MENTAL HEALTH TRENDS AND THE HISTORICAL ROLE OF THE PSYCHIATRIC-MENTAL HEALTH NURSE
Joyce J. Fitzpatrick
Jeffrey S. Jones
EXPECTED LEARNING OUTCOMES
After completing this chapter, the student will be able to:
1. Identify key events that helped to shape the current view of psychiatric-mental health care
2. Describe the early role of the psychiatric nurse
3. Identify the changes in the field of mental health that correlate with the evolution of psychiatric-mental health nursing
4. Define interpersonal relationships as being the foundation for clinical practice
5. Delineate between the roles and functions of basic and advanced practice in psychiatric-mental health nursing
Professional nursing originated from the work of a visionary leader, Florence Nightingale, who identified a need to organize the profession into a respectable discipline with its own body of knowledge and practice skill sets. As professional nursing evolved, so too did the practice of psychiatric-mental health nursing. This evolution paralleled the development in the field of mental health care. Subsequently, mental health care and psychiatric-mental health nursing practice have progressed from a poorly understood and poorly organized area of concern to a highly specialized area of health care.
This chapter provides an overview of the key historical events associated with the evolution of mental health care and their influence on psychiatric-mental health nursing. It also describes the current status of psychiatric-mental health nursing, focusing on the scope of practice for the two levels of psychiatric-mental health nursing practice: basic and advanced. This chapter emphasizes the interpersonal models of practice as the standard of care across the full range of settings and client groups. Relationships, interactions, and environment are important components of these models. This focus was selected to enhance this crucial element of nursing practice, the nurse–patient relationship, and, in particular, to establish interpersonal relations as the cornerstone of psychiatric-mental health nursing practice to assist patients in meeting their needs.
HISTORICAL OVERVIEW OF MENTAL HEALTH AND MENTAL ILLNESS CARE
History reveals that mental illness has been around since the beginning of time. However, it was not until the late 18th century when the view of mental illness became that of a disease requiring treatment and humane care. Overall, the views of mental health and mental illness closely reflect the sociocultural climate of the time.
The Earliest Years
Mental illness is a complex experience, with different values and meanings worldwide. Although some cultures considered mental illness in a negative light, attributing it to possession by spirits or demons, other cultures considered mental illness somewhat differently, even as an exceptional state; one that would prepare that person to become a healer as, for example, in shamanism. However classified or viewed, the complexity of mental illness has prompted treatment, from ridding the person of spirits or demons to enabling the person to explore the possibility that he or she is a potential healer. For the former, magical therapies such as charms, spells, sacrifices, and exorcisms were used. For the latter, various initiation rituals were used.
In the West, however, the prevailing view of mental illness involved possession. A person who exhibited an odd or different kind of behavior without identifiable physical injury or illness was seen as possessed, specifically by an evil spirit or demon, and the patient’s behavior was the result of this state of possession. In response, treatments such as magical therapies were commonplace. Physical treatments such as bleeding, blistering, and surgically cutting into the skull to release the spirit also were done. If the patient was not disruptive, he or she could remain in the community. However, if the patient’s behavior was violent or severe, the patient often was ostracized and driven from the community.
During the Middle Ages and the Renaissance period, the view of mental illness as demonic possession continued. Witch hunts and exorcisms were common. In addition, the strong religious influences at that time led to the belief that mental illness was a punishment for wrongdoings. Persons with mental illness were inhumanely treated, being placed in dungeons or jails and beaten.
The 18th and 19th Centuries
The early to middle 18th century laid the groundwork for future developments in the latter half of this century and the next, especially in the United States. Society was beginning to recognize the need for humane treatment, which led to a gradual reshaping of the view of mental illness. Treatment, rather than punishment, exorcisms, and magical therapies, was becoming the focus. During this time, public and private asylums, buildings specially constructed to house persons with mental illness, were developed. Individuals with mental illness were removed from their homes and placed in these institutions.
This need for treatment prompted the development of institutions where care could be provided. For example, in 1751, Benjamin Franklin established Pennsylvania Hospital in Philadelphia. This was the first institution in the United States to provide treatment and care for individuals with mental illness. As the late 18th century approached, medicine began to view psychiatry as a separate branch. At that time, mental illness embraced only such medical interventions as bloodletting, immobilization, and specialized devices such as the tranquilizer chair both in the United States and abroad. These practices continued until the very late 18th and early 19th centuries. Through the work of Dr. Benjamin Rush in the United States, the focus of treatment began to shift to supportive, sympathetic care in an environment that was quiet, clean, and pleasant. Although humane, this care was primarily custodial in nature. Moreover, individual states were required to undertake financial responsibility for the care of people with mental illnesses, the first example of government-supported mental health care.
