In 1945, Claire H. Favreau, assistant director of the Division of Nurse Education, U.S. Public Health Service, reported that the nurse-patient ratio in psychiatric hospitals was a disturbing 1:135, one nurse to 135 patients, nowhere near the American Psychiatric Association’s recommendation of 1:20, one nurse to 20 patients (Favreau and Menninger 1945, 716-717). Meanwhile theories about the underlying causes of mental illness and projected treatment strategies had been shifting in interesting ways.

Wilhelm Reich, deputy director of Freud‘s outpatient clinic in Vienna, and later Karen Horney, another German psychoanalyst, challenged Freud’s theoretical assumptions in the 1930s. Harry Stack Sullivan developed his theory of personality and interpersonal treatment of mental illness as he worked with mentally ill hospitalized patients. While Carl Rogers (client-centered therapy) started publishing his work in the 1940s, it was later in the 1950s that his work became more clearly understood and led to a popular humanist approach to treatment of mental illness. Abraham Maslow (self-actualization), Erik Erikson (developmental psychology), Viktor Frankl (logotherapy), and Albert Ellis (cognitive-behavioral therapy) made significant contributions as well.

Harry Stack Sullivan and Interpersonal Psychoanalysis

One influential theorist and practitioner was Harry Stack Sullivan (1892-1949). Though categorized as a Neo-Freudian psychiatrist, his approach to psychiatry was broader than Freud’s. Freud’s psychoanalytic theory was generally useful in treating neurosis but not more severe illnesses, such as schizophrenia and other psychotic disorders.

Sullivan took a more psychodynamic approach to the treatment of patients in psychiatric facilities. He hypothesized that the psychological and social elements of interpersonal relationships profoundly influenced personality and behavior not just in a patient’s life but also in healthcare institutions. His approach was to provide therapeutic relationships in a setting that provided a curative environment and improved the health of even severely mentally ill patients. This theory with its application for creating a therapeutic milieu significantly influenced psychiatric nursing practice in residential mental health facilities, in general hospitals, and in psychiatric hospitals. (See Helen Swick Perry 1954, The Interpersonal Theory of Psychiatry.)

Sullivan was the psychiatric consultant to the Selective Service System from 1940-1942. He developed a set of guidelines to assist a psychiatrist in the pre-induction mental examination, an exam which was meant to identify those potential servicemen with severe mental limitations. Sullivan resigned this position in protest when the psychiatric examination was reduced to two minutes per inductee, a time limit which he rightly believed was insufficient to establish an accurate assessment of psychiatric impairment, major or minor. Even with that very brief two-minute assessment, however, over 1,500,000 men were rejected from the draft due to neuropsychiatric problems. And during the war over 700,000 men were released from military service due to neuropsychiatric problems. World War II dramatically underscored the serious need for mental health services.

The National Mental Health Act of 1946

In 1943 the Nurse Cadet Corps (the initiative spearheaded by Frances Payne Bolton) was established to increase the number of nurses serving in the military. At that time Nurse Training Schools included both the study of psychiatric theory and clinical experience with psychiatric patients. Many of those experiences were in state mental hospitals. After WWII there was great concern for the health of returning soldiers. Increased awareness of the appalling conditions of these state psychiatric hospitals prompted new demands for improved care of the mentally ill. (Clayton 1976, “Historical Perspectives of Psychiatric Nursing Higher Education 1946-1975.”)

Thomas Parran, M.D., was serving as the Surgeon General of the Public Health Service after World War II. Convinced of the need for more and better treatment resources for those with mental illness, he encouraged and supported legislation to develop programs to understand mental illness, both its causes and ways to prevent it, as well as to train people to deal with mental and emotional disorders. Legislation submitted to the U.S. Senate and the House of Representatives garnered bipartisan support and passed with a nearly unanimous vote in both chambers. The National Mental Health Act of 1946, identified as P.L.79-487, “authorized the Surgeon General to improve the mental health of U.S. citizens through research into the causes, diagnosis, and treatment of psychiatric disorders.” (https://www.nih.gov/about-nih/what-we-do/nih-almanac/national-institute-mental-health-nimh)

