Theories: Challenging Assumptions, Forging New Tools and Traditions

As a general rule, teachers of psychology or psychiatry teach what they have been taught. In the 1980s, however, some theorists began exploring very different perspectives and their new theories evolved into new traditions and practices. Innovations were undertaken in order to find more effective ways to improve health and wellbeing as well as solve the mystery of what causes severe mental illness. Of equal importance, through the 1980s there was renewed interest in researching health care outcomes. Open and useful debates supporting one approach over another occurred in local and national mental health conferences.

Gender and Personality Studies

• Gender. Theorists recognizing gender differences were attempting to answer questions about illnesses that occurred more often in women, such as depression and anxiety, and for men, substance abuse, and antisocial disorders. (See, for example, “Study Finds Sex Differences in Mental Illness” for the APA summary of the following scholarly article: Eaton, et al., “An Invariant Dimensional Liability Model of Gender Differences in Mental Disorder Prevalence.” https://www.apa.org/news/press/releases/2011/08/mental-illness.)
• Personality. Apart from gender differences, in terms of personality traits researchers were pursuing other avenues. Published in 1986, Albert Bandura’s Social Foundations of Thought and Action: A Social Cognitive Theory, on social learning and self-efficacy, influenced the behaviorist position on the development of personality. Bandura was the first to demonstrate (1977) that self-efficacy, the belief in one’s own capabilities, affects what individuals choose to do, the amount of effort they put into doing it, and the way they feel as they are doing it. (https://www.britannica.com/biography/Albert-Bandura)

Updates on Attachment Theory. Attachment theory states that once an attachment has been formed between a parent and a child, a response such as fear, anger, frustration, or grief inevitably follows when that bond/attachment is broken. In 1978 Mary S. Ainsworth, et al., published their longitudinal study of children’s attachment, Patterns of Attachment: A Psychological Study of the Strange Situation. Then in 1985, Daniel N. Stern published his research on infants, which supported the earlier findings on infant attachment and facial recognition and confirmed Bowlby’s extensive work in prior decades on Attachment and Loss. Stern’s new research approach influenced the field of parental attachment. (Stern 1985, The Interpersonal World of the Infant: A View from Psychoanalysis and Developmental Psychology.)

Family Systems Theory and Family Therapy

Urie Bronfenbrenner established “ecological systems” theory in one of the first books on family systems. His theory explains the role of environment as a person grows up and how one’s social surroundings affect every facet of one’s life. Thus, individuals are seen as maturing not in isolation but within the context of relationships, such as those involving families, friends, schools, neighborhoods, and society. (See Bronfenbrenner 1979, The Ecology of Human Development: Experiments by Nature and Design.)

Another popular approach in the 1980s was family therapy, developed out of the Mental Research Institute (MRI) in Palo Alto, California, and closely associated with Stanford University. Don DeAvila Jackson was the founder and director of MRI. Together with Jackson in studying therapy and family dynamics at MRI were Jay Haley, John Weakland, Paul Watzlawick, Gregory Bateson, and Milton Erickson. All of them wrote significant books on specific aspects of communication, defining a therapist’s role in therapy, and understanding family dynamics and treatment outcomes. Paul Watzlawick, an Austrian-American theoretician in communication theory and radical constructivism, was one of the most influential figures at the Mental Research Institute. He believed that people create their own suffering in the very act of trying to fix their emotional problems. Paul Watzlawick, Janet Beavin Bavelas, and Don D Jackson collaborated in the research and writing of Pragmatics of Human Communication: A Study of Interactional Patterns, Pathologies and Paradoxes (2011), which has formed the foundation of much contemporary research into interpersonal communication, in addition to laying the groundwork for context-based approaches to psychotherapy.

