Chapter 2: Historical Issues in Psychiatric Nursing

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Welcome back to the Deep End.

You are listening to the Deep Dive, and we are diving back into our Last Minute Lecture series.

We are.

And today, we are tackling a beast of a topic.

We are looking at Chapter 2 of Psychiatric Nursing, the seventh edition.

The chapter title is Historical Issues.

And I know what you're thinking.

When students see history in a nursing textbook, the first instinct is to just, you know, flip the page.

Get to the good stuff, the drugs, the diagnoses.

Exactly.

But you really, really can't do that here.

This chapter is fundamental.

It is.

And that's our mission for this Deep Dive.

We're going to provide a

really comprehensive summary.

We want to help the nursing students listening and really anyone else fascinated by the mind understand why our mental health system looks the way it does.

Because it's a bit of a mess, let's be honest.

It is.

It's fragmented.

It's confusing.

It is a completely fragmented, complex system.

And the only way to navigate it or, you know, even begin to think about how to fix it is to understand how we got here.

You have to trace the breadcrumbs back.

So to kick things off, we have a quote.

This comes right from the beginning of the chapter.

It's from Cicero.

Marcus Tullius Cicero, a little Roman philosophy to start your nursing lecture.

He said, not to know what happened before you were born.

That is to be always a boy.

Or, you know, to be forever a child.

It's a bit of a gendered quote given the time, but the sentiment is absolutely crucial.

The text actually calls this out.

The Norm's Notes feature in the source material says that if you don't know history, you don't know context.

And context is everything.

It's the whole ballgame.

Right.

And the chapter makes this point so well.

Without history, you walk down the street, you see a homeless person acting strangely, maybe talking to themselves, and you just see the behavior.

You don't see the why.

Exactly.

You just see a tragedy on a sidewalk.

But if you do know the history, you see the direct fallout of the Community Mental Health Centers Act of 1963.

You see deinstitutionalization.

You see failed transinstitutionalization.

You see the legal battles over civil rights that led to this moment.

It changes your entire perspective from judgment to, well, to understanding.

Or another example the text uses.

You turn on the TV, you see all these ads for antidepressants all day, every day.

Why?

Why so many?

A student today might just think, oh, I guess people are just sadder now.

But history tells a different story.

It tells us about the decade of the brain in the 90s, this huge shift toward biological explanations.

It explains the commercial landscape we're living in.

It absolutely does.

So before we jump into the time machine, we have to look at the scope of the problem right now.

Today, the text gives us this epidemiology snapshot in Table 2 -1.

And the numbers are, well, they're staggering.

They really are.

The source cites epidemiologic evidence that says 25 % of American adults meet the criteria for a mental disorder in any given 12 -month period.

One in four.

One in four adults.

Now, you have to be careful with that number.

The text is quick to clarify that many of these are considered mild in nature and a lot of people go untreated.

Okay.

But when you look at lifetime prevalence, that number jumps to 50%.

Half the population at some point in their lives.

Right.

And it's not just about how common they are.

It's about the impact.

The text highlights that four of the top 10 medical disorders causing disability are psychiatric.

So these are conditions that stop people from living their lives.

Completely.

They stop people from working, from parenting, from functioning in society.

What are those big four?

Major depression, schizophrenia, bipolar disorder, and alcohol abuse.

And Table 2 -1 breaks it down even further.

It shows that anxiety disorders are sitting at about 18 .1 % overall prevalence in a year.

Which is huge.

And then you see major depression right behind it, at around 8 .6%.

And the table also points out gender overrepresentation, which is interesting.

For anxiety and depression, it skews female.

It does.

But then you look at substance use disorders, like alcohol and drugs.

And that skews heavily male.

Right.

It really shows how distress can manifest differently across demographics.

But for the really severe stuff, schizophrenia, bipolar,

the gender split is pretty much 50 -50.

So for the students listening to this, the takeaway here isn't just to memorize a percentage for the test.

No, not at all.

It's to understand the job market, frankly.

It's basically a recruitment pitch.

The text says it explicitly.

The pervasiveness of these maladies and the tremendous costs that they incur indicate a great need for psychiatric health care professionals.

The need is massive.

If you're going into nursing, you will be dealing with this.

It doesn't matter if you specialize in it or not.

You can't avoid the mind.

So that's the now.

Let's talk about the then.

The chapter organizes history into these five benchmarks.

