I

The Nature of
Mental Health and
Mental Illness

1
 1
Social Change and
Mental Health
Mary Ann Boyd

LEARNING OBJECTIVES
After studying this chapter, you will be able to:
Identify agents of social change that affect the delivery of mental health care.
Relate the concept of social change to the history of psychiatricmental health care.
Discuss the history of psychiatricmental health nursing and its place within nursing
history.
Analyze the theoretical arguments that shaped the development of contemporary
scientific thought.
Summarize the impact of current economic and political forces on the delivery of
mental health services.

KEY TERMS
biologic view deinstitutionalization moral treatment psychiatric pluralism
psychoanalytic movement psychosocial theory

KEY CONCEPT
social change

3
4 UNIT I The Nature of Mental Health and Mental Illness

T hroughout history, an interplay of biologic, spiri-

tual, and environmental factors were believed to
cause mental disorders. Acceptable treatment methods
During periods of rapid social change and instability,
there is more general anxiety and fear and subsequently
more intolerance and ill treatment of people with mental
reflected the underlying popular beliefs of the times. disorders. See Table 1-1 for a summary of historical
When the causes of mental disorders were believed to events and correlating perspectives on mental health dur-
be biologic, individuals were treated with the latest bio- ing the Premoral Treatment Era (800 BC to the Colonial
logic therapy. Prehistoric healers practiced an ancient Period).
surgical technique of removing a disk of bone from the
skull to let out the evil spirits. In the early Christian
period (1100 AD), when sin or demonic possession A Revolutionary Idea:
were thought to cause mental disorders, clergymen
treated patients, often through prescribed exorcisms. If
Humane Treatment
such measures did not succeed, patients were excluded The emergence of enlightened political ideas and an
from the community and sometimes even put to death. increasing availability of economic resources in the late
Later in the Medieval era (10001300), many believed 18th century led to the advent of moral treatment in
disorders were products of dysfunctional environments, mental health care, which was characterized by kind-
and individuals were removed from their sick envi- ness, compassion, and a pleasant environment for
ronments and placed in protected asylums. patients. Publicly and privately supported asylums for
The differences in the treatment of mentally ill individuals with mental disorders were built during this
patients typically depends on the communitys per- time, and patients were routinely removed from their
ceived notions and fears of those with mental disor- home environments, which were believed to be causing
ders. History reflects that generally, in periods of rel- the illnesses. It was the first humane treatment period
ative social stability, there is less fear and more since the Greek and Roman eras.
tolerance for deviant behavior, and it is easier for indi- By the height of the French Revolution in 1792,
viduals with mental disorders to live safely within their moral treatment had become standard practice. It was
communities. during this time that Philippe Pinel (17451826) was
appointed physician to Bicetre, a hospital for men that
KEY CONCEPT Social change, the structural and had the unfortunate distinction of being the worst asy-
cultural evolution of society, is constant and at times lum in the world. Pinel believed that the insane were
erratic. Psychiatric mental health care has evolved
sick patients who needed special treatment, and once
within the social framework and cannot be separated
installed in his position, he ordered the removal of the
from economic and political realities.
chains, stopped the abuses of drugging and bloodlet-
ting, and placed the patients under the care of physi-
FAME AND FORTUNE cians. Three years later, the same standards were
extended to Salpetriere, the asylum for female patients.
Joan of Arc (14121431)
At about the same time in England, William Tuke
Famous Warrior
(17321822), a member of the Society of Friends,
Public Personna raised funds for a retreat for members who had mental
Born in 1412 in France, Joan of Arc began hearing disorders. The York Retreat was opened in 1796;
counsel and seeing visions of Saints Catherine and restraints were abandoned, and sympathetic care in
Margaret (two early Christian martyrs) and St.
quiet, pleasant surroundings with some form of indus-
Michael the Archangel at age 12. Initially, the visions
instructed her to be good and to go to church regu- trial occupation, such as weaving or farming, was pro-
larly. Over the years, the visions persisted and vided (Fig. 1-1).
expanded calling her to save France from British While Tuke was influential in England, the Quak-
occupation. Deeply believing that her mission was in ers also exercised their influence in the United States,
response to Gods will, she dressed as a boy and led
where they were instrumental in stopping the practice
an army to defeat the British.
of bloodletting; they also placed great emphasis on
Personal Realities providing a proper religious atmosphere (Deutsch,
At age 19, the simple and faithful maiden was cap- 1949). The Quaker Friends Asylum was proposed in
tured and burned at the stake for heresy. Twenty-
three years later, her conviction was overturned. In
1811 and opened 6 years later in Frankford, Pennsyl-
the 20th century, she was canonized and today she is vania (now Philadelphia), to become the second asy-
the patron saint of France. Some saw Joan of Arc as a lum in the United States. The humane and supportive
messenger from God while others believed that she rehabilitative attitude of the Quakers was seen as an
was the devil. Probably today, neither would apply. extremely important influence in changing tech-
Instead, she might be hospitalized and her visions
explained as symptoms of a mental disorder.
niques of caring for those with mental disorders. As
states were founded, new hospitals were opened that
 CHAPTER 1 Social Change and Mental Health 5

