NSC 401: Mental Health and Psychiatric Nursing.

Study Session 2: Historical Perspective of Mental Health;

Internationally and Nationally.
Introduction
The concept of mental health, given its polysemic nature and its imprecise borders, benefits
from a historical perspective to be better understood. What today is broadly understood by
“mental health” can have its origins tracked back to developments in public health, in clinical
psychiatry and in other branches of knowledge.
In this study session, you will learn the origin of mental health, recent developments in mental
health and the history of psychiatry nursing.

Learning Outcomes for Study Session 2

When you have studied this session, you should be able to;

1.1 Explain the concept of mental health and mental hygiene.

1.2 Describe the origin of mental health.
1.3 Discuss the recent developments in mental health.
1.4 Describe the history of psychiatry nursing, to involve the principles and roles of a
psychiatry nurse.
 NSC 401: Mental Health and Psychiatric Nursing.
2.1 Definitions of Mental health and Mental Hygiene
Although references to mental health as a state can be found in the English language well before
the 20th century, technical references to mental health as a field or discipline are not found
before 1946. During that year, the International Health Conference, held in New York, decided
to establish the World Health Organization (WHO) and a Mental Health Association was
founded in London. Before that date, found are references to the corresponding concept of
“mental hygiene”, which first appeared in the English literature in 1843, in a book entitled
“Mental hygiene or an examination of the intellect and passions designed to illustrate their
influence on health and duration of life”.
Moreover, in 1849, “healthy mental and physical development of the citizen” had already been
included as the first objective of public health in a draft law submitted to the Berlin Society of
Physicians and Surgeons.
In 1948, the WHO was created and in the same year the first International Congress on Mental
Health took place in London. At the second session of the WHO’s Expert Committee on Mental
Health (September 11-16, 1950), “mental health” and “mental hygiene” were defined as
follows:
Box 2.1: Mental health and Mental Hygiene

“Mental hygiene refers to all the activities and techniques which encourage and maintain
mental health.
Mental health is a condition, subject to fluctuations due to biological and social factors, which
enables the individual to achieve a satisfactory synthesis of his own potentially conflicting,
instinctive drives; to form and maintain harmonious relations with others; and to participate in
constructive changes in his social and physical environment.”

However, a clear and widely accepted definition of mental health as a discipline was (and is)
still missing. Significantly, the Dorland’s Medical Dictionary does not carry an entry on mental
health, whereas the Campbell’s Dictionary of Psychiatry gives it two meanings: first, as a
synonym of mental hygiene and second, as a state of psychological wellbeing.
The Oxford English Dictionary defines mental hygiene as a set of measures to preserve mental
health, and later refers to mental health as a state. These lexicographic concepts nonetheless,
more and more mental health is employed in the sense of a discipline (e.g., sections/divisions
 NSC 401: Mental Health and Psychiatric Nursing.
in health ministries or secretaries, or departments in universities), with an almost perfect
replacement of mental hygiene.
In addition, given this polysemic nature of mental health, its delimitation in relation to
psychiatry (understood as the medical specialty concerned with the study, prevention, diagnosis
and treatment of mental disorders or diseases) is not always clear. There is a more or less
widespread effort to set mental health at least aside from psychiatry and at most as an
overarching concept with encompasses psychiatry.

In-Text question 2.1

1. What year was healthy mental and physical development of the citizen” included as the
first objective of public health in a draft law submitted to the Berlin Society of
Physicians and Surgeons?
2. Campbell’s Dictionary of Psychiatry gives mental health two meanings: first, as a
__________and second, as a ______________.

In-Text answer 2.1

1. In 1849, “healthy mental and physical development of the citizen” had

already been included as the first objective of public health in a draft
law submitted to the Berlin Society of Physicians and Surgeons.
2. Synonym of mental hygiene and second, as a state of psychological
wellbeing.

