Mr. Gobind is a 44 year old man. He is married, has 2 sons and 3 daughters. Mr. Gobind lives in a joint family consist of 28 members. He is the owner of the shop where he sales the clothes. He came in psychiatric ward with excessive and irrelevant talking for 12 days and has disturbance in sleep for 5 days. According to him, he is very calm person and has a very good relation ship with his wife and family members. When asked him about the history of depression he said as he has no stresses and he had never suffered from depression. When history took from his brother I came to know that he has records of depression 5 to 6 years back and respond to fluxoteine and was alright .In 2008 he again developed the symptoms of depression, aggressiveness and irrelevant talking and responds to mitrazepine. According to Mr. Gobind he used to take a glass of alcohol once in a blue moon but his brother stated contradictory remarks and said that he is habitual of taking 5 to 8 glasses of alcohol per day since 20 years. They bring him here because of his aggressive attitude, use of abusive language and his irrelevant behavior with family members and outsiders.
There is a variety of defense mechanism that people use under stressful situation in which they either blame others for the problem or refuse to acknowledge that problem has taken place in reality. From the above scenario, I feel that the patient is in depression and he is using denial to escape from the fear of reality. According to the article from psychological medicine ,a study done in Pakistan in the year 2000 says that there are lots of reason which can cause depression including exposure to chronic infectious disease, other physical illness, severe social adversity, especially poverty, poor education and poor access to treatment, complicated, perhaps by cultural beliefs about depressive. Major difficulties involved a marital relationship (26%), low income (24%), a non partner relationship (19%) or poor housing (15%). Other factors associated with depression included low income, poor educational achievement, lack of formal employment and overcrowding. (N.Hussain & B.Tomeson 2000).On the basis of the research, I perceive that the cause of depression in Mr. Gobind is over crowding and poor education achievement as he is living in a large family consist of 28 members and he once stated that he was interested in studies but due to the death of his parents he has to manage all the business responsibilities.
Analyzation of scenario in the light of literature:
In Pakistan one in three people suffer from depression or anxiety (Mirza and Jenkins 2004). Another factor that is very common in patient with depression is denial. While dealing with the patient, some times nurses assume that patient is not telling us the truth but he might be suffering from denial that is hidden in the incorrect perception as I believe that there is a vast difference between lying and denial. According to Mark Worden (2007) Lying is something that a person does consciously something that he or she is aware of on a conscious level. Denial, on the other hand, occurs on a level below consciousness, on a subconscious or unconscious level. It is a psychological process that acts to block out reality that is, to block out conscious awareness within the individual of something that feels threatening to that individual. According to the literature it indicates that the person who is in denial don’t know what they are saying and what reality is and we can often see denial in other person but not in our selves. There are lots of examples of denial which people are using during different situations. Death is a common occasion for denial. When someone learns of the sudden, unexpected death of a loved one, at first he or she may not be able to accept the reality of this loss. Chronic or terminal illnesses also encourage denial. People with such illnesses may think, “It’s not so bad; I’ll get over it,” and refuse to make any lifestyle changes (Bregman, Lucy 1999). Denial can also apply to internal thoughts and feelings. For instance, some children are taught that anger is wrong in any situation. As adults, if these individuals experience feelings of anger, they are likely to deny their feelings to others. There is model of kubler ross which was first introduced by Elisabeth Kübler-Ross in her 1969 book, On Death and Dying. In this he describes five stages of grief, process by which people can deal with grief and anger. In his model the first stage is denial in which person is trying to avoid inevitable. According to my understanding of the model I think the patient is on first stage of grief.
