NLE Foundations of Psychiatric & Mental Health Nursing — Foundations of Mental Health & Psychiatric NursingDetailed Explanation

Concepts of Mental Health and Mental Illness

Mental health is defined by the World Health Organization (WHO) as a state of emotional, psychological, and social well-being in which a person realizes his own abilities, copes with the normal stresses of life, works productively, and contributes to his community. Notice that this definition is POSITIVE — mental health is not just the absence of mental illness. A person can have a diagnosed mental disorder and still experience periods of wellness, and a person with no diagnosis can have poor mental health. Mental illness, on the other hand, refers to clinically significant disturbances in cognition, emotional regulation, or behaviour that cause distress or impairment in functioning. The most important concept here is the CONTINUUM MODEL: mental health and mental illness are not two separate boxes. Every person moves along a spectrum — from optimal mental health to severe mental illness — depending on their stressors, coping resources, and support systems. A nursing student cramming for boards experiences stress but may still be mentally healthy because she has good coping skills and social support. A person who loses their job and has no support may slide toward the illness end of the continuum. Factors that influence position on the continuum fall into three categories: 1. BIOLOGICAL factors — genetics (family history of schizophrenia, bipolar disorder), neurochemical imbalances (dopamine excess in schizophrenia, serotonin deficiency in depression, GABA dysfunction in anxiety disorders), physical health, and nutrition. 2. PSYCHOLOGICAL factors — temperament (how a person is 'wired' at birth), self-concept, past experiences including trauma, and coping skills. 3. SOCIOCULTURAL factors — family dynamics, socioeconomic status, education level, culture, spirituality, and social support networks. In the Philippine context, sociocultural factors are especially important. The strong extended family system (the 'pamilya') and deep religiosity serve as PROTECTIVE FACTORS — they provide social support, belonging, and meaning. However, STIGMA is a major barrier. Many Filipino families still use terms like 'baliw' (crazy) and attribute psychiatric symptoms to spiritual causes (kulam, usog, influence of bad spirits). This stigma prevents early help-seeking and often results in clients reaching care only when the illness is already severe. As a nurse, part of your role is to address this stigma through patient and family education.

