http://exhibits.library.stonybrook.edu/mfp/files/original/b97c9ed1045d743c104ef57163e90f61.pdf cca8258a1cb2c00bbe3baaafbd7ccf91 PDF Text Text Sociopsychologic Aspects of Psychiatric Treatments in a Voluntary Mental Hospital Duration of Hospitalization. Qis‘éttarge Ratings. and Diagnosis ROBERT L. KAHN. P|1.D.; MAX POLLACK. Ph.D.. AND J’ MAX FINKI M.D. GLEN OAKS. N. Y. �Reprinted from the A. ill. .4. Archives of General Psychiatry December 1959, Vol. 1. pp. 565—574 Copyright 1959, by American .llca’ical Association Sociopsychologic Aspects of Psychiatric Treatment in a Voluntary Mental Hospital Duration of Hospitalization, Discharge Ratings, and Diagnosis ROBERT L. KAI-IN, Ph.D.; MAX POLLACK, Ph.D., and The increasing studies of the sociopsy— chological aspects of psychiatric treatment in recent years have primarily been concerned with treatment patterns in the community}? private practice,29 and outpatient clinics.24’2" In the studies reported by Hollingshead, Redlich, and their co—workers “'27 it was found that social class was a major determinant of the type of psy— chiatric treatment in the New Haven com— munity. Patients from the upper classes were more frequently treated with psycho— therapy, while somatic or custodial care was commoner among the lower classes. They summarized their results by noting: “It was found that treatment does not depend on psychological and medical determinants alone, but on the status position of the pa— tient as well.” 27 Weinstock,29 reporting the results of a poll of the American Psycho— analytic Association, observed that the pa— tients being treated by their members in private practice came disproportionately from the better—educated, high—income pop— ulation. Similar ﬁndings have been noted in studies of outpatient facilities. Myers and Schaffer 24 showed that the higher a per— son’s social class the more likely he was to be accepted for psychotherapy, treated by more highly trained personnel, and treated intensively over a long period of time. In another study Rosenthal and Frank 28 Submitted for publication April 16, 1959. From the Department of Experimental Psychiatry, Hillside Hospital. Aided, in part, by Grants M-927 and MY—2092, National Institute of Mental Health, National 1n— stitutes of Health, US. Public Health Service. MAX PINK, M.D., Glen Oaks, N.Y. found almost a linear relationship, between educational level and frequency of referral for psychotherapy. A more critical test of the importance of sociopsychologic factors in relation to psychiatric treatment would be in a setting where the same therapeutic techniques and services were equally available to all patients. This requirement is met at Hillside Hospital, which is a nonproﬁt institution for the treatment of voluntary patients with “early and curable symptoms,” 11 who are admitted regardless of their ability to pay. One of the main criteria for accepting pa— tients is their “ability to participate proﬁt11 in ably Individual psychotherapy.” psychoanalytically oriented psychotherapy is regarded as the primary method of treatment, with physiodynamic therapies available when needed. The average length of hospital stay is seven months, although some patients stay for more than a year. In a previous study of the Hillside Hos— pital population,14 it was shown that the factors of age, education, place of birth, and degree of stereotypy, as measured by the California F Scale,1 were related to the selection of therapy. Those patients who were older, had less education, were foreign—born, and had high scores on the F Scale were more likely to receive convulsive therapy. In contrast, patients who were younger, better—educated, and native—born and obtained low scores on the F Scale re— ceived psychotherapy as their sole form of treatment. The purpose of the present study was to determine the relation of sociopsychological 27/565 �A. M. A. ARCHIVES OF GENERAL PSYCHIATRY factors to (1) the duration of hospitaliza— tion, (2) the clinical evaluations at time of discharge, and (3) the ﬁnal diagnosis. Method Population—The entire inpatient adult population of Hillside Hospital on March 7, 1957, was studied. This consisted of 171 patients, 57 male and 114 female, ranging in age from 16 to 68 years, ' i with a mean of 35 years. Procedure.——The patients were divided according to the duration of hospitalization, clinical response to treatment, and diagnosis. The duration was de— termined by the number of complete months in the hospital. The clinical response and the diagnosis were determined by the medical director at a staff evaluation conference, usually held just prior to the patient’s discharge. Each patient was rated as recovered, much improved, improved, or unim— proved on the basis of the reports of the therapist, supervising psychiatrist, and milieu staff. The discharge diagnoses were divided into four major groups: involutional psychosis, manic—depressive psychosis, schizophrenia, and psychoneurosis. These diagnostic categories included all but three patients in the population. Each patient was tested with a 10-item modi— ﬁcation of the California F Scale.” The F Scale is a questionnaire which has been related to such factors as authoritarianism, acquiescence, ethnocentrism, and rigidity.1 The subject reads 10 statements and indicates to what extent he agrees or disagrees with each, i.e., “a little,” “pretty much," or “very much.” The score for each item 1 to 7, and the total score from range is ranges 10 to 70. High scores indicate greater agreement with the statements. These are extreme, uncritical, or stereotyped expressions. For example, one statement is this: “If people would talk less and work more, everybody would be better off.” 1. Results Length of Hospitalization—In this population the duration of hospitalization ranged from 1 to 16 months, with a median of 7 months. For the purpose of analysis, the population was divided into three groups: 49 patients Who were hospitalized for 1 to 5 months; 64, for 6 to 9 months, and 58 for 10 or more months. The relation of sociopsychological factors to the length of hospitalization is shown in Table l. The group of patients who were hospitalized for the shortest period had 28/566 of Hospitalization: Total Population TABLE 1.