On 9th March 2010, I was assigned a 28years old male patient, at Karawan -e- Hayat. He was diagnosed with bipolar disorder. His present complaints were aggression, anger and harming others. He lives in federal B area of Karachi belongs to a middle class family. He was unmarried. According patients relative his mother died of cancer when he was four years old and his maternal aunty married to his father became her mother then at age of nine his father passed away on ship. Since then he is staying with his grandfather who’s is very strict by nature. Before he was admitted in Baqai Hospital. When I met him for the first time during interview I observed his elated mood and he was verbalizing that to get angry is normal. However my family thinks I need treatment for anger but I want to go home. I promise i will not get angry want to work because people think I am not confident.
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By making the conclusion of client verbalization, I found out he needs help to build a positive thinking in order to create hope and cope successfully with change and misfortune. Losing a parent can be extraordinarily difficult due to the loss of support and characteristics which identify the position and role of a parent as being very special. Supports for children of adults are a very important part of the grieving process and should be connected to characteristics of children and adults how they respond to such loss. As my client never got chance to express his feelings. Eric Erickson’s stages of psycho-social development in regards to the stage of “industry vs. inferiority. When a death of a parent occurs in childhood or adolescents the child may not mourn effectively and this may create problems with depression and inabilities to maintain close relationships with others (p.159). During adolescents there is a pursuit to find ones “identity”, and the parent is a role modeling figure then an adolescent may feel dependent, and even angry due to the death of their parental figure. Mental health promotion in 2008 focus on building resilience campaign. By focusing on the positive aspect in life our emotional resilience is strengthened, stress reduced and improved mental well-being.
Introduction of Concept:
The concept of resilience has been interest to various professional groups for many years; however, it is only recently that the nursing profession has begun to recognize its potential contribution in diverse clinical contexts Most empirical studies of individuals and communities experiencing serious adversity, reveals usually has negative consequences on health. The reason to develop this concept as more and more youths are facing hard times, secondly not only to understand the protective or risk factors also how to help these youth to face these challenges in a positive ways if you see that in today’s time youths are facing many challenges due to global crises.
The founders of resilience Garmezy and Werner cited by McCarty.R (2006):
They emphasis on illness or maladjustment among hazard-exposed groups and towards the strengths of risk-exposed individuals as well, both in terms of adjustment outcomes and in terms of characteristics that promote positive adaptation — assets or protective factors as well as ‘liabilities’ or vulnerability-enhancing ones.(p. 574)
Similarly if my patient had develop resilience in advance then he would have not land up in maladaptive continum that is anger and agression. According to Diagnosis of International Nursing risk of compromising that is resilience related to chronicity of crises as evidence by patient angriness due to loss of parents. There are many internal and external factors that promotes resilience.Positive relationships are with friends, family, problem solving ability. Factors that drain resilience are unsupportive environments, lack of connectedness to others. To build up resilience first we need to focus on anger due to which he was admitted, if we control that then he will be able to focus on his positive strengths for which I gave teaching on anger management by utilizing different strategies. Lopper (2008), “In order to succeed, people need a sense of self-efficacy, struggle together with resilience to meet the inevitable obstacles and inequities of life.” ~Albert Bandura. (p.1)
Unfortunately, Pakistan is the country where less work has been done in the field of psychiatry. Although there is a mental health legislation been develop in 2001 but there is a need to reevaluate it in order to protect the human rights and establish the community based mental health services. According Kasi.P et.al (2007), research on long working hours increases stress and reducing performance and quality of life of individuals in post graduates trainees showed that the factors that contribute to negative coping mechanism that is stress on post graduates raises the risk of patient’s safety. Khan, S. (1998) did studies on resilience and social support. Due to intimidation in the Pakistan, how social support system play role in building resilience promoting mental health. Now in my patient due to lack of awareness about mental health importance he being treated very negatively by the family because he was not taking interest in the studies, nobody tried to find out why he is running away from studies and beating grandfather as well as people living in his vicinity. Mother took him to the doctor, who said that since child hood he loose trust relation ship went into low self esteem which he is compensating by beating which negative coping mechanism raises the risk of safety for self and others.
As in this scenario I have discussed, need to guide positive attitude towards life, this maladaptive behavior can decline his mental health. As long ago as 1948 the World Health Organization focused on a renewed call for attention to positive health and well-being by the WHO European Office for Investment for Health and Development (IHD) has given rise to a pioneering focus on assets rather than deprivation, on strengths rather than deficits. For example, girls become resilient by building strong, caring relationships with others, while boys develop resilience by learning how to problem-solve. Unbridled emotions often take people to a point at which life’s challenges simply overwhelm them. Dr. McCarty, R (2006) said “Increasing resilience can help prevent as well as smooth out many of these emotional gridlocks”. In order to understand how we think, it is necessary to look more closely at the relationship between capability and health. Researchers found fast and effective way to build and store resilience is through coherence. Coherence is the heart, mind and emotions are balanced and operating in sync and the immune, hormonal and nervous systems function in energetic coordination. Before you can bring your heart, mind, emotions and other internal systems into balance, you must override the stressors and negative attitudes that caused them to get out of sync.
One of the most common causes of imbalance is the destructive emotion of anger. It impairs memory, impairs mental function. Dr. McCarty (2006) shows that these are the typical physical effects of anger, reduced concentration at work, school or home. When you are angry for more than a few moments and are unable to step back, you are in a state of incoherence. An individual who has had a healthy childhood will be better able to survive in future. Referring to my patient he said I was unable to pass my B.com exam because I was not able to retain whatever I read could not concentrate on my studies. According to mother patient was not taking interest in the studies and was showing laziness and prefer to sit and watch television although he did few courses. Another case study done on resilience among adolescence focuses on what people can’t do rather then what they can do. It is important to note that both positive and negative patterns can be triggered by significant, events which are powerful in impact to change their lives directions termed as “turning point opportunity” (Howard and Johnson 2006).
