Integrating the Bio Into the Biopsychosocial: Understandingand Treating Biological Phenomena in Psychiatric-MentalHealth Nursing Ivo L. Abraham, Jeanne C. Fox, and Bobbye T. Cohen
Advances in neuroscientific understandings of the interrelationships between brain, behavior, emotion, and cognition offer new opportunities for psychiatricmental health nursing. Yet, even though the discipline conceptually embraces a biopsychosociai perspective as part of its holistic mandate, the factual integration of biological sciences into practice, research, and education is limited. Integrating the biological perspective into a holistic paradigm and progressing toward a discipline in which the biological, psychological, and social interact coherently and interdependently requires a dual focus on understanding and treating patients and their social and physical environments. We describe how in the past the discipline has strived toward understanding and treating patients from predominantly psychological and social perspectives. We also show how progress in the biology of mental health and iliness provides new avenues for understanding and treating patients’ responses to actual and potential health problems. This in turn will contribute to the emergence of a truly holistic discipline of psychiatric-mental health nursing.
Copyright
0 1992 by W.B. Saunders
T
HE DISCIPLINE of psychiatric-mental health nursing has undergone significant changes over the past three decades, many of which were cogently summarized by Fagin (198 1): psychiatricmental health nurses’ achievement of status within the profession and colleagueship with other disciplines; significant involvement in major move-
From the School of Nursing; Department of Behavioral Medicine and Psychiatry, School of Medicine; Center on Aging and Health and Rural Mental Health Research Center; University of Virginia, Charlottesville, VA the Division of Nursing, University of Virginia Medical Center, Charlottesville, VA and the Catholic University of Leuven, Leuven, Belgium. Supported by Grant No. 1 TOlMH19362 from the National Institute of Mental Health (Rockville, MD) and Grant No. UHCBOOO3J from the W.K. Kellogg Foundation (Battle Creek, MI). Address reprint requests to lvo L. Abraham, Ph.D., FMN., C.S., Center on Aging and Health, University of Virginia, 170 Rugby Rd., Charlottesville, VA 22903. Copyright 0 1992 by W.B. Saunders Company 0883~9417/92lO605-0007$3.OOlO
296
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ments of community mental health, family therapy, and the use of systems theory as a foundation for psychotherapeutic practice; the development of the role of clinical nurse specialist; and the emergence of liaison psychiatric nursing as a critical role in hospital settings. What perhaps has been overlooked in these profound changes is a consideration of physical dimensions of mental health and mental illness, and the interaction between physical and mental factors in the development and maintenance of illness and its treatment. The call to integrate the biological sciences into psychiatric-mental health nursing is recent. McBride (1990) argues that we must be responsive to current trends and discontinue ignoring or devaluing the significant new evidence of biological determinants of mental health and illness. She also contends that two major readjustments are necessary for the discipline to experience a renaissance in the 1990s: the need to stop devaluing biological knowledge and the necessity of becoming funda-
Archives of Psychiatric Nursing, Vol. VI, No. 5 (October), 1992: pp. 296-305
INTEGRATING
THE BIO INTO BIOPSYCHOSOCIAL
mentally reassociated with care and caring. In other words, the discipline faces the challenge of integrating the biological into the biopsychosocial, and therefore must cease giving lip service to the biological without rejecting its longstanding and unique hallmarks of psychosocial care. Lowery (1992), Fox (1990, in press), and Underwood (1990) have also challenged psychiatric nurses to access neuroscientific knowledge and apply this knowledge in research about psychiatric nursing care. Both Lowery (1992) and Fox (1990) have questioned the resistance of many psychiatric nurses to the incorporation of this knowledge. Lowery (1992) expresses doubt about Liaschenko’s (1989) claim that integration of neuroscience will be detrimental to the art of psychiatric nursing and patients receiving psychiatric nursing care. Lowery (1992) proposes that unless psychiatric or objectively document nursing can “rationalize [its] practice with the technology and knowledge available” (p. 9) to the discipline, it will do a disservice to both patients and profession. She also questions the logic of psychiatric nursing’s seeming ready adoption of psychological, sociological, and anthropological paradigms, but its resistance to basic biological sciences. The National Institute of Mental Health and psychiatric nursing organizations, such as the Society for Research and Education in Psychiatric-Mental Health Nursing, have promoted psychiatric nursing education about new discoveries in the neuroscience of mental illness. However, individually, many psychiatric nurses appear wedded to the notion that incorporation of this knowledge in explanatory models or intervention strategies will somehow destroy the uniqueness of psychiatric nursing practice and research CONCEPTUALIZING
A BIOPSYCHOSOCIAL
DISCIPLINE OF PSYCHIATRIC-MENTAL HEALTH NURSING
Integrating the biological perspective into a holistic paradigm within psychiatric-mental health nursing and progressing toward a discipline in which the biological, the psychological, and the social interact coherently and interdependently requires a dual focus on understanding and treating patients and their social and physical environments. Understanding patients within a truly biopsychosocial psychiatric-mental health nursing framework requires retrospection: “looking back”
297
and “looking into” through nursing observation and assessment, etiological and causal explanation, and nursing diagnosis. Treating patients is prospective: “looking forward’ ’ by means of nursing prognosis on the basis of systematic and expert intervention. We use this dual focus on understanding/ retrospection and treating/prospection to guide our proposed conceptualization of a biopsychosocial discipline of psychiatric-mental health nursing. We first describe, intuitively rather than empirically, how the discipline has strived to understand and treat patients; and how this has been mostly within the psychological and social spheres (see Fig 1). Similarly, we show how the major treatment paradigms of the discipline have relied mostly on principles of psychological and social intervention (see Fig 2). Next, we show how scientific progress in the biology of mental health and mental illness has opened new avenues for nurses to understand patients’ responses to actual and potential mental health problems (see Fig 4). We also document how nursing, independently as a clinical-scientific discipline and interdependently as a critical discipline within the multidisciplinary team, can care for patients and families by integrating the biological, psychological, and social dimensions (see Fig 5). The content depicted in Figs 4 and 5 must be interpreted within the context of multifocal. balanced knowledge sketched in Fig 3. The Venn diagrams represent the psychological, social. and biological dimensions, and their mutual interdependencies. In these diagrams, each dimension has its separate area to refer to the distinct contributions made independently by the psychological, social, and biological dimensions. These diagrams also feature three joint areas to denote the integration of two dimensions and the contributions thus made to the discipline of psychiatricmental health nursing. These interdependent regions are the psychosocial, psychobiological, and sociobiological areas. Finally, there is the area at the intersection of the three dimensions to refer to the biopsychosocial integration of theoretical. scientific, and clinical knowledge within the discipline. Figures 1, 2, 3, and 4 summarize the knowledge bases used in psychiatric-mental health nursing in understanding (Fig 1) and treating (Fig 2) patients and families in the past, and the emerging context (Fig 3) and knowledge base for under-
