mental health - week 1

ethics of care theory

Carol Gilligan; emphasizes the importance of forming relationships, banding together and putting the needs of those for whom we care about above the needs of strangers; moral development progress through 3 major divisions > not dictated by cognitive ability but rather through personal development and changes in the sense of self pre-conventional: goal is individual survival (selfishness); shown through caring for self conventional: goal is self sacrifice is goodness (responsibility to others); shown through caring for others post-conventional: principle of nonviolence (do not hurt self or others); shown through balancing care for self with caring for others

incidence

conveys information about the risk of contracting a disease; number of new cases of mental disorders in a healthy population within a given time period - usually annually

psychiatric-mental health nursing

dedicated to promoting mental health through the assessment, diagnosis, and treatment of behavioral problems, mental disorders and comorbid conditions across the lifespan; assist people who are in crisis or who are experiencing life problems, as well as those with long-term mental illness

prevalence

describes the total number of cases - new and existing - in a given population during a specific period of time, regardless of when they became ill

decompensation

deterioration of mental health

preconscious

just below the surface of awareness; material that can be retrieved rather easily through conscious effort

3 types of problems that respond well to interpersonal therapy

1. grief and loss: complicated bereavement after death, divorce or other loss 2. interpersonal disputes: conflicts with significant other 3. role transition: problematic change in life status or social/vocational role

human genome project

1990-2003; goals: identify approx 20-25k genes in human dna, determine sequences of the 3 billion chemical base pairs that make up human dna, store this info in databases, improve tools for data analysis, address the ethical, legal and social issues that may arise from project

mental health parity act

1996; required insurers that provide mental health coverage to offer annual and lifetime benefits at the same level provided for medical/surgical coverage

patient protection and affordable care act

2010; improves coverage for most American who are uninsured through a combination of expanded medicaid eligibility (for the very poor), creation of health insurance exchanges int eh states (to serve as a broker to help uninsured consumers choose among various plans) and so called insurance mandate (requirement that people without coverage obtain it)

brain research through advancing innovative neurotechnologies (BRAIN)

2013; Barack Obama; $300 million; develop innovative techniques and technologies to unravel the mystery of how the brain functions; goal to uncover new ways to prevent, treat, and cure psychiatric disorders, epilepsy and traumatic brain injury

cognitive behavioral therapy (CBT)

Aaron T. Beck; an active, directive, time-limited, structured approach; based on underlying theoretical principle that feelings and behaviors are largely determined by the way people think about the world and their place in it; their cognitions (verbal/pictorial events in their streams of consciousness) are based on attitudes or assumptions developed from previous experiences - may be accurate or distorted

theory of human motivation

Abraham Maslow; believed humans are motivated by unmet needs; focused on 6 incremental stages - the bottom of the pyramid the most foundational

rational-emotive therapy

Albert Ellis; remove core irrational beliefs by helping people recognize thoughts that are not accurate, sensible or useful; usually in terms of "shoulds" or "oughts"; believes perception influences all thoughts which in turn influence behaviors; recognizes role of past experience on current beliefs BUT focuses on present attitudes, painful feelings and dysfunctional behaviors

operant conditioning theory

B. F. Skinner; experiment: hungry rat pressed lever and released food pellet > every time rat was hungry, pressed lever, another rat had electric grid underneath and learned if pressed the lever, grid would turn off > learned to go straight to lever to eliminate shock method of learning that occurs through rewards and punishment for voluntary behavior; behavioral responses are elected through reinforcement

theory of psychosocial development

Erik Erikson; believed more than just mom-child-dad triangle influences and individual's development; emphasized culture and society on personality development; development occurs in eight pre-determined, connective life stages which each have a positive or negative outcome; each stage builds on the other

psychosexual stages of development

Freud believed that experiences during first 5 years determined an individual's lifetime adjustment pattern and personality traits oral (0-1): mouth, weaning, mastery of gratification of oral needs, begin to development ego; develop trust in the environment with realization that needs can be met anal (1-3): anal region, toilet training, begin to develop sense of control over instinctual drives, ability o delay immediate gratification to gain future goal, control over impulses phallic (3-6): genitals, oedipus and Electra, sexual identity with parent of same sex, begin to develop superego, identify with parent of same sex latency (6-12): growth of ego functions and the ability to care about and relate to torahs outside of home (specifically peers of the same sex); develop the skills needed to cope with environment genital (12+): genitals, develop satisfying sexual and emotional relationships, emancipation from parents, planing life goals and develop sense of personal identity, ability to be creative and find pleasure in love and work

