http://exhibits.library.stonybrook.edu/mfp/files/original/aaac38fc36161269f14f4617b6ef620f.pdf 09f64ba46dc2ab1bcb50e506d78ad27a PDF Text Text v._, SOCIAL ASPECTS OF PSYCHIATRIC TREATMENT IN THREE HOSPITALS: METHODOLOGICAL PROBLEMS 1/ «- hoWCV‘ in Max Pollack, Ph. D. , Nathaniel Siegel, Ph. D. Robert L. Kahn, Ph. D. , and Max Fink,_M. D. - inst logic P hospit‘ same } scitiﬂg The generalization of findings from one population to another is basic to any science. Psychiatry. perhaps more than other medical specialties. is plagued with controversies concerning the non-reproducibility of results. One factor responsible for this state is the failure of investigators to adequately describe their populations and methods. The organ. ization of multiple hospital studies makes possible the detection and clarification of the" methodological difficulties. We would like to describe some of the problems we encountered in a recent tri-hospital study. with reference to the variables of type of treatment, discharge diagnosis, ratings of clinical improvement at time of. discharge and length of knoWiE tal dis A routin( at MM -ga. would hoapiti hospital stay. pang! Various social psychiatric studies of community and hospital psychiatric populations (1, Z, 6) have established the importance of sociopsychological factors in the type and incidence of mental disorder. the selection and maintenance of treatment and therapeutic evaluations. In these previous studies such selective factors as the patient's financial resources or the extent and type of available treatment facilities may have been more signi. ficant in the observed results than the social variables studied. A more critical test of the role of soda-psychological factors in treatment would be a study in a setting where the same therapeutic techniques and services are available to all patients, regardless of their ability to pay. This requirement is met at Hillside Hospital, and in 1957, we embarked out a program of assaying the relation of sociopsychological factors to the treatment of hospi. talized psychiatric patients (3. 4). Each patient receives individual psychotherapy and by request of his physician, somatotherapy (convulsive or psychopharmacological therapy). Our method of investigation was a census-type survey of all in-patients on a given day (3). In addition a brief modified California F Scale test (2, 5) was administered to all patients. We observed that age, education, sex, foreign-birth. and performance on the California I? Scale were significantly related to choice of treatment, duration of hospitalization, clinical discharge ratings and to clinical diagnosis. order to test the reliability of these findings, we repeated this study at Hillside Hospital in 1958, employing the same procedures and, concurrently extended it to two other institutions. the C. F. Menninger Memorial Hospital and the Massachusetts Mental Health Center (MMHC). These institutions are similar to Hillside Hospital in that both psychoanalytically - oriented psychotherapy and somatic therapies are available. They were selected for the additional reason that one serves predominately socioeconomic Class I and II patients (Menninger Hosp.) and the other. predominately Class IV and V. L soclat' the let that tr psychc of noti chothe basis' with tl tient c psycht chiatr reside I ciplin' .wn-w gists. view $ In (MMHC). Observations Dia n that tl behav the sa sent 5 charg classi these Hospital Structure ducin; reporting data from ones own institution. the structure of the hospital is taken for granted. and either ignored or briefly mentioned. When approaching a new institution._ .When distox Note the department of Experimental Psychiatry, l/ N.From Y. Hillside Hospital Glen Oaks, 1... I. . Aided. in part, by grant MY-Z715 of the National Institute of Mental Health; and the Nassau County Mental Health Board. The cooperation of the staffs of the Massachusetts Mental Health Center and the C. F. ' Menninger Memorial Hospital is gratefully acknowledged. . 202 ‘ and a five-f comp rion ( Disc}: the c: prove �r, 7' attempting to gather comparable data one is made aware of the differences institutions and the nature of the hospital organization is seen as one of the methodoBoth the MMHC and Menninger institutions have day logic problems affecting treatment. physician can care for the hospital units.and Hillside does not. At the MMHC the treating clinic. In such a in the and after-care in the hospital, day in-patient, an ”me patient as the at from an earlier date, hospital ,ctting’ the treating doctor can dischargeforthe‘patient in Hillside Hospiwhereas his patient's care; be he still responsible will that Mowing of the relationship. termination patient-doctor ux discharge means towcvcr- and in . "ru‘ ~1uwv1 different research programs. affecting clinical survey, approximately 20 percent of the patients been had and ill hospitalized for many years. Such a group at MMHC were chronically state would not normally have been in this hospital but they were transferred from another hospital for special study purposes. Designation of Type of Treatment In our assessments of specific variables, we encountered a variety of problems associated with the content of hospital records. For example, it was difficult to determine of time spent in the length of stay prior to referral for a somatic treatment, or the length that treatment. However, a major problem was to learn which patients were receiving psychotherapy. Our task was not to define psychotherapy, but the much simpler problem of noting Which patients were designated by the hospital as having been treated with psy- ‘ chotherapy. At Menninger Hosptial, psychotherapy was administered on a prescription basis by a staff psychiatrist for which the patient was charged an additional fee. Sessions with the psychiatric resident physician were considered part of routine administrative patient care and were not recorded as psychotherapy. At Hillside Hospital the definition of psypsychotherapy was limited to treatment sessions with the psychiatric resident. Staff the chiatrists did not treat patients directly, but restricted their activity to supervising Another problem was the presence of routincs- For example. at the time of the ..... . a. “syn a -w~a.u.r-- M -.M——-.