Mental Health Nursing of Cocaine Addiction Essay

Introduction

Mental health nursing often includes working with drug and alcohol addicts, which adds an extra layer of complexity to their care plan. So is the case of Keith, a twenty-year-old man who suffers from cocaine addiction. Keith is committed to a mental health facility due to his violent outburst. During the said outburst, he assaulted his pottery instructor at the courses he has been attending for a while and genuinely enjoyed. At first glance, Keith does not give an impression of an aggressive person: he is quiet, looks frightened, and has a tremor. The patient does not want to be treated in an acute care unit; however, he does show much resistance.

Upon further analysis, it becomes apparent that Keith comes from an extremely troubled background. Born to a Nigerian mother and a Scottish father, the patient was deprived of proper care in his family setting. Keith’s parents were not able to look after him as they were haunted by their own demons: his mother was schizophrenic, and his father had a severe alcohol problem. The patient was bullied in school, and it made him develop panic attacks, from which cocaine proved to be the only available relief. Keith’s care plan needs to address the physical, mental and social aspects of his condition and be both compassionate and effective. Addiction should be seen not as a problem but a symptom of a bigger issue, a complex phenomenon with many roots.

Case Formulation and Treatment Plan

Assessment

Keith was presented to the acute care unit in a state of extreme agitation and anxiety. The man looked disheveled and extremely thin, with weight loss potentially attributed to his excessive cocaine use. Some of the symptoms that Keith was displaying were matching the description of a panic attack provided by the National Health Services (n.d.). Keith had a racing heartbeat and hot flashes; he was suffering from chest pain and shortness of breath. The present symptoms also match the description for cocaine overuse posted by the National Health Services (n.d.). A large dose of cocaine must have led to the overstimulation of Keith’s heart and nervous system, which caused the aggression.

Keith was committed to the acute care unit under Section 3 of the Mental Health Act (1983). The 1983 Mental Health Act is an Act of the Parliament of the United Kingdom that applies to the residents of England and Wales. The act addresses the reception, care and treatment of patients with mental disorders and other related issues (“Mental Health Act 1983”, 2020). Section 3 of the Mental Health Act contains guidelines regarding the admission of treatment. Namely, it states that admission for treatment may be administered if it is necessary for “the health or safety of the patient or for the protection of other persons (“Admission for Treatment”, 2020).” In Keith’s case, his violent outbursts after doing cocaine over the weekend were threatening to the health and safety of his pottery course instructor. To prevent the altercation from escalating and potentially affecting other people, Keith was arrested and taken to an acute care unit.

Keith’s case contains predisposing, precipitating, perpetuating and protective factors:

• Predisposing factors

Probably, the most significant predisposing factor in Keith’s case is his upbringing. The patient grew up in a broken family where neither of the primary caregivers was able to meet his needs. Kelley et al. (2015) write that children whose parents suffer from addiction and mental illness are at a higher risk of being maltreated and abused. Kelley et al. (2015) specifically point out the risk of maltreatment in “dual” couples – the parental couples where both substance abuse and mental disorders are present. This is exactly the case when it comes to Keith’s situation: his mother was often admitted to the hospital due to schizophrenic episodes, and his father would binge drink on a regular basis. According to Kelley et al. (2015), such parents are unable to connect with children emotionally. At the same time, they tend to be overreactive during disciplinary encounters, which happened when Keith’s father learned about his son’s truancy (Kelley et al., 2015).

It should be noted that adverse childhood experiences have long-standing consequences for victims’ mental health. Adverse childhood experiences are a broad topic that encompasses negligence, loss of a relative, emotional suffering, physical violence and other categories of traumatizing events (Allen, 2018). In Keith’s case, it was total neglect of his needs and abandonment in the time when he needed protection such as when he was bullied in school. The trauma may persist well into adulthood and lead to undesirable life outcomes. Merrick et al. (2017) show a strong relationship between adverse childhood experiences and four categories of outcome: drug use, alcohol use, depressed affect and attempted suicide. For Keith, at least two categories of outcomes are true – cocaine use and depressive syndrome.

• Precipitating factors

The key precipitating factor for Keith’s mental health crisis was his experience of being bullied by his schoolmates. In his younger years, the patient fell victim to the so-called relational bullying. According to Smith (2016), relational bullying encompasses a wide range of behaviors that hurt a person’s social status and prevent them from building relationships in their peer group. For example, the perpetrators might spread rumors, purposefully ignore, boycott, or exclude the victim, which is true in Keith’s case. Chester et al. (2017) show that relational bullying is detrimental to young people’s health-related quality of life. Per the findings made by Evans-Lacko et al. (2017), the effects of school bullying linger for years and predict a person’s need to use mental health services in adulthood.

