Teresa is a 32-year-old woman in your practice who frequently misses her appointments, and at other times shows up without an appointment, often in crisis. She currently uses alcohol and tobacco, and has started to use street drugs.

As you have developed a therapeutic relationship with Teresa, you learn that she grew up in a household with a violent father who frequently assaulted her mother, her siblings and herself. Although now estranged from her father, the impact of his violence presents itself on a daily basis as Teresa struggles to cope with the trauma she experienced.

Teresa left school early, has few marketable skills and has never been able to hold a job for more than three months. Teresa receives $606 per month from Ontario Works and has no money left for food or other essentials at the end of the month. She is currently in a relationship with a man whom you suspect may be violent

Student Questions

What are your next steps with Teresa? How do you go about providing trauma-informed care?

• Is a crisis intervention required?
• What are some other interventions you could take to improve Teresa’s health in this situation that include addressing health inequities and structural drivers of the conditions of daily life, such as the inequitable distribution of power, money and resources?

Educator elaborations

• Assess Teresa’s mental status and history of mental health care; explore her substance use and whether it places her at high risk for self medication and suicide; explore issues of violence in her life, income support and her housing situation.

Discussion Topics

• Cultural competency and mental illness
• Trauma informed care
• Crisis intervention
• Social determinants of health

Joseph is a 55-year-old First Nations man on Ontario Disability Support Program due to a physical back injury in the factory he worked in. Despite his injury, he still receives work health benefits and is able to perform some amount of activities of daily living. Due to his chronic back pain, his doctor has prescribed Oxycodone which he uses occasionally (prn), as prescribed. However, he also uses marijuana daily because it makes him feel more in control. He is recently divorced, lives alone and is finding it hard to cope with this loss. Joseph presents at the clinic reporting of increasing pain. During your conversation you discover that he is gradually increasing the amount of marijuana he is using to combat his pain and feelings of isolation.

Student questions:

• What are your next steps with Joseph?
• How would you conduct a motiva-tional interview?
• What do you suggest talking about with Joseph at his next appointment?
• What strategies could you provide that would support a recovery oriented approach?
• What strategies could you provide that assist with harm reduction?

Educator elaborations

Change the ethnicity of Joseph and layer in cultural nuances. Pose questions that teach cultural competency.

Discussion Topics

• Culture and diversity as it relates to mental health
• The relationship between addiction and mental health
• Grief and loss

Thomas, a 16-year-old high school student, visits you during class in distress. He tells you that he’s being bullied at school because the kids think he is gay. Thomas tells you he thinks he might be transexual, but that he is scared to tell anyone, and voices suicide ideation. He is not supported at home: his mother and father, both professionals, work long hours and his older sister picks on him. Thomas’s best friend since the age of 10 recently told him he didn’t want to hang out with him anymore because he was “weird.” A few months ago another friend who was picked on more than Thomas went missing. Rumour in the school indicates that he ended his life.

Student questions:

• What are your next steps with Thomas?
• Do you have any immediate con-cerns in terms of Thomas’s safety?
• How do you conduct a Mental Status Exam?
• Howdo you conduct a suicide risk assessment?
• Is a crisis intervention required?
• What kinds of community-based support strategies would you recommend?
• Do you approach Thomas’s family? If so, how?
• What your role in terms of mental health advocacy and promotion?
• How does organizational culture influence the current provision of mental health care for students; how might that culture impact any changes you propose?
• What kinds of strategies can you develop?
• Who might be on an inter and intra-professional team?
• What kinds of stakeholders are available to assist with policy or program development?

Educator elaboration

• As school nurse, you want to prevent incidences of bullying and address the systemic issues related to student mental health.

Discussion Topics

• The impact of bullying on youth
• Diversity as it related to mental health
• Sexuality and its impact on mental health, (e.g., sexuality is not an illness)
• Stigma and its impact on mental health
• Developmental psychology/child and youth
• Family-centred-care

Gladys, an 84-year-old widow, is close to being discharged from outpatient services after breaking her hip from a fall. She uses alcohol, and tells you that she has been drinking more heavily since her husband passed away more than a year ago to help her cope with grief. She won’t tell you how often or how much she drinks, but admits that she’s lost over 25 pounds in the past year.