Table 1.1 Social Change in the Premoral Treatment Era

Socioeconomic and Political Events Changing Attitudes and Practice

Period and People in Mental Health Care

Ancient Times to 800 BCE Sickness was an indication of the Persons with psychiatric symptoms
displeasure of deities for sins. were driven from homes and
Viewed as supernatural. ostracized by relatives. When
behavioral manifestations were
viewed as supernatural powers, the
persons who exhibited them were
revered.
Periods of Inquiry: 800 BCE to Egypt and Greek periods of inquiry. Counseling, work, music were provided
1 CE Physical and mental health viewed as in temples by priests to relieve the
interrelated. Hippocrates argued distress of those with mental
abnormal behaviors were due to disorders. Observation and
brain disturbances. Aristotle related documentation were a part of the
mental to physical disorders. care. The mental disorders were
treated as diseases. The aim of
treatment was to correct imbalances.
Early Christian and Early Power of Christian church grew. St. Persons with psychiatric symptoms
Medieval: 11000 CE Augustine pronounced all diseases were incarcerated in dungeons,
ascribed to demons. beaten, and starved.
Later Medieval: 10001300 In Western Europe, spirit of inquiry First asylums built by Moslems.
dead. Healing by theologians and Persons with psychiatric symptoms
witchdoctors. Persons with were treated as being sick.
psychiatric symptoms were
incarcerated in dungeons, beaten,
and starved. In Mideast, Avicenna
said mental disorders are illnesses.
Renaissance: 13001600 In England, differentiated insane from Persons with psychiatric symptoms
criminal. In colonies, mental illness who presented a threat to society
believed caused by demonic were apprehended and locked up.
possession. Witch hunts were There were no public provisions for
common. persons with mental disorders except
jail.
Private hospitalization for the wealthy
who could pay. Bethlehem Asylum
was used as a private institution.

Interior of Bethlehem Asylum, London

Colonial: 17001790 1751: Benjamin Franklin established The beginnings of mental diseases
Pennsylvania Hospital (in viewed as illness to be treated.
Philadelphia)the first institution in
United States to receive those with
mental disorders for treatment and
cure.
(continued )
6 UNIT I The Nature of Mental Health and Mental Illness

Table 1.1 Social Change in the Premoral Treatment Era (continued )

Socioeconomic and Political Events Changing Attitudes and Practice

Period and People in Mental Health Care

1773: First public, free-standing

asylum at Williamsburg, Virginia
1783: Benjamin Rush categorized
mental illnesses and began to treat
mental disorders with medical
interventions, such as bloodletting,
mechanical devices.

The Tranquilizer Chair of Benjamin

Rush. A patient is sitting in a chair,
his body immobilized, a bucket
attached beneath the seat. U.S.
National Library of Medicine, Images
from the History of Medicine,
National Institutes of Health, Depart-
ment of Health and Human Services.

were dedicated to the care of patients with mental farm communities, as was the custom during the first
disorders. half of the 19th century, the poor and indigent were
Even with these hospitals, only a fraction of people often auctioned and bought by landowners to provide
with mental disorders received treatment. Those who cheap labor. Landowners eagerly sought them for their
were judged dangerous were hospitalized; those strong backs and weak minds. The arrangement had its
deemed harmless or mildly insane were treated the own economic usefulness because it provided the com-
same as other indigents and given no public support. In munity with a low-cost way to care for its mentally ill.
Some states used almshouses (poorhouses) for housing
the mentally ill.

The 19th and Early

20th Centuries
HORACE MANN AND THE BEGINNING
OF PUBLIC RESPONSIBILITY
In 1828, Horace Mann, a representative in the Massa-
chusetts state legislature, saw his plea that the insane
are wards of the state become a reality. State govern-
ments were expected to assume financial responsibility
for the care of people with mental illnesses. This is an
important milestone because it set a precedent for tax-
supported mental health funding. In Canada also, men-
tal health care was embraced as a public responsibility,
FIGURE 1.1 The perspective view of the north front of the
retreat near York. U.S. National Library of Medicine, Images and by 1867 when the British North America Act was
from the History of Medicine. National Institutes of Health, passed, creating the Dominion of Canada, the care of
Department of Health and Human Services. the mentally ill was the responsibility of provinces.
 CHAPTER 1 Social Change and Mental Health 7