——Dnrati0n Months in Hospilal to to 1 6 No. 5 S) or more 1.0 49 64 58 l 6 to 51‘s. ﬁlo?) to 5 vs. 10 or more to 9 vs. 10 or more Education. Mean ForeignYr. Born F Score. Mean Mean Yr. 43.9 31.0 45.5 32.5 27.9 10.0 11.9 12.8 Mean M can Diﬂ'e- Mean Differ- ences ences 13.0 § 1.9 T § 40.1 Diﬁ: reneos 1 Age, 3.4 12.9 § 17.6 § 2.8 9.5 § 4.6 * 0.9 41% 19% 10% x ’=15.0 I P<0.05. P<0.02. I P<0.01. § P<0.001. * 1‘ the highest mean F scores, were oldest, and had the least education and the largest per— centage of foreign—born. Conversely, the group in the hospital for 10 months or more had the lowest F scores, were youngest, and had the most education and the smallest percentage of foreign births. Patients who were hospitalized for an intermediate period fell in be;ween these two groups for each of the factors. When the data for those patients who re— ceived convulsive therapy (Table 2) and those who received psychotherapy (Table 3) as their only form of treatment were analyzed separately, similar relationships between sociopsychological factors and length of hospitalization were found within each group. In the psychotherapy group there was an increase in mean years of education with greater months of hospitalization, but the differences fail of signiﬁcance. It may be noted, however, that many of the patients who were in the hospital for 10 months or more were under 19 years of age and were thus unable to achieve more than a limited number of years of schooling. These same relationships of sociopsychological factors to length of hospitalization were found when the patients were classi— Vol. 1, Dec., 1959 �SOCIOPSYCHOLOGIC ASPECTS OF PSYCHIATRIC TREATMENT TABLE 2,—Dnration of Hospitalization: Patients Receiving C onvnlswe Therapy F Score, N0. Mean Months in Hospital to 5 6 to 9 10 or more 15 1 17 25 58.2 45.6 34.9 ences to 5 vs. 1 to 5 v8. more 6 to 9 vs. more * T 1 § to 9 10 or 12.61 6 Differences 9.5 Education, Mean ForeignYr. * ‘ Months 1” Hospital Born 67% 24% 16% x2= 12.0 6.5 12.3 13.2 Mean or 1 '50 § 19.6 § * 10.1 1 t to 5 vs. to 5 vs. more to 9173. more 1 § 0.9 Education, Mean Yr. ForeignBorn 11-4 11-7 12.4 29-1 24-8 30% 16% 8% x2=5.4 istic of patients hospitalized for the longest periods. As a group, patients diagnosed as schizophrenic were the most homoge— neous in relation to time in the hospital, showing major differences only in the F score, without a consistent trend for the factors of education or place of birth. 2. Results of Treatment—The relation of sociopsychological factors to evaluation on discharge is shown in Table 5. There to 9 10 or 6 1.6 12.4 10 ences * Mean Differences 141* 0.3 * 1,0 18.4 or 10.8 4.3 0.7 a deﬁnite, almost linear, relationship be— tween the ratings of improvement and these factors. Patients in the recovered group had the highest F scores, were oldest, least educated, and showed the highest incidence of foreign birth. In contrast, patients in the unimproved group had the lowest F scores, were younger, better educated, and were mostly native—born. Because of the Wide variability within each group, however, only the factor of age reached a level of statistical signiﬁcance. Education also sig— niﬁcantly differentiated the groups when dichotomized according to- those who had less than eight years of education and those who had eight years or more. Of the re— covered patients, 29% had less than eight IS ﬁed according to four major diagnostic groups (Table 4). For each diagnostic class, the lowest F scores, youngest mean ages, most years of education, and least percentages of foreign—born were character— Mean Diﬁer- P=0.001. . - . . . 4.—Duration 0f Hospitalization in Patients Classiﬁed According to Diagnosis Diagnosis Involutional psychosis ___________________ Manic-depressive psychosis .............. Months in Hospital F Score, Mean 1-5 6-9 58.2 150.9 10+ 1—5 6-9 10+ ........................... 1-5 6-9 10+ ............................ 1-5 10+ Kahn et al. 432 Differences * Psychoneurosis 40-2 38-6 27-8 Mean OHCES 6.7 Mean Yr. 26 Mean Diﬂer5.8 F Score, Mean 33 43 5 Age, 1 P<0.05. P<0.02. P<0.01. P<0.001. TABLE N 0- to 9 or more 6 10 6 10.7 Schizophrenia of Hospitalization: Patients Receiving Psychotherapy Only 1 23.3 10 Mean Yr. 51.7 42.2 32.1 Mean Diﬁer1 Age, TABLE 3.———Dnration Age, Mean Yr. Education, Mean Yr. Foreign-Born 35.0 58.8 54.5 52.3 16.0 40.0 46.1 33.1 46.8 39.1 35.5 11.0 11.7 12.3 39% 23% 40.1 36.6 36.1 41.0 27.1 8.7 12.5 27.1 12.5 50% 19% 13% 36.3 38.5 27.6 27.8 27.8 24.1 13.3 12.3 12.9 7.1 9.6 57% 43% 0 0 10% 8% 12% 39/567 �A. M. A. ARCHIVES OF GENERAL PSYCHIATRY TABLE 5.—Discharge Evaluation No. Evaluation ............................... .......................... ................................ ............................. Recovered Much improved Improved Unimproved 17 ' 82 63 9 F Score, Mean Mean Yr. Education, Mean Yr. 42.9 39.0 36.1 31.1 44.5 35.6 31.2 31.1 10.7 11.2 11.2 13.2 Mean Mean Differences M ean Differences Recovered vs. Much Improved _____________________________ Recovered vs. Improved Recovered vs. Unimproved Much Improved vs. Improved Much Improved vs. Unimproved Improved vs. Uni mproved 3.9 6.8 11.8 2.9 7.9 5.0 .................................... ................................. ............................. ........................... ................................. Age, 8.9 13.3 * 13.4 * 4.4 4.5 0.1 T Foreign-Born 41% 22% 16% 11% x2=6.1 Differences I 0.5 0.5 2.5 0.0 2.0 2.0 ‘ P<0.05. t P<0.02. 3 P<0.01. years’ education, while all of the unimproved patients had more than eight years’ educa— tion; the much improved and improved pa— tients were in between. By x2—analysis these results were signiﬁcant at the 5% level of conﬁdence. When the data were analyzed for the patients treated with convulsive therapy, the trends noted for the population as a whole were intensiﬁed (Table 6). Analysis of the patients who received psychotherapy as their only form of treatment (Table 7), however, failed to show any statistically signiﬁcant pattern. The recovered patients were oldest and had the highest percentage of foreign births, but education and F score did not show any clear trend. TABLE relation of sociopsychological factors to diagnosis is shown in Table 8. Those patients classiﬁed as show— ing involutional reactions had the highest F scores, the oldest mean age, the least years of education, and the highest inci— dence of foreign birth. In contrast, pa— tients classiﬁed as schizophrenic had the lowest F scores, the youngest mean age, the most years of education, and the least num— ber of foreign—born. Patients classed in manic—depressive psychosis and psycho— neurosis categories were in between with regard to these social factors. 3. Diagnosis.‘—The Comment The present study has demonstrated that sociopsychological factors, in addition to 6.—Discharge Evaluation in Patients Receiving C onvnlsive Therapy Evaluation No. F Score, Mean Recovered _______________________________ Much improved __________________________ Improved and unimproved _______________ 8 26 23 53.1 41.8 39.7 Foreign-Born 51.6 43.8 32.3 9.4 10.6 12.3 50% 35% 17% x '=3.5 Mean Differences Recovered vs. much improved ______________________________ Recovered ”8. improved and unimproved ____________________ Much improved vs. improved and unimproved _____________ Mean Yr. Education, Mean Yr. Age, 11.3 13.4 " 2.1 Mean Mean Differences 7.8 19.3 I 11.5 T 1.2 2.9 1.7 Differences * ‘ P<0.05. P<0.02. 1 P<0.001. 1 30/568 Vat. 1, Dee, 1959 �SOCIOPSYCHOLOGIC ASPECTS OF PSYCHIATRIC TREATMENT TABLE 7.—Discharge Evaluation in Patients Receiving Psychotherapy Only N0. Evaluation ............................... .......................... Recovered Much improved Improved and unimproved ............... 