Student questions

• How do you establish a therapeutic relationship with Gladys?
• What supports can you provide for Gladys?
• What are some key risk considerations?
• When would you consider a harm reduction approach?
• How do you develop a risk assessment?
• What are the suicide considerations in this scenario?
• What are interventions that would tackle the immediate risks in daily live, such as housing situation or ambulation?
• What are the key medication considerations, especially give her age and alcohol use?
• What other considerations may you have to maintain her safety?
• How would you use a harm reduction approach with Gladys?
• What accommodations at home may she need?

Educator elaborations

Give Gladys an acute scenario, for example, she is in withdrawal from alcohol and experiencing delirium.

Discussion Topics

• Aging and mental illness and addiction
• Coping with grief and loss
• Mental health and illness and addiction; plus concurrent health disorders

Anthony, 29, is under the jurisdiction of your local provincial Mental Health Review Board on your acute care ward. He’s in breach of a disposition because of repeated alcohol and marijuana use; Anthony is also diagnosed with bipolar disorder and is currently prescribed olanzapine 10 mg and lithium 800 mg daily. He experiences mania when he uses substances, and the incident that led to his review occurred when he was under the influence (he racked up over $100,000 in property damages). He uses substances and alcohol due to the negative side effects (weight gain) from his prescribed medications. Anthony is divorced and recently obtained regular visits with his kids. He holds down a steady job in construction, but he’s worried about losing his employment because he sometimes misses shifts.

Student questions

• What is the relationship between addiction and mental illness?
• What is the relationship between the drug and alcohol use and Anthony’s diagnosis?
• What assessments would be completed?
• What medications and lab work should be done (e.g., Lithium levels)?
• In terms of Anthony’s stay on the unit, what are some safety precautions? How is a forensic general/acute unit different than a non-forensic unit?
• How does one balance custody vs. care?
• What is the legislation that pertains to Anthony’s rights?
• What is the criteria for involuntary admission in your jurisdiction?
• How do you evaluate Anthony’s capacity?
• How do you prepare for the hearing that will decide whether Anthony will continue to be committed/detained?
• What is the role of the nurse in Anthony’s case?
• And the role of the community ACT Team?
• Examine your values and beliefs: How do you balance issues of transference and countertransference?
• If you don’t support Anthony’s release, how will you maintain a therapeutic relationship or respond to him when he expresses a sense of betrayal during your day-to-day care?
• How might self-reflection help you? What are your ethical responsibilities to the Anthony and the public?

Discussion Topics

• Mental health and illness legislation
• Ethics and professional responsibilities
• Personal safety

You arrive at work to find out that Rajat, a 48-year-old client diagnosed with chronic schizophrenia, abused his roommate because he thought he was making gestures at him. Rajat was admitted overnight involuntarily when a neighbour who he has a relationship with encouraged him to go to emergency. Rajat was extremely confused and not making any sense. The community he lives is purported to have a high amount of IV drug use. Rajat spends the government provided disability support he gets on rent and the rest on drug use and cigarettes (he has been smoking since he was 8, which he informs you is common in India). He is also obese with metabolic syndrome.

Student questions

• What are your first steps?
• How do you develop a safety plan?
• How do you assess Rajat?
• What are the results of your assessment and how do they impact care?
• What about the link with Schizophrenia and drug use?
• What is the most important aspect you would work on with Rajat?
• How would you prioritize his care?
• How does Rajat’s culture impact influence his illness?
• How do you establish a therapeutic relationship with Rajat?
• What kinds of strategies can you put in place for him when he is eventually discharged?

Educator elaboration

• Give Rajat a specific ethnicity and explore culture competence as it relates to mental illness.

