as physical illnesses, which often have no monetary
caps. However, this has not yet happened.
Mental health care is managed through privately
owned behavioral health care firms that often provide
the services as well as manage their cost. Persons
without private insurance must rely on their county
of residence to provide funding through tax dollars.
These services and the money to fund them often lag
far behind the need that exists. In addition, many per-
sons with mental illness do not seek care and in fact
avoid treatment. These persons are often homeless or
in jail. Two of the greatest challenges for the future
are to provide effective treatment to all who need it
and to find the resources to pay for this care.
The Health Care Finance Administration (HCFA)
administers two insurance programs: Medicare and
Medicaid. Medicare covers people 65 years and older,
with permanent kidney failure, or with certain dis-
abilities. Medicaid is jointly funded by the federal
and state governments and covers low-income indi-
viduals and families. Medicaid varies depending on
the state, because each state determines eligibility re-
quirements, scope of services, and rate of payment for
services. Medicaid covers people receiving either Sup-
plemental Security Income (SSI) or Social Security
Disability Insurance (SSDI) until they reach 65 years
of age, although people receiving SSDI are not eligible
for 24 months. SSI recipients, however, are eligible
immediately. At 65 years of age, Medicare provides
the insurance. Unfortunately not all people who are
disabled apply for disability benefits, and not all peo-
ple who apply are approved. Thus, many people with
severe and persistent mental illness have no bene-
fits at all.
Another funding issue in mental health involves
spending caps by insurers for mental illness and sub-
stance abuse treatment. Some policies place an an-
nual dollar limitation for treatment, while others
limit the number of days that will be covered annu-
ally or in the insured person’s lifetime (of the policy).
There has been some support for parity (or equality)
of coverage for mental health and substance abuse
treatment. This means that insurers would provide
coverage for mental illness equal to coverage they
provide for medical illness or surgery. As yet, not all
states have passed and enacted legislation to provide
parity of coverage.
Cultural Considerations
The United States Census Bureau (2000) estimates
that 62% of the population has European origins.
This number is expected to continue to decrease as
more U.S. residents trace their ancestry to Africa,
Asia, or the Arab or Hispanic worlds in the future.
Nurses must be prepared to care for this culturally
diverse population, and that includes being aware of
cultural differences that influence mental health and
the treatment of mental illness. See Chapter 7 for a
discussion of cultural differences.
Diversity is not limited to culture; the structure
of families in the United States has changed as well.
With a divorce rate of 50% in the United States, sin-
gle parents head many families, and many blended
families are created when divorced persons remarry.
Twenty-five percent of households consist of a single
person (Wright, 1995), and many people live together
without being married. Gay men and lesbians form
partnerships and sometimes adopt children. The face
of the family in the United States is varied, provid-
ing a challenge to nurses to provide sensitive, com-
petent care.PSYCHIATRIC NURSING PRACTICE
In 1873, Linda Richards graduated from the New
England Hospital for Women and Children in Boston.
She went on to improve nursing care in psychiatric
hospitals and organized educational programs in state
mental hospitals in Illinois. Richards is called the
first American psychiatric nurse; she believed that
“the mentally sick should be at least as well cared for
as the physically sick” (Doona, 1984).
The first training of nurses to work with persons
with mental illness was in 1882 at McLean Hospital
in Waverly, Mass. The care was primarily custodial
and focused on nutrition, hygiene, and activity. Nurses
adapted medical-surgical principles to the care of
clients with psychiatric disorders and treated them
with tolerance and kindness. The role of psychiatric
nurses expanded as somatic therapies for the treat-
ment of mental disorders were developed. Treatments
such as insulin shock therapy (1935), psychosurgery
(1936), and electroconvulsive therapy (1937) required
nurses to use their medical-surgical skills further.
The first psychiatric nursing textbook, Nursing
Mental Diseasesby Harriet Bailey, was published in- In 1913, Johns Hopkins was the first school of
nursing to include a course in psychiatric nursing in
its curriculum. It was not until 1950 that the Na-
tional League for Nursing, which accredits nursing
programs, required schools to include an experience
in psychiatric nursing.
Two early nursing theorists shaped psychiatric
nursing practice: Hildegard Peplau and June Mel-
low. Peplau published Interpersonal Relations in
Nursingin 1952 and Interpersonal Techniques: The
Crux of Psychiatric Nursingin 1962. She described
the therapeutic nurse–client relationship with its
phases and tasks and wrote extensively about anxi-
ety (see Chap. 13). The interpersonal dimension that
was crucial to her beliefs forms the foundations of
1 FOUNDATIONS OFPSYCHIATRIC-MENTALHEALTHNURSING 9