9 54 39 F Score, Mean 32-6 38.1 33.5 Mean Diﬂerences .............................. ................... ............. Recovered vs. much improved Recovered vs. improved and unimproved Much improved vs. improved and unimproved 5.5 0.9 4.6 their previously determined importance in the selection of treatment, are also signiﬁ— cantly related to the duration of treatment, the evaluation of the results of treatment, and the psychiatric diagnosis. If such re— sults were obtained in a survey of private practitioners, as in the Weinstock report?9 it could be concluded that the limitation of the number of practitioners and the expense of treatment served to select preferred persons from the upper social classes who could afford the treatment in terms of time and money. The present results, however, were obtained in an institution where the various kinds of treatment were equally available to all patients and where the ability to pay was not a factor in the management of the patient. We postulate, therefore, that TABLE Diagnosis N 0. Involutional psychosis ___________________ Manic-Depressive psychosis ______________ Psychoneurosis ___________________________ Schizophrenia ____________________________ 24 39 37 68 .................. ForeigmBorn 38.2 32.2 31.9 12.3 12.0 12.2 33% 15% 18% Mean Differences 6.0 6.3 0.3 x '= 1.8 Mean Diﬁerences 0.3 0.1 0.2 the observed relationships are not due merely to mechanically selective aspects, such as income or the prestige status of the patient. Social factors are important be— cause they are also related to psychological processes, such as the habitual patterns of communication, modes of expression, and symbolic values. We shall attempt to evaluate these processes and their effect on the psychiatric relationships studied in terms of the inﬂuence of sociopsychological factors on the attitude and behavior of the therapist, the patient, and the therapist—pa— tient interaction. Current data both from this laboratory 14 and from others 19'24'27'28 have demon— strated that psychotherapy is most likely to be sustained with those persons who most 8.—Diagnosis F Score, Mean Mean Yr. 52.3 40.8 36.9 32.8 56.7 41.9 29.4 26.1 Mean Mean Differences Involutional vs. Manic-depressive psychosis ________________ Involutional psychosis vs. psychoneurosis Involutional vs. schizophrenia ______________________________ Manic-depressive psychosis vs. psychoneurosis _____________ Manic-depressive psychosis vs. schizophrenia _______________ Psychoneurosis us. schizophrenia___________________________ Mean Yr. Education, Mean Yr. Age, 11.5 15.4 19.5 3.9 8.0 4.1 I i § ’r Age, Education, Mean Yr. 8.9 11.5 11.9 12.7 Differences 14.8 27.3 30.6 12.5 15.8 3.1 2.0 ‘ 3.0 I 4.5 § 0.4 1.6 0.8 § § § § 46% 26% 22% 10% x==14,2 r Mean Differences § Foreign-Born P<0.05. T P<0.02. I P<0.01. § P<0.001. * K ahn et al 31/569 �A. M. A. ARCHIVES OF GENERAL PSYCHIATRY closely resemble the therapists with regard to cultural background, systems of value, and communication patterns. With stress at Hillside Hospital on psychoanalytically oriented psychotherapy, it is consistent that those patients who are most like the therapists with regard to these factors would be kept in the, hospital for the longest period. This was true for patients receiving convulsive therapy or psychotherapy and for all diagnostic groups. The length of time a patient remains in a psychiatric facility is related to the particular function and philosophy of the insti— tution. In studies of outpatient clinics ' Which have a psychoanalytic orientation 2438 it has been observed that persons from the higher social classes, determined by education' or income, are treated for a longer period. In contrast, in state mental hos— pitals, patients with/the least education are kept longer and form a higher proportion of the chronically hospitalized group‘.6'17"23 The state—hospital therapist, Viewing the in— Stitution primarily as a custodial facility,12 is evidently oriented toward the more rapid discharge of those patients “who come from a background most like his own. The observation of the relation between sociopsycholo-gical factdrs and improvement rating, particularly in those patients receiv— ing convulsive therapy, may also be related to differences in communication patterns between therapist and patient that result in referral for convulsive therapy. The therapist may set different criteria for im— provement for the;older, lesseducated pa— tients than he does for the younger, more sophisticated ones. In the patient with littlr education and with modes of expression different fromhis own, he may regard, for example, the manifestation of denial or minimization of symptoms as improvement.15 But in patients culturally like him— self, the expression of denial is regarded as a defensive operation, and the patient is considered unimproved. Ratings of improvement are also related to the base line of premorbid functioning. _ 32/570 Thus, the rating of recovered is deﬁned at Hillside Hospital as “the reasonable expectation that the patient will be able to return to his community and function as well, or better, than he did before he became ill.” 11 The therapist’s perception of the patient’s premorbid functioning may be influenced by the distance between his value system and that of the patient’s. The greater the social distance between therapist and patient the less rigorous the requirements for behavioral change may be. For example, for older, lower—class patients the ability to resume work may be the major criterion of improvement. For bettereducated patients work adjustment may be one of many criteria, including such intangible aspects of behavior as insight, work gratiﬁcation, and ease of sociability. The patient’s expectancy not only of the type of psychiatric treatment but of improvement is also dependent upon social back— ground.12 While the same trends were shown in the psychotherapy patients, the results did not reach the level of statistical signiﬁcance. This may have been due to the greater homogeneity of these patients for the factors studied, in contrast to the convulsive group. The outpatient study by Rosenthal and Frank 28 also failed to ﬁnd a relation between social factors and improvement rating in the patients who received psychotherapy. This observation, also, was obtained in a population that was more homogeneous after the initial admission selection process and after the spontaneous screening effected by the patient’s willingness to attend treatment after he had been accepted. The marked relationship between socio~ psychological factors and diagnosis is not surprising. Certainly, the relationship of age and diagnosis is an established concept in clinical psychiatry. In the involutional disorders and in dementia precox the names themselves have a chronological connotation. Landis and Page,19 in 1938, stated that age was the “most important single deterVol. 