2.2 The Origins of Mental Health

2.2.1 The mental hygiene movement
The origin of the mental hygiene movement can be attributed to the work of Clifford Beers in
the USA. In 1908 he published “A mind that found itself”, a book based on his personal
experience of admissions to three mental hospitals. The book had a great repercussion and in
the same year a Mental Hygiene Society was established in Connecticut.
The term “mental hygiene” had been suggested to Beers by Adolf Meyer and enjoyed a quick
popularity thanks to the creation in 1909 of the National Commission of Mental Hygiene. From
 NSC 401: Mental Health and Psychiatric Nursing.
1919 onwards, the internationalization of activities of this Commission led to the establishment
of some national associations concerned with mental hygiene:
 in France and South Africa in 1920,
 InItaly andHungary in 1924.
From these national associations the International Committee on Mental Hygiene was created
and later superseded by the World Federation of Mental Health.
The mental hygiene movement, in its origins and reflecting Beers’ experience in mental
hospitals, was primarily and basically concerned with the improvement of the care of people
with mental disorders. In Beers’ own words: “When the National Committee was organized,
in 1909, its chief concern was to humanize the care of the insane: to eradicate the abuses,
brutalities and neglect from which the mentally sick have traditionally suffered.”
It was at a later stage that the Committee enlarged its program to include the “milder forms of
mental disability” and a greater concern with preventive work. The rationale behind this shift
was the belief that “mental disorders frequently have their beginnings in childhood and youth
and that preventive measures are most effective in early life”, and that environmental
conditions and modes of living produce mental ill health.
By 1937, the US National Committee for Mental Hygiene stated that it sought to achieve its
purposes by:
a) Promoting early diagnosis and treatment;
b) Developing adequate hospitalization;
c) Stimulating research;
d) Securing public understanding and support of psychiatric and mental hygiene activities;
e) Instructing individuals and groups in the personal application of mental hygiene principles;
and
f) Cooperating with governmental and private agencies whose work touches at any point the
field of mental hygiene.
Thus, the mental hygiene movement had initially a para-psychiatric nature, directing its efforts
towards the improvement of psychiatric care. The inclusion of preventive activities among its
interests did not distinguish it from psychiatry: the movement aimed at maximizing what was
accepted and proposed by the most advanced psychiatrists of the epoch in the USA, most of
whom followed a psychoanalytical orientation.
According to the group which launched it, the mental hygiene movement “visualized, not a
single patient, but a whole community; and it considered each member of that community as
 NSC 401: Mental Health and Psychiatric Nursing.
an individual whose mental and emotional status was determined by definite causative factors
and whose compelling need was for prevention rather than cure. The Mental Hygiene
Movement, then, bears the same relation to psychiatry that the public-health movement, of
which it forms a part, bears to medicine in general. It is an organized community response to a
recognized community need.” On the other hand, it was also stated that: “At the present time
both psychiatrists and mental hygienists are more than ever conscious that their objectives are
in fact identical and that each group needs the other for the fulfilment of their common task.”

2.2.2 The World Health Organization

From its very beginning, the WHO has always had an administrative section specially
dedicated to mental health, as an answer to requests from its Member States. The first Report
of the WHO’s Director General, in its English version, refers to an administrative section called
“Mental Health”. However, the French version of the same report calls it “HygièneMentale”.
Well until the 1960s we find Hygiène as the French translation of health in some WHO
publications and in some instances we find also mental hygiene used interchangeably with
mental health in the English version of some documents.
The volume no. 9 of the WHO’s series Public Health Papers was published in 1961 in English
with the title Teaching of Psychiatry and Mental Health, in 1962 in French with the title
L’enseignement de la Psychiatrie et de l’HygièneMentale and in 1963 in Spanish with the title
Enseñanza de la Psiquiatria y de la Salud Mental.
In the preamble to the WHO Constitutions, it was stated that “health is a state of complete
physical, mental and social wellbeing and not merely the absence of disease or infirmity”, a
now widely quoted definition. This definition is clearly a holistic one, intended to overcome
the old dichotomies of body vs. mind and physical vs. psychic. It is also a pragmatic one,
insofar as it incorporates into medicine a social dimension, gradually developed in Europe
during the 19th century.
It should be noted that mental, in WHO’s definition of health (as well as physical and social)
refers to dimensions of a state and not to a specific domain or discipline. Therefore, according
to this concept, it is incongruous to refer to physical health, mental health or social health.
Should one wish to specify a particular dimension, the most appropriate noun to designate it
should be wellbeing and not health (e.g., mental wellbeing or social wellbeing). This negligent
use of the word health seems to have been also in operation when mental hygiene (a social
 NSC 401: Mental Health and Psychiatric Nursing.
movement, or a domain of activity) was replaced by mental health (originally intended to
designate a state and later transformed in a particular domain or field of activity).