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Denial is common attitude among individuals who have become addicted to alcohol as alcohol is a depression-causing drug and other drugs that addiction has been referred to as the disease of denial. Indeed, people in recovery from substance abuse are typically surprised at the depth of their denial as it unfolds before them during the recovery process. Alcoholism basically impairs the individual judgment so the person would not be able to asses his present situation and would result in self delusion. An example is the person who honestly believes that he or she can drive just as effectively under the influence of alcohol. In my scenario patient is taking 7-8 glasses of alcohol per day but he denies that he took the alcohol every day. According to Dr Murad Moosa Khan (2007), a professor and chairman of the department of psychiatry at the Aga Khan University and Hospital said, In Pakistan, alcoholism as a hidden problem, alcoholics usually refuse to accept that they are too dependent on drink that they need to be convinced that they have fallen victim to a disease that can sometimes prove to be fatal. He further defines that the people who are taking alcohol for long term may end up with depression. Alcoholism may cause a relapse in patients with depression (B. Martin, Psy.D.2006) .After studying the literature and relating it to my scenario, I believe that my patient was suffering from depression in 2006 and with the use of medicine he become alright but he dint quit alcohol so it again relapse and went into depression. He also refused to accept that he is suffering from depression and also failed to accept that he is addicted to alcohol
Another important factor that has caused denial in the patient is probably the impact of cultural values. In Pakistan one of core cultural value is living in an extended family. In a cross sectional study carried out by Ali and Naeem(2007) in urban middle class population of Karachi, looking specifically at the psychosocial risk factors, found extended family systems to be a particular risk factor of depression. As Pakistan is a male dominant society in which male feel embarrassed or shy in expressing their cries and fears which leads to depression as one fails to express his emotions and ultimately triggers to deny the hard facts and realities of the life (N.Husein journal of psychiatry 2001). Cultural standards and expectations can encourage denial of subjective experience. Men who belong to cultures with extreme notions of masculinity may view fear as a sign of weakness and deny internal feelings of fear. The Chinese culture is thought to discourage the acknowledgment of mental illness, resulting in individuals denying their psychological symptoms and often developing physical symptoms instead. In my view my patient also belongs to the culture where men don’t feel like sharing their fears and anxiety. He is living in the interior Sindh where females are not allowed to speak and males are more dominant, as patient continuously verbalized “I m elder of my family and whatever decision I take my family has to follow .No body is allowed to speak in front of me” which indicates that he as a elder runs the whole family and his ego wont allow him to share his problems with any one not even with his wife. According to the literature and my analyzation, he consolidated within himself all the problems by keeping his feelings secret that leads him to become depressive and he denies that he is in depression because of his superfluous male dominant behavior.
From the above analysis, I think that it’s an uphill task to deal with the denial patient because they have already restricted their level of accepting the reality of life. Here nurses and family have an important role to help them come out of their current position. According to my view, Nurses play a key role in improving the environment of the patient by firstly educating the family of him that they should cooperate by listening the feelings of the patient and the nurse should instruct the family that they should treat him normally by actually understanding what he is trying to say and then at the right time, intervene in a way that he comes in a position to accept the situation from which he is going through. In our culture of Pakistan there is lack of awareness about mental illness, people think mental illness as stigma and family members doesn’t feel comfortable in talking about the illness of their family members with others .In this situation a health care provider should create the environment of acceptance in the patients family member which can enhance their comfortability and would also help in the treatment of the ill member as family support plays an important role in treating the patient .According to Dr murad moosa counseling is very important especially in the patients who came with withdrawal symptoms. He said that counseling of an individual as well as family counseling is very beneficial because in our country there are no such organization that helps recovering alcoholics so they have to rely on their friends and family. Therapist can use motivational enhancement therapy .According to Dr William (1995) MET is a systematic intervention approach for evoking change. It is based on principles of motivational psychology, and is designed to produce rapid, internally-motivated change. This treatment strategy does not attempt to guide and train the client, step by step, through recovery, but instead employs motivational strategies to mobilize the client’s own change resources. It may be delivered as an intervention in itself, or may be used as a prelude to further treatment. This therapy is especially designed for drug abuser or alcoholics. In addition, nurses should develop a level of trust where patients feel comfortable in sharing his views and thoughts without any fear of embarrassment and discomfort. She should try to be very open minded and willing to understand the hidden feelings of the patient because I feel that efficient listening has a critical role in the recovery of the patient problem as he will feel serenity within him self by realizing that there is no harm in sharing feelings and thoughts.
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Health sector should also arrange the seminars related to the psychological areas where people will get awareness about the symptoms and problems of mental disorders so that people will try to identify the developing problems and treat them before things get exaggerated. Furthermore, seminars should include the success stories of the patients who had recovered efficiently and spending their life successfully.
Over all, I find the study very learning by analyzing the case of Mr. Gobind and then relating it to previously done research. The most important aspect that opened up in front of me was that by understanding the psychology in a practical way, one could have control over his life which can lead to successful living of the life. This paper helps me to understand the process of the denial and also helps me to change my perception because when I first dealt with patient, I thought he was lying to me but then I opened up with the new concept of denial that I haven’t even heard before. Therefore, it was really a learning journey as I learnt a new concept and practically implemented it that facilitates me to engrave the concept profoundly.
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