Theory and Therapy

Diagnosis and Treatment. Psychotherapy continued to evolve during the 1990s. Besides the DSM-IV (2^nd edition), two other valuable textbook resources were: Glenn Gabbard’s 1994 Psychodynamic Psychiatry in Clinical Practice, and Ruth P Rawlins, Sophronia R. Williams, and Cornelia K. Beck’s 1992 Mental Health-Psychiatric Nursing. These and other textbooks included overviews of many theories or approaches to therapy, some with their DSM classifications (Diagnostic and Statistical Manual of Mental Disorders) followed by the edition. But what was increasingly more relevant to psychiatric nursing practice were the articles and books on a wide variety of psychiatric and mental health problems and the strategies for treatment that were published during the decade. Because reimbursement was often calculated according to diagnosis, there was increasing pressure from the Federal Government and insurance carriers to demonstrate efficacy that would decrease costs.

Psychotropic Drugs. Authors Frank, Conti, and Goldman (2005) noted that from 1988 -2003, two major classes of psychotropic drugs were produced, and nine new antidepressants and five new antipsychotic drugs were approved by the FDA (Food and Drug Administration). According to their report, seventy-seven percent of mental health cases included psychotropic drugs as part of the treatment in 1996. Obviously, psychotropic medications were increasingly important in the management of mental health problems. (See Frank, Conti, and Goldman 2005, 271-298.)

The following table notes in brief the drug classes for specific mental health disorders. The stared items were introduced between 1987 and 2003 according to Frank, Conti, and Goldman (2005).

Table 1. Pharmacotherapy classes and Mental Health disorders

Frank, Conti, and Goldman (2005)

*Newly developed psychotropic medications

National Influences

Insurance. In the mid to late 1990s research on outcomes became relevant for reimbursement of services. Besides determining reimbursement by outcome measures, insurance companies were trying to limit the outflow of their resources in other ways. One solution was the development of Preferred Provider Organizations (PPOs) where a group of providers would contract with insurance companies to accept a set price for specific services. Insured members could choose from the PPO’s listed providers for health care services, but if patients chose to go to a provider out of the PPO network, costs for services would likely be more expensive and the patients would be responsible to pay any extra cost beyond what the PPO would pay to an out-of-network provider.

In the decades prior to 1990, insurance companies and employer-sponsored health plans may or may not have provided mental health reimbursement. Moreover, coverage for physical problems was substantially more generous for physical problems than mental health problems—if they were included in insurance plans at all. In 1996 the government intervened: Congress passed the Mental Health Parity Act of 1996 prohibiting all large (over 50 employees) employer-sponsored group health plans from imposing annual or lifetime dollar limits on mental health benefits that differ from those for medical or surgical benefits. Admittedly, there were loopholes that companies used to limit reimbursement for services, such as limiting the number of visits for therapy for some mental health disorders. However, the Mental Health Parity Act did also recognize advanced practice registered nurses as eligible for reimbursement for mental health services.

Advances in Research and Development. The 1990s was designated the “Decade of the Brain” by President George H. W. Bush in 1990. His proclamation to the nation followed Congress passing a proposal to do so and thereby stimulate further research and clinical development in neuroscience. The proposal was sponsored by the National Committee for Research in Neurological and Communicative Disorders along with the National Institute of Neurological Disorders and Stroke advisory council. In response, a gathering of sixty prominent neuroscientists signed a “Declaration” of ten research goals to be accomplished by the end of the decade with a commitment to publicize and speak about their ongoing research to generate public interest in neuroscience and promote funding. (“Assessing the Decade of the Brain,” Jones and Mendell 1999, 739.)

Publicity of the designation “Decade of the Brain” created strong public curiosity and, of more critical importance, immediate government investment in neurological research. Some of the findings that came from this investment were:

• development of neural imaging and the beginning of the field of computational neuroscience
• new evidence of neural plasticity and critical periods of neural development (critical information for understanding childhood growth and development)
• the development of second-generation antidepressants and anti-psychotics
• the discovery of genetic mutations for Huntington’s disease, Amyotrophic Lateral Sclerosis (ALS) and Rett’s Syndrome
• the discovery of the neural origins and the influence of alcoholism.

