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Contents

UNIT I  Mental Health Care: Past
and Present, 1
1 The History of Mental Health Care, 1
2 Current Mental Health Care Systems, 10
3 Ethical and Legal Issues, 20
4 Sociocultural Issues, 30
5 Theories and Therapies, 39
6 Complementary and Alternative Therapies, 56
7 Psychotherapeutic Drug Therapy, 66
UNIT II  The Caregiver’s Therapeutic
Skills, 79
8 Principles and Skills of Mental Health Care, 79
9 Mental Health Assessment Skills, 92
10 Therapeutic Communication, 102
11 The Therapeutic Relationship, 116
12 The Therapeutic Environment, 127
UNIT III  Mental Health Problems Throughout
the Life Cycle, 138
13 Problems of Childhood, 138
14 Problems of Adolescence, 154
15 Problems of Adulthood, 169
16 Problems of Late Adulthood, 178
17 Cognitive Impairment, Alzheimer’s Disease,
and Dementia, 191
UNIT V  Clients With Psychosocial Problems,
286
25 Anger and Aggression, 286
26 Outward-Focused Emotions: Violence, 298
27 Inward-Focused Emotions: Suicide, 314
28 Substance-Related Disorders, 326
29 Sexual Disorders, 342
30 Personality Disorders, 353
31 Schizophrenia and Other Psychoses, 364
32 Chronic Mental Health Disorders, 380
33 Challenges for the Future, 390
APPENDIXES
A Answers to Review Questions for the
NCLEX-PN® Examination, 402
B Mental Status Assessment at a Glance, 403
C A Simple Assessment of Tardive Dyskinesia
Symptoms, 404
Bibliography, 405
Suggestions for Further Reading, 412
Glossary, 414
Index, 424

UNIT IV  Clients With Psychological

Problems, 203
18 Managing Anxiety, 203
19 Illness and Hospitalization, 217
20 Loss and Grief, 226
21 Depression and Other Mood Disorders, 237
22 Physical Problems, Psychological Sources, 251
23 Eating and Sleeping Disorders, 262
24 Dissociative Disorders, 276
Standards of Practice
for Psychiatric–Mental Health Nursing
STANDARD 1. ASSESSMENT
The psychiatric–mental health registered nurse col-
lects and synthesizes comprehensive health data that
is pertinent to the healthcare consumer’s health and/
or situation.
STANDARD 2. DIAGNOSIS
The psychiatric–mental health registered nurse ana-
lyzes the assessment data to determine diagnoses,
problems, and areas of focus for care and treatment,
including level of risk.
STANDARD 3. OUTCOMES IDENTIFICATION
The psychiatric–mental health registered nurse identi-
fies expected outcomes and the healthcare consumer’s
goals for a plan individualized to the healthcare con-
sumer or to the situation.
STANDARD 4. PLANNING
The psychiatric–mental health registered nurse develops
a plan that prescribes strategies and alternatives to assist
the healthcare consumer in attainment of expected
outcomes.
STANDARD 5. IMPLEMENTATION
The psychiatric–mental health registered nurse imple-
ments the specified plan.
STANDARD 5A. COORDINATION OF CARE
The psychiatric–mental health registered nurse coordi-
nates care delivery.
STANDARD 5B. HEALTH TEACHING AND HEALTH
PROMOTION
The psychiatric–mental health registered nurse employs
strategies to promote health and a safe environment.
STANDARD 5C. CONSULTATION
The psychiatric–mental health registered nurse pro-
vides consultation to influence the identified plan,
enhance the abilities of other clinicians to provide
services for healthcare consumers, and effect change.
STANDARD 5D. PRESCRIPTIVE AUTHORITY
AND TREATMENT
The psychiatric–mental health advanced practice reg-
istered nurse uses prescriptive authority, procedures,
referrals, treatments, and therapies in accordance with
state and federal laws and regulations.
STANDARD 5E. PHARMACOLOGICAL,
BIOLOGICAL, AND INTERGRATIVE THERAPIES
The psychiatric–mental health registered nurse incor-
porates knowledge of pharmacological, biological,
and complementary interventions with applied clini-
cal skills to restore the healthcare consumer’s health
and prevent further disability.
STANDARD 5F. MILIEU THERAPY
The psychiatric–mental health advanced practice reg-
istered nurse provides, structures, and maintains a
safe, therapeutic, recover-oriented environment in col-
laboration with healthcare consumers, families, and
other healthcare clinicians.
STANDARD 5G. PSYCHOTHERAPY
The psychiatric-mental health registered nurse uses
the therapeutic relationship and counseling interven-
tions to assist healthcare consumers in their individual
recovery journeys by improving and regaining their
previous coping abilities, fostering mental health, and
preventing mental disorder and disability.
STANDARD 5H. PSYCHOTHERAPY
The psychiatric–mental health advanced practice reg-
istered nurse conducts individual, couples, group, and
family psychotherapy using evidence-based psycho-
therapeutic frameworks and the nurse-client thera-
peutic relationship.
STANDARD 6. EVALUATION
The psychiatric–mental health registered nurse evalu-
ates progress toward attainment of expected outcomes.
Copyright 2013 by American Nurses Association, American Psychi-
atric Nurses Association, and International Society of Psychiatric–
Mental Health Nurses. Reprinted with permission. All rights
reserved.
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used terms related to mental 
health care.
•  elpful Phrases for Communicating
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2015v1.0
 6
EDITION

Foundations
of Mental
Health Care

Michelle Morrison-Valfre, RN, BSN, MSN, FNP

Health Care Educator/Consultant
Health and Educational Consultants
Forest Grove, Oregon
3251 Riverport Lane
St. Louis, Missouri 63043

FOUNDATIONS OF MENTAL HEALTH CARE, SIXTH EDITION  ISBN: 978-0-323-35492-9

Copyright © 2017 by Elsevier, Inc. All rights reserved.

No part of this publication may be reproduced or transmitted in any form or by any means, electronic
or mechanical, including photocopying, recording, or any information storage and retrieval system,
without permission in writing from the publisher. Details on how to seek permission, further informa-
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the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website:
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This book and the individual contributions contained in it are protected under copyright by the
Publisher (other than as may be noted herein).

Notices

Knowledge and best practice in this field are constantly changing. As new research and experience
broaden our understanding, changes in research methods, professional practices, or medical treat-
ment may become necessary.
Practitioners and researchers must always rely on their own experience and knowledge in
evaluating and using any information, methods, compounds, or experiments described herein. In
using such information or methods they should be mindful of their own safety and the safety of
others, including parties for whom they have a professional responsibility.
With respect to any drug or pharmaceutical products identified, readers are advised to check
the most current information provided (i) on procedures featured or (ii) by the manufacturer of
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To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors,
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Previous editions copyrighted 2013, 2009, 2005, 2001, 1997

International Standard Book Number: 978-0-323-35492-9

Senior Content Strategist: Nancy O’Brien

Content Development Manager: Ellen Wurm-Cutter
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Publishing Services Manager: Julie Eddy
Project Manager: Mike Sheets
Design Direction: Renee Duenow

Printed in Canada

Last digit is the print number: 9 8 7 6 5 4 3 2 1

 To my beloved husband, Adolph;
my cherished friend Marian McCollum;
and to you, dear reader.

May you leave this book richer in the

knowledge of human behavior.
Reviewers

Susan Gale, RN, BSN Tommie W. Pniewski, RN, BSN, MSN, NEA-BC
Assistant Professor of Nursing Professor of Nursing
Moberly Area Community College Kentucky Community and Technical College System
Mexico, Missouri Hopkinsville Community College
Hopkinsville, Kentucky
Carol Healey, DNP, APN
Senior Professor Elizabeth A. Summers, MSN, RN, CNE
Union County College Coordinator of Practical Nursing Program
Plainfield, New Jersey Cass Career Center
Harrisonville, Missouri
Laura Jaroneski, MSN, RN, OCN, CNE
Nursing Educator Nancy Wiseman, MSN RN
Shelby Township, Michigan PN Instructor
Saline County Career Center
Amy McDonald, MSN, RN, CNE Marshall, Missouri
Assistant Professor of Nursing
University of Rio Grande Elizabeth Woodward, RN, BSN
Holzer School of Nursing Eldon, Missouri
Rio Grande, Ohio
Nancee Wozney, PhD, RN
Elizabeth J. McGinnis, MSN, BSN, RN Dean of Nursing and Allied Health/Human Services
Associate Professor of Nursing, PN Program Minnesota State College—Southeast Technical
Coordinator, Ashland CTC Winona, Minnesota
Sigma Theta Tan IHSN
KLN Board of Directors
KCPN Chair
Ashland, Kentucky

vi
To the Instructor
Foundations of Mental Health Care, sixth edition, is in-
tended for students and practitioners of the health care
professions. Basic and advanced learners will find the
information in this text useful and easy to apply in a
variety of practice settings. Students in fields such as
nursing, social work, respiratory therapy, physical
therapy, recreational therapy, occupational therapy,
rehabilitation, and medical assisting will find concise
explanations of adaptive and maladaptive human
behaviors, as well as the most current therapeutic
interventions and treatments.
Practicing health care providers—all who care for
clients in a therapeutic manner—will find this book a
practical and useful guide in any health care setting.
At its core, this text has three main goals:
1. To help soften the social distinction between mental
“health” and mental “illness”
2. To assist all health care providers in comfortably
working with clients who exhibit a wide range of
maladaptive behaviors
3. To apply the concepts of holistic care when assisting
clients in developing more adaptive attitudes and
behaviors
Unit I, Mental Health Care: Past and Present, pro-
vides a framework for understanding mental health
care. The evolution of care for persons with mental
problems from primitive to current times is described.
Selected ethical, legal, social, and cultural issues relat-
ing to mental health care are explored. Community
mental health care is explained, followed by chapters
pertaining to theories of mental illness and comple-
mentary and alternative therapies. A chapter on psy-
chotherapeutic drug therapy ends the unit.
Unit II, The Caregiver’s Therapeutic Skills, focuses
on the skills and conditions necessary for working with
clients. Eight principles of mental health care are
discussed and then applied to the therapeutic environ-
ment, the helping relationship, and effective communi-
cations. Material devoted to self-awareness encourages
readers to develop introspection—a necessary compo-
nent for working with people who have behavioral
difficulties. Readers explore common basic human
needs, personality development, stress, anxiety, crisis,
and coping behaviors. The section concludes with a
description of the basic mental health assessment skills
needed by every health care provider.
The clients for whom we care are the subject of Unit
III, Mental Health Problems Throughout the Life
Cycle, which focuses on the growth of “normal”
(adaptive) mental health behaviors during each devel-
opmental stage. The most common mental health
problems associated with children, adolescents, adults,
and older adults are discussed using the Diagnostic and
Statistical Manual of Mental Disorders (DSM-5) as a
framework. A chapter on dementia and Alzheimer’s
disease discusses the care of clients with cognitive
impairments.
Unit IV, Clients With Psychological Problems, ex-
plores common behavioral responses and therapeutic
interventions for illness, hospitalization, loss, grief,
and depression. Maladaptive behaviors and mental
health disorders are described in chapters on somato-
form, anxiety, eating, sleeping, mood, sexual, and dis-
sociative disorders.
The chapters in Unit V, Clients With Psychosocial
Problems, relate to the important social concerns of
anger (and its expressions), suicide, abuse and neglect,
AIDS, and substance abuse. Sexual and personality
disorders are also discussed. Chapters on schizophre-
nia and chronic mental illness focus on a multidisci-
plinary approach to treatment. The text concludes
with a chapter titled “Challenges for the Future,”
which prepares students for the coming changes in
mental health care.
STANDARD FEATURES
• Several key features are repeated throughout the
text: Objectives stated in specific terms and a list of
Key Terms with pronunciations and page numbers.
• The nursing process is applied to specific mental
health problems throughout the text, with emphasis
on multidisciplinary care. This helps readers under-
stand the interactions of several health care disci-
plines and determine where they fit in the overall
scheme of managed care.
• A continuum of responses describes the range of
behaviors associated with each topic.
• Development throughout the life cycle relates to
the aspect of each personality being studied.
• Clinical disorders include behavioral signs and
symptoms based on the Diagnostic and Statistical
Manual of Mental Disorders (DSM-5).
• Therapeutic interventions include multidisciplinary
treatment, medical management, application of the
nursing process, and pharmacological therapy.
• Each chapter concludes with Key Points that serve
as a useful review of the chapter’s concepts.
vii
viii TO THE INSTRUCTOR
LEARNING AIDS
Because the majority of mental health care takes place
outside the institution, the book emphasizes the impor-
tance of using therapeutic mental health interventions
during every client interaction. The following features
encourage the reader’s understanding and are de-
signed to foster effective learning and comprehension:
• The full-color design stimulates learning and calls
attention to the important terms and concepts
within the text.
• Selected Key Terms with phonetic pronunciations
and a specific page reference to where the term can
be found are listed at the beginning of each chapter,
and each Key Term appears in color at the first or
most detailed mention in the text. Complete defini-
tions are located in the Glossary. Terms with pho-
netic pronunciations were selected because they are
either (1) difficult medical, nursing, or scientific
terms or (2) words that may be difficult for students
to pronounce.
• Throughout the text, cultural aspects of various
mental health principles are explored in Cultural
Considerations boxes to encourage further thought
and discussion.
• Critical Thinking boxes pose questions designed to
stimulate critical thinking.
• Case Studies with thought-provoking questions
encourage readers to consider the psychosocial as-
pects of providing therapeutic care in both commu-
nity and hospital settings.
• Drug Alert boxes prepare readers for the complex-
ity of therapy with psychotherapeutic medications,
including identifying drug interactions and poten-
tially life-threatening side effects.
• Descriptions of each mental health disorder are
drawn from DSM-5 criteria.
• Multidisciplinary Sample Client Care Plans dem-
onstrate the application of the therapeutic (nursing)
process to the care of individuals with various men-
tal health disorders.
• Nursing diagnoses are stated in multidisciplinary
terms within a holistic framework.
• The holistic approach to care offers readers a view of
the “whole person” context of health care delivery.
• Bibliography and Suggestions for Further Reading
sections encourage further exploration of the topics
presented in the chapter. For easy access, the refer-
ences are grouped by chapter at the back of the book.
• The Glossary of Key Terms, written in an easy-to-
understand format, follows the text.
ANCILLARIES
FOR INSTRUCTORS
We recognize that educators today have limited time to
prepare for classroom and clinical activities. Therefore
we provide a rich collection of supplemental resources
for instructors within the Evolve Resources with
TEACH Instructor Resource (TIR), including:
• TEACH Lesson Plans, based on textbook learning
objectives and providing a roadmap to link and in-
tegrate all parts of the educational package. These
straightforward lesson plans can be modified or
combined to meet your unique teaching needs.
• PowerPoint Presentations, including approxi-
mately 600 slides with i-clicker questions and talk-
ing points for instructors.
• ExamView Test Bank, with more than 800
multiple-choice and alternate-format NCLEX®
Examination–style questions. Each question pro-
vides the correct answer, rationale, topic, client
need category, step of the nursing process, objec-
tive, cognitive level, and text page reference.
• Open-Book Quizzes for each chapter in the text-
book, with page references and separate answer
guidelines.
• Answer Key to the Study Guide.
FOR STUDENTS
In the Student Resources section of the Evolve website,
there are more than 330 NCLEX® Examination–Style
Interactive Questions with rationales for both correct
and incorrect responses; an accompanying Study
Guide; an Answer Key to the in-text Review Ques-
tions; an Audio Glossary; and Helpful Phrases for
Communicating in Spanish.
No text is written alone. The continued support of
my husband, Adolph; my friend Marian McCollum;
and other colleagues has provided the energy to
complete this project when my own energy was low.
The guidance, expertise, and encouragement from
my editors Nancy O’Brien, Becky Leenhouts, and
Mike Sheets are much appreciated. I also thank all the
health care providers who so freely share their time
and expertise with those who want to learn more
about the dynamic and complex nature of human
behavior.
Michelle Morrison-Valfre
Threads and Advisory Board

THREADS with limited proficiency in English to develop a

Foundations of Mental Health Care, sixth edition, shares
some features and design elements with Elsevier LPN
titles. The purpose of these “Threads” is to make it
easier for students and instructors to incorporate mul-
tiple books into their fast-paced and demanding
curriculums.
The shared features in Foundations for Mental Health
Care include the following:
• Full-color design, cover, photos, and illustrations
are visually appealing and pedagogically useful.
• Objectives (numbered) begin each chapter, provide
a framework for content, and are important in pro-
viding the structure for the TEACH Lesson Plans
for the textbook.
• Key Terms with phonetic pronunciations and page
number references are listed at the beginning of
each chapter. Key terms appear in color in the chap-
ter and are defined briefly, with full definitions in
the Glossary. The goal is to help the student reader
greater command of the pronunciation of scientific
and nonscientific English terminology.
• A wide variety of special features relate to critical
thinking, clinical practice, cultural considerations,
drug safety, and more. Refer to the To the Student
section of this introduction for descriptions and ex-
amples of features from the pages of this textbook.
• NCLEX Review Questions, presented at the end of
chapters, give students opportunities to practice
critical thinking and clinical decision-making skills.
• Key Points at the end of each chapter correlate to
the objectives and serve as a useful chapter review.
• A full suite of Instructor Resources includes
TEACH Lesson Plans, Lecture Outlines, Power-
Point Slides, Test Bank, Image Collection, and
Open-Book Quizzes.
• In addition to consistent content, design, and sup-
port resources, these textbooks benefit from the
advice and input of the Elsevier Advisory Board.

ADVISORY BOARD Dolores Cotton, MSN, RN Janet M. Kane, RN, MSN

Karin M. Allen, BSN, RN
Coordinator, Practical Nurse Program
Hutchinson Community College
McPherson, Kansas
Tawne D. Blackful, RN, MSN, MEd
Supervisor of Health Services and
School Nurse
Lawrence Hall Youth Services
Chicago, Illinois
Barbara Carrig, BSN, MSN, APN
LPN Nurse Program Coordinator,
Academic/Clinical Instructor
Passaic County Technical Institute
Wayne, New Jersey
Mary-Ann Cosagarea, RN, BSN
Practical Nursing Coordinator
Portage Lakes Career Center,
W. Howard Nicol School
of Practical Nursing
Uniontown, Ohio
Practical Nursing Coordinator
Meridian Technology Center
Stillwater, Oklahoma
Phyllis Del Mastro, RN, MSN
Corporate Director, Nursing
Porter and Chester Institute
Rocky Hill, Connecticut
Laurie F. Fontenot, BSN, RN
Department Head, Health Services
Division
Acadiana Technical College,
C.B. Coreil Campus
Ville Platte, Louisiana
Shelly R. Hovis, RN, MS
Director, Practical Nursing
Kiamichi Technology Centers
Antlers, Oklahoma
Director of Nursing
NewCourtland Education Center
Philadelphia, Pennsylvania
Patty Knecht, MSN, RN
Director of Practical Nursing
Center for Arts and Technology,
Brandywine Campus
Coatesville, Pennsylvania
Joe Leija, MS, RN, DON
Director of Nursing, Vocational
Nursing
RGV Careers
Pharr, Texas
Hana Malik, MSN, FNP-BC
Family Nurse Practitioner
Take Care Health Systems
Villa Park, Illinois

ix
x THREADS AND ADVISORY BOARD

Barb McFall-Ratliff, MSN, RN
Director of Nursing, Program
of Practical Nurse Education
Butler Technology and Career
Development Schools
Hamilton, Ohio
Toni L.E. Pritchard, BSN, MSN, Barbra Robins, BSN, MSN
EdD Program Director
Allied Health Professor, Practical Leads School of Technology
Nursing Program New Castle, Delaware
Central Louisiana Technical College,
Lamar Salter Campus
Leesville, Louisiana
To the Student
READING AND REVIEW TOOLS
Objectives introduce the chapter topics.
Key Terms are listed with page number references, and
difficult medical, nursing, or scientific terms are accom-
panied by simple phonetic pronunciations. Key terms are
considered essential to understanding chapter content
and are defined within the chapter. Key terms are high-
lighted in color in the narrative and are briefly defined in
the text, with complete definitions in the Glossary.
Each chapter ends with a Get Ready for the NCLEX®
Examination! section that includes (1) Key Points that
reiterate the chapter objectives and serve as a useful
review of concepts, (2) Additional Learning Resources,
and (3) Review Questions for the NCLEX® Examina-
tion, with answers located in Appendix A and on
Evolve (with rationales and page references).
Complete Bibliography and Suggestions for Further
Reading sections in the back of the text cite evidence-
based information and provide resources for enhancing
knowledge.
CHAPTER FEATURES
Case Studies contain critical thinking questions
to help you develop problem-solving skills.
Critical Thinking Boxes contain thought-provoking
scenarios and critical thinking questions.
Cultural Considerations address the mental
health needs of culturally diverse clients.
Drug Alert boxes identify the risks and possible
adverse reactions of psychotherapeutic medications.
Sample Client Care Plans are multidisciplinary
and address how members of the health care
team work collaboratively to meet client needs
EVOLVE RESOURCES
Be sure to visit your textbook’s Evolve website (http://
evolve.elsevier.com/Morrison-Valfre/) for a Study
Guide, an Audio Glossary, NCLEX® Examination–
Style Interactive Review Questions, and more!
xi
Contents