interpersonal theory

Harry Stack Sullivan; brought an understanding to psychiatric alternations that focused on interpersonal problems; viewed loneliness as the most painful human condition; believed that human beings are driven by the need for interaction; early relationship with primary parenting figure (significant other) was crucial for personality development; purpose of all behavior is to get needs met through interpersonal interactions and to reduce or avoid anxiety

cognitive development

Jean Piaget; cognitive development is a dynamic progression from primitive awareness and simple reflexes to complex thought and responses; mental representations of the world depend on the cognitive stage reached sensorimotor (birth to 2): begins with basic reflexes and culminates with purposeful movement, spatial abilities and hand-eye coordination; physical interaction with he environment provides a basic understanding of world; by about 9 months object permanence is achieved and child can conceptualize objects that are no longer visible preoperational (2-7): operations = describe thinking about objects; not yet able to think abstractly or generalize qualities int he absence of specific objects, but rather think in a concrete fashion; egocentric thinking is demonstrated through tendency to expect others to view world as they do; unable to conserve mass, volume or number concrete operational (7-11): logical thought appears and abstract problem solving is possible; able to see a situation from another person's view and can take into account a variety of solutions to a problem; conservation is possible formal operational (11+): conceptional reasoning commences at same time as puberty; basic abilities to think abstracting and problem solve mirror those of an adult

President's New Freedom Commission on Mental Health

Jimmy Carter; goals: Americans understand that mental health is essential to overall health, mental healthcare's consumer- and family-driven, disparities in mental health services are eliminated, early mental health screening, assessment and referral to services are common practice, excellent mental healthcare is delivered and research is accelerated, technology is used to access mental healthcare and information

behavioral theory

John B. Watson; experiment: Albert (9 months) loved animals & every time he reached for a white rat, a loud noise was made with a hammer > every time Albert saw white fur or hair (even without noise) he was terrified; personality traits and responses - adaptive and maladaptive - were socially learned through classical conditioning; controlling environment could mold behavior and that anyone could be trained to be anything "behaviorism"

stages of moral development

Lawrence Kohlberg; understanding the progression from black and white thinking about right and wrong to complex, variable and context-dependent decision-making process regarding the rightness and wrongness of an action pre-conventional stage 1: obedience & punishment - focus on rules and listening to authority; obedience is method to avoid punishment stage 2: individualism & exchange - individuals become aware that not everyone thinks the way they do and different people see rules different conventional stage 3: good interpersonal relationships - begin to view rightness and wrongness as related to motivations, personality or the goodness or badness of the person; generally people should get along and have similar values stage 4: maintaining social order - rules are rules mindset returns but reasoning is not simply to avoid punishment; person has begun to adopt broader view of society post-conventional stage 5: social contract and individual rights - belle that social order is important but the social order must be GOOD stage 6: universal ethical principles - actions should create justice for everyone involved; obliged to break unjust laws

theory of object relations

Margaret Mahler; emphasize past relationships in influencing a person's sense of self as well as the nature and quality of relationships in the present; object refers to another person, particularly a significant person believed that psychological problems were largely the result of a disruption of separation (mother-child); significant other provides secure base of support that promotes enough confidence for child to separate > achieved through balance of holding (emotional and physical) a child enough for the child to feel safe while encouraging independence and natural exploration

classical conditioning

Pavlov; experiment: bell was repeatedly paired with food that triggered salivation > eventually sound of bell only would trigger salivation; responses are involuntary - not under conscious personal control - and are not spontaneous choices

psychoanalytic theory

Sigmund Freud; vast majority of mental disorders resulted from unresolved issues that originated in childhood; focuses on personality structure, levels of awareness, anxiety, the role of defense mechanisms and stages of psychosexual development

