Psychiatric-Mental Health Nursing: From Suffering to Hope

CRITICAL THINKING Lamont – Initial Onset Lamont Clemmons is a 15-year-old high school student who was referred to the clinic because he was expelled from school due after fighting with other students and bringing a handgun to school. Lamont’s parents divorced when he was 5-years-old; he lives with his father and stepmother and their three younger children. Lamont’s father is a Caucasian man who grew up in rural Arkansas and married a Haitian woman he met through work. Although Lamont’s father is over six feet tall, Lamont has his biological mother’s slight stature and dark skin, which contribute to considerable bullying from other kids at Lamont’s school. In the interview with the psychiatric nurse, Lamont explains that he took a handgun to school to show the bullies at school that he was “no sissy” and they needed to fear him. The nurse inquires about Lamont’s heritage. Lamont responds aggressively, “Don’t you call me Black.” He adds that he hates his mother and hopes “She’s goes back to that place she came from.” He has refused to visit with his mother when she comes for court-approved visitations. He has reported to teachers that his mother beats him and denies him food when she has him stay with her; however, several investigations have failed to substantiate this accusation. Following the initial assessment and discussions with both Lamont and his father, Lamont is assigned to work with an advanced practice psychiatric nurse (APRN) named Claire McGill. Application What are your concerns about Lamont at this time? What additional assessment information do you think would be helpful in determining Lamont’s needs? What sociological or cultural factors are important for the nurse working with Lamont to consider? Answers Nursing concerns at this time might include Lamont’s choice of aggression in response to being bullied and his access to a firearm; Lamont’s apparent shame related to his Haitian heritage and its effects on his self-esteem; the discrepancy between Lamont’s report of his mother’s behavior and the investigation findings. Additional assessment information might include identifying Lamont’s interests in and out of school; information about the social organization of his immediate and extended family – his relationship with his father, stepmother, and siblings, including how he behaves at home, and information about any other adults with whom he has a meaningful relationship. In addition to learning more about Lamont’s relationship with his family, other sociological or cultural factors may include learning about how Haitians express feelings, especially in family relationships; information about the Clemmons’ financial ability to support Lamont’s care plan (e.g., health insurance coverage and co-payments); and Lamont’s ability to access care and activities. CRITICAL THINKING Lamont – Recovery Phase During several weeks of therapy with Claire McGill, the APRN, Lamont is sullen, refuses to talk, does not do his therapy homework (e.g., keeping track of his emotions during the week, practicing some emotion regulation skills), and misses several of the skills group he was required to attend. In one session, Claire asks Lamont to draw a picture of himself and is surprised to see that he draws an image of a tall, muscular, light-skinned person with a semi-automatic rifle in each hand and a mean facial expression. His explanation of the picture is that he is “the meanest SOB alive.” Underneath the meanness, though, he agrees that he hates the “little Black boy” he sees in the mirror. At the end of that session, Lamont threatens Claire. He is transferred to Scott Weber, a male APRN. Again after several sessions, Lamont becomes aggressive and threatening. This time, however, Scott takes him to a gym and the two of them work out together using the elliptical equipment and working with a punching bag. Scott works with Lamont to increase Lamont’s time engaged in physical activity and exercise. Within a few more months, Lamont is able to discuss his self-hatred verbally with Scott and practice his verbal skills in group. Lamont begins to develop a muscular physique and begins playing soccer with a team. Other teens admire his skills on the soccer field and ask him to teach them some of his moves. Eventually, Lamont is able to return to regular high school and begins to read about his Haitian heritage. He has not been able to reunite with his mother, though, because she returned to Haiti and relinquished custody to the father and stepmother. Application How does Lamont’s aggressive behavior relate to his cultural identity? What might have made the difference in the two APRNs work with Lamont? How might family affect Lamont’s identity? What concerns do you have for Lamont related to his family? Answers Given Lamont’s drawing, he seems to think of his cultural identity as a weakness, seeking to establish some kind of strength through aggressive behavior. He also appears to be engaging in internalized stigma, accepting the physical characteristics he inherited from his Haitian mother as negative characteristics in himself. This appears to be so entrenched that it takes time for Lamont to open up to Scott Weber, the advanced practice nurse who takes him to the gym. Lamont may have engaged in transference with the first clinician, Claire McGill, transferring his feelings toward his mother onto Claire. Changing his mental health provider to a male likely helped in this regard, but it required Scott engaging Lamont in physical activities that release tension and build strength for Lamont to be able to begin opening up. By building on Lamont’s desire to become stronger and his association of physical activity with success, Scott provided person-centered care that countered Lamont’s internalized stigma of being different because of his cultural background. More information is needed to determine how Lamont’s family is affecting his identity. Although this scenario described Lamont’s anger at his mother, more information is needed related to his relationship with his father and step-mother. Additional concerns may include more information about Lamont’s accusations of abuse by his mother, his relationship with his father and step-mother, and Lamont’s ability to continue to build relationships with his peers.