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.

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).

Current Perspectives

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:

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.

Early Emergence of the Profession

The early beginnings of psychiatric-mental health nursing can be traced back to Florence Nightingale, who first identified the need to view the patient holistically. Her focus was not mental illness; she was an advocate for patient self-care, believing that when a patient developed independence, he or she would be better able to face illness with lessened anxiety.

Specialization for psychiatric-mental health nursing arose along the same time that humane treatment for mental illness was coming to the forefront. Linda Richards, the first nurse trained in the United States, opened a training school for psychiatric-mental health nurses (PMHNs) in 1882. Although the training primarily consisted of meeting the patient’s physical needs, Richards strongly emphasized the need to assess a patient’s physical and emotional needs. Thus, she is credited as being the first American psychiatric nurse.

Figure 1-1

Evolution of mental health care and psychiatric-mental health nursing. Events listed at the right identify key developments associated with mental health care. Events listed at the left identify key developments associated with psychiatric-mental health nursing. Note how significant events in mental health care parallel those in psychiatric-mental health nursing.

Approximately 40 years later, the first nursing program for psychiatric-mental health nursing was established by Effie Taylor at Johns Hopkins Phipps Clinic. Taylor, like Nightingale, emphasized the need to view the patient as an integrated whole. She also believed that general nursing and mental health nursing were interdependent. This was the first time that a course for psychiatric-mental health nursing was included in a curriculum.

Continued Evolution

During the first half of the 20th century, the mental health field continued to evolve through the discovery of new therapies and theories. With the introduction of these new therapies, PMHNs were required to adapt the principles of medical-surgical nursing care to the care of psychiatric patients. In 1920, the first textbook of psychiatric-mental health nursing was written by Harriet Bailey. This book primarily focused on procedure-related care by nurses.

Continued involvement with the use of therapies resulted in a struggle for PMHNs to define their role. However, the social climate of the time promoted a view of women as subservient to men. This view also carried over into the realm of nursing.

Near the middle of the 20th century, INTERPERSONAL MODELS (those that focus on the interaction of the person with others) by leaders such as Harry Stack Sullivan and others began to emerge. Sullivan believed that personality was an observable reflection of an individual’s interaction with other individuals. Thus, a person’s personality, be it healthy or ill, was a direct result of the relationship between that person and others. Sullivan also identified two key needs: the need for satisfactions (biological needs) and the need for security (state of well-being and belonging). Any block to satisfactions or security results in anxiety (Sullivan, 1953).

Again, the emergence of interpersonal models paralleled a shift in nursing practice as interpersonal models of nursing practice were being developed. Interpersonal systems became prominent in mental health around 1945 and then in nursing practice in 1952. Both the field of mental health and the field of nursing flourished during this time period with an abundance of theorists contributing to their respective disciplines.

Nursing as a profession began to again refine itself with the emergence of theorists such as Hildegard Peplau (1952), who defined nursing as “a significant, therapeutic, interpersonal process. It functions cooperatively with other human processes that make health possible for individuals and communities. Nursing is an educative instrument, a maturing force that aims to promote forward movement of personality in the direction of creative, constructive, productive, personal, and community living” (p. 16). Nurse educators thus began to emphasize the importance of interpersonal relations and integrated relevant content in the curricula. Peplau further clarified the PMHN’s role as that of counselor, differentiating PMHNs working as general staff nurses from those who were expert practitioners with advanced degrees. According to Peplau, “psychiatric nursing emphasizes the role of counselor or psychotherapist. . . . From my viewpoint, a psychiatric nurse is a specialist and at this time specialist status can be achieved by two routes—experience and education” (Peplau, 1962, p. 51). (For a more in-depth discussion of Peplau, see Chapter 2.)

As a result, nurses were being educated in modes of THERAPEUTIC COMMUNICATION (patient-focused interactive process involving verbal and nonverbal behaviors), which were seen as integral parts of the patient’s recovery. It was not uncommon for nurses to carry a case load of patients and to spend significant portions of their shift having one-to-one, planned, structured conversations. These conversations were then recorded in the nursing record and their content was processed by the psychiatrist and other health professionals in their evaluation of progress in treatment. (For a more in-depth discussion of therapeutic communication, see Chapter 3.)