A SOCIAL REFORMER: Great Britain and other parts of Europe. During the
DOROTHEA LYNDE DIX Civil War, she was appointed to the post of Superinten-
dent of Women Nurses, the highest position held by a
Dorothea Lynde Dix (18021887), a militant crusader
woman during the war.
for the humane treatment of patients with mental ill-
ness, was responsible for much of the reform of the
mental health care system in the 19th century. At LIFE WITHIN EARLY INSTITUTIONS
nearly 40 years of age, Dix, a retired school teacher liv-
The approach inside the institution was one of practical
ing in Massachusetts, was solicited by a young theology
management, not treatment. The patients did not pos-
student to help in preparing a Sunday School class for
sess the interpersonal and social skills to live within a
women inmates at the East Cambridge jail. Dix led the
family setting, let alone in the complex group-living
class herself and was shocked by the filth and dirt in the
environment of a state hospital with others who were
jail. She was particularly struck by the treatment of
equally ill. The major concern was the management of
inmates with mental disorders. It was the dead of win-
a large number of people who had bizarre thoughts and
ter, and no heat was provided. When she questioned
behaviors and who lived in close quarters.
the jailer about the lack of heat, his answer was that
Women had a particularly difficult time and often
the insane need no heat. The prevailing myth was
were institutionalized at the convenience of their
that the insane were insensible to extremes of temper-
fathers or husbands. Because a womans role in the late
ature. Dixs outrage initiated a long struggle in the
1800s was to function as a domestic extension of her
reform of care.
husband, any behaviors or beliefs that did not conform
An early feminist, Dix disregarded the New England
to male expectations could be used to justify the claim
role of a Puritan woman and diligently investigated the
of insanity. These women were literally held prisoner
conditions of jails and the plight of the mentally ill.
for years. In the asylums, women were psychologically
Her solution was state hospitals. She first influenced
degraded, used as servants, and physically tortured by
the Massachusetts legislature to expand the Massachu-
male physicians and female attendants (Lightner, 1999).
setts State Hospital. Then, through public awareness
These institutions had little more to offer than food,
campaigns and lobbying efforts, she managed to con-
clothing, pleasant surroundings, and perhaps some
vince state after state to build hospitals. She also turned
means of employment and exercise. Because the scien-
her attention to the plight of the mentally ill in
tific hypotheses linking mental disorders to brain dys-
Canada, where she was instrumental in creating mental
function were generally ignored, the emphasis in the
hospitals in Halifax, Nova Scotia, and St. John, New-
institutions was on humane custodial care within an
foundland (Fig. 1-2).
efficient organization. Many people believed that this
At the end of Dixs long career, 20 states had
custodial care was the highest possible level of treat-
responded directly to her appeals by establishing or
ment that could be provided.
enlarging state hospitals. Dix played an important role
People with mental disorders who were warehoused
in the establishment of the Government Hospital for
in state mental institutions had little hope of reentering
the Insane in Washington, DC (which later became St.
society. In 1908, Clifford Beers (18761943) published
Elizabeths Hospital). She also extended her work into
an autobiography, A Mind That Found Itself, depicting
his 3-year experience in three different types of hospi-
tals: a private for-profit hospital, a private nonprofit
hospital, and a state institution. In all of these facilities,
he was beaten, choked, imprisoned for long periods in
dark, dank, padded cells, and confined many days in a
straightjacket. At the end of his book, he recommended
that a national society be established for the purpose of
reforming care and treatment, disseminating informa-
tion, and encouraging and conducting research. Beers
cause was supported by a prominent neuropathologist,
Adolf Meyer (18661950), who suggested the term
mental hygiene to denote mental health. By 1909,
Beers formed a National Committee for Mental
Hygiene. Through the committees efforts, child guid-
ance clinics, prison clinics, and industrial mental health
FIGURE 1.2 Dorothea Lynde Dix. U.S. National Library of
approaches were developed.
Medicine, Images from the History of Medicine. National Insti- Early institutions eventually evolved into self-
tutes of Health, Department of Health and Human Services. contained communities that produced their own food
8 UNIT I The Nature of Mental Health and Mental Illness

and made their own clothing. A medical superinten- the McLean Asylum in Massachusetts, firmly believed
dent, who was usually more adept in executive and busi- that patients in mental hospitals should receive nursing
ness ability than in treatment, managed the closed men- care. His attempts to employ nurses proved fruitless.
tal health community. Attendants, many of whom were Cowles encouraged Linda Richards, the United States
untrained, staffed these institutions. Nursing care was first trained nurse, to open a training school for psychi-
not introduced until the very late 1800s. atricmental health nurses (Cowles, 1887). The Boston
City Hospital Training School for Nurses was estab-
lished in 1882 at McLean Hospital.
THE DEVELOPMENT OF Although there was still much social resistance to
PSYCHIATRICMENTAL HEALTH educating women, especially to care for the insane, the
NURSING THOUGHT first candidates for admission to the McLean training
school were both male and female attendants who
Early Views
worked at the McLean Asylum (Campinha, 1987).
The roots of contemporary psychiatricmental health McLean was noteworthy for more than just providing
nursing thought can be traced to Florence Nightingales nurses with the rudiments of caring for the mentally ill.
seminal work Notes on Nursing, originally published in It was the first institution in the United States to pro-
1839 (Nightingale, 1859). The holistic view of the vide men the opportunity to become trained nurses
patient, with the body and soul seen as inseparable and (Mericle, 1983) (Box 1-1).
the patient viewed as a member of a family and commu- Although nurses were trained in the care of patients
nity, was central to Nightingales view of nursing. in psychiatric institutions, their training was financially
Although she did not address the care of patients in asy- and academically dependent on the institutions organi-
lums, Nightingale was sensitive to human emotion and zational structure and was outside mainstream nursing
recommended interactions that today would be classified education. In 1913 at Johns Hopkins Phipps Clinic,
as therapeutic communication (see Chapter 10). This Effie Taylor initiated the first nursing program of study
early nursing leader advocated promotion of health and organized by nurses for psychiatric training. Taylor
development of independence by encouraging patients to sought to integrate the concepts from general and men-
perform their own health care. She believed that this, in tal health nursing into a more comprehensive knowl-
turn, would reduce their anxiety in the face of illness. edge base for all nursing care. She was committed to the
The need for specialized psychiatricmental health concept of wholeness and warned that mental health
nursing was recognized when the humane care that nursing and general nursing could not and should not
characterized the Moral Treatment Era was emerging exist independently of each other. In Taylors classes at
as a model for practice. Dr. Edward Cowles, director of Johns Hopkins, the psychobiologic orientation was