1, Dec., 19.59 �SOCIOPSYCHOLOGIC ASPECTS OF PSYCHIATRIC TREATMENT mining factor that we can know about men— tal disease.” They asserted that, given the age distribution of a group of patients, they could accurately predict the number in each diagnostic group, as well as the probable outcome with respect to recovery and the length of hospital residence. More recently, Frumkin,8 reporting the median ages of ﬁrst admissions to a mental hospital in Ohio, observed data similar to our own with re— gard to the ages for the various diagnostic groups. In the present study, however, we have also shown that education, place of birth, and F score signiﬁcantly differentiate the major diagnostic groups in the hospital. In view of these ﬁndings, we have postulated that a psychiatric diagnosis is not just a one—to—one reﬂection of a speciﬁc type of behavior pattern but is also a value judg— ment in terms of social interaction. Thus, both in our own studies and in the work of others 12 it has been noted that patients with similar symptoms will receive different diagnoses, depending on their social background. An additional hypothesis relating sociopsychologic factors to diagnosis may be based on the concept that persons from dif— ferent social backgrounds acquire different habitual modes of adaptation, communica— tion, and expression. Accordingly, under conditions of stress, altered brain function, or states associated with the onset of mental illness, a person will show those behavior patterns or symptoms which are similar to his habitual patterns. Thus, persons from a lower—class social background are more apt to communicate in nonverbal, physical terms, while upper—class people are more likely to do so in ideational and verbal modes. Thus, anger may be expressed by lower—class people by physical violence, while persons from the upper classes are more likely to resort to exhortation or argument. Opler and Singer,25 studying schizo— phrenic Irish and Italian patients in a Veteran’s facility, found signiﬁcant difKahn et al. ferences in the types of symptoms related to cultural differences in the family backgrounds. Patients from Irish families in which the active expression of emotions were frowned upon and who had dominant, overprotective mothers, were passive, com— pliant, and withdrawn, and were fearful of anything which might separate them from the protection of the hospital. Patients with Italian family backgrounds that encouraged free expression of emotion and who were ruled by a dominant father, showed as— saultive and destructive behavior, were difﬁ— cult to manage, and were rebellious against authority. In a comparable study, Miller and Swan— '22 noted that hospitalized schizophrenic son patients exhibited signiﬁcant social-class difference in symptomatology. Lower—class patients showed a predominance of “mo— toric themes,” while middle—class patients exhibited “conceptual or r u m i n a t i v e themes.” Hollingshead and Redlich 12 found a marked difference in the type of neuroses shown by persons from different social classes. While hysterical reactions were found predominantly at the lowest social levels, obsessive—compulsive patterns were characteristic of the upper classes. They felt that the lower—class patient expresses his neurosis by acting out, whereas the upper—class neurotic shows his symptoms in ideational dissatisfaction with himself. According to our hypothesis, then, we should expect that persons from lower social levels would show symptoms that are nonverbal, and are expressed predominantly in sensory or motor patterns. Among such types of symptoms would be psychomotor retardation, anorexia, catatonic stupor, muteness, hysterical blindness, and paral— ysis. In this connection it is noteworthy that both hysteria and manic—depressive psychosis have been reported on the wane in the general population."-”4'8'10 This de— crease, in our View, is related to the general increase in educational level of the country as a whole. One cannot, of course, ascribe 33/571 �A. M. A. ARCHIVES OF GENERAL PSYCHIATRY the decrease in hysteria to a greater freedom in sexual matters; hysteria is commonest in more poorly educated people, who are least 2‘6 has reported inhibited sexually.”6 Rees that those British soldiers who had hysteri— cal symptoms in World War II were mainly the mental defectives. He noted that hysterical symptoms were related to intelli— 7 indi— has education. and Freyhan gence cated not only that the present clinical patterns of hysteria are different from those shown at the turn of the century but that such schizophrenic manifestations as “cata— leptic stupors, stereotypical motor peculiar— ities, grandiose excitement, and violent behavior” are difﬁcult to ﬁnd today. These observations suggest that a sociopsycho— logical framework can lead to the prediction of future patterns of mental illness. In our investigations of persons with depressive psychoses, we have frequently noted a pattern of premorbid behavior char— acterized by lack of imagination, creativity, and introspective capacity, and by conven— tionality and general rigidity.13 Similar patterns have been reported by other .authors.3’5"”'21 We believe that a deprived cultural background, such as that involving little or no education, with the early years spent in an illiterate environment with meager cultural resources, is conducive to the development of such a personality pat— tern. When mentally disordered, such per— sons react with the repertoire of behavior patterns that we term “depression.” It is important to keep in mind that While the relationship between social factors and the psychiatric aspects described is probably applicable as a general principle, the speciﬁc ﬁndings may vary in different settings or institutions. For example, Hollingshead and Redlich12 found that schizophrenia was a diagnosis proportionately commoner among the lower than among the upper classes, while at Hillside Hospital the schizophrenic patients had the highest education. This discrepancy may be related to differences in composition of the two populations, the Hillside patients being drawn largely from 34/572 the middle—class groups, with relatively few from the upper or lower social classes. In Hillside Hospital the diagnosis of schizo— phrenia may indicate an “interesting” pa— tient, while in a state hospital population the same diagnosis may represent a patient who is “hopeless.” From the perspectives developed in this report, observations which are commonly explained in motivational and “dynamic” terms may also be understood in other ways. Thus, some situations where a pa~' tient is said to be “hostile” or “resisting psychotherapy” may reﬂect a problem in communication between patient and ther— apist, related to their differences in social background. It also is apparent that the social back— ground of the majority of the mentally ill paients is such as to make the current prac— tice of universally employing a verbal, in— sightful—oriented therapeutic approach a difﬁcult, if not inappropriate, procedure. The answer to the problem of how to treat the vast number of mentally ill may be not to train more and more psychother— apists, but, rather, to develop therapeutic techniques more suitable to the patient’s own systems of value and communication. Summary and Conclusions Signiﬁcant relationships were found be— tween sociopsychological factors and dura— tion of hospitalization, discharge evaluation, and diagnosis in a voluntary mental hos— pital. Patients hospitalized for the shortest period were oldest, had the least education, were most likely to have been foreign—born, and had the highest scores on the California F Scale. Younger, native—born, more educated, and lower F—score patients were hos— pitalized the longest. The same relationship of these factors to length of hospitalization was found when analyses were made according to type of treatment (convulsive therapy or psycho— therapy) and diagnosis. Discharge evaluations of improvement were signiﬁcantly related to age, the older Vol. 1, Dec, 1959 �SOCIOPSYCHOLOGIC ASPECTS OF PSYCHIATRIC TREATMENT . patients having the more favorable ratings. Analysis of the data by type of treatment demonstrated that patients rated as recovered or much improved after convulsive therapy had the highest F scores, the least education, and were most likely to be foreign-born. Diagnoses of schizophrenia or psycho— neurosis were associated with lower F scores, younger ages, more education, and native birth. The older, less educated, foreign—born, high-F-score patients were most frequently classiﬁed under involu— tional or manic-depressive psychosis. It is postulated that these relationships reﬂect the inﬂuence of social background on psychological processes, such as the habitual patterns of communication, modes of eXpression, and symbolic values. These not only contribute to the pattern of mental ill— ness but affect all aspects of the patient— therapist interaction. Hillside Hospital, 75-59 263d St. (Dr. Fink). REFERENCES Adorno, T. W.; Frenkel—Brunswik, E.; Levinson, D. J., and Sanford, R. N.: The Authoritarian Personality, New York, Harper & Brothers, 1950. 