MILIEU MANAGEMENT, which developed after 1950, was adopted by psychiatric care facilities. Milieu management refers to the provision and assurance of a therapeutic environment that promotes a healing experience for the patient. This treatment approach is reflected in everything from the physical attributes of the mental health unit such as wall color and choice and arrangement of furniture, to source and levels of lighting. Nurses became the managers of the milieu, responsible for recognizing that they themselves were part of the milieu and thus had to conduct themselves in a manner conducive to supporting a therapeutic environment. This required an ever-conscious focus on dress, body language, tone, and style of verbal interaction, as well as vigilant awareness of surroundings and environment. For example, it would not be unusual for a nurse who was mindful of milieu management therapy to sense that the unit was tense and volatile and to respond by slowly and subtly adjusting the level of light or noise to produce a more relaxed environment. As much thought was spent on how to manage the unit as on how to manage any individual patient.

Nurses also conducted therapy groups. Sometimes these were with a psychiatrist or other psychiatric staff member. Nurses led PSYCHOEDUCATIONAL GROUPS (groups designed at imparting specific information about a select topic such as medication) and co-facilitated PROCESS GROUPS (more traditional form of psychotherapy where deep feelings, reactions, and thoughts are explored and processed in a structured way). Regardless of the treatment modality, the energy expended by the nurse in the delivery of psychiatric care revolved around the development and maintenance of a therapeutic relationship and the promotion of a therapeutic environment.

From 1954 onward, the discovery and use of antipsychotic medications such as chlorpromazine (Thorazine) impacted the care for the severely mentally ill. It signaled a change of course for both nursing and mental health care. Medication administration and monitoring were now added to the nurse–patient experience. Because of the usage of newer longer acting medications (such as haloperidol [Haldol] and fluphenazine [Prolixin]), the 1960s were a time of care transition from hospital setting to community setting. However, the one-to-one nurse–patient relationship still remained important in nursing (Doona, 1979).

During the 1960s, the Division of Psychiatric and Mental Health Nursing Practice of the American Nurses Association (ANA) published the Statement on Psychiatric Nursing Practice. This was the first document to address the PMHN’s holistic view of the patient. It emphasized involvement in a wide range of activities addressing health promotion and health restoration. Since its initial publication, the document has been updated three times, expanding and clarifying the roles and functions of the PMHN to reflect the status of the current society.

By the 1990s, the biological movement had so firmly been embraced by medicine that along with their alliance with the pharmaceutical industry, a major shift in both mental health care and nursing practice occurred, and medical SOMATIC (referring to the body) interventions became the primary focus of treatment (Whitaker, 2011).

Inpatient stays became shorter and funding for mental health treatment began to diminish both at the in-patient and community levels. The role of the psychiatrist changed from the provider of therapy and medication to that of diagnostic and pharmacological expert as schools of medicine no longer offered psychotherapy as part of physician training. Therapy was also now seen as the domain of the PhD-prepared psychologist and other independent providers such as social workers and to a lesser extent advanced practice psychiatric nurses. With less time, less money, and less integrated service lines, the generalist psychiatric nurse’s role shifted to more of case manager of care. Duties were now more focused on admission and discharge proceedings, medication administration and monitoring, community linkage, and crisis management. Less time was spent on one-to-one therapeutic nurse–patient relationship modes of treatment. These changes are still evident today.

Scope and Standards of Practice

Initially developed in 1973, and with the second edition published in 2014, the Scope and Standards of Practice delineate the specific responsibilities for psychiatric-mental health nursing. The standards are divided into two areas: Standards of Practice and Standards of Professional Performance. The Standards of Practice address six major areas: assessment, diagnosis, outcomes identification, planning, implementation, and evaluation. The Standards of Professional Performance address nine areas: quality of practice, education, professional practice evaluation, collegiality, collaboration, ethics, research, resource utilization, and leadership. Each area includes specific criteria for use in measuring achievement of the standard.

