Keltner: Psychiatric Nursing, 5th Edition

Chapter 1: Introduction to Psychiatric Nursing

Chapter Focus
The human cost of psychiatric health care is great when one considers that mental and
addictive disorders affect more than 25% of Americans 18 years of age or older annually.
Consequently, psychiatric nurses provide some of the most important services in health
care today.

Four major benchmarks have contributed to the evolution of modern psychiatric care:
1. The Period of Enlightenment. This was initiated by the institution of humane care
advanced by Phillippe Pinel and William Tuke in 1793, which ultimately led to the
asylum (sanctuary) movement and, under the influence of Dorothea Dix, the
development of the state hospital system in the United States. It was during this
period that psychiatric nursing had its origins. Within 100 years of the origin of the
asylum movement, the hospitals created had evolved from places of refuge to places
of torment as the ideals of the reformers were lost on a new generation of caretakers.
2. The Period of Scientific Study. This was initiated by the work of Sigmund Freud,
Emil Kraepelin, Eugen Bleuler, and others who sought to understand the mind and
mental illness and who shifted the focus of care from sanctuary to treatment.
Therapies such as psychoanalysis, psychotherapy, and psychosurgery were developed
during this era. A classification of mental illness was developed.
3. The Period of Psychotropic Drugs. In the 1950s, this initiated a radical shift in the
care and treatment of mental illness. Patients who had seemed beyond help became
calmed and accessible. Dramatic cures took place. Hospital stays shortened, the
number of patients confined for long-term institutional care declined, and the
availability of community-based treatment increased.
4. The Period of Community Mental Health. This movement emerged from the
interaction of multiple dynamic forces, culminating in the enactment of federal
legislation that shifted funding from institutional care to extrainstitutional care (the
Community Mental Health Centers [CMHC] Act) and provided income for the
mentally disabled (currently, Supplemental Security Income [SSI] and Social Security
Disability Insurance [SSDI]). These shifts in funding, plus changes in commitment
laws that made involuntary commitment difficult, resulted in a rapid and dramatic
reduction of the state hospital population and the closure of many state hospitals.

Copyright 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.

Instructor's Manual

1-2

The advances and changes in psychiatric care have had far-reaching effects. Most
notably, mental health has become a concern for all. Social and emotional problems have
become a legitimate focus for mental health care professionals. New challenges in
psychiatric care have arisen: recidivism (reflected in increased admission rates), growing
demands on general hospital emergency departments for crisis intervention and acute
outpatient treatment, expansion of the need for psychiatric services by general hospital
inpatient psychiatric facilities and community agencies, and an increased complexity of
problems presented by psychiatric patients (e.g., assaultiveness, homelessness, and
substance abuse).
Parallel to developments in psychiatric treatment, the practice of psychiatric nursing has
evolved from custodial care in the late nineteenth century to interdisciplinary
collaboration in the treatment of the mentally ill, from dependent caregiver to
independent practitioner, and from exclusive focus on the needs of psychotic individuals
to the inclusion of the social and emotional needs of the worried well who are
experiencing situational reactions. Through the influence of leaders such as Hildegarde
Peplau, psychiatric nursing has gained direction, recognition, and professional
accountability, and psychiatric nursing education has advanced. Psychiatric nurses will
increasingly have a major role in resolving problems in mental health care and in
developing a seamless continuum of care designed to meet the needs of the mentally ill.

Key Terms
asylum
community mental health
continuum of care
deinstitutionalization
homelessness
psychotropic drugs
Learning Objectives
After reading this chapter, you should be able to:
1. Describe the enormity of mental health concerns in both human and financial
contexts.
2. Explain the history of psychiatry as a foundation for current psychiatric nursing
practice.
3. Identify the significant changes that occurred during the Period of the Enlightenment.
4. Relate the contributions of early scientists to the current understanding of mental
illness.
5. Explain the impact of psychotropic drugs on psychiatric care.
6. Analyze the immediate and long-term effects of the community mental health
movement.
7. Describe the impact of the Decade of the Brain on psychiatric care.
8. Identify the specific strengths that enable psychiatric nurses to become effective in
the new continuum of care.

Copyright 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.

Instructor's Manual

Chapter Outline
Benchmarks in Psychiatric
History
Benchmark I: Period of
Enlightenment

