The Use of Gibbs Model in Studying the Factors of Tonys Episodes of Mental Ill Health - Essay Example

Reflections Reflection is an everyday process by which daily activities are recalled and thought over. Reflections provide us with information to deal with a problem. Similarly nursing problems can be better evaluated and new information to solve a particular problem practically thought over based on actual practice and experiences. Ideas and conclusions not obvious at the time of event may be better gathered from a patient during reflection. In reflection, one looks carefully at what happened, decides or sorts out what was going on, explores in depth to find out how to improve or change something for a future time. One is able to make sense of an experience. At the time of action, one is unable to fully think out the best manner to handle it. Reflection provides that opportunity. A broader view is obtained and there is a chance to check that nothing is missed. One is also able to acknowledge. Striving for truth is the dictum behind reflection. It helps us admit to certain truths that we do not in the normal sequence of events. Judgement becomes balanced as all views are taken into consideration. Things will be clearer as if in a mirror. Valuable insights become obvious without being taught. Drawing conclusions, changing or developing a strategy or approach or activity may be achieved. Reflections have many advantages. They ensure that ideas and thoughts may be expressed in an easier tone. A creative thinking helps to experiment with one’s own style. Reflection helps to give of the best to the patients especially in psychiatric care. Previous events, the care provided and the outcomes from the provided care are experiences which provide ample information on how to face similar problems in future. Psychiatric care is individual oriented. Each patient may have to be approached in a manner unique to their situation. The nurse who has provided the psychotherapy for that patient would be more knowledgeable as to how to handle a particular situation of that patient later. Psychiatric patients have a tendency to behave in a similar manner each time an episode of self-harm or aggression or tension occurs. The prior nurse would know exactly what to say or do to relieve the patient of his problems if he is unable to see to it himself. Gibbs model Gibbs’ model was introduced in 1998. It provided a method of getting the psychiatric patients to reflect on their previous illness events and getting them to analyse and plan methods to overcome their illness by their own efforts Gibbs Reflective Model The Gibbs reflective model could be used to investigate into the circumstances of the patient going in for self harm, aggression and episodes of losing control resulting in anger. The patient would be encouraged to speak out freely his ideas and views. In the application of Gibbs model in Tony’s case, the care-giver would question Tony when he is well and get him to describe what happened when he had the uncontrollable anger for instance. Tony now more docile would begin thinking how he felt and what caused him to lose his temper. He may say that he felt lonely because his son had left him. Remembering this he had become angry and abusive. His feelings at the time should be investigated. The care-giver would then help him evaluate the experience by getting him to point out the good and the bad features of the incident. The patient would be expected to analyse the situation in his own way. His interpretation of things is the best way to help him solve the next similar problem himself without help. The patient would be asked if there was any other way that he could have solved his problem. Tony may answer that he would like to be staying with his son and did not want the son to leave under any circumstances. This may be one solution for the problem since the patient himself had reached this conclusion. Tony would be able to respond to his feeling of loneliness by immediately contacting his son and convincing him that he needed his son badly. If the son responded, maybe he would not be having any episode of tension and anger in future. The care-giver has to just convince the son about the needs of his father and to respond favourably and promise to visit him soon or even stay a few days with him. Similarly Tony may be questioned about the self harm, the uncontrollable anger, and the overdosages separately. Tony may be asked for reasons for his stresses. Self harm Self harm is deliberate harm to the body without suicidal intent and involves acts like cutting and harming (Andover, 2005, p.581). The self harm could be of lesser intensity like scratching, picking skin and disturbing would healing. 4% of general adult population give a history of self mutilation. However many people do not reveal that they have these habits which shows that only the tip of the iceberg may be evident. Anxiety symptoms accompany the habit and this may date back to incidents in childhood (p. 582). Symptoms of depression also have accompanied the self harm. Borderline personality disorder has been associated with self harm. Studies have compared people with self harm habits to distressed individuals who did not have this habit. It was indicated that the first group had anxiety and depressive symptoms. Literature speaks of episodes of deliberate self harm in 25% of patients in the year prior to suicidal attempts (Parkar, 2006, p. 223). Half the people who indulge in deliberate self harm ultimately kill themselves. Priority issues motivating self-harm need to be identified. Sadness, helplessness, feeling of not being worthy, disturbances of sleep and feeling of guilt all have been associated with self harm. Situational stressors like school failure, feeling cheated, having no children and similar events are closely related to self directed anger and self harm. Perceived causes have been grouped under social (89.3%), psychological (84.7%). Mental turmoil contributes to 81.1% of cases, financial problems in 41.3%, conflicts with inlaws 37.2% and marital problems 20.9 %. Interpersonal conflicts were responsible for most of the immediate causes for self harm (67.9%). Unfulfilled