Discussion Topics

• Metabolic syndrome and its impact mental illness and treatment
• Social determinants of health
• Mental health and illness legislation

You visit Melanie, 58, in her home for a post-hospital discharge visit. She is visibly lethargic and when you ask how she is feeling, she tells you she is grieving for her son who died more than a month ago. Moreover, she worries how her life choices contributed to her son’s problems. As the child of alcoholic and violent parents, she felt alone, and constantly frightened. She ran away at the age of 16, and eventually married an abusive alcoholic, who was the father of her son. She and her son escaped with police help, but at the age of 25, childhood traumas flooded her, and she began to drink and use drugs to cope. Her second husband aided her drug use, which included cocaine, prescription barbiturates and marijuana. At that point, Melanie says she had been in and out mental health hospitals for breakdowns and suicide attempts. Not only was she anorexic, but she also cut herself. Her diagnoses included rapid cycling bipolar disorder, acute anxiety and panic disorders, personality disorders, obsessive compulsive disorders and post-traumatic stress disorders and “the list goes on.” She was treated with medications and rounds of bilateral shock treatments that she says she never wanted. “The worst part was being labeled an alcoholic and drug addict,” she adds, which diminished her true needs. She tells you that she has been alcohol and drug free for over 10 years thanks to meeting her third husband who is very supportive. And that she has had therapy to assist with her past traumas. But none of it was enough to help her help her son who died of an accidental drug overdose caused by a lethal combination of opioids mixed with the newly prescribed high powered psychiatric drugs.

Student questions

• What are you next steps with Melanie?
• How do you assess her risk for re-lapse?
• What kinds of support strategies can you provide?

Discussion Topics

• Recurring trauma and its influence pre-existing mental health illness and substance use disorders
• Community supports necessary to ensure ongoing mental health and wellness for clients with diagnoses

John, 23, is checked into emergency with severe gastro-intestinal pain. This is his sixth visit to the same ER with the same symptoms. He is visibly in discomfort, and requires opioid pain medications. John tells you he has been taking opioids for years to deal wth the flare-ups, which include vomiting and diarrhea, and have led to a 40-pound weight loss and five colonoscopies. This latest flare up occurred after he ran out of his pain medication and couldn’t get a refill. John gets very angry and defensive when the staff suggest he is addicted to pain killers. He contends that he wouldn’t be on the pain killers if the doctors could figure out what is wrong with him. When he calms down, you are able to learn a little more about his past: He tells you he has battled anxiety and panic attacks since he was a kid and diagnosed with learning disabilities. Currently, he feels the only relief for his emotional and physical pain is pain medication and that “he is trapped in this situation.” Finally, he adds that lately he’s experienced auditory, sensory and visual hallucinations. Schizophrenia runs his family.

Student questions

• Is John in crisis?
• How do you initiate a crisis intervention?
• How do you implement a harm reduction approach?
• How do you use trauma-informed approaches with John

Discussion Topics

• Age and linkages with schizophrenia
• Withdrawal symptoms
• Stigma and learning disabilities
• Stigma and substance use and its impact on mental health attitudes and interventions

Below is an anecdotal scenario that seeks to prepare students for a typical inpatient work day. It is structured into three phases and begins with arrival at work.

You’ve just arrived at your shift on a mental health unit and are reviewing your client case load.

Student questions

• How do you prioritize the client case load?
• Provide the rationale for the prioritization.
• What information is missing before you can move forward?

Next, you hone in on one patient, a 61-year-old, Caucasian female, with bipolar disorder who is mildly agitated. You review the night shift vital stats, as well as medications including her lithium levels.

Student questions:

• What are you most worried about?
• What should your immediate action be?
• How do the client assessment results impact care?

Despite your interventions, the patient’s agitation is escalating. You would describe her as aggressive.

Student questions

• How do you intervene in a non-confrontational way?
• What psychosocial interventions should you consider?
• When do you use medications, and what PRN medication do you choose and why?
• Which intramuscular site do you choose, what size syringe do you use and how do you prevent a needle stick injury?
• What assessment do you do after you’ve administered PRN?