1. Introduction

Substance abuse is a global public health problem associated with poor health outcomes and decreased productivity among the affected individuals. Substance use disorders are chronic in nature and usually begin during the teen years or in young adulthood [1]. Substance use disorders contribute to a large proportion of health burdens observed in the communities [2]. Substance use disorders are usually accompanied by absent or infrequent sustained periods of abstinence. The leading drugs and substances of abuse in Africa are cannabis and alcohol [3]. A survey conducted in South Africa reported alcohol abuse as the most prevalent at 51%, followed by cannabis use at 21% [4]. In Kenya, there is an observed increase in drug and substance abuse despite various government efforts and interventions to discourage their use [5]. A survey conducted in Kenya reported the use of alcohol among those aged between 15-65 years in the year 2012 to be 13.6%, with 5.5% of Kenyans being dependent on alcohol [6]. A study carried out in Kakamega County reported a prevalence of 31.7% in alcohol use which was higher than the national average [7]. Most substance-induced psychotic symptoms are considered to be short lived and resolve with sustained abstinence along with other symptoms of substance intoxication and withdrawal [1]. In this article, we detail the management of a case of psychosis induced by substance abuse using Peplau’s theory of interpersonal relations.

2. Hildegard Peplau’s Theory of Interpersonal Relations

Hildegard Peplau was born in Reading, Pennsylvania in 1909. She trained as a nurse at Pottstown (Pennsylvania) Hospital training school and graduated in the year 1931. She specialized in psychiatric/mental health nursing and practiced in that field for very many years. Her major breakthrough in nursing came in the year 1952, when she published the book Interpersonal Relationships in nursing. She thereafter engaged in intellectual pursuits including writing numerous articles for journals and magazines expounding on her interpersonal concepts as they related to nursing. She was privileged to serve in various capacities in different organizations both nationally and internationally until her retirement in 1974. She however continued with her writing and publishing of books and articles until her death in 1999 aged 89 years [8]. Her distinguished career spanning five decades had a profound influence on nursing theory, research and practice.

Peplau is regarded as a leading interactive nursing theorist who emphasised the importance of the nurse-patient relationship. She asserted that nursing is at its core a significant therapeutic and interpersonal process [9]. Her idea of nursing as a collaborative, mutual and interpersonal process changed nursing education, research and practice [10]. She viewed the interpersonal process as an interaction between two or more individuals with a common goal. The common goal forms the basis for the therapeutic process in which the nurse and the patient respect each other as individuals, both of them learning and growing as a result of the interaction [11]. Therefore each therapeutic encounter influences the nurse’s and the patient’s personal and professional development. Peplau asserted that “the kind of person each nurse becomes (that) makes a substantial difference in what each patient will learn as he is nursed throughout his experience of illness” [9].

She viewed personal identity and self awareness as key ingredients in the practice of nursing that affect the outcome of the interpersonal process. In this regard, she framed the concept psychodynamic nursing where the nurse seeks to understand her own and others behaviour and to apply the principles of human relations to one’s identified needs [12]. This approach to nursing allows the nurse to focus on how the psychological meaning of events, feelings and behaviours can be explored and incorporated into nursing interventions [13]. Psychodynamic nursing process also gives nurses an opportunity to teach clients how to identify and express their feelings and to explore with them how to bear their experiences [14]. Peplau also believed that the meaning of behaviour of the patient to the patient is the only relevant basis on which nurses can determine needs to be met [9].

The interpersonal relationship according to Peplau evolves through three phases namely orientation, working and termination phases. The orientation phase is initiated by a patient’s perceived problem/need who then seeks out assistance with it [15]. The working phase is where the key work for the nurse-patient relationship takes place with the patient beginning to understand their reaction to the illness [16]. During the working phase, the patient concentrates on their response to the illness and develops an understanding of what their existing health condition requires of them. The working phase situates the patient as an active participant in understanding and solving his problem rather than as a passive recipient of advises and instruction. The termination phase is where the work accomplished is summarized and closure occurs. The nurse helps the patient to devise actions that would allow the patient to return to a normal productive life with fulfilling relationships and social activities [9, 17]. Within the three phases of the nurse-patient relationship, the nurse adopts many roles including a stranger role, where the nurse first meets the patient. A resource person role, where the nurse provides any required information to the patient. A teacher role, where the nurse educates and informs the patient to enhance his understanding of his needs. A surrogate role, the nurse assists the patient to identify similarities and differences between them which help to determine one’s dependency or independency. A counsellor role, in which the nurse helps the patient to learn from his own experiences to increase his understanding of them [12].

3. Case Summary

Patient J.A, 27 years old was brought by his brother to the emergency department at Kakamega County Referral Hospital with allegations of violence towards family members. He had been well until his presentation in the hospital and subsequent admission. He had a positive history of alcohol abuse from the age of 17 years. He came from a polygamous family with allegations that his father committed suicide due to inability to provide for the two families. He had good developmental milestones with no significant medical history. He performed well in school and was pursuing his studies at a Public University. He is an outgoing person who loved making friends and partying with a positive attitude towards life. He easily becomes irritated and angry during normal interactions with friends and family. He has once been arrested by the police for fighting with other students while drunk. On mental assessment, the patient had tactile hallucinations i.e. he reported that he felt spiders walking on his body. He had no delusions, nor illusions. His mood was euthymic with appropriate affect. On physical examination, he had scars on his left arm following a fight with unknown persons while under the influence of alcohol. No significant finding on other systems was noted. A clinical impression of substance induced psychosis was made and the patient was admitted to the psychiatric unit. Pharmacotherapy was initiated with Chlorpromazine 200mg, 12 hourly per oral and Carbamazepine 600mg once a day per oral.