2.2.3 The International Congress of Mental Health

The First International Congress of Mental Health was organized in London by the British
National Association for Mental Hygiene from 16 to 21 August, 1948. Starting as an
International Conference on Mental Hygiene, it ended with a series of recommendations on
mental health. Throughout the proceedings of the conference, hygiene and health, qualifying
mental, are used interchangeably, sometimes in the same paragraph, without any clear
conceptual distinction. However, in the 17 pages of the recommendations of the conference,
hygiene is very sparingly used. At the end of the congress, the International Committee on
Mental Hygiene was superseded by the World Federation for Mental Health.
In addition to the wording employed in the proceedings of that congress, gradually replacing
hygiene by health, some of its recommendations were also influential at other levels. An
example is recommendation 6 to the WHO that “as soon as practicable, an advisory expert
committee be established, composed of professional personnel in the field of mental health and
human relations”.
The conference had been convened under the theme “Mental Health and World Citizenship”.
From a conceptual point of view, nevertheless, and perhaps reflecting an immediately post-war
situation, discussions over world citizenship prevailed over those on mental health. Only one
concept of mental health was put forward, by J.C. Flugel, Chairman of the Conference’s
Programme Committee: “Mental health is regarded as a condition which permits the optimal
development, physical, intellectual and emotional, of the individual, so far as this is compatible
with that of other individuals.” Echoing concerns about the absence, or rather limited number
of, participants from places such as Far East, South America and the Soviet Union, the hope
was expressed that “mental health as understood in Western countries [is not] necessarily at
variance with the sense in which it is understood in other countries”.
In a more detailed way, some delegates elaborated on what was summarized as the “four levels
of mental health work: custodial, therapeutic, preventive and positive”. It is not difficult to see
a considerable overlapping between this proposal and the one already implemented by the
mental hygiene movement.
At the closing session, O.L. Forel, Lecturer in Psychiatry at the University of Geneva,
answering to criticisms that mental hygiene, as understood in that conference, went beyond the
 NSC 401: Mental Health and Psychiatric Nursing.
medical and scientific framework, made a clearly political (in Plato’s sense) statement by
saying that: “I dare hope to be your interpreter in expressing our pride that so many scientists
came here not at all to develop their respective sciences, but to have them at men’s service”.
Reading through the proceedings of this congress gives one a feeling of the tensions between
a pragmatic approach, developed by the mental hygiene movement (basically defended by
delegates from the USA), and a more politically-oriented approach, proposed by other
participants, perhaps translating the experiences of some delegates from European countries,
which had severely suffered from the war. In the end this latter approach prevailed, with the
transformation of the mental hygiene movement into the mental health movement. Perhaps as
a reflection of this basically political movement, in 1949 the National Institute of Mental Health
started its activities in the USA.

In-Text question 2.2

1. National associations concerned with mental hygiene In Italy and Hungary was
established in ___________.
2. In Beers’ own words, what was its chief concern when the National Committee was
organized, in 1909?
3. mental, in WHO’s definition of health (as well as physical and social) refers to
_____________________
4. The First International Congress of Mental Health was organized in London by the
_________________________ from _____________to _________________

