Contents

Unit 1 Current Theories and Practice

1Foundations of Psychiatric-Mental Health Nursing

Mental Health and Mental Illness 00Diagnostic and Statistical Manual of

Mental Disorders (DSM-IV-TR) 00Historical Perspectives of the Treatment of Mental IllnessMental Illness in the 21st Century 00Psychiatric Nursing Practice 00Self-Awareness Issues

2Neurobiologic Theoriesand Psychopharmacology

The Nervous System and How It WorksBrain Imaging Techniques 00Neurobiologic Causes of Mental IllnessThe Nurse’s Role in Research and Education 00PsychopharmacologyCultural ConsiderationsSelf-Awareness Issues

3Psychosocial Theories and Therapy

Psychosocial TheoriesCultural ConsiderationsTreatment ModalitiesThe Nurse and Psychosocial Interventions 00Self-Awareness Issues

4Treatment Settings and Therapeutic Programs

Treatment Settings 00Psychiatric Rehabilitation Programs 00Special Populations of Clients With Mental Illness 00Interdisciplinary Team 00Psychosocial Nursing in Public Health and Home Care 00Self-Awareness Issues 00

Unit 2 Building the Nurse–Client Relationship

5Therapeutic Relationships

Components of a Therapeutic RelationshipTypes of RelationshipsEstablishing the Therapeutic RelationshipAvoiding Behaviors That Diminish the

Therapeutic RelationshipRoles of the Nurse in a Therapeutic RelationshipSelf-Awareness Issues

6Therapeutic Communication 00

What Is Therapeutic Communication? 00

Verbal Communication Skills00

Nonverbal Communication Skills 00Understanding the Meaning of Communication 00Understanding Context 00

Understanding Spirituality00

Cultural Considerations 00The Therapeutic Communication Session 00Community-Based Care 00Self-Awareness Issues 00

7Client’s Response to Illness 00

Individual Factors 00Interpersonal Factors 00Cultural Factors 00Self-Awareness Issues 00

8Assessment 00

Factors Influencing Assessment 00How to Conduct the Interview 00Content of the Assessment 00Data Analysis 00Self-Awareness Issues 00

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xiv Contents

Unit 3 Current Social and Emotional Concerns

9Legal and Ethical Issues 00

Legal Considerations 00Ethical Issues 00Self-Awareness Issues 00

10Anger, Hostility, and Aggression 00

Onset and Clinical Course 00Related Disorders 00Etiology 00Cultural Considerations 00Treatment 00Application of the Nursing Process 00Community-Based Care 00Self-Awareness Issues 00

11Abuse and Violence 00

Clinical Picture of Abuse and Violence 00Characteristics of Violent Families 00Cultural Considerations 00Spouse or Partner Abuse 00Child Abuse 00Elder Abuse 00Rape and Sexual Assault 00Community Violence 00Psychiatric Disorders Related to Abuse and Violence 00Application of the Nursing Process 00Self-Awareness Issues 00

12Grief and Loss 00

Types of Losses 00The Grieving Process 00Dimensions of Grieving 00Cultural Considerations 00Disenfranchised Grief 00Complicated Grieving 00Application of the Nursing Process 00Self-Awareness Issues 00

Unit 4Nursing Practice for Psychiatric Disorders

13Anxiety and Anxiety Disorders 00

Anxiety as a Response to Stress 00Incidence 00Onset and Clinical Course 00Related Disorders 00Etiology 00Cultural Considerations 00Treatment 00

Community-based Care 00Mental Health Promotion 00Panic Disorder 00Application of the Nursing Process: Panic Disorder 00Phobias 00Obsessive-Compulsive Disorder 00Application of the Nursing Process:

Obsessive-Compulsive Disorder 00

Generalized Anxiety Disorder00

Posttraumatic Stress Disorder 00Acute Stress Disorder 00Self-Awareness Issues 00

14Schizophrenia 00

Clinical Course 00Related Disorders 00Etiology 00Cultural Considerations 00Treatment 00Application of the Nursing Process 00Community-Based Care 00Mental Health Promotion 00Self-Awareness Issues 00

