Mental Health Problem
Generalised Anxiety Disorder (GAD) is an illness which is “characterised by chronic and persistent worry” (Stein and Sareen, 2015, p.2059). The origins of worrying behaviour can come from different sources and show themselves in a variety of ways. For example, multifocal worrying about such topics as money, one’s family and friends or one’s health can be challenging to manage for persons with GAD (Mind Set, 2016; Stein and Sareen, 2015). Such excessive worry which a person is unable to control or overcome is the primary determining aspect of GAD and its first symptom. Nevertheless, a number of other following symptoms may also exist for some individuals. For instance, some persons may feel restless which often leads to the lack of sleep, tiredness and trouble concentrating (Stein and Sareen, 2015). Some emotional changes may also be visible in persons with GAD, including increased irritability, stress, avoidance of social contacts and others (Cuijpers et al., 2014). Repetitive negative thinking (RNT) is another characteristic of this disorder (McEvoy et al., 2015).
Some physical symptoms may include exhaustion due to the lack of sleep or continuous tension (Stein and Sareen, 2015). Headaches and excessive sweating, as well as stomachache, can also come from worrying. Some individuals may experience differences in heart palpitations, insomnia, muscle tension, and breathing problems during more active periods of the illness (Stein and Sareen, 2015). Some of the stronger and more pain-inducing symptoms may occur periodically if a person encounters a specific problem that increases worrying. In this case, a person may have panic attacks – short and mostly unexpected periods of increased uncontrolled worrying followed by fear, intrusive thoughts, and physical pain (Hakansson, 2005; Stein and Sareen, 2015). However, the focus of one’s anxiousness is not always clear for persons with GAD as their condition often involves RNT and inability to control one’s emotions.
A person with GAD may encounter a number of problems during his or her everyday activities. The symptoms of GAD may be strong enough to interfere with one’s daily life and disrupt one’s ability to socialise, work and even care for oneself (Stein and Sareen, 2015). Some symptoms that are influenced by worrying such as insomnia and restlessness can affect one’s life significantly by altering other health-related aspects. Families and friends of persons with GAD may also be impacted as their loved one may continuously express negative thoughts (Hakansson, 2005). The frustration of family members who may not understand the cause of one’s worrying can lead to conflicts and personal disputes further enhancing one’s symptoms (Koszycki et al., 2014).
While GAD can be treated with the help of medication, the individual must focus on psychosocial strategies as they may increase one’s success of recovery and have a lasting positive effect on one’s mental health (Cuijpers et al., 2014). According to Stein and Sareen (2005), medical treatments for persons with GAD are most often combined with or substituted by cognitive behavioural therapy (CBT). While methods that use drugs may be useful as well, CBT can help a person to reduce the levels of worrying. Here, the difference between relying on medication and using psychosocial strategies may lie in one’s approach to recovery. While clinical rehabilitation can be successful for persons who rely solely on medicine, personal recovery, an internal changing process to live a healthy and satisfying life, may be harder to reach without psychological intervention and communication (Slade, 2013). Thus, psychosocial strategies should be considered central to recovery for people with GAD.
The significance of finding a viable psychosocial strategy also lies in the importance of relationships for people with anxiety disorders. Mental health problems are often worsened by the lack of positive relationships or a robust support framework, which further supports the idea that social interventions can improve one’s mental health (Edwards et al., 2016). Anxiety, depression and other mental health problems can also originate from the isolation of people at an early age or their unstable relationships with peers, parents, and authoritative figures. For adults, relationships also play a crucial role in the formation of their identity. While persons with mental health problems may find it difficult to build new and support old relations, the existence of a support framework may improve their path to recovery (Edwards et al., 2016). Here, a relationship with a counsellor can also positively influence one’s recovery as it may promote hope and allow one to feel in control of his or her life (Shepherd, Boardman and Slade, 2008).