Phenomena of Concern

The psychiatric-mental health practice division of the ANA has developed a list of 13 specific areas or “phenomena of concern.” The phenomena provide the focus of patient care for PMHNs. These areas reflect the holistic view of the patient including the needs of the patient, family, group, and community. Therefore, when providing care to patients, PMHNs focus on the following:

Levels of Psychiatric-Mental Health Nursing Practice

Two levels of psychiatric-mental health nursing currently are recognized: basic and advanced. The levels are distinguished by the educational preparation, complexity of practice, and specific nursing functions (ANA, 2007). The American Nurses Credentialing Center (ANCC) certifies both basic and advanced practice psychiatric nurses through an examination and credential review process.

Basic-level PMHNs are registered nurses who have graduated from an accredited nursing education program and are licensed to practice in their state. In addition, basic-level PMHNs possess specialized knowledge and skills to care for patients with mental health issues and psychiatric problems. They apply the nursing process through the use of the therapeutic nurse–patient relationship, therapeutic interventions, and professional attributes such as self-awareness, empathy, and the therapeutic use of self (ANA, 2007). The ANCC recognizes the baccalaureate degree in nursing as the preferred level of educational preparation.

Advanced practice PMHNs are educated at the master’s or doctorate level of education in the specialty and have achieved certification in this specialty by the ANCC. Advanced practice focuses on the “application of competences, knowledge, and experience to individuals, families, or groups with complex psychiatric-mental health problems” (ANA, 2007, p. 19). Mental health promotion, collaboration, and referral are key components of the advanced practice PMHN.

When graduate programs in psychiatric-mental health nursing were first introduced, the focus was on preparing educators to teach in basic nursing programs. Faculty members were also prepared to integrate psychiatric-mental health concepts throughout the undergraduate nursing curricula. Components such as communication skills, process recordings, and understanding of the emotional dimensions of physical illness were integrated into all nursing courses. The first psychiatric advanced practice role was the psychiatric clinical nurse specialist implemented by Hildegard Peplau. During the mid-1960s, more clinical nurse specialist (CNS) programs were introduced, emphasizing the preparation of specialists both for psychiatric-mental health nursing direct care roles and for teaching, consultation, and liaison with other nurses in clinical practice. The core focus of CNS practice today emphasizes three spheres of influence: organizational and systems; nursing practice; and client (patient). The CNS seeks to improve patient outcomes by influencing nursing practice via research and mentorship, influencing organizational systems via consultation or through direct care to individuals or communities (Fulton, Lyon, & Goudreau, 2010). Most psychiatric CNSs have training in individual psychotherapy, group psychotherapy, organizational consultation and liaison work, and research. More recently, some psychiatric CNSs have opted to add prescriptive authority to their set of services.

In the early 1960s the nurse practitioner (NP) role was introduced in rural areas of the United States. By the late 1990s, the psychiatric-mental health NP role was introduced. Traditionally, this role has been seen as a provider of common physician services such as direct patient care for complex diagnosis and management of medical illnesses with medication prescription. More recently, the development is the blending of the CNS and NP roles for preparation of advanced practice nurses (APNs) in psychiatric-mental health nursing. The challenge to educators, however, is how to combine the two roles while preserving the uniqueness of each (Jones, 2010). The American Psychiatric Nurses Association (APNA) and the International Society of Psychiatric Nurses (ISPN), two professional psychiatric-mental health nursing organizations, have reviewed the standards for credentialing for future psychiatric-mental health nursing practice at both basic and advanced levels. According to ANCC, the current plan is to eliminate the title and role of the psychiatric CNS in favor of a psychiatric family NP model. This clinician would no longer be a specialist in any one area of psychiatric-mental health nursing, but would see clients from childhood through elderly age groups (Jones & Minarik, 2012).

Roles and Functions of the PMHNs

Both basic and advanced practice PMHNs are guided by the Scope and Standards of Practice developed by the ANA. However, specific standards and criteria used for measurement are expanded for the advanced practice PMHN. Table 1-1 highlights the key functions for each level of practice.