2. 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Disorder, prepared by a committee of the Society for Study of Social Problems, edited by A. M. Rose, New York, W. W. Norton & Company, Inc., 1955, pp. 136-160. Hamilton, D. M., and Mann, W. A.: The Hospital Treatment of Involutional Psychoses, in Depression, Proceeding 42d Annual Meeting of American Psychopathological Association, edited by P. H. Hoch and J. Zubin, New York, Grune & Stratton, Inc., 1952, pp. 199-209. 10. Harvey, W. A.: Changing Syndrome and Culture: Recent Studies in Comparative Psychiatry, Internat. J. Soc. Psychiat. 2:165—171, 1956. 11. Hillside Hospital: Twenty—Ninth Annual Report, 1956. 12. Hollingshead, A. B., and Redlich, F. C.: Social Class and Mental Illness: A Community Study, New York, John Wiley & Sons, Inc., 1958. 13. Kahn, R. L., and Fink, M.: Personality Factors in Behavioral Response to Electroshock Therapy, J. N europsychiatry, to be published. 14. Kahn, R. L.; Pollack, M., and Fink, M.: Social Factors in the Selection of Therapy in a. Voluntary Mental Hospital, J. Hillside Hosp. 6: 9. 216-228, 1957. Kahn, R. L., and Fink, M.: Changes in Language During Electroshock Therapy, in Psychopathology of Communication, Proceedings of 46th Annual Meeting of American Psychopathological Association, edited by P. H. Hoch and J. Zubin, New York, Grune & Stratton, Inc., 1958. 16. Kinsey, A. C.; Pomeroy, W. B., and Martin, C. 13.: Sexual Behavior in the Human Male, Philadelphia, W. B. Saunders Company, 1948. 17. Kramer, M.; Goldstein, H.; Israel, R. H., and JohnsonpN. A.: A Historical Study of the Disposition of First Admissions to a State Mental Hospital, Public Health Monograph No. 32, Government Printing Ofﬁce, 1955. 18. Kramer, K.; Pollack, E. S., and Redick, R. W.: Studies of Incidence and Prevalence of Hospitalized Mental Disorders in the United States: Current Status and Future Goals, paper read at the 49th Annual Meeting of the American Psychopathological Association, New York, 1959. 19. Landis, C., and Page, I. D.: Modern Society and Mental Disease, New York, Farrar & Rinehart, Inc., 1938. 20. Gallagher, E. B.; Levinson, D. J., and Erlich, I.: Some Sociopsychological Characteristics of Patients and Their Relevance for Psychiatric Treatment, in The Patient and the Mental Hos— pital, edited by M. Greenblatt, D. I. Levinson, and R. H. Williams, Chicago, Free Press, 1957. 21. Malamud, W.; Sands, S. L., and Malamud, I.: The Involutional Psychoses: A Socio—Psy— chiatric Study, Psychosom. Med. 3:410-426, 1941. 22. Miller, D. R., and Swanson, (3.: Defense Against Conﬂict and Social Background, paper 15. 35/573 V �A. M. A. ARCHIVES OF GENERAL PSYCHIATRY read as part of a symposium at the meeting of the American Psychological Association, September, 1953. 23. Morgan, N. C., and Johnson, N. Disorder, New York, Milbank Memorial Fund, 1950, pp. 51-52. 27. Robinson, H. A.; Redlich, F. C., and Myers, J. K.: Social Structure and Psychiatric Treatment, Am. J. Orthopsychiat. 24:307-316, A.: Failures in Psychiatry: The Chronic Hospital Patient, Am. J. Psychiat. 113 :824-830, 1957. 24. Myers, J. K., and Schaffer, L.: Social Stratiﬁcation and Psychiatric Practice: A Study of an Out-Patient Clinic, Am. Sociol. Rev. 19: Frank, J. D.: The Fate of Psychiatric Clinic Outpatients Assigned to Psychotherapy, J. Nerv. & Ment. Dis. 127:330— L.: Ethnic I.: Report of the Central 307-310, 1954. 25. Opler, M. K., and Singer, J. Differences Internat. J. 26. Rees, Gruenberg, 36/574 in Behavior and Psychopathology, Soc. Psychiat 2:11—22, 1956. J. R.: in discussion on paper by E. M., in Epidemiology of Mental Printed and Published 1954. 28. Rosenthal, D., and 343, 1958. 29. Weinstock, H. Committee of the American Psychoanalytic Association, paper read at the 48th Annual Meeting of the American Psychopathologi— cal Association, New York, 1958. Fact—Gathering in the United States of Amerm �a. "—1 “‘1 Sociopsychological Aspects of Psychiatric Treatment in Three Voluntary Hospitals Robert L. Kahn, Ph.D.*, Max Fink, M.D.**, Nathaniel Siegel, Ph.D.*** __..1 Fl l I J2 P ] �Sociopsychological Aspects of Psychiatric Treatment in Three Voluntary Hospitals Robert L. Kahn, Ph.D.*, Max Fink, M.D.**, Nathaniel Siegel, Ph.D.*** �This study was done when the authors were associated at the Department of Experimental Psychiatry, Hillside Hospital, Glen L.I. Oaks, New York, 1959—1962. The cooperation of Dr. Max Pollack and the staffs of the Massachusetts Mental Health Center and the C.F. Menninger Memorial Hospital is gratefully acknowledged. ' " Aided, in part, by grants My-2092 and MY—2715, of the National Institute of Mental Health, U.S. Public Health Service; and the Nassau County Mental Health Board. * Present Address: Division of Psychiatry, Montefiore .Hospital and Medical Center, 111 East 210th Street, York MIP 10467. New York, New ** Present Address: Department of Psychiatry at the Missouri Institute of Psychiatry, School of Medicine, University of Missouri, 5400 Arsenal Street, St. Louis, Missouri 63139 *** Present Address: National Institute of Mental Health, 2/1/65 Bethesda, Maryland �their studies of the psychiatric patient popsignificant relationships between an individual's position in the social class structure .and the incidence of treated illness, types of diagnosed disorders and kindsand duration of psychiatric treatment administered (2)9 The influence of the economic status of the patient on the availability of treating personnel, however, was not excludedo ulation, In New Haven Hollingshead and Redlich have reported Studies of the role of social factors in the treatment of hospitalized patients independent of their financial status and the availability of treatments were undertaken at Hillside Hospital in 1957. In this hospital, a variety of treatment modes, including in— dividual psychotherapy, pharmacotherapy and convulsive therapies were available to all patients regardless of their ability to paya In these surveys (3,4) we observed that patients hospitalized for the shortest periods were older, had less education and were more often of foreign birtho These older, less educated patients were predom— inantly treated by convulsive therapy and received more favorable clinical discharge ratings. In contrast, younger, native born and more educated patients were hospitalized for longer periods, treated primarily by psychotherapy and received poorer discharge ratingso These clinical factors were also related to a measure of stereotypy, the California F Scale (1,5)o Higher F scores, i429, greater stereotypy, were often fOund in patients