• Perpetuating factors

The perpetuating factor in Keith’s story is the actual benefits that cocaine use presents for him. Apparently, the patient uses cocaine to treat his panic attacks: it helps him to take control of his irritability and boost his confidence. What aggravates the situation is that Keith’s drug addiction was a shared behavior with probably his first real friend John that he met at one of the facilities. Terrion, Rocchi and O’Reilly (2015) opine that friendships made in rehabilitation facilities are ambiguous. On the one hand, they can be a protective factor as due to the high level of antisociality among the residents, they might be a rare chance at intimacy and bonding with another human being (Terrion, Rocchi & O’Reilly, 2015). On the other hand, during the process of recovery, it is recommended to cut ties with substance-abusing friends. It seems that in Keith’s case, the friendship with John was more a negative than a positive factor.

• Protective factors

Even though Keith was not receiving enough care and affection from his parents, his early years were not completely devoid of meaningful adult figures. Brown and Shillington (2016) show that the presence of protective adult relationships moderated the link between adverse childhood experiences and substance use. Adverse childhood experiences are considered “tolerable stress” when young people are supported by protective relationships, especially those that helped them to develop adaptive coping skills (Brown & Shillington, 2016). In Keith’s case, his relationship with his grandmother was protective. Despite her old age, she helped to meet his most basic needs. Apart from that, the grandmother introduced him to painting and furniture repair that for Keith, were serving as a major relief from stress. Some other protective factors include Keith’s interest in pottery and his desire to continue working.

Planning

The planning of treatment should not exclude the patient himself – instead, it is critical that he be an equal participant in the discussion with autonomy and decision-making power. The proposed framework for Keith’s case is the three-phase conversational model of communication. The model seeks to help health professionals with self-supervision (Acott, 2015). The framework offered may guide their interactions as well as act as a tool for self-reflection (Acott, 2015). As proposed by Acott (2015), the three-phase conversational model has the potential of resolving the dialectic of care.

On the one hand, the patient is the leading expert of their own life: only they get to decide which course to take and what decisions to make. On the other hand, patients, especially those admitted to mental health facilities, often suffer and struggle with dealing with the reality of their life. For this reason, they need gentle, compassionate input and some guidance from a professional. In summation, the three-phase conversational model is not a psychotherapeutic or counselling model. As noted by Acott (2015), first and foremost, the model promotes change.

The three stages of the proposed model are connected, sharing information and finding agreement (Acott, 2015). In Keith’s case, the initial connection is pivotal to his treatment. The patient is apprehensive about starting a new treatment plan; he does not like being admitted to a psychiatric facility. At the same time, Keith is young, lonely and above all, might be seeking understanding and companionship. For this reason, the initial connection that the team makes with him might turn them into tyrants or friendly helpers in his eyes.

Compassion has been long seen as a fundamental element of nursing practice. Hewison and Sawbridge (2016) write that to be compassionate means to understand what the patient is going through. According to Hewison and Sawbridge (2016), compassionate nursing means alleviating patients’ pain and not causing unnecessary suffering. Truly, Keith has had enough pain and suffering in his life, and if he is met with contempt in a place where he is supposed to receive help, he might as well become even more enclosed and isolated. A compassionate nurse addresses individualised care needs, as in, he or she does not see a patient as their disease but treats them as a human being (Hewison & Sawbridge, 2016). This is consistent with the concept of person-centered care that prioritises listening to, informing and involving patients in the process of care administration (Townsend & Morgan, 2017). Following this logic, Keith should not be treated by just another drug addict but a person with their own story, strengths and weaknesses.

The second stage is sharing information about past medical history and important life events. Sharing information follows building a connection because being honest about oneself is impossible without good rapport and trust. At this stage, electronic health information exchange (HIE) should play a central role in bringing together a multidisciplinary team of doctors, nurses, pharmacists and other health care workers. HIE lets all the stakeholders access and securely share the patient’s vital medical information through electronic media. If health information exchange is well-maintained, each of the specialists treating Keith will be making informed decisions because they will be seeing the full picture of his case. As a result, the patient can enjoy the improved speed, quality, safety and cost of care.

Lastly, the third stage is coming to a mutual agreement (Acott, 2015). If Keith does not accept a treatment plan or misunderstands its purpose, he is less likely to adhere to it. The third stage needs to highlight patients’ benefits if he manages to put his life in order. At that, the strengths-based approach that deploys a patient’s personal strengths to aid their recovery might be especially useful (Golightley & Holloway, 2019). As mentioned before, Keith’s case does contain protective factors that could be a source of empowerment for him. Firstly, he has a family member who is on his side – his grandmother. Secondly, the patient has career aspirations and hobbies: he seems to be particularly interested in art and manual work. These factors should be employed to guide Keith’s recovery process.

Because Keith’s problem has physical, mental and social roots, it requires a multidisciplinary team (MDT) of professionals. As members of an MDT, nurses are assigned a variety of roles. Nurses serve as case managers when they are taking charge of a patient and supporting them through investigation, diagnosis and treatment (East et al., 2015). Nurses help with the coordination of the procedures that are prescribed by other professionals (East et al., 2015). On top of that, nurses intervene as health educators and patient advocates (East et al., 2015). When needed, nurses may take part in data management and participate in study protocols, especially when it comes to research nursing.