Personality Development Theories

Personality theories explain how a person's character, thinking patterns, and behaviors develop over time. Two theories dominate the NLE: Freud's Psychoanalytic Theory and Erikson's Psychosocial Theory. Understanding these helps nurses identify which stage a client is struggling with and tailor interventions accordingly. --- FREUD'S PSYCHOANALYTIC THEORY --- Freud proposed that the personality has three structural components: 1. THE ID — Present from birth. Entirely UNCONSCIOUS. Operates on the PLEASURE PRINCIPLE — it demands immediate gratification of instinctual drives (hunger, sex, aggression) without regard for reality or consequences. Think of the id as a newborn crying for milk — it wants what it wants, RIGHT NOW. 2. THE EGO — Begins developing in infancy. Largely CONSCIOUS (but has preconscious and unconscious parts). Operates on the REALITY PRINCIPLE — it mediates between the demands of the id, the moral demands of the superego, and external reality. The ego finds realistic ways to satisfy the id's demands. It is the EXECUTIVE and the seat of all defense mechanisms. Think of the ego as the manager who balances a demanding boss (id) with company rules (superego). 3. THE SUPEREGO — Develops around ages 3-6. The MORAL component — the conscience. It incorporates the values, rules, and standards of parents and society. It strives for PERFECTION and punishes deviation with GUILT. Think of the superego as the strict parent inside your head. Freud's LEVELS OF AWARENESS: - Conscious: material currently in awareness - Preconscious: memories that can be brought to awareness with effort (like remembering yesterday's lunch) - Unconscious: repressed material that is outside awareness but drives behavior — this is the largest part of the mind (iceberg analogy: the conscious is the tip above water; the unconscious is the vast portion below) Freud's PSYCHOSEXUAL STAGES (know the names and approximate ages): - Oral (birth–18 months): pleasure from feeding; fixation leads to dependency, smoking, overeating - Anal (18 months–3 years): pleasure from elimination/retention; fixation leads to excessive orderliness (anal retentive) or messiness (anal expulsive) - Phallic (3–6 years): Oedipus/Electra complex; conscience (superego) develops - Latency (6–12 years): sexual energy is dormant; focus on social and intellectual skills - Genital (puberty onward): mature sexual development --- ERIKSON'S PSYCHOSOCIAL THEORY --- Erikson expanded Freud's work across the ENTIRE LIFESPAN (not just childhood). He described 8 stages, each with a CENTRAL CONFLICT (crisis) that must be successfully resolved to develop a VIRTUE (strength). Unsuccessful resolution leads to maldevelopment. This is the most NLE-tested theory in psychiatric nursing. MEMORIZE all 8 stages: 1. Infancy (0–18 months): TRUST vs. MISTRUST → Virtue: HOPE - Task: develop trust through consistent, responsive caregiving - Failure: mistrust, insecurity, withdrawal - Nursing application: A consistently inconsistent caregiver may produce an infant who cannot trust others, potentially underlying future attachment problems 2. Toddler (18 months–3 years): AUTONOMY vs. SHAME/DOUBT → Virtue: WILL - Task: develop self-control and independence - Failure: shame, self-doubt, dependency - Nursing application: Allow toddler clients choices (which cup, which shirt) to support autonomy 3. Preschool (3–6 years): INITIATIVE vs. GUILT → Virtue: PURPOSE - Task: explore, take initiative, develop conscience - Failure: excessive guilt, passivity 4. School Age (6–12 years): INDUSTRY vs. INFERIORITY → Virtue: COMPETENCE - Task: learn skills, gain competence, achieve academically - Failure: inferiority complex - Nursing application: School-age clients need productive activities during hospitalization 5. Adolescence (12–20 years): IDENTITY vs. ROLE CONFUSION → Virtue: FIDELITY - Task: develop a stable personal identity (Who am I?) - Failure: role confusion, identity crisis - Nursing application: Peer relationships are crucial; avoid environments that isolate teens from peers 6. Young Adult (20–40 years): INTIMACY vs. ISOLATION → Virtue: LOVE - Task: form deep, committed relationships - Failure: isolation, loneliness - Nursing application: Depression or social withdrawal in young adults may reflect unresolved intimacy vs. isolation 7. Middle Adult (40–65 years): GENERATIVITY vs. STAGNATION → Virtue: CARE - Task: contribute to society, guide the next generation (work, parenting, mentoring) - Failure: stagnation, self-absorption 8. Older Adult (65+ years): EGO INTEGRITY vs. DESPAIR → Virtue: WISDOM - Task: reflect on life with acceptance and satisfaction - Failure: despair, regret, fear of death - Nursing application: Life review therapy is appropriate for older adults --- OTHER IMPORTANT THEORISTS --- Harry Stack SULLIVAN: Interpersonal theory — personality develops through interpersonal relationships; the 'self-system' develops to protect against anxiety in relationships. Key stages: infancy, childhood, juvenile, preadolescence, early adolescence, late adolescence. Hildegard PEPLAU: Applied Sullivan to nursing; defined the NURSE-PATIENT RELATIONSHIP as the core of psychiatric nursing practice. Phases: Orientation, Identification, Exploitation, Resolution. Peplau defined nursing roles: stranger, resource person, teacher, leader, surrogate, counselor. Abraham MASLOW: Hierarchy of Needs — physiologic (food, air, water) → safety/security → love/belonging → esteem → self-actualization. Used in nursing to PRIORITIZE care: always address lower-level needs first. In psychiatric nursing, safety is the overriding priority.

