disinterest or lack of enjoyment in daily activities, social withdrawal, difficulty showing emotion, and difficulty functioning in daily life activities. It is typically diagnosed in the late teen years to early thirties.^[10],[11]

Depressive Disorders

Depression is a common illness worldwide affecting an estimated 5% of adults. Depression is different from mood fluctuations or short-lived emotional responses to everyday life stressors or events, such as the loss of a loved one or the end of a relationship. Depression can become so severe that it affects the individual’s ability to function at work, at school, and in their family roles. It can cause self-neglect, such as the failure to meet one’s hygiene needs or obtain sufficient nutritional intake. At its worst, depression can lead to suicide.^[12],[13]

During a depressive episode, the person experiences a depressed mood (feeling sad, irritable, or empty) or a loss of pleasure or interest in activities they normally enjoy. Other symptoms may include poor concentration, feelings of excessive guilt or low self-worth, hopelessness about the future, thoughts about dying or suicide, disrupted sleep, changes in appetite or weight, and feeling fatigued.

Bipolar Disorders

Bipolar disorders include shifts in mood from abnormal highs (called manic episodes) to abnormal lows (i.e., depressive episodes). These shifts cause significant impairment in the person’s functioning socially or at work. A manic episode is an elevated or irritable mood with abnormally increased energy that lasts at least one week. As the manic episode worsens, the individual may become psychotic with hallucinations. During a manic episode, the person often experiences a reduced need to sleep or eat and can exhibit risky behaviors like excessive buying sprees, unrestrained gambling, or sexual indiscretions. Depressive episodes have opposite symptoms of manic episodes and are exhibited by low energy, low motivation, and loss of interest in daily activities.^[14],[15]

Trauma Disorders

Trauma results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life-threatening and can have lasting adverse effects on their functioning and mental, physical, social, emotional, or spiritual well-being. For example, a person may experience trauma from an event like a mass shooting, physical assault, rape, violent accident, or after natural disasters such as hurricanes or tornadoes. Trauma is also associated with experiences by military personnel/veterans or victims of war.

Types of trauma disorders include the following^[16],[17]:

• Post-traumatic stress disorder (PTSD) is a disorder that can be caused by experiencing, witnessing, or hearing about a traumatic event. After a month of being removed from the event, a person may continue to experience sleeplessness, increased heart rate, mood shifts, physically lashing out, or any combination of responses. These responses may be brought on by any environmental stimuli that reminds the person of the terrifying event or by recurring thoughts about the event.
• Acute stress disorder is a disorder that has similar symptoms as post-traumatic stress disorder, but the symptoms only last for three days to one month. If symptoms last for longer than one month, it meets the criteria for PTSD. This disorder is experienced by individuals who have been exposed to actual or threatened death, serious injury, or sexual violence. It can be caused by directly experiencing the event, witnessing the event, learning the event occurred to a close family member or friend, or experiencing repeated exposure to details of traumatic events.^[18]

Personality Disorders

A person’s personality is a relatively stable pattern of thinking, feeling, and behaving that evolves over their lifetime. A personality disorder is a pattern of inner experiences and behaviors that deviates from the expectations of the individual’s culture. It can be traced back to adolescence or early adulthood and leads to impaired functioning the remainder of the person’s life.

There are ten types of personality disorders that can include distrust of others, isolation, habitual lying, and aggressive or violent acts with little remorse. Three common personality disorders are as follows^{[19],[20],[21]}:

• Obsessive-compulsive personality disorder (OCD): OCD includes a pattern of preoccupation with orderliness, perfectionism, and control. This preoccupation may impair one’s social life, health, or ability to function in the outside environment. This is the most common personality disorder in the United States.
• Borderline personality disorder: Borderline personality disorder includes a pattern of instability in interpersonal relationships, altered self-image and emotions, and significant impulsivity. People with borderline personality disorder may experience chronic feelings of emptiness and exhibit frantic efforts to avoid real or imagined abandonment. They may have difficulty controlling their anger or experience dissociative symptoms where they feel detached from their body with a loss of memory of the experience.
• Narcissistic personality disorder: Narcissistic personality disorder includes a pattern of grandiosity, need for admiration, and lack of empathy for others.