Ellis's negative thinking - ABC

a: activating event b: beliefs about the event c: emotional consequence as a result of the event

extinction

absence of reinforcement; decreases behavior by withholding reward that has become habitual

recovery

a process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential emerges from hope, person driven, occurs through many pathways, holistic, supported by peers and allies, supported through relationships and social networks, culturally based and influenced, supported by addressing trauma, involves individual, family, and community strengths and responsibility, based on respect

negative reinforcement

a response by the removal, escape from, or avoidance of an unpleasant stimulus

postive reinforcement

a response that encourages a particular positive behavior

levels of awareness

conscious, preconscious, unconscious

biological model

aka medical model; assumes that abnormal behavior is the result o fa physical problems; focuses on neurological, chemical, biological and genetic issues; seek to understand how the body and brain interact to create emotions, memories and perceptual experiences; locates the illness or debase in the body and targets the site of illness using physical interventions such as drugs, diet or surgery

patient centered medical homes

aka primary care medical homes; developed in response to fragmented care that result in some services never being delivered while others are duplicated; focused on patient care and provides access to physical & behavioral health, supportive community and social services; provide with orange of support for preventative care, acute care, chronic disease management & end of life issues; electronic and record keeping are viewed as essential 5 key characteristics: 1. patient centered - patient is core member of team 2. comprehensive care - all levels of mental and physical care are addressed 3. coordination of care 4. improved access - does not have standard hours of operation 5. systems approach - evidence-based care with continuous feedback loop of evaluation and quality improvement

Common Cognitive Distortions

all or nothing thinking: thinking in black and white, reducing complex outcomes into absolutes overgeneralization: using a bad outcome as evidence that nothing will ever go right again labeling: a form of generalization in which a characteristic or event becomes definitive and results in an overly harsh label for self or others mental filter: focusing on a negative detail or bad event and allowing it to taint everything else disqualifying the positive: maintaining a negative view by rejecting info that supports a positive view as being irrelevant, inaccurate or accidental jumping to conclusions: making a negative interpretation despite the fact there is little or no supporting evidence mind reading: inferring negative thoughts, responses and motives of others fortune telling error: anticipating that things will turn out badly as an established fact magnification or minimization: exaggerating the importance of something or reducing the importance of something catastrophizing: an extreme form of magnification in which the very worst is assumed to be a probable outcome emotional reasoning: drawing a conclusion based on an emotional state "should" & "must" statements: rigid self-directives that presume an unrealistic amount of control of external events personalization: assuming responsibility for an external event or situation that was likely outside personal control

mental illness

all psychiatric disorders that have definable diagnoses; manifested in significant dysfunctions that may be related to developmental, biological or psychological disturbances in mental functioning - ability to think, emotions, behaviors

unconscious

all repressed memories, passions and unacceptable urges lying deep below the surface; may be associated with trauma; exerts a powerful yet unseen effect on the conscious thoughts and feelings of an individual; unable to retrieve material without assistance of trained therapist

self-system

all the security operations an individual uses to defend against anxiety and ensure self-esteem

anxiety (Sullivan)

any painful feeling or emotion that arises from social insecurity or prevents biological needs from being satisfied

humanistic theory

arose as a protest against both behavioral and psychoanalytic schools; thought to be pessimistic, deterministic and dehumanizing; focus on human potential and free will to choose life patterns supportive of personal growth; emphasizes a person's capacity for self-actualization; focuses on understanding the patient's perspective as he or she subjectively experiences it

behavioral therapy

based on assumption that changes in maladaptive behavior can occur without insight into the underlying cause; works best when directed at specific problems and goals are well defined best candidates: treating people with phobia, alcoholism, schizophrenia four types: modeling, operant conditioning, systematic desensitization, aversion therapy

operant conditioning

basis for behavior modification and uses positive reinforcement to increase desired behaviors, ex: token economy - gets token when desired goals are achieved or behaviors are performed; been useful in improving the verbal behaviors mute, autistic and developmentally disabled children

diathesis-stress model

biological predisposition and stress represents environmental stress or trauma

clinical epidemiology

broad field that examines health and illness at the population level; includes studies of natural history of an illness, studies of diagnostic screening tests; observational and experimental studies of interventions used to treat people with illness or symptoms

reinforcement

cause behavior to occur more frequently

psychiatric home care

community based treatment modality; social workers with master's degree (counseling) and psychiatric registered nurses (evaluation, therapy and teaching); services are in patient's home setting medicare requires 4 elements for service to be reimbursed (varies by home care & payers): 1. homebound status of the patient - patient's inability to leave home independently due to physical or mental conditions 2. presence of a psychiatric diagnosis 3. need for the skills of a psychiatric registered nurse 4. development of a plan of care under orders of a physical or advanced registered nurse