BOX 1.1
History of Psychiatric Mental Health Nursing

1882 First training school for psychiatric nursing at McLean Asylum by E. Cowles; first nursing program to admit men.
1913 First nurse-organized program of study for psychiatric training by Euphemia (Effie) Jane Taylor at Johns Hopkins
Phipps Clinic.
1914 Mary Adelaide Nutting emphasized nursing role development.
1920 First psychiatric nursing text published, Nursing Mental Disease, by Harriet Bailey.
1950 Accredited schools required to offer a psychiatric nursing experience.
1952 Publication of Hildegarde E. Peplaus Interpersonal Relations in Nursing.
1954 First graduate program in psychiatric nursing established at Rutgers University by Hildegarde E. Peplau.
1963 Perspectives in Psychiatric Care and Journal of Psychiatric Nursing published.
1967 Standards of PsychiatricMental Health Nursing Practice published. American Nurses Association (ANA) initiated the
certification of generalists in psychiatric mental health nursing.
1979 Issues in Mental Health Nursing published. ANA initiated the certification of specialists in psychiatric mental
health nursing.
1980 Nursing: A Social Policy Statement published by the ANA.
1982 Revised Standards of Psychiatric and Mental Health Nursing Practice issued by the ANA.
1985 Standards of Child and Adolescent Psychiatric and Mental Health Nursing Practice published by the ANA.
1987 Archives of Psychiatric Nursing and Journal of Child and Adolescent Psychiatric and Mental Health Nursing published.
1994 Statement on PsychiatricMental Health Clinical Nursing Practice and Standards of PsychiatricMental Health Clinical
Nursing Practice.
1996 Guidelines specifying course content and competencies published by Society for Education and Research in
PsychiatricMental Health Nursing (SERPN).
2000 Scope and Standards of PsychiatricMental Health Nursing Practice.
 CHAPTER 1 Social Change and Mental Health 9

basic to all patients, not just to those labeled mentally deprivation. Moral management (nonrestraint, kind-
ill. Taylor, like Nightingale before her, encouraged ness, and hygiene) in an asylum was the answer. The
nurses to avoid the false dichotomy of mind and body biologic view held that mental illnesses had a biologic
(Church, 1987). She believed that the integrated whole cause and could be treated with physical interventions.
was the focus of nursing. However, biologic science was not far enough
In 1914, distinguished nursing leader and educator advanced to offer reasonable treatment approaches,
Mary Adelaide Nutting (18581948) addressed a confer- and existing primitive physical treatments, such as
ence at the new Psychopathic Hospital in Boston on the venesections (bloodletting) and gyrations (strapping
role of the psychopathic nurse. Her unique message was patients to a rotating board), were either painful or
that nursing care should be based on scientific study and considered barbaric.
conceptualized in terms of diagnosis, care, and treatment.
Meyer and Psychiatric Pluralism
Social Influences
Adolf Meyer attempted to bridge the ideologic gap
The development of nursing thought has been signifi- between the two groups by introducing the concept of
cantly influenced by the larger social climate in which psychiatric pluralism, an integration of human bio-
women in the profession operated. During Cowles era, logic functions with the environment. His approach
women could neither vote nor own property, and nurs- focused on investigating how the organs related to the
ing training reflected the societal view of women as person and how the person, constituted of these organs,
helpmates of men (physicians). In the early 1900s, related to the environment (Neill, 1980). However, the
nurses were expected to stay subservient to physicians biologic explanations were so far removed from later
and administrators and quietly play out the maternal scientific evidence that Meyers concept of psychiatric
role outside the home (Church, 1987). Although this pluralism won little support. The times were right for
may have been an acceptable social policy, it effectively another approach.
barred nurses from obtaining full access to information
they needed to treat their patients properly. For exam-
Freud and the Psychoanalytic Theory
ple, in 1920, Effie Taylor complained bitterly to Adolf
Meyer that nurses were not allowed to view medical Sigmund Freud (18561939) and the psychoanalytic
records, whereas medical students (men) were. movement of the early 1900s promised an even more
Despite the oppressive social climate for psychiatric radical approach to psychiatricmental health care.
nurses, nursing thought continued to develop. The first Freud, trained as a neuropathologist, developed a per-
psychiatric nursing textbook, Nursing Mental Disease, sonality theory based on unconscious motivations for
was written by Harriet Bailey in 1920. The content of behavior, or drives. Using a new technique, psycho-
the book reflected an understanding of mental disor- analysis, he delved into the patients feelings and emo-
ders of the times and set forth nursing care in terms of tions regarding past experiences, particularly early
procedures. childhood and adolescent memories, to explain the
basis of aberrant behavior. He showed that symptoms of
hysteria could be produced and made to disappear while
Modern Thinking patients were in a subconscious state of hypnosis.
As psychoanalytic theory gained in popularity, ideas
EVOLUTION OF SCIENTIFIC THOUGHT
of the mindbody relationship were lost. According to
As psychiatricmental health nursing continued to the freudian model, normal development occurred in
develop as a profession in the early part of the 20th cen- stages, with the first three being the most important:
tury, modern perspectives on mental illness were oral, anal, and genital. The infant progressed through
emerging in research, and these new theories would the oral stage, experiencing the world through symbolic
profoundly shape the future of mental health care for all oral ingestion; through the anal stage, in which the tod-
practitioners. Chapter 7 examines the underlying ide- dler developed a sense of autonomy through withhold-
ologies, but it is important to understand their develop- ing; and on to the genital stage, in which a beginning
ment within the social and historical context to appre- sense of sexuality emerged within the framework of the
ciate fully their impact on treatment approaches. oedipal relationship. If there was any interference in
In the early 1900s, two opposing views were held normal development, such as psychological trauma,
regarding mental illnesses: the belief that mental disor- psychosis or neurosis would develop.
ders had biologic origins and the belief that the prob- Primary causes of mental illnesses were now viewed
lems were attributed to environmental and social as psychological, and any physical manifestations or
stresses. The psychosocial theory proposed that men- social influences were considered secondary (Malamud,
tal disorders resulted from environmental and social 1944). It was generally believed within the psychiatric
10 UNIT I The Nature of Mental Health and Mental Illness