But before we get to benchmark on, we have to talk about the pre -Enlightenment era.

The text calls them the bad old days.

And that's putting it mildly.

Oh, yeah.

Before the Enlightenment, we're talking before the 1790s.

The mentally ill weren't really seen as people.

The common view was that they were no better than wild animals.

The source actually mentions that people believed the mentally ill were immune to biological stressors.

Yes, like they couldn't feel cold or hunger.

Which is so bizarre, but it's also a convenient belief.

It's incredibly convenient because it justifies terrible neglect.

If you think a patient can't feel the cold, you don't feel bad about leaving them in an unheated cell in the middle of a London winter.

It's a lie society told itself to avoid feeling guilty.

Absolutely.

And it wasn't just neglect.

It was outright exploitation.

We have to talk about Bedlam.

St.

Mary of Bethlehem Hospital in England, the infamous Bedlam.

We still use that word for chaos.

And for good reason.

It was chaos.

The text notes that until 1770, visitors could pay a small fee to go in and just stare at the patients.

Like a zoo.

It was exactly like a zoo.

It was a form of entertainment.

Families would go on a Sunday outing to look at the mad people.

That is just so grim.

And it wasn't just England.

In France, at the Bisette hospital, the attendants were described as ringmasters.

Ringmasters?

As in a circus?

Yes.

They literally use whips to encourage patients to perform for the public.

They would make them dance or act out for the paying crowd.

It was a closed system.

The text calls them warehouses for the tormented.

They discouraged any outside intrusion.

And the people they hired to work there were, and I'm quoting the text, at the bottom levels of society, both socially and morally.

So you have a vulnerable population being cared for by people who are abusive and unchecked.

A recipe for disaster.

So that sets the stage.

It is dark.

It's abusive.

And then the sun comes up.

We hit benchmark Wern.

The Enlightenment.

This is around the 1790s.

This is the big shift.

The fundamental realization that these people weren't animals.

And this is the crucial part, that they could get better.

And we have two key figures here that students absolutely need to know.

First, let's go to France.

Félix Pinel.

Pinel is really the father of modern psychiatry in many ways.

In 1793, he became the superintendent of Bisette for men, and later the salpetrière for women.

The same place with the ringmasters.

The very same.

And he walked in and was just appalled.

He wrote, they were abandoned to the incompetence of a callous director and to the cold brutality of servants.

So what did he do?

He literally unchained them.

That's the iconic image of Pinel.

He walked into the dungeons, unchained the shackled men and women.

He gave them clothes.

He gave them food.

He abolished the whips.

He brought humanity back into the room.

That must have been seen as incredibly risky.

I mean, these people were considered wild animal.

It was incredibly risky.

The text says the revolutionaries in France thought he was crazy for doing it.

But a funny thing happened.

When you start torturing people, they tend to calm down.

Imagine that.

Revolutionary idea.

Right.

And at the exact same time, across the channel in England, we have William Tuke.

William Tuke.

Now, he wasn't a doctor.

No, he was a Quaker.

And that religious background is very important because his approach was based on Quaker teachings of kindness and humanity.

He established the York Retreat in 1796.

The name retreat is interesting.

It's not a hospital or an asylum.

It was very intentional.

Tuke wanted it to be a quiet haven.

The text quotes him saying it was a place where the shattered bark might find a means of reparation or safety.

The shattered bark.

That's beautiful.

Like a broken ship finding a harbor to repair itself after a storm.

It really is.

And this whole concept leads us to a word that has become so loaded.

Asylum.

Yeah, let's unpack this.

Because today, if I say asylum, you think of a scary movie.

You think of flickering lights and ghosts in a rundown building.

Right.

But the text makes a very point to define it accurately.

Originally, asylum meant sanctuary.

It meant protection and social support.

Like a political refugee seeking asylum.

Exactly.

They're looking for safety from persecution.

That's what Pinel and Tuke were building.

They were building asylums in the truest sense of the word.

They saw that mental illness worsened when people were stressed and abused.

So the treatment was a better environment.

The treatment was the environment.

Provide a sanctuary free from stress and people can start healing.

Now, we have to bring this across the ocean to the United States.

And that brings us to Dorothea Dix.

An absolute powerhouse.

Dorothea Dix, 1802 to 1887.

And again, she wasn't a nurse, wasn't a doctor.

She was a reformer.

The text describes her work as a crusade.

What sparked this crusade?

She witnessed the conditions here in the US.

