The challenges associated with mental illness and the care of persons with mental disorders have been traced through time since 400 B.C. as Hippocrates treated mental illness as a disturbance of physiology, parting ways from the belief systems of his contemporaries that attributed these disorders to demonic possession (PBS, 2014). One way to look to the advances in psychiatric nursing practice is to reflect upon where we have been.
The mentally ill have suffered maltreatment from the time of Hippocrates into the present day, treated as criminals, delinquents, and defectives; burdened by atrocities of social and personal abuse. Champions mark these dark years, among which our authors march in their good company. Some I am sure are familiar to you: Dorothea Dix (1801-1887) advocate for humane treatment; Clifford Beers (1876-1943), an early founder of the client-advocate movement; and President Truman (1946) who established the National Mental Health Act and the National Institutes for Mental Health which promotes research in the field (PBS, 2014; Dix, n.d.). Along with the discovery of antipsychotic medications in the mid-1950s, the number of hospitalized mentally ill persons peaked, and by 1961, sociologist Erving Goffman identified the effects of institutionalization upon psychotic symptoms (Goffman, 1961). By the mid-1960s de-institutionalization begins, in large part because of psychopharmacological treatments. Trans-institutionalization, another cycle back into prisons begins, as the promise of community resources fails (Lamb & Weinberger, 2005). In 1979, the National Alliance for the Mentally Ill is formed, and by the early 1980s one-third of the homeless population is considered to have a mental disorder. Although a new generation of anti-psychotics becomes available in the early 1990s, society’s tolerance for homeless persons with mental disorders has reached its limit. Over seven percent of jail intakes are persons with serious mental illness, and of those, 25% were held without charges (Lamb & Weinberger, 2005).
Advocacy in mental health care has shifted toward policy initiatives since the 1990s. The Mental Health Parity Act, which broke down some of the discrimination against mental health care has been under consideration by congress since the mid-1990s (National Alliance on Mental Illness [NAMI], 2014). The Americans with Disabilities Act, which took effect in 1992, supported parents and consumers in the workplace and with public accommodations (Frank & Glied, 2007). Participation in public disability insurance programs, such as Medicare, Medicaid, Social Security Disability Insurance (SSDI) and its sister program, Supplemental Security Income (SSI), provide a stable, though often minimal, source of income for people disabled by mental illness. More recently, the Affordable Care Act promises improved access to care and parity protection through expanded insurance coverage for mental illness and substance abuse disorders (Beronio, Po, Skopec, & Glied, 2013). Today, mental health care for most people with severe mental illnesses is paid for by one or more of these programs. Mental health policymakers have come to recognize that changes in these programs can have powerful effects on the well-being of the population with mental illness and their families.
Our authors for this OJIN topic recognize the effects of these policy changes upon the well-being of the mentally ill in their bracing discussion of the contemporary issues confronting mental health providers and persons with mental disorders today. The changes that author Kane highlights in her article, “The 2014 Scope and Standards of Practice for Psychiatric Mental Health Nursing: Key Updates” are cross-cutting themes repeated in the articles submitted by the following authors, giving credence to their significance. In particular, these cross-cutting topics focus upon consumerism and recovery as an achievable goal in mental health care; the need for nurse contributions in psychiatric treatment research; and the importance of and difficulties associated with achieving prevention strategies in care at the individual or systems level.
Beliefs that mental health problems are not serious are also a recurring theme. Holliday et al. examine efficacious nurse education interventions aimed at preventing suicide in their article, “Suicide Assessment and Nurses: What Does the Evidence Show?” Given the high rates of suicide in the community and among the selected populations discussed among authors, few educational interventions have been rigorously tested. This reinforces the idea suggested by Kane that psychiatric clinical nursing research and its dissemination has not kept pace with patient care needs. Holliday and colleagues suggest that gatekeeper training is most helpful. This is not surprising as it aligns with assessment, one of nursing’s most powerful tools.