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standing (Fig 4) and treatment (Fig 5) in the future. Figures 1 and 2 depict, by means of arrows, the major trends of dynamic knowledge integration across dimensions for understanding and treatment within a psychiatric-mental health nursing framework. Thick arrows denote strong exchanges, while thin arrows refer to weaker exchanges. The direction of arrows indicates the predominant direction of these exchanges, many of which may be unidirectional. PAST DEVELOPMENTS AND TRENDS
Understanding Mental Health and Mental Illness
The discipline’s predominant approaches to understanding mental health and illness have been within the psychological and social spheres, with both dimensions drawing to a limited extent on the
Emotion, behav-
Emotion, cogni-
Global, undifferentiated, and
ior, and cogni-
tion, and behav-
tion determined
ior determined
system-nonspe-
by intraper-
by dynamics of:
cific views on
sonal dynamics
family of origin,
biophysical dys-
current family,
function, orga-
No. of dyadic
nicity, manifest
Emotion-focused coping
biological dimension (Fig 1). The psychological dimension has contributed the insight that emotion, cognition, and behavior are determined by intrapersonal dynamics, many of which in turn are traced developmentally through application of frameworks that emphasize the role of childhood development in maturation to adulthood. Within a more applied context, the psychological dimension has also brought to the discipline an understanding of the coping processes people use to deal with a variety of life or developmental events. The social dimension, which historically has differentiated psychiatric-mental health nursing from many other mental health disciplines, has taught us that emotion, cognition, and behavior are influenced by social forces encompassing family and community (the latter including cultural and racial subgroups). Family forces include family of origin, extended
Biologic4
Social
relationships,
physical illness,
friends, small
manifest physi-
social groups,
cal impairment
large social groups, ethnicity, and community Psychosocial Intrapersonal terminants
deof
social function-
Mind to body in-
Social determiof intra-
Interpersonal
im-
biophysical im-
Adaptation to Intrapersonal
Sociobiological
pairment due to
teraction physical illness
ing nants
Psychobiological
pairment
im-
pairment due to
personal func-
biophysical im-
tioning
pairment
Psychosocial adaptation Behavior-focused coping Social support Relational adequacy Community
inte-
gration Fig 1.
FOX, AND COHEN
Past nursing understandings
of mental health and illness.
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family, and dyadic and other significant relationships. Community forces range from friends and other small groups bound by affection and common interests to larger social entities, with ethnicity (in the broad sense of the word, including but not limited to race) and community interwoven throughout the extended social relationships and affiliations of people. Contributions from the biological dimension, existent only modestly in the past, have been global, rather undifferentiated, and often etiologically removed from organ systems. The biological contributions mostly have been views, rather than empirically substantiated knowledge, on the role of biophysical dysfunction and organicity, manifest physical impairment, and manifest physical illness on emotion, cognition, and behavior. Knowledge about understanding mental health and mental illness at the interchange of dimensions has been very strong in the psychosocial area, less strong in the psychobiological and sociobiological areas, and quasi-nonexistent in the biopsychosocial area (see also the thick and thin arrows in Fig 1). Psychosocial understanding of mental health and illness has emphasized the intrapersonal and the interpersonal determinants of social behavior and social functioning. It has brought to the discipline knowledge about how people adapt psychosocially to stressors, including the interpersonal nature of behavioral coping strategies. Psychosocial knowledge also includes understandings about the role of social support in mental health. Psychosocial knowledge stresses the importance of personal and significant relationships to people’s mental health and to the functioning of families and social groups. Relational adequacy at the interpersonal level and community integration at the social level are seen as significant determinants of mental health. At the interchange of psychobiological knowledge, the discipline’s emphasis on understanding largely has been from the psychological to the biological, and only to a lesser extent from the biological to the psychological (note the different arrows in Fig 1). The psychological-tobiological knowledge is well accepted within the discipline of psychiatric-mental health nursing. The impact of mind on body is recognized; yet perhaps inappropriately we have called this the “mind-body interaction,” when in fact most of the emphasis has been unidirectionally (and therefore “noninteractionally”) on the impact of mind on
physiology. Other important psychological-tobiological understandings pertain to how people adapt to physical illness (see thick arrow in Fig 1) and how biophysical impairment may lead to intrapersonal impairment (see thin arrow in Fig 1). At the interchange of sociobiological knowledge, there has been some consideration of the impact of biophysical impairment on interpersonal functioning. Treating Mental Health and Mental Illness
In concert with past trends in understanding mental health and illness in psychiatric-mental health nursing, the discipline’s treatment foci have emphasized psychological and social approaches, perhaps the hallmarks of the discipline in decades past (Fig 2). Within the psychological dimension, nurses have provided therapy and counseling services. In keeping with psychological understandings, the emphasis has been primarily on emotions, and secondarily on behavioral management. Treatment approaches targeting cognitions and their impact on well- and ill-being have been less prevalent. Nurses have also provided clinical leadership in using various micro and macro social environments as media for treatment. The integration of systems theory into psychiatric-mental health nursing has facilitated nursing interventions linking patients to their significant others and families. Recognition of the therapeutic effects of group process has encouraged a variety of nursing interventions. These have ranged from conventional group therapies-mostly stressing emotion, behavior, and cognition, in that order-to diverse applications of therapeutic group work to promote interpersonal skills, social integration, and functional independence. Within the mental health field at large, nursing has also provided the clinical leadership in using the social environment at large as a treatment medium, as evidenced by nursing interventions to promote social integration and the use of the milieu as context and agent for intervention. In contrast to these psychological and social strengths, nursing’s biological treatment commitments have been limited largely to the administration of psychopharmacologic agents and occasional assistive involvement in other somatic treatments, that is, the execution of physicianprescribed treatment regimens. Nursing’s strength in the psychological and social treatment dimensions is evidenced most in its
ABRAHAM,
Psychological Individual coun-
Social
Biological
Counseling and
seling and ther-
therapy involv-
apy, focused
ing significant
primarily on
other, family,
emotion, sec-
FOX, AND COHEN
and groups
Administration
of
pharmacological treatments Selective involvement in the so-
ondarily on be-
Social integration
havior, and ter-
Milieu therapy
matic treatments
tiarily on cognition Psychosocial Counseling and
Psychobiological Observation
of
therapy aimed
emotional
at psychosocial
provement
functioning and
behavioral ad-
integration
imand
Sociobiological Observation
of so-
cial improvement and adaptation due to
aptation due to
pharmacologi-
pharmacologi-
cal/somatic
cal/somatic
treatment
treatment
Monitoring for so-
Monitoring for
cial side and in-
side and inter-
teraction effects
action effects
to pharmacolog-
due to pharma-
ical/somatic
cological/so-
treatment
matic treatment
Fig 2.