— 5" t V_ . . ,. v.71 _ .I-uv-n- ‘-.p..o-i.m ‘W, runny-.9. -l residents. ‘4,"V‘OQ‘M'A'ﬁ In contrast, at the MMHC psychotherapy was designated as a function of many disciplines - psychiatric residents, nurses. medical students, social workers and psychologists. To ascertain whether or not a patient was receiving psychotherapy we had to inter- view the resident physician in charge of the case. ‘71-'Nuo-nyap ..._...,. ,— —-— -vw“ Diagnosis -\» ,... a... assessment of diagnosis was another problem area. It is not surprising that there are institutional diagnostic “styles which reflect staff orientations rather than the behavior of the patient. Pasamanick and his associates (7) has shown that diagnoses within the same institution are vulnerable to individual differences among examiners. In our present study. there were differences in the terminology of the discharge diagnosis. Discharge diagnoses at Menninger Hospital were more descriptive and employed a multiple classification system. Table I illustrates several examples and shows how we converted these into more generic categories that could be applicable to all three institutions. In reducing multiple diagnoses to single generic ones, we were aware that we were introducing distortions through this maneuver. Table II illustrates the distribution of diagnostic categories within each institution. Note that at the Menninger Hospital there was a lower incidence of diagnosed schizophrenia and affective psychoses. while the diagnosis of personality disorder exceeds by three and five-fold that found in the other two hospitals.- We would emphasize that cross hospital comparisons of populations basedpn diagnosis as the single or the most important criterion does not insure comparability of populations. The .i-u.v.-.‘Mdh& M u--. , ~ ~m.va-»..... P... wv" 4 r .. R." s ~. , . —w . n—‘w—w-vw- \*_sm,~,-.w...—mp-- ' 7 ”avcuuuft Discharge Ratings of Improvement .- Similar problems exist for the equivalence of global ratings of improvement. As in the case of diagnosis, Menninger Hospital had the most elaborate discharge ratings of improvement and Hillside Hospital. the simplest. . 1 ~ A .w» wo-ﬁ-‘v. - w- 2 203 l ': l . . T 1’ �TYPES OF DISCHARGE DIAGNOSIS Patient Discharge Rating 1. Depression Reaction Narcissistic Personality 2. Anxiety Reaction Narcissistic Personality 3. Narcissistic Personality 4. Narcissistic Personality Alcoholism Chronic Infantile Personality 5. Passive Aggressive Personality Alcoholism 6. Infantile Personality Schizophrenic Reaction Schizo-Affective Type Classification Rating Psychoneurosis Psychoneurosis Personality Trait Disturbance Sociopathic Personality Disturbance ' ‘ Sociopathic Personality Disturbance Schizophrenic Psychosis TABLE II DISTRIBUTION OF DIAGNOSIS (PERCENTAGE) Menninger Hillside MMHC Schizophrenia 41 52 52 Personalitybisorders 33 6 Psychoneuroses Affective Psychoses Organic Psychoses Transient Personality Disorder 14 18 8 21 16 5 l 5 2 2 6 100 173 N: 13 , 93 ‘ As shown in Table, III the discharge rating at Menninger Hospital was tripartite and a separate rating given for social, characterological and syndrome changes. Hillside and MMHC had similar global ratings and it is difficult to state how much weight was given to each of the three factors incorporated in the Menninger system. Such differences in systems makes it difficult to compare treatment results of hospitalization. Hospitalization Length of hospitalization for most illnesses, including psychiatric disorders, commonly denotes both severity of illness and response to treatment. As such. it is frequently used as an index for interhospital comparison. Table IV compares length of hospitalization by age at the time of the study. There was an observable relation between length of stay and age within each institution, with age being inversely related to length of hospitalization. Yet. among these three hospitals there were marked differences. When diagnosis is employed a similar pattern is obtained. At Menninger Hospital the over one percentage of patients with the diagnosis of schizophrenia who were hospitalised ' year was 91%. at Hillside Hospital 35% and at MMHC. 77o. 204 We 11: ' factor not generalizir , methodolog There single diag sociopsych difficulty. 5‘ ‘ Studiii: birth, edui nificantly 1. improvemc: choanalyti<- tures - one the other. ‘ �TABLE III ‘ RATINGS OF CLINICAL CONDITION AT TIME OF HOSPITAL DISCHARGE Hillside Menninger Improved Unimproved r. MMHC “'““”i“"‘ ,- «a..——q SOCIAL ADJUSTMENT , "VT'~M-» Recovered Recovered Much Improved Markedly Improved a. waw 9.9. «an::r:r;t?.'ﬁ~'"'ﬁ'f”“ o“ . Improved CHARACTER STRUCTURE Moderately Improved Slightly Improved ' ‘ Unimproved Improved Unimproved . .v-‘n. 1 . Unimproved ’ ~ ~VWT~I Regression SYNDROME .. V ' Complete Remission ””"1" Improved Unchanged (or worse) a'v‘r‘.':'§l':"t'.“"""""""‘ TABLE IV . HOSPITAL STAY BY AGE PERCENTAGE OF AGE GROUP STAYING OVER ONE YEAR A~-; _- Inf.) . .,i ~- -‘ .a-.<__. u- .,.I Age Menninger Hillside MMHC Below 20 20-29 30-39 40-49 81 42 14 73 36 6 61 30 6 30 20 0 50+ -_.-..-< vm r , 36 0 , ““*‘".'"‘-'-«rvm-AﬁuvnrcM-mvr“ V" ' ' 0 u‘ "rm-J'W- V 12219122192 ﬂ." j J.“ ~.. 4.... We have indicated that the philosophy and organization of institutions is an essential {actor not to be ignored in assessing observations and reports. Faced with the problem of generalizing our findings, how do we overcome these institutional methodological stumbling blocks to scientific activity? ‘.r‘a-..—..,._ differences that are the «4“le .-,... a... 5“ -.... 5hérv~naVvu .-- a .-.4 .. “4‘... «a; .v” .. . There is an urgent need for objective techniques to describe populations. The use of diagnostic terms is obviously inadequate. It is likely that detailed behavioral and sociopsychological descriptions of patients may be the best technique for overcoming this single «M-M~—,t...y.