diagnosed as involutional psychosis, who were referred for convulsive therapy, hospitalized for shorter periods, and more often were rated as much improved or recoveredg it was suggested that differencesin psychiatric treatment among hospitals should reflect the influence of social factors as noted for the patients within Hillside Hospitala To test this suggestion it was decided to employ the procedures of the 1957 Hillside study in three institutions Hillside In the survey reported here, —w F. Menninger Memorial Hospital in Topeka and the Hospital, the Massachusetts Mental Health Center in Boston, These institutions were selected with the expectation that they had diverse treatment modalities C. equally available, yet served patients of different social classeso Each provided short—term treatment of voluntary patients and did not provide custodial careo Each is a residency training center with a full time supervisory staff and active research units, emphasizing psycho- analytically—oriented psychotherapyo This study was designed to determine the population characterof the three institutions with respect to social class, age, education and F score; and to relate these characteristics to treatment variables of type of treatment, duration of hospitalization, diagnosis and discharge evaluation among the institutions, istics �METHOD A census of institutions all voluntary, adult patients in residence in in January, 1959. While Menninger and patients only, a small number of those at the Massachusetts Mental Health Center (MMHC) were assigned by the courts for psychiatric evaluation or were members of a chronic schizophrenic state hospital group transferred for a specific research project. These patients were excluded from the study because of their non—voluntary status. The California F scale was scored for each patient on the census the was undertaken Hillside Hospitals had voluntary day. Eighteen months later the records of discharged patients were examined to determine the social and psychiatric factors of the study. For a measure of social class, the Hollingshead 2-factor index a weighted score of education and occupation - was used (3,4,7). The study population consisted of 173 patients at Hillside, 100 at Menninger and 95 at the Massachusetts Mental Health Center. The study included examination of the relations of the social to the psychiatric variables within each institution as well as between institutions. These comparisons were difficult however, because of various methodological differences discussed below. These difficulties were most marked in the intra—hospital comparisons, and accordingly, in the analyses of psychiatric variables emphasis will be placed on the differences between institutions with citation of intra—institutional trends. These difficulties also led to missing information for some data, which is reflected in the tables by the varying population sample Sizes. �RESULTS A. Methodological Problems When of the hospital reporting studies tioned briefly. from one institution, the structure be taken for granted and either ignored or men— In gathering comparable data from multiple institu— may tions, however, the many differences between institutions are accen- tuated. While these institutions were selected as comparable in teaching, research and treatment programs, they were functionally unlike in ways which influenced the data of the study. Specific dif— ferences were prominent in the designation of type of treatment, diagnostic classifications, and the evaluation of treatment outcome. 1. Designation of Type of Treatment: designating that the institutions, a The criteria for patient received "psychotherapy" differed making comparisons difficult. among Hospital psychotherapy was designated as treatment administered on a prescription basis by a staff psychia— trist for which the patient was charged a feeo Sessions with the psychiatric resident were considered part of routine administrative patient care. At Menninger At Hillside Hospital psychotherapy was defined as treatment sessions with a psychiatric resident. Staff psychiatrists did not treat patients, but restricted their activities to supervising res— ident physicians. No additional fees were charged. At the Massachusetts Mental Health Center psychotherapy designated as the activity of many disciplines -- psychiatric residents, psychologists, social workers, nurses and medical students. Formal records of such sessions were not routinely included in the patient's record and to ascertain which patients received psychotherapy it was necessary for members of the study team to interview the resident responsible for each case. was Individual institutional diagnostic styles At Menninger Hospital diagnoses employed the multiple evaluative scheme recommended by the American Psychiatric Association, while both Hillside and MMHC followed different unitary systems. Several examples of diagnoses from Menninger are listed in Table I, with our suggested conversions into categories comparable to that of the other two institutions. These conversions provide a 2. Diagnosis: made comparisons source of difficult. distortion. �Table I 30 Discharge Ratings of Improvement: Ratings of imw provement at the three hOSpitals varied in format and detail. The discharge rating at Menninger Hospital was tripartite with a separate evaluation for social, characterological and syndrome changes. Hillside Hospital and Massachusetts Mental Health Center had global ratings.making it difficult to assess the contribution of each factor of the Menninger system (Table II), For this study the Menninger syndrome rating was compared to the global ratings of the other institutions, Table B. II Inter—hospital Comparison lo Sociopsycholqgical Variables The distribution of the variables of social class, age, among the three institutions education and California F Scale score is presented in Table III. Table III . a) Social Class: The anticipated difference in social class composition of the three institutions was observedo At Menninger Hospital the population was predominantly upper class; At Hillside Hospital, middle class; and at Massachusetts Mental Health Center, predominantly lower class. b) Age: There were no differences in age distribution in the institutional populationso �populations also differed in edu_” more years of education at Menninger Hospital than at Massachusetts Mental Health Center. While 41 per cent of the patients at MMHC had not completed high school, only 32 per cent at Hillside and 23 per cent at Menninger did not graduateo c) Education: The cational attainment, with patients having d) F Score: Differences in the distribution of scores on the California F Scale were also observed. Fifty—one per cent of Menninger patients had F scores below 30, and only eight perm cent with scores of 50 or above -— the higher F scores being assoc— iated with higher degrees of stereotypy, In contrast, at Hillside thirty—one per cent of the patients had F scores below 30 while at MMHC only twenty per cent were below 309 Thus, differences in social class, educational attainment and performance on the F Scale were observed. These differences permit a test of the hypotheses relating sociopsychologi- cal factors to the treatment variables among these institutions. 