Past nursing treatments
psychosocial interventions (see also Fig 2). Recognizing the importance of bringing intrapersonal well-being into the realm of social relations, and asserting the significance of social contexts in shaping intrapersonal dynamics, psychiatricmental health nursing has assumed the leadership in interventions focused on psychosocial functioning and psychosocial integration. The intellectual strength, clinical vigor, and recognized leadership in the psychosocial dimension contrast sharply with the relative superficiality of psychiatricmental health nursing at the biological interfaces. At the psychobiological interface, nursing’s role has involved important but limited responsibilities associated with pharmacologic and somatic treatment: observing for emotional improvement and behavioral adaptation, and monitoring for emotional, behavioral, or cognitive side and interaction effects. Likewise, at the sociobiological interface, nursing’s role has been confined to observing for improvement in social functioning and monitoring for social side and interaction effects associated with pharmacologic therapy. Truly biopsychosocial nursing intervention has been quasi-absent to date.
of mental health and illness.
TOWARD BIOPSYCHOSOCIAL INTEGRATION
To effectively respond to McBride’s (1990) call to integrate the biological knowledge with the discipline’s traditional commitments of care and caring, a dynamic balance between psychological, social, and biological forces of knowledge must be achieved. This balance, moreover, goes beyond the boundaries of holism, as it is situated within nursing’s larger context of patient, environment, and health. Figure 3 sketches the balance in biopsychosocial forces to be achieved, depicted by the arrows within the Venn diagrams. These arrows, identical in form, reemphasize the importance of psychosocial, psychobiological, and sociobiological interchanges in how we understand and treat mental health and mental illness. They also mirror the mandate to focus inward toward the holistic merging of knowledge into biopsychosocial understandings of the development, maintenance, and resolution of mental health and mental illness as the basis for biopsychosocia1 approaches to nursing-and, by consequence, multidisciplinary intervention. In addition, Fig 3 outlines the multiple contextual forces that shape the intellectual and
INTEGRATING
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THE BIO INTO BIOPSYCHOSOCIAL
Social Environment
Growth
Family
Physical
clinical environment within which the future practice of psychiatric-mental health nursing must take place. This context is composed of the patient as a person, influenced and profiled by the forces of growth and development, yet also endowed with the talents of free will and self-determination. The patient interacts with a continuum of social forces that range from immediate family, through interpersonal relations in smaller groups, to the larger social environment of community and ethnicity. The patient interacts with clinicians, thus becoming the focal point in the therapeutic processes of understanding health and illness; treating and preventing illness; and promoting, restoring, or maintaining health. Understanding Mental Health and Mental Illness
The biopsychosocial integration of knowledge about mental health and mental illness must draw on the intellectual and clinical traditions of the discipline of psychiatric-mental health nursing. Past approaches to understanding mental health and illness within the psychological, social, and psychosocial dimensions continue in importance and provide essential direction in the interpretation of psychosocial determinants. To this must be added the expanded knowledge dimensions of biological understandings of mental health and the pathogenesis and treatment of mental illness. As Fig 4 illustrates, these understandings are centered predominantly on the brain: neuroanatomy, neuro-
Enwronment
Fig 3. Context of biopsychosocial nursing understanding and treatment.
physiology, and neuropathology; cortical, subcortical, and limbic systems; intracellular, neuronal processes; intercellular processes, including the biochemistry of neurotransmitters, receptors, presynaptic and postsynaptic activity, and synaptic cleft activity; biochemical trajectories within the brain; and functional information processing trajectories within the brain. In addition, biological knowledge includes the role of other organ systems on mental health and illness, especially the interactions among organ systems; endocrinological determinants; genetic factors, both in terms of direct genetic determination and in terms of familial predisposition; and sensory processes as they interface with the pathogenesis and clinical course of mental illnesses. Last, the biological dimension also includes the pharmacodynamics and pharmacokinetits of various classes of biological agents within the human body and brain. All of this biological evidence from the basic sciences offers the discipline of psychiatric-mental health nursing new opportunities for understanding health and illness. The psychosocial interface can expand to include, foremost, a truly bidirectional appraisal of the interaction between mind, as both a biological and psychological entity, and body, as a biological entity: how mental processes influence biological processes, but also how biological processes influence mental processes. Cognitive processes, as a subset of mental processes, can be better understood, again in a bidirectional sense: how cognition impacts on biological processes, but
302
ABRAHAM,
FOX, AND COHEN
6iclogical Emotion,
cogni-
Emotion,
cogni-
tion, and behav-
tion, and be-
ior determined
havior
deter-
by intrapersonal
mined
by
dynamics
dynamics
Emotion-focused coping
Intrapersonal
de-
terminants
of
tems
of origin,
among
family,
systems
dyadic
relation-
Endocrinology Genetics
small and large
Sensorium
social groups,
Pharmacodynam-
and
macokinetics
Psychobiological
Sociobiological
Mind and body interaction
Psychosocial
ad-
aptation
cogni-
Adaptation
to and
mental
illness
Intrapersonal
im-
pairment
due to
biophysical pairment
quacy gration
inte-
Social cognition Interpersonal
im-
pairment
due to
biophysical
physical
Relational Community
tox-
ins
Social support ade-
Impact of environmental
tion
func-
its and phar-
community
Personal
tioning
organ
ships, friends,
ing
personal
Interactions
current
Intelligence
nants of inter-
system
family
social functionSocial determi-
nervous
Other organ sys-
of
ethnicity,
Psychosocial
Brain and central
im-
pairment
im-
Biopsychoaociel Schizophrenic spectrum
disor-
ders Major depressive disorders Other bipolar
dis-
orders Appetitive
disor-
ders Obsessive-compulsive
disor-
ders Organic
syn-
dromes Anxiety
and
panic disorders Dementias Sexual
disorders
Violence Fig 4.
Biopsychosocial
also how the biochemistry of mental processes enhances or diminishes various cognitive operations. Past understandings about psychological adaptation to physical illness and the impact of biophysical impairment on intrapersonal well-being can
understandings.
now be expanded with knowledge about physical adaptation to both physical and mental illness. Sociobiological knowledge for the discipline extends beyond its past limitations about the impact of biophysical impairment on social functioning.