Substance Use Disorders

Prolonged, repeated misuse of substances can produce changes to the brain that can lead to substance use disorder. Substances may include alcohol, caffeine, cannabis, hallucinogens, inhalants, opioids, sedatives, stimulants, or misuse of other prescription or over-the-counter medications. All these substances taken in excess have a common effect of intensely activating the reward system in the brain so much that normal life activities may be neglected. Substance use disorder (SUD) is an illness caused by repeated misuse of these substances.^[22]

Over 40 million Americans are diagnosed with SUD (14.5% of the population). Severe substance use disorders are commonly referred to as addiction. Addiction is associated with compulsive or uncontrolled use of one or more substances. Addiction is a chronic illness that has the potential for relapse or recovery. Relapse refers to the return to substance use after a significant period of abstinence. Recovery is a process of change when individuals improve their health and wellness and strive to reach their full potential. Individuals with severe SUD can overcome their disorder with effective treatment and regain health and social functioning, referred to as remission.^[23]

Care Considerations

Treatment for mental health and SUDs often involves a variety of approaches such as medication, individual or group therapy, and peer support groups. These interventions may happen in an outpatient or inpatient setting. While you will not be involved in providing these treatments as a nursing assistant, it is important to understand what someone with any of these diagnoses is experiencing. Your support and the manner in which you provide assistance can make a large impact on the quality of life for those in recovery.

When providing ADLs and other assistance for those with mental health disorders, substance use disorders, or developmental disorders, the same considerations apply as when providing care to any individual with respect to promoting their dignity, privacy, and preferences. It is also important to be aware of exposure to potential situations or environments that may feel overwhelming to the individual and/or trigger their symptoms or behaviors.

Major themes of care to implement for individuals with developmental, mental health, or substance use disorders include the following:

• Communication: As with all caregiving relationships, work to build a trusting relationship through good communication. Allow time for the client to talk about any concerns and report any changes in outlook to the nurse for additional support. When providing care, explain the procedure and look for body language, as well as verbal cues, to determine the client’s level of comfort.
• Routine: Keep things as predictable as possible. The daily schedule should remain as consistent as possible by waking, providing meals, engaging in activities, and going to bed around the same times each day. Staff involved in personal care and other support should remain consistent whenever feasible. Change and unexpected situations can provoke anxiety in anyone but can be especially upsetting for people with mental health, substance use, or developmental disorders.
• Empathy: Remember that interactions with the environment, family, friends, and caregivers are often processed differently by those with mental health or development disorders and may result in disruptive behaviors. Do not take their behaviors personally or assume they are trying to be difficult, but instead be aware their ability to respond calmly or cope with excessive stimuli or interactions may be diminished.
• Redirect or Reapproach: If a client with a developmental or mental health disorder displays disruptive behaviors, focus on their safety and determine what is absolutely necessary to accomplish at this point in time. Do not focus on completing a task now if doing it at a later time when the client is calmer will have the same outcome. Attempt to redirect their attention by carefully encouraging engagement in another activity that may be more appealing or by tactfully changing the subject of a conversation that may be upsetting. For example, if a resident becomes agitated because they don’t want to get dressed right away in the morning, will it matter if they wear their pajamas until they need to go outside of their room? You can reapproach them at a later time when they may be calmer. This is no different than accommodating preferences for any resident.

There are specific care considerations based on the individual’s diagnosis and things the caregiver should be aware of when trying to meet their personal needs. See Table 10.4 for care considerations for individuals with mental health and developmental disorders.

Table 10.4 Care Considerations for Individuals With Mental Health and Developmental Disorders