INSTITUTIONALIZATION

 MENTAL HEALTH - INSTITUTIONALIZATION

Chakupopa a known psychiatric patient of chainama hospital has been refusing to be discharged from the hospital despite feeling well after suffering an episode of a manic attack. Last month he brought himself and gave a bed to himself, after investigations a diagnosis of institutionalization was made

A.                 Define institutionalization     5%

B.                 State five (5) Features of Institutional Syndrome     30%

C.                 Describe five (5) Contributing factors to institutionalization 30%

D.                 Explain five (5) Preventive and Curative measures to address institutionalization  (35%)

DEF;

Institutionalization is a condition which has been recognized as being quite separate from the psychiatric illness which originally initiated the patient’s admission to hospital. The condition was first observed among the inmates of various types of institutions, thus the term became established. .

1. Features of Institutional Syndrome

2. Contributing factors

3. Preventive and Curative measures to address institutionalization

 

DEFINITIONS OF INSTITUTIONALIZATION

1. Also known as institutional syndrome, it is the condition of apathy resulting from lack of motivation characterizing patients and staff in institutions who have been subjected to rigid regimen with deprivation of choice and decision making.

2. It is a deficit or a disability in social and life skills, which develop after a person has long lived or spent a long time in a psychiatric hospital, prison or any other remote institution.

3. A condition of apathy and withdrawal occurring in residents of long stay institutions, prisons etc., as a result of rigid routines and lack of independence. The person may resist leaving because the routine has become predictable and familiar, making minimal demands (Barbara F. Weller, 2009).

CAUSES OF INSTITUTIONALISATION

1. Lack of guardian and family

2. Lack of material resources

3. Abandonment by family and guardians

4. Domestic violence

5. Substance abuse of parents or guardians

6. Extreme poverty

·     Lack of guardian and family; due to lack of family or guardian, the patient prefers yo stay in the hospital or prisons where they feel protected.

·     Abandonment by guardian and family; the family and friends tends to reject the patient due to his condition which might be violent such as theft, set fire etc

·     Domestic violence; because where the patient comes from there physically abused hence the patient is put chains, is being denied food  and there beaten.

·     Substance abuse by parents or guardian; after parents abuse substances they cause harm to the victim, hence they refused to go back home.

·     Lack of material and resources; when these people become institutionalized they fear to go back because they don’t have capital to establish a living.

·     Extreme poverty; the victim knows where he/she comes from there is poverty , so prefer to be institutionalized

 

 EXAMPLES OF INSTITUTIONS

1. Prisons

2. Mental hospitals

3. Orphanages

 

FEATURES OF A CLIENT WHO DEVELOPED INSTITUTIONALIZATION

1. Apathy – lack of interest in issues affecting one’s life and the patient may appearance indifferent or unconcerned, with no response to stimuli or display of emotion.

2. Lack of initiative – the patient lacks the ability to begin a process or activity on their own without the aid of a staff.

3. Total submissiveness – patient follow whatever he/she asked to do without questioning or reasoning whether it is good or bad for them.

4. Inability to plan for the future, as they are used to the daily rigid routines of the environment

5. Lack of individuality – patient fails to do things alone; they lack self-reliance and independence in their day to day activities which later lead to learned helplessness behavior

6. Passive dependence on staff – the patient depends on everything which the staffs plan for him/her.

7. Low self-esteem – they lack confidence in their own abilities or worthiness.

8. Idleness – this comes as a result of low self-esteem or a patient doing nothing in his or her time due to imposed ward activities and because of not being involved in planning of their day to day activities at a particular time, they lose interest in ward activities.

9. Feeling of Hopelessness – definitely any person may lack feelings of hope if they are found in a depressing or an environment in which their humanity is denied through being beaten, teased or passing of negative comments.

FACTORS CONTRIBUTING TO THE DEVELOPMENT OF INSTITUTIONALIZATION

Stigma and Discrimination: Patients, who have been admitted in a psychiatric hospital, are negatively tagged or labelled by the public that they cannot contribute to development in the community; hence they refuse to be discharged and prefer being in the hospital where they feel accepted.

The stripping process: this is the term used to describe the patient who has lost his/her identity, dignity, self-esteem and autonomy. Stripping is depriving someone of their power, rank or property which leads to being fearful of going back into the community, resuming work, etc., hence they lose identity, personal respect and self-esteem.

 Conducive ward environment to achieve therapeutic goals: when the patient is in the ward  he/she is involved in the planning of care, individual therapy , group therapy,.

Loss of contact with the outside world: the patient is not aware of what is happening around him/her and the world as a whole.

Enforced idleness: the patient’s day is fully planned and organized for him/her. Hence he/she does not decide on what to do at a particular time, e.g. time to bath or have a meal.

Lack of independence and responsibility in hospital: In hospital patients depend on staff instructions and care provided to them, freedom to do other things as a mean of satisfying their basic needs is not given to them and because they are not accountable of anything not being responsible for provision of their own needs, they remain in the hospital in fear of responsibilities at home

Leaving with unsupportive Family and home Environment: Patient who lacks family support is likely to be institutionalized, as the patient may prefer being in the hospital other than at home. Adequate family support will enhance the patients’ recovery, allowing the patient to be discharged as the home environment is more suitable for them.