UNIT I MENTAL HEALTH CARE: PAST Ethics, 22

AND PRESENT, 1 Ethical Principles, 22
Codes of Ethics, 23
1 The History of Mental Health Care, 1 Ethical Conflict, 23
Early Years, 1 Laws and the Legal System, 23
Primitive Societies, 2 General Concepts, 23
Greece and Rome, 2 Legal Concepts in Health Care, 24
Middle Ages, 2 Laws and Mental Health Care, 25
The Renaissance, 3 Client-Caregiver Relationship, 25
The Reformation, 4 Adult Psychiatric Admissions, 25
Seventeenth Century, 4 Areas of Potential Liability, 26
Eighteenth Century, 4 Care Providers’ Responsibilities, 27
Nineteenth-Century United States, 5 The Reasonable and Prudent Caregiver
Twentieth Century, 5 Principle, 28
Psychoanalysis, 6
Influences of War, 6 4 Sociocultural Issues, 30
Introduction of Psychotherapeutic Drugs, 6 Nature of Culture, 30
Congressional Actions, 7 Characteristics of Culture, 31
Twenty-First Century, 8 Influences of Culture, 31
Health and Illness Beliefs, 32
2 Current Mental Health Care Systems, 10 Cultural Assessment, 34
Mental Health Care in Canada, 10 Communication, 34
Mental Health Care in Norway, 10 Environmental Control, 35
Mental Health Care in Britain, 11 Space, Territory, and Time, 35
Mental Health Care in Australia, 11 Social Organization, 36
Mental Health Care in the United States, 11 Biological Factors, 36
Care Settings, 11 Culture and Mental Health Care, 37
Inpatient Care, 11
Outpatient Care, 12 5 Theories and Therapies, 39
Delivery of Community Mental Health Historical Theories, 39
Services, 12 Darwin’s Theory, 39
Community Care Settings, 12 Psychoanalytic Theories, 40
Multidisciplinary Mental Health Care Team, 15 Other Theories, 42
Care Team, 15 Developmental Theories and Therapies, 43
Client and Family, 16 Cognitive Development, 43
Client Populations, 17 Psychosocial Development, 43
Impact of Mental Illness, 17 Behavioral Theories and Therapies, 44
Incidence of Mental Illness, 17 B. F. Skinner, 45
Economic Issues, 18 Other Behavioral Therapies, 45
Social Issues, 18 Humanistic Theories and Therapies, 45
Perls and Gestalt Therapy, 45
3 Ethical and Legal Issues, 20 Maslow’s Influence, 45
Values and Morals, 20 Rogers’s Client-Centered Therapy, 46
Acquiring Values, 21 Current Humanistic Therapies, 47
Values Clarification, 21 Systems Theories, 47
Rights, 22 Cognitive Theories and Therapies, 47
Client Rights, 22 Cognitive Restructuring Therapies, 47
Care Provider Rights, 22 Coping Skills Therapies, 48

xii

Problem-Solving Therapies, 48
Reality Therapy, 48
Sociocultural Theories, 48
Mental Illness as Myth, 48
Biobehavioral Theories, 49
Homeostasis, 49
Stress Adaptation Theory, 49
Psychobiology, 49
Psychoneuroimmunology, 50
Nursing Theories, 51
Psychotherapies, 52
Individual Therapies, 52
Group Therapies, 52
Online Therapy, 53
Somatic Therapies, 53
Brain Stimulation Therapies, 53
Pharmacotherapy, 53
Future Developments, 53
6 Complementary and Alternative Therapies, 56
Definition of Terms, 56
National Center for Complementary
and Alternative Medicine, 57
Body-Based CAM Therapies, 57
Whole Medical Systems, 57
Biologically Based Practices, 59
Body-Based Practices, 59
Energy-Based CAM Therapies, 60
Mind-Body Medicine, 60
Energy Medicine, 62
Technology-Based CAM Applications, 63
CAM Approaches to Mental Health Care, 63
CAM Mental Health Therapies, 63
Words of Caution, 64
Adverse Effects, 64
Implications for Care Providers, 64
7 Psychotherapeutic Drug Therapy, 66
How Psychotherapeutic Drug Therapy Works, 66
Classifications of Psychotherapeutic Drugs, 68
Antianxiety Medications, 69
Antidepressant Medications, 70
Mood Stabilizer Medications, 71
Antipsychotic (Neuroleptic) Medications, 72
Other Psychotropic Medications, 73
Client Care Guidelines, 74
Assessment, 74
Coordination, 75
Drug Administration, 75
Monitoring and Evaluating, 75
Client Teaching, 76
Special Considerations, 76
Adverse Reactions, 76
Noncompliance, 76
Informed Consent, 77
CONTENTS xiii
UNIT II THE CAREGIVER’S THERAPEUTIC
SKILLS, 79
8 Principles and Skills of Mental Health Care, 79
Principles of Mental Health Care, 79
The Mentally Healthy Adult, 79
Mental Health Care Practice, 80
Do No Harm, 80
Accept Each Client as a Whole Person, 80
Develop Mutual Trust, 81
Explore Behaviors and Emotions, 81
Encourage Responsibility, 82
Encourage Effective Adaptation, 83
Provide Consistency, 85
Skills for Mental Health Care, 86
Self-Awareness, 86
Caring, 86
Insight, 86
Risk Taking and Failure, 87
Acceptance, 87
Boundaries and Overinvolvement, 88
Commitment, 88
Positive Outlook, 89
Nurturing Yourself, 90
Principles and Practices for Caregivers, 90
9 Mental Health Assessment Skills, 92
Mental Health Treatment Plan, 92
DSM-5 Diagnosis, 93
Nursing (Therapeutic) Process, 93
About Assessment, 94
Data Collection, 94
Assessment Process, 95
The Health History, 95
Effective Interviews, 95
Physical Assessment, 96
Mental Status Assessment, 96
General Description, 97
Emotional State, 98
Experiences, 98
Thinking, 98
Sensorium and Cognition, 99
10 Therapeutic Communication, 102
Theories of Communication, 103
Ruesch’s Theory, 103
Transactional Analysis, 103
Neurolinguistic Programming, 103
Characteristics of Communication, 104
Types of Communication, 104
Process of Communication, 104
Factors That Influence Communication, 105
Levels of Communication, 105
Verbal Communication, 105
Nonverbal Communication, 106
Intercultural Communication, 106
Intercultural Differences, 106
xiv CONTENTS
Therapeutic Communication Skills, 107
Listening Skills, 107
Interacting Skills, 109
Nontherapeutic Communication, 109
Barriers to Communication, 109
Nontherapeutic Messages, 111
Problems With Communication, 111
Communicating With Mentally Troubled
Clients, 111
Assessing Communication, 113
11 The Therapeutic Relationship, 116
Dynamics of the Therapeutic Relationship, 116
Trust, 116
Empathy, 117
Autonomy, 117
Caring, 118
Hope, 118
Characteristics of the Therapeutic
Relationship, 119
Acceptance, 119
Rapport, 119
Genuineness, 120
Therapeutic Use of Self, 120
Phases of the Therapeutic Relationship, 120
Preparation Phase, 120
Orientation Phase, 121
Working Phase, 121
Termination Phase, 122
Roles of the Caregiver, 122
Change Agent, 122
Teacher, 122
Technician, 123
Therapist, 123
Problems Encountered in the Therapeutic
Relationship, 123
Environmental Problems, 123
Problems with Care Providers, 123
Problems with Clients, 124
12 The Therapeutic Environment, 127
Use of the Inpatient Setting, 128
Crisis Stabilization, 128
Acute Care and Treatment, 128
The Chronically Mentally Ill Population, 128
Goals of a Therapeutic Environment, 129
Help Clients Meet Needs, 129
Teach Psychosocial (Adaptive) Skills, 129
The Therapeutic Environment and Client
Needs, 129
Physiologic Needs, 130
Safety and Security Needs, 132
Love and Belonging Needs, 132
Self-Esteem Needs, 133
Self-Actualization Needs, 134
Variables of the Therapeutic Environment, 134
Admission and Discharge, 134
Compliance, 134
UNIT III MENTAL HEALTH PROBLEMS
THROUGHOUT THE LIFE
CYCLE, 138
13 Problems of Childhood, 138
Normal Childhood Development, 139
Common Behavioral Problems of
Childhood, 140
Mental Health Problems of Childhood, 141
Environmental Problems, 141
Homelessness, 142
Abuse and Neglect, 143
Problems with Parent-Child Interaction, 143
Parent-Child Conflicts, 143
Emotional Problems, 143
Anxiety, 143
Depression, 144
Somatoform Disorders, 144
Posttraumatic Stress Disorder, 144
Behavioral Problems, 145
Children and Violence, 145
Children and Electronic Media, 145
Attention-Deficit/Hyperactivity Disorder, 145
Disruptive Behavioral (Conduct) Disorder, 146
Problems with Eating and Elimination, 147
Eating Disorders, 147
Elimination Disorders, 148
Developmental Problems, 148
Mental Retardation, 148
Learning Disorders, 149
Communication Disorders, 149
Pervasive Developmental Disorders, 149
Autism, 150
Schizophrenia, 150
Therapeutic Actions, 150
Meet Basic Needs, 151
Provide Opportunities, 151
Encourage Self-Care and Independence, 151
14 Problems of Adolescence, 154
Adolescent Growth and Development, 154
Physical Development, 154
Psychosocial Development, 155
Common Problems of Adolescence, 157
Internal (Developmental) Problems, 157
External (Environmental) Problems, 157
Teens and Electronic Media, 159
Mental Health Problems of Adolescence, 159
Behavioral Disorders, 159
Emotional Disorders, 161
Eating Disorders, 161
Chemical Dependency, 163
Personality Disorders, 164
Sexual Disorders, 164
Psychosis, 164
Suicide, 165
Therapeutic Interventions, 165
Surveillance and Limit Setting, 166

Building Self-Esteem, 167
Skill Development, 167
15 Problems of Adulthood, 169
Adult Growth and Development, 169
Common Problems of Adulthood, 171
Internal (Developmental) Problems, 171
External (Environmental) Problems, 173
Mental Health Problems of Adults, 175
Therapeutic Interventions, 175
Health Care Interventions, 175
Preventing Mental Illness, 175
16 Problems of Late Adulthood, 178
Overview of Aging, 178
Facts and Myths of Aging, 178
Physical Health Changes, 180
Mental Health Changes, 180
Research and Aging, 181
Common Problems of Older Adults, 181
Physical Adaptations, 181
Psychosocial Adaptations, 183
Mental Health Problems of Older Adults, 185
Elder Abuse, 185
Depression, 186
Therapeutic Interventions, 187
Standards of Geriatric Care, 187
Age-Related Interventions, 187
Mentally Ill Older Adults, 188
Mental Health Promotion and Prevention, 188
17 Cognitive Impairment, Alzheimer’s Disease,
and Dementia, 191
Confusion Has Many Faces, 191
Normal Changes in Cognition, 191
The Five “Ds” of Confusion, 191
Medications and the Elderly Population, 192
Clients With Delirium, 192
Finding the Cause, 193
Treating Delirium, 193
Causes of Dementia, 194
Symptoms of Dementia, 194
Alzheimer’s Disease, 195
Symptoms and Course, 195
After the Diagnosis, 196
Principles of Management, 197
Therapeutic Interventions, 197
Assessment, 198
Interventions With Alzheimer’s Disease, 198
Caregiver Support, 201
UNIT IV CLIENTS WITH PSYCHOLOGICAL
PROBLEMS, 203
18 Managing Anxiety, 203
Continuum of Anxiety Responses, 203
Types of Anxiety, 203
CONTENTS xv
Types of Anxiety Responses, 204
Coping Methods, 205
Defense Mechanisms, 205
Crisis, 206
Self-Awareness and Anxiety, 206
Theories Relating to Anxiety, 207
Biological Models, 207
Psychodynamic Model, 207
Interpersonal Model, 207
Behavioral Model, 207
Other Models, 207
Anxiety Throughout the Life Cycle, 208
Anxiety in Childhood, 208
Anxiety in Adolescence, 208
Anxiety in Adulthood, 209
Anxiety in Older Adulthood, 209
Anxiety Disorders, 209
Separation Anxiety Disorder, 209
Generalized Anxiety Disorder, 209
Panic Disorders, 210
Agoraphobia, 210
Phobic Disorders, 210
Selective Mutism, 211
Obsessive Compulsive Disorder, 211
Body Dysmorphic Disorder, 211
Hoarding Disorder, 212
Hair-Pulling Disorder (Trichotillomania), 212
Excoriation Disorder (Skin Picking), 212
Behavioral Addictions, 212
Stressor and Trauma Disorders, 212
Traumatic Stress Reaction, 212
Acute Stress Disorder, 213
Adjustment Disorder, 213
Posttraumatic Stress Disorder, 213
Therapeutic Interventions, 213
19 Illness and Hospitalization, 217
The Nature of Illness, 218
Stages of the Illness Experience, 218
Effects of Illness, 219
The Hospitalization Experience, 220
Situational Crisis, 220
Psychiatric Hospitalization, 221
Therapeutic Interventions, 221
Psychosocial Care, 222
Discharge Planning, 224
20 Loss and Grief, 226
The Nature of Loss, 226
Characteristics of Loss, 226
Loss Behaviors Throughout the Life
Cycle, 227
The Nature of Grief and Mourning, 228
The Grieving Process, 228
Stages of the Grieving Process, 228
The Dying Process, 230
Age Differences and Dying, 230
Terminal Illness, 230
xvi CONTENTS
Cultural Factors, Dying, and Mourning, 231
Stages of Dying, 231
Therapeutic Interventions, 232
Hospice Care, 233
Meeting the Needs of Dying Clients, 233
Loss, Grief, and Mental Health, 235
21 Depression and Other Mood Disorders, 237
Continuum of Emotional Responses, 237
Theories Relating to Emotions and Their
Disorders, 238
Biological Evidence, 238
Other Theories, 238
Emotions Throughout the Life Cycle, 238
Emotions in Childhood, 238
Emotions in Adolescence, 239
Emotions in Adulthood, 239
Emotions in Older Adulthood, 240
Characteristics of Mood Disorders, 240
Mood Disorders, 240
Major Depressive Episode, 241
Major Depressive Disorder, 241
Dysthymia (Persistent Depressive Disorder), 242
Premenstrual Dysphoric Disorder, 242
Bipolar Disorders, 242
Cyclothymic Disorder, 243
Other Problems With Affect, 243
Medical Problems and Mood Disorders, 244
Therapeutic Interventions, 244
Treatment and Therapy, 244
Drug Therapies, 245
Nursing (Therapeutic) Process, 248
22 Physical Problems, Psychological Sources, 251
Role of Emotions in Health, 251
Anxiety and Stress, 252
Childhood Sources, 252
Common Psychophysical Problems, 253
Theories of Psychophysical Disorders, 253
Somatic Symptom Disorders, 254
Cultural Influences, 254
Criteria for Diagnosis, 255
Somatic Symptom Disorder, 255
Illness Anxiety Disorder, 257
Conversion Disorder, 257
Factitious Disorders and Malingering, 258
Clinical Presentations, 258
Implications for Care Providers, 259
23 Eating and Sleeping Disorders, 262
Eating Disorders, 263
Anorexia Nervosa, 264
Bulimia, 265
Obesity, 267
Other Eating Disorders, 268
Guidelines for Intervention, 269
Sleep-Wake Disorders, 270
Dyssomnias, 271
Parasomnias, 273
Other Sleep Disorders, 273
Guidelines for Intervention, 273
24 Dissociative Disorders, 276
Continuum of Self-Concept Responses, 276
The Healthy Personality, 276
Self-Concept Throughout the Life Cycle, 277
Self-Concept in Childhood, 277
Self-Concept in Adolescence, 277
Self-Concept in Adulthood, 277
Self-Concept in Older Adulthood, 278
Dissociative Disorders, 278
Characteristics, 278
Depersonalization/Derealization Disorder, 279
Dissociative Amnesia, 280
Dissociative Trance Disorder, 281
Dissociative Identity Disorder, 281
Therapeutic Interventions, 282
Treatments and Therapies, 282
UNIT V CLIENTS WITH PSYCHOSOCIAL
PROBLEMS, 286
25 Anger and Aggression, 286
Anger and Aggression in Society, 287
Gender Aggression, 288
Aggression Throughout the Life Cycle, 288
Scope of the Problem Today, 289
Theories of Anger and Aggression, 289
Biological Theories, 289
Psychosocial Theories, 289
Sociocultural Theories, 289
The Cycle of Assault, 290
Trigger Stage, 290
Escalation Stage, 290
Crisis Stage, 290
Recovery Stage, 291
Depression Stage, 291
Anger-Control Disorders, 291
Aggressive Behavioral Disorders of Childhood,
291
Impulse-Control Disorders, 291
Adjustment Disorders, 292
Guidelines for Intervention, 292
Assessing Anger and Aggression, 292
Therapeutic Interventions, 293
26 Outward-Focused Emotions: Violence, 298
Social Factors and Violence, 298
Theories of Violence, 299
Abuse, Neglect, and Exploitation Within the
Family, 300
Domestic Violence, 300
Gender Abuse, 301
Abuse During Pregnancy, 301
Child Abuse, 301