15Mood Disorders and Suicide 00

Categories of Mood Disorders 00Related Disorders 00Etiology 00Cultural Considerations 00Major Depressive Disorder 00Application of the Nursing Process: Depression 00Bipolar Disorder 00Application of the Nursing Process: Bipolar Disorder 00Suicide 00Community-Based Care 00Mental Health Promotion 00Self-Awareness Issues 00

16Personality Disorders 00

Categories of Personality Disorders 00Onset and Clinical Course 00Etiology 00Cultural Considerations 00Treatment 00Paranoid Personality Disorder 00

Schizoid Personality Disorder00

Schizotypal Personality Disorder 00Antisocial Personality Disorder 00Application of the Nursing Process:

Antisocial Personality Disorder 00Borderline Personality Disorder 00Application of the Nursing Process:

Borderline Personality Disorder 00Histrionic Personality Disorder 00Narcissistic Personality Disorder 00Avoidant Personality Disorder 00Dependent Personality Disorder 00

Obsessive-Compulsive Personality Disorder 00Depressive Personality Disorder 00Passive-Aggressive Personality Disorder 00

Community-Based Care 00Mental Health Promotion 00

Self-Awareness Issues00

17Substance Abuse

Types of Substance Abuse 00Onset and Clinical Course 00Related Disorders 00Etiology 00Cultural Considerations 00Types of Substances and Treatment 00Treatment and Prognosis 00Application of the Nursing Process 00Community-Based Care 00Mental Health Promotion 00Substance Abuse in Health Professionals 00

Self-Awareness Issues00

18Eating Disorders

Overview of Eating Disorders 00Etiology 00Cultural Considerations 00Treatment 00Application of the Nursing Process 00Community-Based Care 00Mental Health Promotion 00

Self-Awareness Issues00

19Somatoform Disorders

Overview of Somatoform Disorders 00Onset and Clinical Course 00Related Disorders 00Etiology 00Cultural Considerations 00Treatment 00Application of the Nursing Process 00

Contents xv

Community-Based Care 00Mental Health Promotion 00Self-Awareness Issues 00

2000 Child and Adolescent Disorders 00

Autistic Disorder 00

Rett’s Disorder00

Childhood Disintegrative Disorder 00Asperger’s Disorder 00Attention Deficit Hyperactivity Disorder 00

Application of the Nursing Process: ADHD00

Conduct Disorder00

Application of the Nursing Process: Conduct Disorder 00Community-Based Care 00mental health promotion 00Oppositional Defiant Disorder 00Pica 00Rumination Disorder 00Feeding Disorder 00

00 Tourette’s Disorder 00Chronic Motor or Tic Disorder 00

Separation Anxiety Disorder 00

Selective Mutism00

Reactive Attachment Disorder 00Stereotypic Movement Disorder 00Self-Awareness Issues 00

21Cognitive Disorders 00

Delirium 0000 Application of the Nursing Process: Delirium 00

Community-Based Care 00

Dementia 00Application of the Nursing Process: Dementia 00Community-Based Care 00mental health promotion 00Role of the Caregiver 00Related Disorders 00Self-Awareness Issues 00

Preface

The second edition of Psychiatric Mental Health Nurs-ing continues to have students as the primary focus. It presents sound nursing theory, therapeutic modal-ities, and clinical applications across the treatment continuum. Chapters are short, to the point, and easy to read and

understand. They highlight and empha-size important material to facilitate student learning.

This text uses the nursing process framework and emphasizes assessment, therapeutic communication, neurobiologic theory, and pharmacology throughout. Interventions focus on all aspects of client care, in-cluding communication, client and family teaching, and community resources, and their practical appli-cation in various clinical settings.

Organization of the Text

Unit 1: Current Theories and Practice provides a strong foundation for students. It addresses current issues in psychiatric nursing, as well as the many treatment settings in which nurses encounter clients. It discusses neurobiologic

theories and psychophar-macology and psychosocial theories and therapy thoroughly as a basis for understanding mental illness and its treatment.