Jay Haley was the founding editor of the journal Family Process. His book The Art of Strategic Therapy on short-term family therapy, based on his work in the ‘80s, was crucial to the family therapy movement. Haley was a proponent of brief therapies that focused on solving concrete and immediate problems rather than delving into the past for root causes. Haley insisted that it was “the therapist’s job to change the patient, not to help him understand himself.” This approach also shifted the focus from the client in isolation to the social context, particularly the family unit. Carl Rogers, founder of client-centered therapy, found fault with Haley’s briefer, family-centered approach, condemning it as essentially shallow and manipulative. Haley, however, objected to current standard practices that based therapy fees on length and frequency of sessions. (https://www.washingtonpost.com/wp-dyn/content/article/2007/03/01/AR2007030101741.html)

Later, Haley was instrumental in developing the Family Therapy Institute in Washington, DC. Prior to that, Haley worked at the Philadelphia Child Guidance Clinic with Salvador Minuchin who later wrote (1974) Families and Family Therapy. He also worked with family theorist Braulio Montalvo in Philadelphia. This cross-fertilization allowed Family Therapy to flourish across the nation. (See Minuchin, et al. 1967, Families of the Slums: An Exploration of their Structure and Treatment.)

Group Psychotherapy

Irvin D. Yalom, a psychiatrist at Stanford University, continued revising and updating his book on The Theory and Practice of Group Psychotherapy. (His sixth edition was published in 2020.) In addition, he wrote extensively, both professional books and novels, and gave many lectures in Utah. His many books were translated into from twelve to twenty different languages. His congenial personality was reflected in his books, and his methodical, though sensitive manner of handling a wide variety of people in groups made his treatment approach respected and it was taught in classes across the University of Utah Campus and around the world. Group Therapy solved many problems in accessing affordable treatment. A therapist could treat 5-12 people at once, lowering individual costs for group members. In addition, given the limited number of licensed mental health therapists, group therapy could increase access to qualified therapists. (Yalom and Leszcz 2020)

National Developments: Research and Technology

Research and Innovation. During this decade, the MRI (Mental Research Institute) in Palo Alto, California, and the Family Therapy Institute in Washington, D.C., both informed and influenced national policy and funding in health care. As in the past, NIMH continued to support research in mental health, now including studies on family dynamics and mental health. Innovative treatments for health problems such as diabetes, heart disease, and children with chronic conditions were approached through strategic family therapies, and the role of family members in rehabilitation or management of these chronic conditions was recognized and studied.

Society for Education and Research in Psychiatric Nursing (SERPN). Of major significance for Utah’s evolving graduate program, the Society for Education and Research in Psychiatric Nursing (SERPN) was organized in October 1986. Directors of Psychiatric Nursing Programs from each state and their associated college and university faculty would gather annually for business meetings. Equally important, research and educational presentations were part of these meetings. Of vital interest to Utah’s attendees also, Jeannette Chamberlain, the Chief of Psychiatric Education Training Branch at NIMH, would provide a summary of the programs available to psychiatric nurses and the grants available to colleges and universities with graduate programs.

Technology: Computers, Mobile Phones, Internet

• Computers. The 1980s was the beginning of the technology/computer age. By the end of the 1970s Apple and Microsoft were creating software and hardware to provide fast, clear, reliable access to and exchange of information. Microsoft Word for word processing and Microsoft Windows came out in the first half of 1983. Originally, computers were cost prohibitive. Only universities and large corporations could afford computers as well as employees trained in programming skills and text navigation. Later, personal computers developed by IBM became not only more affordable but desirable for many people in the workplace. In addition, graphical user interface (GUI) allowed for user-friendly navigation of the computer with icons, buttons, and menus instead of text-based commands.
• Cellular mobile phones. The mobile phone was first developed in the 1970s using radio frequency. In 1983 Motorola developed the cellular mobile phone which allowed people to communicate in real time anywhere. Weighing in at 2 pounds, the Motorola DynaTac, nicknamed “The Brick,” provided 30 minutes of talk time and took roughly 10 hours to charge. The evolution from large, clunky to smaller versions occurred over time. Subscription use grew from 1983-2014 to over seven billion people worldwide, “enough to provide one for every person on Earth.” (https://en.wikipedia.org/wiki/Mobile_phone#History ) (https://www.cengn.ca/information-centre/innovation/timeline-from-1g-to-5g-a-brief-history-on-cell-phones/)
• Internet. The third significant technological development was the beginnings of the World Wide Web. The World Wide Web (www.) is made up of text, images, and other resources accessed through a web browser via the internet. Access to information around the world was available almost instantly. These three developments have dramatically changed most American’s lives as well as the profession of psychiatric nursing.