She went to a jail in Massachusetts to teach a Sunday school class and saw mentally ill people freezing in unheated rooms.

And she didn't just stay home and write letters about it.

No, she got to work.

She traveled all over the country, systematically visiting jails and alms houses.

And the text lists some of the things she saw.

It's pretty graphic.

Yeah.

A woman in a cage,

one idiotic subject chained, one in a closed stall for 17 years.

Losing the use of his limbs from want of exercise.

It was medieval barbarism happening in 19th century America.

So she documented all of this.

She did.

She took these meticulous observations and wrote these scathing documents she called memorials.

She presented them directly to state legislatures.

She shamed them into action.

And it worked.

It worked.

She is directly credited with playing a role in opening 32 state hospitals.

These were meant to be those sanctuaries, places with nutritious food, warm clothing and safety.

So we have this golden age of the asylum, a place of rest and recovery.

But it didn't last.

The text says the period of enlightenment was relatively short -lived.

Sadly, yes.

Within about a hundred years, the sanctuary had devolved back into a warehouse.

How did that happen so quickly?

It was a combination of factors.

The text points to geographic isolation.

These hospitals were built way out in the countryside.

The idea was that it would be peaceful, but it also meant they were cut off from society.

Out of sight, out of mind.

Exactly.

They were totally isolated from public scrutiny and they became these closed systems.

When you have a closed system with no eyes on it, abuse creeps back in.

And the original visionaries weren't there anymore.

Right.

The beneficence of people like Tuke and Pinel wasn't shared by the low -paid, often cruel caretakers who came after them.

And then you had massive overcrowding.

The population grew and these hospitals were just stuffed to the brim.

Right.

So any kind of individualized care just vanished.

It became about containment, not treatment.

The asylum became a place of torment again.

And that failure brings us to the next big shift, benchmark two,

the period of scientific study.

We're moving into the mid to late 1800s now.

And the quote that defines this era is from a historian named George Macari.

He said,

medicine moved from the clinic into the laboratory,

from prognosis and care to diagnosis and cure.

So we stopped just caring for them, just housing them.

And we start trying to figure out what is wrong so we can fix it.

A totally different mindset.

And you can't talk about this era without talking about Sigmund Freud.

Freud.

The text calls him a giant.

It says, if we see far today, it is because we stand on the shoulders of giants.

You absolutely have to know Freud.

Even though, as the text notes, belittling his thinking was popular for a long time.

It was.

And a lot of his theories are not in favor now, but his impact is undeniable.

Before Freud, there was no systematic way to even talk about the mind.

He gave us the vocabulary.

They gave us the vocabulary.

Eye, ego, superego, free association, psychoanalysis.

And the idea of catharsis.

The talking cure.

This revolutionary idea that mental illness could be treated by talking about it, by unlocking the hidden parts of the unconscious mind.

He challenged society to look at human behavior objectively.

He made it something we could study, not just fear or lock away.

But he wasn't the only giant.

We have the scientists to counterpart the analysts.

We need to talk about Emil Kraepelin.

Yes.

Kraepelin is so important for nursing students because he is essentially the grandfather of the DSM.

He was a classifier.

What does that mean?

He looked at symptoms.

He meticulously observed patients and started grouping their symptoms into specific disorders.

He brought medical rigor to it.

And he had a different view on the cause of these illnesses, right?

A completely different view.

Unlike the psychoanalysts who focused on upbringing and psychology, Kraepelin believed brain pathology was the root of illness.

He was looking for the biological cause.

He described dementia precox, what we now call schizophrenia, with incredible accuracy.

But he didn't call it schizophrenia.

No, that was Eugen Bleuler.

He came along a bit later and coined the term schizophrenia, which means split mind.

And the text notes he added a note of optimism to its treatment, suggesting it wasn't always a progressive downhill slide.

So we have the classifiers and we have the analysts.

But here's the thing.

We still don't really have a cure in a bottle.

We can label you.

We can analyze you.

But if you're agitated and hearing voices, we can't actually stop them.

Not yet.

But that's about to change.

Right.

Until benchmark three.

The 1950s, the psychotropic revolution.

This is arguably the biggest game changer in the entire history of psychiatry.

The text lists the big three introductions.

Let's run through them for the students listening.

First, in 1949, you have lithium.

This is the first effective anti -minenic agent.

Finally, something to treat the crushing highs of what we now call bipolar disorder.

A huge deal.