In the case of GAD, CBT is used to allow individuals to assess their thought process, evaluate their patterns of thinking and review negative behaviours and habits that one can use during the thinking process. The method of recovery of a person with GAD can involve the help of other people as one’s worrying often revolves around family, friends and personal health. Thus, people’s recovery process should include changes in attitudes and the understanding of self (Shepherd, Boardman and Slade, 2008). The personal recovery perspective supports these developments and offers a framework that can incorporate a number of actions leading to a deeper understanding of the problem and a more satisfying outcome of recovery (Slade, 2013). For example, CBT for anxiety is focused on self-evaluation and the process of eliminating harmful and strengthening positive thinking patterns (Cuijpers et al., 2014; McEvoy et al., 2015). Such an approach directly corresponds with the personal recovery framework as it values self-discovery and the focus of hope and positive sides of one’s identity.
The focus of CBT in treating anxiety disorders lies in finding the root of their worrying and the process of constructing fears and thinking behaviours. Moreover, this approach also teaches people how to relax, reassess the situations that make them feel anxious and develop skills to meet and solve problems without adhering to negative thinking models. As the primary purpose of CBT is to address such patterns, its effectiveness is often highlighted, and it is chosen to be the first-line treatment for this disorder (Stein and Sareen, 2015). The basis of CBT is that people’s thoughts can act as a lever to affect their emotions and behaviours. Therefore, by changing one’s judgments, a person can develop new attitudes and positive approaches to solve problems. This strategy is useful for anxiety disorders because their symptoms are heavily connected with repetitive thinking patterns – persons with GAD fixate on a specific issue and develop escalating negative thinking behaviours (Mind Set, 2016). The process of changing maladaptive thoughts is a large part of personal recovery.
Metacognitive therapy (MCT) is another strategy that can be taken to treat individuals with GAD. According to this approach, symptoms of the disorder are created by one’s thoughts and behaviours that support and encourage harmful practices (McEvoy et al., 2015). For example, a worrying person may create an adverse coping mechanism and ruminate on negative thoughts or search for non-existent threats. Thus, this individual focuses on practices that further exacerbate his or her condition. All these processes are guided by metacognitive beliefs of the person and his or her assuredness that they are helping to cope with problems. The approach of MCT suggests that these metacognitive beliefs can and should be changed with talking therapy. By outlining and analysing these behaviours and thoughts, the patient and the counsellor build a model to improve these processes to lead to positive results. For example, RNT can be substituted with positively-focused thinking and hopeful concepts. Furthermore, during this therapy, patients can learn new coping strategies that do not rely on rumination and focus on future outcomes and perspectives instead.
The importance of self-reflection in the therapy strategies described above directly corresponds to the main features of personal recovery. To enhance their effectiveness and promote independence and self-reliance, one can use a self-maintenance plan such as WRAP (Wellness Recovery Action Plan) (Copeland, 2000). This strategy can help people assess their feelings and understand their thought processes. The focus on positive activities and self-reflection also contribute to one’s recovery. WRAPs allow people to outline possible positive and negative outcomes of their actions and stress the need to have an active supporting system for crises (Copeland, 2000). This strategy is individualistic, patient-focused, flexible, and focused on one’s level of satisfaction. All these descriptions align with the personal recovery perspective (Slade, 2013). Therefore, WRAPs are useful in providing patients with a tool for successful recovery unbound by medication and clinical achievements.
Core Features of the Therapeutic Relationship
As was mentioned above, relationships play a significant role in people’s recovery process. The significance of personal connections cannot be overstated as patients’ families and friends often become their main source of support. However, a successfully established connection between a patient and a healthcare professional, namely a mental health nurse, can also contribute to one’s recovery process. Mental health staff can have a significant impact on one’s health by creating and promoting meaningful therapeutic relationships (Browne, Cashin and Graham, 2012; Slade, 2013). Healthcare workers can use specific strategies to foster such relations and help patients on their path to recovery. Here, it is vital to mention that a personal recovery perspective outlines the need to create coaching and not manage relations with patients (Gunasekara et al., 2014).
The fundamental feature of this approach is the focus on the patient and not on the condition (Slade, 2013). Thus, people with mental illnesses should be viewed first and foremost as people whose mental health is a part of their complicated life. This approach can allow patients to feel in control of their recovery and give them more opportunities to engage in the process. Furthermore, nurses should value patients’ contribution to recovery. These people should be viewed as capable of managing their own lives (Slade, 2013). Otherwise, their inability to care for themselves should be considered temporary and treatable. The personal recovery perspective stresses the importance of focusing on patients and their decisions regarding the treatment process. Such a viewpoint also values flexibility and self-confidence of patients as it gives them necessary moral support. Patients who do not feel controlled by healthcare professionals may be more encouraged to create individual approaches to recovery and be more active in the process.
