By Kylie Smith, PhD
Post-traumatic Stress Disorder (PTSD) is a complex mental health disorder that affects up to 7% of the population, and as much as 17% of returned service personnel from combat zones. The American Psychiatric Association’s (APA) Diagnostic and Statistical Manual of Mental Disorders (DSM) defines PTSD broadly as a cluster of four distinct symptoms: re-experiencing, negative alterations in cognition and mood, avoidance, and hyperarousal. The DSM also notes that PTSD may or may not be co-morbid with other mental health issues such as anxiety, depression, traumatic brain injury, substance abuse or suicide.
The issue of how to define PTSD has been the subject of recent controversy because of the way the APA has re-categorized some illnesses, and discarded others entirely. Arguments on definitions of mental illness are as old as mental illness itself, but they were bought into sharp focus after World War II with the recognition that ‘combat neurosis,’ as it was then called, and the difficulties experienced by many returned service personnel, were not easily explained away as individual weakness.
With the passage of the 1946 National Mental Health Act and establishment of the National Institute for Mental Health in 1949, the US Government made a commitment to understanding and treating mental illness. The result was a huge influx of federal funding for mental health services and efforts to educate and recruit an army of mental health professionals, including nurses who entered graduate programs for specialized training.
Several prominent nurse leaders emerged during this time. For example, in 1952 noted nursing theorist Hildegard Peplau published her seminal text Interpersonal Relations in Nursing: A Conceptual Frame of Reference for Psychodynamic Nursing. In this text and other works, Peplau argued that mental illness could not be defined as normal or abnormal behavior, but rather, existed along a continuum. All people were susceptible to mental illness, and issues such as stress, anxiety and problems of living needed to be related to the social, cultural and familial contexts in which they occurred. In this conception, Peplau overtly rejected definitions and labelling of mental illness, suggesting that labelling did more harm than good. In 1972, influenced by the critical sociology of Erving Goffman and Thomas Szasz, she wrote: “diagnostic labels, particularly in the absence of known causes, tend in this society to be used as epithets to disparage people with whom one is in disagreement. Unlike other medical diagnoses, such labels are thought to characterize the person…behaviours not in accordance with social norms are called a disease…Diagnostic labels for ‘mental illness’ not only stigmatise and disparage but also suggest a sick-role to be taken” (source: Hildegard E. Peplau papers, Barbara Bates Center for the Study of the History of Nursing).
Peplau actively engaged in the development of mental health nursing in the context of the influx of psychological injury post WWII, and broad social conflict and anxiety as a result of the Cold War and Civil & Women’s rights movements. Given the 1946 National Mental Health Act, many nurses received the necessary financial support to pursue graduate degrees in psychiatric nursing enabling them to provide informed psychiatric care.
Two recent New York Times (NYT) articles engage with the history of debates about categorization of mental illness, highlighting the influence of past policies on contemporary practice. The first, “Redefining mental illness” by T. M. Luhrmann, articulates current discussions taking place within the disciplines of psychiatry and psychology on the biomedical model approach to psychiatric illness. Luhrmann contends that historically American psychiatry privileged treatment models that categorized symptoms into ‘diseases,’ usually with a basis on neurophysiology that relied heavily on pharmacological therapies. He notes challenges to this approach seen in a recent report from the British Psychological Society, which states that there is no clear dividing line between mental health and illness, and that categories, labels and definitions may serve to harm rather than help. In the second NYT article, “After PTSD, More Trauma,” author David J. Morris describes his experience at a VA Hospital with both ‘prolonged exposure’ and ‘cognitive processing’ therapies arguing that there is mixed evidence concerning the efficacy of current treatments, and this impacts the quality of care available to veterans, and others with trauma.
Now more than ever, nurses are consistently exposed to the impact of mental illness in all aspects of patient care and are at the forefront of developing innovative approaches to issues like PTSD. Recently, the American Nurses Association developed the “Have you ever served?” campaign in order to raise awareness of the impact of issues like PTSD on health and to provide nurses with tools for treatment and care (Cipriano, 2013). At the University of Pennsylvania, Associate Professor Nancy Hanrahan in association with the American Nurses Foundation has developed the PTSD Toolkit which provides nurses with information on how to use motivational interviewing techniques to work with patients to seek help and to refer them to appropriate services. These interventions recognise the impact of traumatic events, especially for returned service people, on both physical and mental health outcomes.
Nurses are on the frontlines of every day health care through the move towards community, primary and advanced practice nursing, and nurse-led interventions that recognise the impact of contemporary social and cultural factors on health and wellbeing. Nurses encourage recognition of the role of social and cultural unrest on individual mental health and utilize approaches which emphasise the importance of listening and talking as therapeutic interventions, and motivating patients to take an active role in their own health decision making. Significantly, nurses recognise that given the complexity of PTSD, there is, and may never be, an easy fix.
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