Defense Mechanisms

Defense mechanisms are UNCONSCIOUS psychological strategies that the ego uses to protect itself from overwhelming anxiety, internal conflict, and the demands of the id and superego. Because they are unconscious, the person using them is NOT AWARE they are doing so. Defense mechanisms are NORMAL and ADAPTIVE when used in moderation — they help us cope with daily stress. They become MALADAPTIVE (pathological) when they are overused, when they prevent healthy problem-solving, or when they distort reality to a significant degree. KEY RULE TO REMEMBER: ALL defense mechanisms are UNCONSCIOUS except SUPPRESSION, which is the only CONSCIOUS defense mechanism. Here are the defense mechanisms you MUST know for the NLE: 1. REPRESSION — The CORNERSTONE (most basic, most fundamental) defense mechanism. The ego INVOLUNTARILY pushes painful, anxiety-provoking memories, thoughts, or feelings out of conscious awareness into the unconscious. The person genuinely does not remember. Example: A client who was sexually abused as a child has no memory of the abuse. 2. SUPPRESSION — The ONE CONSCIOUS defense mechanism. The person DELIBERATELY and INTENTIONALLY sets aside a disturbing thought or feeling to deal with it later. Example: A nurse who receives bad news before a 12-hour shift decides, 'I'll deal with this after work.' 3. DENIAL — Refusing to acknowledge an anxiety-provoking reality. The person acts as though the reality does not exist. Example: A client newly diagnosed with cancer says, 'The doctors must be wrong. I can't have cancer.' 4. PROJECTION — Attributing one's OWN unacceptable feelings, thoughts, or impulses to ANOTHER person. Memory cue: Think 'PROJECTor' — projecting your feelings onto a screen (another person). Example: A client who feels angry at the nurse says, 'I know you're angry with me.' (The anger is the client's, projected onto the nurse.) 5. DISPLACEMENT — Transferring feelings from a threatening or unavailable target to a SAFER, less threatening target. Example: A client who is angry at her doctor but cannot express it safely shouts at a student nurse instead. 6. RATIONALIZATION — Offering LOGICAL, ACCEPTABLE reasons (excuses) to justify unacceptable behavior or feelings. The reasons sound reasonable but cover the true motive. Example: A student who failed an exam says, 'The questions were poorly written and unfair' (rather than admitting inadequate preparation). 7. REACTION FORMATION — Behaving in the EXACT OPPOSITE way to one's true (unacceptable) feelings. The behavior is exaggerated and rigid. Example: A person who harbors deep resentment toward a coworker is excessively friendly and complimentary to that person. 8. REGRESSION — Returning to an EARLIER DEVELOPMENTAL STAGE (immature behavior) when under stress. The behavior is age-inappropriate. Example: A 6-year-old who has been toilet-trained begins bedwetting after being hospitalized. A stressed adult throws a tantrum. 9. SUBLIMATION — Channeling UNACCEPTABLE impulses or energy into SOCIALLY ACCEPTABLE and CONSTRUCTIVE activities. Considered the MOST MATURE and ADAPTIVE defense mechanism. Example: A person with aggressive impulses becomes a surgeon or plays competitive rugby. 10. UNDOING — Performing an act to SYMBOLICALLY CANCEL OUT or reverse a previous unacceptable act or thought. Example: A person who was cruel to a friend buys them an expensive gift afterward. 11. COMPENSATION — Covering up a WEAKNESS or deficiency in one area by EXCELLING in another. Example: A student who struggles academically becomes an exceptional athlete. 12. IDENTIFICATION — Unconsciously MODELING ONESELF after an admired or significant person. Example: A nursing student unconsciously adopts the mannerisms and values of an admired clinical instructor. 13. CONVERSION — Channeling unresolved EMOTIONAL CONFLICT into a PHYSICAL SYMPTOM that has no organic (medical) cause. This is the basis of conversion disorder. Example: A student who is terrified of failing the NLE develops sudden blindness on the day of the exam, with no neurological cause found on workup. 14. INTELLECTUALIZATION — Using excessive INTELLECTUAL ANALYSIS to avoid dealing with the emotional aspects of a situation. Example: A client diagnosed with terminal cancer spends all their time researching statistics and treatment protocols, avoiding discussion of feelings about dying. 15. ISOLATION — Separating an emotion from its associated thought or memory; discussing a traumatic event with no emotional expression. Example: A client describes being assaulted in a flat, detached voice, as if reading a news report. NLE TIP: NLE questions on defense mechanisms almost always present a SCENARIO and ask you to identify which defense mechanism is being used. Practice identifying the keyword in each scenario: - 'Doesn't remember' or 'blocked out' → REPRESSION - 'Deliberately puts aside' → SUPPRESSION - 'Refuses to believe' → DENIAL - 'Accuses others of own feelings' → PROJECTION - 'Takes it out on someone else' → DISPLACEMENT - 'Gives excuses/justifications' → RATIONALIZATION - 'Acts opposite to true feelings' → REACTION FORMATION - 'Reverts to childlike behavior' → REGRESSION - 'Channels into healthy activity' → SUBLIMATION (MOST ADAPTIVE) - 'Does something nice to cancel out bad behavior' → UNDOING

The Mental Status Examination (MSE)