To help patients understand their capabilities, mental health nurses can use assessment – a technique of locating one’s strengths, positive aspects, and aspirations (Slade, 2013). Assessment is part of recovery as it creates a direction in which a person might want to move and establishes a set of positive characteristics that can help one during the recovery process (Simpson et al., 2016). Furthermore, assessment helps to create a trusting relationship between a healthcare professional and a patient. Persons who feel the support from mental health service workers may also hold more positive attitudes about their recovery and be more open to sharing their thoughts. Moreover, assessment can help individuals to realise the purpose of their recovery and find the underlying reasons and motivations for their behaviour. Assessment is a process that should be centred on one’s positive aspects and relevant history.
For example, nurses’ empathy can greatly contribute to the success of the assessment process. Mental health professionals should allow patients to express their emotions in relation to health concerns to shape their understanding of recovery. Thus, patients through working with nurses should be able to find meaning in their path to recovery (Slade, 2013). If persons have negative emotions and experiences, these should not be ignored in favour of positive aspects. Instead, a person should be able to analyse all emotions and limitations to find a way to incorporate them into one’s life. For instance, losses should not be neglected but grieved for and incorporated into the process of recovery (Slade, 2013). Here, empathy may help nurses to engage with patients and help them open up to the process of recovery. In the case of GAD, patients may feel worried about their behaviour and thoughts. Therefore, they may need additional reassurance in the necessity of analysing their cognitive patterns from another angle.
Positivity is another pillar of therapeutic relations. Nurses should focus on guidance and support and highlight persons’ strengths and not their limitations. While acknowledging problems is important, one’s recovery is a continuous process of self-improvement and achievement of goals for the present and the future. Thus, one’s positive outlook may contribute to immediate or fast changes. To promote positivity, nurses can centre on patients’ previous achievements, positive encounters and experiences, dreams and personal skills (Slade, 2013). In the process of assessment, these strategies can be introduced in the form of questions formulated in a way that promotes positive thinking. For instance, asking a person about his or her role models and moral lessons learned from them can encourage people to reflect on qualities that they aspire to have (Bowers et al., 2009). Thus, while they are thinking about the question, individuals are concentrated on aspects that can help them recover.
Therapeutic engagement is essential for patients’ recovery because it fosters necessary mechanisms for them to implement in daily life. Therefore, the relationship between nurses and patients is essential to the recovery of the latter. Therapeutic time spent with individuals can enhance their rate of recovery and improve their new relations with nurses and other individuals (McAndrew et al., 2014; Thomson and Hamilton, 2012). Thus, patients whose relationships with nurses fail to give them necessary support may feel the need to disengage with the treatment, leaving their recovery unfinished (O’Brien, Fahmy and Singh, 2009). The success of establishing a therapeutic relationship can affect one’s mental health significantly even after the person leaves clinical care.
Stigma and Social Exclusion
The stigma that surrounds mental health and related problems creates many obstacles for patients and healthcare professionals as well. Some obstacles may stop people from engaging with clinical services entirely, while others may create difficulties for community treatment. For instance, for patients with anxiety, the problem may lie in the misunderstanding of their behaviour. As GAD is often a component of other conditions, it may be hard to treat without considering other issues. Furthermore, GAD symptoms may be dismissed by some people as particular character traits or misunderstood as signs of stress or exhaustion. Thus, anxiety can go untreated for some people who believe that they are simply stressed and tired because they have many responsibilities. There is a low probability of help-seeking in these situations, which means that GAD may progress in people who dismiss it (Clement et al., 2014).
Some group specific stigmatisation is also possible in patients with GAD, For example, women are more often associated with anxiety disorders than men, as the rate of diagnosis for females is twice as high (Stein and Sareen, 2015). Moreover, women are more likely to be diagnosed with a number of other conditions, including eating disorders (bulimia and anorexia), social anxiety, and depression. The combination of these diagnoses shows that women may be more often exposed to social pressure and the weight of expectations that affect their well-being. Therefore, the choice to engage with therapy may be undermined by negative perceptions of receiving a diagnosis. The negativity connected to having a mental health-related diagnosis stops many people from seeking treatment, which further exacerbates their condition (Clement et al., 2014). Thus, anxiety disorders in women may present more dangers to their health as they often remain untreated for long periods of time.