In-Text answer 2.2

1. 1924
2. In Beers’ own words: “When the National Committee was organized, in 1909, its chief
concern was to humanize the care of the insane: to eradicate the abuses, brutalities and
neglect from which the mentally sick have traditionally suffered.”
3. Dimensions of a state and not to a specific domain or discipline.
4. British National Association for Mental Hygiene from 16 to 21 August, 1948.
 NSC 401: Mental Health and Psychiatric Nursing.
2.3 Recent Developments in Mental Health.
After half a century of the mental health, and almost a century of the mental hygiene
movements, some developments can be perceived. On a more general level, the WHO’s very
concept of health has been recently questioned; formulated half a century ago, it is no longer
felt by some as much appropriate to the current situation.
On the whole, mental health continues to be used both to designate a state, a dimension of
health – an essential element in the definition of health – and to refer to the movement derived
from the mental hygiene movement, corresponding to the application of psychiatry to groups,
communities and societies, rather than on an individual basis, as is the case with clinical
psychiatry. However, mental health is, quite unfortunately, still viewed by many as a discipline,
either as a synonym of psychiatry, or as one of its complementary fields.
A recent trend has been the addition of the qualifier public to either mental health or to
psychiatry, as it can be seen in a WHO document entitled Public mental health, or in a journal
named PsiquiatríaPública, published in Spain since 1989. This is very much in line with the
concept of mental health as a movement rather than a discipline.
In 2001, the WHO dedicated its annual report (The World Health Report - Mental health: new
knowledge, new hope) to mental health. In that same year, the theme of the World Health Day
was Stop Exclusion – Dare to Care, a quite clear political statement, that I am sure would have
immensely pleased Clifford Beers.
In the message from the WHO Director-General that opens that report, Gro H. Brundtland
summarizes the three main knowledge areas covered by the document:
a) Effectiveness of prevention and treatment,
b) Service planning and provision, and
c) Policies to break down stigma and discrimination and adequate funds for prevention and
treatment.
If one allows for the semantic variations between the beginnings of the 20th and the 21st
centuries, the same concerns of the origins of the mental hygiene movement, discussed earlier
on, can be found in the mental health content of the World Health Report. Perhaps the biggest
difference between these two political platforms is the emphasis on the improvement of
hospital care in the former (the only form of treatment available by then), and the contemporary
emphasis on distancing mental health from psychiatric hospitals and placing it in the
community.
 NSC 401: Mental Health and Psychiatric Nursing.
However, one must admit that, unfortunately, what was high in Beers’ agenda in 1909, namely,
an improvement in the standards of mental health care and an eradication of the abuses to which
people with mental disorders are usually subject, is still a major concern of the most progressive
and advanced agenda of people interested in the promotion of mental health around the world.

In-Text question 2.3

Highlight the three areas covered by the report of WHO director general in its 2001 annual
report?

In-Text answer 2.3

The three main knowledge areas covered by the document:

a) Effectiveness of prevention and treatment,
b) Service planning and provision, and
c) Policies to break down stigma and discrimination and adequate funds for prevention and
treatment.

2.4 History of Psychiatry Nursing

Box 2.2: Psychiatry Nursing

“Psychiatry nursing is a specialty nursing practice focusing on theidentification of mental

health issues, prevention of mental health problems, and the care and treatment of persons
with psychiatric disorders." - The American Psychiatric Nurses Association