The Mental Status Examination (MSE) is the psychiatric equivalent of the head-to-toe physical assessment. It is a structured, systematic assessment of the client's CURRENT mental functioning at a specific point in time. It is NOT a historical account of past mental health — it documents what you observe and what the client reports RIGHT NOW. Think of the MSE as the nurse's 'psychiatric vital signs.' Just as you assess temperature, blood pressure, and pulse at every contact, you perform key components of the MSE at every psychiatric nursing contact. The MSE has 10 standard components (use the mnemonic 'AB STAMP CT JI' or remember them in order): 1. APPEARANCE What the nurse OBSERVES about the client's physical presentation: - Grooming and hygiene (neat, unkempt, malodorous?) - Dress (appropriate to weather/situation? bizarre clothing?) - Posture (erect, slumped, rigid?) - Apparent versus stated age (looks older or younger than age?) - Nutritional status, any obvious physical abnormalities Significance: Neglected grooming/hygiene is common in depression, schizophrenia, and severe cognitive disorders. 2. BEHAVIOUR / PSYCHOMOTOR ACTIVITY Movement, activity level, and cooperation: - Eye contact (appropriate, avoiding, intense staring?) - Gait (normal, shuffling, ataxic?) - Psychomotor agitation (restlessness, pacing, hand-wringing) vs. psychomotor retardation (slowed movements, long latency before responding) - Tics, tremors, stereotypies - Level of cooperation with the examination Significance: Agitation in mania; retardation in depression; shuffling gait in Parkinsonism or medication side effects. 3. SPEECH How the client speaks (not what they say — that is thought content): - Rate (rapid/pressured in mania; slow in depression) - Volume (loud, soft, whispering?) - Quantity (talkative/logorrheic; sparse/poverty of speech) - Articulation and fluency (slurred? dysarthric?) - Spontaneity Significance: Pressured speech is a hallmark of mania; poverty of speech is seen in depression and schizophrenia. 4. MOOD The client's SELF-REPORTED, SUSTAINED emotional state. - Mood is SUBJECTIVE — it is what the client TELLS you they feel - Documented in the client's own words when possible: 'I feel hopeless' or 'sad' or 'on top of the world' - Described as: depressed, anxious, euphoric, irritable, angry, labile, euthymic (normal) NLE KEY DISTINCTION: MOOD = SUBJECTIVE (reported by the client) 5. AFFECT The nurse's OBSERVATION of the client's EXPRESSED emotion — the outward display. - Affect is OBJECTIVE — it is what the nurse OBSERVES - Described in QUALITY: broad (normal range), restricted (diminished range), blunted (significantly reduced), flat (no emotional expression at all), labile (rapidly shifting, unstable) - Described in CONGRUENCE: Is the affect CONGRUENT with the mood (matching) or INCONGRUENT (not matching)? Example: A client says 'I feel so sad' (mood = sad) while laughing (affect = incongruent, labile) — this is seen in schizophrenia. NLE KEY DISTINCTION: AFFECT = OBJECTIVE (observed by the nurse) 6. THOUGHT PROCESS The FORM, logic, and organization of thinking — HOW the client thinks: - Logical and coherent (normal) - Circumstantial: takes many detours but eventually gets to the point - Tangential: goes off on tangents and NEVER returns to the point - Flight of ideas: rapid jumping from one idea to another (connected by association, seen in mania) - Loose associations: ideas jump without logical connection (seen in schizophrenia) - Word salad: incoherent mix of words with no meaningful connection (severe disorganization) NLE KEY DISTINCTION: Thought PROCESS = the FORM/HOW of thinking 7. THOUGHT CONTENT WHAT the client thinks about — the actual ideas and beliefs: - Delusions: fixed, false beliefs not based in reality and not culturally explained - Persecutory: 'They are trying to kill me' - Grandiose: 'I am God' - Erotomanic: believes a famous person loves them - Somatic: 'My organs are rotting' - Ideas of reference: believes random events have special personal meaning ('that TV newscaster is talking about me') - Obsessions: intrusive, unwanted, repetitive thoughts - Phobias: persistent irrational fears - Suicidal ideation (SI): ALWAYS assess directly — 'Are you having any thoughts of hurting yourself or ending your life?' - Homicidal ideation (HI): thoughts of harming others NLE KEY DISTINCTION: Thought CONTENT = the WHAT of thinking 8. PERCEPTION How the client experiences sensory information: - Hallucinations: FALSE sensory perceptions without an external stimulus - Auditory (most common in schizophrenia — hearing voices) - Visual (most common in delirium and substance withdrawal — especially alcohol) - Tactile (feeling bugs crawling — formication, seen in cocaine use, alcohol withdrawal) - Olfactory (smelling something that isn't there) - Gustatory (tasting something that isn't there) - Illusions: MISINTERPRETATIONS of REAL external stimuli (seeing a curtain and thinking it is a person — has a real stimulus, unlike hallucinations) 9. COGNITION (SENSORIUM) Basic mental functioning — the 'hardware' of the mind: - Level of consciousness (alert, lethargic, stuporous, comatose) - Orientation to person, place, time (and sometimes purpose/situation) - Attention and concentration (can client spell 'WORLD' backward? Serial 7s: subtract 7 from 100 repeatedly) - Memory: - Immediate/working (repeat 3 words after 2 minutes) - Recent (what did you have for breakfast?) - Remote (date of birth, historical facts) - Abstract thinking: interpret proverbs ('A rolling stone gathers no moss'); identify similarities ('How are an apple and an orange alike?') - The MINI-MENTAL STATE EXAMINATION (MMSE) is a structured tool often used here — scores 0-30; score <24 suggests cognitive impairment 10. INSIGHT AND JUDGMENT - INSIGHT: Does the client recognize that they have a mental illness and need treatment? - Full insight, partial insight, or no insight (anosognosia) - Poor insight is a major barrier to treatment adherence - JUDGMENT: Can the client make sound, safe decisions? - Assessed through scenarios: 'If you found a stamped envelope on the sidewalk, what would you do?' - 'What would you do if you smelled smoke in a crowded theater?' - Impaired judgment is a safety concern — may require legal protection measures