Adolescent Abuse, 304
Elder Abuse, 305
Sexual Abuse, 305
Abuse, Neglect, and Exploitation Within the
Community, 306
Violence, Trauma, and Crime, 306
Group Abuse, 306
Mental Health Disorders Relating to Violence, 307
Posttraumatic Stress Disorder, 307
Rape-Trauma Syndrome, 308
Therapeutic Interventions, 308
Special Assessments, 308
Treating Victims of Violence, 308
Preventing Violence in Your Life, 311
27 Inward-Focused Emotions: Suicide, 314
Continuum of Behavioral Responses, 314
Myths About Suicide, 315
Impact of Suicide on Society, 315
Cultural Factors, 316
Social Factors, 316
Dynamics of Suicide, 317
Characteristics of Suicide, 317
Categories of Motivation, 318
Theories About Suicide, 318
New Biological Evidence, 319
Effects of Suicide on Others, 319
Suicide Throughout the Life Cycle, 319
Suicide and Children, 319
Suicide and Adolescents, 320
Suicide and Adults, 321
Suicide and Older Adults, 321
Therapeutic Interventions, 321
Assessment of Suicidal Potential, 322
Therapeutic Interventions for Suicidal Clients,
323
28 Substance-Related Disorders, 326
Vocabulary of Terms, 327
Role of Chemicals in Society, 327
Substance Use and Age, 327
Scope of the Problem Today, 329
Categories of Abused Substances, 329
Chemicals of Abuse, 329
Other/Medications, 334
Characteristics of Substance Use and Abuse, 335
Stages of Addiction, 335
Criteria for Diagnosis, 336
Clinical Presentation, 336
Guidelines for Intervention, 336
Assessment, 337
Treatments and Therapies, 337
Relapse, 339
Nursing/Therapeutic Process, 339
29 Sexual Disorders, 342
Continuum of Sexual Responses, 343
Self-Awareness and Sexuality, 343
CONTENTS xvii
Sexuality Throughout the Life Cycle, 344
Sexuality in Childhood, 344
Sexuality in Adolescence, 344
Sexuality in Adulthood, 344
Sexuality in Older Adulthood, 345
Sexuality and Disability, 345
Modes of Sexual Expression, 345
Bisexuality, 345
Heterosexuality, 345
Homosexuality, 346
Transgenders, 347
Transvestism, 347
Theories Relating to Psychosexual Variations, 347
Psychosexual Disorders, 348
Sexual Dysfunctions, 348
Gender Dysphoria, 348
Paraphilias, 349
Sexual Addiction, 349
Therapeutic Interventions, 350
Psychosexual Assessment, 350
Nursing/Therapeutic Process, 350
30 Personality Disorders, 353
Continuum of Social Responses, 353
Personality Throughout the Life Cycle, 354
Personality in Childhood, 354
Personality in Adolescence, 354
Personality in Adulthood, 354
Personality in Older Adulthood, 355
Theories Relating to Personality Disorders, 355
Biological Theories, 355
Psychoanalytical Theories, 355
Behavioral Theories, 355
Sociocultural Theories, 356
Personality Disorders, 356
Eccentric Cluster, 356
Erratic Cluster, 358
Fearful Cluster, 359
Dual Diagnosis, 360
Therapeutic Interventions, 360
Treatment and Therapy, 360
Nursing (Therapeutic) Process, 362
31 Schizophrenia and Other Psychoses, 364
Continuum of Neurobiological Responses, 364
Psychoses Throughout the Life Cycle, 365
Psychoses in Childhood, 365
Psychoses in Adolescence, 366
Psychoses in Adulthood, 366
Psychoses in Older Adulthood, 366
Theories Relating to Psychoses, 367
Biological Theories, 367
Other Theories, 368
Psychotic Disorders, 368
Schizophrenia, 368
Other Psychoses, 371
Therapeutic Interventions, 372
Treatments and Therapies, 372
xviii CONTENTS
Nursing (Therapeutic) Process, 372
Special Considerations, 373
32 Chronic Mental Health Disorders, 380
Scope of Mental Illness, 380
Public Policy and Mental Health, 381
Effects of Deinstitutionalization, 381
Experience of Chronic Mental Illness, 381
Meeting Basic Needs, 382
Access to Health Care, 382
Characteristics of Chronic Mental Illness, 383
Behavioral Characteristics, 383
Physical Characteristics, 383
Psychological Characteristics, 384
Special Populations, 384
Children and Adolescents with Chronic Mental
Illness, 384
Older Adults With Chronic Mental Illness, 385
Persons With Multiple Disorders, 385
Providing Care for Chronically Mentally Ill
People, 385
Inpatient Settings, 385
Outpatient Settings, 386
Psychiatric Rehabilitation, 386
Therapeutic Interventions, 386
Treatments and Therapies, 387
Nursing (Therapeutic) Process, 387
33 Challenges for the Future, 390
Changes in Mental Health Care, 390
Change in Settings, 391
Homelessness, 391
Drug Use and Abuse, 392
The Americans With Disabilities Act, 392
Cultural Influences, 393
The Mental Health Care Team, 393
Team Members, 394
Mental Health Care Delivery Settings, 394
Change and Mental Health Clients, 394
Competency, 394
Empowerment of Clients, 395
Obligations of Clients, 395
Obligations of Care Providers, 395
Providers of Care, 396
Expanded Role for Nurses, 396
Managing Change, 397
The Change Process, 398
Other Challenges, 398
Challenges to Society, 399
Information Overload, 399
The Challenge to Care, 399
A Look to the Future, 399
Appendix
A Answers to Review Questions for the
NCLEX® Examination, 402
B Mental Status Assessment at a Glance, 403
C A Simple Assessment of Tardive Dyskinesia
Symptoms, 404
Bibliography, 405
Suggestions for Further Reading, 412
Glossary, 414
Index, 424
Unit I Mental Health Care: Past and Present
The History of Mental Health Care
Objectives
Upon completion of this chapter, the student will be able to:
1. Develop working definitions of mental health and mental
illness.
2. List three major factors believed to influence the
development of mental illness.
3. Describe the role of the Church in the care of the mentally
ill during the Middle Ages.
4. Compare the major contributions made by Philippe Pinel,
Dorothea Dix, and Clifford Beers to the care of persons
with mental disorders.
5. Discuss the effect of World Wars I and II on American
attitudes toward people with mental illnesses.
Key Terms
catchment (KĂCH-mĭnt) area (p. 7)
deinstitutionalization (dē-ĭn-stĭ-TOO-shәn-lĭ-ZĀ-shәn) (p. 6)
demonic exorcisms (dē-MŎN-ĭk ĔK-sŏr-sĭs-әms) (p. 2)
electroconvulsive therapy (ē-lĕk-trō-kŏn-VŬL-sĭv THĔR-ә-pē)
(ECT) (p. 6)
health-illness continuum (cŭn-TĬN-ū-әm) (p. 1)
humoral (HŪ-mŏr-ăl) theory of disease (p. 2)
Mental/emotional health is interwoven with physical
health. Behaviors relating to health exist over a broad
spectrum, often referred to as the health-illness con-
tinuum (Fig. 1.1). People who are exceptionally healthy
are placed at the high-level wellness end of the con-
tinuum. Severely ill individuals fall at the continuum’s
opposite end. Most of us, however, function some-
where between these two extremes. As we meet with
the stresses of life, our abilities to cope are repeatedly
challenged, and we strive to adjust in effective ways.
When stress is physical, the body calls forth its defense
systems and wards off illness. When stress is emo-
tional or developmental, we respond by creating new
(and hopefully effective) behaviors.
Mental health is the ability to “cope with and adjust
to the recurrent stresses of living in an acceptable
way” (Anderson, Anderson, and Glanze, 2002). Men-
tally healthy people successfully carry out the activi-
ties of daily living, adapt to change, solve problems,
set goals, and enjoy life. They are self-aware, directed,
chapter
1
http://evolve.elsevier.com/Morrison-Valfre
6. State the major change in the care of people with mental
illnesses that resulted from the discovery of
psychotherapeutic drugs.
7. Describe the development of community mental health
care centers during the 1960s and 1970s.
8. Discuss the shift of mentally ill clients from institutional
care to community-based care.
9. Evaluate how congressional actions have affected mental
health care in the United States.
lobotomy (lŏ-BŎT-ә-mē) (p. 6)
lunacy (LOO-nә-sē) (p. 3)
mental health (MĒN-tăl) (p. 1)
mental illness (disorder) (DĬS-ŏr-dĕr) (p. 1)
psychoanalysis (sī-kō-ă-NĂL-Ĭ-sĭs) (p. 6)
psychotherapeutic (SĪ-kō-THĔR-ә-PŪ-tĭk) drugs (p. 6)
trephining (tre-PHIN-ing) (p. 2)
and responsible for their actions. Mentally healthy
people are able to cope well.
Mental health is influenced by three factors: inher-
ited characteristics, childhood nurturing, and life cir-
cumstances. The risk for developing ineffective coping
behaviors increases when problems exist in any one of
these areas. If behaviors interfere with daily activi-
ties, impair judgment, or alter reality, an individual is
said to be mentally ill. Simply, a mental illness (disor-
der) is a disturbance in one’s ability to cope effectively.
There is a rich history with examples of changing at-
titudes toward people with mental health problems.
EARLY YEARS
Illness, injury, and insanity have concerned humanity
throughout history. Physical illness and injury were
easy to detect with the senses. Mental illness (insanity)
was something different—something that could not be
seen or felt—and therefore a condition to be feared.
1
2 UNIT I Mental Health Care: Past and Present
HEALTH-ILLNESS CONTINUUM
Severe Illness High-Level Wellness
Risk factors to
functioning in all
dimensions
FIGURE 1-1 ​The health-illness continuum, ranging from high-level
wellness to severe illness, provides a method of identifying a client’s
level of health.
PRIMITIVE SOCIETIES
Although the historical record is vague, it can be as-
sumed that some care was given to sick people. Early
societies believed that everything in nature was alive
with spirits. Illness was thought to be caused by the
wrath of evil spirits. Therefore, people with mental ill-
nesses were thought to be possessed by demons or the
forces of evil.
Treatments for mental illness focused on remov-
ing the evil spirits. Magical therapies made use of
“frightening masks and noises, incantations, vile
odors, charms, spells, sacrifices, and fetishes” (Kelly,
1991). Physical treatments included bleeding, mas-
sage, blistering, inducing vomiting, and the practice
of trephining—cutting holes in the skull to encourage
the evil spirits to leave. Mentally ill individuals were
allowed to remain within society as long as their
behaviors were not disruptive. Severely ill or violent
members of the group were often driven into the
wilderness to fend for themselves.
GREECE AND ROME
Superstitions and magical beliefs dominated thinking
until the Greeks introduced the idea that mental illness
could be rationally explained through observation.
The Greeks incorporated many ideas about illness
from other cultures. By the sixth century bce, medical
schools were well established. The greatest physician
in Greek medicine, Hippocrates, was born in 460 bce.
He was the first to base treatment on the belief that
nature has a strong healing force. He felt that the role
of the physician was to assist in, rather than direct, the
healing process. Proper diet, exercise, and personal
hygiene were his mainstays of treatment. Hippocrates
viewed mental illness as a result of an imbalance of
humors—the fundamental elements of air, fire, water,
and earth. Each basic element had a related humor or
part in the body. An overabundance or lack of one
or more humors resulted in illness. This view (the
humoral theory of disease) persisted for centuries.
Plato (427–347 bce), a Greek philosopher, recog-
nized life as a dynamic balance maintained by the
soul. According to Plato a “rational soul” resided in
the head and an “irrational soul” was found in the
heart and abdomen. He believed that if the rational
soul was unable to control the undirected parts of the
irrational soul, mental illness resulted. In theory, Plato
had foreseen Sigmund Freud by almost 2000 years.
The principles and practices of Greek medicine be-
came established in Rome around 100 bce, but most
physicians still thought that demons caused mental ill-
ness. The practice of frightening away evil spirits to
cure mental illness was reintroduced, and its use contin-
ued well into the Middle Ages. The Romans showed
little interest in learning about the body or mind. Most
Roman physicians “wanted to make their patients com-
fortable by pleasant physical therapies” (Alexander and
Selesnick, 1966), such as warm baths, massage, music,
and peaceful surroundings.
By 300 ce, “six epidemics killed hundreds of thou-
sands of people and desolated the land” (Alexander
and Selesnick, 1966). Churches became sanctuaries for
the sick, and soon hospitals were built to accommo-
date the sufferers. By 370 ad, Saint Basil’s Hospital in
England offered services for sick, orphaned, crippled,
and mentally troubled people.
MIDDLE AGES
Dark Ages
From about 500 ce to 1100 ce, priests cared for the sick as
the Church developed into a highly organized and pow-
erful institution. Early Christians believed that “disease
was . . . punishment for sins, possession by the devil, or
the result of witchcraft” (Ackerknecht, 1968). To cure
mental illness, priests performed demonic exorcisms—
religious ceremonies in which patients were physically
punished to drive away the evil possessing spirit. Fortu-
nately, Christian charity tempered these practices as
members of the community cared for the mentally ill
with concern and sympathy.
As time passed, medieval society declined. Re-
peated attacks from barbaric tribes led to chaos and
moral decay. Epidemics, natural disasters, and over-
whelming taxes wiped out the middle class. Cities,
industries, and commerce disappeared. “The popula-
tion declined, crime waves occurred, poverty was
abysmal, and torture and imprisonment became prom-
inent as civilization seemed to slip back into semi-
barbarianism” (Donahue, 1996). Only monasteries
remained as the last refuge of care and knowledge.
Throughout the Middle Ages, medicine and reli-
gion were interwoven. However, by 1130 laws were
passed forbidding monks to practice medicine because
it was considered too disruptive to their way of life. As
a result, responsibility for the care of sick people once
again fell to the community.
In the late 1100s, a strong Arabic influence was felt in
Europe. Knowledge of the Greek legacy had been re-
tained and improved upon by the Arabs. They had an
extensive knowledge of drugs, mathematics, astron-
omy, and chemistry, as well as an awareness of the re-
lationship between emotions and disease. The Arabic

influence resulted in the establishment of learning cen-
ters, called universities. Many were devoted to the
study of medicine, surgery, and care of the sick.
Problems of the mind, however, received only spir-
itual attention. Church doctrine still stated that if a
person was insane, it must be the result of some exter-
nal force—a heavenly body such as the moon. Thus
the term lunacy was coined and “literally means a
disorder caused by a lunar body” (Alexander and
Selesnick, 1966). In time, large institutions were estab-
lished, and mentally ill individuals were herded into
“lunatic asylums.” Magic was still used to explain the
torments of the mind. A few Church scholars even
suggested that witches might be the source of human
distresses.
Superstitions, Witches, and Hunters
The Church’s doctrine of imposed celibacy failed to
curtail many of the clergy’s sexual behaviors, and so
began an antierotic movement that focused on women
as the cause of men’s lust. Women were thought to be
carriers of the devil because they stirred men’s pas-
sions. “Psychotic women with little control over voic-
ing their sexual fantasies and sacrilegious feelings
were the clearest examples of demoniacal possession”
(Alexander and Selesnick, 1966). This campaign, in
turn, flamed the public’s mounting fear of mentally
troubled people.
Witch-hunting was officially launched in 1487 with
the publication of the book The Witches’ Hammer, a
textbook of both pornography and psychopathology.
Soon after, Pope Innocent VIII and the University of
Cologne voiced support for this “textbook of the In-
quisition.” As a result of this one publication, women
as well as children and mentally ill persons were tor-
tured and burned at the stake by the thousands. There
were few safe havens for individuals with mental ill-
ness during these troubled times.
The first English institution for mentally ill people
was initially a hospice founded in 1247 by the sheriff
of London. By 1330, Bethlehem Royal Hospital had
developed into a lunatic asylum that eventually be-
came infamous for its brutal treatments. Violently ill
patients were chained to walls in small cells and often
provided “entertainment” for the public. Hospital staff
would charge fees for their “tourist attractions” and
conduct tours through the institution. Less violent pa-
tients were forced to wear identifying metal armbands
and beg on the streets. Insane people were harshly
treated in those times, but Bethlehem Royal Hospital,
commonly called Bedlam (Fig. 1.2), was preferable to
burning at the stake.
By the middle of the 14th century, the European
continent had endured several devastating plagues
and epidemics. One quarter of the earth’s popula-
tion, more than 60 million people, perished from
infectious diseases during this period. The feudal
CHAPTER 1 The History of Mental Health Care 3
FIGURE 1-2 ​Bethlehem Royal Hospital in London. (William Hogarth,
“The Rake in Bedlam,” c. 1735. From the series titled The Rake’s
Progress. Copyright The British Museum, London.)
system lost power and declined. Cities began to
flourish and housed a growing middle class. “Lux-
ury and misery, learning and ignorance existed side
by side” (Donahue, 1996). Society was at last begin-
ning to demand reforms. However, as the age of art,
medicine, and science dawned, the hunting of
“witches” became even more popular. It was a time
of great contradictions.
THE RENAISSANCE
The Renaissance began in Italy around 1400 and spread
throughout the European continent within a century.
Upheavals in economics, politics, education, and com-
merce brought the real world into focus. The power of
the Church slowly declined as an intense interest in
material gain and worldly affairs developed. At the
same time, the medieval view of a sinful, naked body
changed into a celebration of the human form by art-
ists such as da Vinci, Raphael, and Michelangelo.
Thousand-year-old anatomy books were replaced by
realistic anatomic drawings. Observation, rather than
ancient theories, revolutionized many of the ideas of
the day.
Sixteenth-century physicians, relying on observa-
tion, began to record what they saw. Mental illness
was at last being recognized without bias. By the
mid-1500s, behaviors were accurately recorded for
melancholia (depression), mania, and psychopathic
personalities. Precise observations led to classifica-
tions for different abnormal behaviors. Mental prob-
lems were now thought to be caused by some sort of
brain disorder—except in the case of sexual fantasies,
which were still considered to be God’s punishment
or possession by the devil. However, despite great
advances in knowledge, the actual treatment of men-
tally troubled people remained inhumane.
4 UNIT I Mental Health Care: Past and Present

THE REFORMATION
Another movement that influenced the care of the
sick—the Reformation—occurred in 1517. People were
displeased with the conduct of the clergy and wide-
spread abuses occurring within the Catholic Church.
Martin Luther (1483–1546), a dissatisfied monk, and
his followers broke away from the Catholic Church
and became known as Protestants. As a result of this
separation, many hospitals operated by the Catholic
Church began to close. Once again the poor, sick, and
insane were turned out into the streets.

SEVENTEENTH CENTURY
During the 17th and 18th centuries, developments in
science, literature, philosophy, and the arts laid the
foundations for the modern world. Reason was slowly
beginning to replace magical thinking, but a strong
belief in demons persisted.
The 1600s produced many great thinkers. Knowl-
edge of the secrets of nature brought a sense of self-
reliance. However, many people were uncomfortable,
so they once again moved toward the security of
FIGURE 1-3 ​A patient in chains in Bedlam, London’s notorious
witch-hunting as a means of protecting themselves Bethlehem Royal Hospital. (Courtesy U.S. National Library of
from the unexplainable. Medicine, Bethesda, MD.)
It was during the 17th century that conditions for
mentally ill individuals were at their worst. While
physicians and theorists were making observations
and speculations about insanity, patients were bled,
starved, beaten, and purged into submission. Treat-
ments for the mentally troubled remained in this un-
happy state until the late 1700s.

EIGHTEENTH CENTURY
During the latter part of the 18th century, psychiatry
developed as a separate branch of medicine. Inhu-
mane treatment and vicious practices were openly
questioned. In 1792 Philippe Pinel (1745–1826), the
director of two Paris hospitals, liberated patients from
their chains “and advocated acceptance of the men-
tally ill as human beings in need of medical assistance,
nursing care, and social services” (Donahue, 1996).
During this period, the Quakers, a religious order, es-
tablished asylums of humane care in England.
In the American colonies the Philadelphia Alms-
house was erected in 1731. It accepted sick, infirm, and FIGURE 1-4 ​Tranquilizing chair. (Courtesy U.S. National Library of
Medicine, Bethesda, MD.)
insane patients as well as prisoners and orphans. In
1794 Bellevue Hospital in New York City was opened
as a pesthouse for the victims of yellow fever. By 1816
the hospital had enlarged to contain an almshouse for of Alice Fisher, a Florence Nightingale–trained nurse,
poor people, wards for the sick and insane, staff quar- in 1884.
ters, and even a penitentiary. By the close of the 18th century, treatments for
Unfortunately, the care and treatment of people with people with mental illness still included the medieval
mental illness remained as harsh and indifferent in the practices of bloodletting, purging, and confinement
United States as it was in Europe. The practice of allow- (Fig. 1.3). Newer therapies included demon-expelling
ing poor people to care for mentally ill individuals tranquilizing chairs (Fig. 1.4) and whirling devices
continued well into the late 1800s and was only slowly (Fig. 1.5). The study of psychiatry was in its infancy,
abandoned. Actual care of mentally ill persons in the and those who actually cared for insane people still
United States did not begin to improve until the arrival relied heavily on the methods of their ancestors.

FIGURE 1-5 ​Circulating swing and bed. (Redrawn from U.S. National
Library of Medicine, Bethesda, MD.)
NINETEENTH-CENTURY UNITED STATES
By the early 1800s the Revolutionary War had ended,
and the United States was a growing nation. Changes
that occurred during this century had an enormous
effect on the care of the mentally ill population.
One of the most important figures in 19th-century
psychiatry was Dr. Benjamin Rush, a crusader for the
insane. Dr. Rush (1745–1813) graduated from Princeton
University at 15 years of age. By the time he was 31,
he had been a professor of chemistry and medicine, a
chief surgeon in the Continental Army, and a signer
of the Declaration of Independence. His book Diseases
of the Mind was the first psychiatric text written in the
United States. In it, he advocated clean conditions
(good air, lighting, and food) and kindness. As a re-
sult of Rush’s efforts, mentally troubled people were
no longer caged in the basements of general hospi-
tals. However, only a few institutions for insane per-
sons were actually available in the United States at
this time. Mildly affected people were commonly
sold at slave auctions, whereas the more violent re-
mained in asylums that were a combination of zoo
and penitentiary.
During the 1830s, attitudes toward mental illness
slowly began to change. The “once insane, always in-
sane” concept was being replaced by the notion that
cure might be possible. A few mental hospitals were
built, but the actual living conditions for most patients
remained deplorable.
It was not until 1841 that a frail 40-year-old
schoolteacher exposed the sins of the system.
Dorothea Dix was contracted to teach Sunday school
at a jail in Massachusetts. While there, she saw both
CHAPTER 1 The History of Mental Health Care 5
criminals and mentally ill prisoners living in squalid
conditions. For the next 20 years Dix surveyed asy-
lums, jails, and almshouses throughout the United
States, Canada, and Scotland. It was not uncommon
for her to find mentally ill people “confined in
cages, closets, cellars, stalls, and pens . . . chained,
naked, beaten with rods and lashed into obedience”
(Dolan, 1968).
Dorothea Dix presented her findings to anyone who
would listen. Her untiring crusade had results that
shook the world. The public became so aroused by
Dix’s efforts that millions of dollars were raised, more
than 30 mental hospitals throughout the United States
were constructed, and care of the mentally ill greatly
improved.
By the late 1800s, a two-class system of psychiatric
care had emerged: private care for the wealthy and
publicly provided care for the remainder of society.
The newly constructed mental institutions were
quickly filled, and soon chronic overcrowding began
to strain the system. Cure rates fell dramatically. The
public became disenchanted, and mental illness once
again was viewed as incurable. Only small, private
facilities that catered to the wealthy had some degree
of success. State facilities had evolved into large, re-
mote institutions that became completely self-reliant
and removed from society.
By the close of the 19th century, many of the gains
in the care for the mentally ill population had been
lost. Overpopulated institutions could offer no more
than minimal custodial care. Theories of the day gave
no satisfactory explanations about the causes of men-
tal problems, and current treatments remained ineffec-
tive. It was a time of despair for mentally troubled
people and those who cared for them.
TWENTIETH CENTURY
The 1900s were ushered in by reform movements. Po-
litical, economic, and social changes were beginning.
For the first time in history, disease prevention was
emphasized. For the mentally ill population, however,
conditions remained intolerable until 1908 when a
single individual began his crusade.
Clifford Beers was a young student at Yale Univer-
sity when he attempted suicide. Consequently, he
spent 3 years as a patient in mental hospitals in
Connecticut. On his release in 1908, Beers wrote a book
that would set the wheels of the mental hygiene move-
ment in motion. His book, A Mind That Found Itself,
recounted the beatings, isolation, and confinement of a
mentally ill person. As a direct result of Beers’s work,
the Committee for Mental Hygiene was formed in 1909.
In addition to prevention, the group focused on
removing the stigma attached to mental illness. Under
Beers’s energetic guidance, the movement grew na-
tionwide. The social consciousness of a nation had
finally been awakened.
6 UNIT I Mental Health Care: Past and Present
PSYCHOANALYSIS
In the early 1900s, a neurophysiologist named Sig-
mund Freud published the article that introduced the
term psychoanalysis to the world’s vocabulary. Freud
believed that forces both within and outside the per-
sonality were responsible for mental illness. He devel-
oped elaborate theories around the theme of repressed
sexual energies. Freud was the first person who suc-
ceeded in “explaining human behavior in psychologic
terms and in demonstrating that behavior can be
changed under the proper circumstances” (Alexander
and Selesnick, 1966). The first comprehensive theory
of mental illness based on observation had emerged,
and psychoanalysis began to gain a strong hold in
America (see Chapter 5).
INFLUENCES OF WAR
By 1917 the United States had entered World War I.
Men were drafted into service as rapidly as they could
be processed, but many were considered too “mentally
deficient” to fight. As a result, the federal government
called on Beers’s Committee for Mental Hygiene to
develop a master plan for screening and treating men-
tally ill soldiers. The completed plan included meth-
ods for early identification of problems, removal of
mentally troubled personnel from combat duty, and
early treatment close to the fighting front. The commit-
tee also recommended that psychiatrists be assigned to
station hospitals to treat combat veterans with acute
behavioral problems and provide ongoing psychiatric
care after soldiers returned to their homes.
Because of the war, a renewed interest in mental
hygiene was sparked. During the 1930s, new therapies
for treating insanity were developed. Insulin therapy
for schizophrenia induced 50-hour comas through the
administration of massive doses of insulin. Passing
electricity through the patient’s head (electroconvulsive
therapy [ECT]) helped to improve severe depression,
and lobotomy (a surgical procedure that severs the
frontal lobes of the brain from the thalamus) almost
eliminated violent behaviors. A new class of drugs that
lifted spirits of depressed people, the amphetamines,
was introduced. All these therapies improved behav-
iors and made patients more receptive to Freud’s psy-
chotherapy. Public interest was renewed, and in 1937
Congress passed the Hill-Burton Act, which funded
the construction of psychiatric units throughout the
United States.
From 1941 to 1945, the United States was immersed
in World War II. Many draftees were still rejected for
enlistment because of mental health problems. A large
number of soldiers received early discharges based on
psychiatric disorders, and many active-duty personnel
received treatment for psychiatric problems.
In 1946, Congress passed the National Mental
Health Act, which provided funding for programs in
research, training of mental health professionals, and
expansion of state mental health facilities. By 1949,
the National Institute of Mental Health was orga-
nized to provide research and training related to
mental illness. New approaches to the care of the
mentally ill population (the therapeutic community
movement, family care, halfway houses) sparked the
public’s enthusiasm.
The Korean War of the 1950s, the Vietnam War of
the 1960s and 1970s, and other armed conflicts contrib-
uted significant knowledge to the understanding of
stress-related problems. Posttraumatic stress disorders
became recognized among soldiers fighting wars. To-
day stress disorders are considered the basis of many
emotional and mental health problems.
INTRODUCTION OF PSYCHOTHERAPEUTIC
DRUGS
Psychotherapeutic drugs are chemicals that affect the
mind. These drugs alter emotions, perceptions, and
consciousness in several ways. They are used in com-
bination with various therapies for treating mental
illness. Psychotherapeutic drugs are also called psy-
chopharmacologic agents, psychotropic drugs, and
psychoactive drugs.
“By the 1950s, more than half the hospital beds
in the United States were in psychiatric wards”
(Taylor, 1994). Patients were usually treated kindly,
but effective therapies were still limited. Treatments
consisted of psychoanalysis, insulin therapy, electro-
convulsive (shock) therapy, and water/ice therapy.
More violent patients were physically restrained in
straitjackets or underwent lobotomy. Drug therapy
consisted of sedatives (chloral hydrate and paralde-
hyde), barbiturates (phenobarbital), and amphet-
amines that quieted patients but did little to treat
their illnesses.
In 1949, an Australian physician, John Cade, dis-
covered that lithium carbonate was effective in con-
trolling the severe mood swings seen in bipolar
(manic-depressive) illness. With lithium therapy,
many chronically ill clients were again able to lead
normal lives and were released from mental institu-
tions. Encouraged by the apparent success of lithium,
researchers began to explore the possibility of control-
ling mental illness with the use of various new drugs.
Chlorpromazine (Thorazine) was introduced in
1956 and proved to control many of the bizarre behav-
iors observed in schizophrenia and other psychoses
(Keltner and Folks, 2001). The 1950s concluded with
the introduction of imipramine, the first antidepres-
sant. Soon other drugs, such as antianxiety agents,
became available for use in treatment.
As more patients were able to control their behav-
iors with drug therapy, the demand for hospitaliza-
tion decreased. Many people with mental disorders
could now live and function outside the institution.
At this time, the federal government began the move-
ment called deinstitutionalization, the release of large
numbers of mentally ill persons into the community.

