Most people in the modern era recognize and are grateful that mental illness and psychiatric disorders are afflictions that can be remedied. Diagnoses and treatment strategies, however, remain controversial. There are even some who deny the reality of mental illness. Roy Porter (2006) notes in The Cambridge History of Medicine that “leaders of the antipsychiatry movement launched in the 1960s—notably Ronald Laing in Britain and Thomas Szasz in the USA—denied the reality of mental illness.” Laing and Szasz claimed instead that mental illness was simply “a witch-hunting label pinned on ‘deviants’ or scapegoats for the purpose of psychiatric empire-building and to exercise social control” (238).

This far-fetched accusation may be easily dismissed by anyone who has suffered with a mental disorder or has cared for the mentally ill, but what constitutes appropriate and effective treatment is still debated. Porter states, “Even those satisfied that madness is a disease contest what it is, what causes it, and what may be done about it” (238). Whatever these three “whats” are thought to be, some sufferers require hospitalization and nurses are and have always been the frontline caregivers. As such they have been leading advocates for more humane treatment of the mentally ill. Especially in the early years of the twentieth century, nurses and other professionals also recognized that psychiatric nurse training programs were essential to the reforms that needed to take place and worked to establish them.

Dorothea Dix

As noted above, Dorothea Dix fostered more humane treatment of the mentally ill. Her advocacy during the 1840s evolved into the development of over 30 state-supported mental or psychiatric hospitals, also called asylums. The need for caregivers in these settings resulted in the hiring of many men. Psychiatric hospitals offered Nurse Training Programs to attract both men and women to staff these hospitals. Following the Civil War, Dix resumed her crusade on behalf of the mentally ill combined with efforts to improve the care of prisoners and the disabled as well (Norwood 2017, “Dorothea Dix,” https//www.womenshistory.org/education-resources/biographies/dorothea-dix).

Clifford Beers and Mental Health America

Clifford Beers (1876-1943) came from a family with multiple psychological distresses. All four of his siblings were institutionalized at different times in mental hospitals. Three years after graduating in 1897 from Yale, Clifford Beers was himself hospitalized in a private mental institution for depression and paranoia. His trial by fire did not end there. He was hospitalized twice more after that.

Beers wrote an autobiographical account of his hospitalizations and the abuses he both experienced and witnessed. His book A Mind That Found Itself (1908) became a best seller and with the support of the medical profession, Beers and others worked to reform the treatment of the mentally ill. He founded the National Committee for Mental Hygiene, now called Mental Health America. Initiating a major change in treatment options, he started the first outpatient mental health clinic in New Haven, Connecticut. He was an advocate for better treatment of the mentally ill for the rest of his life. He died in 1943 at age 67. (https://en.wikipedia.org/wiki/Clifford_Whittingham_Beers )

Adelaide Nutting and Lavinia Dock: Nurse Administrators, Professors, and Activists

Alongside reforms in treatment came the recognition that any permanent progress in caring for the mentally ill depended on nurse education not just in medicine but in leadership. Besides knowledge of general medicine and of mental disorders, nurses needed to learn how to be effective teachers, leaders, and administrators as well. To further these aims the education committee of The American Society of Superintendents of Training Schools for Nurses recommended a one-year course in hospital economics. (Such progressive thinkers as Isabel Hampton Robb, M. Adelaide Nutting, Linda Richards, Agnes Snively, and Lucy Downs were on the Society’s education committee.) The Society even offered financial support to nurses interested in learning this essential component of administration and leadership. In 1899, two students enrolled in the course in hospital economics for nurses at New York’s Columbia University Teachers College. This academic program became the centerpiece for advancing the Society’s education mission for equipping nurses to become leaders and teachers.

In 1907, Adelaide Nutting (1858-1948), one of the program’s sponsors, was the first nurse to become a professor at Columbia University Teachers College. Eight years earlier, in 1889, Adelaide Nutting had been one of 17 students to enroll in the inaugural class at the Johns Hopkins School of Nursing. Lavinia Dock (1858-1956) had just been appointed assistant superintendent of nurses at Johns Hopkins Hospital, the affiliated teaching and research facility. Dock was already gaining notoriety as an activist for woman’s suffrage and for charitable work among the working-class poor. As teacher of the first-year nursing classes she befriended Nutting, who was Dock’s same age, and they would eventually co-author a multivolume History of Nursing. Dock had previously published Materia Medica for Nurses (1890), the first nurses’ drug manual. (See Garofalo and Fee, “Lavinia Dock (1858–1956): Picketing, Parading, and Protesting,”276-277.)

Psychiatric Nursing Education

In 1911, the newly organized American Nurses Association recognized the importance of mental health knowledge by establishing a Mental Hygiene Nursing Committee as one of its five standing committees. This committee conducted a survey of psychiatric nurses. At that time, 1915, forty-one mental institutions were operating training schools for nurses. The committee would request more be done. Unless nurses who cared for the mentally ill argued for it, neither doctors nor the public were likely to recognize the critical need for specialized education in this area (Jones, Fitzpatrick, and Rogers 2016).