In addition to these technological advances, the 1980s witnessed a welcome change on the global stage: the Berlin Wall came down in 1989, and the world gave a sigh of relief. The Cold War between the United States and Russia (two global superpowers) seemed to have ended, and there were joint explorations of the universe through shuttles and International Space Stations (ISS).

Leadership and Curriculum

Dr. Linda Amos became the Dean of the College of Nursing in the Fall of 1980. She served for 20 years as the Dean of the College, offering stability and advancement as the field of nursing was changing. Dr. Beth Cole was director of the graduate Psychosocial Nursing Program from late 1978 through Spring 1981. And then again from 1983 through 2002. Dr. Bonnie Clayton served as director from 81-83. Dr. Karen Busch became part of the faculty mid-decade. Imogene Rigdon joined the faculty as well.

Curriculum Changes: Thesis Options, Core Course Adjustments and Concerns. A lot was going on during this decade. The psychiatric and psychological fields were in considerable conflict over the theories and explanations of mental illness. Keeping credibility and keeping up with the new ideas was challenging. There may have been (probably were) some internal conflicts over proposed changes within the program as well.

One significant change was in the core courses. The requirement that students complete a thesis was no longer deemed necessary for the master’s degree. It was still an option, but students could also choose a less intensive thesis option, one which usually required an in-depth paper in a nursing related area. Students were still required to take the “Research” course as part of the core courses, but the “Thesis Option” gave students a wide variety of projects and activities that would support their knowledge and/or clinical practice. Comprehensive exams were still required.

Courses in the Graduate Psychosocial Nursing Program became more specific. Instead of N. 636 Advanced Psychiatric Nursing Specialist Theory for 2-4 Credits, the course of study became N636 A: Family Theory and N636 B: Research and Evaluation of Family Therapy. Family dynamics and growth and development were significant approaches to understanding the development of persons with mental illness. Understanding relationship issues was essential to solving problems and helping people with mental illnesses adapt and improve their mental health. A course (N638) in Preventive Issues in Mental Health was added to the curriculum. Also added to the curriculum was N639 I and II Chronic Mental Illness I: Schizophrenia and II Affective and Organic Syndromes. The curriculum requirements remained the same throughout the decade.

Several of the graduate nursing programs were well over the University average of 45 credit hours for a master’s degree. There was pressure put on programs to decrease the number of course credits required for the degree. When the College of Nursing added their Ph.D. program (1977), there was concern that the credit hours for a master’s degree almost met the requirements for course work for a doctoral degree.

NIMH: Obtaining Grants for Utah. National Institute of Mental Health grants were secured for the Graduate Psychosocial Nursing Program throughout the decade. Money was for student stipends as money for faculty was diminishing. The 1986-90 grant, which focused on developing more effective psychiatric nursing skills, was awarded from NIMH for Clinical Training: Family/Social Network of Nursing for the Chronically Mentally Ill.

Associate Dean Judith Maurin secured a grant to assist with funding doctoral students to conduct their doctoral dissertations in family research. After Dr. Judith Maurin bowed out due to illness, Dr. Beth Cole took over as lead on the doctoral program grant for Family Nursing (awarded from the National Institute of Nursing Research). Throughout the decade there was strong support for nursing care of families through the Family and Pediatric Nurse Practitioner Program, the Psychosocial Nursing Program, and the Ph.D. Nursing Program.

Utah Nurse Practice Act

Nurse Practitioners: Prescriptive Practice. In 1983, Utah Nurse Practitioners were licensed with prescriptive practice. According to Sheila Bittle and Lee Moss, prescriptive practice legislation was passed “following a successful 3-year pilot project conducted by nurse practitioners working in primary health care settings with physician supervision according to a complicated and cumbersome protocol.” (Sheila Bittle 2022, Interview; Lee Moss 2022, Interview)

Psychiatric Nurse Clinical Specialists: Reimbursement Issues Adjudicated. In 1984 The Nurse Practice Act was changed to include statements of diagnosis and treatment, along with the Consultation and Referral Plan (CRP). (However, it did not include a prescriptive practice component.)