The Philippine Mental Health Act — RA 11036

Republic Act No. 11036, known as the PHILIPPINE MENTAL HEALTH ACT, was signed into law in 2018. It is the FIRST comprehensive national mental health legislation in the Philippines. Every Filipino nurse must know this law — it directly affects how you practice psychiatric nursing in any setting. Here is what you MUST know: --- KEY FACTS --- - Full name: Republic Act 11036 — Philippine Mental Health Act - Year signed: 2018 - Significance: FIRST national mental health law in the Philippines - Implementing agency: Department of Health (DOH) - Oversight body created: PHILIPPINE COUNCIL FOR MENTAL HEALTH (an inter-agency body under the DOH) --- CORE PRINCIPLES --- 1. RIGHTS-BASED APPROACH RA 11036 is anchored in human rights. It affirms the following rights of persons with mental health conditions (called 'SERVICE USERS' in the law): - Right to the BEST AVAILABLE mental health care - Right to CONFIDENTIALITY of all mental health information - Right to INFORMED CONSENT before any treatment - Right to be treated in the LEAST RESTRICTIVE ENVIRONMENT appropriate to their condition - Right to be FREE FROM DISCRIMINATION, torture, and inhumane treatment - Right to be involved in TREATMENT PLANNING - Right to have an ADVANCE DIRECTIVE for mental health care - Right to REFUSE TREATMENT (with specific exceptions for imminent danger) 2. INTEGRATION INTO PRIMARY CARE AND COMMUNITY One of the most revolutionary aspects of RA 11036 is the DECENTRALIZATION of mental health services: - Mandates integration of mental health into the GENERAL HEALTH SYSTEM (not just specialty hospitals) - Mental health services must be available at the PRIMARY CARE level, including in community health centers and at the BARANGAY level - Local Government Units (LGUs) are required to include mental health in their basic health services - This shifts the model from institution-based (NCMH, psychiatric hospitals) to community-based care — aligning with RECOVERY MODEL principles 3. PHILIPPINE COUNCIL FOR MENTAL HEALTH - Created by RA 11036 as the primary oversight and coordination body - Under the DOH - Responsible for developing and implementing mental health policies, plans, and programs 4. MENTAL HEALTH IN SCHOOLS AND WORKPLACES - Requires mental health programs in ALL educational institutions (from basic education to tertiary level) - Requires mental health programs in ALL workplaces - Includes provisions for ANTI-STIGMA education and campaigns 5. SUICIDE PREVENTION - RA 11036 includes provisions for SUICIDE PREVENTION programs - Public awareness and education to reduce stigma are mandated --- RELATED LEGISLATION AND PROGRAMS --- 1. RA 9173 — Philippine Nursing Act of 2002: Governs the nursing profession. Section 28 includes psychiatric and mental health nursing as a specialty area. Nurses practice psychiatric care within the scope defined by RA 9173. 2. RA 9165 — Comprehensive Dangerous Drugs Act: Governs substance use disorders. Nurses caring for clients with drug dependency work within both RA 11036 (mental health) and RA 9165 (dangerous drugs). 3. RA 11223 — Universal Health Care Act (2019): Mental health services are included in the PHILHEALTH benefit package under the UHC Act, ensuring financial coverage for psychiatric care. 4. NATIONAL CENTER FOR MENTAL HEALTH (NCMH): - Located in MANDALUYONG CITY, Metro Manila - The primary government psychiatric referral center - Operates the NCMH CRISIS HOTLINE: for suicide prevention and mental health emergencies - Under the DOH 5. NATIONAL MENTAL HEALTH PROGRAM: - The DOH's operational program for implementing RA 11036 - Focuses on community-based mental health, deinstitutionalization, and integration into primary care --- INFORMED CONSENT AND INVOLUNTARY TREATMENT --- RA 11036 strongly protects the right to REFUSE TREATMENT. However, INVOLUNTARY TREATMENT is permitted in specific circumstances: - When the person presents an IMMINENT DANGER to self or others - In these cases, the LEAST RESTRICTIVE intervention must still be used - The client must be informed of the reason for involuntary treatment - Regular review of involuntary status is required NURSING IMPLICATION: If a client refuses medication, the nurse must: 1. Assess WHY they are refusing (side effects? Lack of insight? Fear?) 2. Educate about the medication and its benefits 3. Explore alternatives 4. Document the refusal 5. Report to the physician and treatment team 6. NEVER forcibly medicate a competent client who refuses, EXCEPT in a genuine emergency with imminent danger to self or others (and only with physician order and proper documentation).