expectations accounted for 39.8% and victimization in 32.1%. Mental turmoil is found to be the main cause but definite mental ill health has been recognised as a trigger for the self harm events.. Five components have been thought to be the reasons for self harm: seeking care, influencing others, a temporary escape from punishment or inability to cope, final exit due to loss of interest to live on and loss of control. Suicidal deaths have focused on psychopathology being the cause. The reduction in psychophysiological response rather than the emotional response has probably caused the self harm. Depression, increased tension and anxiety could be the feelings preceding the cutting. Some people cannot resist the urge to self-cut. Painless self injury is probably allowed by a depersonalised state. When blood is seen, repersonalisation occurs and the tension s relieved. Effective treatment could reduce the self mutilating behaviours. Studies have shown that self mutilating behaviours can be treated without seeing any effect on the accompanying symptomatology. The patients feel less distressed and stop the habit of self cutting. Aggression The theories of aggression are the psychoanalytic theory, drive theory and the social learning theory (Bjorkly, 2006, p. 28). Sigmund Freud considered aggression to be a form of instinctual drive in the psychoanalytic theory. He believed that anger and hostility were similar to sexual drive in that they all lead to conflict and unconscious guilt. The death instinct makes the person indulge in direct aggressive acts which aim at saving himself from destruction by directing the acts against the social and physical environment (Bjorkly, 2006, p. 29). The inner dynamic process was involved in reaching outcomes like coping, creativity, self destruction and aggression. Tension reduction procedures or catharses reduce the strength of the inclinations. Legal, professional and ethical consideration The patient is given an equal status as the care-giver or therapist though the client is a more needy person. The care-giver looks for the good rather than the true in the client. Therapy is the exchange of two autonomous selves where the client is in a bigger need. The therapist or the care-giver responds according to the ethical need of the client. A process of problem solving, resolving transference issues, validating the Self, self-actualization all accompany the psychotherapy. Therapeutic communication would improve and the process would be systemically ethical. The outcome of restraint would be a period of peace rather than the violence or aggression expected. The therapist is professionally and legally responsible fro the care of the patient. In case of a legal proceedings, the therapist is legally responsible for the actions of his client. Direct Observations Tony’s problems Borderline personality disorder is usually accompanied by deficits in affect regulation and impulse control. Substance abuse, decreased self- esteem and defective interpersonal relations are commonly associated with this disorder. Dissociative features are also present with plenty of tension. Rejection, failure and loneliness produce the feelings of tension. These patients eliminate their feelings of tension by self injurious harm. Tony’s self mutilating acts are probably acts for releasing tension. Intense impulsivity can lead to intense and uncontrollable anger. Aggressive behaviour is expected in borderline personality disorder. Gibbs model could also reflect the feelings of the patient better. Tony may reveal what happens when he becomes angry. It may be because his bills are not paid and telephone enquiries about when the payment may make him angry and violent. The drive concept or the frustration-aggression hypothesis is believed to be an expansion of Freud’s theory. When people become frustrated, they become aggressive. The drive is not instinctual. It occurs due to external stimuli (Bjorkly, 2006, p. 33). The aggressive drive varies according to three factors: “the amount of frustration, the degree of interference with a goal-seeking response and the number of frustrated responses experienced by the individual” (p. 33). Punishment could reduce the dominant aggressive response through learned inhibition. The response could remain unexpressed till a really frustrating event occurs. Biological and social factors could produce the frustrating event. Understanding the frustrating precipitants is significant for prevention of aggressive episodes. Bandura describes aggression as personal injury and physical destruction. His theory of social learning talks about four inter-related processes (Bjorkly, 2006, p. 38). The cues, behaviour and outcomes of the event must be attended to. The observations must be remembered. The cognitive processes must then be changed into new response patterns. Appropriate incentives could then model the behaviour into a more accepted response. Two groups of motivators are believed to be involved: biologically based ones and the cognitive representations of future outcomes. Aggressive behaviour may be instigated by the different types of modeling: directive, disinhibitory, emotional arousal and stimulus enhancing. Bandura believes that bizarre internal beliefs could also be instigators for aggression (p. 38). The dialectical behaviour therapy is used for patients with borderline personality disorder (p. 41) Planning for the therapy The right type of therapy may differ from person to person. Tony appears to have only episodes of uncontrollable anger and has good days most of the time. He is able to understand that he develops his episodes following certain problems. The dialectical behaviour therapy is most suited for him as he has a borderline personality problem. His problems could be mainly triggered by the loneliness caused by his son moving out. His illnesses of pancreatitis and Type II diabetes mellitus are also significant problems which need to be dosed properly and requiring frequent visits to the physician. We can expect Tony to be careless in taking medicines properly. This is a requirement which needs to be solved. The borderline personality disorder probably made things