Thus, prolonged failure to treat the disorder may negatively affect people’s view of anxiety as well. To overcome these problems, healthcare professionals should focus on proper assessment techniques for people. The awareness about anxiety and its symptoms in the community may allow such groups as women and young people to evaluate their mental health and seek appropriate help. Moreover, it is vital to engage with patients and let them understand that a diagnosis does not prevent them from living a joyful and fulfilling life (NHS Evidence, 2011). The focus should be shifted from the disorder to the person, his or her capabilities and aspirations. Here, the personal recovery approach is particularly useful as it neglects clinical success and replaces it with self-identification and confidence enhancement for patients. Spirituality can also impact the community and help people to cope with their issues. Some practices such as meditation can help with self-reflection – a helpful technique for people with GAD.
Many practices can help patients enhance their recovery process. Spirituality is often viewed as a concept that is hard to implement into mental health treatment (Gilbert, 2016). Nevertheless, spirituality can become a viable way for some people to increase the effectiveness of therapy. The use of religion in treating mental health issues can be seen as one of significant elements in recovery along with compassion and empowerment. Allowing patients to explore their spirituality may open new paths to treatment and recovery. Different disorders and conditions can be improved with various religious and spiritual activities. For example, prayer may help a person to remain calm and relaxed. Similarly, meditation can have a number of positive effects on one’s cognition. These processes can also be viewed as coping mechanisms with stressful situations. Particular rituals and habits based on one’s religion can also bring order and stability into one’s life, allowing them to deal with conditions rooted in the lack of control or compulsive behaviours.
Listening to talks and focusing on the voices or sounds of preachers may also be a helpful way for individuals to concentrate on particular practices and analyse their behaviour. There is a variety of other activities that religion can introduce into the lives of people. Some symbols and connected acts can allow them become more grounded and balanced. Therefore, spirituality can use utilised by mental health professionals to increase the effectiveness of treatment. One should remember that the patient should have a choice of implementing these practices into the process of recovery and a counsellor should not impose any restrictions or rules onto anyone. The freedom of expressing one’s spiritual beliefs should be followed by other principles of holistic care such as empathy and compassion.
As one’s spirituality can be used in a number of activities, it can also be included in the daily plan of recovery such as WRAP. While using WRAPs as a basis for self-assessment, a person can incorporate religious activities into the list of regular practices that support one’s positive mood or help to cope with negative experiences. Here, spirituality may be useful in both crises and the stable phases because of its focus on the mind and repetitiveness of practices. Moreover, spirituality can offer a person a community of supporting individuals with similar values and goals. Through spirituality, a person can create a network of reliable connections and help others as well.
Reflection and Learning Impact
The learning from this module will allow me to implement different approaches to patient care. As my understanding of primary concepts for therapeutic relationships has been improved, I will try to use it in my practice. The importance of creating a meaningful relationship with patients, for example, showed me that patient-centred care is a valuable approach in mental health nursing not only because it gives patients more freedom but also because it allows them to concentrate on their strengths. Here, the issue of stigma connected with mental illnesses comes into light as patient-centred recovery approaches attempt to stop the stigmatisation from affecting people’s health. Nurses should play a significant role in ensuring that communities are aware of the problems that originate from neglecting one’s mental health. Moreover, nurses should foster community support and engagement and provide other organisations with tools to help undermined community members.
Another significant learning that I will implement in my practice is the approach to patients rooted in positivity, congruity and hope. The focus on one’s strengths and capabilities may help patients to become more involved with their recovery and allow them to create a course towards a happy life. A positive outlook does not have to neglect some adverse experiences and challenging situations. On the other hand, through acceptance and empathy, nurses can use the past experiences and help patients develop a new path to recovery. Here, the focus should remain on the patient and his or her decisions. Nurses should serve as enablers and coaches to their patients and use holistic care as the basis of all strategies. Successful mental health nursing uses compassion and hope as drives for patients to strive towards recovery on their terms.