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THE BIO INTO BIOPSYCHOSOCIAL
Advances in the biology of mental health and illness offer psychiatric-mental health nursing with a framework for understanding the interplay between environmental toxins and emotion, behavior, and cognition. Social cognition, or how people process information about others in relation to themselves, relies on both social and biological processes, offering nurses an expanded approach to appraising patient interactions and relations with significant others, families, small and large groups, and community and ethnicity. This leaves the knowledge dimension at the biopsychosocial interface. Figure 3 shows this interface area as listing several major classes of mental illness. Why is this conceptualized as an apparent return to an unpopular perspective in nursing, the so-called “medical model”? While hindsight always has the illusion of being perfect, the discipline of psychiatric-mental health nursing perhaps can be faulted for having abandoned mental illness for mental health. Opposition within nursing at large to medical terminology, couched as opposition to all matters medical, has isolated many of its specialties, including psychiatric-mental health nursing, from its associated health disciplines. This evolution has been grounded in a dual premise rather than in cogent and unbiased argumentation. The dual premise is (1) that, because historically health/illness terminology has evolved from medical disciplines, this terminology exclusively advocates the interests of medical practice; and (2) that medicine at large has long thwarted the development of nursing at large and should therefore be perpetually cast in the role of an (unnatural) adversary, rather than a (natural) ally in health care. The utility of established medical terminology lies in its hierarchical organization, which is of clinical and scientific benefit to medicine, as well as any other health discipline. This hierarchy describes the multiple and interacting levels of knowledge and accompanying individual languages that must be employed in understanding and treating the human conditions, actual and potential, described alternately as diseases or illnesses. The nursing discipline accesses these same levels of knowledge and languages and philosophically uses this knowledge to understand and practice caring, rather than curing. The common knowledge base shared by medicine and nursing provides a natural mechanism for communication and improved treatment and care if members of the
disciplines can clearly articulate the differences in the application of this knowledge in practice and research. Asserting the superior importance of one or the other principal application (medicine or nursing) is not in the best interest of human health. Instead, increasing efforts to investigate, understand, and describe effective alternative applications may result in advancement of nursing and medical sciences and in turn improve the health conditions of interest. Mental illnesses are health conditions to be cured, prevented, or palliated by psychiatricmental health nurses independently and interdependently. In keeping with emerging new classifications within the mental health domain at large, they include the following classes: (1) the schizophrenic spectrum disorders, from schizophrenic disorders to the more insidious thought disorders; (2) major depressive disorders as biologically determined mental illnesses; (3) other bipolar disorders, with or without documented or presumed biological determinants, including mood disorders related to coping with the problems of life and living, relationships and relating; (4) appetitive disorders, from abuse of legal and illegal substances, to impairment due to excessive and inappropriate adherence to, use of, or practice of substances (e.g., food), cognitions (e.g., obsessions, ideologies, religions, imaginations), behaviors (e.g., compulsions, exercise). or emotions (e.g., exaltation); (5) obsessive-compulsive disorder; (6) organic syndromes; (7) anxiety and panic disorders, including conditions of acute or chronic uncertainty; (8) dementias of various biological or nonbiological etiology; (9) sexual disorders of appetite, as well as intrusion/violence: and (10) violence directed at self or others. Treating Mental Health and Mental Illness
How does the biopsychosocial integration of clinical knowledge create new opportunities for the practice of psychiatric-mental health nursing? Parallel to our earlier recommendation to draw on established and respected traditions, nursing contributions to the treatment and prevention of mental illness and the promotion of mental health must rely on its past achievements in the psychological, social, and psychosocial dimensions. The areas in Fig 5 that represent these dimensions retain the clinical interventions of the past. Added to the psy-
ABRAHAM,
Social Individual coun-
Interventions
FOX, AND COHEN
BiologIcal
in-
Interdependent
seling and ther-
valving signifi-
apy focusing
cant other, fam-
pharmacologi-
simultaneously
ily, and groups
cal and somatic
on emotion,
Social integration
behavior, and
Milieu
participation in
treatments
cognition Personal support Psychosocial Interventions
Psychobiological Patient and family
Sociobiological Observation
of
aimed at psy-
education about
social response
chosocial func-
pharmacologi-
to pharmaco-
tioning and in-
cal and somatic
logical and so-
tegration
treatment
Social support Psychosocial rehabilitation
Observation emotional,
matic treatment of be-
Observation
and
partial manage-
havioral, and
ment of social
cognitive re-
side and inter-
sponses to
action effects
pharmacological and somatic treatment Observation
and
partial management of emotional, behavioral, or cognitive side and interaction effects
Fig 5.
Biopsychosocial intervention.
chological dimension is personal support, and added to the social dimension is social support and psychosocial rehabilitation. This reflects the need to formalize within the practice of psychiatricmental health nursing the integration of supportive services that assist patients and families in accepting their entire treatment, and explore and test new ways of coping and living as treated patients and families. These support functions preeminently fall within the practice domain of nursing as it contributes to multidisciplinary and multifocal care. Thus the critical role of nursing in assuring, at the very personal level of patient and family, both foundation to and continuity of recovery from mental illness is underscored. Biological insights expand the scope of practice in the biological dimension of treatment opportunities for psychiatric-mental health nursing. The passive and prescribed administration of pharmacologic agents and involvement in other somatic therapies of the past can now unfold into the in-
terdependent participation of nursing in somatic treatments at the purely biological level as well as at the psychobiological level. In addition to, say, administration and monitoring of physical parameters at the biological level, care at the psychobiological level can include patient and family education about somatic treatments; pretreatment, peritreatment, and posttreatment psychosocial support; promotion of appropriate and sustained medication behaviors; and assessment of cognitive deficits and development of supportive interventions designed to assist patients to cope with deficits, to name a few. Nursing interventions at the psychobiological and sociobiological interface further include the partial management of emotional, behavioral, cognitive, and social side and interaction effects due to somatic treatments as a follow-up to their nursing observation, in addition to continued observation of change in these areas in response to somatic intervention. These expanded practice opportunities associ-
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ated with biopsychosocial integration also mirror the growing interchange between nursing and other mental health disciplines. In fact, as Fig 5 illustrates, perhaps the most significant impetus created by biopsychosocial integration and the renaissance of the discipline of psychiatric-mental health nursing is the development of multifocal and multidisciplinary care-preventative, restorative, and palliative-for patients and families through collaboration across disciplines and professions and by bridging professional care to nonprofessional care (e.g., self-help groups). This, we believe, is the ultimate clinical gain to be achieved by patients and families and the ultimate professional benefit to be attained by psychiatric-mental health nursing. CONCLUSION
Multifocal and multidisciplinary care incorporating biological, psychological, and social dimensions from the diverse vantage points of multiple disciplines is essential to the growth of the mental health field at large, as well as the further development of psychiatric-mental health nursing. The advances in neuroscientific understandings of the interrelationships between brain, behavior, emotion, and cognition offer new opportunities for psychiatric-mental health nursing. Perceived by
some as holding the danger of fragmenting or diverting psychiatric nursing from its past strengths, this knowledge constitutes the third, yet often forgotten, dimension in the biopsychosocial mandate that is generally accepted within the discipline REFERENCES Fagin, C.M. (1981). Psychiatric nursing at the crossroads: Quo vadis? Journal of Psychosocial Nursing and Mental Health Services. 19, 99-106. Fox, J.C. (1990, November). Biologicfactors and information processing deficits associated with schizophrenia: A review of thefindings. Paper presented at the Second Annual State of the Science of Psychiatric Nursing Conference. National Institute of Mental Health, Bethesda. MD. Fox, J.C. (in press). Psychiatric nursing in the 1990s. In L. Aiken & C. Fagin (eds.), Nursing in health policy: Issues of the 1990’s. Philadelphia: Lippincott. Liaschenko, J. (1989). Changing paradigms within psychiatry: Implications for nursing research. Archives of Psychiatric Nursing,3, 153-158. Lowery,
B.J. (1992). Psychiatric nursing in the 1990s and beyond. Journal of Psychosocial Nursing and Mental Health Services, 30. I- 13
McBride, A.B. (1990). Psychiatric chives of Psychiatric Nursing,
nursing 4.
in the 1990s. Ar-
2 l-28,
Underwood, P. (1990, November). Schizophrenia: Psyehosocial environmental factors. Paper presented at the Second Annual State of the Science of Psychiatric Nursing Conference. National Institute of Mental Health, Bethesda, MD.