To their credit, superintendents of asylums took seriously their responsibilities to improve the care of their patients. They saw those general hospitals with nurse training schools had greatly improved outcomes and success. These administrators of American asylums or psychiatric hospitals decided to do the same. They started their own Nurse Training Schools. They wanted their nurses to sit for the same nursing exam as those trained in general hospitals so their nurses could be known as RNs, registered nurses. Even though psychiatric nurses in these asylum schools did not have the same opportunities for medical, surgical, and obstetric experiences that nurses at general hospitals had, the psychiatric hospitals prevailed in securing their nurses status as RNs.

Little literature exists on the impact of these better trained nurses on the treatment of patients in mental asylums, and with the onset of the economic trials of the Great Depression there may have been little to record. This disastrous economic downturn pressed on states to cut appropriations for state asylums and most psychiatrists moved away from hospital settings to clinics and private practice (D’Antonio, Bates, and Davis, History of Psychiatric Hospitals, https://www.nursing.upenn.edu/nhhc/nurses-institutions-caring/history-of-psychiatric-hospitals/ ).

Some important achievements can be highlighted, however. Linda Richards, who would later be a member of the (ASSTSN) Society’s education committee, graduated in 1882 from Boston City College and is considered the first psychiatric nurse graduate in the United States. A second major step forward came in 1913 when Johns Hopkins University lead out as the first College of Nursing in the United States to offer psychiatric nursing as part of its general curriculum. Then as the ranks of shell-shocked soldiers grew during and in the aftermath of World War I, the National League for Nursing Education included “nervous and mental diseases to their curriculum guides” (History of Psychiatric-Mental Health Nursing, www.apna.org/history/ ). Psychiatric Hospitals and General Hospitals Training Schools continued their separate ventures through the early 20^th Century.

Hospitals and Universities Collaborate on Nurse Training Programs

Hospital-based nurse training schools were unquestionably a benefit to hospitals financially. They provided student nurses to staff hospitals; their unpaid work was required as part of their “education.” In addition, student nurses paid tuition to the hospitals. While hospitals did provide housing and food, the substantial financial benefits of student tuition and unpaid work were strong incentives for hospitals to keep nurse trainees in hospital-based programs rather than college programs. Of concern, however, hospital-based nursing programs were basically apprenticeships where the focus was on developing skills without acquiring the knowledge of medicine available through university coursework.

“By mid-century,” historian Jessie Embry (2008) notes, “a fundamental question was raised by the nursing profession: should nursing students be ‘trained’ or ‘educated’?” One graduate of a 1930s Nurse Training Program interviewed by Embry commented that the word training correctly described these programs. The term was both accurate and, in her opinion, “demeaning. ‘You train animals; you educate people. We were trained.’” She recalled being “required to manage floors of patients and provide services” that were “beyond [her] knowledge” (284). Nurses needed both clinical skills and book learning. The Goldmark Report of 1923 led the way forward toward that much needed change. (https://issuu.com/utah10/docs/uhq_volume76_2008_number3/s/10216412)

The Goldmark Report, researched and authored by Josephine Goldmark, successfully argued for hospital nurse training programs to collaborate with institutions of higher learning. Shortly thereafter, colleges and universities began working with Nursing Training Schools by offering such courses as anatomy and physiology, public health, psychiatric nursing, and pharmacology. Some of these colleges began offering college credit, which prompted more nurses to seek college degrees. These college graduates often became the faculty for nurse training programs, or they would teach the college courses for the training schools. (Bullough and Sentz 2004, “Josephine Goldmark,” 98-101.)

Clarification: Graduate Nurse vs. Graduate Nurse

In reviewing the literature for nursing education there could be some confusion about the term graduate nurse. Prior to the 1940s, a graduate nurse was a person who had graduated from a Nurse Training School. She/he might also have been referred to as a Registered Nurse (RN). That designation meant that the nurse had either graduated from a nurse training school or else from a collegiate nursing program (there were very few at the time). Eventually, in line with current standards, to be called a Registered Nurse (RN), a graduate nurse must pass the national nurse exam and be licensed in the state where she/he is practicing.

A second use of the term graduate nurse arose in academic settings. If a graduate from a nurse training school then went on to college, enrolling in an academic program leading to a baccalaureate degree, she/he would sometimes be referred to as a graduate nurse student. As more collegiate nursing programs came into being, and more masters and doctoral programs in nursing began to flourish across the U.S., the term graduate nurse began to mean a nurse in graduate school, that is, nurses who were enrolled as students in master’s or doctoral programs.

“Massive Neglect and Abuse.”

Albert Deutsch (1905–1961), an American journalist and social historian, published The Mentally Ill in America: A History of Their Care and Treatment from Colonial Times (1937) summarizing the history of the treatment of people with mental illness up until that time (Weiss 2011, “Remembering Albert Deutsch, an Advocate for Mental Health,” 353-57). Around the same time, three professional entities—The United States Public Health Service, the National Mental Hygiene Committee, and the American Psychiatric Association—collaborated in a three-year survey of public state hospitals and described “the massive neglect and abuse common in publicly supported mental institutions throughout the country.” Their hope was that this powerful and vivid portrayal would move the federal government toward legislation to help remedy this situation. However, World War II overshadowed this social concern.