Evolving Theory and Treatment Approaches.

While practitioners in the field of psychiatry and psychology in the early twentieth century were approaching mental illnesses, both severe and less severe, from several new theoretical perspectives, scientists were investigating physical causes, viewing mental illness as primarily a physiologic and developmental or environmental dysfunction. Both approaches to the causes of mental illness have proved valuable, and both science and psychology refuted the benighted notions of past eras that condemned mental illness as a character flaw or, worse, as evidence of an evil and inevitably criminal character defect. Even as late as the 1950s, some cases of depression and apathy were attributed to just being lazy and some of the symptoms of PTSD following wars were perceived either as simply laziness or as purposeful feigned dysfunctions.

Yet, despite more scientific perspectives pushing back against inherited misunderstanding and fear, a terrible stigma remained against those with mental illnesses. On the upside, in the 1950s medications to alleviate some of the symptoms of the illness emerged. Up until the 1950s, the only medications were morphine and scopolamine used to control excitement and agitation. (By then, insulin-induced coma therapy had been discontinued.) However, electroconvulsive therapy (ECT), also referred to as (EST) electroshock therapy, and even hot/cold water treatments (hydrotherapy) were still used to alleviate the most crippling or distressing manifestations of mental illnesses.

Shifting Tides of Theory and Therapy

During this decade, the major treatment interventions were based on psychoanalytic, psychodynamic, and interpersonal theories. As previously mentioned, Wilhelm Reich, deputy director of Freud‘s outpatient clinic in Vienna, and later Karen Horney (1885-1952), also a German psychoanalyst, challenged Freud’s assumptions in the 1930s. An American, Harry Stack Sullivan (1892-1949) focused on interpersonal relationships. He developed his theory of personality and treatment of mental illness as he worked with mentally ill hospitalized patients. While Carl Rogers (1902-1987) started publishing his theories in the 1940s, it was not until the 1950s that his work became more clearly understood and led to a popular humanist approach (client-centered therapy) to treatment of mental illness. Other influential and innovative theorists made important contributions following World War II as well, including Abraham Maslow (self-actualization), Erik Erikson (developmental psychology), Viktor Frankl (logotherapy), B.F. Skinner (behaviorism), Aaron T. Beck (cognitive-behavioral therapy) and Albert Ellis (REBT or rational emotive behavior therapy).

After Sullivan, whose interpersonal theory was widely embraced by mental health practitioners in the 1960s, perhaps the next most influential of the decade’s new theorists was Carl Rogers (1902-1987) who in 1956 became the first president of the American Academy of Psychotherapists. Rogers persuasively argued in Client Centered Therapy (1951) and On Becoming a Person (1961) that all people possess an inherent need to grow and achieve their full potential. This need to achieve, he believed, was one of the primary motives driving human behavior. His approach to psychotherapy was cognitive, focused on the client’s perception, consciousness, and thought processes, and was grounded in his philosophy of the value of human existence. (https://en.wikipedia.org/wiki/Carl_Rogers )

The first major departure from cognitive, client-centered theories and therapies originated with B. F. Skinner who argued that human behavior is not internally motivated but externally driven by a person’s genetic and environment histories. This revolutionary view came to be known as behaviorism. Behaviorists would promote “operant conditioning” to address mental illness, an approach derived from Skinner’s theory of learning, which asserts that a person is first exposed to a stimulus, which elicits a response, and the response is then reinforced (stimulus, response, reinforcement). Behaviorism wasn’t widely accepted or adopted by mental health practitioners, however.

In the ‘60s the prominent psychologists, most notably Carl Rogers, of course, but also Albert Ellis, continued to pursue cognitive therapeutic approaches. In 1962 Albert Ellis (1913-2007) published Reason and Emotion in Psychotherapy in which he presented his theory of Rational Emotive Behavior Therapy (REBT). He viewed therapists as teachers, initiating a major shift in treatment approach. Along similar lines, Aaron T. Beck (1921-2021) would develop his theory of Cognitive Behavioral Therapy (CBT) in the ‘70s, publishing Cognitive Therapy and the Emotional Disorders in 1975. Both Ellis and Beck dismissed B. F. Skinner’s behavioral approach to mental illness, although they recognized repetitive dysfunctional behaviors as symptoms of mental illness and proposed that by changing behaviors one could improve a patient’s mental health. They both strongly influenced the field of mental health.