2. Psychiatric Treatment Variables a) Selection of Treatment: Among the institutions, significantly fewer patients at Menninger Hospital (43%) received somatic therapy than at Hillside (64%) or MMHC (68%) (Table IV)c b) Duration of Hospitalization: The three insti~ tutions differed with regard to patient's length of stay (Table IV)o Patients at Menninger Hospital were hospitalized longest, with 65% of patients remaining for twelve months or more, compared to 31 per-cent of the Hillside patients and only 5 per—cent at the Massachusetts Mental Health Center. The modal stay of the Hillside group was between seven and eleven months while two—thirds of the patients were discharged within six months of hospitalizatione MMHC 1,—— c) Discharge Evaluation: In each hospital, most were evaluated at the time of discharge as "improved" (Table IV), At Menninger Hospital, however, a higher percentage (19%) of patients were rated as "unimproved” and only a single patient was scored "recovered" or "much improved"a The highest percentage of "recovered" or "much improved" ratings (28%) and the lowest proportion of "unimproved" (10%) were found at the Massachu— patients setts Mental Health Centera d) nostic groupings Diagnosis: For statistical analysis three diagwere made: schizophrenia, affective disorders, and �psychoneurosis and personality disorders (Table IV)» The diag~ nostic proportions of patients within these groups were similar for Hillside and MMHC, as slightly more than half were diagnosed as schizophrenia and one~quarter as psychoneurosis or affective disordero In contrast, at Menninger Hospital psychoneurosis and personality disorder accounted for more than fifty perucent of the populationo Table Co IV Intra—Hospital Comparisons lack of meaningful criteria for the subdivision of populations, their homogeneity within each institution, and the limited sample size (several groupings were obtained which had fewer than five cases) precluded significant intra—hospital comparisonso However, the trends appeared similar to those found in the earlier studyg Age and F score were found related to the selection of treatment at Menninger Hospital (older and higher F score patients more frequently receiving somatic therapy), and F score alone at Hillsideo Length of hospitalization and chron— ological age were related at both the Menninger and Hillside Hospitals the younger patients remaining for the longest periodso While such relationships were significant in these two hospitals, a similar trend was noted at the MMHC (Table V) where no patients over 40, but 14% of patients under the age of 20 remained longer than a year, The — Table V �-7DISCUSSION The patients of three voluntary psychiatric hospitals exhibited significant inter-institutional differences in social class and years of education, but not age; in distribution of California F Scale scores; and in each of the treatment var~ duration of hospitalization, selection of treatments iables and distributions of diagnoses and discharge evaluations (7), Expectations based on our earlier intra—Hillside Hospital were confirmed, The institution serving upper class patients did have the longest duration of stay, a higher proportion of psychoneurotic diagnoses and more complex diagnostic schemata, a lower proportion of patients receiving somatic forms of therapy, and the poorest discharge ratings among the three institutions“ Similarly, the institution serving lower class patients did have the shorter periods of hospitalization, lower preportions of psychoneurotic diagnoses, and the better discharge evaluations, —— It is our impression that these differences in psymore to differences in staff attitudes and social class variables than psychiatric differences in populations, The contrasts between institutions in duration of hospitalization are great, as are the complexity of diagnostic formulations, discharge evaluations, definitions of psychotherapy, and the details and amount of recorded data. While these styl~ istic differences may be dismissed as idiosyncratic, they follow a pattern related to social differences, and their consistency with expectations suggests a greater dependence on social class variables than ordinarily acknowledged. chiatric treatment are related Such population and treatment variable relationships interactive are processes, determined both by the attitude of the physician and the administrative staff and by the constellation of symptoms or history which patients presente Such relationships are marked most in those psychiatric conditions where diagnostic criteria are least specific, i£§,, where objective criteria defining diseases of known etiology are absent, as in schizophrenia, psychoneurosis, personality and behavior disordersw Under these conditions of perceptual and situational ambiguity, the observer's attitudes and expectations become significant aspects of his perceptions, classifications, and decisions. A similar situation was clearly documented by Pasamanick, Dinitz and Lefton (6) in their study of variations in diagnosis within a single institution, They observed that patients assigned at random to different wards did not differ in type of admission, marital status, education, age or residenceo Significant differences did occur, however, in �the incidence of various diagnostic classifications among the three wards and among three administrators on one ward. As no differences in the populations were demonstrated, we believe the different incidence of diagnoses reflect the attitudes of the examinerso Present psychiatric concepts of diagnosis and clinical evaluation have little meaning when transferred from one insti— tution to anothero Literal adherance to these concepts produces paradoxical resultso For example, Menninger Hospital with the more highly trained personnel conducting treatment, keeps its patients for the longest time, has the fewest patients diagnosed as schizophrenia, and yet, reports the poorest treatment results. At MMHC, in contrast, which is most inclusive in defining a therapist, keeps patients for the shortest periods, and has a higher proportion of the population classed as schizophrenia, reports the best treatment results, In the absence of independent criteria for the quality of care or the assessment of comparability of populations for degree of illness among the institutions, these findings do not reflect the relative therapeutic efficacy of the institutionso Since the evaluations are based on the institution's own ratings, we believe that the differences reflect variations in the criteria used for evaluation of improvement rather than intrinsic psychi- atric characteristics. In our initial Hillside study (4) it was postulated that different criteria of improvement were utilized for persons of different social background° It was suggested that the higher the person's social background the more complex the criteria em— ployed° This has been literally confirmed in the present study, with the staff of Menninger Hospital using a tripartite rating compared to the global rating of the other two institutionso Even considering the syndrome rating on which our comparative statistical analyses were based, it is our contention that for lower class persons we are apt to assess improvement in relation to symptom relief or the patient's capacity to resume work, while for upper class