worse. His substance abuse was probably triggered by his various conditions including mental illness. Tony is not in a position to withstand mental stress. Not having a loved one to provide care may be his main problem. He needs ongoing support. Depression is another feature of his mental status. When he does not have problems he is able to look after himself. Not having a steady job is another of his woes. He is unable to continue with full attendance. His other problems come in between. Payment of bills is the next cause for unahappiness. This is the main trigger for his mental ill health episodes. Earlier therapy had introduced him to support groups which would help him manage his problems. However he has never been able to make it to the meetings. His disability and living allowances help him to a certain extent. His friends are there for contact and some moral support. His present unhappiness is due to his father’s death. Tony needs to be provided ample support for his problems. In a nutshell, he would be needing appropriate treatment for his illnesses, frequent checks by physician and behaviour therapy for his borderline personality. Tony must be helped to analyse himself the circumstances which provoked his mental problems and making an action plan to handle the periods of frustration and not allowing aggression to take over. Substance abuse must be subjected to an intensive detoxication programme, this time till success is reached. The son must be convinced of the need to stand by his father and help him come out of his ill health. Moral and psychosocial support by the son and friends would go a long way to help Tony. If his bills are paid in time by his son or some agency, Tony may not have similar episodes in future. This is a suggestion practical to a certain extent. The therapist may suggest that this could be looked after and in case he gets unpaid bills in future, Tony is to let his son know as a temporary solution so that he does not progress to the anger and aggression stage. His son would be warned to give his father some attention and response when he complains about the unpaid bills. Therapy plan 1. Tony may be put in a nursing home where he will be under supervision by health staff or qualified nurses. The physician would ensure that his pancreatitis and diabetes are controlled. Medical management will be taken over by the staff. 2. The next step but simultaneously rendered would be to use the Gibbs model to study the factors which trigger Tony’s episodes of mental ill health. Getting Tony to identify the factors which frustrate him, the care-giver should be able to help him prevent aggressive attitudes using the frustration-aggression theory. Tony must be able to understand what frustrates him and what could stimulate an aggressive attitude within him. He must be able to look for early warning signs of frustrating factors while the level of frustration is still low and call for help or take precautions (Bjorkly, 2006, p. 37). Helping Tony to discover the frustrating situational precipitants of aggression is my job. 3. Tony must be trained to look for early warning signs at the low frustration state itself and manage things by himself. He would be trained to identify precipitants and adjust his behaviour duly so that he manages his own condition at the level of low frustration by adopting certain behaviours which would abort the progress before full frustration or aggression is reached. Bandura believes that people can keep a control over their own behaviours through “self-generated inducements and self produced consequences” ( Bjorkly, 2006, p. 40). This kind of self regulatory process helps patients to model their behaviour using self rewarding or self punishing ways. Cognitive behavior therapy interventions now follow these ideas and incorporate origins, instigators and regulators. Tony’s therapy would be using ideas from Bandura. 4. The dialectical behaviour therapy would be best for Tony’s condition of borderline personality disorder (Bjorkly, 2006, p. 41). Four behavioural skill models are followed: mindfulness, distress tolerance, emotion regulation and interpersonal effectiveness. Lack of self regulation is managed by mindfulness which stresses the self awareness. Distraction and self soothing techniques are managed by the distress tolerance skills. Emotion regulation helps people to increase positive emotions (Bjorkly, 2006, p. 41). Assertiveness and how to deal with conflicts are taught by the interpersonal effectiveness skills. 5. Psychosocial therapy is instituted by including the son and family and convincing them of the support they could give Tony. The therapy schedules would include meetings with them. Tony also has to be convinced that he must make use of the support of the others. Support groups consisting of similar patients must include Tony in their groups and Tony must attend them. Maintaining a record I would be keeping a record of the events in Tony’s life as he goes through the therapy planned. The progress that he makes would be indicative of a successful plan. Tony would be given a diary to record his feelings and moods and events in his daily life to know what is happening between schedules. He is assured of maximum support. The monitoring and evaluation of the diary and my records are significant and help to assess and change the plan as necessary. My job would be nearly complete if I could convince Tony to accept a job close to his qualification of an electronic engineer. However regular checkups after longer intervals are still necessary. Andover, M.S. et al. (2005). “Self mutilation and symptoms of depression, anxiety and borderline personality disorder”. Suicide and Life threatening behaviour, Vol. 35, No.5 ProQuest Educational Journals Bjorkly, S. (2006). “Psychological Theories of Aggression: Principles and Application to Practice “Violence in Mental health Settings” (Eds.) Dick Richter and Richard Whittington, Springer Science and Business Media, New York. Parkar, S.R. et al, (2006). “Clinical diagnostic and sociocultural dimensions of deliberate self harm in Mumbai, India, Suicide and Life threatening behaviour, Vol. 36, No.2 ProQuest Educational Journals Read More