To illustrate, 560,000 patients were cared for in state
hospitals in 1955. By 1994, the number of institutional-
ized patients had dropped to fewer than 120,000 people
(Harrington, 1999). The introduction of psychothera-
peutic drugs opened the doors of institutions and set
the stage for a new delivery system, community mental
health care.
The 1960s were filled with social changes. With the
introduction of psychotherapeutic drugs came the
concept of the “least restrictive alternative.” If patients
could, with medication, control their behaviors and
cooperate with treatment plans, then the controlled
environment of the institution was no longer neces-
sary. It was believed that people with mental disorders
could live within their communities and work with
their therapists on an outpatient basis.
In 1961, the Joint Commission on Mental Illness and
Health published a 338-page report titled Action for
Mental Health. The report motivated President John
Kennedy to appoint a special committee to study the
problem of mental illness and recommend specific ac-
tions. Recommendations from Kennedy’s committee
called for a bold new approach to mental health care
that included the development of an entirely new en-
tity, the community mental health center.
CONGRESSIONAL ACTIONS
As the population of people with mental illnesses
shifted from the institution to the community, the de-
mand for community mental health services expanded.
To meet this demand, the federal government acted to
establish a nationwide network of community mental
health centers.
The Community Mental Health Centers Act was
passed by Congress in October 1963. This act was
designed to support the construction of mental
health centers in communities throughout the United
States. At these centers, the needs of all people expe-
riencing mental or emotional problems, as well as
those of acute and chronic mentally ill people, would
be met. Physicians (psychiatrists), nurses, and vari-
ous therapists would develop therapeutic relation-
ships with clients and monitor their progress within
the community setting. Each center was to provide
comprehensive mental health services for all resi-
dents within a certain geographic region, called a
catchment area.
It was believed that community mental health cen-
ters would provide the link in helping mentally ill
people make the transition from the institution to the
community, thus meeting the goal of humane care de-
livered in the least restrictive way. Passage of the
Medicare/Medicaid Bill of 1965, combined with the
Community Mental Health Centers Act, led to the re-
lease of more than 75% of institutionalized mentally ill
persons into the community (Morrissey and Goldman,
1984). Unfortunately, most chronically mentally ill
people were “dumped” into their communities before
CHAPTER 1 The History of Mental Health Care 7
realistic strategies, programs, and facilities were in
place.
Community mental health centers expanded through-
out the 1970s, but funding was inadequate and spo-
radic. Demands for services overwhelmed the system
and non–revenue-generating services (prevention
and education) were eliminated. Services for the gen-
eral public dwindled, and many centers began to
close their doors. Finally, in 1975, Congress passed
amendments to the Community Mental Health Cen-
ters Act that provided funding for community
centers based on a complex set of guidelines. The
President’s Commission on Mental Health was
established in 1978 by President Jimmy Carter. Its
task was to assess the mental health needs of the
nation and recommend possible courses of action to
strengthen and improve existing community mental
health efforts. The commission’s final report resulted
in 117 specific recommendations grouped into four
broad areas: coordination of services, high-risk popu-
lations, flexibility in planning services, and least re-
strictive care alternatives.
By 1980 Congress passed one of the most progres-
sive mental health bills in history. The Mental Health
Systems Act addressed community mental health care
and clients’ rights and established priorities for re-
search and training. However, before the recommen-
dations could be nationally implemented, the United
States elected a new president, and mental health re-
form changed dramatically.
Just as legislation that comprehensively dealt with
mental health issues was about to be enacted, the po-
litical climate changed. Federal funding for all mental
health services was drastically reduced. The passage
of the Omnibus Budget Reconciliation Act (OBRA)
of 1981 essentially repealed the Mental Health Sys-
tems Act. This resulted in block grant funding through
which each state received a “block” or designated
amount of federal money. The state then determined
where and how the money was spent. Unfortunately,
many states proved less committed to mental health
with the use of their block grant money. As a result,
many hospitalized mentally ill people (especially the
older adult population) were transferred to less appro-
priate nursing homes or other community facilities.
To stem the practice of inappropriate placement for
the chronic mentally ill population, the Omnibus Bud-
get Reconciliation Act of 1987 was passed. Because
people with chronic mental problems could no longer
be “warehoused” in nursing homes or other long-
term facilities, many were discharged to the streets.
As concern for a rapidly expanding federal budget
deficit grew, funding for mental health care dwindled.
By the late 1980s, funding was curtailed for most in-
patient psychiatric care. Following the trend, most
insurance companies withdrew their coverage for
psychiatric care. See Table 1.1 for a brief history of
mental health care.
8 UNIT I Mental Health Care: Past and Present

Table 1-1 History at a Glance

HISTORY AT A GLANCE VIEW OF MENTAL ILLNESS
Greece and Rome Imbalance of humors
Middle Ages Demonic possession
Renaissance Brain disorder, possession by
devil
Reformation Demonic possession, some
reasoning
17th and 18th centuries Demonic possession
19th century Disease of the mind, may be
curable
20th century Freud’s psychoanalytic theories,
behavior can be changed
21st century Biochemical imbalances
EVENTS
Plagues, the Church cared for mentally ill
Bedlam institution for mentally ill, 1247; witch-hunts
Treatment remains inhumane
Church stopped caring for the sick
Quakers opened asylums
Pinel advocated humane care
Treatment remained harsh
D. Dix advocated humane care
B. Rush wrote first text on mental illness
Two class system of private and public care
World Wars I and II advance study of mental illness
Psychotherapeutic drugs introduced
Mentally ill were deinstitutionalized
Lawmakers defining national health policies
Physical causes of mental illness investigated

that was equal to the coverage for medical problems.

TWENTY-FIRST CENTURY
In 2006, the National Alliance for Mental Illness
(NAMI) conducted the “first comprehensive survey
and grading of state adult mental health care systems
conducted in more than 15 years” (NAMI, 2006). The
results revealed a fragmented system with an overall
grade of D. Recommendations focused on increased
funding, availability of care, access to care, and greater
involvement of consumers and their families.
Today many of our population’s most severely
mentally ill people still wander the streets in abject
poverty and homelessness as a result of federal and
state funding cuts. Community mental health centers
have closed their doors or drastically reduced their
services. Federal funding is limited to block grants (for
all health care) to each state. The original goals of com-
prehensive care, education, rehabilitation, prevention,
training, and research were lost in the efforts to curtail
costs.
To address the growing lack of mental health care,
Congress passed the Mental Health Parity and Addic-
tion Equity Act of 2008. This bill required insurance
coverage for mental health and substance use conditions
Under the Affordable Care Act of 2010, all insurers are
required to cover 10 Essential Health Benefit groups.
Mental health problems are included conditions. It is
estimated that the Affordable Care Act will include “fed-
eral parity protection to 62 million Americans” (Beronio,
Po, Skopec, and Glied, 2013).
Currently, lawmakers in the United States are work-
ing to define a new national health policy. Models for
delivering cost-effective health care are being investi-
gated, but no comprehensive plan is yet in place.
Other countries, such as Canada, the United Kingdom,
and Australia, are faced with similar mental health
care issues. It is in all of our best interests to accept the
challenge of providing for our societies’ mental and
physical health care needs. The Critical Thinking exer-
cise offers something to consider.
Critical Thinking
• What do you think are the most important services in a
national health care plan?
• What priority would you give to care of people with mental
illness?

Get Ready for the NCLEX® Examination!
Key Points
• Mental health is the ability to cope with and adapt to
the stresses of everyday life.
• Mentally healthy people are self-aware, directed, and
responsible for their actions.
• Mental illness is an inability to cope that results in
impaired functioning.
• Mental health is influenced by inherited characteristics,
childhood nurturing, and life circumstances.
• The causes and treatments of mental illness were based
in superstition, magical beliefs, and demonic possession
from primitive societies into the 1800s.
• Priests cared for the sick and exorcised demons, but
mentally troubled people were treated with care by the
Christian community during the Middle Ages.
• By the late Middle Ages, large asylums housed the
insane, and the belief that witches were the carriers of
the devil led to the burning of thousands of women,
children, and mentally ill people.
• By the 1500s, psychotic behaviors were being
accurately observed and recorded, but the Reformation
movement returned many insane people to the streets
as church sanctuaries closed.
• During the 1800s, Americans Dr. Benjamin Rush and
Dorothea Dix crusaded for the humane care of mentally
ill people.
• Standards for the care of the insane population
improved during the mid-1800s until huge waves of
people overwhelmed the mental health care system,
causing the conditions to deteriorate.
• A book written by Clifford Beers about his experience
as a mental patient set the mental hygiene movement of
the early 1900s into motion.
• By the 1920s, Sigmund Freud’s psychoanalytic theo-
ries became a popular method for treating emotional
problems.
• The First and Second World Wars pointed out the need
for comprehensive mental health care.
• With the introduction of psychotherapeutic drug treat-
ment, many psychiatric institutions closed.
• Community mental health centers were built during the
1970s, but a change in political climate left the project
uncompleted and countless mentally ill people without
treatment.
• Today many legislative changes again challenge us to
develop comprehensive, cost-efficient care for society’s
mentally ill members.
CHAPTER 1 The History of Mental Health Care 9
Additional Learning Resources
SG Go to your Study Guide for additional learning activi-
ties to help you master this chapter content.
Go to your Evolve website (http://evolve.elsevier.
com/Morrison-Valfre/) for additional online resources.
Review Questions for the NCLEX® Examination
1. During the Dark Ages, demonic exorcisms were
performed as a result of the belief that mental illness
was punishment for sins, the result of witchcraft, or
caused by:
1. Imbalance of fundamental elements
2. Possession by the devil
3. Rational soul controlling the irrational soul
4. Chemical imbalances within the body
2. In the early 1800s, Dr. Benjamin Rush wrote the first
psychiatric text, Diseases of the Mind, in which he advo-
cated which conditions for the mentally ill? Select all
that apply.
1. Kindness
2. Clean conditions
3. Good air, lighting, and food
4. Proper administration of psychotherapeutic drugs
5. Tranquilizing chairs
3. If a person’s behaviors interfere with daily activities,
impair her judgment, or alter her perception of reality,
this person is considered to be:
1. Confused
2. Disoriented
3. Mentally healthy
4. Mentally ill
4. In the early 1900s, the neurophysiologist Sigmund Freud
is credited with introducing which concept?
1. Psychoanalysis
2. Insanity
3. Lunacy
4. Mental illness
5. According to the concept of the health-illness continuum,
which actions can mentally healthy individuals do?
Select all that apply.
1. Avoid stressors during activities of daily living.
2. Respond to stress with effective behaviors.
3. Develop effective coping mechanisms.
4. Set realistic goals for themselves.
5. Take no responsibility for own actions.
chapter
2 Current Mental Health Care Systems
http://evolve.elsevier.com/Morrison-Valfre/
Objectives
Upon completion of this chapter, the student will be able to:
1. Describe the current mental health care systems in
Canada, Norway, the United Kingdom, Australia, and the
United States.
2. State one major difference between inpatient and
outpatient psychiatric care.
3. Explain the community support systems model of care.
4. List four settings for community mental health care
delivery.
Key Terms
advocacy (ĂD-vә-kә-sē) (p. 14)
case management (KĀS MĂN-ăge-MĬNT) (p. 14)
community (kă-MŪN-ĭ-tē) mental health centers (p. 12)
community support (kă-MŪN-ĭ-tē să-PŎRT) systems (CSS)
model (p. 12)
consultation (KŎN-sŬl-TĀ-shәn) (p. 14)
crisis intervention (KRĪ-sĭs ĬN-tәr-VәN-shәn) (p. 15)
diagnosis-related groups (DRGs) (DĪ-әg-NŌ-sĭs) (p. 18)
homelessness (HŌM-lĕs-nĕs) (p. 18)
The delivery of a population’s health care varies with
the culture. Because cultures, values, and beliefs differ,
international comparisons of health care systems are
difficult to make. The more developed nations have
complex health care systems, but almost half of
all countries in the world “have no explicit mental
health policy and nearly a third have no program
for coping with the rising tide of brain-related dis-
abilities” (A Source of Hope for All [ASHA], 2011).
MENTAL HEALTH CARE IN CANADA
By the late 1960s, Canada had adopted a government-
administered health insurance plan. Today a “single-
payer arrangement” is used in the Canadian health
care system, which is based on five principles: univer-
sality, portability, accessibility, comprehensiveness,
and public administration. Each guiding principle is
explained in Box 2.1.
Each province or territory organizes, administers,
and monitors the health care delivery system of its
citizens. Benefits may vary, but all Canadian citizens
are eligible for diagnostic, emergency, outpatient,
medical, hospital, convalescent, and mental health
10
5. Describe five components of the case management
method of mental health care.
6. Discuss the roles and purpose of the multidisciplinary
mental health care team.
7. Name four high-risk populations served by community
mental health centers.
8. List five community-based mental health services for
people with HIV/AIDS.
inpatient psychiatric (ĬN-PĀ-shәnt sī–k-Ē-ăt-rĭc) care (p. 11)
multidisciplinary (MŬL-tĭ-dĭ-sĭ-plә-nă-rē) mental health
care teams (p. 16)
outpatient (ŎWT-PĀ-shәnt) mental health care (p. 12)
psychosocial rehabilitation (sī-kō-SŌ-shәl RĒ-hă-bĭl-ә-TĀ-
shәn) (p. 14)
recidivism (rē-SĬD-ĭ-vĭz-әm) (p. 12)
resource linkage (RĒ-sŏrs LĒNK-әg) (p. 14)
services. Medications for people over age 65 years are
also provided. The agency responsible for the health of
Canadians is the Department of National Health and
Welfare. It provides technical and financial support for
each provincial health care program; enforces federal
food and drug laws; promotes health; and administers
social welfare programs.
Canada’s health care system is divided into curative
and preventive operations with the major focus on cure
and treatment. Preventive services, including mental
health, are delivered through public health depart-
ments. “Private psychotherapy, community mental
health, other day programs, and hospital psychiatric
services” (Kirkpatrick, 1999) are available to every
Canadian based on need.
MENTAL HEALTH CARE IN NORWAY
Like other European countries, Norway has adopted
a national insurance system. The National Insurance
Act of 1967 provides access to health care for every-
one living in Norway. Employees contribute a per-
centage of their wages and pay out-of-pocket fees for
health care until a “payment ceiling” (about $175) is

Box 2-1 Principles of the Canadian Health Act
1. Universality. Everyone in the nation is covered.
2. Portability. People can move and still retain their health
coverage.
3. Accessibility. Everyone has access to the system’s
health care providers.
4. Comprehensiveness. Provincial plans cover all medi-
cally necessary treatment.
5. Public administration. The system is publicly run and
publicly accountable.
From Edelman CL, Mandle CL: Health promotion throughout the lifespan, ed 5,
St Louis, 2002, Mosby.
reached. Thereafter, all services are covered except
adult dental care.
Financing and delivery of health care services oc-
cur on three levels. Health policy is legislated, and
health service delivery is monitored by national au-
thorities. Hospitals and specialized medical services
are managed by Norway’s 19 counties, whereas pri-
mary health care services are organized on the mu-
nicipal level. Mental health care is available to all
citizens of Norway.
MENTAL HEALTH CARE IN BRITAIN
All British citizens are provided health care through a
government-managed national health care system.
The Secretary for Social Services is responsible for set-
ting fees for private health care providers, budgets for
hospitals, and salaries for hospital physicians. Parlia-
ment allocates funds for the health care system and
regulates the rates at which general practitioners are
paid. Tax revenues provide most of the financing for
health care.
Mental health care is available for all British citizens
as part of the standard benefit package. Physician ser-
vices, emergency surgeries, hospital stays, and pre-
scription drugs, along with preventive, home, and
long-term care, are all provided by the government.
Eye care is not included and dental care is limited, but
all other basic health care needs are provided. Private
insurance is also available.
MENTAL HEALTH CARE IN AUSTRALIA
Australians are provided an interesting mix of health
care plans. The government provides a public health
plan that covers all public hospitals and physician ser-
vices. Also available is a national private plan, which
supplements the basic public plan. In addition, numer-
ous private insurance plans are available for eye care,
rehabilitative services, and psychiatric treatment.
National health care is financed by a tax on all citi-
zens above a certain income. Policy and budget deci-
sions are made at the federal level. Individual states
are responsible for the administration and delivery of
CHAPTER 2 Current Mental Health Care Systems 11
health care services that are available through local
government agencies, semivoluntary agencies, and
profit-oriented, nongovernmental organizations. The
Mental Health Bill of 2013 addresses fairness, account-
ability, and inclusion of significant others when caring
for the mentally ill in Australia’s basic health plan.
MENTAL HEALTH CARE IN THE UNITED STATES
Health care in the United States is based on the private
insurance model. Today more than 75% of United
States citizens are covered by private insurance or
public programs (Medicare and/or Medicaid). How-
ever, more than 15% of U.S. residents do not have any
health care coverage. It is hoped that this number is
reduced with the introduction of the Affordable Care
Act (Obamacare) system of health care delivery.
The distinction between public and private mental
health care financing is beginning to blur. Federal
funds (Medicare) and state funds (Medicaid) are being
used to cover costs in both the private and public sec-
tors. Currently, Medicare funds about 30% to 50% of
all state mental health systems.
CARE SETTINGS
Admission rates to psychiatric inpatient facilities were
at an all-time low by 1983 as mental health care was
delivered primarily in community settings. However,
by 1988, hospitalizations for mental illness were on the
rise and emergency departments saw huge increases
in clients with psychiatric problems. Today there are
more people in need of care than there are treatment
settings.
INPATIENT CARE
Individuals are admitted to inpatient psychiatric care
based on need. The severity of the client’s illness, the
level of dysfunction, the suitability of the setting for
treating the problem, the level of client cooperation,
and the client’s ability to pay for services all enter into
the decision regarding inpatient psychiatric care.
Clients who receive inpatient care remain in a safe
environment for 24 hours per day; all aspects of care
focus on providing therapeutic assistance. Discharge
occurs when client behavior has appropriately im-
proved and treatment goals have been attained. The
majority of clients are discharged into the commu-
nity. A few go to a group home or other structured
setting or to another institution for long-term psychi-
atric care.
The most important advantage of inpatient psychi-
atric care is that it provides clients with a safe and se-
cure environment where they can focus and work on
the problems that brought them there. Clients may
also be committed to psychiatric care by way of the
criminal justice system. The legal aspects of involun-
tary commitment are discussed in Chapter 3.
12 UNIT I Mental Health Care: Past and Present
OUTPATIENT CARE
As the emphasis shifts to community mental health
care, the demand for outpatient psychiatric service
grows. An outpatient mental health care setting is a fa-
cility that provides services to people with mental
problems within their home environments. With these
services, psychiatric clients are able to remain within
their communities, associating with the real world.
Community-based mental health care occurs within
a dynamic society. Supervision is limited, and the re-
sponsibility for controlling behavior lies squarely with
the individual. Clients are assessed in relation to their
environment and therapies are designed to assist them
in functioning appropriately within their communi-
ties. Unfortunately, the number of outpatient psychiat-
ric care facilities in the United States is being rapidly
outpaced by the mental health needs of a nation un-
dergoing many changes.
Mentally ill people make use of community services
only sporadically. This “hit and miss” approach makes
effective care difficult. Many wait until major prob-
lems occur before seeking treatment. When services
are used, a “Band-Aid” approach that treats only the
presenting complaint is often used. As a result, many
individuals who end up in the emergency depart-
ments of general hospitals or county jails are in need
of inpatient psychiatric care. It is estimated that mental
illness affects “up to 20% of prisoners. Between 200,000
and 300,000 incarcerated persons have serious mental
illness, with tens of thousands actively psychotic on
any given day. The rate of mental illness in prison is as
much as 3 times higher than in the general popula-
tion” (Easley and Allen, 2005). “Approximately 20% of
state prisoners and 21% of local jail prisoners have a
recent history of a mental health condition” (National
Alliance on Mental Illness, 2014).
Unable to cope in the community setting, people
with chronic psychiatric problems often return to insti-
tutions or use community services on a revolving-door
basis. This behavior pattern is known as recidivism and
means a relapse (return) of a symptom, disease, or
behavior. Recidivism is a major problem in mental
health care. It is associated with negative treatment
outcomes, staff frustration, and inappropriate use of
services. Lower rates of recidivism are seen in com-
munities where coordination and cooperation among
community agencies and mental hospitals exist.
Psychiatry and mental health care policies are based
on the medical treatment model: identify the symptom
and then treat it. This point of view became inadequate
once clients were released into the community. A
broader, community-oriented, more flexible outlook
was needed.
Community Support Systems Model
For mentally ill people to function well within their
communities, a wide range of support services is
Clients
FIGURE 2-1 Community support system. (Modified from Stuart GW:
Principles and practice of psychiatric nursing, ed 10, St. Louis, 2013,
Mosby.)
necessary. The community support systems (CSS)
model views clients holistically—as individuals with
basic human needs, ambitions, and rights. The goal
of the CSS model is to create a support system that
fosters individual growth and movement toward in-
dependence through the use of coordinated social,
medical, and psychiatric services. Effective commu-
nity support systems are consumer-oriented, cultur-
ally appropriate, flexible enough to meet individual
needs, accountable, and coordinated. A typical pro-
gram may include services such as health care, hous-
ing, food, income support, rehabilitation, advocacy,
and crisis response (Fig. 2.1).
Community mental health centers are outpatient set-
tings that support the CSS model by providing a com-
prehensive range of services. Many have forged strong
links with community agencies, services, and govern-
ment. Other centers have developed slowly, but the
CSS model of mental health care is proving to be one
of the most comprehensive and workable concepts for
aiding the mentally ill.
DELIVERY OF COMMUNITY MENTAL
HEALTH SERVICES
Mental health services and support systems are avail-
able through a variety of community agencies, support
groups, and civic organizations. Services focus on pre-
vention, maintenance, treatment, and rehabilitation of
mental health problems. Some agencies or groups
limit their focus to one area (eg, Alcoholics Anony-
mous focuses on treatment of alcohol addiction). Indi-
viduals, families, and communities benefit from the
activities of various groups. Box 2.2 lists examples of
commonly available community services.
COMMUNITY CARE SETTINGS
Community mental health services are based on the
needs of specific populations. In addition, mentally ill
people must be treated in the least restrictive manner.
Therefore several services are available in various set-
tings throughout the community. See Table 2.1 for
examples.
 CHAPTER 2 Current Mental Health Care Systems 13

Box 2-2 Examples of Community Services

SERVING INDIVIDUALS Recreation centers
Rape crisis centers Day care centers for young, disabled, or elderly people
Churches and synagogues Family planning agencies
Employment, job-training agencies Family recreation centers and groups
Recreational clubs Shelters for victims of domestic violence
Adult education programs
SERVING THE COMMUNITY
Literacy programs
Environmental groups
Mediation groups
Education groups (eg, American Lung Association, March
Meals on Wheels
of Dimes)
Colleges and universities
Utility companies
Mental health agencies
Community emergency shelters
SERVING FAMILIES Government agencies
Women, Infants, and Children (WIC) Police and fire departments
Children’s groups (eg, Camp Fire Girls) Fair housing bureau or agency
Nutritional services Prisons
Church groups Performing arts centers
Community “Welcome Wagon” Public forests and parks
Data from Haber J et al.: Comprehensive psychiatric nursing, ed 5, St Louis, 1997, Mosby.