4. Application of the Theory in Managing a Patient with Substance Induced Psychosis

The case presented above was a patient who was experiencing psychotic symptoms from current or recent psychoactive substance abuse. He had a history of alcohol abuse whose direct physiological effects were exhibited in the symptoms he presented with. A short term treatment with antipsychotics was commenced, though the central focus in his treatment was on the substance abuse management. We subsequently highlight the use of Peplau’s theory of interpersonal relations as a framework in managing this patient.

In the orientation phase, the stranger role of the nurse occurred in the psychiatric ward when he first met with the patient during the individual therapy sessions. The nurse called the patient by name, introduced himself as a professional nurse who was qualified and experienced to help the patient. The nurse welcomed the patient to a seat and sat next to him. They were friendly to each other which signified receptiveness. In this initial interaction, the nurse as a matter of concern asked the patient why he had been admitted to the unit. The patient reported having been violent to some family members after taking alcohol. The nurse quietly listened to the patient narration with empathy. This facilitates initial trust in the nurse-patient relationship [16]. The goal for the nurse in the stranger role was to create rapport, build trust and confidence with the patient. Establishing rapport with the patient allows him to freely express his feelings, emotions and thoughts. A compassionate verbal and non-verbal communication, a respectful approach and a non-judgemental behaviour is required in the stranger role [18]. The nurse then requested the patient if he could allow him to further discuss his alcoholism problem. This was to allow for a mutual discussion of the alcoholism problem by both the nurse and the patient. It was also an opportunity for the nurse to understand the lived experience of the patient and the effects of alcoholism to his life. The patient obliged and recounted his experience with alcoholism as the nurse actively listened. Focusing on the interpersonal relations tends to direct the nurses from a reductionist focus on diseases and treatments towards a more inclusive view about the experiences of the illness in individuals, families and the health systems in which they find expression [13].

After the narration, the nurse needs to explore his own feelings and beliefs when dealing with the patient [16]. From the dialogue, both the nurse and the patient agreed and defined the problem of the patient to be alcoholism. The patient was remorseful and requested to be assisted to stop abusing alcohol. He reported that his abusing of alcohol was due to peer influence since his close friends also abused alcohol and other drugs. Peer influence has been documented in several studies as a major contributor to substance abuse [19-21]. Development of a trusting relationship with the patient enhances the ability of the nurse to offer education, support and professional expertise [22]. The nurse informed the patient that he had understood his concerns and was willing to provide professional help as they also explored other available sources of help to him.

The nurse and the patient are at this point familiar, trust and respect each other. Having agreed on the common goal with the patient, the subsequent encounters had the nurse play the teacher, leader and resource person roles in the working phase. The nurse explained to the patient the physiological effects of alcohol and what remedies existed towards resolving the problem of alcoholism. Information about the negative effects of substance abuse can empower patients to make informed decisions about changing their behaviour. The primary goal of the teacher and resource person role is to assist the patient attain knowledge and information to aid him in better understanding of his health status [12, 23]. The nurse further clarified his expectations from the patient with regard to his abstinence from alcohol. The patient expressed an understanding of the effects of alcoholism and was willing to comply with the nurse’s guidance to resolve his problem. He was now an active participant in group therapy sessions and other recreational activities in the hospital without the nurse.

The patient also accepted a member of the family to be included in the therapeutic process following a request from the nurse. He was more optimistic about solving his alcoholism problem and reported wanting to continue with his studies at the university to secure a better future. The nurse in performing his leadership role discussed with the patient and family member about the need to engage other professionals who would be valuable in the therapeutic process. Having agreed to the nurse’s suggestion, a counsellor and a social worker were introduced to the patient while still in the hospital. The counsellor helped the patient identify productive activities he would engage in during his free time to reduce the pressure from his peers. The patient expressed a desire to join a neighbourhood football team upon discharge from the hospital. The counsellor would also assist the patient in choosing and maintaining friends who do not abuse substances. This would assist him stay away from his current friends who abuse drugs and minimize opportunities to be influenced again [24, 25]. The social worker visited the patient’s home and discussed with the other family members regarding the support the patient required in his treatment. He also linked the patient to an alcoholics support group that met on a monthly basis. The patient made an appointment with the counsellor on his own before he was discharged from the unit. This was after the counsellor had agreed to continue having weekly counselling sessions with the patient as an outpatient upon discharge.

The nurse and the patient reviewed their discharge plan including attending monthly support meetings and the weekly outpatient counselling sessions, resumption of his university studies, and identification of two friends who do not abuse alcohol. He expressed gratitude to the nurse, counsellor and social worker with the belief that he would immensely benefit from their support. The nurse appreciated their relationship and his cooperation in the care. The nurse terminated the relationship. The patient was discharged from the hospital after 12 days of inpatient care.

5. Conclusions

Peplau’s theory of interpersonal relations provides for a therapeutic process through which a nurse in partnership with the patient can mutually and collaboratively resolve an agreed upon health problem. The health concerns of most patients are not only physical in nature but are also psychological, social and spiritual. Application of this theory in a psychiatric ward is appropriate in facilitating the nursing process of psychosocial care. The nurse-patient relationship allows the patient to freely express their emotions, feelings and thoughts about a given health problem. This enhances understanding of the health problem and guides nurses to helping the patients meet their individual needs. Nursing practice should focus on strengthening interpersonal relationships with patients to improve health outcomes.