Advances in neuroscientific understandings of the interrelationships between brain, behavior, emotion, and cognition offer new opportunities for psychiatricmental health nursing. Yet, even though the discipline conceptually embraces a biopsychosociai perspective as part of its holistic mandate, the factual integration of biological sciences into practice, research, and education is limited. Integrating the biological perspective into a holistic paradigm and progressing toward a discipline in which the biological, psychological, and social interact coherently and interdependently requires a dual focus on understanding and treating patients and their social and physical environments. We describe how in the past the discipline has strived toward understanding and treating patients from predominantly psychological and social perspectives. We also show how progress in the biology of mental health and iliness provides new avenues for understanding and treating patients’ responses to actual and potential health problems. This in turn will contribute to the emergence of a truly holistic discipline of psychiatric-mental health nursing.
Copyright
0 1992 by W.B. Saunders
T
HE DISCIPLINE of psychiatric-mental health nursing has undergone significant changes over the past three decades, many of which were cogently summarized by Fagin (198 1): psychiatricmental health nurses’ achievement of status within the profession and colleagueship with other disciplines; significant involvement in major move-
From the School of Nursing; Department of Behavioral Medicine and Psychiatry, School of Medicine; Center on Aging and Health and Rural Mental Health Research Center; University of Virginia, Charlottesville, VA the Division of Nursing, University of Virginia Medical Center, Charlottesville, VA and the Catholic University of Leuven, Leuven, Belgium. Supported by Grant No. 1 TOlMH19362 from the National Institute of Mental Health (Rockville, MD) and Grant No. UHCBOOO3J from the W.K. Kellogg Foundation (Battle Creek, MI). Address reprint requests to lvo L. Abraham, Ph.D., FMN., C.S., Center on Aging and Health, University of Virginia, 170 Rugby Rd., Charlottesville, VA 22903. Copyright 0 1992 by W.B. Saunders Company 0883~9417/92lO605-0007$3.OOlO
296
Company
ments of community mental health, family therapy, and the use of systems theory as a foundation for psychotherapeutic practice; the development of the role of clinical nurse specialist; and the emergence of liaison psychiatric nursing as a critical role in hospital settings. What perhaps has been overlooked in these profound changes is a consideration of physical dimensions of mental health and mental illness, and the interaction between physical and mental factors in the development and maintenance of illness and its treatment. The call to integrate the biological sciences into psychiatric-mental health nursing is recent. McBride (1990) argues that we must be responsive to current trends and discontinue ignoring or devaluing the significant new evidence of biological determinants of mental health and illness. She also contends that two major readjustments are necessary for the discipline to experience a renaissance in the 1990s: the need to stop devaluing biological knowledge and the necessity of becoming funda-
Archives of Psychiatric Nursing, Vol. VI, No. 5 (October), 1992: pp. 296-305
INTEGRATING
THE BIO INTO BIOPSYCHOSOCIAL
mentally reassociated with care and caring. In other words, the discipline faces the challenge of integrating the biological into the biopsychosocial, and therefore must cease giving lip service to the biological without rejecting its longstanding and unique hallmarks of psychosocial care. Lowery (1992), Fox (1990, in press), and Underwood (1990) have also challenged psychiatric nurses to access neuroscientific knowledge and apply this knowledge in research about psychiatric nursing care. Both Lowery (1992) and Fox (1990) have questioned the resistance of many psychiatric nurses to the incorporation of this knowledge. Lowery (1992) expresses doubt about Liaschenko’s (1989) claim that integration of neuroscience will be detrimental to the art of psychiatric nursing and patients receiving psychiatric nursing care. Lowery (1992) proposes that unless psychiatric or objectively document nursing can “rationalize [its] practice with the technology and knowledge available” (p. 9) to the discipline, it will do a disservice to both patients and profession. She also questions the logic of psychiatric nursing’s seeming ready adoption of psychological, sociological, and anthropological paradigms, but its resistance to basic biological sciences. The National Institute of Mental Health and psychiatric nursing organizations, such as the Society for Research and Education in Psychiatric-Mental Health Nursing, have promoted psychiatric nursing education about new discoveries in the neuroscience of mental illness. However, individually, many psychiatric nurses appear wedded to the notion that incorporation of this knowledge in explanatory models or intervention strategies will somehow destroy the uniqueness of psychiatric nursing practice and research CONCEPTUALIZING
A BIOPSYCHOSOCIAL
DISCIPLINE OF PSYCHIATRIC-MENTAL HEALTH NURSING
Integrating the biological perspective into a holistic paradigm within psychiatric-mental health nursing and progressing toward a discipline in which the biological, the psychological, and the social interact coherently and interdependently requires a dual focus on understanding and treating patients and their social and physical environments. Understanding patients within a truly biopsychosocial psychiatric-mental health nursing framework requires retrospection: “looking back”
297
and “looking into” through nursing observation and assessment, etiological and causal explanation, and nursing diagnosis. Treating patients is prospective: “looking forward’ ’ by means of nursing prognosis on the basis of systematic and expert intervention. We use this dual focus on understanding/ retrospection and treating/prospection to guide our proposed conceptualization of a biopsychosocial discipline of psychiatric-mental health nursing. We first describe, intuitively rather than empirically, how the discipline has strived to understand and treat patients; and how this has been mostly within the psychological and social spheres (see Fig 1). Similarly, we show how the major treatment paradigms of the discipline have relied mostly on principles of psychological and social intervention (see Fig 2). Next, we show how scientific progress in the biology of mental health and mental illness has opened new avenues for nurses to understand patients’ responses to actual and potential mental health problems (see Fig 4). We also document how nursing, independently as a clinical-scientific discipline and interdependently as a critical discipline within the multidisciplinary team, can care for patients and families by integrating the biological, psychological, and social dimensions (see Fig 5). The content depicted in Figs 4 and 5 must be interpreted within the context of multifocal. balanced knowledge sketched in Fig 3. The Venn diagrams represent the psychological, social. and biological dimensions, and their mutual interdependencies. In these diagrams, each dimension has its separate area to refer to the distinct contributions made independently by the psychological, social, and biological dimensions. These diagrams also feature three joint areas to denote the integration of two dimensions and the contributions thus made to the discipline of psychiatricmental health nursing. These interdependent regions are the psychosocial, psychobiological, and sociobiological areas. Finally, there is the area at the intersection of the three dimensions to refer to the biopsychosocial integration of theoretical. scientific, and clinical knowledge within the discipline. Figures 1, 2, 3, and 4 summarize the knowledge bases used in psychiatric-mental health nursing in understanding (Fig 1) and treating (Fig 2) patients and families in the past, and the emerging context (Fig 3) and knowledge base for under-