-.r, difficulty. Summary Studies of the in-patient population of Hillside Hospital indicated that age, foreignbirth. education and stereotypic attitudes as measured by the California F Scale were significantly related to choice of treatment, duration of hospitalization. discharge ratings of improvement and diagnosis. We have extended this study to other institutions offering psychoanalytically-orientedpsychotherapy and somatic therapies with different social structures - one the Massachusetts Mental Health Center. serving "lower-class" patients and the other, the C. F. Menninger Memorial Hospital. serving "upper-class" patients. . ‘vvw-WOv—u-wm-Mvr- . ws—vt‘v-~.o-‘- .-,. '< ' 205 u r ~-. . .- ”4...”.-. �,rm We have encountered a variety of problems in this comparison. including difference. in l) the type of hospital organization; 2) the definition of the treatment as in the designstion of which patients were receiving psychotherapy; 3) discharge rating systems of clinical improvement; and 4) diagnostic "styles” employed. ..... ~. a .w»-._.r ..x a The importance of these methodological problems in current psychiatric research are discussed. References (l) Hollingshead, A. B. , and Redlich, F. C.: Social Class and Mental Illness: A Commun. ity Study. New York, John Wiley & Sons. Inc. . l958. a...» .' (Z) Gallagher, E. B. : Levinson. D. J. , and Erlich, 1.: Some Sociopsychological Characteristics of Patients and Their Relevance for Psychiatric Treatment, in The Patient and the Mental Hospital. edited by M. Greenblatt, D.J. Levinson, and R. H. Williams, Chicago. Free Press. 1957. , Pollack, M. and Fink. M. : Social Factors in Selection of Therapy in a Voluntary Mental Hospital. J. Hillside Hospital 6: 216-228, 1957. (3) Kahn, R. L. L., Pollack, M. and Fink, M. Sociopsychologic Aspects of Psychiatric Treatment in A Voluntary Mental Hospital: Duration of Hospitalization, Discharge Ratings. and Diagnosis. A.M.A. Arch. Gen. Psychiat. 1: 565-574. 1959. (5) Kahn, R. L., Pollack, M. and Fink, M.: Social Attitude (California F Scale) and Convulsive Therapy. J. Neu. Ment. Dis.‘ 130: 189-192, 1960. (4) Kahn, R. (6) Myers, J. K. , and Schaffer. L. : Social Stratification and Psychiatric Practice: AStudy of an Out-Patient Clinic, Am. Sociol. Rev.l 19:307-310. 1954. (7) Pasamanick. B. , Dinitz. S. and Lefton. M. : Psychiatric Orientation and its Relation to Diagnosis and Treatment in a Mental Hospital. Amer. J. Psychiat. . l_l_6_: 127-132. 1959. DISCUSSION DR. KLERMAN: One of the ways to overcome the biasing factors related to length of stay is to calculate the mean stay for each hospital. In this way interhospital comparisons of the effect of such variables as age on length of stay could be compared in terms of quartiles. . r .4 g DR. POLLACK: .9101. .. ;v That's a good suggestion, however it still doesn't overcome the problem of differences in hospital structure. e. g. , the presence or absence of a day hospital facilities. in inﬂuencing length of hospital stay. «2' ‘Z uhwﬁﬁl'nl DR. OPPENHEIM: The finding that younger patients tended to stay longer at the hospital seemed to be at variance with experience at VA Hospitals. I ask what was it about the therapeutic programs at the three hospitals that led to these findings? What are the theoretical implications of these findings ? “AL. in \:A 9;.- .41: ..., s ——....-.-A..— .-..~u-....v-l-~ .e... “4...-..“ -.‘_......-c DR. POLLACK: The length of time a patient is hospitalized in a psychiatric facility is related to the particular function and philosophy of the institution. In those hospitals that stress psychoanalytically oriented psychotherapy, patients who are most like the therapists with regard to sociopsychological factors are kept in treatment for the longest period. In studies of out-patient clinics with a psychoanalytic orientation, it has been found that persons from higher social levels. as determined by education and income, are treated longer. In contrast. in state hospitals the results are quite different. Thus, it has been shown that state hospital patients with the least education will be institutionalized longer and are more likely to become the chronic patients. Consistent with the concept of state hospitals as largely providing long-term custodial care for lower class patients, the state hospital psychiatrist may be oriented toward a comparatively more'rapid discharge of those patients who come from a background most like his own. 206 v" .va —v : ��Social Aspects of Psychiatric Treatment in Three Hospitals: Methodological Problems Max Pollack, Ph.D., Nathaniel Siegel, Ph.D. Robert L. Kahn, Ph.D., and Max Fink, M.D. the Department of Experimental Psychiatry, Hillside Hospital, Glen Oaks, L.I., N.Y. ﬁos Presented at the Sixth Annual Veterans Administration Research Conference, March 28, 1961, Cincinnati, Ohio. Aided, in part, by grant MY~2715 of the National Institute of From Mental Health; and the Nassau County Mental Health Board. The cooperation of the staffs of the Massachusetts Mental Health Center and the C.F. Menninger Memorial Hospital is gratefully acknowledged. IV: h/17/6l �Social ASpects of Psychiatric Treatment in Three Hospitals: Methodological Problems generalization of findings from one population to another is basic to any science. Psychiatry, perhaps more than other medical specialties, is plagued with controversies concerning the non-reproducibility of results. One factor responsible for this state is the failure of investigators to adequately describe their populations and methods. The advent The of simultaneous multiple hOSpital studies makes possible the detection and clarification of these methodological difficulties. We would like to describe some of the problems we encountered in a recent tri-hospital study, and will consider the variables of type of treatment, discharge diagnosis, ratings of clinical improvement at time of discharge and length of hospital stay. Various social psychiatric studies of community and heapital psychiatric populations (1, 2, 6) had established the importance of sociopsychological factors in the type and incidence of mental disorder, the selection and mainten— ance of treatment and therapeutic evaluations. previous studies such selective factors as the In these patient's extent and type of available treatment facilities may have been more significant in the observed results than the social