The influence of these findings for the mental health field would bear fruit throughout the next decades. (NIMH Project on the Decade of the Brain, Library of Congress Home Page https://www.loc.gov/loc/brain) Not all fruit would prove to be desirable. According to one assessment (Jones, Fitzpatrick, and Rogers 2016), “Along with the burgeoning pharmaceutical industry and the embracing of the biological model of illness by physicians, this era led to a major shift away from more humane, less-invasive forms of therapy, such as counseling, as the main psychiatric treatment to one involving medical-somatic options as first-line intervention” (5). (Jones, Fitzpatrick, and Rogers refer the reader to Whitaker, R. 2011. Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America.)

Shuffling the Deck: Dismantling and Repurposing Bureaus. The 1990s was a time of tumult for NIMH, along with other related bureaus. In 1992, Congress abolished the Alcohol, Drug Abuse, Mental Health Administration (ADAMHA). This proved to be a prelude to the dismantling of various other agencies and reassignments by purpose: research or service. The research components of the National Institute of Alcohol Abuse and Alcoholism (NIAAA), National Institute of Drug Abuse (NIDA), and NIMH rejoined the National Institutes of Health. At the same time the service components of each of these agencies became part of a new Public Health Service (PHS) agency called SAMHSA (Substance Abuse and Mental Health Services Administration. These changes required NIMH to form new offices for Prevention, Special Populations, Rural Mental Health, and HIV/AIDS (Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome). (https://en.wikipedia.org/wiki/National_Institute_of_Mental_Health)

Goals for studying and improving health and mental health care in rural areas applied to Utah with its high rural population. The government launched more major changes in 1994, 1996, and 1999. Of particular interest to psychiatric nursing, in 1999, U.S. Surgeon General David Satcher released “the Surgeon General’s Call to Action to Prevent Suicide.”

Drug overdoses were often computed separately from suicide, because of the difficulty discerning intentionality. Whatever the cause, the numbers of deaths by either suicide or overdose were increasing and were devastating to their families. (U.S. Surgeon General David Satcher’s full report is available at NIH National Library of Medicine https://profiles.nlm.nih.gov/spotlight/nn/catalog/nlm:nlmuid-101584932X6-doc.)

Technology: Genome Research. Technological advances continued to dramatically influence the study of health and mental health. Many of these new technologies were developed with support from the National Human Genome Research Institute (NHGRI) and its Genome Technology Program that developed Advanced DNA Sequencing technology. Along with the focus on the “Decade of the Brain” there was great emphasis on genome mapping. In 1994 the first map linking the human genome was developed. In 1989, The National Center for Human Genome Research was established in NIH. The Center became an institute within NIH in 1997. While the linking of genomes had already been accomplished, the genetic code for a specific chromosome first occurred in 1999.

Genome research aroused great interest. The question of nature versus nurture as factors in both physical and mental development continued to dominate health care. Genes for tendencies for breast cancer, ovarian cancer, and prostate cancer ignited hope that if genes could be identified that seem to cause or exacerbate an illness, maybe interventions could be developed to prevent or eliminate that illness altogether or at the very least improve outcomes. This research suggests that mental illnesses might be more genetic than earlier hypothesized.

Leadership and Curriculum

Leadership and Faculty. Leadership for the College and for the graduate Psychosocial Nursing Program continued with Dr. Linda Amos as dean for the entire decade and Dr. Beth Cole as the director of the Graduate Psychosocial Program. In addition, from 1991-1996, Dr. Cole was the Division Chair of one of two divisions of the College of Nursing. Dr. Kathi Mooney was the Chair of the other Division. (The College of Nursing faculty with teaching assignments were assigned to one of the two divisions.)

Beth Cole, Ann Hutton, Alice Parkinson, Lee Walker, Rae Jeanne Memmott, and Linda Mabey, Imogene Rigdon, Gerry Matsumura, Carolyn Anich, and Grace Forsythe were the faculty in the Graduate Psychosocial Nursing Program in the 1990s.