Table 2-1 Community Mental Health Care Delivery

SETTING
Emergency care (community
hospital EDs, emergency
psychiatric clinics)
Residential programs (group
homes)
Partial hospitalization (day
treatment centers)
Psychiatric home care
Community mental health
centers
CNSs, Clinical nurse specialists; ED, emergency department.
FOCUS/SERVICES
Stabilization, assist with the
crisis, refer to appropriate
community resources
Offer a protected, supervised
environment within the
community
Provides care and treatment
for clients who are too ill
to be independent; clients
are gradually introduced
into the community
Delivers care to clients and
families in their homes;
helps clients and families
transition from institution
to home; crisis interven-
tions; referral to resources
Services include crisis inter-
vention, family counseling,
education, care for the
chronically mentally ill,
medical care, vocational
and skills training
STAFF MEMBERS
Nurses, social workers,
therapists, psychologists,
psychiatric technicians
Home care providers, thera-
pists, nurses, technicians,
physician
Psychologists, therapists,
nurses, counselors, social
workers, technicians
Psychiatric CNSs, home-
care providers
Psychologists, therapists,
nurses, counselors, social
workers, technicians
COMMENTS
Many chronically mentally ill
use ED settings as entries
into the mental health care
network
Provide food, shelter, clothing,
supervision, counseling,
vocational training,
socialization
Multidisciplinary care and
treatment have led to cli-
ent success and proven
the effectiveness of these
programs
Collaborates with client, fam-
ily, other mental health
professionals to provide
ongoing care
Lack of adequate financing
has resulted in fragmented
services

With short institutional stays and the release of
people with chronic mental illness into the commu-
nity, the need for home psychiatric care providers to
fill the gap between institution and community is
rapidly growing. Psychiatric clinical nurse special-
ists (CNSs) ease the transition from hospital to home
for clients and their families and assist clients in
navigating the mental health care system. They
also provide psychosocial crisis interventions and
collaborate with clients, families, and other profes-
sionals to deliver the most appropriate and cost-
accountable psychiatric care. The following case
study illustrates the role of the mental health CNS in
the home care setting.
14 UNIT I Mental Health Care: Past and Present
Case Study
Joanne is a 59-year-old woman with severe depression, an-
orexia, and suicidal ideation. The psychiatric home care referral
was an effort by her husband to prevent nursing home place-
ment. Joanne presented with a 30-year history of scleroderma
(a disfiguring skin condition), numerous surgeries and hospital-
izations, and a 10-year psychiatric history with numerous sui-
cide attempts. She has severe anxiety and agoraphobia (fear
of crowds and open spaces). Her anorexia was severe, with
her weight at 77 pounds. Medical and psychiatric problems
were interwoven, and she needed comprehensive intervention.
The clinical nurse specialist (CNS) served as case manager.
Because Joanne could not leave home and needed
medication management, a psychiatrist made home visits.
Companion services were supplied while the husband was at
work. The husband was actively involved in the decision
making regarding his wife’s care, but he needed supportive
interventions.
Over a 4-month period, Joanne progressed from a severely
withdrawn, suicidal person to someone who was dealing with
her panic attacks, agoraphobia, and scleroderma. Her weight
had increased to 90 pounds. Although she would continue to
cope with a chronic illness, her hopelessness was gone, and
her ability to function in her daily life had markedly improved.
She was able to continue living in her home and community
with the help of community mental health services.
• What follow-up care would you plan for Joanne?
• What activities would help Joanne meet her social needs?
Modified from Mellon SK: Mental health clinical nurse specialist in home care
for the 90s. Issues Ment Health Nurs 15:229, 1994.
Case Management
Defined as a system of interventions, case management
is designed to support mentally ill clients living in the
community. The major components of case management
are psychosocial rehabilitation, consultation, resource
linkage (referral), advocacy, therapy, and crisis interven-
tion. Clients are involved with the assessment, planning,
and evaluation of their care. Goals are stated as client
outcomes. Success is measured in terms of client satis-
faction, improved coping behaviors, and appropriate
use of services. The overall goal of case management is
a successfully functioning client who is able (with sup-
port) to avoid relapse and achieve productive patterns of
living. A look at each component of case management
may help clarify the process.
Psychosocial Rehabilitation
Use of multidisciplinary services to help clients gain the
skills needed to carry out the activities of daily living as
actively and independently as possible best describes
psychosocial rehabilitation. Clients are first assessed for
physical, social, emotional, and intellectual levels of
function. Then specific plans for teaching needed skills
are developed. If clients are capable of work, vocational
rehabilitation is offered.
The psychosocial rehabilitation model of care en-
courages decision making, thus empowering clients.
This empowerment fosters a sense of self-esteem and
mastery that results in improved coping abilities. As
clients feel the success of making their own decisions,
they are encouraged to take control of other areas of
their lives. Education is also a strong component of
psychosocial rehabilitation because mastering daily
living skills motivates clients to more productive and
independent ways of functioning.
Consultation
In mental health care, consultation is a process in
which the assistance of a specialist is sought to help
identify ways to work effectively with client problems.
The case management system relies on the expertise of
psychiatrists, nurses, psychologists, social workers,
counselors, and various therapists to find ways for
clients to receive the services and support that help
them to achieve their goals. For example, a nurse
might work with a client on personal grooming skills,
while a social worker locates supported housing and a
vocational counselor seeks out an appropriate work
setting. By covering all the bases, care providers hope
to maintain clients in the least restrictive setting (the
community) and assist them with their needs.
Resource Linkage
The process of matching clients’ needs with the most
appropriate community services best describes resource
linkage. Health care providers have traditionally re-
ferred clients to other services, but resource linkage
adds the component of periodic monitoring. The ad-
vantages of coordinating and linking services are sev-
eral: clients can be more easily moved into different
programs because background information moves with
them; duplication of services is avoided; and as the cli-
ents’ level of functioning improves, services can be tai-
lored to support the new, more effective behaviors. With
resource linkage, the focus for treatment of clients is on
care instead of the more traditional emphasis on psychi-
atric symptoms and illness.
Critical Thinking
You are a health care provider who has recently moved to this
area. As a staff member in a community mental health clinic,
you are responsible for helping refer clients to appropriate
agencies.
• How would you go about locating agencies in the com-
munity that provide services for mentally ill individuals?
Advocacy
A critical concept of case management, advocacy is pro-
viding the client with the information to make certain
decisions. Advocacy for mentally ill people involves
more than other areas of health care. Advocates work to
protect clients’ rights, help to clarify expectations, pro-
vide support, and act on behalf of clients’ best interests.
Every person involved in mental health care can act as
an advocate by supporting community efforts and poli-
cies that encourage healthy living practices.
 CHAPTER 2 Current Mental Health Care Systems 15

Therapy day” (Salkever et al., 1999). The team usually consists

Therapy is provided for each client based on assessed
needs, client cooperation, and available services. Medi-
cations may be included as part of the overall plan of
treatment. Therapies may include the use of counseling,
support groups, vocational rehabilitation programs,
and techniques to assist clients with problem-solving
and adaptive behaviors.
Crisis Intervention
The crisis intervention component of case manage-
ment is crucial to the success of the client. People with
chronic mental dysfunction have great difficulty in
coping with stress. What may be bothersome or incon-
venient to us could provoke a crisis in someone with
mental illness. When problems, frustration, anxiety, or
even loneliness become too intense, a crisis erupts. The
client becomes unable to cope and retreats into the
safety of his or her illness.
Crisis intervention describes a short-term, active
therapy that focuses on solving the immediate problem
and restoring the client’s previous level of functioning.
Crisis services help stabilize the client, prevent further
deterioration, and support the client’s readjustment
process. The use of crisis services also results in bet-
ter distribution of resources. Emergency department
visits decrease, rehospitalization is prevented, and
law enforcement resources are better focused on
those who break the law instead of apprehending
mentally ill individuals. For clients with severe,
treatment-resistant mental illness, a new approach,
known as continuous intensive case management,
is being used.
A highly flexible model of care, known as assertive
community treatment (ACT), provides “medical, psy-
chosocial, and rehabilitation services by a community-
based team that operates 7 days a week, 24 hours a
of a social worker, psychiatrist, addictions counselor,
and four clinicians (two social workers and two regis-
tered nurses). Clients are seen individually and in sup-
portive therapy groups. They attend day treatment
programs or pursue vocational training. Many clients
live in supervised housing arrangements. Table 2.2
provides a summary of the continuous care team’s
treatment activities. In short, care teams direct the cli-
ent’s treatment during all encounters with the mental
health care system.
Intensive case management programs have dem-
onstrated that clients with chronic and severe men-
tal illness can be effectively stabilized within the
community with appropriate support systems. As
the pressures of increased demand for services and
cost restrictions force the system into trying new ap-
proaches, mental health care professionals must not
lose sight of the most important element in the
equation—the client.
MULTIDISCIPLINARY MENTAL HEALTH CARE TEAM
Professionals working within the mental health sys-
tem have various educational backgrounds. In the
past, each would work with clients from his or her
particular point of view or specialty. This approach
resulted in disjointed, fragmented care. In some cases
care providers worked at cross-purposes, leaving cli-
ents unsure and confused. The need for coordinated
assessment and treatment was filled by the multidisci-
plinary mental health care team concept.
CARE TEAM
The main purpose of the team approach to treating
mental illness is to provide effective client care.
The mental health care team “provides a forum where

Table 2-2 Continuous Care Team Treatment Strategies

SETTING MENTAL HEALTH CARE TEAM INTERVENTIONS
Community Meets with clients 2–4 times per week
Accompanies client to appointments and other community activities
Helps with daily living/social skill needs
Monitors medications
Nurtures relationships with persons interested in client’s well-being
Encourages client to call team instead of using ED
Emergency room Prearranges for ED staff to notify clinician on arrival of continuous care client
Conducts assessment of client and planning of care jointly with ED physician
Avoids unnecessary hospitalizations
Hospital Care team psychiatrist and primary therapist remain in charge of the client’s case
Helps with decisions regarding admission, treatment, and discharge
Coordinates treatment with inpatient staff
Modified from Arana JD, Hastings B, Herron E: Continuous care teams in intensive outpatient treatment of chronic mentally ill patients. Hosp Community Psych
42:503, 1991.
© American Psychiatric Association. Reprinted by permission.
ED, Emergency department.
16 UNIT I Mental Health Care: Past and Present

psychiatrists, social workers, psychologists, nurses,
and others can democratically share their professional
expertise and develop comprehensive therapeutic
plans for clients” (Haber et al., 1997). The team ap-
proach can also be cost effective by preventing dupli-
cation of services and fragmentation of care. Clients
and their significant others contribute to the plan of
care and remain actively involved throughout the
course of treatment.
Multidisciplinary mental health care teams exist in
both inpatient and outpatient settings. The number
of team members may vary, but the core of the team
is usually composed of a psychiatrist, a psychologist,
a nurse, and a social worker. Other team members,
known as adjunct therapists, join the team as
needed.
Each team member holds a degree or certificate in a
specialized area of mental health. This approach al-
lows clients to be assessed and treated from various
points of view. As data are compiled, a broad, hope-
fully holistic picture of the client emerges and indi-
vidualized therapeutic plans are developed. Table 2.3
identifies team members, their educational prepara-
tion, and their function.
CLIENT AND FAMILY
No discussion of the mental health team is complete
without including the client. As the consumers of ser-
vices and the focus of therapeutic interventions, clients
contribute important information that may make the dif-
ference between success or failure of therapeutic plans.
Including clients and their families in the treatment

Table 2-3 Mental Health Team Members

TEAM MEMBER EDUCATIONAL PREPARATION
Psychiatrist MD with residency in psychiatry
Clinical psychologist PhD in clinical psychology
Psychiatric social worker Master’s degree in social work
(MSW)
Psychiatric nurse Master’s degree; advanced level
preparation; baccalaureate de-
gree; diploma nurse; associate
degree nurse; licensed practical
nurse
Psychiatric assistant or technician High school education; special
on-job training in setting of
employment
Occupational therapist Advanced degree in occupational
therapy (OT)
Expressive therapist Advanced degree and specialized
training in art therapy
Recreational therapist Advanced degree and specialized
training in recreational therapy
Dietitian Advanced degree and special
training in dietetics (RD)
Auxiliary personnel (housekeepers, Various backgrounds and on-job
volunteers, clerks, secretaries) training
Chaplain Seminary pastoral counselor or
rabbinical education
Modified from Haber J et al.: Comprehensive psychiatric nursing, ed 5, St Louis, 1997, Mosby.
RESPONSIBILITIES AND FUNCTIONS
Physician; leader of the team; responsible for
administration and planning; diagnostic and
medical functions are main tasks
Specializes in study of mental processes and
treatment of mental disorders; performs
diagnostic testing; treats clients
Evaluates families; studies environmental and
social causes of illness; conducts family
therapy; admits new clients
Responsible for client’s activities of daily living/
environment management and individual,
family, and group psychotherapy; coordinates
care team activities; supervises technicians
and psychiatric assistants; active in various
community roles
Supervised by professional nurse; assists in
providing basic needs of clients; carries out
nursing functions; maintains the therapeutic
environment; supervises leisure-time activity;
assists with individual/group therapy
Assesses potential for rehabilitation; provides
socialization therapy and vocational retraining
Helps make use of spontaneous creative work
of the client; works with groups; encourages
members to analyze artwork; adjunct to care
team in diagnosis and treatment of children
Provides leisure-time activities for clients;
teaches hospitalized clients useful pastimes;
uses pet therapy, psychodrama, poetry, and
music therapy
Provides attractive, nourishing meals; helps treat
food-related illnesses
Assists clients with activities of daily living and
other practical jobs; can be invaluable in
helping clients
Attends to the spiritual needs of clients and
families; pastoral, marital counseling

process reflects a fundamental change in attitude toward
those with mental illness and their families. Mental ill-
ness today is considered to be a manageable, even treat-
able, complex of disorders.
CLIENT POPULATIONS
Community mental health care was originally de-
signed to provide prevention, education, and treat-
ment services for all members living within an area.
Community mental health services for the general
public include crisis interventions, working with busi-
nesses to decrease costs and improve the effectiveness
of mental health programs, and providing aid for indi-
viduals and families to adjust to life difficulties.
However, certain groups of people are at a high risk
for developing mental health problems in every com-
munity, large or small. They include more obvious
populations, such as homeless people, and more sub-
tle high-risk groups, such as children, families, adoles-
cents, older people, people who are HIV positive and
veterans of armed conflicts. People living in rural ar-
eas present a challenge because of distances among
services.
Clients with HIV infection or acquired immunode-
ficiency syndrome (AIDS) are using community mental
health services in ever-growing numbers. People with
AIDS face overwhelming physical, emotional, and so-
cial consequences. Mental health problems associated
with HIV disease include organic problems, such as
impairments in memory, judgment, or concentration
progressing to dementia. Psychosocial problems in-
clude anxiety, depression, adjustment disorders, in-
creased substance abuse, panic disorders, and suicidal
thoughts. In addition, many researchers believe that
stress directly affects the immune system. Fear of AIDS
may hasten the onset of complications. AIDS-related
anxiety can increase everyday apprehensions in the
lives of many noninfected people.
Comprehensive community mental health services
for people with HIV/AIDS are not yet available in all
areas. Treatment facilities that offer comprehensive
services focus on persons with AIDS, their families
and friends, and the public. Clinicians accept referrals
from other agencies, provide mental status and suicide
risk assessments, offer crisis intervention services, and
provide individual or group therapies for clients with
HIV/AIDS. Family members and significant others
are encouraged to join support groups. Some mental
health care centers train family members in techniques
for keeping clients oriented or on task. Respite care
(time off for the caregiver) services are sometimes co-
ordinated through the center. Some mental health care
centers work with interested community groups to
provide prevention strategies and education about
AIDS for all citizens of the community.
Clients living in rural areas present a special chal-
lenge for mental health care providers. Small villages,
CHAPTER 2 Current Mental Health Care Systems 17
settlements, and farms dot the country landscape of
the United States and Canada. In the United States
rural residents define and relate to health differently
from people in cities. Children and adolescents living
in rural areas have less access to services. Mental
health care providers (eg, nurses, therapists) who
work in rural areas cope with clients of all ages and
with all types of problems. They are also expected to
provide and coordinate comprehensive mental health
care with few available resources.
Military personnel who have served in war-
affected areas of the world present special challenges.
The number of U.S. veterans in 2009 was approxi-
mately 23 million men and women (Veterans, Inc,
2014). Many return with stress-related problems
severe enough to interfere with daily living. More
than 30% of Vietnam veterans have suffered with
posttraumatic stress disorder. The number of veter-
ans of the Afghanistan and Iraq wars is more than
2.8 million. “In 2011, more than 1.3 million Veterans
received specialized mental health treatment from
VA” (U.S. Department of Veterans Affairs). Veterans
have higher rates of depression, substance abuse, and
homelessness than the general population. Many have
difficulty adjusting to life after military service.
Other populations, such as families, the elderly,
children, and adolescents, are vulnerable to mental
health problems. Community mental health services
are a vital link to the well-being of a population. Social
and economic changes will continue to influence com-
munity mental health care, but as the system matures,
the goal of individualized, holistic mental health care
for all people should not be forgotten.
IMPACT OF MENTAL ILLNESS
Mental illness affects everyone directly or indirectly.
Many people personally know someone with behav-
ioral problems. Indirectly, mental illness costs taxpay-
ers millions of dollars as the costs of care and number
of clients needing care continue to escalate. As a result
of ongoing armed conflicts, veterans are flooding the
system with stress-related disorders. Today health care
reform is part of an overall strategy to distribute scarce
resources and control expenses.
INCIDENCE OF MENTAL ILLNESS
Worldwide, 25% of the world’s population will experi-
ence a mental illness during their lifetime (ASHA
2011). Although exact statistics are unavailable, it is
estimated that at any given time at least 61.5 million
adults in the United States suffer from mental-
emotional disorders. “Approximately 18.1% of American
adults—about 42 million people—live with anxiety
disorders” (National Alliance on Mental Illness, 2014).
Chronic severe mental disorders, such as schizophre-
nia and depression, have emerged as major challenges
to treatment. Substance abuse has become a national
18 UNIT I Mental Health Care: Past and Present
problem. The incidence of Alzheimer’s disease and
other dementias is expected to increase threefold over
the next 15 years. Social problems such as AIDS, home-
lessness, violence, and abuse occur with mental prob-
lems. Millions of divorces each year place families in
crisis situations. It is easy to see why there are growing
numbers of mentally troubled people in today’s
society.
ECONOMIC ISSUES
The nationwide movement to treat people with mental
illness in the least restrictive environment is part of a
plan to reduce mental health care costs while still pro-
viding ongoing care. Unfortunately, funding has not
kept pace with the need for services.
To control costs, Congress in 1983 established the
Health Care Financing Administration, which devel-
oped a cost-containment method whereby health care
providers are paid at predetermined rates. A group of
more than 400 diagnosis-related groups (DRGs) classifies
each illness. Medicare, the funded health plan for el-
derly and disabled people, adopted these groups. Pay-
ment guidelines, based on clients’ average lengths of
inpatient stay, determine each DRG. If clients are not
discharged from hospitals within the specified time,
funding is stopped, and the facility or client becomes
responsible for payment. Today mental health facilities
provide services for more than 57 million mentally
troubled people in the United States. Mental health care
costs taxpayers $500 billion a year (Kingsbury, 2008).
“Serious mental illness costs America $193.2 billion in
lost earnings per year” (National Alliance on Mental
Illness, 2014).
Mental illness also influences economics in less di-
rect ways. Unemployed, homeless, and troubled fami-
lies cost society in many more ways than dollars. Loss
of productivity and unfulfilled potential are difficult to
appraise financially. Clearly, economic issues have and
will continue to play a major role in the availability
and delivery of mental health care.
SOCIAL ISSUES
Many social problems are related to mental illness.
Changing lifestyles, work patterns, family structures,
and health are a few of the many changes that influ-
ence a society. Mentally ill individuals, however, are
likely to be struggling with more basic issues, such as
poverty, homelessness, and substance abuse.
By 2001 nearly 12% of U.S. citizens lived below the
poverty line. This means that almost 33 million people,
with 6.8 million poor families, live without life’s neces-
sities (Procter and Dalaker, 2002). By 2012 that number
has grown to 14.5% or more than 54 million persons
(U.S. Census Bureau, 2014). A significant number of
persons in poverty are incapable of making a living as a
result of mental problems. They exist along the fringes
of society, attempting to meet the most basic needs of
food, shelter, and clothing. Within this environment of
poverty, hopelessness grows, and it becomes easier to
retreat into one’s mental illness than face the grim real-
ity of poverty.
After a time, homelessness becomes poverty’s com-
panion. The National Academy of Sciences defines
homelessness as the lack of a regular and adequate
nighttime dwelling. Millions of U.S. citizens are home-
less on any given day. About 10% of the homeless are
older than 60 years. Many are families, and as many as
85% of the homeless population suffer from addictions
or mental disturbances (Walker, 1998).
Homelessness is a national problem that continues
to grow. The actual number of homeless people is dif-
ficult to count because with no regular housing they
tend to melt into society and disappear into the world
of soup kitchens and temporary shelters. In the past,
most homeless people were single men, usually with
alcohol problems. However, today’s statistics present a
different picture. Women, children, and families now
account for many of the homeless people.
Several factors contribute to homelessness. Social
conditions, such as a lack of low-income housing,
public assistance eligibility requirements, and the
movement of chronically mentally ill people into com-
munities that lack adequate support systems, have all
had an adverse effect on homelessness. Community
resources relating to available housing, steady em-
ployment, and welfare services affect homeless peo-
ple. Family dysfunction, poverty, and health status all
relate to the homeless problem.
Many families live from paycheck to paycheck,
with just enough money to scrape by until the next
check. Even a small event can trigger a crisis. An in-
crease in the rent, for example, may force a family out
of their home. Most community mental health centers
offer services for homeless people. Currently, short-
term strategies for working with the homeless popu-
lation include temporary shelters, assisted-housing
programs, and volunteer efforts such as Habitat for
Humanity.
Society’s use of mind-altering chemicals has resulted
in many mentally ill individuals becoming addicted to
“recreational drugs,” such as crack, cocaine, LSD, and
heroin. When used in combination with prescribed psy-
chotherapeutic drugs, overdoses, permanent psychotic
states, and death may occur. Street drugs also cost
money. It is not uncommon for people with mental
problems to spend money on drugs before they buy
food. Addicted people with mental disorders suffer
from two separate disorders, with each compounding
the severity of the other. Illicit drugs and mental illness
become a vicious circle.
The current mental health care system in the United
States is undergoing major changes as budgets decline,
social issues emerge, and needs for treatment grow.
Organization and technology may address some of the
system’s problems, but provider-client contact is and
will remain the core of mental health treatment.