variables studied. A more financial resources or the �-2- critical test sociopsychological factors in treatment would be a study in a setting where the same therapeutic techniques and services are available to all patients, regardless of their ability to pay. This requirement is not at Hillside Hospital, and in 1957, we embarked on a program of assaying the relation of sociopsychological factors to the treatment of hospitalized psychiatric patients (3, h). Each patient receives individual psychotherapy and by request of his physician, somatotherapy (convulsive or psychopharmacological therapy). Almost all patients are non-chronic, as their admission to the hospital is associated either with first hospitalization or a recurrence of illness after a long period of remission. The case load is small, with at most ten patients to one resident physician. Our method of all in—patients on modified California all patients. birth, role of the We of investigation was a census«type survey of a given day (3). In addition a brief F Scale observed test (2, 5) was administered to that age, education, sex, foreign- California F Scale were significantly related to choice of treatment, duration of hOSpitalization, clinical discharge ratings and to clinical diagnosis. In order to test the reliability of these findings, we repeated this study at Hillside Hospital in 1958, employing the same procedures and, concurrently extended it to two other institutions, the C.F. Menninger Memorial Hospital and and performance on the �-3the Massachusetts Mental Health Center (MMHC). These insti- tutions are similar to Hillside Hospital in that both psychoanalytically - oriented psychotherapy and somatic therapies are available. They were selected for the additional reason that one serves predominately socialogical Class I and II patients and the other, predominately Class IV and V. �-hOBSERVATIONS Hospital Structure: When reporting data from ones own institution, the structure of the hOSpital is taken for granted, and either ignored or briefly mentioned. However, when approaching a strange institution and attempting to gather comparable data one is made aware of the differences in institutions and the nature of the hospital organization is seen as one of the methodologic problems affecting treatment. .Both the Menninger does institutions not. At the MMHC MMHC and hospital units, and Hillside the treating physician can care for have day the same patient as an in-patient, in the day hOSpital, and in the after-care clinic. In such a setting, the treating doctor can discharge the patient from the hospital at an earlier date, knowing that he will still be reSponsible for his patient's care; whereas in Hillside Hospital discharge termination of the patient—doctor relationship. Another problem was the presence of different research programs, affecting clinical routines. For example, at the time of the survey, approximately twenty percent of the patients at MMHC were chronically ill and had been hOSpitalized for many years. Such a group would not normally have been in means this hospital but they were transferred hOSpital for Special study purposes. from another state �-5Designation of Type of Treatment: In our assessments of specific variables, we encountered a variety of problems associated with the content of hoSpital records. For example, it was difficult to determine the length of stay prior to referral for a somatic treatment, or the length of time spent in that treatment. However, a major problem was to learn which patients were receiving psychotherapy. Our task was not to define psychotherapy, but the much simpler problem of noting which patients were designated by the hospital as having been treated with psychotherapy. At Menninger Hospital psychotherapy was administered on a prescription basis by a staff psychiatrist for which the patient was charged an additional fee. Sessions with the psychiatric resident physician were considered part of routine administrative patient care. At Hillside Hospital the definition of psychotherapy was limited to treatment sessions with the psychiatric resident. Staff psychiatrists did not treat patients directly, but restricted their activity to supervising the residents. In contrast, at the MMHC psychotherapy was designated as a function of many disciplines - psychiatric residents, nurses, medical students, social workers and psychologists. To ascertain whether or not a patient was receiving psychotherapy we had to interview the resident physician in charge of the case. �Diagnosis: The assessment of diagnosis was another problem area. It is not surprising that there are institutional diagnostic styles which reflect staff orientations rather than the behavior of the patient. Pasamanick and his associates (7) have shown that diagnoses within the same institution are vulnerable to individual differences among examiners. In our present study, there were differences in the terminology of the discharge diagnosis. Discharge diagnoses at Menninger Hospital were more descriptive and employed a multiple classification system. Table I illustrates several examples and shows how we converted these into more generic categories that could be applicable to all three institutions. In reducing multiple diagnoses to single generic ones, we are aware that we are introducing distortions through this maneuver. II illustrates the distribution of diagnositic categories within each institution. Note that at the Table Menninger Hospital there was a lower incidence of diagnosed schizophrenia and affective psychoses, while the diagnosis of personality disorder exceeds by three and five-fold that found in the other two hospitals. �We would emphasize tions based that cross hospital comparisons of popula- diagnosis as the single or the most important criterion does not insure comparability of populations. on Discharge Ratings of Improvement: Similar problems exist for the equivalence of global ratings of improvement. As in the case of diagnosis, Menninger HOSpital had the most elaborate discharge ratings of improvement and Hillside Hospital, the simplest. As shown in Table III the discharge rating at Menninger