1-3

Teaching Strategies
Pre-Enlightenment: ABCsassistance, banishment, and
confinement
Important figures:
Tuke: an English Quaker who started York Retreat
Pinel: a Frenchman responsible for unchaining the
mentally ill
Asylum
Two meanings: protection, sanctuary; a place of
maltreatment, hopelessness, and abuse
Dorothea Dix: developed concept of asylum in United States,
resulting in beginning of state hospital system
Benchmark II: Period of
Major scientists who emerged had an unquenchable curiosity
Scientific Study
about the mind and human behavior:
Sigmund Freud (18561939): introduced psychoanalysis
Emil Kraepelin (18561926): made detailed
observations and descriptions of mentally ill patients
Eugen Bleuler (18571939): coined term schizophrenia
Benchmark III: Period of Approximate beginning: 1950s
Psychotropic Drugs
Chlorpromazine (Thorazine): first antipsychotic
Imipramine (Tofranil): first tricyclic antidepressant (~1958)
Lithium: introduced in late 1940s but not used in the United
States until ~1970
Benchmark IV: Period of Convergence of forces led to mental health legislation:
Community Mental Health Publics declining confidence in state hospital system
Failure of various treatment approaches
Progressive legislative climate
Faith in psychotropic drugs
Negative effect: confusion about the boundaries of mental
illness
Deinstitutionalization
Depopulation of State Hospitals began in 1955, but
deinstitutionalization movement was fostered by CMHC Act
of 1963 and federal legislation that provided mentally
disabled persons with an income while living in the
community (SSI and SSDI).
Shifting the Cost of Mental State governments found that using federal monies
Illness
supplemented by state funds to provide aid to disabled
mentally ill individuals resulted in huge cost savings.
Commitment laws underwent change out of new concern for
individual civil rights. It became more difficult to effect
involuntary commitment to a state hospital.
Depopulation of State
Peak population (1955): 558,922 patients
Hospitals
Current population: 70,000
Many state hospitals have closed. Former patients live in
nursing homes, prisons, homes with families, groups of
similarly affected individuals, boarding homes, or on their
Copyright 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.

Instructor's Manual

Community Effects
Benchmark V: Decade of
the Brain

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own.
Hospitalized patients require a high level of care, have few
social relationships, are psychotic and are typically acutely ill
young men.
Emergency department use is increased.
General hospital psychiatric units are overwhelmed.
Todays patients are seen to be more aggressive.
During the 1990s, an increase in brain research studies
coincided with increased interest in biologic explanations for
mental disorders.
The Diagnostic and Statistical Manual of Mental Disorders
was revised.
Public awareness of mental disorders grew.
Nursing textbooks began to provide more detailed
information about psychobiology and psychopharmacology.

Issues That Affect the

Delivery of Psychiatric Care
Paradigm Shift in
As interest in psychotherapy and disinterest in severely
Psychiatric Care
mentally ill patients grew during the 1930s and 1940s, public
mental hospitals lost prestige, as did those who worked in
them. Psychiatry changed focus from the severely mentally ill
to the worried well. However, in 1980, publication of the
DSM-III returned the focus to individuals with psychiatric
disorders.
Homelessness
This problem is linked to deinstitutionalization.
About 800,000 are homeless each night, including families
with children and individuals employed in low-paying jobs,
who have been displaced by social policies over which they
have no control. Living arrangements include community
shelters, halfway houses, board-and-care homes, cheap hotels,
rehabilitation programs, prisons, and jails.
As many as 20% to 25% of the homeless have a severe
mental illness.
As many as 50% to 75% of the homeless suffer from alcohol
or drug abuse, many from both.
Community-Based Care
The future of psychiatric care and psychiatric nursing will be
linked to efforts to prevent mental health problems and treat
existing disorders more effectively. Based on economic
reality, much of that effort will be community based as part of
a continuum of care.
Developing a Continuum of Factors leading to unmet needs of SMI:
Care
Liberalization of commitment laws, allowing SMI patients
to go untreated
Restrictive confidentiality rulings to meet needs of SMI
Develop a seamless continuum of care to:

Copyright 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.

Instructor's Manual

Role for Nursing in the

Continuum of Care

The Diagnostic Bible of

Psychiatry

Psychiatric Nursing
Education: Three Firsts
First Psychiatric Nurse
First Psychiatric Nursing
Textbook
First Psychiatric Nursing
Theorist

1-5
coordinate activities of diverse treatment sources.
facilitate movement between and among continuum
entities.
Develop a new conceptualization of system:
Focus more on recovery and reintegration, less on
symptom stabilization
Involve consumers and family members more
Focus on holistic thinking (stabilizing housing, medical
health, finances) rather than on medication management.
CMH role defined in 1982 by ANA: nurse participates with
other members of community in assessing, planning,
implementing, and evaluating mental health services and
community services. These include promotion of continuum
of primary, secondary, and tertiary prevention of mental
illness
Nursing values that fit with concept of a care continuum:
Holistic view of patient
Working with families
Treating patients in own home
Developing relationships over time
Educating patients
Assessing environment for safety, hygiene, and supports
The current manual, DSM-IV-TR provides five axes to use in
patient assessment:
Axis I: clinical disorders
Axis II: personality or developmental disorders
Axis III: general medical conditions that relate to axes 1
and II or have a bearing on treatment
Axis IV: severity of psychosocial stressors
Axis V: global assessment of functioning (scale of 0 to
100)
Linda Richards: first American psychiatric nurse; active in
developing nursing care in psychiatric hospitals; directed a
school of psychiatric nursing ~1880
Written by Harriet Bailey in 1920
1937: NLN recommended that psychiatric nursing become
part of general nursing curriculum
Hildegarde Peplau: developed model for psychiatric nursing;
wrote Interpersonal Relations in Nursing in 1952;
emphasized the interpersonal dimension of practice

Copyright 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.