Unit 2: Building the Nurse–Client Relationship presents the basic elements essential to the practice of mental health nursing. Chapters on therapeutic relationships and therapeutic communication pre-pare

students to begin working with clients both in mental health settings and in all other areas of nurs-ing practice. The chapter on the client’s response to illness provides a framework for understanding the individual client. An entire chapter is devoted to as-sessment, emphasizing its importance in nursing.

Unit 3: Current Social and Emotional Concerns covers topics that are not exclusive to mental health settings, including legal and ethical issues; anger, aggression, and hostility; abuse and violence; and grief and loss. Nurses in all practice settings find themselves confronted with issues related to these topics. Additionally, many legal and ethical concerns are interwoven with issues of violence and loss.

Unit 4: Nursing Practice for Psychiatric Dis-orders covers all the major categories identified in the DSM-IV-TR. Each chapter provides current informa-tion on etiology, onset and clinical course, treatment, and nursing care.

New Features in the Second Edition

0• A

new chapter on Legal and Ethical Issues ad-dresses some current dilemmas in psychiatric nursing today.

0• Sections on Mental Health Promotion in Units 3 & 4 include the latest research.

0• Additional NCLE

X-style multiple-choice ques-tions are found in the Chapter Study

Guide sections.

0• Updates in pharmacology include new drugs currently being tested and FDA Black Box Warnings for psychotropic medications.

0• Additional artwork illustrates key terms and concepts.

Pedagogical

Features

Psychiatric Mental Health Nursing incorporates several pedagogical features designed to facilitate student learning:

0• Learning Objectives to focus the student’

s read-ing and study

0• Key Terms that identify new terms used in the chapter. Each term is identified in bold and defined in the text.

0• Application of the nursing process using the as-sessment framework presente

d in Chapter 8, so students can compare and contrast the var-ious disorders

more easily

0• Critical thinking questions to stimulate stu-dents’ thinking about current dilemmas and issues in mental health

0• Key points that summarize chapter content to reinforce important concepts

0• Chapter

Study Guides that provide wor

kbook-style questions for students to test their knowl-edge and understanding of each chapter

ix

x PREFACE

Special Features

0• Clinical vignettes are provided for each major disorder discussed in the text to “paint a pic-ture” for better understanding.

0• Drug alerts highlight essential points about psychotropic drugs.

0• Cultural considerations are emphasized in a separate section of each chapter in response to increasing diversity.

0• Therapeutic dialogues give specific examples of nurse–client interaction to promote thera-peutic communication skills.

0• Internet resources with URLs are located at the end of each chapter to further enhance study.

0• Client and family education checklists are highlighted to strengthen students’ roles as educators.

0• Symptoms and interventions are highlighted for all chapters in Units 3 and 4.

0• Sample nursing care plans are provided for all chapters in Units 3 and 4.

0• Self-awareness feature at the end of each chap-ter encourages students to reflect upon them-selves, their emotions, and their attitudes as a way to foster both personal and professional development.

To the Faculty

The following ancillary materials have been pre-pared to help you plan class and clinical learning activities, and evaluate students’ learning:

0• Instructor’s Resource Manual will include a variety of instructional support features for each chapter, including chapter summa-ries, lecture outlines, and teaching–learning

strategies that involve classroom, clinical, and self-awareness activities. In addition, guide-lines are provided for leading class discussion relating to Critical Thinking Questions in-cluded in the textbook. Transparency masters provide summary lists of symptoms, interven-tions, and Client and Patient Teaching check-lists for each of the 12 disorder chapters.

0• CD-ROM, included in the Instructor’s Resource Manual, contains:

0• Testbank containing 350 NCLEX-style test-ing items

0• Lecture outlines for each chapter 0• Powerpoint slide presentation

To the Student

This textbook has been written for you. Above all, it is designed to be “student-friendly.” Chapters are easy to read and understand, and pertinent infor-mation about caring for clients is presented in a practical, hands-on approach. Mental health nurs-ing is an exciting and challenging field, and hope-fully that attitude comes through in this text. The knowledge and skills you develop while studying mental health nursing will promote your growth as a nurse and improve the care you provide to clients in all settings.