Hospital was tripartite and a separate rating given for social, characterological had and syndrome changes. weight was and MMHC it is difficult to state how given to each of the three factors incorpora- similar global ratings and much Hillside ted in the Menninger system. Such differences in systems makes it difficult to compare treatment results of hospitaliza- tion. Hospitalization: Length of hosPitalization for most illnesses, including psychiatric disorders, commonly denotes both severity of �-8- illness and response to treatment. As such, it is frequently interhospital comparison. Table IV length of hospitalization by age at the time of the used as an index for compares study. There was an observable relation between length of stay and age within each institution, with age being inversely related to length of hospitalization. Yet, among these three hospitals there were marked differences. diagnosis is employed a similar pattern is obtained. At Menninger Hospital the percentage of patients with the diagnosis of schizophrenia who were hospitalized over one When year was 91%, at Hillside Hospital 35% and at MMHC, 7%. DISCUSSION indicated that the philosophy and organization of institutions is a factor not to be ignored in assessing observations and reports. Faced with the problem of generalizing our findings, how do we overcome these institutional differences that are the methodological stumbling blocks to We have scientific activity? is for objective techniques to describe populations. The use of single diagnostic terms is obviously inadequate. It is possible that detailed behavioral There an urgent need �-9sociopsychological descriptions of patients best technique for overcoming this difficulty. and may be the �-10SUMMARY Studies of the in~patient population of Hillside Hospital indicated that age, foreign-birth, education and stereotypic attitudes as measured by the California F Scale were signifi- cantly related to choice of treatment, duration of hoSpitalization, discharge ratings of improvement and diagnosis. The same therapeutic facilities were equally available to all patients, predominantly middle-class, and ability to pay was not a factor in treatment. We have extended this study to Other institutions offering psychoanalytically-oriented psychotherapy and somatic therapies with different social structures - one the Massachusetts Mental Health Center, serving "lower-class" patients and the other, the C.F. Menninger Memorial Hospital, serving "upper-class" patients. We have encountered a variety of problems in this comparison, including differences in: l) the type of hospital organization; 2) the definition of the treatment as in the designation of which patients were receiving psychotherapy; 3) discharge rating systems of clinical improvement; and h) diagnostic The "styles" employed. importance of these methodological problems in current psychiatric research are discussed. �TABLE I TYPES OF DISCHARGE DIAGNOSIS PATIENT DISCHARGE RATING CLASSIFICATION RATING 1. Depression Reaction Psychoneurosis Narcissistic Personality \2. Anxiety Reaction Narcissistic Personality 3. Narcissistic Personality h. Narcissistic Personality Alcoholism Chronic Infantile Personality 5. Passive Aggressive Personality Alcoholism 6. Infantile Personality Schizophrenic Reaction Schizo-Affective Type Psychoneurosis Personality Trait Disturbance Sociopathic Personality Disturbance Sociopathic Personality Disturbance Schizophrenic Psychosis �TABLE II DISTRIBUTION OF DIAGNOSIS (PERCENTAGE) Menninger Hillside MEEE Schizophrenia Personality Disorders hl 52 S2 33 6 13 Psychoneuroses 1h 18 8 Affective Psychoses 5 21 16 Organic Psychoses S l 5 Transient Personality 2 2 6 100 173 93 Disorder N = �TABLE III RATINGS OF CLINICAL CONDITION AT TIME OF HOSPITAL DISCHARGE Menninger Hillside MMHC SOCIAL ADJUSTMENT Recovered Recovered Much Improved Markedly Improved Improved Moderately Improved Unimproved Slightly Improved Unimproved CHARACTER STRUCTURE Improved Unimproved SYNDROME Complete Remission Improved Unchanged (or worse) Improved Unimproved Regression �TABLE IV HOSPITAL STAY BY AGE PERCENTAGE OF AGE GROUP STAYING OVER ONE YEAR Menninger Hillside yﬁﬁg Below 20 81 h2 lb 20-29 73 36 6 30-39 61 30 6 ho-h9 3o 20 0 50+ 36 0 0 ggg_ �REFERENCES Hollingshead, A.B., and Redlich, F.C.: Social Class and Mental Illness: A Community Study, New York, Joha Wiley & Sons, Inc., 1958. Gallagher, E.B.: Levinson, D.J., and Erlich, Y.: Some Sociopsychological Characteristics of Patients and Their Relevance for Psychiatric Treatment, in Ehe Patient and the Mental Hospital, edited by M. Greenblatt, D.J. Levinson, and R.H. Williams, Chicago, Free Press, 1957. Kahn, R.L., Pollack, M. and Fink, M.: Social Factors in Selection of Therapy in a Voluntary Mental Heepital. J. Hillside Hospital é: 216-228, 1957. Kahn, R.L., Pollack, M. and Fink, M.: Sociopsychologic Aspects of Psychiatric Treatment in a Voluntary Mental Hospital: Duration of Hospitalization, Discharge Ratings and Diagnosis. A.M.A. Arch. Gen. Psychiat. l: 565-57h, 1959. R.L., Pollack, M. and Fink, M.: Social Attitude (California F Scale) and Convulsive Therapy. J. Nerv. Ment. Kahn, 2i§., Egg: 189-192, 1960. J.K., and Schaffer, L.: Social Stratification and Psychiatric Practice: A Study of an Out-Patient Clinic, Myers, Sociol. Rev., 19: 307-310, 19Sh. Pasamanick, B., Dinitz, S. and Lofton, M.: Psychiatric Orientation and its Relation to Diagnosis and Treatment in a Mental Hospital. Amer. J. Psychiat., 116: 127-132, 1959. Am. ��Mmunattm of Patton Populations: Catapult-ability of 5mm 2!: Evaluating Thmpiu Mam Mutation! The Mam Fink. M. From A the D. Miami Its-mat. of Ptycmuy at 8:. Loans sum Hospital. 