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standing (Fig 4) and treatment (Fig 5) in the future. Figures 1 and 2 depict, by means of arrows, the major trends of dynamic knowledge integration across dimensions for understanding and treatment within a psychiatric-mental health nursing framework. Thick arrows denote strong exchanges, while thin arrows refer to weaker exchanges. The direction of arrows indicates the predominant direction of these exchanges, many of which may be unidirectional. PAST DEVELOPMENTS AND TRENDS
Understanding Mental Health and Mental Illness
The discipline’s predominant approaches to understanding mental health and illness have been within the psychological and social spheres, with both dimensions drawing to a limited extent on the
Emotion, behav-
Emotion, cogni-
Global, undifferentiated, and
ior, and cogni-
tion, and behav-
tion determined
ior determined
system-nonspe-
by intraper-
by dynamics of:
cific views on
sonal dynamics
family of origin,
biophysical dys-
current family,
function, orga-
No. of dyadic
nicity, manifest
Emotion-focused coping
biological dimension (Fig 1). The psychological dimension has contributed the insight that emotion, cognition, and behavior are determined by intrapersonal dynamics, many of which in turn are traced developmentally through application of frameworks that emphasize the role of childhood development in maturation to adulthood. Within a more applied context, the psychological dimension has also brought to the discipline an understanding of the coping processes people use to deal with a variety of life or developmental events. The social dimension, which historically has differentiated psychiatric-mental health nursing from many other mental health disciplines, has taught us that emotion, cognition, and behavior are influenced by social forces encompassing family and community (the latter including cultural and racial subgroups). Family forces include family of origin, extended
Biologic4
Social
relationships,
physical illness,
friends, small
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social groups,
cal impairment
large social groups, ethnicity, and community Psychosocial Intrapersonal terminants
deof
social function-
Mind to body in-
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Interpersonal
im-
biophysical im-
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teraction physical illness
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pairment
Psychosocial adaptation Behavior-focused coping Social support Relational adequacy Community
inte-
gration Fig 1.
FOX, AND COHEN
Past nursing understandings
of mental health and illness.
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family, and dyadic and other significant relationships. Community forces range from friends and other small groups bound by affection and common interests to larger social entities, with ethnicity (in the broad sense of the word, including but not limited to race) and community interwoven throughout the extended social relationships and affiliations of people. Contributions from the biological dimension, existent only modestly in the past, have been global, rather undifferentiated, and often etiologically removed from organ systems. The biological contributions mostly have been views, rather than empirically substantiated knowledge, on the role of biophysical dysfunction and organicity, manifest physical impairment, and manifest physical illness on emotion, cognition, and behavior. Knowledge about understanding mental health and mental illness at the interchange of dimensions has been very strong in the psychosocial area, less strong in the psychobiological and sociobiological areas, and quasi-nonexistent in the biopsychosocial area (see also the thick and thin arrows in Fig 1). Psychosocial understanding of mental health and illness has emphasized the intrapersonal and the interpersonal determinants of social behavior and social functioning. It has brought to the discipline knowledge about how people adapt psychosocially to stressors, including the interpersonal nature of behavioral coping strategies. Psychosocial knowledge also includes understandings about the role of social support in mental health. Psychosocial knowledge stresses the importance of personal and significant relationships to people’s mental health and to the functioning of families and social groups. Relational adequacy at the interpersonal level and community integration at the social level are seen as significant determinants of mental health. At the interchange of psychobiological knowledge, the discipline’s emphasis on understanding largely has been from the psychological to the biological, and only to a lesser extent from the biological to the psychological (note the different arrows in Fig 1). The psychological-tobiological knowledge is well accepted within the discipline of psychiatric-mental health nursing. The impact of mind on body is recognized; yet perhaps inappropriately we have called this the “mind-body interaction,” when in fact most of the emphasis has been unidirectionally (and therefore “noninteractionally”) on the impact of mind on
physiology. Other important psychological-tobiological understandings pertain to how people adapt to physical illness (see thick arrow in Fig 1) and how biophysical impairment may lead to intrapersonal impairment (see thin arrow in Fig 1). At the interchange of sociobiological knowledge, there has been some consideration of the impact of biophysical impairment on interpersonal functioning. Treating Mental Health and Mental Illness
In concert with past trends in understanding mental health and illness in psychiatric-mental health nursing, the discipline’s treatment foci have emphasized psychological and social approaches, perhaps the hallmarks of the discipline in decades past (Fig 2). Within the psychological dimension, nurses have provided therapy and counseling services. In keeping with psychological understandings, the emphasis has been primarily on emotions, and secondarily on behavioral management. Treatment approaches targeting cognitions and their impact on well- and ill-being have been less prevalent. Nurses have also provided clinical leadership in using various micro and macro social environments as media for treatment. The integration of systems theory into psychiatric-mental health nursing has facilitated nursing interventions linking patients to their significant others and families. Recognition of the therapeutic effects of group process has encouraged a variety of nursing interventions. These have ranged from conventional group therapies-mostly stressing emotion, behavior, and cognition, in that order-to diverse applications of therapeutic group work to promote interpersonal skills, social integration, and functional independence. Within the mental health field at large, nursing has also provided the clinical leadership in using the social environment at large as a treatment medium, as evidenced by nursing interventions to promote social integration and the use of the milieu as context and agent for intervention. In contrast to these psychological and social strengths, nursing’s biological treatment commitments have been limited largely to the administration of psychopharmacologic agents and occasional assistive involvement in other somatic treatments, that is, the execution of physicianprescribed treatment regimens. Nursing’s strength in the psychological and social treatment dimensions is evidenced most in its
ABRAHAM,
Psychological Individual coun-
Social
Biological
Counseling and
seling and ther-
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apy, focused
ing significant
primarily on
other, family,
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FOX, AND COHEN
and groups
Administration
of
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ondarily on be-
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havior, and ter-
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tiarily on cognition Psychosocial Counseling and
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of
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of so-
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Fig 2.
