Talking Therapy: Knowledge and Power in American Psychiatric Nursing by Kylie Smith

Abstract

Reviewed by: Talking Therapy: Knowledge and Power in American Psychiatric Nursing by Kylie Smith Dominique Tobbell Kylie Smith. Talking Therapy: Knowledge and Power in American Psychiatric Nursing. Critical Issues in Health and Medicine. New Brunswick, N.J.: Rutgers University Press, 2020. 192 pp. Ill. $28.95 (978-1-978801-45-5). “Where Are the Nurses in the History of Psychiatry?” asks Kylie Smith in the introduction of Talking Therapy (p. 1). Despite robust literatures on both the history of American psychiatry and the history of American nursing, historians have given little consideration to the question. Talking Therapy, however, makes clear that nurses have been central historical actors in the development of psychiatry and mental health since the late nineteenth century. As the largest workforce in relation to mental health, nurses not only have delivered vital care but also have produced, disseminated, and integrated new knowledge about mental health that has been integral to the transformation of psychiatric and mental health practices over the course of the twentieth century. In five concise chapters and a brief conclusion and epilogue, Smith documents the “journey of nurses in psychiatry,” beginning in the late nineteenth century with the intersecting emergence of trained nurses and specialty psychiatric practice (p. 2). As Smith shows, trained nurses were a critical source of legitimacy for the newly emergent profession of psychiatry. For psychiatry to be “taken seriously as a medical and scientific practice,” asylums needed to become “serious places of treatment and care, more than mere institutions of custodial containment” (p. 15). This hinged on psychiatrists’ ability to control the training and practices of the nurses working within the asylum walls. Yet psychiatric nurses had their own professionalizing agenda, which depended on their ability to expand and control the knowledge base and scope of their practice. Debates over who should and would control psychiatric nursing education continued through the interwar years. But after World War II, concerns about the psychological health of returning soldiers and the establishment in 1948 of the National Institute of Mental Health helped facilitate the establishment of advanced education in psychiatric nursing (at the master’s degree level) controlled by and for nurses in university-based nursing schools. As psychiatric nurses established themselves as independent expert mental health practitioners, they moved out of the hospital and into increasingly important roles in outpatient and community health settings. Drawing upon the published writings of psychiatric nurses, the reports of professional nursing organizations, and the personal papers of psychiatric nurse leaders, Talking Therapy is a history of the “ideas that informed psychiatric nursing in the critical stage of its development” (p. 134). Smith is particularly interested in the ways in which psychiatric nurses conceived of the care they would provide, how their notions of care changed over time, and the tensions that emerged between the ideals of care as developed in theory and the realities of care as practiced. In doing so, Smith demonstrates a series of contradictions within psychiatric nurses’ efforts to transform psychiatric care, which included reinforcing the problematic tendency of social control within psychiatry even as they sought to challenge it. For example, during the interwar years, psychiatric nurses engaged the concept of mental hygiene, which aimed to prevent mental illness through the practice [End Page 264] of public health nursing and to reform care within the psychiatric hospital. But “in its emphasis on prevention, mental hygiene also relied on surveillance of the patient in their total environment, and despite its liberating potential also had strong tendencies to normalization and even eugenics” (p. 29). So too, Smith makes clear the complicated role of psychiatric nurses in upholding and dismantling racial segregation in psychiatry. Black nurses, for example, encountered profound barriers to education, training, and careers in psychiatric nursing because of widespread racial discrimination even beyond the segregated South. And as nurses worked, after World War II, to integrate psychiatric nursing and to bring much-needed psychiatric services to Black patients in the South, their efforts to do so were undermined by “the effects of deeply held racist beliefs and segregated practices” (p. 110). The professionalization of psychiatric nursing was also a gendered project. At the turn of the twentieth century, when psychiatrists advocated for...