A key player in the evolution of mental health and mental illness care during the 19th century was Dorothea Dix. A retired schoolteacher, Dix was asked to teach a Sunday school class for young women who were incarcerated. During her classes, she witnessed the deplorable conditions at the facility. In addition, she observed the inhumane treatment of the women with mental illness. As a result, she began a crusade to improve the conditions. She worked tirelessly for care reform, advocating for the needs of the mentally ill through the establishment of state hospitals throughout the United States. Unfortunately, these state institutions became overcrowded, providing only minimal custodial care. Although she was a nurse, her impact on the evolution of mental health and mental illness may be overlooked because her work was primarily humanitarian.
Dorothea Dix was instrumental in advocating for the mentally ill. She is credited with the development of state mental hospitals in the United States.
The 20th Century
The 20th century ushered in a new era of ideas regarding mental health and illness. Scientific thought was coming to the forefront. In the beginning of the 1900s, two schools of thought about mental illness were prevalent in the United States and Europe. One school viewed mental illness as a result of environmental and social deprivation that could be treated by measures such as kindness, lack of restraints, and mental hygiene. The other viewed mental illness as a result of a biological cause treatable with physical measures such as bloodletting and devices. This gap in thinking—deprivation on one end of the spectrum and biological causes on the other end—led to the development of several different theories attempting to explain the cause of mental illness.
One such theory was the psychoanalytic theory developed by Sigmund Freud. His theory focused on a person’s unconscious motivations for behaviors, which then influenced a person’s personality development. Freud, a neuropathologist, examined a person’s feelings and emotions about his or her past childhood and adolescent experiences as a means for explaining the person’s behavior. According to Freud, an individual develops through a series of five stages: oral, anal, phallic/oedipal, latency, and genital. He considered the first three of these five stages (oral, anal, and phallic) to be the most important. If the person experiences a disruption in any of these stages, experiences difficulty in moving from one stage to the next, remains in one stage, or goes back to a previous stage, then that individual will develop a mental illness. Freud’s views became the mainstay of mental health and mental illness care for several decades.
The development of PSYCHOPHARMACOLOGY, the use of drugs to treat mental illness and its symptoms, also changed treatment for mental illness. The intent was control of symptoms through the use of drugs to allow individuals to be discharged from institutions and return to the community where they could function and live productive lives. Subsequently, the numbers of persons requiring hospitalization dramatically decreased. Moreover, psychopharmacology provided a lead into the future for deinstitutionalization and for addressing the underlying biological basis for mental illness.
Research into the proposed causes or factors associated with mental illness exploded during the 1990s, which was dubbed “the decade of the brain.” Interest in neurotransmitters and their role in influencing mental illnesses was explored. New medications were developed based on proposed theories of how medications may regulate neurotransmitter reuptake. Along with the burgeoning pharmaceutical industry and the embracing of the biological model of illness by physicians, this era led to a major shift away from more humane, less-invasive forms of therapy, such as counseling, as the main psychiatric treatment to one involving medical-somatic options as first-line intervention (Whitaker, 2011).
Governmental Involvement and Legislation
Governmental involvement in mental health care took on an expanded role during the 20th century. In the United States at the time of World War II, individuals were rejected for military service due to psychological problems. Additionally, those returning from combat were often diagnosed with emotional or psychological problems secondary to the effects of the war. The view that anyone could develop a mental illness was beginning to take root. As a result, the National Mental Health Act was passed in 1946. This act provided governmental funding for programs related to research, mental health professional training, and expansion of facilities including state mental health facilities, clinics, and treatment centers. It also called for the establishment of a National Advisory Mental Health Council and a National Institute of Mental Health (NIMH), which was formally established in 1949. NIMH focused its activities on research and training in mental health and illness.
In 1955, the Mental Health Study Act was passed, which called for a thorough analysis of mental health issues in the nation. This resulted in a Joint Commission on Mental Illness and Health, which prepared a major report titled Action for Mental Health. The report established a need for expanded research and training for personnel, an increase in the number of full-time clinics as well as supplemental services, and enhanced access to emergency care and treatment. In addition, the report recommended that consumers should be involved in planning and implementing the delivery systems and that funding would be shared by all levels of government.
The impact of psychopharmacology coupled with the social and political climate of the 1960s led to the passage of the Mental Retardation Facilities and Community Mental Health Centers Act. This act was designed to expand the resources available for community-based mental health services. It called for the construction of mental health facilities throughout communities to meet the needs of all those experiencing mental health problems. The result was to ease the transition from institutionalized care to that of the community. The ultimate goal was to provide comprehensive humane treatment rather than custodial care. This legislation was part of President John F. Kennedy’s New Frontier program and led to the DEINSTITUTIONALIZATION (the movement of patients in mental health institutions back into the community) of many who had been in state-run and other mental health facilities that had provided long-term mental health care and treatment.
At this time, the NIMH expanded its service role and assumed responsibility for monitoring the community mental health centers programs (National Institutes of Health [NIH], 2010). Unfortunately, the number of community mental health centers grew slowly and often were understaffed. Care was fragmented and inadequate. Thus, the demands resulting from deinstitutionalization became overwhelming.