Get Ready for the NCLEX® Examination!
Key Points
• The health care systems of many developed countries
are undergoing financial challenges.
• Canada’s health care system is administrated by each
province under the guidance of the Department of
National Health and Welfare and includes coverage for
most medical, hospital, convalescent, and mental health
services.
• Norway has a national insurance system that provides
access to health care for everyone and covers all
services, including mental health care.
• All British citizens are provided health care through a
government-managed national health care system.
• Australians are provided a mix of health care plans that
include a public health plan, a supplemental national
private plan, and private insurance plans.
• Funds for health care in the United States are provided
through federal (Medicare) and state (Medicaid)
programs, private insurance coverage, and direct
client payments.
• Mental health care is offered in inpatient and outpatient
(community) care settings.
• The community support systems (CSS) model for
mental health care is an organized network of people
committed to assisting those with mental illness within
the community setting.
• Community mental health care settings include
psychiatric clinics, general hospitals, residential care
programs, day treatment facilities, and psychiatric
home care.
• Case management is a holistic system of interventions
designed to support the integration of mentally ill clients
into the community.
• Psychosocial rehabilitation is the use of multidisciplinary
services to help clients learn the skills and supports
needed to carry out the activities of daily living as
actively and independently as possible.
• Psychosocial rehabilitation, consultation, resource linkage,
advocacy, crisis intervention, and therapy are the basic
components of the case management system.
• Intensive case management may use continuous care or
assertive community treatment (ACT) teams who assume
responsibility for the client in and out of the hospital.
• Community mental health services serve high-risk
populations, such as children, people in crisis situations,
homeless individuals, veterans, clients with HIV/AIDS,
clients living in rural areas, and elderly people.
• Mental health services are commonly delivered by the
multidisciplinary care team—a group of physicians,
nurses, psychologists, therapists, and their assistants
who each contribute to the client’s plan of care and
treatment.
• Social and economic issues must be considered when
discussing mentally troubled persons.
CHAPTER 2 Current Mental Health Care Systems 19
Additional Learning Resources
SG Go to your Study Guide for additional learning activi-
ties to help you master this chapter content.
Go to your Evolve website (http://evolve.elsevier.
com/Morrison-Valfre/) for additional online resources.
Review Questions for the NCLEX® Examination
1. Because many individuals in the United States do not
seek health care for mental illness until late into the
illness, many end up being seen in:
1. Hospitals and nursing homes
2. Outpatient and community services
3. Emergency rooms and jails
4. Physicians’ offices
2. What percentage of U.S. citizens have no health
insurance?
1. 5%
2. 15%
3. 25%
4. 35%
3. The concept of recidivism is prevalent among individuals
with chronic psychiatric problems. Which is the most
accurate description of this concept?
1. Relapse of symptoms of a client’s mental health
disease, resulting in frequent readmission to facilities
2. Coordination and cooperation between community
mental health agencies and hospitals, resulting in
continuity of care
3. Providing mental health care services to a client who
lives on his own in his own home
4. Limited supervision in a community setting with
emphasis on individual responsibility for care
4. Which type of community setting involves care for
individuals with mental health issues in a protected and
supervised environment within the community?
1. Psychiatric home care
2. Community mental health centers
3. Residential programs
4. Partial hospitalization
5. The brother of a male mental health client is concerned
because he works during the day and has no one
to care for his brother, who requires almost constant
supervision. He wants to keep his brother at home but
is unsure of what resources are available in the commu-
nity. What is the nurse’s best response?
1. “Have you considered a residential group home?”
2. “Let me give you some information on a community
day treatment center.”
3. “Psychiatric home care might be an option.”
4. “A community mental health center would be good
for your brother.”
chapter
3 Ethical and Legal Issues
http://evolve.elsevier.com/Morrison-Valfre/
Objectives
Upon completion of this chapter, the student should be able to:
1. Compare the differences among values, rights, and ethics.
2. Explain the purpose of the Patient Care Partnership.
3. List six steps for making ethical decisions.
4. Identify the legal importance of practice acts.
5. Describe the process of involuntary psychiatric
commitment.
Key Terms
assault (p. 26)
attitudes (ĂT-ĭ-toodz) (p. 20)
autonomy (aw-TŎN-ә-mē) (p. 23)
battery (BĂ-tәr-Ē) (p. 26)
belief (bĕ-LĒF) (p. 20)
beneficence (b-NĔ-fĬ-sәn[t]s) (p. 23)
civil (SĬ-vĭl) law (p. 24)
codes of ethics (Ĕ-thĭks) (p. 23)
confidentiality (KŎN-fĭ-DĔN-shē-ĂL-ĭ-tē) (p. 23)
contract (KŎN-trăkt) law (p. 24)
controlled substances (KŎN-trŏld SŬB-stăn-sәs) (p. 26)
criminal (KRĬM-ĭn-әl) law (p. 24)
defamation (dĕf-ә-Mā-shәn) (p. 26)
duty (DŪ-tē) to warn (p. 27)
elopement (ĭ-LŌP-mәnt) (p. 27)
ethical dilemmas (ĔTH-ĭ-kәl dĭ-LĔM-ăz) (p. 23)
ethics (ĔTH-ĭks) (p. 22)
false imprisonment (făls ĭm-PRĬZ-әn-mĕnt) (p. 27)
felonies (FĔL-ә-nēs) (p. 24)
fidelity (p. 23)
fraud (frăwd) (p. 26)
informed consent (ĭn-FŎRMd cŭn-SĔNT) (p. 27)
Health care professions are defined by certain beliefs,
rights, and principles that serve as the basis for ethical
and legal concepts. The framework for delivering ap-
propriate therapeutic interventions is rooted in these
concepts.
Attitudes, beliefs, values, and morals influence who
we are. To be effective with mentally ill clients, we
must first appreciate these concepts within ourselves
and then understand them as they apply to our clients
and their support persons.
20
6. Name four areas of potential legal liability for mental health
care providers.
7. Know the difference between the legal terms negligence
and malpractice.
8. Discuss three legal responsibilities that relate to nursing
and health care providers.
invasion of privacy (ĭn-VĀ-shŭn PRĪ-vă-sē) (p. 26)
involuntary admission (ĭn-VŎL-ŭn-tăr-ē ăd-MĬ-shŭn) (p. 25)
laws (lăws) (p. 23)
libel (LĪ-bәl) (p. 26)
malpractice (măl-PRĂC-tĭs) (p. 27)
misdemeanors (MĬS-dĭ-ME-nrs) (p. 24)
morals (MŎR-әls) (p. 21)
negligence (NĔG-lĭ-jĕns) (p. 27)
nonmaleficence (nŏn-mә-LĔF-ә-sәn[t]s) (p. 23)
parity (PĂR-ĭ-tē) (p. 22)
The Patient Care Partnership: Understanding
Expectations, Rights, and Responsibilities (p. 22)
professional (prō-FĔ-shŭn-әl) (nurse) practice acts (p. 25)
reasonable and prudent (PROO-dәnt) care provider (p. 28)
right (RĪT) (p. 22)
slander (SLĂN-dәr) (p. 26)
standards (STĂN-dәrds) of practice (p. 25)
tort law (tŏrt) (p. 24)
value (VĂL-ŭ) (p. 20)
values clarification (VĂL-ŭs CLĂR-ĭ-fĭ-CĀ-shŭn) (p. 21)
veracity (p. 23)
VALUES AND MORALS
Attitudes are ideas that help shape our points of view.
The term can also describe one’s outlook, such as, “He
has a cheerful attitude.” A belief is a conviction that is
intellectually accepted as true whether or not it is
based in fact. A value is something that is held dear, a
feeling about the worth of an item, idea, or behavior.
Values are formed in childhood. They shape our reac-
tions, influence our behaviors, and reflect the society
in which we live. Values are often used as a basis for
 CHAPTER 3 Ethical and Legal Issues 21

making decisions. Values are individual, and they may People who choose to work in the health care pro-
change. Morals are based on one’s attitudes, beliefs, fessions usually arrive with strong personal values.
and values. One’s morals define right or wrong behav- Human values important in caregivers include a con-
ior. Once established, morals become deeply ingrained cern for the welfare of others (altruism), respect for the
and are not easily changed. uniqueness and worth of people (human dignity),
equality, justice, truth, freedom, and acceptance. Car-
ACQUIRING VALUES ing is the foundation of health care, for if we do not
As children grow, they observe and take on the reac- care, we will be unable to effectively treat, teach, or
tions of others in their environment. These adopted work with clients.
reactions become our earliest attitudes. Preschool chil-
dren learn the difference between right and wrong be- VALUES CLARIFICATION
haviors. They adopt the family’s beliefs and traditions. Every society has a value system. Habits, customs, and
As attitudes and beliefs develop, values begin to form. traditions are important to traditional societies. Mod-
Children are exposed to a variety of values at ern societies rapidly change, and people are often not
school. They develop work habits and learn to solve aware of their values until they experience difficulties
problems, interact with others, and make decisions. and their values are questioned.
Parental values are still modeled because the family Values clarification is a step-by-step process to help
remains the major source of values until adulthood. identify significant values. The process helps care pro-
During the teen years, adolescents begin to identify viders become aware of how their own values affect
their own significant values. By early adulthood, an indi- interactions with clients. Values clarification involves
vidual value system is established. Adults may feel secure three steps: choosing, prizing, and acting (Table 3.2).
with their values or discard them for new ones. Older To illustrate, let us assume that you are working at
adults may feel threatened by the changing social values, the local clinic. Today a large, scruffy man who has not
but they tend to hold on to their own value systems. bathed in weeks presents himself for care. There is a
Culture, society, personality, and experiences all wild look in his eyes, and he is arguing with himself as
shape our values. How values are shared largely de- he approaches you. What you really want to do is run,
pends on the sociocultural environment. Most societies but you must cope with this client. How does the
use a combination of methods to transmit values value of caring apply here?
(Potter and Perry, 2013). The methods of transmitting First, you have freely chosen to care about people;
values are outlined in Table 3.1. otherwise you would have selected another line of
work. Second, you prize the value of caring because
your clients see you as compassionate and concerned.
Third, you act on your values by accepting the un-
Table 3-1 How Values Are Transmitted
kempt, scruffy man as a person worthy of care. You ask
MODE OF him what you can do to help. He begins to cry and tells
TRANSMISSION DEFINITION
you that since the death of his wife and children in a
Modeling Copying an example: One person house fire, no one has cared if he lives or dies. By acting
behaves in the ideal or preferred
on your value (caring), you have touched this person
manner, and the other copies the
and paved the way for him to improve his situation.
behavior.
You have chosen to care. You cherish the value of
Moralizing Sets standards for right and wrong:
caring enough to act, even when that value is threat-
Choice is not allowed.
ened. Be clear about your values. Be aware of your
Laissez-faire Unrestricted choices: No direction is
given. One is free to explore and
learn from experiences. This mode Table 3-2 Values Clarification Process
of transmission may result in confu-
STEP PROCESS
sion or frustration.
Choosing Consider all possible alternatives.
Reward/ Rewards valued behaviors and pun- Consider all possible consequences.
punishment ishes undesirable acts; authoritarian. Choose freely without pressure or coercion
Children learn that strength is right. from others.
This mode of transmission may
send the message that violence is Prizing Cherish or prize the choice.
acceptable. Share choice with others.
Reaffirm importance of value.
Responsible A balance of freedom and restriction:
choice One may choose among stated Acting Make value a part of behaviors (internalize
options. New behaviors and conse- value).
quences are explored. Generalize value to all situations.
Repeatedly act with consistent behavioral
Modified from Potter PA, Perry AG: Fundamentals of nursing: concepts, process, pattern.
and practice, ed 5, St Louis, 2001, Mosby.
22 UNIT I Mental Health Care: Past and Present
client’s values because they are the guidelines for
one’s lifestyle, conduct, and relationships.
RIGHTS
A right is described as a power, privilege, or existence
to which one has a just claim. Rights have several roles
in society; they can be used as expressions of power, to
justify actions, and to settle disputes. Rights help de-
fine social interactions because they contain the prin-
ciple of justice; they equally and fairly apply to all
citizens. For example, we all have the right to be re-
spected as human beings and treated with dignity.
Rights also have obligations. You have the right to
drive down the road, but inherent in this right is the
obligation to obey traffic laws.
CLIENT RIGHTS
The 1972 Patient’s Bill of Rights states that all clients
have the rights to respectful care, privacy, confidential-
ity, continuity of care, and relevant information. It also
addresses clients’ rights to examine their bills, refuse
treatment, and participate in research. A revised docu-
ment, The Patient Care Partnership: Understanding
Expectations, Rights, and Responsibilities, was adopted
in 2003. Statements of rights now exist for the elderly,
young, disabled, pregnant, dying, developmentally
disabled, and mentally ill—the most vulnerable peo-
ple in society.
People with mental illness tend to lose their rights in
two ways. First, the problems with which they are coping
require energy. Sometimes reality eludes them. Many are
not able to recognize their rights, much less exercise
them. Second, the mental health delivery system can
impose limits on clients’ abilities to exercise their rights.
To protect their rights, the Mental Health Systems Act Bill
of Rights was passed by the U.S. Congress in 1980. This
bill served as a pattern from which state bills of rights for
the mentally ill population were developed. For an ex-
ample of a client’s right to treatment, see Box 3.1.
Currently, federal legislation has established mental
health parity laws that require insurance companies to
include coverage for mental illness that is equal to the
coverage for physical illness. Treatment for substance
abuse is also addressed in the parity laws.
CARE PROVIDER RIGHTS
The rights of nurses and other care providers relate to
respect, safety, and competent assistance. Care provid-
ers have the right to respect as individuals. Nurses
have the right to full and equal participation as mem-
bers of the health care team. All health care providers
have the right to set standards for quality and develop
policies that affect client care.
Every health care provider has the right to function
within a safe environment. This applies to both the
physical environment (i.e., properly maintained equip-
ment) and the affective or emotional environment.
Box 3-1 Example of the Right to Treatment
In 1957, Mr. Donaldson was involuntarily committed, on his
father’s initiation, to a Florida state hospital for care, treat-
ment, and maintenance. For 14 years before his commit-
ment, he was gainfully employed. Despite the fact that
Mr. Donaldson posed no danger to himself or others, his
requests for ground privileges, occupational training, and an
opportunity to discuss his case with the superintendent,
Dr. O’Connor, or others were denied. During his 15 years of
confinement, he was not provided with any treatment.
Mr. Donaldson frequently requested his release, which
the superintendent was authorized to grant even though
Mr. Donaldson was lawfully confined, because even if he
continued to be mentally ill, he posed no danger to himself
or others. Between 1964 and 1968, Mr. Donaldson’s friend
requested on four separate occasions that Mr. Donaldson
be released into his custody. These requests, and requests
made by a halfway house on Mr. Donaldson’s behalf, were
all denied by Dr. O’Connor, who believed that Mr. Donaldson
should be released into his parents’ custody. Dr. O’Connor
further believed that Mr. Donaldson’s parents were too old
and infirm to care for him adequately.
In O’Connor v. Donaldson (1975), the court found that
Mr. Donaldson’s care was merely custodial because he
received no treatment. He was not dangerous, community
alternatives were available for him, and the physician’s re-
fusal to release him was “malicious.” The Federal Court of
Appeals ruled that Mr. Donaldson had a constitutional right
to treatment and awarded him $38,000 in damages.
From Varcarolis EM, Carson VB, Shoemaker NC: Foundations of psychiatric
mental health nursing: a clinical approach, ed 5, Philadelphia, 2006, Saunders.
Care providers who strive to minimize the physical
and emotional stresses of the working environment
are exercising their right to function safely.
The right to competent assistance includes the right
to receive assistance from people who are capable of
performing at the stated level. For example, the certi-
fied nurse assistant (CNA) who is assigned to work
with a nurse is able to function adequately and safely
as a nursing assistant. Health care providers need to
exercise their rights. By doing this, we remind the sys-
tem of the therapeutic values inherent in the caregiver-
client relationship.
ETHICS
Ethics are a set of rules or values that govern right
behavior. Ethics reflect values, morals, and principles
of right and wrong. The purpose of ethical behavior is
to protect the rights of people. Health care ethics focus
on the moral aspects of health care availability, deliv-
ery, and policy. They are also called biomedical ethics,
bioethics, or medical ethics.
ETHICAL PRINCIPLES
Ethical principles are the concepts that form the basis
for professional codes of ethics (Edelman and Mandle,

2006). They are the behaviors that define what is good
or right conduct. Ethical codes serve two purposes:
(1) They act as guidelines for standards of practice,
and (2) they let the public know what behaviors can be
expected from their health care providers.
The concepts of autonomy, beneficence, nonmalefi-
cence, and justice are the main ethical principles on
which codes of ethics are established. Remember these
principles. They will serve you well as you encounter
the many ethical situations inherent in health care.
Autonomy refers to the right of people to act for
themselves and make personal choices, including
refusal of treatment. Caregivers who practice the
principle of autonomy encourage clients to partici-
pate in informed decision making. The procedure
known as informed consent promotes autonomy by
providing relevant information and choice for the
client.
Beneficence means to actively do good. Actions that
promote client health are beneficent. Choosing the ac-
tion that is the most therapeutic for the client is an
example of beneficence.
The principle of nonmaleficence can be stated in
three words: do no harm. Perhaps it is the most impor-
tant ethical principle of the caregiving professions.
Although nurses must sometimes carry out proce-
dures that result in pain, they are considered in light of
the benefits gained. Therapeutic interventions are de-
livered only after client safety and comfort are consid-
ered. Nonmaleficence ensures that clients will not be
harmed during care.
Justice implies that all clients are treated equally,
fairly, and respectfully. Because health care resources
are limited, the application of justice can be difficult.
However, all clients deserve respect and a share of the
available resources.
The concepts of confidentiality, fidelity, and veracity
are other important ethical principles. The client’s
rights to privacy, truth, and duty are protected by
these ethical principles.
Confidentiality is the duty to respect private infor-
mation. It is a legal and ethical duty of health care
providers to keep all information about clients limited
to only those directly involved with care. Sharing pri-
vate information not only is unethical but also may be
grounds for legal action.
Fidelity is the obligation to keep your word. Telling
the client that you will return in 10 minutes is a prom-
ise. Keep that appointment because your client relies
on you, and your credibility grows or diminishes de-
pending on how well you keep your promises. Do
what you say, or do not say it.
The final principle, veracity, is the duty to tell the
truth. Be careful here. Answer client’s questions hon-
estly, but remember to stay within your standards and
limitations of practice. It is not within your realm, for
example, to discuss the disease prognosis or lead a cli-
ent toward a certain decision.
CHAPTER 3 Ethical and Legal Issues 23
CODES OF ETHICS
Codes of ethics for practical (vocational) and regis-
tered nurses have been developed by the International
Council of Nurses, the American Nurses Association,
the National Federation of Licensed Practical Nurses,
and the Canadian Nurses Association (Box 3.2). Codes
of ethics have been developed for other health care
professions and may differ slightly, but all are based
on the same ethical principles. Provide information to
clients, be truthful, and support your clients, but con-
sult your supervisor if there is any question of appro-
priateness. It is important to practice with ethical
principles in mind.
ETHICAL CONFLICT
In today’s world of advanced technologies and com-
plex situations, no clear-cut answers exist for compli-
cated questions that arise.
Ethical dilemmas (conflicts) exist when there is un-
certainty or disagreement about the moral principles
that endorse different courses of action.
In health care, ethical dilemmas arise when prob-
lems cannot easily be solved by decision making, logic,
or use of scientific data. Answers to ethical dilemmas
usually have broad effects. Because of this, many health
care institutions have established bioethics commit-
tees to study, educate, and assist staff members in cop-
ing with ethical dilemmas.
Most of the time, no clear-cut solutions exist for
ethical dilemmas. Although each ethical dilemma is
unique, the method for making ethical decisions can
be applied to all situations. Guidelines for dealing
with such dilemmas are given in Box 3.3. “Making
ethical decisions in an orderly systematic manner in-
creases one’s ability to deal with the dynamic and
sometimes complex issues relating to ethics. The qual-
ity of care depends on the skills and ethical integrity of
the practitioner” (Morrison, 1993).
LAWS AND THE LEGAL SYSTEM
Every health care provider must be familiar with the
basic concepts of the legal system.
Laws are the controls by which a society governs
itself. They are derived from rules, regulations, and
moral and ethical principles. Laws apply to every
member of society.
GENERAL CONCEPTS
Laws exist at every level of government. In the United
States federal law defines the organization of the gov-
ernment. Federal law is based on the U.S. Constitu-
tion. Laws at the state level are derived from the state’s
constitution and apply to citizens living within its
boundaries. Local and city laws evolve from state law.
Laws change as society changes, but they are all
based on the principles of justice (fairness), change,
standards, and individual rights and responsibilities.
24 UNIT I Mental Health Care: Past and Present
Box 3-2 ICN Code of Ethics for Nurses
1. NURSES AND PEOPLE
The nurse’s primary responsibility is to those requiring nurs-
ing care.
The nurse promotes an environment in which human rights,
values, customs, and spiritual beliefs of the individual,
family, and community are respected.
The nurse ensures that the client receives sufficient informa-
tion on which to base consent for care and treatment.
The nurse holds in confidence personal information and
uses judgment in sharing that information.
The nurse shares with society the responsibility for initiating
and supporting actions to meet health and social needs
of the public, in particular those of vulnerable populations.
The nurse shares the responsibility to sustain and protect
the natural environment from depletion, pollution, degra-
dation, and destruction.
2. NURSES AND PRACTICE
The nurse carries personal responsibility and accountability
for nursing practice, and for maintaining competence by
continual learning.
The nurse maintains a standard of personal health such that
the ability to provide care is not compromised.
The nurse uses judgment regarding individual competence
when accepting and delegating responsibility.
Modified from the International Council of Nurses: The ICN code of ethics for nurses, Geneva, Switzerland, 2006, The Council.
Box 3-3 Guidelines for Making Ethical Decisions
1. Identify all elements of the situation. Gather data.
Identify each person involved in the decision-making
process.
2. Assume goodwill. All care providers want a satisfactory
resolution to the problem. When working with emo-
tionally charged issues, remember that there is
no need for competition.
3. Gather relevant information. Thoroughly assess life-
style, preferences, wishes, and support systems. Try
to form an “ideal picture” of the resolution for the
dilemma.
4. List and order values. Decide which ethical principles
are most important in the situation. List them in order
of importance, and then determine a plan or course of
action.
5. Take action. Implement the plan. Monitor any changes.
6. Evaluate the effectiveness of the plan.
Modified from Potter PA, Perry AG: Fundamentals of nursing: concepts, process,
and practice, ed 8, St Louis, 2013, Mosby.
Laws have several functions in our society. They
define relationships, describe appropriate and objec-
tionable behaviors, and explain what kind of force is
applied to maintain rules. Laws help provide solutions
for many social and legal problems, and they serve to
protect the rights of people while defining the limits of
acceptable behaviors.
There are two types of law: public law and private
law. Public law focuses on the relationship between
The nurse at all times maintains standards of personal con-
duct that reflect well on the profession and enhance
public confidence.
The nurse, in providing care, ensures that the use of tech-
nology and scientific advances is compatible with the
safety, dignity, and rights of people.
3. NURSES AND THE PROFESSION
The nurse assumes a major role in determining and imple-
menting acceptable standards of clinical nursing practice,
management, research, and education.
The nurse is active in developing a core of research-based
professional knowledge.
The nurse, acting through professional organizations, partic-
ipates in creating and maintaining safe, equitable social
and economic working conditions in nursing.
4. NURSES AND COWORKERS
The nurse sustains a cooperative relationship with cowork-
ers in nursing and other fields.
The nurse takes appropriate action to safeguard individuals,
families, and communities when their health is endan-
gered by a coworker or any other person.
the government and its citizens. The division of public
law that is of importance to caregivers is known as
criminal law. Its main function is to protect the mem-
bers of society. Serious crimes, known as felonies, are
punishable by death or imprisonment. Less serious
crimes are called misdemeanors, with punishments
ranging from fines to prison terms of less than 1 year.
Private law is commonly called civil law. Its function
is to deal with relationships between individuals. Two
important types of civil law for caregivers are contract
law and tort law.
Contract law deals with agreements between indi-
viduals or institutions. These agreements or contracts
may be written or implied. For example, on employ-
ment, health care providers enter into contracts with
the employing institution.
“A tort is a legal wrong that is committed against
the person or the property of another individual”
(Morrison, 1993).
Tort law relates to individuals’ rights and includes
the need to be compensated for a wrong. Tort law is
especially important for caregivers because many po-
tential legal problems exist in every health care setting.
Fig. 3.1 lists the areas of law that are most significant
for care providers.
LEGAL CONCEPTS IN HEALTH CARE
The health care professional and the system are gov-
erned by rules and standards. Nursing, for example, is
regulated by state boards of nursing that define the
practice of nursing and regulate the profession through