Another international article on resilience written by Kappler.S (2010), leader of Fort Jackson School in Pennsylvania open by the army staff in Fort Jackson at forefront. This article is on how this program benefits soldiers, families, civilians and the army as a whole, it is a long-term effort to improve emotional, social, family and spiritual strength in soldiers. The program, which was initiated in October 2008, is rapidly growing and will be a mark milestone with the opening of the Master Resilience Training school this will benefit the soldiers to maximize their performance.
Resilience concept or Basch’s developmental model (2008) emphasizes on coping reservoirs can help promote well-being and minimize burnout (anger and aggression). This model also helps a person with mental illness to recognize risk factors that influence resilience as in my patient the internal and external factors were parents died when he was very small and didn’t get enough support from the family and friends, his own coping style because of that he could not study as he couldn’t remember and concentrate and solve problem diminished coping reservoir. Although my patient was educated but due to circumstances he was unable to perform as a healthy person while this model was used earlier for medical students well being and stress coping named as coping reservoir, It involves person mind biology, personal attitude and environment which exhibit and inhibit the symptoms. There is not a single factor responsible for maladaptive behavior; my patient used his coping skills in a negative direction that is anger or burn out. On the other hand there is a protective factor which is not only protects a person from suffering a relapse because we spend less time on health promoting activities like exercise and socializing. The coping reservoir is drained and filled repeatedly as person confront the many competing demands for their, cognitive and emotional resources, ability to recognize when to rest and recharge.
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In contrast, when the person gets family support, psychosocial support the reservoir replenished, the natural process of resilience can blossom. An assessment of the patient internal state and coping reserve-and how these may be affecting resilience or burnout-is needed by using scale. Again referred the patient scenario, the patient does not use any protective factor that is why patient came again due to relapse (anger and aggression). Patient must be given the resources and opportunities to become more aware of their own health and well-being during training and to develop lifelong abilities to keep their reservoirs full. By considering Basch’s developmental model, we are better able to see the fluidity of the reservoir model. By strengthening the internal structure, and promoting resilience and personal growth. ( See Appendix A).
As far as nursing process is concern, referred to patient scenario the entire above article mentioned the internal and external factors that helps to build resilience my first step was to build relationship which was necessary to initiate resilience then reflect him his own emotions that is anger.
In planning, and implementation phase my goal was to make him learn positive thinking and socialize after reading literature although it’s a long term goal. I had plan according to our cultural context that can benefit the patient and the mental health professional as well. According to Mayo Clinic.com article of (2007). Some people are naturally more resilient than others, probably because of a tendency to be optimistic thinkers. But we all can learn to be more resilient with practice. Life experience tends to show us that most of the negatives of life are transient. We lose a relationship, but enter into a better one. But learn from it and make better choices in the future initially, at individual level, I planned for counseling session. This gives a person chance to talk through everyday issues. Patient able to verbalize his feelings and work collaboratively to solve his problems. For assessment i used anger scale (happy, sad, upset, angry and rage) The purpose of doing this to see what is the actual reason for anger that exercise help him to reflect upon himself, so he can identify his own positive capabilities. Firstly, I used resilience scale to assess how resilient he is? According to Dr. Gail Wagnild, co-inventor Resilience Scale User’s Guide (2006), said if your resilience level is low but this doesn’t mean you have zero resilience (p.2). Everyone is resilient to some degree my patient score was 127 which is low, can strengthen a resilience by doing so will make a significant positive change in one’s life. Secondly I asked him to write an essay on “Myself” which he did then next step I asked him to write a letter of forgive and forget for his family additionally , arranged a gift wrapping activity to socialize and compromise by controlling anger .Simultaneously he indulges himself in group activities as well.
Another strategy used was yoga and guided imagery with help of a community social worker and doctors of Karwan-e -e Hayat which he started doing and was feeling confident by doing mild strengthening exercise. Fortunately, talk to his mother on phone how family support helps him, arranged family meeting with senior Psychiatrist. Lastly, I asked him to continue practice of religion which is also a helpful strategy for building resilience in mental health. In the article Role of Faith written by Dr Niaz (2006), prayer used as a key coping technique for coming out of the problems. The balance of faith seems to contribute more resilience than vulnerability. Many other researchers support this fact. I m glad the result family and doctors were very happy to see the patient motivation getting better and family also willing to support. Further, there is a need to make support group, which serves as a platform, helps the patient to ventilate their frustration. For government part I plan to publish in news paper about why people have maladaptive behaviors in regards to mental health.
Own thinking/ prejudices and learning:
Journey of mental health was very interesting and tough as a health care professional to help patient to build resilience at individual, family, and community which I was not aware of. Furthermore, we cannot change the health policy of the country rather we can take initiative to give awareness programme by educating the family and staff if my patient family got this information earlier they would have helped him to live a normal life without stigmatization of being mentally ill. Through literature I realized concept of resilience applied not only to mentally ill but healthy person also. Similarly I m using the same concept of resilience in my senior citizen rotation as well. During this rotation we are organizing trainers of the trainee programme at institutional level plus community level to promote mental health.
Conclusion and Summarization:
I conclude that Nursing is a science concerned with promoting the physical and mental health, learning new things about yourself and the outside world, nurturing your self-confidence and self-esteem so that you feel strong, capable and self-reliant and hopeful. If this awareness gets by the people of Pakistan then there will be a great decrease in number of mental illness in the country. An understanding of this concept will better prepare nurses to enhance well being and better out.