The clinical clues are the client's age (16, adolescence) and the specific language: 'I don't know who I am anymore.' This directly maps to the Identity vs. Role Confusion crisis of Erikson's adolescent stage. The nurse's plan should address the developmental task — not treat this only as a depressive episode. The most important intervention for an adolescent in this stage is facilitation of PEER GROUP THERAPY, because peer relationships are the primary arena for identity development during adolescence.

This question tests multiple MSE components simultaneously. Key distinctions: (1) Mood is what the client says = 'I feel nothing'; affect is what the nurse observes = incongruent smiling with flat voice. (2) The belief about poisoning is a DELUSION = thought CONTENT (not process — there is no disorganization of form described). (3) Hearing voices = hallucination = PERCEPTION component. (4) Incongruent affect (smiling while reporting no feelings) is a classic MSE finding in schizophrenia. Documenting each component separately is essential for accurate psychiatric nursing assessment.

This problem tests integration of RA 11036 rights-based principles into clinical practice. The key legal and ethical principle: A competent person who is not in imminent danger has the right to refuse treatment, even psychiatric medication. Forced medication in this context violates RA 11036 and nursing ethics (autonomy principle). The nurse's role is ADVOCATE, EDUCATOR, and COMMUNICATOR — not enforcer. Document, explore, educate, and report. Covert administration of medication (hiding it in food/drinks) is both illegal and an ethical violation.

Key differentiation tips: REPRESSION vs. DENIAL — repression involves FORGETTING (memories are gone from consciousness); denial involves REFUSING TO BELIEVE current reality. DISPLACEMENT vs. PROJECTION — displacement transfers the feeling TO a different person; projection attributes the feeling to another person (blaming). RATIONALIZATION vs. REACTION FORMATION — rationalization is making excuses; reaction formation is acting the OPPOSITE of true feelings. SUBLIMATION is the most adaptive — always a positive redirect of energy into something constructive.

This problem integrates Erikson's final stage with clinical psychiatric nursing. The telltale signs of Ego Integrity vs. Despair failure: the client is older (68), reviews life with REGRET ('I wasted my life'), feels his contributions were MEANINGLESS, and appears despondent. Life review therapy is the evidence-based, stage-specific intervention for older adults. IMPORTANT: Always assess for suicidal ideation in any client presenting with hopelessness and despair, regardless of age — older adult males are a HIGH-RISK demographic for suicide completion.