And then in 1950.

Chlorpromazine, also known by the trading thorazine, the first anti -psychotic.

This was massive, just earth shattering.

And then we get imipramine or Tofrenil.

The first modern antidepressant.

So within a few years, you have tools for mania, psychosis and depression.

What was the scene like on the wards when these drugs hit?

Can you paint a picture?

The text describes it vividly.

You have to imagine these state hospital wards.

They were noisy, chaotic, sometimes violent places.

And suddenly,

patients who were agitated, psychotic, screaming, they calmed down.

And the patients who were withdrawn.

Patients who were catatonic or deeply depressed, who hadn't spoken or eaten in weeks.

They regained their feelings.

They started interacting again.

It must have felt like a miracle to the staff who had been working there for years.

It absolutely did.

The noise level on the wards plummeted.

The violence decreased.

And it had a very practical effect.

Hospital stays got shorter.

Because you could stabilize people faster?

Right.

And for the very first time, you could actually imagine treating these patients outside of the hospital.

The drugs made discharge a possibility.

It's interesting.

The text calls them the chemical handcuffs that replaced the physical chains of Pinel's era.

It's a cynical but, in some ways, accurate phrase.

They made management easier.

And they opened the door for discharge.

Which sets the stage perfectly for the next massive shift.

Benchmark 4.

Community mental health.

This is the 1960s.

And it's a perfect storm of different forces all coming together at once.

So the text says the public had lost confidence in the state hospitals.

Why?

What happened?

Well, media played a huge role.

The text mentions a popular movie called The Snake Pit from 1948.

It portrayed the asylum as this mindless, cruel bureaucracy.

So it's in the popular culture.

Right.

And then a very influential book came out called The Shame of the States by Albert Deutsch.

It had photographs of the horrific conditions.

It exposed the reality behind those isolated walls.

So the public is horrified.

They see the filth, the overcrowding, the neglect.

The public is horrified.

Legislators are feeling the pressure.

President Kennedy, whose own sister had a mental illness, becomes a champion for the cause.

And in 1963, we get the Community Mental Health Centers Act.

What was the goal of that act?

What was it supposed to do?

The goal was explicit to destroy the state hospital system.

The vision was to move care from the large, isolated institution to a network of local community centers.

This is what we call deinstitutionalization.

Exactly.

The process of depopulating the state mental hospital.

But the text is very, let's say, cynical or maybe just realistic about the reasons why this happened.

It wasn't all just benevolence.

It wasn't just, let's set them free because it's the right thing to do.

Not at all.

The text lists four converging forces.

One, we just mentioned, the public's distrust of the hospitals.

Two, this new, almost magical faith in drugs like Thorazine.

People thought, hey, we have a pill now.

They don't need to be locked up anymore.

OK, so that's two.

What's number three?

The civil rights movement.

There was a growing legal and legislative climate that emphasized the rights of the mentally ill not to be locked away against their will.

Patient rights became a huge issue.

And the fourth one, follow the money.

Always follow the money.

This is a critical point for understanding the system we have today.

The text explains that a new federal program called Aid to the Disabled, which we now know as SSI or SSDI, was created.

How did that drive deinstitutionalization?

What's the connection?

Well, think about it.

If a patient is in a state hospital who pays for their care.

The state.

The state.

The state pays for the food, the bed, the nurses, everything.

But if that same patient is discharged into the community, they become eligible for federal benefits like SSI.

Oh, I see.

So the states realize, wait a minute, if we discharge these people, they become the federal government's financial problem, not ours.

Bingo.

It was a massive cost shift from state budgets to the federal budget.

The text says the federal share of mental health costs grew by 3 ,100 % between 1963 and 1994.

The states emptied the hospitals to save their own money.

That puts a very, very different spin on the idea of freedom.

It does.

It wasn't just about liberty.

It was about the ledger.

Now, right in the middle of this era, in 1973,

there was a study that the text highlights in a deep dive box, box 2 -1, the Rosenhan study,

on being sane in insane places.

Oh, this is one of the most famous and controversial studies in the history of psychology.

The text says, if you don't get fired up reading this, check your pulse.

And it's right.

Walk us through the setup.

What did he do?

OK, so a psychologist named David Rosenhan wanted to answer a simple question.

Can psychiatrists actually tell the same from the insane in a hospital setting?

So he got eight pseudo patients.

Fake patients.

Fake patients.

