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Chapter: Psychiatric Mental Health Nursing : Client’s Response to Illness

Individual Factors - Client’s Response to Illness

A person’s age seems to affect how he or she copes with illness.



Age, Growth, and Development


A person’s age seems to affect how he or she copes with illness. For instance, the age at onset of schizophrenia is a strong predictor of the prognosis of the disease (Buchanan & Carpenter, 2005). People with a younger age at onset have poorer outcomes, such as more negative signs (apathy, social isolation, and lack of volition) and less effective coping skills, than do people with a later age at onset. A possible reason for this difference is that younger clients have not had experi-ences of successful independent living or the opportunity to work and be self-sufficient and have a less well-developed sense of personal identity than older clients.


A client’s age also can influence how he or she expresses illness. A young child with attention deficit hyperactivity disorder may lack the understanding and ability to describe his or her feelings, which may make management of the disorder more challenging. Nurses must be aware of the child’s level of language and work to understand the expe-rience as he or she describes it.


Erik Erikson described psychosocial development across the life span in terms of developmental tasks to accomplish at each stage (Table 7.1). Each stage of development depends on the successful completion of the previous stage. In eachstage, the person must complete a critical life task that is essential to well-being and mental health. Failure to com-plete the critical task results in a negative outcome for that stage of development and impedes completion of future tasks. For example, the infancy stage (birth to 18 months) is the stage of “trust versus mistrust,” when infants must learn to develop basic trust that their parents or guardians will take care of them, feed them, change their diapers, love them, and keep them safe. If the infant does not develop trust in this stage, he or she may be unable to love and trust others later in life because the ability to trust others is essential to establishing good relationships. Specific devel-opmental tasks for adults are summarized in Table 7.2.

According to Erikson’s theory, people may get “stuck” at any stage of development. For example, a person who never completed the developmental task of autonomy may become overly dependent on others. Failure to develop identity can result in role confusion or an unclear idea about whom one is as a person. Negotiating these develop-mental tasks affects how the person responds to stress and illness. Lack of success may result in feelings of inferiority, doubt, lack of confidence, and isolation—all of which can affect how a person responds to illness.



Genetics and Biologic Factors


Heredity and biologic factors are not under voluntary con-trol. We cannot change these factors. Research has identi-fied genetic links to several disorders. For example, some people are born with a gene associated with one type of Alzheimer’s disease. Although specific genetic links have not been identified for several mental disorders (e.g., bipo-lar disorder, major depression, and alcoholism), research has shown that these disorders tend to appear more fre-quently in families. Genetic makeup tremendously influ-ences a person’s response to illness and perhaps even totreatment. Hence, family history and background are essential parts of the nursing assessment.


Physical Health and Health Practices


Physical health also can influence how a person responds to psychosocial stress or illness. The healthier a person is, the better he or she can cope with stress or illness. Poor nutri-tional status, lack of sleep, or a chronic physical illness may impair a person’s ability to cope. Unlike genetic factors, how a person lives and takes care of himself or herself can alter many of these factors. For this reason, nurses must assess the client’s physical health even when the client is seeking help for mental health problems.


Personal health practices, such as exercise, can influence the client’s response to illness. Exercising is one self-help inter-vention that can diminish the negative effects of depressionand anxiety (Morgan & Jorm, 2008). Further, when individu-als participated with others in exercise, the members of the group reported increased social support and an improved sense of well-being (Carless & Douglas, 2008). This suggests that continued participation in exercise is a positive indicator of improved health, whereas cessation from participation in exer-cise might indicate declining mental health.


Response to Drugs


Biologic differences can affect a client’s response to treat-ment, specifically to psychotropic drugs. Ethnic groups differ in the metabolism and efficacy of psychoactive com-pounds. Some ethnic groups metabolize drugs more slowly (meaning the serum level of the drug remains higher), which increases the frequency and severity of side effects. Clients who metabolize drugs more slowly generally need lower doses of a drug to produce the desired effect (Purnell


·     Paulanka, 2008). In general, nonwhites treated with Western dosing protocols have higher serum levels per dose and suffer more side effects. Although many non-Western countries report successful treatment with lower dosages of psychotropic drugs, Western dosage protocols continue to drive prescribing practices in the United States. When evaluating the efficacy of psychotropic medications, the nurse must be alert to side effects and serum drug lev-els in clients from different ethnic backgrounds.