community that mental illnesses were a result of dis- INCREASED GOVERNMENT

turbed personality development and faulty parenting. INVOLVEMENT IN MENTAL
Mental illnesses were categorized either as a psychosis HEALTH CARE
(severe) or neurosis (less severe). A psychosis impaired
As scientific advances led to an increased intellectual
daily functioning because of breaks in contact with real-
understanding of the biologic foundations of mental ill-
ity. A neurosis was less severe, but individuals were
ness, social change and historical events fostered a new
often distressed about their problems. The terms psy-
level of empathy on an emotional level. During World
chosis and neurosis entered common, everyday language
War II, mental illness was beginning to be seen as a prob-
and added credibility to Freuds conceptualization of
lem that could happen to anyone. Many normal people
mental disorders. Soon, Freuds ideas represented the
who volunteered for the armed services were disqualified
forefront of psychiatric thought and began to shape
on the grounds that they were psychologically unfit to
societys view of mental health care. Freudian ideology
serve. Others who had already served a tour of duty
dominated psychiatric thought well into the 1970s.
received diagnoses of psychiatric and emotional prob-
Intensive psychoanalysis, which focused on repairing
lems believed to be caused by the war. Consequently, in
the trauma of the original psychological injury, was the
1946, President Truman signed into law the National
treatment of choice. Psychoanalysis was costly, time-
Mental Health Act, which supported research, training,
consuming, and required lengthy training. Few could
and the establishment of clinics and treatment centers.
perform it. Thousands of patients in state institutions
This act created a six-member National Mental Health
with severe mental illnesses were essentially ignored.
Advisory Council that established the National Institute
of Mental Health (NIMH), which was responsible for
Integration of Biologic Theories overseeing and coordinating research and training.
Into Psychosocial Treatment The Hill-Burton Act of 1946 provided substantial
federal support for hospital construction, which facili-
Until the 1940s, the biologic understanding of mental
tated the expansion of psychiatric units in general hos-
illness was fairly unsophisticated and often misguided.
pitals. With the passage of the National Mental Health
Biologic treatments during this century often were
Act, the federal government became more involved in
unsuccessful because of the lack of understanding and
financing and controlling the delivery of care. Under
knowledge of the biologic basis of mental disorders. For
the Acts provisions, the federal government provided
example, the use of hydrotherapy, or baths, was an estab-
grants to states to support existing outpatient facilities
lished procedure in mental institutions. The use of warm
and programs to establish new ones. Before 1948, more
baths and, in some instances, ice cold baths produced
than half of all states had no clinics; by 1949, all but five
calming effects for patients with mental disorders. How-
had one or more. Six years later, there were 1,234 out-
ever, the treatments success was ascribed to its effective-
patient clinics.
ness as a form of restraint because the physiologic
responses that hydrotherapy produced were not under-
stood. Baths were applied indiscriminately and used as a
CONTINUED EVOLUTION OF
form of restraint, rather than a therapeutic practice.
PSYCHIATRICMENTAL
Other examples of biologic procedures applied either
HEALTH NURSING
indiscriminately or inappropriately include psy-
chosurgery and electroconvulsive therapy (see Chapter Another outcome of the Acts passage was the provision
8). Thanks to modern technology, neurosurgical tech- of training grants to institutions for stipends and fel-
niques and electroconvulsive therapy can be humanely lowships to prepare specialty nurses in advanced prac-
applied with positive therapeutic outcomes for some psy- tice (Chamberlain, 1983). The first graduate nursing
chiatric disorders. program, developed by Hildegarde E. Peplau in 1954 at
Support for the biologic approaches increased as suc- Rutgers University, was in the specialty of psychiatric
cessful symptom management with psychopharmaco- nursing. Subspecialties began to emerge focusing on
logic agents was reported. When a pharmacologic agent children, adolescents, or elderly people. Today in the
made a difference in care, a biologic hypothesis was United States, many masters degree programs offer
considered. Modern psychopharmacology began in the specializations in psychiatricmental health.
1930s, when barbiturates, particularly amobarbital In 1952, Peplau published the landmark work Inter-
sodium (Amytal Sodium), were tried for treating men- personal Relations in Nursing. It introduced psychi-
tal diseases (Malamud, 1944). Psychopharmacology atricmental health nursing practice to the concepts of
revolutionized the treatment of mental illness and led to interpersonal relations and the importance of the ther-
an increased number of patients discharged into the apeutic relationship. In fact, the nursepatient relation-
community and the eventual focus on the brain as the ship was defined as the very essence of psychiatric
key to understanding psychiatric disorders. mental health nursing (see Chapters 6 and 10). This was
 CHAPTER 1 Social Change and Mental Health 11