These were totally sane people, a grad student, a pediatrician, a psychiatrist, a painter, a housewife, a good mix.

And he sent them to different hospitals.

12 different hospitals across five states.

East Coast, West Coast, public, private.

He wanted a good representative sample.

And what were their instructions?

What did they have to do?

It was simple.

They had to go to admissions and say they were hearing voices.

Just that.

Just that.

And they had to be specific words.

They reported hearing the words empty, hollow, and thud.

Empty, hollow, thud.

Why those particular words?

Because they imply a sort of existential crisis, but they aren't typical command hallucinations telling you to go hurt someone.

They were vague and not obviously psychotic.

And other than that one lie and lying about their names and jobs, they were told to act totally normal.

Totally normal.

They gave their real life histories, their real relationships.

They didn't act crazy at all.

So what happened?

Did the hospitals see through it?

Not a single one.

All eight pseudo patients were admitted immediately.

Most were diagnosed with schizophrenia.

One was diagnosed with manic depressive psychosis.

Wow.

And once they were inside, what did they do?

This is the key part of the experiment.

The moment they passed through the doors, they stopped faking everything.

They acted completely normal.

They told the staff the voices were gone.

They said they felt fine and wanted to be released.

And the staff?

They let them go, right?

No.

They're hospitalized for an average of 19 days.

One was in there for 52 days.

52 days for a sane person who was acting sane?

And here's the kicker.

The professional staff,

the doctors, the nurses, never once detected that they were sane.

But you know who did?

Who?

The other patients.

The real patients knew they were faking.

Yes.

The text says about a third of the real patients voiced suspicions.

They'd say things like, you're not crazy.

You're a journalist checking up on the hospital.

Or you're a professor.

They saw right through it.

But the trained professionals, they were completely blind to it.

So why?

What was Rosenhand's conclusion from all this?

His conclusion was all about the power of labeling.

Once you slap that label of schizophrenic on someone, everything they do from that point forward is seen through that lens.

The text gives an example of this with the note -taking.

It's the perfect example.

The pseudo -patients were obviously taking extensive notes for the study.

The nurses observed this and wrote in their charts.

Patient engages in writing behavior.

They turned a normal activity into a symptom.

Exactly.

They pathologized normal behavior.

The study proved how sticky those labels are and how incredibly hard it is to get out of the system once you've been labeled.

It's easy to get in, very hard to get out.

That is genuinely terrifying.

And it must have poured gasoline on the fire of the anti -asylum movement.

Oh, it was a bombshell.

It reinforced the civil rights argument that we were locking people up too easily and that the so -called experts couldn't even tell who was sick and who wasn't.

So we let everyone out.

Deinstitutionalization happens.

Which brings us to section five.

The consequences.

Yeah, the fallout.

And we have to look at the numbers to really grasp the scale of this.

In 1955, there was one psychiatric hospital bed for every 300 Americans.

By 2010, there was one bed for every 3 ,000 Americans.

That's a 90 % reduction, basically.

The state hospital population dropped by over 85%.

A massive, massive emptying of the hospitals.

Where did they go?

Did they all go to these wonderful community mental health centers that were promised in the 1963 act?

Some did.

But the community centers were never fully funded.

The promise was never met.

So many of them fell into what the text calls transinstitutionalization.

Define that term for us.

It means moving from one institution to another,

specifically from the psychiatric hospital to the prison or jail.

And the text has a shocking statistic about this.

It's one of the most important stats in the chapter.

It says there are 300 % more patients with severe mental illness in our jails and prisons than in our hospitals in the United States.

300 % more.

The text quotes one source that calls the Los Angeles County Jail the largest mental health system in the world.

We essentially criminalize mental illness.

We swap the hospital nurse for the prison guard.

That is just heavy.

And it's not just jails, it's also emergency departments.

Right.

The EDs are, to use the book's word, sagging under the load.

And the text makes the point that the patients today are different than in the 60s.

They're often more aggressive, sometimes armed.

The ED staff is dealing with a level of volatility they were never designed or trained for.

And then there's the other major outcome.

Homelessness.

The text draws a very clear, direct line.

It says 20 to 25 % of the homeless population has a severe mental illness.

And it debunks that old stereotype of the skid row bum.

Yeah, the old idea that these were just older alcoholic men.

Now, the homeless population includes entire families, veterans, people displaced by the economy.

And for the mentally ill, homelessness isn't just about not having a roof.

The text argues it's about a lack of support systems.

