us public inpatient 1830- 1955 public inpatient 1955-2006
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US PUBLIC INPATIENT 1830-1955
0
100
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600
1830 1875 1920 1955
residents
PUBLIC INPATIENT 1955-2006
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200
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1955 1970 1990 2006
residents
TRANSFORMATION IN 20th CENTURY
• CUCKOO’S NEST • PUBLIC MENTAL HOSPITALS CENTRAL• LONG INPATIENT STAYS – “CHRONICS”• MORE SOCIAL CONTROL THAN
TREATMENT• NO PATIENT RIGHTS• VOLUNTARIES• INSTITUTIONALISM
NO PLACE ON EARTH FOR ME
• SYLVIA FRUMKIN
• SHORT HOSPITAL STAYS
• LONG STAYS IN COMMUNITY
• MUCH LESS SOCIAL CONTROL
• MORE PATIENT RIGHTS
• HARD TO ENTER VOLUNTARILY
• ANTI-INSTITUTIONALISM
TRANSFORMATION
• INCREDIBLY SHORT PERIOD - CUCKOO’S NEST IN 1963 (1975); FRUMKIN IN 1978 (1982)
• WHAT WAS TRANSFORMATION?
• REASONS FOR TRANSFORMATION.
I. 1800-1850
• AROSE IN U.S. ABOUT 1800
• PREVIOUSLY FAMILY RESPONSIBILITY
• IF NO FAMILY EXILED OR JAILED
• MENTAL HOSPITALS INITIALLY HUMANE REFORM
ENLIGHTENMENT PHILOSOPHY
• REMOVE PEOPLE FROM STRESSFUL ENVIRONMENT
• COUNTRY SETTINGS - ISOLATED FROM FAMILIES AND COMMUNITIES
• PROVIDE MORAL TREATMENT IN CALM AND RESTFUL ENVIRONMENT
• MAINLY MIDDLE AND UPPER CLASS CLIENTS
II. TRANSFORMATION
• GROWTH OF POPULATION
• HUGE BUREAUCRACIES
• NO EFFECTIVE TREATMENTS
• MANAGEMENT AND CONTROL
PATIENTS 1850-1955
• LOWER SES, IMMIGRANT, ELDERLY
• LONG STAYS, HIGH DEATH RATES
• CHRONIC CONDITIONS - SCHIZ., SYPHILUS, ALCOHOLISM
• INSTITUTIONALISM: APATHY, ADJUST, DON’T WANT TO LEAVE
SUMMARY AS OF 1955
• LARGE ISOLATED INSTITUTIONS
• CUSTODIAL WITH LITTLE TREATMENT
• LONG STAYS, FEW RELEASES, MANY ELDERLY PATIENTS
• NO ALTERNATIVES
III. DI (1955 - PRESENT)
• REMOVE PATIENTS FROM HOSPITAL, ADMIT FEWER PATIENTS, USE OF COMMUNITY TREATMENT
• BEGINS IN 1955 - REVERSAL OF 150 YEAR OLD TREND
• HIGHLY CONTROVERSIAL - CRIME, HOMELESSNESS, NEGLECT
PUBLIC INPATIENT 1955-2006
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1955 1970 1990 2006
residentsadmit
RESIDENTS OF PUBLIC MENTAL HOSPITALS
• DRASTIC DECLINE IN RESIDENTS, 1955-2006 (“OPENING BACK DOOR”)
• 1955 - 560,000; 1970 - 450,000; 1980 - 140,000; 1990 - 100,000; 2006 - 80,000
• INCREASE IN ADMISSIONS 1955-1970, DECREASE SINCE THEN (“CLOSING FRONT DOOR”)
PUBLIC MENTAL HOSPITALS NOW
• NO LONGER THE MAJOR PART OF SYSTEM
• PLACE OF LAST RESORT - VIOLENT, DIFFICULT TO TREAT (FRUMKINS) OR NOWHERE ELSE TO GO
• STILL 2/3 OF STATE EXPENSE
• FIXED COSTS, UNIONS, COMMUNITIES
CHANGE IN PATIENTS
• FROM ELDERLY, LONG-TERM, SCHIZ. AND BRAIN DISEASE
• TO YOUNG, SHORT-TERM, DRUG USERS (MICA)
• SAME: POOR, MINORITIES, MALES
INPATIENT TREATMENT NOW
• MOST IN GENERAL HOSPITALS• GROWTH OF PRIVATE, SPECIALIZED
HOSPITALS• SHORT STAYS – 1 TO 2 WEEKS OR AS
LONG AS HAVE INSURANCE • WHITE, FEMALE, DEPRESSION,
ALCOHOL, EATING DISORDERS• ELDERLY NOW IN NURSING HOMES
SUMMARY OF CHANGES
• DRASTIC DECLINE IN NATURE AND CENTRALITY OF PUBLIC MENTAL HOSPITALS
• NOT LONG STAYS BUT SHORT STAYS WITH LONG SPELLS IN COMMUNITY
• MOST INPATIENT TREATMENT IN GENERAL OR PRIVATE HOSPITALS
• RISE OF NURSING HOMES
PATIENTS
• PATIENTS IN PUBLIC MENTAL HOSPITALS STILL POOR/ MINORITY
• NOW YOUNG, DRUG USING, HARD TO HANDLE; NOT OLD, COMPLIANT, AND INSTITUTIONALIZED
Grade distribution – 2nd Hourly ExamGrade Range N
A 90-100 77 B+ 88 12B 80-86 65C+ 78 20C 60-76 63D 50-58 8F <50 3
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