Law
Criminal law Civil law
Felony Misdemeanor Tort law Contract law
Intentional torts Unintentional torts
Assault and Fraud Invasion of Negligence Malpractice
battery privacy
False Defamation
imprisonment
FIGURE 3-1 ​Laws important for health care providers.
licensing procedures and disciplinary actions. Each
state’s board of nursing identifies the limits and scope
of practice through a series of regulations known as
that state’s nurse practice act. Nurses need to be famil-
iar with their state’s nurse practice act because it is the
legal framework for practice in that state. Other
health care providers are responsible for knowing
their state governing regulations. Caregivers are le-
gally responsible for their actions. They are expected
to know what is contained within their professional
practice acts.
Institutional policies also help to define health care
practices. Policies are statements that define a course
of action. What is to be done is stated in policies. How
a task or skill is to be performed is defined in the insti-
tution’s procedure manual. Job descriptions define
the job, its functions, its qualifications, and to whom
the caregiver reports. Guidelines for sound health care
delivery can be found in each state’s practice act; pro-
fessional standards; and the employing institution’s
policies, procedures, and job descriptions.
A standard is a measurement for comparison by
which one evaluates an action.
Standards of practice are developed by specific
health care disciplines. Standards of nursing practice,
for example, are a set of guidelines that provide mea-
surable criteria for nurses, clients, and others to evalu-
ate the quality and effectiveness of the nursing care
provided. Psychiatric mental health standards for
nursing practice can be found at the front of the book.
LAWS AND MENTAL HEALTH CARE
Historically, people with mental illnesses were af-
forded few legal rights. Only recently have mental
health clients been able to exercise their claims to fair
and adequate treatment in settings helpful to their
care. Nurses and their colleagues need to be aware of
CHAPTER 3 Ethical and Legal Issues 25
clients’ legal rights to freedom, privacy, and choice.
Laws relating to mental health issues “attempt to bal-
ance the basic rights of the individual against society’s
interest in being protected from persons who, because
of mental disorder, present a threat of harm” (Keltner
and Steele, 2014).
CLIENT-CAREGIVER RELATIONSHIP
An awareness of the obligations in the client-caregiver
relationship ensures safe, legal practice. From a legal
point of view, the caregiver and client enter into an
implied contract on acceptance of service. The care-
giver provides services that are accepted by the client.
This idea of contractual obligations is one legal aspect
of the caregiver-client relationship. Two other impor-
tant aspects are liability and standards of care.
The concept of liability states that care providers
are legally responsible for their professional obliga-
tions and behaviors. It includes the obligation to re-
main competent, maintain a current knowledge base,
practice at a level appropriate to one’s education, and
practice unimpaired by drugs, disability, or illness.
Clients still retain their legal rights when they enter
the mental health care system. The 1980 Mental Health
Systems Act states that mentally ill individuals have
rights to obtain information and treatment within a
supportive, humane environment. The Patient Self-
Determination Act of 1991 gives clients the right to
make decisions about their care (Loewy, 1998). Indi-
viduals who are admitted to psychiatric facilities re-
tain the right to vote, to buy and sell property, and to
possess a driver’s license.
People with mental illness may be unaware of their
legal rights or unable to exercise them. Clients’ judg-
ments may be limited as the result of their illness and/
or medications. It is important to recognize and safe-
guard clients’ legal rights because behind every men-
tal disorder lives a real person.
ADULT PSYCHIATRIC ADMISSIONS
The decision to seek psychiatric care, whether made
by the client, family, or community, is difficult. When
the client originates the request for mental health ser-
vices, it is considered a voluntary admission. Because
they are often aware of their problems, most volun-
tarily admitted clients are active participants in their
treatments and have a low potential for violence. Vol-
untarily admitted clients may legally discharge them-
selves at any time.
When individuals engage in behavior that is harm-
ful to themselves or others, the involuntary admission
process is undertaken. The 1953 Act Governing Hospi-
talization defines an involuntary admission as a process
for institutionalization initiated by someone other
than the client. Involuntary psychiatric admissions
provide a protected, therapeutic environment, which
is usually necessary for the client’s safety. Clients may
stay for days to years.
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Kanó, while the bleached calico and the cambric attract the wealthier
people on account of their nobler appearance. In Timbúktu on the
contrary, where the native cloth is dearer, unbleached calico is in
request; and it would be so in an extraordinary degree, if it were
dyed dark blue. It is very interesting to observe that a small
proportion of the calico imported into Kanó is again exported, after
having been dyed, returning even the long way to Ghadámes. I
estimate the whole amount of Manchester goods imported into Kanó
at about forty millions; but it may be somewhat more. The sale of
tanjips is very considerable; and the import of this article into Kanó
certainly equals in value that of the former.
The very coarse silk, or rather refuse, which is dyed in Tripoli, is
imported to a very considerable amount, this forming the principal
merchandise of most of the caravans of the Ghadamsíye merchants,
and about one-third of their whole commerce, amounting certainly to
not less than from three to four hundred camel-loads annually, worth
in Kanó each about two hundred thousand kurdí; this would give a
value of about seventy millions imported. But according to some
well-informed people, even as many as one thousand loads of this
article pass annually through Ghadámes; so that, if we take into
consideration that the supply of the northerly markets (as Tasáwa,
Zínder) may well be compensated by what is brought by way of
Múrzuk, the value of the import of this article into Kanó may be much
more. A great deal of this silk, I have no doubt by far the greatest
part, remains in the country, being used for ornamenting the tobes,
sandals, shoes, and other things.
Woollen cloth of the most ordinary quality, chiefly red, but about
one-third of the whole amount of green colour, was formerly imported
to a great extent; but it has gone out of fashion, and I think a better
quality, like that with which the market of Timbúktu is supplied by
way of Mogador or Swaira, would succeed. I estimate this branch at
present at only fifteen millions.
Beads, in very great variety,[31] form an important article of import;
but the price has become so low of late years that there has been
very little profit, and the supply has been kept back to raise the
prices. The import of this article certainly amounts to more than fifty
millions of kurdí, of which sum the value of twenty may remain in the
country.
Of sugar, I think about one hundred camel-loads are imported
every year, each containing eighty small loaves, of two and a half
pounds each, which are sold in general at fifteen hundred kurdí; so
that the import of this article would amount to about twelve millions. It
is very remarkable that in all Central Negroland the large English
sugar-loaf is scarcely ever seen, while it is the only one seen in
Timbúktu. However, I was greatly surprised when, on my return from
that place in 1854, ʿAlíyu, the Emír el Mumenín of Sókoto, presented
to me an English loaf of sugar; and I heard that he had received
several of them as presents from a merchant of Tawát. The small
loaf has certainly a great advantage in such a country, where money
is scarce; and I found in 1854 that its weight had even been reduced
to two pounds.
Common paper, called on the coast “tre lune,” from the mark of
three moons which it bears, is imported in great quantity, being used
for wrapping up the country cloth; but it is a bulky, heavy article, and
in larger quantities is sold at a very cheap rate. The whole amount of
this import may be about five millions of kurdí.
Needles, with the emblem of the pig,[32] and small looking-glasses
called “lemmʿa” in boxes, form important but very cheap articles, and
I think their amount together will not much exceed the value of eight
millions. Generally, the needles in large quantities are sold for one
“urí” or shell each, but often even cheaper; and I was obliged to sell
a thousand for six hundred kurdí. Also, fine needles for silk-work are
in request, but only in small quantity, while large darning-needles are
not at all wanted here, where the cotton cloth is fine, but are the
most profitable thing in Eastern Negroland, from Bagírmi inclusive to
Abyssinia.
Sword-blades, which are set here, are imported in considerable
quantity; as not only the Kél-owí and the neighbouring Tárki tribes,
but also the Háusáwa, Fúlbe, Nyffáwa, and Kanúri or Bórnu people,
are supplied from this market. Fifty thousand may be the general
annual amount of this article, which produces (the blade being
reckoned at one thousand kurdí) fifty millions. Almost all of them that
I saw, not only here, but even among the Tuarek near Timbúktu,
were from Solingen. Only a small proportion of the import remains in
the country; but the setting of the blades, which are again exported,
secures a great profit to the natives.
Very few firearms, as far as I became aware, are imported into this
market, although common muskets have begun to be imported by
way of Nýffi at extraordinarily cheap prices by the Americans. Pistols
and blunderbusses are privately sold by the merchants to princes or
great men.
The common razors made in Styria, with black, wooden handles,
bad as they are, are very much liked by the inhabitants, who know
how to sharpen them most beautifully, and strengthen the wretched
handle with a guard of copper. I had a tolerable supply of English
razors, and found that those bought for sixpence at home would sell
profitably, but that nobody would give, for a good razor, though ever
so excellent, more than one thousand kurdí; however, the better sort
are very fit for presents to men of importance, who know well their
value. In any case the handles ought to be strong, and not likely to
break. This commodity does certainly not much exceed two or three
millions.
French silks, called “hattáya,” were formerly in great request, but
at present seem to be a little out of vogue; and most of what is
imported here is exported again by second-hand buyers to Yóruba
and Gónja. The amount of this import into the Kanó market, I think,
does not exceed twenty millions.
An important branch of import is formed by articles of Arab dress,
chiefly bernúses, caftans, sedríyas, trousers, red caps, red sashes,
shawls. It is difficult to state, even approximately, the value of these
articles; but it cannot certainly be much less than fifty millions
altogether. The sort of dress most in request comes from Tunis, but a
good deal also from Egypt; and from the latter country come all the
white shawls with red borders, called “subéta” in Arabic, “aliyáfu” in
Háusa, and very much liked by the negroes as well as by the Tuarek.
The import of this article alone exceeds the value of ten millions. The
common articles of dress, of coarser workmanship, are made in
Tripoli. Red caps of very coarse description are now imported from
Leghorn, and find a sale, but are not liked by the free people.
Frankincense and spices—principally jáwi, benzoin, the resin
obtained from a species of styrax, “símbil” or Valeriana Celtica, and
cloves—form a not inconsiderable article of import, perhaps
amounting to fifteen millions. However, I exclude from this sum the
value of the rose oil which is annually imported in considerable
quantity, and begin a dear article, forms also an important one; but
very little of it comes into the general trade, almost all of it being
disposed of privately to the princes and great men, or given to them
in presents. I am inclined to estimate the value of this article
imported at about forty millions. Tin and many other smaller articles
may together be estimated at ten millions.
In the trade of Kanó there is another very interesting article, which
tends to unite very distant regions of Africa; this is copper—“ja-n-
kárfi.” A good deal of old copper—say fifty loads, together with about
twenty loads of zinc—is imported from Tripoli; but a considerable
supply of this useful and handsome metal is also imported every
year by the Jellába of Nímro in Wadáy, who bring it from the
celebrated copper-mine, “el hófra,” situate to the south of Dar-Fúr, of
which I shall have occasion to speak later.[33] I estimate the whole
import of this metal at about from fifteen to twenty millions; but it is to
be remarked that, so far from being to the disadvantage of the
Kanáwa, it proves a new material of industry, while only the smaller
part remains in the country.
With regard to the precious metals, a small supply of silver is
imported by the merchants, but rather exceptionally, most of the
latter being but agents or commissioners engaged to effect the sale
of the merchandise forwarded from Tripoli and Fezzán. The silver
likewise supplies a branch of industry, the silversmiths, who are
generally identical with the blacksmiths, being very clever in making
rings and anklets. In Kanó scarcely any tradesman will object to
receive a dollar in payment. With regard to iron, which forms a very
considerable branch of industry in the place, I will only say that it is
far inferior to that of Wándala or Mándara and Bubanjídda, which I
shall mention in the course of my proceedings. Spears, daggers,
hoes, and stirrups are the articles most extensively produced in iron.
As for gold, though a general standard, of the mithkál at four
thousand kurdí, is usually maintained, in Timbúktu its price greatly
varies, from three thousand five hundred up to four thousand five
hundred kurdí; but this unreasonable fluctuation is but nominal, gold
being scarcely ever bought in Timbúktu for ready money, but for
túrkedís, when a túrkedí bought in Kanó for eighteen hundred, or at
the utmost two thousand, fetches there a mithkál. One hundred
mithkáls of gold may easily be bought in Kanó at any time. Even the
common currency of the Kanó market, the “uri” (pl. kurdí) or shell
(Cypræa moneta), two thousand five hundred of which are equal to
the Spanish or Austrian dollar,[34] forms an important article of import
and commerce, though I have not been able to ascertain that a large
quantity is ever introduced at a time. Nevertheless that must
sometimes happen, as a great amount of shells has been exported
to Bórnu, where they have been recently introduced as currency;
and this obviously explains why since the year 1848 the demand for
these shells has so greatly increased on the coast.
These merely approximative figures cannot be reduced to the form
of a balance-sheet; but they will give a general idea of the
commercial activity of the place. I will conclude these few remarks by
observing that the market of Kanó is better supplied with articles of
food than any other market in Negroland; but meat as well as corn is
dearer here than in Kúkawa, particularly the latter. Besides the great
market-place, there are several smaller ones dispersed through the
town, the most noted of which are the káswa-n-kurmí, Mandáweli,
Hanga, káswa-n-máta, káswa-n-áyagi, káswa-n-Jírba, káswa-n-
Yákase, káswa-n-kófan Wámbay, and the káswa-n-kófan Náyisa.
The province of Kanó, which comprises a very fertile district of
considerable extent, contains, according to my computation, more
than two hundred thousand free people, besides at least an equal
number of slaves; so that the whole population of the province
amounts to more than half a million; though it may greatly exceed
this number. The governor is able to raise an army of seven
thousand horse, and more than twenty thousand men on foot. In the
most flourishing state of the country, the governor of Kanó is said to
have been able to bring into the field as many as ten thousand
horse.
The tribute which he levies is very large, considering the state of
the country, amounting altogether to about one hundred millions of
kurdí, besides the presents received from merchants. The most
considerable item of his revenue consists in, the “kurdí-n-kása” (what
is called in Kanúri “lárderám”), or the ground-rent. It is said to
amount to ninety millions, and is levied, both here and in the
province of Kátsena, not from the ground under cultivation, but every
head of a family has to pay two thousand five hundred kurdí, or just
a Spanish dollar; in the province of Zégzeg, on the contrary, the
kurdí-n-kása is a tax of five hundred kurdí levied on every fertáña or
hoe, and a single hoe will cultivate a piece of ground capable of
producing from one hundred to two hundred “démmi” or sheaves of
grain (sorghum and pennisetum), each of which contains two kél,
while fifty kél are reckoned sufficient for a man’s sustenance during a
whole year. Besides the kurdí-n-kása, the governor levies an annual
tax called “kurdí-n-korófi,” of seven hundred kurdí[35] on every
dyeing-pot or korófi, of which there are more than two thousand in
the town alone; a “fítto” of five hundred kurdí on every slave sold in
the market; an annual tax, “kurdí-n-debíno,” of six hundred kurdí on
every palm-tree, and a small tax called “kurdí-n-ráfi” on the
vegetables sold in the market, such as dánkali or sweet potatoes,
gwáza or yams, rísga, rógo, etc. This latter is very singular, as the
meat, or the cattle brought into the town, as far as I know, does not
pay any tax at all. Clapperton was mistaken in stating that all the
date-trees in the town belong to the governor, which is not more true
than that all the sheds in the market belong to him.
The authority of the governor is not absolute, even without
considering the appeal which lies to his liege lord in Sókoto or
Wúrno, if the subjects’ complaints can be made to reach so far; a
sort of ministerial council is formed, to act in conjunction with the
governor, which in important cases he cannot well avoid consulting.
At the head of this council stands the ghaladíma, whose office
originated, as we shall see, in the empire of Bórnu, and who very
often exercises, as is the case in Kanó, the highest influence,
surpassing that of the governor himself; then follows the “serkí-n-
dáwakay” (the master of the horse), an important charge in
barbarous countries, where victory depends almost always on the
cavalry; then the “bánda-n-Kanó” (a sort of commander-in-chief);
then the “alkáli” or chief justice, the “chiróma-n-Kanó” (the eldest son
of the governor, or some one assuming this title), who exercises the
chief power in the southern part of the province; the “serkí-n-báy”
(properly, the chief of the slaves), who has the inspection of the
northern districts of the province as far as Kazáure; then the “gadó”
or lord of the treasury, and finally the “serkí-n-sháno” (the master of
the oxen, or rather the quartermaster-general), who has all the
military stores under his care; for the ox, or rather the bull, is the
ordinary beast of burden in Negroland. It is characteristic that, when
the governor is absent paying his homage to his liege lord, it is not
the ghaladíma, but the gadó and the serkí-n-sháno who are his
lieutenants or substitutes.
With regard to the government in general, I think, in this province,
where there is so much lively intercourse, and where publicity is
given very soon to every incident, it is not oppressive, though the
behaviour of the ruling class is certainly haughty, and there is, no
doubt, a great deal of injustice inflicted in small matters. The
etiquette of the court, which is far more strict than in Sókoto, must
prevent any poor man from entering the presence of the governor.
The Fúlbe marry the handsome daughters of the subjugated tribe,
but would not condescend to give their own daughters to the men of
that tribe as wives. As far as I saw, their original type has been well
preserved as yet, though, by obtaining possession of wealth and
comfort, their warlike character has been greatly impaired, and the
Féllani-n-Kanó have become notorious for their cowardice
throughout the whole of Negroland.
 CHAPTER XXVI.
STARTING FOR KÚKAWA.—THE FRONTIER
DISTRICT.