In addition to the text itself, we are including a free CD-ROM in the back of the book. This CD contains an interactive Case Study on Anxiety, helpful additional NCLEX review questions, view guides to accompany films depicting common psychiatric disorders, and printable psychotropic drug monographs. Also, for more psychiatric-related materials to enhance your learning, be sure to visit http://connection.lww.com

Sheila L. Videbeck, PhD, RN

Contributor

Chapter 12Charlotte M. Spade, MS, RN, CS

Associate Professor of NursingCommunity College of DenverDenver, Colorado

vii

Reviewers

Linda Barratt, RN, BA, MAInstructorBritish Columbia Institute of TechnologyBurnaby, British Columbia, Canada

Carolyn R. Pierce Buckelew, BSN, MA, APN, RNCS,

NCC, ChPNursing InstructorCE Gregory School of NursingRaritan Bay Medical CenterPerth Amboy, New Jersey

Lucindra Campbell, MSN, APNPAssistant Professor of NursingHouston Baptist UniversityHouston, Texas

Pattie Garrett Clark, RN, MSNAssociate Professor and Nursing Outreach CoordinatorAbraham Baldwin CollegeTifton, Georgia

Carol Cornwell, PhD, MS, RN, CSAssistant

Professor of

Nursing and Director, Center for Nursing Scholarship

Georgia Southern University School of Nursing Statesboro, Georgia

Lesly Curtis, RN, BS, MS, MAAssistant Professor of Clinical NursingDirector, Entry to Practice ProgramColumbia University school of NursingNew York, New York

Pamela Farley, RN, PhDProfessor and ChairpersonBerea CollegeBerea, Kentucky

Suzette Farmer, RN, MSAssistant Professor, Assistant Program DirectorUtah Valley State CollegeOrem, Utah

Cynthia Foust, PhD, RNAssociate ProfessorDivision of NursingSouthwestern Oklahoma State UniversityWeatherford, Oklahoma

Judith A. Gardner, MSN, RN, CNSFull-Time Nursing Faculty and ConsultantStark State College

Canton, Ohio

Alice Grady, MSN, RN, FNPAssistant ProfessorNursing DepartmentTennessee Wesleyan College, Fort SandersKnoxville, Tennessee

Mary Ann Helms, MSN, MRE, RNAssistant ProfessorTennessee State UniversitySchool of NursingNashville, Tennessee

Barbara A. Jones, DNSc, RNAssociate ProfessorSchool of NursingGwynedd-Mercy CollegeGwynedd Valley, Pennsylvania

Nancy G. McAfee, MSN, RNProgram Director, Upward Mobility ProgramLamar State College—OrangeOrange, Texas

v

vi REVIEWERS

Elaine Mordoch, RN, BN, MN Charlotte D. Taylor RN, MSNLecturer, Faculty of Nursing Associate Professor of NursingUniversity of Manitoba University of Arkansas–MonticelloWinnipeg, Manitoba, Canada Monticello, Arkansas

Susan R. Seager, RN, MSN, EdD Arlene Wandel Zawadzki, MS, RN, CS, HNCAssociate Professor, Nursing Part-time InstructorTennessee State University School of Nursing Niagara County Community CollegeNashville, Tennessee Sanborn, New York

Margaret R. Swisher, RN, MSNAssistant Professor of NursingMontgomery County Community CollegeBlue Bell, Pennsylvania