The asylum, the sanctuary is gone, and nothing adequate ever replaced it.

This feels like a very grim picture we're painting.

But history keeps moving.

We hit the 1990s.

Benchmark V.

The decade of the brain.

And this was an official declaration, right, from the government?

It was.

George H .W.

Bush signed a presidential proclamation.

The goal was to raise public awareness and, more importantly, funding for brain research.

The 1990s saw this huge boom in MRI technology, neurotransmitter research, genetics.

So it feels like we swung all the way back to Kraepelin's ideas.

We came full circle, back to biologic explanations for mental illness.

How did this impact nursing specifically?

What did this mean for a nursing student in, say, 1995?

It changed everything about their education.

The text notes that nursing textbooks published before 1990 had almost no psychobiology.

If you graduated in the 70s or 80s, you didn't really learn about neurotransmitters.

You learned about Freud and behaviorism.

And now?

Now it's mandatory.

You have to understand the brain chemistry.

You have to know your SSRIs from your SNRIs.

And there was a huge benefit to this shift, which the text points out.

It moved us away from blaming.

Blaming who?

Blaming parents, mostly.

Blaming the patient themselves.

For decades, there were these awful psychoanalytic theories like the schizophrenogenic mother.

The idea that a cold, rejecting mother actually caused schizophrenia in her child.

Which is just horrible for families.

I cause so much unnecessary guilt and pain.

But if schizophrenia is a biological irregularity, a chemical imbalance in the brain, then it's not because your mother was cold to you.

It's biology.

It reduces stigma.

So that brings us pretty much up to the modern era.

Section 7 covers issues in delivery of care.

And it talks about these paradigm shifts.

It really just tracks the pendulum swing that we've been discussing.

We went from the asylum, which focused on severe mental illness, or SMI, to psychoanalysis, which the text argues focused on the worried well.

Wait, define worried well.

That's a really catchy phrase.

It is a fascinating concept that the text brings up.

In the mid -20th century, when psychoanalysis was king,

many professionals, nurses, and doctors kind of drifted away from working with the most severely ill psychotic patients.

Why would they do that?

Because it's easier.

The text is very blunt about it.

It says, it is much easier to counsel a woman going through the crisis of divorce than to attempt to understand the babblings of a person with disorganized schizophrenia.

They gravitated toward patients they could identify with more easily.

Exactly.

People with existential unhappiness.

But the decade of the brain forced the focus back onto the severe biological illnesses.

It was a course correction, reminding the profession that our core mission is to help those who are most disabled by their illness.

The text also talks about the continuum of care.

Box 23 lays this out.

What's the ideal goal here?

The goal is a seamless system.

You want to have a ladder of care that a patient can move up and down on as needed.

So what's at the most restrictive end of that ladder?

The most restrictive is the state hospital, usually involving a legal commitment.

This is for when someone is in acute danger to themselves or others.

Then as you improve, you might step down to a day treatment program, maybe five days a week.

Then maybe one to three days a week.

Then maybe just a scheduled follow -up with a therapist and psychiatrist in the community while you're living at home.

That sounds perfectly logical.

It sounds like how we treat physical injuries.

You go from the ICU to the main hospital floor to a rehab facility and then home with physical therapy.

It is perfectly logical.

The problem is what the text calls bureaucratic dysfunction.

People slip through the cracks between the rungs of that ladder.

Can you give an example?

A classic one is you get discharged from the hospital on a Friday,

but your follow -up appointment with the community clinic isn't for three weeks.

What happens in those three weeks?

You run out of your meds.

You start to decompensate.

You end up back in the ER or worse in jail.

Exactly.

The seamless system is the goal, but it's rarely the reality.

We have what's called the revolving door phenomenon because of these cracks in the system.

Now we have to talk about a tool that every nursing student sees and has to deal with.

The DSM.

The text calls it the Bible of Psychiatry.

The Diagnostic and Statistical Manual.

It is the lingua franca, the common language of mental health.

And it has evolved a lot over the years.

Oh, massively.

The DSMI from 1952 was a little spiral notebook with 106 diagnoses.

A spiral notebook.

A little spiral -bound notebook.

And it was heavily Freudian and talked about reactions to stressors.

Now we have the DSM -5.

And notice they switched to an Arabic numeral.

That's five, not the Roman numeral V.

This was a signal that it was a major rewrite.