8t. Loni: hand an and“. madman: at tho mum. nuptial. New York in ramwith Du. R. I... Kuhn. N. 310901 and M. Pollack, and tar be puhmhod «Remnant 'smmyohtﬂoqtal Aspects at madman Truman m m mammary Hospitals“ uin 1863. �Recent community studies have demonstrated a between social factors and psychiatric treatment. relationship In their study psychiatric patient population, Hollingshead and Redlich reported significant relationships between an individual's position in the social class structure and the prevalence of treated of the New Haven illness, types of diagnosed disorders and kinds and duration of psychiatric treatment administered (3). The influence of patient economic status upon the availability of treating personnel, however, was not excluded in these studies. To test the role of social factors in the treatment of hospitalized patients independent of patient's finances and availability of treatments, undertaken at Hillside Hospital in 1957. variety of treatment In a survey was this hospital, a including individual psychotherapy and organic therapies are available to all patients regardless of their ability to pay. In the Hillside studies (h,5) it was observed that patients hospitalized for the shortest period were the oldest, had the least education and were most likely to have been foreign born. The older, modes, less educated patients were predominantly treated by convulsive therapy and received the more favorable discharge ratings. Younger, native born and more educated patients were hospitalized the longest, treated primarily generally received the poorer discharge ratings. The clinical factors were also related to a measure of stereotypy, the California F Scale (1,6). Higher F scores, i.e., greater stereotypy, were often found in patients by psychotherapy and �-2diagnosed as involutional psychosis who were referred for somatic therapy, hospitalized for a shorter period, and more often were rated as much improved or recovered. Another hypothesis developed at this time was that differences in various aSpects of psychiatric treatment among hospitals should show the same relationship to social factors as noted within Hillside Hospital. To test this suggestion it was decided to employ the procedures of the 195? Hillside study in three institutions ~— Hillside HOSpital, the C.F. Menninger Memorial Hospital of Topeka the Massachusetts Mental Health Center of Boston. These institutions were selected with the expectation that they served patients of different social classes. It was anticipated that in these hospitals there would be a similarity in attitude towards treatment and and education. is a teaching hospital with a full time superactive research departments. They emphasize Each visory staff and psychoanalytically-oriented psychotherapy but provide other treatments such as somatic therapies and active programs of milieu therapy. Each stresses short-term treatment of voluntary patients and does not provide custodial care. The specific aims of this study were to determine the population characteristics of the three institutions with respect to social class, age, education and F score: and to relate these characteristics to the treatment variables of type of treatment, duration of hospitalization, diagnosis and discharge evaluation among the institutions. �-3METHOD A census of institutions all voluntary, adult patients in residence in these undertaken in January, 1959. While Menninger and Hillside Hospitals had voluntary 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 was schizophrenic state hospital group transferred for a Specific research project. These patients were excluded from the study because of their non-voluntary status. given the California F scale on the census 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 (2). The study population consisted of 173 patients at Hillside, 100 at Menninger Each patient and 95 was 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 intrahospital comparisons, and accordingly, in the analyses of psychiatric variables emphasis will be placed on the differences between institutions with citation of intrainstitutional trends. These difficulties also led to missing information for some data, which is reflected in the varying population sample sizes in the tables. �4,. RESULTS A. Inter-hospital Comparisons l. Methodological Problems reporting studies from a home institution, the structure of the hospital is taken for granted and either ignored or mentioned briefly. However, in studying a strange institution and attempting to gather comparable data one is made aware of the many differences between institutions. While we selected these institutions as comparable in teaching, research and treatment programs, we found that they were unlike structurally in ways which influenced the data of the study. Specific problems were noted in the designation of type of treatment, diagnostic classes and the evaluation of treatment outcome. 3) Designation of Type of Treatment: The criteria for designating that a patient received "psychotherapy" differed among the institutions, making uniformity in classification difficult. At Menninger Hospital psychotherapy was designated as treatment administered on a prescription basis by a staff psychiatrist for which the patient was charged a fee. Sessions with the psychiatric resident were considered part of routine administrative patient care. At Hillside Hospital psychotherapy was defined as treatment sessions with the psychiatric resident. Staff psychiatrists did not treat patients, but restricted their activities to supervising the resident physicians. No additional fees were charged. When �-5the Massachusetts Mental Health Center psychotherapy was designated as a function 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 in charge of each case. b) Diagnosis: Individual institutional diagnostic styles made comparisons difficult. At Menninger Hospital diagnoses employed the multiple evaluative data scheme recommended by the American Psychiatric Association while both Hillside and MMHC followed unitary At 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 source of distortion. Ratings of improvement 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 c) Discharge Ratings of Improvement: Menninger system (Table II). For this study the Menninger syndrome �~6— rating was compared to the global ratings of the other institutions. ----- ------Table II Sociopsychological Variables The distribution of the variables of social class, age, Jacation and California F Scale score among the three institutions 2. is presented in Table III. ------------a) Social Class: There was a marked