In the late 1960s, care of the mentally ill began to shift to community clinics.
The overwhelming demands faced by the community mental health centers continued. In addition, society was changing. Population shifts, a growing aging population, changes in family structures, and increased numbers of women in the workforce further complicated the system. In 1980, the Mental Health Systems Act was passed in response to the report findings of the President’s Commission on Mental Health. This act was designed to establish research and training priorities and address the rights of patients and community mental health centers. However, the election of a new president led to dramatic changes in focus. In 1981, the Omnibus Budget Reconciliation Act (OBRA) was passed, which provided a set amount of funding for each state. Each state would then determine how to use these funds. Unfortunately, mental health care was not a priority for the majority of states and, subsequently, mental health care suffered. Individuals with chronic mental illness often were placed in nursing homes or other types of facilities. In an attempt to address the issues associated with OBRA, Congress passed the Omnibus Budget Reconciliation Act of 1987, which was to provide a means for ensuring that the chronically mentally ill would receive appropriate placement for care. However, the political climate of concern for an ever-widening federal budget deficit led to a significant decrease in funding for mental health care.
In 1992, NIMH joined the NIH as one of the institutes that continues today to fund research on mental health and illness. NIMH also serves as a national leadership organization for mental health issues (NIH, 2010).
As a result of the changes in society and the political climate of the times, mental health care suffered once again. In response, Surgeon General David Satcher issued The Surgeon General’s Report on Mental Health in 1999. This was the first national report that focused on mental health. The report included recommendations for broad courses of action to improve the quality of mental health in the nation as follows: continuing the research on mental health and illness to build the science base; overcoming the stigma of mental illness; improving public awareness of effective treatment; ensuring the supply of mental health services and providers; ensuring delivery of state-of-the-art treatments; tailoring treatment to age, gender, race, and culture; facilitating entry into treatment; and reducing financial barriers to treatment (Satcher, 1999). Subsequently, mental health care was brought to the forefront.
Following publication of The Surgeon General’s Report on Mental Health in 1999, another key report focusing on children’s mental health was published. The Report of the Surgeon General’s Conference on Children’s Mental Health: A National Action Agenda called for:
Improved recognition/assessment of children’s mental health needs and promotion of public awareness of children’s mental health issues
Continued development, dissemination, and implementation of scientifically proven prevention and treatment services
Reduction and/or elimination of disparities in access to mental health services and increased access and coordination of quality mental health services (U.S. Public Health Service, 2000)
This report further emphasized the need for improved mental health care.
Continued problems in the mental health system prompted the launch of the President’s New Freedom Commission on Mental Health in 2001. Its goal was to promote increased access to educational and employment opportunities for people with mental health problems. This commission was specifically targeted with reducing the stigma associated with mental illness, lifting the financial and access barriers to treatment, and addressing the system fragmentation. The report, Achieving the Promise: Transforming Mental Health Care in America, was issued in 2003 with several recommendations for service delivery. It identified the need for changing the current system to one that is more consumer and family driven and that underscored the need for mental illnesses to receive the same attention as other medical illnesses. Many of these changes are in the process of being implemented on the national and state levels (President’s New Freedom Commission on Mental Health, 2003).
Mental health, which first appeared as a major priority area in the Healthy People 2000 objectives, continued to be a priority for Healthy People 2020 (U.S. Department of Health and Human Services, 2016). In December 2010, the Healthy People 2020 objectives were released. As in 2010, mental health and mental disorders were a priority concern. The Healthy People 2020 objectives for mental health and mental disorders are highlighted in Box 1-1.
BOX 1-1: HEALTHY PEOPLE 2020 OBJECTIVES
MENTAL HEALTH AND MENTAL DISORDERS
1. Reduce the suicide rate.
2. Reduce the rate of suicide attempts by adolescents.
3. Reduce the proportion of adolescents who engage in disordered eating behaviors in an attempt to control their weight.
4. Reduce the proportion of persons who experience major depressive episode.
4.1. Adolescents aged 12–17 years.
4.2. Adults aged 18 years and older.
5. Increase the proportion of primary care facilities that provide mental health treatment onsite or by paid referral.
6. Increase the proportion of children with mental health problems who receive treatment.
7. Increase the proportion of juvenile residential facilities that screen admissions for mental health problems.
8. Increase the proportion of persons with serious mental illness who are employed.
9. Increase the proportion of adults with mental health disorders who receive treatment.
9.1. Adults aged 18 years and older with serious mental illness.
9.2. Adults aged 18 years and older with major depressive episode.
10. Increase the proportion of persons with co-occurring substance abuse and mental disorders who receive treatment for both disorders.
11. Increase depression screening by primary care providers.
11.1. Increase the proportion of primary care physician office visits that screen adults aged 19 years and older for depression.
11.2. Increase the proportion of primary care physician office visits that screen youth aged 12–18 years for depression.
12. Increase the proportion of homeless adults with mental health problems who receive mental health services.