Sunday, March 9.—The traveller who would leave a place where

he has made a long residence, often finds that his departure involves
him in a great deal of trouble, and is by no means an easy affair.
Moreover my situation when, after much delay, I was about to leave
Kanó, was peculiarly embarrassing. There was no caravan; the road
was infested by robbers; and I had only one servant upon whom I
could rely, or who was really attached to me, while I had been so
unwell the preceding day as to be unable to rise from my couch.
However, I was full of confidence; and with the same delight with
which a bird springs forth from its cage, I hastened to escape from
these narrow, dirty mud-walls into the boundless creation.
There being scarcely anyone to assist my faithful Gatróni, the
loading of my three camels took an immense time, and the
horseman destined to accompany me to the frontier of the Kanó
territory grew rather impatient. At length, at about two o’clock in the
afternoon, I mounted my unsightly black four-dollar nag, and
following my companion, who (in a showy dress, representing very
nearly the German costume about the time of the Thirty Years’ War,
and well mounted), gave himself all possible airs of dignity, started
forth from the narrow streets of Dalá, into the open fields.
I felt my heart lightened, and, forgetting what had passed, began
to think only of the wide field now opening before me, if fresh means
should reach us in Kúkawa. We had taken a very circuitous road in
order to pass through the widest of the fourteen gates of the town;
but the long passage through the wall was too narrow for my
unwieldy luggage; and my impatient, self-conceited companion fell
into despair, seeing that we should be unable to reach the night’s
quarters destined for us. At length all was again placed upon the
patient animals; and my noble Bú-Séfi taking the lead of the short
string of my caravan, we proceeded onwards, keeping at a short
distance from the wall, till we reached the highroad from the Kófa-n-
Wámbay. Here too is a considerable estate belonging to a ba-
Ásbenchí (a man from Asben), who has a company of slaves always
residing here. Going slowly on through the well-cultivated country,
we reached a small watercourse. Being anxious to know in what
direction the torrent had its discharge, and unable to make it out from
my own observation, I took the liberty of asking my companion; but
the self-conceited courtier, though born a slave, thought himself
insulted by such a question, and by the presumption that he ever
paid attention to such trivial things as the direction of a watercourse,
or the name of a village!
Having watered our horses here, I and my friend went on in
advance, to secure quarters for the night, and chose them in a small
hamlet, where, after some resistance, a mʿallem gave us up part of
his courtyard surrounded with a fence of the stalks of Guinea-corn.
When the camels came up we pitched our tent. The boy ʿAbdallah,
however, seeing that my party was so small, and fearing that we
should have some misadventure, had run away and returned to
Kanó.
Though there was much talk of thieves, who indeed infest the
whole neighbourhood of this great market-town, and, excited by the
hope of remaining unpunished under an indolent government, very
often carry off camels during the night even from the middle of the
town, we passed a tranquil night, and got off at a tolerably early hour
the next morning. The character of the country is almost the same as
that during our last day’s march in coming from Kátsena, small
clusters of huts and detached farms being spread about over the
cultivated country, where we observed also some tobacco-fields just
in flower: my attention was more attracted by a small range of hills in
the distance on our left. I was also astonished at the little traffic
which I observed on this route, though we met a considerable
natron-caravan coming from Zínder, the ass and the bullock going on
peaceably side by side, as is always the case in Negroland. The
country continued to improve; and the fields of Charó, shaded as
they were by luxuriant trees, looked fertile and well cared for, while
the clusters of neat huts scattered all about had an air of comfort.
Here we ought to have passed the previous night; and my
companion had gone in advance to deliver his order, and probably to
get a good luncheon instead of his missed supper. Beyond this
village, or rather district, cultivation seemed to be less careful; but
perhaps the reason was only that the villages were further from the
road.
The quiet course of domestic slavery has very little to offend the
mind of the traveller; the slave is generally well treated, is not
overworked, and is very often considered as a member of the family.
Scenes caused by the running away of a slave in consequence of
bad and severe treatment occur every day with the Arabs, who
generally sell their slaves, even those they have had some time, as
soon as occasion offers; but with the natives they are very rare.
However, I was surprised at observing so few home-born slaves in
Negroland—with the exception of the Tuarek, who seem to take
great pains to rear slaves—and I have come to the conclusion that
marriage among domestic slaves is very little encouraged by the
natives; indeed I think myself justified in supposing that a slave is
very rarely allowed to marry. This is an important circumstance in
considering domestic slavery in Central Africa; for if these domestic
slaves do not of themselves maintain their numbers, then the
deficiency arising from ordinary mortality must constantly be kept up
by a new supply, which can only be obtained by kidnapping or, more
generally, by predatory incursions, and it is this necessity which
makes even domestic slavery appear so baneful and pernicious. The
motive for making these observations in this place was the sight of a
band of slaves, whom we met this morning, led on in two files, and
fastened one to the other by a strong rope round the neck.
Our march was to be but a short one, as we were to pass the
remainder of the day and the following night in Gezáwa; and as it
was still long before noon, and we had the hottest time of the day
before us, I was anxious to encamp outside the town in the shade of
some fine tree, but my escort would not allow me to do so. We
therefore entered the town, which is surrounded with a clay wall in
tolerable repair, and moreover by a small ditch on the outside; but
the interior presents a desolate aspect, only about a third part of the
space being occupied by detached cottages. Here I was lodged in a
small hot shíbki (reed hut), and passed the “éni” most uncomfortably,
cursing my companion and all the escorts in the world, and resolved
never again to take up my quarters inside a town, except where I
was to make a stay of some length. I was therefore delighted, in the
course of the afternoon, to hear from the man who had taken the
camels outside the town upon the pasture-ground, that the sheríf
Konché had arrived and sent me his compliments.
I had once seen this man in Kanó, and had been advised to wait
for him, as he was likewise on his way to Kúkawa; but knowing how
slow Arabs are, and little suspecting what a sociable and amiable
man he was, I thought it better to go on; whereupon he, thinking that
my company was preferable to a longer stay, hastened to follow me.
To-day, however, I did not see him, as he had encamped outside the
town; still I had already much reason to thank him, as he had
brought back my fickle runaway servant ʿAbdallah, whom after some
reprimand, and a promise on his side to remain with me in future, I
took back, as I was very much in want of a servant. He was a native
of the country, a Baháushe with a little Arab blood in him, and had
been reduced to slavery. Afterwards, in Bórnu, a man claimed him as
his property. His mother, who was living not far from Gérki, was also
about this time carried into slavery, having gone to some village
where she was kidnapped. Such things are of daily occurrence in
these countries on the borders of two territories. The lad’s sister had
a similar fate.
The inhabitants of Gezáwa seem to be devoted almost entirely to
cattle-breeding; and in the market which was held to-day (as it is
every Monday) outside the town, nothing else was offered for sale
but cattle and sheep, scarcely a piece of cotton cloth being laid out,
and very little corn. Also round the town there are scarcely any
traces of cultivation. The mayor seemed not to be in very enviable
circumstances, and bore evident traces of sorrow and anxiety;
indeed the laziness and indolence of the governor of Kanó in
neglecting the defence of the wealth and the national riches of his
province are incredible, and can only be tolerated by a liege lord just
as lazy and indifferent as himself. But at that period the country still
enjoyed some tranquillity and happiness, while from the day on
which the rebel Bokhári took possession of Khadéja, as I shall soon
have occasion to relate, the inhabitants of all the eastern part of this
beautiful province underwent daily vexations, so that the towns on
this road were quite deserted when I passed a second time through
this country, in December 1854.
Early next morning we loaded our camels and left the town, in
order to join our new travelling companion, who by this time had also
got ready his little troop. It consisted of himself on horseback, his
“sirríya,” likewise on horseback, three female attendants, six natives,
and as many sumpter-oxen. He himself was a portly Arab, with fine,
sedate manners, such as usually distinguish wealthy people of the
Gharb (Morocco); for he was a native of Fás, and though in reality
not a sheríf (though the title of a sheríf in Negroland means scarcely
anything but an impudent, arrogant beggar), yet, by his education
and fine, noble character, he deserved certainly to be called a
gentleman. The name “Konché” (Mr. Sleep) had been given to him
by the natives, from his very reasonable custom of sleeping, or
pretending to sleep, the whole day during the Ramadan, which
enabled him to bear the fasting more easily. His real name was ʿAbd
el Khafíf.
Our first salutation was rather cold; but we soon became friends;
and I must say of him that he was the most noble Arab merchant I
have seen in Negroland. Though at present he had not much
merchandise of value with him, he was a wealthy man, and had
enormous demands upon several governors and princes in
Negroland, especially upon Múniyóma, or the governor of Múniyo,
who was indebted to him for about thirty millions—shells, of course,
but nevertheless a very large sum in this country. Of his “sirríya,”
who always rode at a respectful distance behind him, I cannot speak,
as she was veiled from top to toe; but if a conclusion might be drawn
from her attendants, who were very sprightly, well-formed young
girls, she must have been handsome. The male servants of my
friend were all characteristically dressed, and armed in the native
fashion with bows and arrows,—knapsacks, water-bottles, and
drinking vessels all hanging around them in picturesque confusion;
but among them there was a remarkable fellow, who had already
given me great surprise in Kanó. When lying one day in a feverish
state on my hard couch, I heard myself saluted in Romaic or modern
Greek. The man who thus addressed me had long whiskers, and
was as black as any negro. But I had some difficulty in believing him
to be a native of Negroland. Yet such he was, though by a stay in
Stambúl of some twenty years, from his boyhood, he had not only
learned the language perfectly, but also adopted the manners, and I
might almost say the features, of the modern Greeks. In such
company we continued pleasantly on, sometimes through a
cultivated country, at others through underwood, meeting now and
then a motley caravan of horses, oxen, and asses, all laden with
natron, and coming from Múniyo. Once there was also a mule with
the other beasts of burden; and on inquiry, on this occasion, I learnt
that this animal, which I had supposed to be frequent in Negroland,
is very rare, at least in these parts, and in Kanó always fetches the
high price of from sixty to eighty thousand kurdí, which is just double
the rate of a camel. In Wángara and Gónja the mule seems to be
more frequent. But there is only one in Kúkawa and in Timbúktu, the
latter belonging to one of the richest Morocco merchants.
Animated scenes succeeded each other:—now a well, where the
whole population of a village or zángo were busy in supplying their
wants for the day; then another, where a herd of cattle was just being
watered; a beautiful tamarind-tree spreading a shady canopy over a
busy group of talkative women selling victuals, ghussub-water, and
sour milk, or “cotton.” About ten o’clock detached dúm-palms began
to impart to the landscape a peculiar character, as we approached
the considerable but open place Gabezáwa, which at present
exhibited the busy and animated scene of a well-frequented market.
In this country the market days of the towns succeed each other by
turns, so that all the inhabitants of a considerable district can take
advantage every day of the traffic in the peculiar article in which
each of these places excels.
 While pushing our way through the rows of well-stocked sheds, I
became aware that we were approaching the limits of the Kanúri
language; for being thirsty, I wished to buy ghussub-water (“furá” in
Háusa), but in asking for it, received from the woman fresh butter
(“fulá” in Kanúri), and had some difficulty in making them understand
that I did not want the latter. Continuing our march without stopping,
we reached at noon the well-known (that is to say, among the
travelling natives) camping ground of Kúka mairuá, an open place
surrounded by several colossal specimens of the monkey-bread-
tree, kúka or Adansonia digitata, which all over this region of Central
Africa are not of that low, stunted growth which seems to be peculiar
to them near the coast, but in general attain to a height of from sixty
to eighty feet. Several troops of native traders were already
encamped here, while a string of some thirty camels, most of them
unloaded, and destined to be sold in Kanó, had just arrived. A wide-
spreading tamarind-tree formed a natural roof over a busy market-
scene, where numbers of women were selling all the eatables and
delicacies of the country. The village lay to the south-east. Here we
pitched our tents close together, as robbers and thieves are very
numerous in the neighbourhood; and I fired repeatedly during the
night, a precaution which the event proved to be not at all useless.
The name of the place signifies “the Adansonia with the water.”
However, the latter part of the name seemed rather ironical, as I had
to pay forty kurdí for filling a water-skin, and for watering my horse
and my camels; and I would therefore not advise a future traveller to
go to a neighbouring village, which bears the name of “Kúka
maífurá,” in the belief that he may find there plenty of cheap furá or
ghussub-water.
Wednesday, March 12.—Our encampment was busy from the very
first dawn of day, and exhibited strong proof of industry on the part of
the natives; for even at this hour women were offering ready-cooked
pudding as a luncheon to the travellers. Some of our fellow-sleepers
on this camping-ground started early; and the two Welád Slimán
also, who led the string of camels, started off most imprudently in the
twilight. As for us we waited till everything was clearly discernible,
and then took the opposite direction through underwood; and we had
advanced but a short distance when a man came running after us,
bringing us the exciting news that a party of Tuarek had fallen upon
the two Arabs, and after wounding the elder of them, who had made
some resistance, had carried off all their camels but three. I
expressed my surprise to my horseman that such a thing could
happen on the territory of the governor of Kanó, and urged him to
collect some people of the neighbouring villages, in order to rescue
the property, which might have been easily done; but he was quite
indifferent, and smiling in his self-conceit, and pulling his little straw
hat on one side of his head, he went on before us.
Small villages belonging to the district of Zákara were on each
side, the inhabitants indulging still in security and happiness; the
following year they were plunged into an abyss of misery, Bokhári
making a sudden inroad on a market-day, and carrying off as many
as a thousand persons. I here had a proof of the great
inconvenience which many parts of Negroland suffer with regard to
water, for the well at which we watered our horses this morning
measured no less than three and thirty fathoms; but I afterwards
found that this is a very common thing as well in Bórnu as in
Bagírmi, while in other regions I shall have to mention wells as much
as sixty fathoms deep. Beyond this spot we met a very numerous
caravan with natron, coming from Kúkawa; and I therefore eagerly
inquired the news of that place from the horsemen who
accompanied it. All was well; but they had not heard either of the
arrival or of the approach of a Christian. This natron, which is
obtained in the neighbourhood of the Tsád, was all in large pieces
like stone, and is carried in nets, while that coming from Múniyo
consists entirely of rubble, and is conveyed in bags, or a sort of
basket. The former is called “kílbu tsaráfu,” while the name of the
latter is “kílbu bóktor.” We soon saw other troops laden with this
latter article; and there were even several mules among the beasts
of burden. The commerce of this article is very important; and I
counted to-day more than five hundred loads of natron that we met
on our road.
I then went on in advance with “Mr. Sleep,” and soon reached the
village Dóka, which by the Arabs travelling in Negroland is called, in
semi-barbarous Arabic, “Súk el karága,” karága being a Bórnu word
meaning wilderness. The village belongs to the ghaladíma. Here we
sat tranquilly down near the market-place, in the shade of some
beautiful tamarind-trees, and indulged in the luxuries which my
gentlemanlike companion could afford. I was astonished, as well as
ashamed at the comfort which my African friend displayed, ordering
one of the female attendants of his sirríya to bring into his presence
a basket which seemed to be under the special protection of the
latter, and drawing forth from it a variety of well-baked pastry, which
he spread on a napkin before us, while another of the attendants
was boiling the coffee. The barbarian and the civilized European
seemed to have changed places; and, in order to contribute
something to our repast, I went to the market and bought a couple of
young onions. Really is incredible what a European traveller in these
countries has to endure; for while he must bear infinitely more
fatigue, anxiety, and mental exertion than any native traveller, he is
deprived of even the little comfort which the country affords—has no
one to cook his supper, and to take care of him when he falls sick, or
to shampoo him;

“And, ah! no wife or mother’s care

For him the milk or corn prepare.”

Leaving my companion to indulge in the “kief” of the Osmánli, of

which he possessed a great deal, I preferred roving about. I
observed that during the rainy season a great deal of water must
collect here, which probably explains the luxurious vegetation and
the splendid foliage of the trees hereabouts; and I was confirmed in
my observation by my companion, who had travelled through this
district during the rainy season, and was strongly impressed with the
difficulties arising from the water, which covers a great part of the
surface.
Having allowed our people, who by this time had come up, to have
a considerable start in advance of us, we followed at length, entering
underwood, from which we did not emerge till we arrived near Gérki.
According to instructions received from us, our people had already
chosen the camping ground on the north-west side of the town; but
my horseman, who had gone in advance with them, thought it first
necessary to conduct me into the presence of the governor, or rather
of one of the five governors who rule over this place, each of them
thinking himself more important than his colleague. The one to whom
he presented me was, however, a very unprepossessing man, and
not the same who on my return from the west in 1854 treated me
with extraordinary respect. Yet he did not behave inhospitably to me:
for he sent me a sheep (not very fat indeed), with some corn and
fresh milk. Milk during the whole of my journey formed my greatest
luxury; but I would advise any African traveller to be particularly
careful with this article, which is capable of destroying a weak
stomach entirely; and he would do better to make it a rule always to
mix it with a little water, or to have it boiled.
The town of Gérki is a considerable place, and under a strong
government would form a most important frontier-town. As it is, it
may probably contain about fifteen thousand inhabitants; but they
are notorious for their thievish propensities, and the wild state of the
country around bears ample testimony to their want of industry. The
market, which is held here before the south-west gate, is of the most
indifferent description. The wall with its pinnacles is in very good
repair. In order to keep the thievish disposition of the natives in
check, I fired some shots late in the evening; and we slept
undisturbed. On my return journey, however, in 1854, when I was
quite alone with my party, I was less fortunate, a most enterprising
thief returning thrice to his task, and carrying away, one after the
other, first the tobe, then the trousers, and finally the cap from one of
my people.
Thursday, March 13.—Not waiting for the new horseman whom I
was to receive here early in the morning, I went on in advance with
my companion, in order to reach Gúmmel before the heat of the day;
and we soon met in the forest a string of twelve camels, all laden
with kurdí or shells, and belonging to the rich Arab merchant Bú-
héma, who resides in Múniyo, and carries on a considerable
commerce between Kanó and Kúkawa. I will here mention, that in
general one hundred thousand kurdí are regarded as a camel-load;
a fine animal, however, like these will carry as much as a hundred
and fifty thousand, that is, just sixty dollars or twelve pounds’ worth.
It is easy to be understood that, where the standard coin is of so
unwieldy a nature, the commerce of the country cannot be of great
value.
About two miles before we reached the frontier town of the Bórnu
empire in this direction, we were joined by the horseman of the
governor of Gérki; and we here took leave of Háusa with its fine and
beautiful country, and its cheerful and industrious population. It is
remarkable what a difference there is between the character of the
ba-Háushe and the Kanúri—the former lively, spirited, and cheerful,
the latter melancholic, dejected, and brutal; and the same difference
is visible in their physiognomies—the former having in general
pleasant and regular features, and more graceful forms, while the
Kanúri, with his broad face, his wide nostrils, and his large bones,
makes a far less agreeable impression, especially the women, who
are very plain and certainly the ugliest in all Negroland,
notwithstanding their coquetry, in which they do not yield at all to the
Háusa women.
Birmenáwa is a very small town, but strongly fortified with an
earthen wall and two deep ditches, one inside and the other outside,
and only one gate on the west side. Around it there is a good deal of
cultivation, while the interior is tolerably well inhabited. Konché, who
was in a great hurry to reach Gúmmel, would have preferred going
on directly without entering the town: but as I was obliged to visit it in
order to change my horseman, it being of some importance to me to
arrive in Gúmmel with an escort, he accompanied me. The
population consists of mixed Háusa and Kanúri elements.
Having obtained another man, we continued our march through a
country partly under cultivation, partly covered with underwood, and
were pleased, near the village Tókun, to find the Háusa custom of a
little market held by the women on the roadside still prevailing; but
this was the last scene of the kind I was to see for a long time. We
reached the considerable town of Gúmmel just when the sun began
to shine with great power; and at the gate we separated, the sheríf
taking his way directly towards his quarters in the southern part of
the town, while I was obliged to go first to the house of the governor,
the famous Dan-Tanóma (the son of Tanóma, his own name being
entirely unknown to the people); but on account of his great age,
neither on this nor on a later occasion did I get a sight of him.
Indeed, he was soon to leave this world, and by his death to plunge
not only the town wherein he resided, but the whole neighbouring
country, into a destructive civil war between his two sons.
However, on my first visit Gúmmel was still a flourishing place, and
well inhabited, and I had to pass through an intricate labyrinth of
narrow streets enclosed between fences of mats and reeds
surrounding huts and courtyards, before I reached the dwellings of
the few Arabs who live here: and after looking about for some time I
obtained quarters near the house of Sálem Maidúkia (the Rothschild
of Gúmmel), where my Morocco friend was lodged. But my lodgings
required building in the first instance, as they consisted of nothing
but a courtyard, the fence of which was in a state of utter decay, and
a hut entirely fallen in, so that there was not the least shelter from
the sun, whereas I had to wait here two days at least for my new
friend, whose company I was not inclined to forego, without very
strong reasons, on my journey to Kúkawa.
However, building is not so difficult in Negroland as it is in Europe;
and a most comfortable dwelling, though rather light, and liable to
catch fire, may be erected in a few hours; even a roof is very
sufficiently made, at least such as is here wanted during the dry
season, with those thick mats, made of reed, called “síggedi” in
Bórnu. But most fortunately Sálem had a conical roof just ready,
which would have afforded satisfactory shelter even from the
heaviest rain. I therefore sent immediately my whole remaining
supply of kurdí to the market to buy those mats and sticks; and
getting four men practised in this sort of workmanship, I immediately
set to work, and, long before my camels arrived, had a well-fenced
private courtyard, and a splendid cool shade, while my tent served
as a store for my luggage, and as a bedroom for myself.
Having, therefore, made myself comfortable, I was quite prepared
to indulge in the luxurious luncheon sent me by the maidúkia,
consisting of a well-cooked paste of Negro millet with sour milk; after
which I received visits from the few Arabs residing here, and was
pleased to find one among them who had been Clapperton’s
servant, and was well acquainted with the whole proceedings of the
first expedition. He had been travelling about a good deal, and was
able, with the assistance of a companion of his, to give me a
tolerably complete itinerary of the route from Sókoto to Gónja, the
gúro-country and the northern province of Asianti. These Arabs
necessarily lead here a very miserable sort of existence; Sálem,
however, a native of Sókna, has succeeded in amassing a
considerable fortune for these regions, and is therefore called by the
natives maidúkia. He had a freed slave of the name of Mohammed
Abbeakúta, who, though not at all an amiable man, and rather self-
conceited, nevertheless gave me some interesting information.
Among other things, he gave me a very curious list of native names
of the months, which are not, however, those used by the Háusáwa,
nor, I think, by the Yórubáwa, he having been evidently a native of
Yóruba. He also gave me the following receipt for an antidote in the
case of a person being wounded by poisoned arrows: a very young
chicken is boiled with the fruits of the chamsínda, the áddwa
(Balanites), and the tamarind-tree; and the bitter decoction so
obtained, which is carried in a small leathern bag ready for use, is
drunk immediately after receiving the poisonous wound, when, as he
affirmed, the effect of the poison is counteracted by the medicine.
The chicken would seem to have very little effect in the composition,
but may be added as a charm. The next morning I went with ʿAbd el
Khafíf to pay our compliments to old Dan-Tanóma. His residence,
surrounded by high clay walls, and including, besides numbers of
huts for his household and numerous wives, some spacious halls of
clay, was of considerable extent; and the courtyard, shaded by a
wide-spreading, luxuriant tamarind-tree, was a very noble area.
While we sat there awaiting the governor’s pleasure, I had a fair
insight into the concerns of this little court, all the well-fed, idle
parasites coming in one after the other, and rivalling each other in
trivial jokes. The Háusa language is the language of the court; and
the offices are similar to those which I mentioned above with regard
to Kanó. Having waited a long time in vain, the weak old man
sending an excuse, as he could not grant us an interview, we
returned to our quarters.