a significant switch in perspective from the neurobio- care. The supporters of this 1963 legislation believed
logic approach that had characterized the discipline the exact opposite of what the supporters of Dorothea
before that time. Peplaus perspective was also impor- Dix believed during the previous century. That is,
tant in its conceptualization of nursing care as truly instead of viewing custodial care as the treatment of
independent of physicians. The nurses use of self as a mental disorders, institutionalization was viewed as
nursing tool was outside the dominance of both hospi- contributing to the illness. The predominant view was
tal administrators and physicians. that many of the problems of mental disorders were
Gradually, nursing education programs in special- caused by the deplorable conditions of the state mental
ized hospitals were phased into generalized programs in institutions and that, if patients were moved into a
nursing (Peplau, 1989). Nursing programs offered in normal community-living setting, the symptoms of
psychiatric hospitals closed. This mainstreaming of mental disorders could easily be treated and eventually
psychiatricmental health nursing education into the would disappear. Thus, deinstitutionalization, the dis-
general nursing curriculum obviated the need for charge of the institutionalized people into the commu-
specialized hospitals. nity, became a national objective. The inpatient popula-
tion fell by about 15% between 1955 and 1965 and by
about 59% during the succeeding decade.
The Late 20th Century The goal of the Community Mental Health Centers
Construction Act was to expand community mental
COMMUNITY HEALTH MOVEMENT
health services and diminish societys sole reliance on
AND DEINSTITUTIONALIZATION
mental hospitals. Guidelines for implementing the act
In 1955, the Joint Commission on Mental Illness and were somewhat vague, and administering the program
Health was formed to study the problems of mental became the responsibility of the federal government.
health care delivery. During its 6-year existence, the Any mention of the role for or linkages to state hospi-
commission sponsored several scholarly studies and tals was absent.
created an atmosphere conducive to the discussion of The Community Mental Health Construction Act,
new federal policy initiatives that eventually would originally a construction grant, was amended in 1965 to
undermine the traditional emphasis on institutional strengthen the funding for staffing new facilities. Even
care. In 1961, the commission transmitted its final so, the number of community mental health centers
report: Action for Mental Health. The report called (CMHCs) grew slowly. There were a limited number of
for larger investments in basic research; national person- communities with populations large enough to support
nel recruitment and training programs; one full-time the centers and a shortage of trained personnel, even in
clinic for every 50,000 individuals, supplemented by urban areas. In smaller and rural communities, there
general hospital units and state-run regional intensive was often no one (or no mental health provider) pre-
psychiatric treatment centers; and access to emergency pared for the new role. By the spring of 1967, only 173
care and treatment in general, both in mental hospitals funded projects existed.
and community clinics. It was recommended that plan- There was no evidence that deinstitutionalized
ning and implementation of the system would include patients constituted a significant population of those
the consumers and that funding for the construction and receiving services at the new CMHCs. One problem
operation of the community mental health system would was that the treatment of choice in most of the centers,
be shared by federal, state, and local governments. individual psychotherapy, had not proved effective for
Action for Mental Health was presented at a time patients with long-term mental disorders. Many urban
that was politically ripe for the new ideas. The 1960 CMHC patients, as compared with former state hospi-
presidential election of John F. Kennedy brought a new tal patients, tended to be younger and poorer and were
type of leadership to the United States. The ideas disproportionately drawn from minority backgrounds.
expressed in the report clearly shifted authority for In addition, many centers focused on the treatment of
mental health programming to the federal government. alcoholism and drug addiction.
This report was the basis of the federal legislation, the
Mental Retardation Facilities and Community Mental
Sanctioning of Holistic Nursing Care
Health Centers Construction Act, which Kennedy
signed into law in 1963. By 1963, two nursing journals focused on psychiatric
In reality, this act included only some of the ideas nursing: the Journal of Psychiatric Nursing (now the Jour-
proposed by the commission and did not encompass nal of Psychosocial Nursing and Mental Health Services) and
state-run regional intensive psychiatric centers. Sup- Perspectives in Psychiatric Care. In 1967, the Division of
porters of the legislation believed that the new commu- Psychiatric and Mental Health Nursing Practice of the
nity-oriented policy would provide better care and American Nurses Association (ANA) published the
eliminate the need for institutions providing custodial Statement on Psychiatric Nursing Practice. For the first
12 UNIT I The Nature of Mental Health and Mental Illness