nursing outcomes classification (NOC)

comprehensive source for standardized outcomes and definitions of these outcomes; uses 5 point likert scale organized in 7 domains: functional health, physiological health, psychosocial health (psychological well-being, psychosocial adaptation, self control and social interaction), health knowledge and behavior, perceived health, family health and community health

superego

develops between ages of 3-5; represents the moral component of personality; resides in conscious, preconscious and unconscious levels of awareness; consists of the conscience (internalized should nots) and the ego ideal (internalized shoulds); may induce guilt or allow sense of pride

cognitive theory

dynamic interplay between individuals and environment; believe that thoughts come before feelings and actions and thoughts about the world and our place in it are based on our own unique perspectives which may or may not be based on reality

interpersonal therapy

effective short-term therapy; reduce or eliminate psychiatric symptoms (particularly depression) by improving interpersonal functioning and satisfaction with social relationships; proven successful in the treatment of depression; therapist identifies nurse of the problem to be resolved and then selects strategies consistent with that problem area

primary care providers

first choice for most people when they are ill; general healthcare provider who may be a physician, an advanced practice nurse or physical assistant in an office, clinic or hospital pros: can lessen the degree of stigma, self-perceived or societally attached to getting psychiatric care cons: time constraints, limited training in psychiatry and may lack experience in diagnosis and treatment

psychodynamic therapy

follows the psychoanalytic model by using many of the same tools - free association, dream analysis, transference, and countertransference; but therapist has increased involvement and interacts with patient more freely; oriented toward the here and now; often lasts longer than common therapeutic modalities and may extend for more than 20 sessions (which insurance rarely covers) best candidates: healthy, well functioning individuals who are "worried well"; have clear area of difficulty and are intelligent, psychologically minded and well motivated for change picks one issue to focus on, weekly meetings, both patient and therapist are actively participating

Quality and Safety Education for Nurses (QSEN)

funded by Robert Wood Johnson Foundation; developed structure to support the education of future nurses who possess the knowledge, skills, and attitudes to continuously improve the safety and quality of healthcare key areas: patient-centered care, teamwork and collaboration, evidence-based practice, quality improvement, safety, informatics

specialized psychiatric care providers

have educational background experience in care of psychiatric problems and mental health; include psychiatrists (can prescribe meds), psychiatric-mental health advanced practice registered nurses (depending on state may be able to prescribe meds), psychologists (talk therapy & group therapy), social workers, counselors and other licensed therapists; partner with primary care providers

behavioral theorists

have no concern with inner conflicts but agree that personality simply consists of learned behaviors; personality becomes synonymous with behavior - if behavior changes so does the personality; believe that behavior can be influenced through conditioning

phenomena of concern

human experiences and responses

personality structure

id, ego, superego

mental health influencers

individual characteristics/attributes (genetics); economic circumstances (poverty); social circumstances (family/friends); environment (cultural beliefs, attitudes, practices)

anxiety - Freud

inevitable part of living; environment in which we live presents dangers and insecurities, threats and satisfactions

Erikson's 8 stages of development

infancy (0-1.5): trust vs. mistrust; forming attachment to mom > foundation for later trust in others early childhood (1.5-3): autonomy vs. shame/doubt; gaining some basic control of self/environment (toilet training/exploration) preschool (3-6): initiative vs. guilt; becoming purposeful and directive school age (6-12): industry vs. inferiority; developing social, physical and school skills adolescence (12-20): identify vs. role confusion; making transition from childhood to adulthood, developing sense of identity early adulthood (20-35): intimacy vs. isolation; establishing intimate bonds of love and friendship middle adulthood (36-65): generatively vs. self absorption; fulfilling life goals that involve family, career and society, developing concerns that embrace future generations later years (65+): integrity vs. despair; looking back over one's life and accepting its meaning