Bowers, L., Brennan, G., Winship, G. and Theodoridou, C. (2009) Talking with People Who Are Acutely Unwell. London: City University.
Browne, G., Cashin, A. and Graham, I. (2012) The therapeutic relationship and Mental Health Nursing: it is time to articulate what we do! Journal of Psychiatric and Mental Health Nursing. 19 (9), pp. 839-843.
Clement, S., Schauman, O., Graham, T., Maggioni, F., Evans-Lacko, S., Bezborodovs, N., Morgan, C., Rüsch, N., Brown, J.S.L. and Thornicroft, G. (2015) What is the impact of mental health-related stigma on help-seeking? A systematic review of quantitative and qualitative studies. Psychological Medicine. 45 (1), pp. 11-27.
Copeland, M.E. (2000) WRAP: Wellness Recovery Action Plan. Colorado Springs, CO: Peach Press.
Cuijpers, P., Sijbrandij, M., Koole, S., Huibers, M., Berking, M. and Andersson, G. (2014) Psychological treatment of generalized anxiety disorder: a meta-analysis. Clinical Psychology Review. 34 (2), pp. 130-140.
Edwards, J., Goldie, I., Elliott, I., Breedvelt, J., Chakkalackal, L. and Foye, U. (2016) Relationships in the 21st Century. London: Mental Health Foundation.
Gilbert, K. (2016) Spirituality as an Evidence Based Practice. Web.
Gunasekara, I., Pentland, T., Rodgers, T. and Patterson, S. (2014) What makes an excellent mental health nurse? A pragmatic inquiry initiated and conducted by people with lived experience of service use. International Journal of Mental Health Nursing. 23 (2), pp. 101-109.
Hakansson, M. (2005) Reflective practice in the community. Mental Health Practice. 9 (1), pp. 18-21.
Koszycki, D., Bilodeau, C., Raab‐Mayo, K. and Bradwejn, J. (2014) A multifaith spiritually based intervention versus supportive therapy for generalized anxiety disorder: A pilot randomized controlled trial. Journal of Clinical Psychology. 70 (6), pp. 489-509.
McAndrew, S., Chambers, M., Nolan, F., Thomas, B. and Watts, P. (2014) Measuring the evidence: reviewing the literature of the measurement of therapeutic engagement in acute mental health inpatient wards. International Journal of Mental Health Nursing. 23 (3), pp. 212-220.
McEvoy, P.M., Erceg-Hurn, D.M., Anderson, R.A., Campbell, B.N., Swan, A., Saulsman, L.M., Summers, M. and Nathan, P.R. (2015) Group metacognitive therapy for repetitive negative thinking in primary and non-primary generalized anxiety disorder: an effectiveness trial. Journal of Affective Disorders. 175, pp. 124-132.
Mind Set (2016) What causes anxiety and depression – Inside Out. YouTube. Web.
NHS Evidence (2011) Service User Experience in Adult Mental Health: Improving the Experience of Care for People Using Adult NHS Mental Health Services [online]. London: NHS Evidence. Web.
O’Brien, A., Fahmy, R. and Singh, S.P. (2009) Disengagement from mental health services. Social Psychiatry and Psychiatric Epidemiology. 44 (7), pp. 558-568.
Shepherd, G., Boardman, J. and Slade, M. (2008) Making Recovery a Reality. London: Sainsbury Centre for Mental Health. Web.
Simpson, A., Hannigan, B., Coffey, M., Barlow, S., Cohen, R., Jones, A., Všetečková, J., Faulkner, A., Thornton, A. and Cartwright, M. (2016) Recovery-focused care planning and coordination in England and Wales: a cross-national mixed methods comparative case study. BMC Psychiatry. 16 (1), p. 147.
Slade, M. (2013) 100 Ways to Support Recovery. 2nd ed. London: Rethink Mental Illness.
Stein, M.B. and Sareen, J. (2015) Generalized anxiety disorder. New England Journal of Medicine. 373 (21), pp. 2059-2068.
Thomson, D.A. and Hamilton, R. (2012) Attitudes of mental health staff to protected therapeutic time in adult psychiatric wards. Journal of Psychiatric and Mental Health Nursing. 19, pp. 911-915.