Curriculum: Changing Times, Changing Needs. The 1990s was a period of change for the curriculum. The many new hypotheses for understanding mental illness and the competing treatment approaches influenced the search for a relevant, responsible curriculum that would educate mental health care professionals to relieve the suffering and dysfunction of individuals and families. As the decade began, the curriculum was essentially the same as previous years, although the content in the courses was shifting to include some of the newer approaches, often depending on who was teaching the course.

There has always been a close tie between the graduate Psychiatric Nursing Program and the clinical supervisors who work with our students. Since it would be impossible to teach every possible theory or treatment approach, faculty recognized that preparing students to be employable upon graduation needed to be the priority. Feedback came from employed Psychiatric Nurse Clinicians, who were engaged in working in a wide variety of health care settings, that more pharmacology needed to be part of the academic program. Psychiatric Nurse Clinicians wanted more knowledge in psychopharmacology to add to their intervention strategies with clients.

This request was quickly addressed. A course was added in the early 1990s on Psychopharmacology for Nurses. This course first appears in the 1993 College of Nursing Bulletin for Graduate Programs, but the College Bulletin was often a year or more behind actual curricular changes since course bulletins were crafted after courses were taught experimentally. (Courses were allowed to be taught as experimental for a year while the course was going through the College and University line of approval.)

One superficial change to the program was its name as recorded in the College of Nursing Bulletin of 1993. It changed back to Psychiatric/Mental Health Nursing. This name was typical of programs across the nation that wanted to be recognized for their nursing roots.

By the 1990s, some of the graduate psychiatric nursing programs were pairing up with graduate Nurse Practitioner programs at their colleges to take advantage of psychopharmacology courses taught in the Nurse Practitioner programs. Often this was influenced by the Nurse Practice Act of their states. In Utah, psychiatric nurse specialists already in practice were working toward acquiring skills in prescriptive practice by taking extra courses in pharmacology, pathophysiology, and advanced health assessment in the Family Nurse Practitioner Program at the University of Utah College of Nursing. There was a period of time at the University of Utah when graduate Psychiatric Mental-Health students were taking these courses in the Nurse Practitioner Program. However, the students were dissatisfied, because there was very little course work on neuropathology and the psychotropic medications that were commonly prescribed in psychiatric practice.

By the late 1990s, an Advanced Health Assessment course was being taught to both the Family Nurse Practitioner students and the Psychiatric-Mental Health students. The Pathophysiology course had been divided: there was a Neuropathology course specifically designed for the Psychiatric Nursing students and a Pathophysiology course specifically for the Nurse Practitioner students. A Psychopharmacology course was also required for the Psychiatric/Mental Health Nursing program students.

Additional changes to the curriculum included specific courses on Mood and Anxiety Disorders, Severe Mental Illness, and Personality/Substance Use Disorders. Thus, the curriculum was moving away from theories of personality and psychiatric disorders to symptom management and treatment approaches (including psychotropic medications).

Funding: Federal grants for graduate psychiatric nursing programs in the 1980s focused on families with a mentally ill member and/or people with chronic mental Illness. A grant for Graduate Nursing Education: Serving the Seriously Mentally Ill was secured for 1990-1994. Again, most of the funding was to provide student tuition and stipends.

Long–Distance Learning: From Videotape to Television to Internet. Prior to a grant received in 1997, students living in St. George, Utah, (over 300 miles away), who found it difficult, especially in winter months, to be on campus for classes were encouraged to have the class videotaped and then have the video recording sent to them. This was an awkward learning technique because students often would not get the video before the next class meeting, so they always fell behind. In 1997, a grant for Rural Utah Mental Health Nurse Education was received from the NIH: Office of Health and Human Services. Again, resources were primarily for student tuition and stipends. However, it did include some monies to purchase face-to-face video time. The Graduate Psychiatric Nursing Program was granted time on the Utah state tele-network station UEN (Utah Education Network).