Hildegard Peplau

influenced by work of Sullivan and learning theory; first systematic theoretical framework for psychiatric nursing; established foundation fro professional practice of psychiatric nursing and continued to enrich psychiatric nursing theory and work for the advancement of nursing practice; first use to identify psychiatric-mental health nursing both as an essential element of general nursing and a speciality area that embraces specific governing principles; first nurse theorist to describe the nurse-patient relationship as the foundation of nursing practice - shifted focus from what nurses do TO patients to what nurses do WITH patients; believed that illness offered a unique opportunity for experiential learning, personal growth and improved coping strategies

biofeedback

instruments provides immediate and exact information regarding muscle activity, brain waves, skin temp, heart rate, blood pressure and other bodily functions (vital signs & physiology); successful for controlling the body's physiological response to stress and anxiety

brain stimulation therapy

involved focused electrical stimulation of the brain; oldest is electroconvulsive therapy > convulsive, cortical, depression, mania, catatonia transcranial magnetic stimulation repetitive (rTMS) > not convulsive, cortical, depression vagus nerve stimulation (VNS) > not convulsive; cervical cranial nerve, depression deep brain stimulation (DBS) > not convulsive, subcortical, depression, OCD example of biological therapy

conditioning

involves pairing a behavior with a condition that reinforces or diminishes the behavior's occurence

community health mental centers

mainstay for those who lack funding for mental healthcare; offer free or low-cost sliding scale care; provides emergency, community/home-based and outpatient services across the lifespan; common treatments include medication prescribing & administration, individual therapy, psychoeducational & therapy groups, family therapy and dual diagnosis (mental health & substance use); may be aligned with structured program that offers rehab, vocational services and residential services; utilize multidisciplinary teams - psychiatric-mental health registered nurses are key members > med administration and education; advanced nurse practitioners > patient intakes, psychotherapy & medication management

security operations

measures the individual employs to reduce anxiety and enhance security

schemata

mental representations of the world

continuum of psychiatric-mental healthcare

movement is fluid and can go in either direction least restrictive - primary care - speciality care - patient centered medical homes - community mental health centers - psychiatric home care - assertive community treatment - intensive outpatient programs - partial hospitalization programs - emergency care - crisis stabilization/observation units - general and private hospitals - state hospital most restrictive

psychiatric-mental health registered nurse (basic)

needs 2 years working full time as RN, 2000 clinical hours in a psychiatric setting and 30 hours of continuing ed in psychiatric nursing, pass board certified credentialing test role: coordination of care, health teaching and health maintenance, milieu therapy, pharmacological, biological and integrative therapies

psychiatric mental health advanced practice registered nurse (advanced)

needs MSN or DNP in psychiatric nursing role: everything a PMH-RN does PLUS medication prescription and treatment, psychotherapy, consultation

health

not possible without good mental health; a sate of complete physical, mental and social well-being and not merely the absence of disease or infirmity

cultural competence

nurses adjust their own practices to meet their patients' cultural beliefs, practices, needs and preferences

stigma

overall person is flawed; characterized by social shunning, disgrace and shame

aversion therapy

pairing of a negative stimulus with a specific target behavior, thereby suppressing the behavior; may be used when other less drastic measures have failed to produce desired effects; used to treat alcoholism, paraphilia disorders, shoplifting, violent/aggressive behaviors, self-mutilation must ask and answer following questions FIRST: is this therapy in the best interest of patient? does its use violate the patient's rights? is it int he best interest of society? if most appropriate, then ongoing supervision, support and evaluation must occur

conscious

part of the mind is the tip of the iceberg; contains all material a person is aware of at any one time including perceptions, memories, thoughts, fantasies and feelings

relationship between physical and mental health

poor physical health can lead to mental distress and disorders; poor mental health can lead to physical problems

peplau's theory of interpersonal relationships

processes by which the nurse helps patients make positive changes in their healthcare status and well-being; self-awareness is key - nurses are both participants and observers in therapeutic conversations

diagnostic and statistical manual 5th ed (DSM-5)

publication of American psychiatric association; describes criteria of 157 disorders for inpatient, outpatient, partial hospitalization, consultation liaison, clinics, private practice, primary care and community settings; influenced by clinical field trials conducted by psychiatrists, psychiatric-mental health advanced practice RNs, psychologists, licensed clinical social workers, licensed counselors, and licensed marriage and family therapists; serves as a tool for collecting epidemiological statistics about diagnostic of psychiatric disorders

epidemiology

quantitative study of the distribution of mental disorders in human populations

automatic thoughts/cognitive distortions

rapid, unthinking responses based on schemas; particularly intense and frequent in psychiatric disorders such as depression and anxiety; irrational and lead to false assumptions or misinterpretations pattens are taught to challenge their own negative thinking and substitute with positive, rational thoughts; learn how to recognize when thinking is based on distortions and misconceptions