The significance of risk factors, specifically poverty and substance abuse in combination with Antisocial Personality Disorder diagnosis, increases the likelihood of criminal justice system involvement. In her discussion of this target population in the article, “Mental Illness and Prisoners: Concerns for Communities and Healthcare Providers,” author Hoke discusses the need for structured rehabilitative programming to reduce use of this system in favor of more appropriate community-based mental health care and other stabilizing services such as housing and employment. The effect of appropriate service utilization would be preventive toward further deviant behavior.
Authors Westphal and Convey discuss the challenges presented to individuals in the military in their article, “Military Culture Implications for Mental Health and Nursing Care.” We can trace the stress and injuries associated with mental illness over time among the veteran population. The functional disabilities, anger management, and readjustment problems that plague these returning warriors and the barriers to help-seeking imposed by military ethos reinforces the need for recovery strategies and preventive measures to support family units.
Jha et al. target yet another vulnerable population, those with dementia. Their article, “Positive Mental Health Outcomes in Individuals with Dementia: The Essential Role of Cultural Competence” presents a detailed case study to illustrate the impact of cultural competence in a family dealing with early-onset dementia. Again, themes of caregivers managing cognitive, psychological, and behavioral symptoms of the illness are evident, along with the debilitating physical decline of the later stages of dementia and the added burden of end of life decision-making. Family support, with attention to cultural competence skills from associated providers, emerges repeatedly as a priority for nursing care.
Holiday et al. and Westphal and Convoy focus on psychiatric nurse education and training for these and other targeted populations and health problems. One wonders how the discipline of nursing can meet the call to action made through policy to expand access to care? As Dr. Kane aptly points out, the synergistic effects of integrating mental health nursing within undergraduate curricula; poor funding for advanced practice and doctoral psychiatric nursing research; and limited mentored research training in psychiatric nursing are significant barriers to this call. Further, how can efficacy of treatment be discovered to intervene and reduce the synergistic effects of bio-psycho-social burdens among persons with an incarceration experience, or better yet, impart effective prevention strategies, as articulated by Hoke? Further, how can we best consider the consumer-focused needs, as noted by Jha et al in their discussion of the impact of cultural competence in caregiving?
As hundreds of years have passed in the history of healthcare for persons with mental illness, right now our OJIN topic authors call us to bring to the forefront again the significance of psychological well-being into our contemporary thinking. The message these authors provide is clear - we have a responsibility through our standards of practice; our care of these special populations; in the design and execution of our academic programming; and our diligent pursuit of discovery through research to demonstrate in an active way our commitment to the specialty of Psychiatric and Mental Health Nursing and our patients, families, students, and peers.
This group of articles stimulate and support us to go forward renewed in spirit as champions in a more enlightened era of hope and science. The journal editors invite you to share your response to this OJIN topic addressing Emotional Health either by writing a Letter to the Editor or by submitting a manuscript which will further the discussion of this topic which has been initiated by these introductory articles.
Deborah Shelton, PhD, RN, NE-BC, CCHP, FAAN
© 2015 OJIN: The Online Journal of Issues in Nursing
Article published January 31, 2015
Beronio, K., Po, R., Skopec, L. & Glied, S. (2013, February). Affordable care act expands mental health and substance use disorder benefits and federal parity protections for 62 million Americans. (ASPE Issue Brief). Washington, DC: Department of Health and Human Services. Retrieved from http://aspe.hhs.gov/health/reports/2013/mental/rb_mental.cfm.
Dorothea Dix. (n.d.). Retrieved December 22, 2014 from Biography.com website: www.biography.com/people/dorothea-dix-9275710.
National Alliance on Mental Illness. (2014). The mental health parity act of 1996. Retrieved from http://nami.org/Content/ContentGroups/E-News/1996/The_Mental_Health_Parity_Act_of_1996.htm.
PBS. (2014). Timeline: Treatments for mental illness. Retrieved from www.pbs.org/wgbh/amex/nash/timeline/.