How do you summarize 66 years of a nurse education program? Over this time, mental health care has progressed from restrictive, even harmful practices to more curative, compassionate models of care for people with mental illnesses. Today’s treatment interventions alleviate some symptoms and dramatically reduce others, promoting more long-lasting emotional and psychological well-being. The mystery of what causes severe mental illness is still illusive. Rather than approaching mental illness from a “nature vs. nurture” perspective, complementary approaches that offer both medication and psychotherapy are often more effective.

Genetics and other avenues of research, combined with sophisticated computer data, are starting to bridge the gap in our understanding of our brains. Many environmental factors that contribute to mental illness have been identified; yet it is still not clear how the mechanism of mental illness operates or what triggers it. Less severe mental illnesses often readily respond to psychotherapy and medications, and even those with severe mental illness may do so as well. However, these interventions are not universally available or sought out, and those with severe mental illnesses account for large portions of our homeless populations. Part of the problem is that medications for severe mental illness often have unacceptable side effects or else that patients sometimes don’t respond to them at all.

Suicide, addiction, and mental illness are societal ills that have not been solved. Much has been discovered or hypothesized but there is still much to be learned. For those who are afflicted, even with medications, living with a chronic mental illness is difficult, stressful, economically and emotionally taxing. In addition, family members of a mentally ill member strain to identify where they can be helpful and nurturing, without sacrificing everything they have, all their financial and emotional resources. More sustained and serious attention needs to be directed toward families and family safety nets as well as developing newer, more successful treatment approaches for individuals with mental illnesses. Without family support the mentally ill-homeless population will continue to grow.

Foundations to Stand On

Initially, graduate level programs in psychiatric nursing were an attempt to improve the treatment of traumatized war veterans of WWII, and hospitalized mentally ill patients who were hidden away or housed in asylums, or private institutions. Nurses and hospital attendants worked in close proximity with these patients on a daily basis. Nurses were clearly involved in the everyday care of people with mental illnesses, but if their care was to be more than merely custodial, their education needed enhancement. To that end, graduate psychiatric-mental health programs were encouraged and federally supported for many years.

As theories of illness, and theories of treatment evolved, nurses’ knowledge increased and their skill in working with mentally ill people was recognized. When the National Institute of Mental Health was created by Congress in 1949, nursing was one of the four core professions recognized in the field. The others were psychiatrists, psychologists, and social workers.

Graduate education for nurses to serve those with mental illnesses began in the late 1940s. Originally, courses were taught to prepare nurse educators. Those educators would promote the role of nurses to care for psychiatric patients. Gradually, graduate programs at academic institutions were developed to treat the mentally ill in outpatient settings.

The Community Mental Health Act of 1963 (CMHA), also known as the Community Mental Health Centers Construction and Mental Retardation Facilities and Construction Act, Public Law 88-164, changed the focus of mental health care from institutionalized care to public community-based care. The current theories were more applicable to outpatient treatment interventions. But there were significant unmet needs for the severely mentally ill. Unable to be cared for in their family homes (if they had any family ties), those with severe mental illness started living a wanderer’s life. Protective care was limited, funding was limited, and the freedom many experienced on the street was preferable to them than institutional care.

Early graduate psychiatric nursing education programs were supported by NIMH grants. Funding from NIMH covered student stipends, faculty support, and gave money to institutions that had these programs. The University of Utah graduate program in psychiatric nursing began with a grant from NIMH in 1957. A curriculum was adopted that was similar to other graduate psychiatric nursing programs. Psychopharmacology was still quite limited at that time. The program taught psychodynamic theories of mental illness and included medication management. It also focused on training in individual, family and group interventions. In the ‘60s, ‘70s, and ‘80s curriculum began incorporating and teaching other current theories and treatment interventions as they became available in professional literature.

The 1990s introduced the “Decade of the Brain” at NIH, out of which emerged a greater understanding of the biological underpinnings of many diseases, including but not limited to mental illness. By the late 1990s and 2000s with better understanding of neurology, theories of mental illness emphasized neurobiology. Pharmacology had developed a wide variety of new medications over the previous thirty years, adding significantly to the choice of treatment strategies for all mental illnesses, including severe mental illness.

According to data from SAMHSA (Substance Abuse and Mental Health Services Administration), most people being treated currently for a mental health diagnosis engaged in both therapy and medication management. Unfortunately for psychiatrists and psychiatric nurses, the workplace, focused as it is on income and reimbursement, has often defined their roles as only prescribers. Insurance companies pay better for prescribers than for psychotherapy interventions. Furthermore, prescribers can and often do see 3-4 people an hour, rather than the traditional therapy of an hour per patient.