time, there was official sanction of a holistic approach to The Age of Managed Care
nursing care, with psychiatricmental health nurses
Both public and private expenditures for health care ser-
practicing in a variety of settings with a variety of clien-
vices have increased in the United States. Financial bar-
tele. The emphasis was on activities ranging from health
riers account for the different resource allocation rules
promotion to health restoration. Since 1967, there have
for financing mental health services compared with gen-
been three more updates of the psychiatricmental
eral health care services, which leads to less overall fund-
health nursing practice statement that continue to
ing for mental health. To control costs, privately
expand the role of the psychiatric nurse and delineate
insured mental health care has been carved out from
practice functions and roles.
the rest of health care and is managed separately. Pri-
vately owned behavioral health care firms not only man-
age care but also provide services through directly
CONTEMPORARY ISSUES
owned or contracted networks of providers. In theory,
Changing Demographics people with psychiatric problems have direct access to
the specialists who provide the best care. In reality, ser-
The social changes of the 1980s set the stage for the
vices are still limited and sometimes withheld. Once care
continuing evolution of mental health care. The popu-
is limited or denied, individuals once again turn to pub-
lation was rapidly aging. Family structure was diversify-
lic funds, which may or may not be available.
ing through divorce, cohabitation, and a variety of fam-
Now, large networks of public and private organiza-
ily configurations. Women entered the work force in
tions share responsibility for mental health care, with
record numbers. Rapid growth of cities, or urbaniza-
the state remaining as the major decision maker for
tion, was the single most characteristic phenomenon in
resource allocation. Emphasis is on reducing expensive
the United States (Aldrich, 1986). The population in
institutional care and increasing the resources devoted
the United States was shifting toward the southwest.
to communities of individuals with mental disorders.
(In 1983, Los Angeles replaced Chicago as the second
The mental health work force is shifting from providing
largest city.) Many of the new residents had migrated to
care in traditional health care institutions to community
the southwest from Mexico and Asian countries; they
settings: clinics, homes, schools, and treatment centers.
had not simply relocated from other areas of the coun-
try. In North America, because of favorable immigra-
tion policies, the population was expected to grow
National Mental Health Objectives
(Deming, 1996).
By the 1990s, wrinkles in the social fabric had begun In 1999, Mental Health: A Report of the Surgeon General
to show. The deinstitutionalization movement, so long was the first report by the Office of the Surgeon Gen-
hailed as an efficient, cost-effective means of reabsorb- eral and supported two main findings (U.S. Department
ing the mentally ill into society, was considered a fail- of Health and Human Services, 1999):
ure. People with mental disorders were discharged into The efficacy of mental health treatments is well
communities that were unprepared to offer them little documented.
in the way of treatment, housing, or vocational oppor- A range of treatments exists for most mental disor-
tunities. These communities were also sometimes vastly ders.
different from the ones they had left behind at the time The following year, another landmark report, Report of
of their hospitalization. In addition, fewer community- the Surgeon Generals Conference on Childrens Mental
based facilities were in place to serve the growing pop- Health: A National Action Agenda, was published. This
ulation of people with mental disorders. report highlights consensus recommendations for iden-
The 2,000 projected CMHCs that should have been tifying, recognizing, and referring children to services,
in place by 1980 never materialized. By 1990, about increasing access to services for families, and identifying
1,300 programs provided various types of psychosocial the evidence in treatment services, systems of care, and
rehabilitation services, such as vocational, educational, financing (U.S. Public Health Service, 2000). In 2001,
or social-recreational services (International Associa- the World Health Organization focused its annual
tion of Psychosocial Rehabilitation, 1990). The World Health Report on mental health, emphasizing the
CMHCs, by and large, ignored the legions of people importance of mental health to the well-being of indi-
with serious mental illnesses. Today mental health ser- viduals (WHO, 2001). In 2003, the Presidents New
vices are inadequate and fragmented. Millions of adults Freedom Commission on Mental Health presented its
and children are disabled by mental illness every year. report on mental illness in the United States. It recom-
When compared with all other diseases, mental illness mended the development of efficient and effective ser-
ranks first in terms of causing disability in the United vices that should be integrated into the community
States, Canada, and Western Europe (World Health (New Freedom Commission on Mental Health, 2003).
Organization [WHO], 2001). See Box 1-2.
 CHAPTER 1 Social Change and Mental Health 13

BOX 1.2 SUMMARY OF KEY POINTS

U.S. Goals in a Transformed Mental Throughout history, attitudes and treatment
Health System toward those with mental disorders have drastically
changed as a result of the changing socioeconomic
Goal 1 Americans understand that mental health is
backdrop of our society and the development of new
essential to overall health.
Goal 2 Mental health care is consumer and family driven. theories and study by key individuals and groups.
Goal 3 Disparities in mental health services are eliminated. During the 1800s, as mental illness began to be
Goal 4 Early mental health screening, assessment, and viewed as an illness, more humane and moral treat-
referral to services are common practice. ments began to develop.
Goal 5 Excellent mental health care is delivered and
True social reformers, such as Dorothea Dix,
research is accelerated.
Goal 6 Technology is used to access mental health care Horace Mann, and Clifford Beers, dedicated their
and information. efforts to raising societys awareness and advocating
public responsibility for proper treatment of patients
Source: New Freedom Commission on Mental Health. (2003). with mental disorders.
Achieving the promise: Transforming mental health care in America,
p. 8. DHHS Publication No. SMA-03-3831. Rockville, MD.
Theoretic arguments characterized the evolution
of scientific thought and psychiatric practice. Grad-
ually, the importance of the biologic aspect of men-
tal disorders has been recognized.
One of the most important documents for the Although the need for psychiatricmental health
advancement of a mental health agenda is Healthy People nursing was recognized near the end of the 19th cen-
2010: National Health Promotion and Disease Prevention tury, there was much resistance to training women
Objectives, which contains many health care goals that for the care of the insane. At the urging of Dr.
pertain specifically to mental health (Box 1-3) (U.S. Edward Cowles, director of the McLean Asylum in
Department of Health and Human Services, 2000). The Massachusetts, Linda Richards opened the Boston
challenge before nurses is to strive to meet these goals City Hospital Training School for Nurses in 1882.
while obeying marketplace demands to provide the most Gradually, all psychiatric nursing education in the
cost-effective care possible. This translates into an United States and Canada was phased into basic nurs-
emphasis on preventing the symptoms of mental disor- ing education, and nursing programs offered in psy-
ders and using hospitalization as a treatment of last chiatric hospitals closed. The first graduate program
resort. Devising and implementing a continuum of men- in psychiatricmental health nursing was initiated in
tal health services that provides access for all is an inte- 1954 by Hildegarde Peplau at Rutgers University.
gral part of the strategy for accomplishing these goals.