 In the 1840s, Florence Nightingale made an attempt to meet the needs of psychiatric
patients with proper hygiene, better food, light and ventilation and the use of drugs to
chemically restrain violent and aggressive patients. (Reddemma K &Nagarajaiah,
2004)
 NSC 401: Mental Health and Psychiatric Nursing.
 Linda Richards, the first psychiatric nurse graduated in the United States in 1882 from
Boston City College.
 In 1913 Johns Hopkins University was the first college of nursing in the United States
to offer psychiatric nursing as part of its general curriculum.
 The first psychiatric nursing textbook, Nursing Mental Diseases wasauthored
by Harriet Bailey, in 1920.
 The registration of psychiatric nurses was done by 1920 in the UK and degree courses
in psychiatric nursing began in the USA.
 Psychiatric nursing was included in the basic nursing curriculum by the International
Council of Nurses in 1961.
 In 1963, President John F. Kennedy in United States passed the Community Mental
Health Act which proposed the deinstitutionalization of mentally ill persons.
 In fourth century AD, during the period of Emperor Ashoka, hospitals with 15 beds for
mentally ill with two male and two female nurses. In1964-65 Psychiatric nursing was
included in curriculum. (Reddemma K &Nagarajaiah, 2004)
 For the first time in India, 11 British nurses along with one matron were brought from
the UK to work in the mental hospital at Ranchi in the 1930s.
 Short training courses of three to six months were conducted in Ranchi in 1921, which
were recognized by the Royal Medical Psychological Association.
 During 1948-50 four nurses were sent to the U.K.by Govt. of India for mental health
nursing diploma.
 From 1943, the Chennai Government organised a three months’ psychiatric nursing
course (subsequently stopped in 1964), for male nursing students at
the Mental Hospital, Chennai (in lieu of midwifery).
 During 1954 Manzil Medical Health centre, Lucknow gave psychiatric nursing
orientation course of 4 - 6weeks duration.
 Govt. of India decided to start training psychiatric nurses during 1953-54 and started
the first organized course at All India Institute of Mental Health (presently NIMHANS).
 In 1964–1965, the Indian Nursing Council (INC) made it a requirement to integrate
psychiatric nursing in the nursing diploma and degree courses.
 In 1967, a separate Psychiatric Nursing Committee was formed in the Trained Nurses
Association of India.
 Diploma in Psychiatric Nursing is conducted in three institutions in India.
 NSC 401: Mental Health and Psychiatric Nursing.
 Master of Psychiatric Nursing (MPN) programme is conducted in many institutions.

2.4.1 Principles of Psychiatric Nursing

 Allow client opportunity to set own pace in working with problems.

 Nursing interventions should center on the client as a person, not on control of the
symptoms. Symptoms are important, but not as important as the person having them.
 Recognize your own feelings toward clients and deal with them.
 Go to the client who needs help the most.
 Do not allow a situation to develop or continue in which a client becomes the focus of
attention in a negative manner.
 If client behavior is bizarre, base your decision to intervene on whether the client is
endangering self or others.
 Ask for help—do not try to be a hero when dealing with a client who is out of control!
 Avoid highly competitive activities that are, having one winner and a room full of
losers.
 Make frequent contact with clients—it lets them know they are worth your time and
effort.
 Remember to assess the physical needs of your client.
 Have patience! Move at the client’s pace and ability.
 Suggesting, requesting, or asking works better than commanding.
 Therapeutic thinking is not thinking about or for, but with the client.
 Be honest so the client can rely on you.
 Make reality interesting enough that the client prefers it to his or her fantasy.
 Compliment, reassure, and model appropriate behavior.

2.4.2 Theories Applied in Psychiatric Nursing

 Psychiatric nursing uses theories of human behavior as its scientific framework and

requires the use of the self as its art or expression in nursing practice.
 Some of the theories applied in psychiatric nursing are
o Hildegard Peplau - Theory of interpersonal relations
o Psychoanalytic theory
o Behaviourism
o Jean Piaget: Theory of Cognitive Stages of Development
o Humanistic Theories - Abraham Maslow, Carl Rogers
 NSC 401: Mental Health and Psychiatric Nursing.
o Existential Theories
o Tidal model by Dr Phil Barker and Poppy Buchanan-Barker

2.4.3 Role of a Psychiatric Nurse

 Providing a safe therapeutic milieu

 Working with patients or clients on the real day-to-day problems they face
 Identifying and caring for the physical aspects of the patient's problems
 Assuming the role of social agent or parent for the patient in various recreational,
occupational, and social situations
 Conducting psychotherapy
 Providing leadership and clinical assistance for other nurses and health care workers.

In-Text question 2.4

1. Psychiatry nursing as defined by the American psychiatry nurses
association is
_________________________________________________________
2. The first psychiatric nursing textbook, Nursing Mental Diseases was
authored by ______________________.
3. Highlight at least three theories applied in psychiatry nursing.