Self-efficacy is a belief that personal abilities and efforts affect the events in our lives. A person who believes that his or her behavior makes a difference is more likely to take action. People with high self-efficacy set personal goals, are self-motivated, cope effectively with stress, and request support from others when needed. People with low self-efficacy have low aspirations, experience much self-doubt, and may be plagued by anxiety and depression. It has been suggested that focusing treatment on developing a client’s skills to take control of his or her life (developing self-effi-cacy) so that he or she can make life changes could be very beneficial. Four main ways to do so follow:

a. Experience of success or mastery in overcoming obstacles


b.     Social modeling (observing successful people instills the idea that one can also succeed)


c.  Social persuasion (persuading people to believe in themselves)


d. Reducing stress, building physical strength, and learning how to interpret physical sensations positively (e.g., view-ing fatigue as a sign that one has accomplished some-thing rather than as a lack of stamina).


Cutler (2005) reports a relationship between self-efficacy and the client’s motivation for self-care and follow-up after discharge from treatment. Clients returning to the commu-nity with higher self-efficacy were more confident and had positive expectations about their personal success. Cutler suggests that therapeutic interventions designed to promote the client’s self-efficacy can have positive effects on interper-sonal relationships and coping on return to the community.




Hardiness is the ability to resist illness when under stress. First described by Kobasa (1979), hardiness has three components:


·    Commitment: active involvement in life activities


·    Control: ability to make appropriate decisions in life activities


·    Challenge: ability to perceive change as beneficial rather than just stressful.


Hardiness has been found to have a moderating or buffer-ing effect on people experiencing stress. Kobasa (1979) found that male executives who had high stress but low occurrence of illness scored higher on the hardiness scale than executives with high stress and high occurrence of illness. Study findings suggested that stressful life events caused more harm to people with low hardiness than with high hardiness.


Personal hardiness is often described as a pattern of atti-tudes and actions that helps the person turn stressful cir-cumstances into opportunities for growth. Maddi (2005) found that persons with high hardiness perceived stressors more accurately and were able to problem-solve in the situa-tion more effectively. Hardiness has been identified as an important resilience factor for families coping with the mental illness of one of their members (Greeff, Vansteenween, & Mieke, 2006).


Some believe that the concept of hardiness is vague and indistinct and may not help everyone. Some research on hardiness suggests that its effects are not the same for men and women. In addition, hardiness may be useful only to those who value individualism, such as people from some Western cultures. For people and cultures who value rela-tionships over individual achievement, hardiness may not be beneficial.


Resilience and Resourcefulness


Two closely related concepts, resilience and resourceful-ness, help people to cope with stress and to minimize theeffects of illness (Edward & Warelow, 2005). Resilience is defined as having healthy responses to stressful circum-stances or risky situations. This concept helps to explain why one person reacts to a slightly stressful event with severe anxiety, whereas another person does not experi-ence distress even when confronting a major disruption.


Keyes (2007) found that high resilience was associated with promoting and protecting one’s mental health, described as flourishing. Family resilience refers to the successful cop-ing of family members under stress (Black & Lobo, 2008). Factors that are present in resilient families include positive outlook, spirituality, family member accord, flexibility, fam-ily communication, and support networks. Resilient families also spend time together, share recreational activities, and participate in family rituals and routines together.


Resourcefulness involves using problem-solving abili-ties and believing that one can cope with adverse or novel situations. People develop resourcefulness through inter-actions with others, that is, through successfully coping with life experiences. Examples of resourcefulness include performing health-seeking behaviors, learning self-care, monitoring one’s thoughts and feelings about stressful sit-uations, and taking action to deal with stressful circum-stances. Chang, Zauszniewski, Heinzer, Musil, and Tsai (2007) found building resourcefulness skills to be the key in reducing depressive symptoms and enhancing adaptive functioning among middle school children whose female caregivers were depressed.




Spirituality involves the essence of a person’s being and his or her beliefs about the meaning of life and the purpose for living. It may include belief in God or a higher power, the practice of religion, cultural beliefs and practices, and a relationship with the environment. Although many clients with mental disorders have disturbing religious delusions, for many in the general population, religion and spiritual-ity are a source of comfort and help in times of stress or trauma. Studies have shown that spirituality is a genuine help to many adults with mental illness, serving as a pri-mary coping device and a source of meaning and coher-ence in their lives or helping to provide a social network (Anthony, 2008).


Religious activities, such as church attendance and praying, and associated social support have been shown to be very important for many people and are linked with better health and a sense of well-being. These activities also have been found to help people cope with poor health. Hope and faith have been identified as critical factors in psychiatric and physical rehabilitation. Chaudry (2008) described patients who depended on their religious faith as significantly less depressed and anxious than those who are less reliant on their faith. Religion and spirituality can also be helpful to families who have a relative with mental illness, providing support and solace to caregivers. Becausespiritual or religious beliefs and practices help many clients to cope with stress and illness, the nurse must be particu-larly sensitive to and accepting of such beliefs and prac-tices. Incorporating those practices into the care of clients can help them cope with illness and find meaning and pur-pose in the situation. Doing so can also offer a strong source of support (Huguelet, Mohr, Borras, Gillieron, & Brandt, 2006).


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