Intervention

Today, it is safe to say that mental health issues in the United Kingdom remain largely untreated or undertreated. The MHFA England (2020) provides pessimistic numbers and figures regarding how the burden of mental illness is managed in the country. The MHFA England (2020) reports that 75% of people suffering from mental disorders were receiving any kind of treatment. Out of those who were in fact receiving care, only one-third had access to resources matching their level of need (Mental Health Foundation, 2020). These statistics suggest that there are faults in the system that prevent those in need from receiving the necessary services, which might as well affect the success of Keith’s treatment.

Now, Keith is currently administered a few medications that are helping him to manage his state:

• Sertraline (50 mg daily) is an antidepressant belonging to a group of drugs called selective serotonin reuptake inhibitors (SSRIs). Sertraline targets the chemicals in the brain that are unbalanced in individuals suffering from depression, anxiety and panic attacks. Keith has been suffering from panic attacks since school, and they are one of the reasons why he seeks relief in substance abuse;
• Ramipril (10 mg) is a drug used to treat high blood pressure. In Keith’s case, ramipril is used to mitigate the effects of cocaine use on his cardiovascular system and prevent him from collapsing;
• Promethazine (25 mg) is a drug that among other purposes, is used to sedate people who are anxious or agitated. Alongside sertraline, promethazine is prescribed to help Keith to relieve his panic attacks and overall agitation due to cocaine use;
• Clonazepam (0.25 mg) is a tranquiliser of the benzodiazepine class. It is prescribed to Keith to prevent seizures as well as treat panic attacks.

While the patient is likely to benefit from the prescribed drugs, medical treatment is not the end-all-be-all of mental health and addiction care. The entire intervention plan needs to be trauma-informed as it needs to promote a culture of safety, empowerment and healing. Keith’s addiction problem needs to be addressed at three levels: physical, mental and social. The aforementioned medications do help to tackle the physical side of his mental illness and addiction. However, full recovery is likely to require a bigger change such as becoming more physically active and gaining weight, especially muscle, through healthy eating and training. Since Keith has long had problems with body image (he was bullied in school for being overweight), he might find power in becoming fit and feeling more satisfied with his appearance.

At a mental level, Keith needs to address the root cause of his addiction – unresolved childhood trauma. As Mearns and Cooper (2017) note every problem once used to be a solution. Apparently, Keith’s cocaine use is a response to the overwhelming reality of neglect and isolation. The patient is likely to benefit from individual and group counseling. It is hard to say which kind of therapy would be the most efficient in his case. Mearns and Cooper (2017) write that victims of child abuse and generally patients with adverse childhood experiences do not show significant improvements when receiving cognitive behavioral therapy (CBT). CBT is based on rational “reprogramming” of negative thoughts and stepwise changes in behavior. Humanistic psychology that studies the whole person and puts emphasis on their uniqueness might be a potentially good choice.

Keith’s social situation has to undergo an overhaul as well if he wants to see any improvements. Firstly, the patient needs to double down on protective factors that were described previously in this paper. If his grandmother is still alive, it would be beneficial for the patient to keep in touch with her. His career ambitions and work interests should be also given the attention they deserve. Keith should continue attending his pottery courses or other courses of his choice and try to socialise with other students.

However, when it comes to comprehensive mental health interventions, there are significant barriers to successful administration. In the present case, there may be two kinds of barriers: on the patient’s side and on the facility’s side (Harvey & Gumport, 2016). According to Harvey and Gumport, patients often lack the motivation to adhere to treatment. Such non-adherence might stem from the inconvenience associated with receiving care, for example, if a mental facility is too far from the patient’s place of residence. Another reason is the patient’s lack of conviction that the prescribed treatment will help them to improve their life. Alternatively, the quality of mental health interventions might be compromised due to the issues on the provider’s side. For instance, a unit might be overwhelmed with patients or lack both human and financial resources to invest in individualised care. Harvey and Gumport (2016) do not offer any easy solutions for removing these barriers apart from slowly but steadily reforming the mental health care system in the United Kingdom.

Conclusion and Recommendations

Keith’s case is complicated on many levels: the young patient’s cocaine addiction has roots in his troubled childhood and traumatizing experiences such as parental neglect and school bullying. Apparently, cocaine use serves as a form of stress relief and a source of confidence for the patient. However, Keith’s case is not dead-end: his story contains a few protective factors that if used thoughtfully, could guide him on his way to recovery. His treatment plan needs to be trauma-informed and person-centered. The patient needs a holistic approach that would not only tackle the physical manifestation of his disease but would also improve his mental well-being.

If the proposed intervention proves to be successful, Keith is expected to leave the mental health facility in the nearest future. The first indication of change should be his behavior and self-discipline. With enough willpower, Keith will adhere to his medication plan as well as continue working and learning the trade without truancy. With the foundation of self-discipline and healthy habits, the patient might find it within himself to address his mental health and rebuild his social circle.

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