Unit 1Current Theories

and Practice

1Learning ObjectivesAfter reading this chapter, thestudent should be able to

1. Describe characteristics of mental health and mental illness.

2. Discuss the purpose and use of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR).

3. Identify important histori-cal landmarks in psychi-atric care.

4. Discuss current trends in the treatment of people with mental illness.

5. Discuss the American Nurses Association stan-dards of practice for psychiatric-mental health nursing.

6. Describe common student concerns about psychiatric nursing.

Foundations of Psychiatric-Mental Health Nursing

Key Termsasylum mental disorder

case management mental health

deinstitutionalization phenomena of concern

Diagnostic and Statistical psychotropic drugs

Manual of Mental revolving door

Disorders (DSM-IV-TR) self-awareness

managed care standards of care

managed care organizations utilization review firms

2

1 FOUNDATIONS OF PSYCHIATRIC-MENTAL HEALTH NURSING 3

As you begin the study of psychiatric-mental health nursing, you may be excited, uncertain, and even a little anxious. The field of mental health often seems a little unfamiliar or mysterious, making it hard to imagine “What is this experience going to be like?” or “What does a nurse do in this area?” This chapter ad-dresses these and other questions by providing an overview of the history of mental illness, advances in treatment, current issues in mental health, and the role of the psychiatric nurse.

MENTAL HEALTHAND MENTAL ILLNESS

Mental health and mental illness are difficult to de-fine precisely. People who can carry out their roles in society and whose behavior is appropriate and adap-tive are viewed as healthy. Conversely those who fail to fulfill roles and carry out responsibilities or whose behavior is inappropriate are viewed as ill. The cul-ture of any society strongly influences its values and beliefs, and this in turn affects how that society de-fines health and illness. What one society may view as acceptable and appropriate, another society may see as maladaptive or inappropriate.

Mental Health

The World Health Organization (WHO) defines health as a state of complete physical, mental, and social wellness, not merely the absence of disease or infirmity. This definition emphasizes health as a pos-itive state of well-being, not just absence of disease. People in a state of emotional, physical, and social well-being fulfill life

responsibilities, function effec-tively in daily life, and are satisfied with their inter-personal relationships and themselves.

No single, universal definition of mental health exists. Generally a person’s behavior can provide clues to his or her mental health. Because each person can have a different view or interpretation of behavior (depending on his or her values and beliefs), the de-termination of mental health may be difficult. In most cases, mental health is a state of emotional, psycho-logical, and social wellness evidenced by satisfying interpersonal relationships, effective behavior and coping, positive self-concept, and emotional stabil-ity. Mental health has many components, and a wide variety of factors influence it (Mohr, 2003):

0• Autonomy and independence: The person can look within for guiding values and rules by which to live. He or she considers the opinions and wishes of others but does

not allow them to dictate decisions and behavior. The person who is autonomous and independent can work interdependently

or cooperatively with others without losing his or her autonomy.

0• Maximization of one’s potential: The person is oriented toward growth and self-actualization. He or she is not content with the status quo and continually strives to grow as a person.

0• Tolerance of life’s uncertainties: The person can face the challenges of day-to-day living with hope and a positive outlook despite not knowing what lies ahead.

0• Self-esteem: The person has a realistic aware-ness of his or her abilities and limitations.

0• Mastery of the environment: The person can deal with and influence the environment in a capable, competent, and creative manner.

0• Reality orientation: The person can distin-guish the real world from a dream, fact from fantasy, and act accordingly.

0• Stress management: The person can tolerate life stresses, appropriately handle anxiety or grief, and experience failure without devas-

tation. He or she uses support from family and friends to cope with crises, knowing that the stress will not last forever.

These factors constantly interact; thus, a person’s mental health is a dynamic or ever-changing state.

Factors influencing a person’s mental health can be categorized as individual, interpersonal, and so-cial/cultural. Individual factors include a person’s biologic makeup, sense of harmony in life, vitality, ability to find meaning in life, emotional resilience or hardiness, spirituality, and positive identity (Seaward, 1997). Interpersonal factors include effec-tive communication, ability to help others, intimacy, and a balance of separateness and connection. Social/ cultural factors include a sense of community, access to adequate resources, intolerance of violence, and support of diversity among people. Individual, inter-personal, and social/cultural factors are discussed in Chapter 7.