Past nursing treatments
psychosocial interventions (see also Fig 2). Recognizing the importance of bringing intrapersonal well-being into the realm of social relations, and asserting the significance of social contexts in shaping intrapersonal dynamics, psychiatricmental health nursing has assumed the leadership in interventions focused on psychosocial functioning and psychosocial integration. The intellectual strength, clinical vigor, and recognized leadership in the psychosocial dimension contrast sharply with the relative superficiality of psychiatricmental health nursing at the biological interfaces. At the psychobiological interface, nursing’s role has involved important but limited responsibilities associated with pharmacologic and somatic treatment: observing for emotional improvement and behavioral adaptation, and monitoring for emotional, behavioral, or cognitive side and interaction effects. Likewise, at the sociobiological interface, nursing’s role has been confined to observing for improvement in social functioning and monitoring for social side and interaction effects associated with pharmacologic therapy. Truly biopsychosocial nursing intervention has been quasi-absent to date.
of mental health and illness.
TOWARD BIOPSYCHOSOCIAL INTEGRATION
To effectively respond to McBride’s (1990) call to integrate the biological knowledge with the discipline’s traditional commitments of care and caring, a dynamic balance between psychological, social, and biological forces of knowledge must be achieved. This balance, moreover, goes beyond the boundaries of holism, as it is situated within nursing’s larger context of patient, environment, and health. Figure 3 sketches the balance in biopsychosocial forces to be achieved, depicted by the arrows within the Venn diagrams. These arrows, identical in form, reemphasize the importance of psychosocial, psychobiological, and sociobiological interchanges in how we understand and treat mental health and mental illness. They also mirror the mandate to focus inward toward the holistic merging of knowledge into biopsychosocial understandings of the development, maintenance, and resolution of mental health and mental illness as the basis for biopsychosocia1 approaches to nursing-and, by consequence, multidisciplinary intervention. In addition, Fig 3 outlines the multiple contextual forces that shape the intellectual and
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Social Environment
Growth
Family
Physical
clinical environment within which the future practice of psychiatric-mental health nursing must take place. This context is composed of the patient as a person, influenced and profiled by the forces of growth and development, yet also endowed with the talents of free will and self-determination. The patient interacts with a continuum of social forces that range from immediate family, through interpersonal relations in smaller groups, to the larger social environment of community and ethnicity. The patient interacts with clinicians, thus becoming the focal point in the therapeutic processes of understanding health and illness; treating and preventing illness; and promoting, restoring, or maintaining health. Understanding Mental Health and Mental Illness
The biopsychosocial integration of knowledge about mental health and mental illness must draw on the intellectual and clinical traditions of the discipline of psychiatric-mental health nursing. Past approaches to understanding mental health and illness within the psychological, social, and psychosocial dimensions continue in importance and provide essential direction in the interpretation of psychosocial determinants. To this must be added the expanded knowledge dimensions of biological understandings of mental health and the pathogenesis and treatment of mental illness. As Fig 4 illustrates, these understandings are centered predominantly on the brain: neuroanatomy, neuro-
Enwronment
Fig 3. Context of biopsychosocial nursing understanding and treatment.
physiology, and neuropathology; cortical, subcortical, and limbic systems; intracellular, neuronal processes; intercellular processes, including the biochemistry of neurotransmitters, receptors, presynaptic and postsynaptic activity, and synaptic cleft activity; biochemical trajectories within the brain; and functional information processing trajectories within the brain. In addition, biological knowledge includes the role of other organ systems on mental health and illness, especially the interactions among organ systems; endocrinological determinants; genetic factors, both in terms of direct genetic determination and in terms of familial predisposition; and sensory processes as they interface with the pathogenesis and clinical course of mental illnesses. Last, the biological dimension also includes the pharmacodynamics and pharmacokinetits of various classes of biological agents within the human body and brain. All of this biological evidence from the basic sciences offers the discipline of psychiatric-mental health nursing new opportunities for understanding health and illness. The psychosocial interface can expand to include, foremost, a truly bidirectional appraisal of the interaction between mind, as both a biological and psychological entity, and body, as a biological entity: how mental processes influence biological processes, but also how biological processes influence mental processes. Cognitive processes, as a subset of mental processes, can be better understood, again in a bidirectional sense: how cognition impacts on biological processes, but
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ABRAHAM,
FOX, AND COHEN
6iclogical Emotion,
cogni-
Emotion,
cogni-
tion, and behav-
tion, and be-
ior determined
havior
deter-
by intrapersonal
mined
by
dynamics
dynamics
Emotion-focused coping
Intrapersonal
de-
terminants
of
tems
of origin,
among
family,
systems
dyadic
relation-
Endocrinology Genetics
small and large
Sensorium
social groups,
Pharmacodynam-
and
macokinetics
Psychobiological
Sociobiological
Mind and body interaction
Psychosocial
ad-
aptation
cogni-
Adaptation
to and
mental
illness
Intrapersonal
im-
pairment
due to
biophysical pairment
quacy gration
inte-
Social cognition Interpersonal
im-
pairment
due to
biophysical
physical
Relational Community
tox-
ins
Social support ade-
Impact of environmental
tion
func-
its and phar-
community
Personal
tioning
organ
ships, friends,
ing
personal
Interactions
current
Intelligence
nants of inter-
system
family
social functionSocial determi-
nervous
Other organ sys-
of
ethnicity,
Psychosocial
Brain and central
im-
pairment
im-
Biopsychoaociel Schizophrenic spectrum
disor-
ders Major depressive disorders Other bipolar
dis-
orders Appetitive
disor-
ders Obsessive-compulsive
disor-
ders Organic
syn-
dromes Anxiety
and
panic disorders Dementias Sexual
disorders
Violence Fig 4.
Biopsychosocial
also how the biochemistry of mental processes enhances or diminishes various cognitive operations. Past understandings about psychological adaptation to physical illness and the impact of biophysical impairment on intrapersonal well-being can
understandings.
now be expanded with knowledge about physical adaptation to both physical and mental illness. Sociobiological knowledge for the discipline extends beyond its past limitations about the impact of biophysical impairment on social functioning.
