Transformation in 20th century cuckoo’s nest

US PUBLIC INPATIENT 1830-1955

PUBLIC INPATIENT 1955-2006

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

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 Exam

• Grade Range N

• A 90-100 77

• B+ 88 12

• B 80-86 65

• C+ 78 20

• C 60-76 63

• D 50-58 8

• F <50 3