The role for Advanced Practice Psychiatric Nurses is not set in stone. Both educators and practitioners have the power to define the future. Already, nurses in many fields have resisted being cast solely, or even primarily, in the role of “pill pusher” even though medication management has been and will remain an important part of nursing care. Far more than their skill in managing medication, however, nurses bring to the clinical arena their knowledge and understanding of human development, family dynamics, human behavior, anatomy, and physiology, not to mention their knowledge of pathophysiology, pharmacology, genetics, and background in other sciences, philosophies, and humanitarian service.

Voicing the Needs

New models of care need to be designed and evaluated. Here are a few issues to be addressed:

Can Psychiatric-Mental Health Nurse Practitioners prescribe and offer psychotherapy? How can that be incorporated in practice and reimbursed fairly?

Whether brief, or long term, it would be difficult to prescribe medications without gathering information similar to that gathered for psychotherapy. When two people are involved in treatment, there can be conflicting messages given to the client.

Can there be concurrent overlapping treatments by mental health professionals?

When there is more than one mental health professional treating an individual or family, there needs to be clear collaboration. What are the models for collaboration?

According to yearly Gallup Polls, nurses have topped the list of most trusted professionals ever since they were first included in 1999 on up to the last poll in 2022 (www.gallup.com, accessed 22 July 2023). In addition, nurses are in the top of respected professionals for their “expertise” and “societal impact.” (https://finance.yahoo.com) Given this level of trust and respect, how do Psychiatric Mental Health Nurses most effectively use compassion, trust, knowledge, as well as their skill in psychotherapy to help others?

Mental health is about people, their bodies and minds, their relationships, and about their lived experiences. And sometimes they go awry. Psychiatric-Mental Health Nurses can provide health care that integrates both physical and mental health strategies to assist those with mental Illness to improve, recover from, or adjust to their health problems. Psychiatric-Mental Health Nurse Practitioners (PMH-NP), or whatever their name will be in the future, will always be needed.

Most PMN-NP have focused on their clinical skills, which is very important, but there is so much more to the field and so much more that is needed. Perhaps most essential, critical, and immediately needed are thoughtful writers to articulate practice issues, treatment strategies, and successful collaborative communication patterns with other professionals.

Second, there is a serious need for Psychiatric Nursing Professionals who not only teach but conduct data-driven research that more clearly articulates nursing’s unique contribution to the advancement of mental health. As a science-based profession, nursing needs to study, analyze, evaluate, and disseminate its knowledge and practices. Nurse clinicians have the data from their practices that demonstrate their impact on their clients. Individual PMH-NPs or groups could greatly benefit from studying their own practices and sharing that knowledge with nurse educators and researchers. Yet, research is not only time-consuming and expensive, but is often not acknowledged or valued by clinicians. Although there is both a need and nurses who are interested in pursuing education in the field of mental health, there is little outside funding for these advanced programs. Federal funding for graduate mental health programs, including research, has diminished even as the need for it has grown. Funding for education is always a dilemma.

Third, nursing theories of treatment need to be articulated for the mentally ill and their families. Understanding and clearly articulating the reasoning or principles of PMH-NP practice provides others with knowledge about the profession and its goals and, most important, why a particular model of care will improve the mental health of a patient. Adapting theories from other disciplines is appropriate, but there needs to be a clear linkage between why those theories are appropriate for the nursing profession. For example, Sullivan’s Theory of Interpersonal Psychiatry was clearly adapted to nursing by Hildegard Peplau. Nursing theory is the underpinning of practice. Clearly articulated theory verified through responsible study and research, advances the health and wellbeing of our families and friends and society in general. Nurses, both in practice and as educators, need to find their own words to describe what they are doing as clinicians, as teachers, as researchers.

But there is more that the profession needs. We need to safeguard the profession. As noted in this document, the Nurse Practice Act was nurtured over many decades by nurses who worked with other disciplines advocating for changes that would allow nurses to practice to the full extent of their knowledge and skill. Still there need to be watchdogs to keep track of any changes that might be proposed to alter the Nurse Practice Act. So, fourth, the profession needs more nurses to contribute to the larger sphere of mental health. Nurses who are willing to donate their time and attention to engage in policy, both locally, and nationally, to advance the profession of nursing. To provide evidence for this endeavor, nurse historians are needed to track the ups and downs of a profession’s growth. Without a history there is no learning from the past, no foundation to stand on, and no clear path forward.

And finally, we need leaders. Willing leaders to move the profession forward through organizations that will bring about legislative action that benefits those with mental illnesses and their families. Outstanding, capable leaders in practices. Dedicated leaders in teaching, research, and administration. We need leaders with vision, energy, and ability. While there is no perfect leader, there are rallying points that can help us help each other and help and heal others. And that is our overarching goal: Take care of yourself as you care for others.