difference in the social class composition of the three institutions. At Menninger Hospital the population was predominantly upper class; at Hillside Hospital, class; lower class. middle b) age: and at Massachusetts Mental Health Center, predominantly There were no differences in age distribution in the institutional populations. c) Education: The populations differed in educational attain~ ment, with patients having more years of education at Menninger Hospital than at Massachusetts Mental Health Center. While bl 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 graduate. d) F Score: Significant differences in the distribution of scores on the California F Scale were observed. Fifty-one per cent �-7of Menninger patients had F scores below 30, and only eight per cent with scores of 50 or above -- the higher F scores being associated with higher degrees of stereotypy. In contrast, at Hillside thirtyone per cent of the patients had F scores below 30 while at MMHC only twenty per cent were below 30. Thus, the anticipated differences in the social class of the populations were observed, as well as significant differences in educational attainment and performance on the F Scale. These differences permit testing the hypothesis concerning the relation of sociopsychological factors to the treatment variables among the insti- tutions. 3. Psychiatric Treatment Variables a) Selection of Treatment: Among institutions, significant- ly fewer patients at Menninger Hospital (h3%) received somatic therapy than at Hillside (6h%) or MMHC (68%) as shown in Table IV. b) Duration of Hospitalization: The three institutions differed markedly with respect to patient's length of stay (Table IV). Hospital patients were hospitalized longest, with 65% of patients remaining for twelve months or more, uumynugd to 31 per baht of the Hillside patients and only 5 per cent of those at the Massachusetts Mental Health center. The modal stay of the Hillside group was between seven and eleven months while two-thirds of the MMHC patients were discharged within six months of hospitalization. c) Discharge Evaluation: In each hospital, most patients were evaluated at the time of discharge as "improved" (Table IV). At Menninger �-9- either none or fewer than five cases, thus not permitting a satisfactory intrahospital test of the hypothesis. 2. Intra-Hospital Comparison With this methodological limitation some trends similar to that found in the earlier study were observed, although few were of statistical significance. With regard to selection of treatment, for example, age and F score were found related at Menninger Hospital (older and higher F score patients more frequently receiving somatic therapy), and F score alone at Hillside. Length of hospitalization and chronological age were related at both the Menninger and Hillside Hospitals - the younger patients remaining for the longest period. While such relationships were significant in these two hospitals, a similar trend was noted at the MMHC (Table V) where no patients over ho, but lh% of patients under the age of 20 remained longer than a year. Table V ----------- �-10DISCUSSION this comparison of three voluntary psychiatric hospitals we have observed significant interinstitutional differences of patients in the social variables of years of education and social class, but not age: in distribution of California F Scale scores: and in each of the treatment variables -- duration of hoSpitalization, selection of treatments and distributions of diagnoses and discharge evaluations. The expectation that the institution serving upper class patients In the longest duration of stay, higher proportion of psychoneurotic diagnoses and more complex diagnostic schemata, lower proportion of patients receiving organic forms of therapy, and poor- would have a est discharge ratings were each confirmed. Similarly, the institution serving lower class patients evinced shorter periods of hospitaliza— tion, low proportions of psychoneurotic diagnoses, and better dis— V charge evaluations. It is our impression that these differences in psychiatric treatment are more related to differences in staff attitudes than to differences in population samples. 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. These .stylistic differences cannot be dismissed as merely idiosyncratic since they follow a pattern related to social differences consistent with previous findings. �-11- population and treatment variable relationships appear to be interactive processes, determined both by the attitude of the physician and the administrative staff as by the constellation of Such history which patient may present. Such relationships will be most marked in those psychiatric conditions where diagnostic criteria are least specific, 343., where the objective criteria symptoms or a defining diseases of known organic impairment are absent, as in schizophrenia, psychoneurosis and personality and behavior disorders. Under conditions of perceptual or situational ambiguity the observer's attitudes and expectations become the basis for perception and classi~ fication. This view was clearly demonstrated by Pasamanick, Dinitz and Lefton (7) in their study of variations in diagnosis within a single institution. They observed that patients randomly assigned to different wards did not differ in type of admission, marital status, education, age or residence. Significant differences did occur, however, in diagnoses among the three wards and among three administrators on one ward. As it is highly unlikely that these differences were inherent in the population, we believe they are largely reflections of the attitudes of the examiners. It is clear that many of the present psychiatric concepts of diagnosis or clinical evaluation have relatively little meaning when transferred from one institution to another. If these concepts are taken literally the results become paradoxical. For example, Menninger Hospital has the most highly trained personnel conducting treatment, keeps its patients for the longest time and has fewest �-12- patients diagnosed as schizophrenia. And yet, despite these resources and favorable factors, it reports