The Role of Nurses, Hildegard E. Peplau

Hospitals or asylums still housed the most seriously ill and dysfunctional, often for decades. Psychiatrists and psychologists served the less severely ill in clinics or private practice sites. Nurses were the major caretakers of those hospitalized. Although some psychiatrists did practice in hospitals, nurses and attendants provided the 24-hour care.

Psychoanalytic and psychodynamic techniques were most effective in weekly one-hour, one-on-one therapy sessions. Sullivan’s interpersonal theory was adaptable to in-patient milieu as well as out-patient treatment. Hildegard E. Peplau (1909–1999), an American nurse, was the first published nursing theorist since Florence Nightingale. Her efforts toward mental health law reform brought about more humane treatment of patients with behavior and mental health disorders. With Hildegard Peplau’s adaptation for nurses, Interpersonal Relations in Nursing: A Conceptual Frame of Reference for Psychodynamic Nursing (1952), interpersonal theory became a significant approach in psychiatric nursing. (Gonzalo 2023, “Hildegard Peplau: Interpersonal Relations Theory,” https://www.nurselabs.com .)

Medications

Three drugs developed in the 1950s influenced the treatment of mental illnesses for the next few decades.

• • Chlorpromazine. Chlorpromazine (the most common derivative was Thorazine, a typical antipsychotic drug) was first developed in France in early 1950s as an adjunct to surgical anesthesia. The calming effect of the medication was noted, and it was subsequently given to psychiatric patients.
  • Clozapine. In the late 1950s a second medication was found to benefit patients with severe mental illnesses. Developed in Switzerland, Clozapine (an atypical antipsychotic, a benzodiazepine), addresses many of the symptoms of schizophrenia, and it also has a significant anti-aggressive effect.
  • Haloperidol. The third drug for mental illness, Haloperidol, was developed in the 1958 in Belgium. Haloperidol was another drug that modified the symptoms of agitation. It also proved effective for treating hallucinations and delusions.

Understanding the psychopharmacologic actions of the drugs strongly encouraged the biological study of mental illness. Since the side effects of these medications are problematic, caution in prescribing them was required as was further research to find drugs with similar outcomes, without the side effects.

NIMH and U of U Psychiatric Nursing Program

As noted earlier, the establishment of the National Institute of Mental Health increased emphasis on training scientists to study mental illnesses and on educating health professionals to treat people with mental illnesses. The University of Utah College of Nursing received two grants from NIMH. One was to increase the integration of mental health knowledge and skills in the undergraduate education of nurses, and another was to develop a graduate program in psychiatric nursing for nurses.

Community Mental Health Act (CMHA) and Community–Based Care

As medications were seen to decrease the need for institutionalizing people, even those with more severe mental illness, pressure mounted to enhance care for the mentally ill in community settings. The Community Mental Health Act of 1963 (CMHA), also known as the Mental Retardation Facilities and Construction Act, Public Law 88-164, provided funding both for research and for states to construct community mental health centers. These centers would provide outpatient and short-term inpatient care for the mentally ill as an alternative to expensive long-stay psychiatric hospitals. Signed by President John F. Kennedy, this federal law was instrumental in the evolution of the mental health field.

While the CMHA bill was forward thinking, the associated Construction Act was significantly underfunded, and with the death of President Kennedy the law evolved into block grants for states. By then, ninety percent of the nation’s psychiatric institutions had closed their beds and community resources were not available to create state-sponsored community mental health centers or programs to assist the mentally ill with getting treatment or medications. Without resources many of the severely mentally ill have become a significant portion of the homeless. (https://en.wikipedia.org/wiki/Community_Mental_Health_Act)