Mental Illness

The American Psychiatric Association (APA, 2000) defines a mental disorder as “a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with present distress (e.g., a painful symptom) or disabil-ity (i.e., impairment in one or more important areas of functioning) or with a significantly increased risk of suffering death, pain, disability, or an important loss

of freedom” (p. xxxi). General criteria to diagnose mental disorders include dissatisfaction with one’s characteristics, abilities, and accomplishments;

in-effective or nonsatisfying relationships; dissatisfac-tion with one’s place in the world; ineffective coping

4 Unit 1 CURRENT THEORIES AND PRACTICE

with life events; and lack of personal growth. In ad-dition, the person’s behavior must not be culturally expected or sanctioned, nor does deviant behavior necessarily indicate a mental disorder (APA, 2000).

Factors contributing to mental illness also can be viewed within individual, interpersonal, and social/ cultural categories. Individual factors include bio-logic makeup, anxiety, worries and fears, a sense of disharmony in life, and a loss of meaning in one’s life (Seaward, 1997). Interpersonal factors include in-effective communication, excessive dependency or withdrawal from relationships, and loss of emotional control. Social and cultural factors include lack of re-sources, violence, homelessness, poverty, and discrim-ination such as racism, classism, ageism, and sexism.

DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS (DSM-IV-TR)

The Diagnostic and Statistical Manual of Men-tal Disorders-Text Revision (DSM-IV-TR), now in its fourth edition, is a taxonomy published by the APA. The DSM-IV-TR describes all mental dis-orders, outlining specific diagnostic criteria for each based on clinical experience and research. All mental health clinicians who diagnose psychiatric disorders use the DSM-IV-TR.

The DSM-IV-TR has three purposes:0• To provide a standardized nomenclature and

language for all mental health professionals 0• To present defining characteristics or symp-

toms that differentiate specific diagnoses 0• To assist in identifying the underlying

causes of disorders A multi-axial classification system that involves

assessment on several axes, or domains of informa-tion, allows the practitioner to identify all the factors that relate to a person’s condition:

0• Axis I is for identifying all major psychiatric disorders except mental retardation and personality disorders. Examples include depression, schizophrenia, anxiety, and substance-related disorders.

0• Axis II is for reporting mental retardation and personality disorders as well as promi-nent maladaptive personality features and defense mechanisms.

0• Axis III is for reporting current medical conditions that are potentially relevant to understanding or managing the person’s mental disorder as well as medical condi-tions that might contribute to understanding the person.

0• Axis IV is for reporting psychosocial and environmental problems that may affect the diagnosis, treatment, and prognosis of men-tal disorders. Included are problems with primary support group, social environment, education, occupation, housing, economics, access to health care, and legal system.

0• Axis V presents a Global Assessment of Functioning (GAF), which rates the person’s overall psychological functioning on a scale of 0 to 100. This represents the clinician’s assessment of the person’s current level of functioning; the clinician also may give a score for prior functioning (for instance, high-est GAF in past year or GAF 6 months ago).

All clients admitted to a hospital for psychi-atric treatment will have a multi-axis diagnosis from the DSM-IV-TR. Although student nurses do not use the DSM-IV-TR to diagnose clients, they will find it a helpful resource to understand the rea-son for the admission and to begin building knowl-edge about the nature of psychiatric illnesses.

HISTORICAL PERSPECTIVES OFTHE TREATMENT OF MENTAL ILLNESS

Ancient Times

People of ancient times believed that any sicknessindicated displeasure of the gods and in fact was pun-

Demons ishment for sins and wrongdoing. Those with mental

1 FOUNDATIONS OF PSYCHIATRIC-MENTAL HEALTH NURSING 5

disorders were viewed as being either divine or de-monic depending on their behavior. Individuals seen as divine were worshipped and adored; those seen as demonic were ostracized, punished, and sometimes burned at the stake. Later Aristotle (382–322 BC) at-tempted to relate mental disorders to physical dis-orders and developed his theory that the amounts of blood, water, and yellow and black bile in the body controlled the emotions. These four substances, or humors, corresponded with happiness, calmness, anger, and sadness. Imbalances of the four humors were believed to cause mental disorders, so treatment aimed at restoring balance through bloodletting, starv-ing, and purging. Such “treatments” persisted well into the 19th century (Baly, 1982).