Robert Felix and the Birth of NIMH

The bill established a National Advisory Mental Health Council to oversee the implementation of the new law. Robert Felix, M.D., was tapped to head this Council. Felix was exceptionally well qualified for the position. After completing medical school at the University of Colorado and residency at the Colorado Psychopathic Hospital, he enlisted in the Commissioned Corps of the Public Health Service. Then during WWII, he joined the Coast Guard where he was assigned to be chief medical officer and served as a psychiatrist. After the War he rejoined the U.S. Public Health Service. Appointed to head the Bureau of Mental Hygiene because of his background in psychiatry, he developed a proposal for a national mental health program. The proposal led both to the development of the legislation that became the Mental Health Act of 1946 and to the Advisory Mental Health Council that Felix would be asked to head. Three years after President Truman signed the bill into law, the Council under Felix’s leadership formally established the National Institute of Mental Health (NIMH) in 1949. The Institute promoted biomedical research, psychiatric and psychological services, and community-based mental health policies. (For a timeline of NIMH’s goals and progress see “Important Events in NIMH History,” https://www.nih.gov/about-nih/what-we-do/nih-almanac/national-institute-mental-health-nimh and Grob 1996, “Creation of the National Institute of Mental Health,” 378-381.) Having worked with nurses on mental health care teams in Colorado and Maryland, Felix wisely added psychiatric nurses to the group recognized as essential mental health professions: psychiatrists, psychologists, and social workers.

Also to his credit, during his term as head of NIMH until 1964 Felix implemented many valuable pieces of mental health legislation, especially the Mental Retardation Facilities and Community Mental Health Centers Act of 1963. This Act, Public Law 88-164, significantly shifted the focus of mental health care from public and private hospitals to community mental health centers. Monies were available for construction of these centers, with support for mental health services for those who could not pay. This change affected the educational curriculum by leading training schools to alter some of their courses, but it affected most significantly the clinical sites where students learned (Clayton 1976, 108).

Esther Garrison and NIMH

Before NIMH was formally established, Felix had asked Lucile Petry Leone to identify a psychiatric nurse who could direct the Nurse Training Branch of NIMH. Leone recommended Esther Garrison, whom she had known from her work with the Cadet Nurse Corps. Esther Garrison brought considerable training as an educator as well as experience in nursing to her work with NIMH. In 1925, Garrison had completed the Nurse Training School at St. Louis City Hospital. She then worked at a hospital in her hometown for eight years, eventually becoming the nurse education consultant at the hospital. She next attended the University of Minnesota and received her Bachelor of Science degree in nursing education in 1941.

Some years later, resuming her education at the University of Minnesota, she received a master’s degree in educational psychology in 1944. It was at this point that Lucile Petry Leone recruited Garrison to serve as nurse education consultant for the Cadet Nurse Corps. In this capacity, Garrison visited many of the nurse training programs that enrolled nurses in the Corps. She reported that many of these programs were poor in quality, short-staffed, and had no psychiatric nursing content (Bullough and Sentz 2004, 96-97).

From 1946-47 Garrison attended Columbia Teachers College. After her graduation, Robert Felix asked her to join NIMH and in Fall 1947 she accepted. Esther Garrison then became the Chief, Psychiatric Nursing Branch, Division of Manpower and Training Programs, National Institute of Mental Health, a position she served in for the next 22 years (Bullough and Sentz 2004, 97-98).

Garrison recognized that to advance the field of psychiatric nurses, there needed to be strong, well-prepared professional nurses. This could only be attained if nurses were prepared at advanced levels, beyond basic schooling and on-the-job experience. The first task of the new NIMH Nursing Division, then, was to encourage nurses to seek advanced training in the field of psychiatric nursing. Those nurses in hospital training schools needed to go on to baccalaureate education. Those in baccalaureate programs needed to advance to master’s and doctoral programs. As Clayton (1976) points out, “In psychiatric nursing that meant the initiation and continued support of graduate programs in a field virtually innocent of experience in higher education” (35).

Garrison’s initial efforts to foster interest in advancing psychiatric nursing logically focused on reaching out to nursing associations, nurse educators, and mental health agencies. She worked with the National League for Nursing and the American Nurses Association and organized conferences for nurse educators as well as for service personnel in mental health and public health agencies.