BOX 1.3
Mental Health and Mental Disorders Objectives for the Year 2010
Mental Health Status Improvement Increase the proportion of adults with mental disor-
Reduce the suicide rate to no more than 6.0 per ders who receive treatment.
100,000 (baseline, 10.8/1,000 in 1998) Increase the proportion of persons with co-occurring
Reduce the suicide attempts by adolescents to no substance abuse and mental disorders who receive
more than 1% (baseline, 2.6% in 1997) treatment for both disorders.
Reduce the proportion of homeless adults who have Increase the proportion of local governments with
serious mental illness (SMI) community-based jail diversion programs for adults
Increase the proportion of persons with serious men- with serious mental illness.
tal illness who are employed State Activities
Treatment Expansion Increase the number of states and the District of
Reduce the relapse rates for persons with eating Columbia that track consumers satisfaction with the
disorders, including anorexia nervosa and bulimia mental health services they receive.
nervosa. Increase the number of states, territories, and the Dis-
Increase the number of persons seen in primary trict of Columbia with an operational mental health
health care who receive mental health screening and plan that addresses cultural competence.
assessment. Increase the number of states, territories, and the Dis-
Increase the proportion of children with mental health trict of Columbia with an operational mental health
problems who receive treatment. plan that addresses mental health crisis interventions,
Increase the proportion of juvenile justice facilities that ongoing screening, and treatment services for elderly
screen new admissions for mental health problems. persons.
14 UNIT I The Nature of Mental Health and Mental Illness

Through key federal and state legislative initia-

tives, mental health services were funded, but remain
inadequate. One Flew Over the Cuckoos Nest. 1975. This classic
The U.S. Surgeon Generals reports, The Presi- film stars Jack Nicholson as Randle P. McMurphy, who
dents New Freedom Commission on Mental takes on the state hospital establishment. This picture
Health, and the goals of Healthy People 2010 continue won all five of the top Academy Awards: Best Picture,
to highlight the need for resources for the care of Best Actor, Best Actress, Best Director, and Best
persons with mental illness. Adapted Screenplay. The film depicts life in an inpa-
tient psychiatric ward of the late 1960s and increased
public awareness of the potential human rights viola-
CRITICAL THINKING CHALLENGES tions inherent in a large, public mental system. How-
ever, the portrayal of electroconvulsive therapy is
1 Compare the ideas of psychiatric care during the stereotyped and inaccurate, and the suicide of Billy
1800s with those of the 1990s and 2000s and identify appears to be simplistically linked to his domineering
the major political and economic forces that influ- mother. Overall, this film probably contributes to the
enced care. stigma of mental illness.
2 Analyze the social, political, and economic changes VIEWING POINTS: This film should be viewed from
that influenced the community mental health move- several different perspectives: What is the basis of
ment. McMurphys admission? How does Nurse Ratchet
3 Present an argument for the moral treatment of peo- interact with the patients? What is missing? What is
ple with mental disorders. different in todays public mental health systems?
4 Trace the history of biologic psychiatry and highlight
major ideas and treatments. An Angel at My Table. 1989, New Zealand. This
thought-provoking three-part television mini-series is
based on Janet Frames autobiography that traces her
life from being a shy, socially inept little girl to New
WEB LINKS Zealands most famous writer/poet. Produced by Jane
Campion and starring Kerry Fox, the story is told in
www.health.gov/healthypeople This is the Healthy three stages of the main characters life: childhood,
People 2010 website. young adulthood, and adulthood. During the second
www.surgeongeneral.com This website of the U.S. period, Janet Frame received an inaccurate diagnosis of
Surgeon General contains major mental health schizophrenia and was hospitalized for 8 years. She
reports. barely avoided a leukotomy.
www.nlm.nih.gov The National Library of Medicine VIEWING POINTS: Observe how the role of the
site offers excellent access to PUBMED for nursing woman in society influenced Janet Frames admission to
articles and mental health information. It provides the hospital. Would she be considered mentally ill and
links to the History in Medicine Library. needing hospitalization by todays standard?
www.mentalhealth.com This site is an excellent Beautiful Dreamers. 1992, Canada. This film is based
resource on disorders and diagnoses and provides on a true story about poet Walt Whitmans visit to an
links to other sites. asylum in London, Ontario, Canada. Whitman, played
www.cmhc.com This site provides access to the by Rip Torn, is shocked by what he sees and persuades
Mental Health Net, self-help groups, professional the hospital director to offer humane treatment. Even-
resources, and discussions. tually, the patients wind up playing the townspeople in
www.mentalhealthcommission.gov This site pro- a game of cricket.
vides access to Achieving the Promise: Transforming VIEWING POINTS: Observe the stigma that is associ-
Mental Health Care in America. Final Report of The ated with having a mental illness.
Presidents New Freedom Commission on Mental Health
( July 2003).
www.samhsa.gov/oas/oasftp.htm This Substance REFERENCES
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 CHAPTER 1 Social Change and Mental Health 15

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