In early Christian times (1–1000 AD), primitive beliefs and superstitions were strong. All diseases were again blamed on demons, and the mentally ill were viewed as possessed. Priests performed exor-cisms to rid evil spirits. When that failed, they used more severe measures such as incarceration in dun-geons, flogging, starving, and other brutal treatments.

During the Renaissance (1300–1600), people with mental illness were distinguished from criminals in England. Those considered harmless were allowed to wander the countryside or live in rural communities, but the more “dangerous lunatics” were thrown in prison, chained, and starved (Rosenblatt, 1984). In 1547, the Hospital of St. Mary of Bethlehem was of-ficially declared a hospital for the insane, the first of its kind. By 1775, visitors at the institution were charged a fee for the privilege of viewing and ridicul-

ing the inmates, who were seen as animals, less than human (McMillan, 1997). During this same period in the colonies (later the United States), the mentally ill were considered evil or possessed and were pun-ished. Witch hunts were conducted, and offenders were burned at the stake.

Period of Enlightenment andCreation of Mental Institutions

In the 1790s, a period of enlightenment concerning persons with mental illness began. Phillippe Pinel in France and William Tukes in England formulated the concept of asylum as a safe refuge or haven of-fering protection at institutions where people had been whipped, beaten, and starved just because they were mentally ill (Gollaher, 1995). With this move-ment began the moral treatment of the mentally ill. In the United States, Dorothea Dix (1802–1887) began a crusade to reform the treatment of mental illness after a visit to Tukes’ institution in England. She was instrumental in opening 32 state hospitals that offered asylum to the suffering. Dix believed that so-ciety was obligated to those who were mentally ill

and promoted adequate shelter, nutritious food, and warm clothing (Gollaher, 1995).

The period of enlightenment was short-lived. Within 100 years after establishment of the first asy-lum, state hospitals were in trouble. Attendants were accused of abusing the residents, the rural location of hospitals was viewed as isolating patients from fam-ily and their homes, and the phrase “insane asylum” took on a negative connotation.

Sigmund Freud and Treatmentof Mental Disorders

The period of scientific study and treatment of men-tal disorders began with Sigmund Freud (1856–1939) and others such as Emil Kraepelin (1856–1926) and Eugene Bleuler (1857–1939). With these men, the study of psychiatry and the diagnosis and treatment of mental illnesses started in earnest. Freud challenged society to view human beings objectively. He studied the mind, its disorders, and their treatment as no one had before. Many other theorists built on Freud’s pi-oneering work (see Chap. 3). Kraepelin began classi-fying mental disorders according to their symptoms, and Bleuler coined the term “schizophrenia.”

Development ofPsychopharmacology

A great leap in the treatment of mental illness began in about

1950 with the development of psychotropic drugs (drugs used to treat mental illness). Chlor-promazine (Thorazine), an antipsychotic drug, and lithium, an antimanic agent, were the first drugs to be developed. Over the following 10 years, mono-amine oxidase inhibitor antidepressants; haloperidol (Haldol), an antipsychotic; tricyclic antidepressants; and antianxiety agents called benzodiazepines were introduced. For the first time, drugs actually reduced agitation, psychotic thinking, and depression. Hos-pital stays were shortened, and many people were well enough to go home. The level of noise, chaos, and violence greatly diminished in the hospital setting (Trudeau, 1993).

Move Toward CommunityMental Health

The movement toward treating those with mental ill-ness in less restrictive environments gained momen-tum in 1963 with the enactment of the Community Mental Health Centers Act. Deinstitutionalization, a deliberate shift from institutional care in state hos-pitals to community facilities, began. Community men-tal health centers served smaller geographic catch-ment (service) areas that provided less restrictive

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