In-Text answer 2.4

1. Psychiatry nursing is a specialty nursing practice focusing on the identification
of mental health issues, prevention of mental health problems, and the care and
treatment of persons with psychiatric disorders
2. The first psychiatric nursing textbook, Nursing Mental Diseases was authored
by Harriet Bailey, in 1920.
3. Some of the theories applied in psychiatric nursing are
 Hildegard Peplau - Theory of interpersonal relations
 Psychoanalytic theory
 Behaviourism
 Jean Piaget: Theory of Cognitive Stages of Development
 NSC 401: Mental Health and Psychiatric Nursing.

Summary of study session 2

In Study Session 2, you have learnt that:

1. What today is broadly understood by “mental health” can have its origins
tracked back to developments in public health, in clinical psychiatry and in other
branches of knowledge.

2. Although references to mental health as a state can be found in the English

language well before the 20th century, technical references to mental health
as a field or discipline are not found before 1946.

3. Moreover, in 1849, “healthy mental and physical development of the citizen”

had already been included as the first objective of public health in a draft law
submitted to the Berlin Society of Physicians and Surgeons.

4. In 1948, the WHO was created and in the same year the first International
Congress on Mental Health took place in London.

5. Mental hygiene refers to all the activities and techniques which encourage
and maintain mental health.

6. Mental health is a condition, subject to fluctuations due to biological and

social factors, which enables the individual to achieve a satisfactory
synthesis of his own potentially conflicting, instinctive drives; to form and
maintain harmonious relations with others; and to participate in constructive
changes in his social and physical environment.

7. The origin of the mental hygiene movement can be attributed to the work of
Clifford Beers in the USA.

8. The mental hygiene movement, in its origins and reflecting Beers’

experience in mental hospitals, was primarily and basically concerned with
the improvement of the care of people with mental disorders.

9. The First International Congress of Mental Health was organized in London

by the British National Association for Mental Hygiene from 16 to 21
August, 1948. Starting as an International Conference on Mental Hygiene, it
ended with a series of recommendations on mental health.
 NSC 401: Mental Health and Psychiatric Nursing.
10. Psychiatry nursing is a specialty nursing practice focusing on
theidentification of mental health issues, prevention of mental health
problems, and the care and treatment of persons with psychiatric disorders.

11. In the 1840s, Florence Nightingale made an attempt to meet the needs of
psychiatric patients with proper hygiene, better food, light and ventilation
and the use of drugs to chemically restrain violent and aggressive patients.
(Reddemma K &Nagarajaiah, 2004)

12. Diploma in Psychiatric Nursing is conducted in three institutions in India.

13. Master of Psychiatric Nursing (MPN) programme is conducted in many

institutions.
 NSC 401: Mental Health and Psychiatric Nursing.
Glossary of terms

1. Mental hygiene refers to all the activities and techniques which encourage
and maintain mental health.

2. Mental health is a condition, subject to fluctuations due to biological and

social factors, which enables the individual to achieve a satisfactory
synthesis of his own potentially conflicting, instinctive drives; to form and
maintain harmonious relations with others; and to participate in constructive
changes in his social and physical environment.

3. Psychiatry nursing is a specialty nursing practice focusing on

theidentification of mental health issues, prevention of mental health
problems, and the care and treatment of persons with psychiatric disorders.

Self-Assessment Questions (SAQs) for Study Session 2

Now that you have completed this study session, you can assess how well you have achieved
its Learning Outcomes by answering these questions. You can check your answers with the
Notes on Self- Assessment Questions at the end of this Module.
 NSC 401: Mental Health and Psychiatric Nursing.
SAQ 2.1 (Tests Learning Outcome 2.1)
1. Describe the concept of mental health and mental hygiene?
SAQ 2.2 (Tests Learning Outcome 2.2)
2. Discuss the mental hygiene movement in the origin of mental health
SAQ 2.3 (Tests Learning Outcome 2.3)
3. What are the recent developments in mental health?
SAQ 2.4 (Tests Learning Outcome 2.4)
4. Describe the principles of psychiatry nursing.
5. Highlight the roles of a psychiatric nurse.