After a couple of years of managing classroom teaching through the television network, the College of Nursing facilitated the acquisition of direct off-site student learning via internet in real time. Students were in Vernal and St. George, Utah, and some even in Boston, Massachusetts, and Jackson Hole, Wyoming. Teaching via these new technologies did not run smoothly. Everyone was learning how to use this new technology. At times phone lines were used when video conferencing failed. It was a costly venture, but one that did allow students from long distances to get their advanced degrees. Graduate Psychiatric Nursing faculty worked with faculty and staff from Utah State University (Logan, Utah) who had been using this technology for several years with their satellite campuses in Utah. Faculty gradually adapted to and mastered the new technology, and since the curriculum was the same for on-campus and off-site students, long-distance learning did not require review beyond the College of Nursing approval at that time. The University’s Continuing Education Department was also attempting to use long-distance technology; however, there were no degree-granting programs at the University of Utah that were using videoconferencing except this Nursing program. This grant continued through 2001.

Some of the graduates of the master’s graduate psychiatric nursing program returned to the College of Nursing to receive their Ph.D. degrees: Marilyn Park, Sheila Bittle, Karen Dearing, Sheryl Steadman, Marge McCoy, and Sue Fisher. They became important influences in advancing roles for psychiatric mental health nurses in the community.

Utah Nurse Practice Act

1992, Revisions Passed. In 1992, the revised Utah Nurse Practice Act was passed by the Utah Senate and the Utah House of Representatives with 100% approval. The Revised Act clarified the designation and definition for the Advanced Practice Registered Nurse (APRN) which allowed prescriptive practice for all advanced practice nurses, including psychiatric nurse specialists. It was quite restrictive, however, in the kinds of medications they could prescribe and the length of time for supervision (two years) as well as who could be a supervisor. APRNs had to consult and comply with a State-approved formulary that identified which medications they could prescribe.

1998, Proposed Changes and National Credentialling Requirements. In the 1998 Utah Legislative Session several changes to the Nurse Practice Act were proposed. One was to request administrative and technical changes to conform with other states and reduce duplicate licenses and costs. Another was to address APRN scope of practice, which included prescriptive practice for Schedule II and III medications. Consultation and Referral Plans were now only required for APRNs who were prescribing Schedule II and III medications.

Licensure already required certification by an approved national organization such as American Nurses Credentialing Center (ANCC) for the Advanced Practice Registered Nurse (APRN).

To itemize, Utah Nurse Practice Act requirements for licensure would be:

• Advanced Practice Registered Nurses (APRN) had to have a graduate degree in a nursing specialty and completed course work in advanced health assessment, pharmacotherapeutics, and pathophysiology.
• The APRN must have a Consultation and Referral Plan only if they choose to prescribe Schedule II and III controlled substances.
• The APRN must have a Controlled Substance license and a DEA (Drug Enforcement Agency) number to prescribe Schedule II drugs.
• There was still a requirement that psychiatric nurses have 2 years of supervised practice after graduation if they were prescribing medications.

As for requirements on the national front, ANCC (American Nurses Credentialing Center), the nurse credentialling organization, became an essential body in certifying eligibility to practice as a licensed Advanced Practice Registered Nurse (APRN). They credentialed Nurse Specialists, Nurse Practitioners, and Nurse Anesthetists. National tests were developed to demonstrate proficiency in one of the three fields. Letters from faculty were required as well as graduation from a recognized academic institution.

1990s, Nurse Practitioner or APRN. During the 1990s, the American Nurses Association attempted to get all the nurses who graduated with an advanced degree who were focused on clinical practice the designation APRN (Advanced Practice Registered Nurses). In the early 1990s, however, the advanced practice nurse was better known to the public as a nurse practitioner and changing this habitual designation was going to take time and would also require reworking some state nurse practice acts besides Utah’s. In Utah, the term Nurse Practitioner is recognized as an advanced practice nurse, usually with either a master’s degree or a Doctor of Nursing Practice (DNP).

Giving Back to the Community

Birthcare/Healthcare. In the early 1990s, Beth Cole and Ann Hutton joined with the nurse midwives in a practice site in Salt Lake City called Birthcare/Healthcare. The midwives offered health care services to low-income women who did not have insurance both gynecologically and obstetrically. Cole and Hutton offered psychotherapy services to the women and their families. Cole and Hutton were both licensed Advanced Practice Registered Nurses, and the College of Nursing was building its Clinical Practice sites. The College of Nursing midwifery faculty had a long tradition of clinical practice supported by College of Nursing funds.