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Advances in the biology of mental health and illness offer psychiatric-mental health nursing with a framework for understanding the interplay between environmental toxins and emotion, behavior, and cognition. Social cognition, or how people process information about others in relation to themselves, relies on both social and biological processes, offering nurses an expanded approach to appraising patient interactions and relations with significant others, families, small and large groups, and community and ethnicity. This leaves the knowledge dimension at the biopsychosocial interface. Figure 3 shows this interface area as listing several major classes of mental illness. Why is this conceptualized as an apparent return to an unpopular perspective in nursing, the so-called “medical model”? While hindsight always has the illusion of being perfect, the discipline of psychiatric-mental health nursing perhaps can be faulted for having abandoned mental illness for mental health. Opposition within nursing at large to medical terminology, couched as opposition to all matters medical, has isolated many of its specialties, including psychiatric-mental health nursing, from its associated health disciplines. This evolution has been grounded in a dual premise rather than in cogent and unbiased argumentation. The dual premise is (1) that, because historically health/illness terminology has evolved from medical disciplines, this terminology exclusively advocates the interests of medical practice; and (2) that medicine at large has long thwarted the development of nursing at large and should therefore be perpetually cast in the role of an (unnatural) adversary, rather than a (natural) ally in health care. The utility of established medical terminology lies in its hierarchical organization, which is of clinical and scientific benefit to medicine, as well as any other health discipline. This hierarchy describes the multiple and interacting levels of knowledge and accompanying individual languages that must be employed in understanding and treating the human conditions, actual and potential, described alternately as diseases or illnesses. The nursing discipline accesses these same levels of knowledge and languages and philosophically uses this knowledge to understand and practice caring, rather than curing. The common knowledge base shared by medicine and nursing provides a natural mechanism for communication and improved treatment and care if members of the
disciplines can clearly articulate the differences in the application of this knowledge in practice and research. Asserting the superior importance of one or the other principal application (medicine or nursing) is not in the best interest of human health. Instead, increasing efforts to investigate, understand, and describe effective alternative applications may result in advancement of nursing and medical sciences and in turn improve the health conditions of interest. Mental illnesses are health conditions to be cured, prevented, or palliated by psychiatricmental health nurses independently and interdependently. In keeping with emerging new classifications within the mental health domain at large, they include the following classes: (1) the schizophrenic spectrum disorders, from schizophrenic disorders to the more insidious thought disorders; (2) major depressive disorders as biologically determined mental illnesses; (3) other bipolar disorders, with or without documented or presumed biological determinants, including mood disorders related to coping with the problems of life and living, relationships and relating; (4) appetitive disorders, from abuse of legal and illegal substances, to impairment due to excessive and inappropriate adherence to, use of, or practice of substances (e.g., food), cognitions (e.g., obsessions, ideologies, religions, imaginations), behaviors (e.g., compulsions, exercise). or emotions (e.g., exaltation); (5) obsessive-compulsive disorder; (6) organic syndromes; (7) anxiety and panic disorders, including conditions of acute or chronic uncertainty; (8) dementias of various biological or nonbiological etiology; (9) sexual disorders of appetite, as well as intrusion/violence: and (10) violence directed at self or others. Treating Mental Health and Mental Illness
How does the biopsychosocial integration of clinical knowledge create new opportunities for the practice of psychiatric-mental health nursing? Parallel to our earlier recommendation to draw on established and respected traditions, nursing contributions to the treatment and prevention of mental illness and the promotion of mental health must rely on its past achievements in the psychological, social, and psychosocial dimensions. The areas in Fig 5 that represent these dimensions retain the clinical interventions of the past. Added to the psy-
ABRAHAM,
Social Individual coun-
Interventions
FOX, AND COHEN
BiologIcal
in-
Interdependent
seling and ther-
valving signifi-
apy focusing
cant other, fam-
pharmacologi-
simultaneously
ily, and groups
cal and somatic
on emotion,
Social integration
behavior, and
Milieu
participation in
treatments
cognition Personal support Psychosocial Interventions
Psychobiological Patient and family
Sociobiological Observation
of
aimed at psy-
education about
social response
chosocial func-
pharmacologi-
to pharmaco-
tioning and in-
cal and somatic
logical and so-
tegration
treatment
Social support Psychosocial rehabilitation
Observation emotional,
matic treatment of be-
Observation
and
partial manage-
havioral, and
ment of social
cognitive re-
side and inter-
sponses to
action effects
pharmacological and somatic treatment Observation
and
partial management of emotional, behavioral, or cognitive side and interaction effects
Fig 5.
Biopsychosocial intervention.
chological dimension is personal support, and added to the social dimension is social support and psychosocial rehabilitation. This reflects the need to formalize within the practice of psychiatricmental health nursing the integration of supportive services that assist patients and families in accepting their entire treatment, and explore and test new ways of coping and living as treated patients and families. These support functions preeminently fall within the practice domain of nursing as it contributes to multidisciplinary and multifocal care. Thus the critical role of nursing in assuring, at the very personal level of patient and family, both foundation to and continuity of recovery from mental illness is underscored. Biological insights expand the scope of practice in the biological dimension of treatment opportunities for psychiatric-mental health nursing. The passive and prescribed administration of pharmacologic agents and involvement in other somatic therapies of the past can now unfold into the in-
terdependent participation of nursing in somatic treatments at the purely biological level as well as at the psychobiological level. In addition to, say, administration and monitoring of physical parameters at the biological level, care at the psychobiological level can include patient and family education about somatic treatments; pretreatment, peritreatment, and posttreatment psychosocial support; promotion of appropriate and sustained medication behaviors; and assessment of cognitive deficits and development of supportive interventions designed to assist patients to cope with deficits, to name a few. Nursing interventions at the psychobiological and sociobiological interface further include the partial management of emotional, behavioral, cognitive, and social side and interaction effects due to somatic treatments as a follow-up to their nursing observation, in addition to continued observation of change in these areas in response to somatic intervention. These expanded practice opportunities associ-
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ated with biopsychosocial integration also mirror the growing interchange between nursing and other mental health disciplines. In fact, as Fig 5 illustrates, perhaps the most significant impetus created by biopsychosocial integration and the renaissance of the discipline of psychiatric-mental health nursing is the development of multifocal and multidisciplinary care-preventative, restorative, and palliative-for patients and families through collaboration across disciplines and professions and by bridging professional care to nonprofessional care (e.g., self-help groups). This, we believe, is the ultimate clinical gain to be achieved by patients and families and the ultimate professional benefit to be attained by psychiatric-mental health nursing. CONCLUSION
Multifocal and multidisciplinary care incorporating biological, psychological, and social dimensions from the diverse vantage points of multiple disciplines is essential to the growth of the mental health field at large, as well as the further development of psychiatric-mental health nursing. The advances in neuroscientific understandings of the interrelationships between brain, behavior, emotion, and cognition offer new opportunities for psychiatric-mental health nursing. Perceived by
some as holding the danger of fragmenting or diverting psychiatric nursing from its past strengths, this knowledge constitutes the third, yet often forgotten, dimension in the biopsychosocial mandate that is generally accepted within the discipline REFERENCES Fagin, C.M. (1981). Psychiatric nursing at the crossroads: Quo vadis? Journal of Psychosocial Nursing and Mental Health Services. 19, 99-106. Fox, J.C. (1990, November). Biologicfactors and information processing deficits associated with schizophrenia: A review of thefindings. Paper presented at the Second Annual State of the Science of Psychiatric Nursing Conference. National Institute of Mental Health, Bethesda. MD. Fox, J.C. (in press). Psychiatric nursing in the 1990s. In L. Aiken & C. Fagin (eds.), Nursing in health policy: Issues of the 1990’s. Philadelphia: Lippincott. Liaschenko, J. (1989). Changing paradigms within psychiatry: Implications for nursing research. Archives of Psychiatric Nursing,3, 153-158. Lowery,
B.J. (1992). Psychiatric nursing in the 1990s and beyond. Journal of Psychosocial Nursing and Mental Health Services, 30. I- 13
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