persons the criteria emphasize such complex intangibles as "developing insight," or "working through one's problems." While these investigations have again demonstrated the role of social factors in psychiatric treatment, we have been greatly impressed by the methodological problems of studies across institutions. These institutions were selected for their educational �leadership and the expectation that the recorded variables would clearly defined. But differences in institutional style made to obtain comparable data. This experience is a cue difficult it to the problems of the conventional use of comparative statistics, especially in the evaluation of psychiatric therapieso The use of discharge ratings, diagnostic classifications or length of hospitalization as criteria in therapeutic evaluations or the iden— tification of comparable populations are subject to extensive error unless the institutions are clearly matched for staff attitudes and style as well as social class patterns in patient populationsc These difficulties also extend to the failures of scientists to confirm clinical or laboratory observations made in other labor— atories, for the lack of confirmation may reflect differences in populations and psychiatric criteria as much as errors in the original hypotheses. The use of the terms "schizophrenia" or "psycho— neurosis" to explore changes in psychological and biological features of mental illness has led to a science burdened by negative resultsa Even were a valid observation to be reported from one laboratory today, we do not have the methods to describe psychiatric populations adequately for a satisfactory test of the hypothesis. Increased attention must be paid to the classification of subjects by "objective" criteria rather than our present methods, so highly dependent on institutional and observer attitudes and the sociopsychological aspects of the therapist—patient interaction, be �-10_ SUMMARY AND CONCLUSION Population characteristics, defined by social class, and F score, were related to treatment variables education age, in three voluntary teaching hospitals. Treatment variables in~ cluded type of treatment, duration of hospitalization, diagnosis and discharge evaluationo Inter-institutional differences were observed in patient social class, years of education and distri— bution of California F scores, but not age. variations in treatment characteristics among significantly different in the predicted di— rection. The institution serving upper class patients did have the longest duration of stay, a higher proportion of psychoneurotic diagnoses and more complex diagnostic schemata, a lower proportion of patients receiving somatic forms of therapy, and the poorest discharge ratings among the three institutionso a-Similarly, the institution serving lower class patients did have the Shorter periods cf hospitalization, lower proportions of The institutions were psychoneurotic diagnoses, and the better discharge evaluations, These variations in psychiatric practices followed a with the social class differences among the inconsistent pattern and are not regarded as idiosyncratic. stitutions Such differences in institutional style make comparisons of diagnoses, duration of hospitalization and treatment results between institutions difficult and tenuous, and the need for more objective criteria for the classification of psychiatric popula- tions is emphasizedo �REFERENCES 1. Adorno, T. W., Frenkel-Brunswik, E., Levinson, D. J. and Sanford, R. N. The Authoritarian Personality. Harper and Brothers, New York, 1950, 990 pp. . and Redlich, F. C. Social Class and Community Study. John Wiley and Sons, Illness: New York, 1958, 442 pp. Hollingshead, Mental Inc., A. B. A . Kahn, R. L., Pollack, M. and Fink, M. Social Factors in the Selection of Therapy in a Voluntary Mental Hospital. J. Hillside Hosp., 1957, 6: 216—228. . Kahn, R. L., Pollack, and Fink, M. Sociopsychologic Aspects of Psychiatric Treatments in a Voluntary Mental Hospital: Duration of Hospitalization, Discharge Ratings and Diagnosis. Arch, Gen Psychiat., 1959, 15 565—574. M. Kahn, R. L., Pollack, M. and Fink, M. Social Attitude (Ca1— ifornia F Scale) and Convulsive Therapy. J4_Akuabhlkuugkjlui., 1960, lﬁQ: 187—192. Pasamanick, B., Dinitz, S. and Lefton, M. Psychiatric Orientation and its Relation to Diagnosis and Treatment in a Mental Hospital. Amari_Jm_EﬁxnhiaL., 1959, 116: 127-132. Siegel, N. H., Kahn, R. L., Pollack, M. and Fink, M. Social Class, Diagnosis and Treatment in Three Psychiatric Hospitals. Social Problems, 1962, lg; 191—196. �TABLE I Redesignation of Discharge Diagnoses Menninger Discharge Diagnoses Depressive Reaction Narcissistic Personality Anxiety Reaction General Classification Psychoneurosis Narcissistic Personality Psychoneurosis Narcissistic Personality Personality Trait Disturbance Narcissistic Personality Alcoholism, Chronic Infantile Personality Sociopathic Personality Disturbance Passive Aggressive Personality Alcoholism Sociopathic Personality Disturbance Infantile.Personality Schizophrenic Reaction, Schizo—Affective Type Schizophrenic Psychosis �TABLE II Comparative Ratings of Clinical Condition At Time of Hospital Discharge MENNINGER HOSPITAL Social Adjustment Improved Unimproved Character Structure Improved Unimproved Syndrome Complete Remission Improved Unchanged (or worse) HILLSIDE HOSPITAL MASSACHUSETTS MENTAL HEALTH CENTER Recovered Recovered Much Improved Markedly Improved Improved Moderately Improved Unimproved Slightly Improved Unimproved �III TABLE InterhospitaI Comparisons for Sociopsychological Variables Menninger Hillside N (87) (133) 1 31% 7% Hospital Social Class Massachusetts Mental Health Center Hospital (72) 3% 11 51 20 28 III 17 34 13 , 1v 1 34 28 v 0 5 28 x2 = 121.5; df=8: p:<.001 Age N (100) (173) ”(95) < 20 19% 19% 15% 20—39 59 ‘58 52 40 + 22 23 33 : x2 = =~ 32% 41% 12-15 54 51 49 16+ 23 17 10 7 = (91) 9.7; df=4; p<.05 (92) (163) (7%) 10-29 51% 33% 20% 30—49 41 50 38 8 17 42 N s °°re “—— 23% x2 F —= (173) -<12 Education -——'———“:=;= (100) N Years of 3.9; df=4; p=n.s. 50—70 1 x2 = 39.2; df=4; p<.001 �TABLE IV Interhospital Differences in Treatment Variables iMenninger Hillside (100) (173) Hospital N Type of Psychotherapy Treatment Somatic Other X2 = Duration 0? Hospital— lzat1°n Hospital Massachusett Mental Health Center (89) 21% 36% 24% 43 64 68 36 —- 8 82.8; df=4; p(.001 N (100), (173) (95) *7 months 22% 27% 67% 13 42 27 65 31 5 7—11 months 511 months Xzf 90.6; df=4' p<.001 N Recovered, Much Improved Discharge Evaluation Improved Unimproved XZ'= N Schizophrenia Discharge Diagnosis Affective Psychosis Psychoneurosis and Personality Disorder x2 = (99) (172) (88) 1% 23% 28% 80 62 61 19 15 10 29.3; df=4; p<.001 (95) (171) 4185) 43% 52% 54% 5 22 17 52 26 29 23.8; df=4; p<.001 �Duration of Hospitalization By Age PERCENTAGE OF AGE GROUP STAYING OVER ONE YEAR Age. Menninger Hillside 81 42 20-29 73 36 30-39 61 3O 40—49 30 20 50+ 36 Below 20 MMHC l4 �� Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Published Works Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Sociopsychologic aspects of psychiatric treatment in a voluntary mental hospital: duration of hospitalization, discharge ratings, and diagnosis. AMA Arch Gen Psychiatry. 1959 Dec;1:565-74. 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