ego

resides in the conscious, preconscious and unconscious levels of awareness; problem solver and reality tester; attempts to navigate outside world; able to differentiate subjective experiences/memory images and object reality

research domain criteria (RDoC) initiative

seek causes for mental disorders at molecular level; create new classification system

mental health continuum

well being: characterized by adequate to high-level functioning; time, exercise, balanced diet, rest, interaction with others and mental reframing may alleviate issues mental illness: emotional problems/concerns and experience mild to moderate discomfort and distress; experience altered thinking, mood and behavior; might need to seek professional help

hierarchy of needs

self-actualization: strive to be everything they are capable of becoming esteem: high self-regard and have it reflected to them from others; feel confident, valued and valuable belonging and love: intimate relationships, love, affection and belonging and will seek to overcome feelings of loneliness and alienation safety: security, protection, freedom from fear, anxiety and chaos, the need for law, order and limits physiological: food, water, oxygen, sleep, sex and constant body temp **two were added later: cognitive needs (the desire to know and understand) and aesthetic (need for beauty and symmetry)

psychiatric case management

service to assist patients in finding housing or obtaining entitlements

electronic healthcare

services provided from a distance; effective way to reach underserved populations and those who are homebound; allows for assessment and diagnosis, medication management and group therapy

comorbid condition

simultaneous existence of two or more disorders (mental or medical)

mental health

state of wellness being in which each individual is able to realize his or her own potential, cope with the normal stresses of life, work productively, and make a contribution to the community; provides capacity for rational thinking, communication skills, learning, emotional growth, resilience and self esteem

resilience

the ability and capacity for people to secure the resources they need to support their wellbeing; does not mean unaffected by stressors - just effective at regulating emotions, not falling victim to negative, self-defeating thoughts

systematic desensitization

the development of behavior tasks customized to the patient's specific fears; these task are presented to the patient while using learned relaxation techniques 1. patient's fear broken into components by exploring particular stimulus cues to which patient reactions 2. patient is exposed to fear little by little. situations are confronted while patient is in a relaxed state. gradually over period of time, exposure is increased until anxiety or fear has ceased 3. patient is instructed in how to design a hierarchy of fears 4. patient practices these techniques every day

least restrictive environment

the setting that provides the necessary care while allowing the greatest personal freedom

psychopharmacology therapy

the use of medications to treat mental illness such as chlorpromazine (Thorazine) and lithium; greatly reduce need for hospitalization and dramatically improve lives of those suffering from serious psychiatric difficulties; exert differential effect on different neurotransmitters nd help restore brain function, allowing patients with mental illness to continue living productive lives with greater satisfaction and far less emotional pain example of biological therapy

modeling

therapist provides a role model (themself or other) for specific identified behaviors and patient learns through imitation

defense mechanisms

to ward off anxiety by preventing conscious awareness of treating feelings; they all (except for suppression) operate on an unconscious level and they deny, falsify or distort reality to make it less threatening; cannot survive without them, but can also distort reality to such a degree that we experience difficulty with healthy adjustment and personal growth

id

totally unconscious and impulsive; source of all drives, instincts, reflexes and needs; cannot tolerate frustration and seeks to discharge tension and return to more comfortable level of energy; lacks the ability to problem solve and is illogical

countertransference

unconscious feelings that the healthcare workers has toward the patient; can be positive or negative

transference

unconscious feelings that the patient has toward a healthcare worker that were originally felt in childhood for a significant other; can be positive or negative

psychoanalytic therapy

uncover unconscious conflicts; tools used are free association, area and fantasy analysis, defense mechanism recognition and interpretation Freud's classical psychoanalysis is rarely used

schemas

unique assumptions about themselves, others and the world in general

punishment

unpleasant consequence; decreases chances of same behavior will occur

nursing interventions classification (NIC)

used to standardize, define and measure nursing care; any treatment based upon clinical judgment and knowledge that a nurse performs to enhance patient/client outcomes including direct and indirect care through a series of nursing activities organized in 7 domains: basic physiological, complex physiological, behavioral (communication, coping, education), safety (covering crisis and risk management), family, health system and community