It's a massive volume and it's trying to be idiopathophysiological, meaning it's trying to group disorders by their underlying cause in biology.

So why do nurses need to know the DSM?

I mean, we don't diagnose, right?

The doctors and psychologists do.

That's true.

But the text gives two absolutely critical reasons.

One, professional communication.

You have to know what the doctor is talking about.

You need to be able to read the chart and understand the treatment plan.

You have to speak the language.

And the second reason.

Money.

Third -party payers, like insurance companies and Medicare, require a DSM diagnosis for reimbursement.

No code, no cash.

Exactly.

If you don't speak the language of the DSM, you can't document properly and the hospital or clinic can't get paid for the care you provide.

OK, we are in the home stretch now.

Section 8, the history of psychiatric nursing itself.

Students, get your flashcards out.

There are three firsts you really need to memorize.

These are the names that will 100 % be on the test.

First psychiatric nurse.

Who was it?

Linda Richards, back in the 1880s.

She was a graduate of the New England Hospital for Women.

She went on to direct the nursing school at the McLean Asylum.

She is the pioneer who stood up and said, nurses need specific formal training to care for this population.

OK, so Linda Richards is the first nurse.

What's the first textbook?

That was written by Harriet Bailey in 1920.

The book was called Nursing Mental Diseases.

1920 seems kind of late for the first textbook.

It is late.

And here is a fascinating fact from the text to explain why.

Psychiatric nursing wasn't even part of the standard general nursing curriculum until 1937.

Really?

Yeah.

Before that, if you were a psych nurse, you were trained inside the asylum, and you usually stayed inside the asylum for your whole career.

You were almost institutionalized, just like the patients.

You were completely separate from the rest of medicine.

Wow.

OK, so we have the first nurse, the first textbook.

What's the third one?

First theorist.

This is the big one.

Heldegard Pepla.

In the 1950s, her book was called Interpersonal Relations in Nursing.

So what was her focus?

What was her big idea?

The relationship.

She was heavily influenced by another theorist named Harry Stack Sullivan.

She argued that nursing isn't just about doing things to the patient, giving them pills, taking their vitals.

She argued that the interpersonal process between the nurse and the patient is, in itself, therapeutic.

So the nurse is the therapy, in a way.

The nurse is the instrument of healing.

Exactly.

How you talk, how you listen, how you build trust.

That is what helps people get better.

She is arguably the single most important historical figure in psychiatric nursing.

Let's wrap this up.

We have covered a century and a half of history here.

Let's just recap those five benchmarks really fast.

Just the headlines so it sticks.

Great idea.

Benchmark 1.

The Enlightenment in the 1790s.

Pinell and Tuke.

The Asylum is Sanctuary.

Benchmark 2.

The period of scientific study in the late 1800s.

Freud and Kreipelin.

The shift from care to diagnosis and cure.

Benchmark 3.

The psychotropic drugs in the 1950s.

Thorazine.

The chemical handcuffs that open the hospital doors.

Benchmark 4.

Community mental health in the 1960s.

Deinstitutionalization.

The closing of the hospitals.

The rise of homelessness and that crucial money shift to the federal government.

And benchmark 5.

The decade of the brain in the 1990s.

Biology is back and the focus returns to severe mental illness.

That's the roadmap of how we got here.

So leave us with a final provocative thought.

We've looked at all this history.

What does it mean for the student listening right now about to go on their clinical rotation?

I want to go back to that word asylum.

We spent decades, rightly,

destroying the asylum system because we saw it as a prison.

We equated freedom with being out in the community.

Right.

And that's not wrong.

Liberty is important.

It's not wrong at all.

But looking at the transinstitutionalization into prisons, looking at the homeless population, I think we have to ask a really hard question.

Which is?

In our effort to provide freedom, did we remove the sanctuary that some of the most severely ill people desperately need?

The text quotes a writer named Wasso who said,

some people's illnesses are so severe that they will always need asylum.

They will always need that protection.

That is a heavy thought.

That maybe we threw the baby out with the bath water.

It is.

And for you, the student,

you need to understand that you aren't just a pill dispenser.

You are entering a system that is constantly trying and often failing to balance those two powerful things, freedom and safety.

You are a part of a very long story trying to fix a fragmented system.

And with that, we will sign off.

Thanks for listening to this deep dive into chapter two.

Good luck with your studies.

Dig into the history.

It really, truly matters.

This has been a production of the Last Minute Lecture Team.

We'll see you next time.