Over sedation: Large doses of tranquilizers may be given to a patient who is acutely disturbed and this produces lethargy and drowsiness, making the patient highly inactive leading to them being unable to plan and aid in their care.

Loss of prospects outside the institution: In the hospital, patient lack expectations of success. They think they cannot do anything prosperous in future especially job career. They view themselves as people who cannot be reintegrated in society, they become incapable of managing certain tasks of daily life outside world because of mental illness, hence adapt to sick role and fear.

 

MEASURES TO PREVENT AND CURE INSTITUTIONAL SYNDROME

 This aspect caters for measures to carry out before and when the institutional syndrome has occurred though these measures can be used interchangeably, mainly curative measures help in lessening of its manifestations. Some of the measures are listed below but before you initiate them, always establish and maintain a therapeutic relationship based on empathic understanding, unconditional positive regard, respect and confidentiality as this will help in gaining trust and cooperation of the patient. A therapeutic relationship will also provide interaction hence enhancing a sense of self- worthiness. The nurse should show a non-judgmental attitude with an unconditional positive regard in order to promote patients trust in the nurse for the purpose of facilitating verbalization of negative thoughts and bottled-in-feelings.

1. Fighting Stigma and Discrimination

This is important because if patients feel accepted in the community, they would likely spend less time in the hospital, as they will have a feeling of belonging to a community. Fighting stigma is through community sensitization about the negative aspects of stigma and its effects.

2. Encouraging Family Support

3. Adequate support from the family will encourage short hospital stay, as care can be continued from the home setup after the patient recovers. Family support will also enable the patient to be in contact with the outside world during their stay in the hospital. If they cannot afford to visit on a regular basis, encourage them if possible to communicate through the phone as this will help the patient to regain self-esteem and to be in contact with the family and outside world. The hospital should also be giving or granting patients leave and the ward should allow the patient to watch TV, listen to radio so as to avoid loss of and promote contact with reality and relatives.

4. Reducing on Enforced Idleness

This can be by involving the patients in the planning of their day to day care, recreational activities such as indoor and outdoor games can also be done to keep the patient occupied during the day other than leaving them sleeping and wandering about the ward.

5. Reversing the Stripping Process

A nurse should encourage the patient to put on personal clothes and let them keep some personal valuables, this gives the patient a sense of individuality and responsibility. Allow them to bath and sleep at their own time.

6. Motivating and Encouraging the Client to use Initiative

This is by encouraging patients to be highly involved in planning for their care and also ensuring they carry out some activities of daily living without being forced but with their free will. In addition, allow and encourage the patient to come up with ideas on how to solve problems or situations given as this will enhance independence and prevent learned helplessness behaviors.

7. Promote Clients Individuality or Independence to carry out tasks with minimal supervision, the client should be responsible to handle some of their basic needs.

8. Ensuring clients have short stays in the hospital and this can be by linking them to community mental health and other available social supports services. The shorter the duration of stay the lesser the chances of a client being institutionalized.

9. Being flexible and having less rigid and fixed routines which will make the client or patient to be programmed and increase the chances of institutionalization.

10.               Individual and Family Psychotherapy

11.               Social skills training – Uses recreational activities to promote clients to redirect their thinking or to re-channel destructive energy in an appropriate manner. Clients learn skills that can be used during leisure time and during times of stress following discharge from treatment. Examples include football, volleyball, exercises, and jogging. Some programs include activities such as picnics, swimming, and even group attendance at other activity when it is in session, and assess how the patient behaves while there. Lastly, the nurse must apply positive and negative reinforcements such as Token Economy or removal of Token Economy so as to repeat acceptable behaviors.

12.               Assertiveness skills training – this will increase self-esteem in the patient which will lead to an increased ability to develop satisfying interpersonal relationships. It also improves the communication with and helps in maintaining honesty in relationship with others, and enhances feelings in a patient of being in control of his or her life styles. This training will also make a patient not to be submissive as he or she will be able to stand for their rights and feelings.

13.               Occupational therapy - Works with clients to help develop (or redevelop) independence in performance of activities of daily living. Focus is on rehabilitation and vocational training skills such as basket making, doormat making, carpentry, etc, in which clients learn to be productive, thereby enhancing self-esteem, ability to plan for the future, initiative and may prevent idleness. Creative activities and therapeutic relationship skills are used.

14.               Reduction in Dosages that usually make the client inactive during the day, so that they time where they are aware of their environment and are able to initiate in productive activities.

15.               Ensure that the Ward environment is conducive to achievement of the goals of therapy: Space is provided so that each client has sufficient privacy, as well as physical space, for therapeutic interaction with others. Furnishings are arranged to present a homelike atmosphere—usually in spaces that accommodate communal living, dining, and activity areas—for facilitation of interpersonal interaction and communication