End of Life Care. In 1997, the College of Nursing and the University of Utah Hospitals and Clinics participated in a project with the Institute for Healthcare Improvement (IHI): Improving End of Life Care. From the hospital, nurses Lynn Elstein, Rosemary Field, and Sandy Martin along with Dr. Perry Fine, MD from the College of Medicine and Beth Cole from the College of Nursing became the team representing University of Utah in this Healthcare project. Cole’s role was to spearhead the fourth goal of the project: “Attend to the spiritual needs and opportunities for meaningfulness of patients and families.” Cole worked with the Hospital Social Work Department, the Chaplain, Psychiatric Nurse Clinical Specialist Jan Harvey, and others to develop agency strategies to meet the IHI goal.

Caring Connections: A Hope and Comfort in Grief Program. After reviewing the literature on bereavement, availability of services in the community, and working with Dean Amos, Beth Cole and Jan Harvey proposed a pilot project for offering supportive mental health services to recently bereaved individuals. Sherry Poulson joined the Caring Connections team shortly after the program started. She was instrumental in coordinating the many Caring Connections programs and activities. She spearheaded the Carrie Bears Project that took 343 stuffed bears to the families of New York Police, firefighters, and Port Authority Police who died in the Twin towers attacks.

While originally the bereavement groups were for families that lost a loved one at the University of Utah Hospital, word spread about the grief support groups, and the project evolved into “Caring Connections: A Hope and Comfort in Grief Program.” Soon the grief groups were 10 weeks long and offered 3 or 4 times a year. They began focusing on different kinds of loss: loss of a spouse, loss of a child, loss due to suicide (always filled up quickly), perinatal loss, loss due to homicide, and age-based adolescents’ groups and children’s groups dealing with loss. The groups were all led by professional mental health workers from a wide variety of disciplines, and often had co-leaders who were students in mental health programs on campus (graduate psychiatric nursing students, graduate social work students, counseling students, graduate psychology students, and medical students). Caring Connections staff gave public lectures, offered grief education to school counselors, had a bi-monthly newsletter, and more. This exceptional and much-needed program would not have survived without the support of many willing mental health professionals offering their time, knowledge, and skills. Important funding came from the Ben B and Iris M. Margolis Foundation.

Representing Utah within National Nursing Organizations

Another element of advancing nursing as a respected profession was the movement toward requiring national certification. Even though certification exams were available for nurses with baccalaureate degrees, national certifications became the bellwether for advanced practice nurses in the 1990s. APRN Psychiatric-Mental Health Nurses with national certification became Psychiatric-Mental Health Nurse Practitioner-BC (Psychiatric-Mental Health Nurse Practitioner-Board Certified). While the state license was as an APRN (Advanced Practice Registered Nurse), the certification allowed the APRNs who had certification as a Nurse Practitioner to be known as Nurse Practitioners, and they would often follow Nurse Practitioner with all the credentials, i.e., APRN, PMH-NP-BC. (Advanced Practice Registered Nurse, Psychiatric-Mental Health Nurse Practitioner-Board Certified)

The Society for Education and Research in Psychiatric-Mental Health Nursing (SERPN) was an important national organization, which originated with faculty and directors of Psychiatric Nursing programs across the country gathering to discuss academic issues of advanced education, research, policy, and current issues in the field. This evolved into SERPN. Cole represented the western region on the board of SERPN for over 10 years and also served at times as its Research Director. Other faculty from the University of Utah graduate Psychiatric Nursing Program participated in this group as well. There were four major psychiatric nursing programs in the ‘90s:

• Association of Child and Adolescent Psychiatric Nursing (ACAPN)
• International Society of Psychiatric Consultation-Liaison Nurses (ISPCLN)
• American Psychiatric Nurse Association (APNA)
• SERPN.

Discussions in the mid-nineties focused on merging the four groups. Three of the groups—ACAPN, ISPCLN, and SERPN—agreed to merge into one group called International Society of Psychiatric Nursing (ISPN) in 1999. APNA continued as a separate organization.

In addition to SERPN, Cole served on NIH-Division of Nursing grant review committees for psychiatric nursing education for many years during the 1990s and early 2000s. Faculty participations in these national organizations assisted Utah’s program in being recognized nationally plus facilitated the program to recognize trends in education, which fostered consistent federal grant approval.