Psychiatric Clinical Specialist nurses again approached Insurance Commissioner Roger Day, who accepted the changes and “made a ruling that Blue Cross/Blue Shield should pay for mental health services rendered by Psychiatric Nurse Specialists.” (Bittle interview, 2022). However, Blue Cross/Blue Shield, again, refused to pay Psychiatric Nurse Specialists for mental health services. Bittle and Reiss-Brennan filed a complaint with Commissioner Day.

In June of 1984 Commissioner Day wrote a “cease and desist order” against Blue Cross and Blue Shield and ordered them to pay master’s-prepared, Psychiatric Mental Health Clinical Nurse Specialists.

In July 1984, Blue Cross/Blue Shield requested a continuance, thus delaying any payments to Psychiatric Mental Health Clinical Nurse Specialists.

In February 1985, the Utah Nurses Association requested a review of the insurance action for the second time. In March 1985 BlueCross filed a motion for Summary Judgement against Insurance Commissioner Day and the Department of Business Regulations (later called DOPL). In April 1985 a hearing was held before Honorable Judge Timothy Hansen.

Utah Nurses Association hired attorney Elliot Williams as an Amicus Curiae (friend-of-the-court) and the case was reviewed in the Third District Court of Utah. Both the Council of Specialists in Psychiatric-Mental Health Nursing and the Utah Nurse Practitioners group helped fund attorney Williams along with UNA.

In June 1985 in a ruling by Judge Hansen, he upheld the Insurance Commissioner’s June 1984 Order. Blue Cross did not appeal the decision to the Supreme Court. Psychiatric Nurse Specialists were reimbursed for Blue Cross/Blue Shield claims, which had been pending for 3 years.

Two Steps Forward, One Step Back. Thus, this decade’s changes to the Utah Nurse Practice Act might appear to be two steps forward, one step back: Psychiatric Clinical Nurse Specialists were granted direct reimbursement, but not prescriptive authority; and Nurse Practitioners were granted prescriptive authority under physician supervision, but no direct payment for services. While reimbursement was accomplished, the accompanying “Consultation and Referral Plans (CRPs)” for both professions were complicated and time-consuming. Psychiatric Nurses were required to have 3000 hours of supervised clinical work. 1000 hours could be obtained through their graduate programs. Therefore, 2000 hours were required after graduation in an appropriate clinical practice, with a supervisor who would certify that the graduate had met the hours and quality of professional practice. Originally, Psychiatric Advanced Practice Nurses (who had at least 3 years of experience) and psychiatrists were qualified to supervise new graduates. Students who had graduated but not completed the additional hours after graduation had an “I” for intern after their license; this meant they could not practice independently. Often agencies that wanted to hire Psychiatric APRNs did not have qualified supervisors for these advanced practice nurses.

In 1986, the Nurse Practice Act Rules and Regulations specified that a master’s degree in nursing was the accepted minimum educational standard for Nurse Practitioners (NP), Psychiatric Mental Health Clinical Nurse Specialists (NS), and Nurse Anesthetist (CNA).

Community Support

As discussed above, Utah’s Commissioner Day and others, including litigators, stepped forward to help secure reimbursement from insurance companies for Advance Practice nurses. Another community source of support to the nursing profession came from the Utah State Legislature as it sought a way to provide healthcare to lower income families. The University of Utah’s College of Nursing Bulletin 1981-82 noted the Family Nurse Clinician Program for the first time. This program was supported by the Utah State Legislature as a pilot project, intended to meet the health care needs of low-income people in Utah. The Family Nurse Clinician Program changed to the Nurse Practitioner Program in 1988, with a choice of three tracks: adult, geriatric, and pediatric. These were three separate tracks with their own rules and regulations with DOPL.