NIMH and Psychiatric Nursing Initiatives

In an article appearing in The American Journal of Nursing in 1950, Pearl R. Shalit reported progress. In 1948, nine university training centers received grant support to expand and improve programs of study in advanced work in psychiatric and mental health nursing. The next year, 1949, fifteen more centers were given grants. (These grants supported students in seeking baccalaureate degrees in nursing as well as graduates seeking master’s degrees with a specialty in psychiatric nursing.) At this time emphasis was placed on training in leadership and teaching. The focus changed in 1953 to include paying more attention to the clinical practice of treating patients with mental health problems and to providing preventative mental health services to communities. Historically, public health and psychiatric mental health often served similar people. Because NIMH was a department within the U.S. Public Health Service, there was a strong, productive collaboration between public health and mental health agencies. (Shalit 1950, “The Nurse and the Mental Health Act,” 94-96, and Clayton 1976, Appendix B.)

The NIMH Nursing Division sponsored two important conferences, “Advanced Psychiatric Nursing” held in Minneapolis in 1950 and “Mental Health Programs” held in Cincinnati in 1951. These two conferences engaged participants in formulating the teaching objectives, nursing functions, and learning experiences for the role of the clinical specialist in psychiatric nursing.

Starting in 1952, traineeships, including student stipends, were available through university programs for students pursuing advanced education in psychiatric nursing. These efforts to create interest and subsidize scholarship produced results. In 1954 there were nine graduate school programs in psychiatric nursing eligible for nurse traineeship monies from NIMH. They were:

• Boston University School of Nursing
• Catholic University of America School of Nursing (Washington, D.C.)
• Columbia University, Teachers College, Division of Nursing Education (New York City)
• University of Colorado, School of Nursing, (Boulder Colorado)
• University of Minnesota, School of Nursing, (Minneapolis)
• University of Pittsburgh
• University of Washington (Seattle)
• Washington University (Saint Louis)
• Yale University (New Haven).

(“News About Nursing” 1952, American Journal of Nursing 52 (no. 5): 623-624.)

(Curiously, some sources state that the first graduate psychiatric nursing program was started by Hildegard Peplau in 1954, a puzzling discrepancy.) From 1946 through 1962, legislation continued to be enacted that supported the growth and development of NIMH and by extension the profession of psychiatric nursing as well. Some of the Acts that were passed into law advanced the field of psychiatric nursing by focusing specifically on nursing education.

Of vital importance to the profession of psychiatric nursing also, Hildegard Elizabeth Peplau (1909-1999) wrote her seminal text, Interpersonal Relations in Nursing: A Conceptual Frame of Reference for Psychodynamic Nursing. Though finished in 1948, her book would not find a publisher for four more years because at the time it was “groundbreaking” for a nurse to publish “scholarly work without a co-authoring physician.” Published in 1952, the book strongly influenced psychiatric nursing education for many years and was translated into nine other languages. (Gonzalo 2023, “Hildegard Peplau: Interpersonal Relations Theory,” https://www.nurselabs.com)

Peplau was a tremendous influence in the psychiatric nursing community, persuasively arguing that psychiatric nurses needed to be “further educated to provide truly therapeutic care to patients rather than the custodial care that was prevalent in the mental hospitals of that era” (Gonzalo 2023). Extraordinarily well-educated herself, in 1931 she had received her nursing degree from Pottstown, Pennsylvania School of Nursing and in 1943 a bachelor’s in interpersonal psychology from Bennington College in Vermont. She then studied with famous psychodynamic theorists Erich Fromm, Frieda Fromm-Reichmann, and Harry Stack Sullivan at Chestnut Lodge (a private psychiatric hospital in Maryland). As its title suggests, Peplau’s book was focused on adapting Sullivan’s interpersonal theory for use in nursing practice. Peplau received her master’s and doctoral degrees from Teachers College, Columbia University in 1947.

Another important piece of legislation was The Mental Retardation Facilities and Community Mental Health Centers Act of 1963, Public Law 88-164. It significantly shifted the focus of mental health care from public and private hospitals to community mental health centers. Monies were available for construction of these centers, with support for mental health services for those who could not pay (Clayton 1976, “Chapter 3,” 52-65). This change led the educational curriculum designers to alter some courses, but it affected most significantly the clinical sites where students learned.