the poorest treatment results. At MMHC, in contrast, which is most inclusive in defining a therapist, which keeps patients for the shortest periods, and which has a higher proportion of the population classed asschizophrenia, the reported treatment results are the best. It is probable that this study does not reflect the relative therapeutic efficacy of the institutions. Our data furnishes no independent criteria for determining which heapital provides the better care; nor for assessing the comparability of the population in the degree of institution's own illness. Since the evaluations are based on the ratings, we believe that the differences reflect variations in the criteria used for evaluation of improvement rather than any intrinsic psychiatric characteristics. In our initial Hillside study (5) 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 employed. This has literally confirmed in the present study, with Menninger's using tripartite rating compared to the global rating of the other two been a institutions. considering the syndrome rating on which our comparative statistical analysis 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 persbns the criteria stress such complex Even �~13- 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 considerably impressed by the methodological problems of studies across institutions. These institutions were selected for their educational leader- ship and the expectation that the recorded variables would be clearly defined. But the differences in institutional style making it difficult to obtain comparable data are important cues to the problem of the conventional use of comparative statistics, especially in the evaluation of psychiatric therapies. The use of discharge ratings, diagnostic classifications or length of hospitalization as criteria in therapeutic evaluations or the identification of comparable populations are subject to considerable error unless the institutions are clearly matched for social class patterns in patient population and for staff attitudes and style. These difficulties may also extend to the failures of scientists to confirm observations made in other laboratories, for the lack of confirmation may be as much a reflection of differences in populations and psychiatric criteria as to errors in the original hypotheses. The widespread use of such terms as "schizo— phrenia" or "psychoneurosis" to explore the changes in psychological or biological features with mental illness has led to a science burdened by negative results. Even were a valid observation to be reported from one laboratory, we do not have methods available to describe populations adequately to provide a sound confirmation. �-111- Increased attention must be paid to the methodological problems of classifying subjects by "objective" criteria rather than the present methods which appear to be so highly dependent on institutional and observer attitudes and the sociopsychological aspects of the thera- pist-patient interaction. �-15.. SUMMARY and CONCLUSION In three psychotherapeutic-oriented teaching hospitals, population characteristics were related to treatment variables. 1. Populations were defined by social class, age, education and F score, and were related to type of treatment, duration of hospitalization, diagnosis and discharge evaluation. Significant interinstitutional differences were observed in characteristics of patient social class, years of education and distribution of California F scores, but not age. 3. The variations in treatment characteristics among institutions were found to be significantly different in the predicted direction. h. These variations in psychiatric practices follow a pattern consistent with social class differences among institutions and are not regarded as being idiosyncratic. S. The differences in institutional style make comparisons of diagnoses, duration of hospitalization, and treatment results between 2. institutions difficult and tenuous, and the need for more objective criteria of classification of populations is emphasized. �REFERENCES Adorno, T.W., Frenkel-Brunswik, E., Levinson, D.J. and Sanford, R.N.: Authoritarian Personality, The New York, Harper & Brothers, 1950. Hollingshead, A.B.: graphed Two-Factor Index of Social Position, mimeo- publication. Hollingshead, A.B. and Redlich, F.C.: Illness: A Community Study, New Social Class and Mental York, John Wiley & Sons, Inc., 1958. R.L., Pollack, M. and Fink, M.: Social Factors in the Selection of Therapy in a Voluntary Mental Hospital, J. Hillside £332., 9: 216-228, 1957. Kahn, R.L., Pollack, M. and Fink, M.: Sociopsychologic Aspects of Psychiatric Treatments in a Voluntary Mental Hospital: Kahn, Duration of Hospitalization, Discharge Ratings and Diagnosis, Arch. Gen. Psychiat., l: S65-57h, 1959. R.L., Pollack, M. and Fink, M.: Social Attitude (California F Scale) and Convulsive Therapy, J. Nerv. & Ment. Dis., Kahn, 130: 187-192, 1960. Psychiatric Orienta— tion and Its Relation to Diagnosis and Treatment in a Mental Hospital, Amer. J. Psychiat., 116: 127-132, 1959. Pasamanick, B., Dinitz, S. and Lefton, M.: �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 Passive Aggressive Personality Sociopathic Personality Disturbance Sociopathic Personality Alcoholism Disturbance Infantile Personality Schizophrenic Reaction, Schizo-Affective Type Schizophrenic Psychosis �TABLE II Comparative Ratings of At Time of MENNINGER HOSPITAL Social Adjustment Improved Unimproved Character Structure Improved Unimproved Syndrome Complete Remission Improved Unchanged (or worse) Clinical Condition Hospital Discharge HILLSIDE HOSPITAL MASSACHUSETTS MENTAL HEALTH CENTER Recovered Recovered Much Improved Markedly Improved Improved Moderately Improved Unimproved Slightly Improved Unimproved �TABLE 1;; InterhOSpital Comparisons for Sociopsychological Variables Hillside Menninger Hospital Social Class 'v“ N (87) (133) I 31% 7% (72) 3% 20 28 III 17 3h 13 IV 1 3h 28 v o 5 28 x2=121.5; df=8z p<.001 'N (100) (173) (95) 19% 19% 15% 20-39 59 58 52 ho 22 23 33 + x3=3.9; df=h; p=n.s. (100) (173) <12 Education Center ' 51 N Years of Mental Health I II <20 Age Hospital Massachusetts i (91) 23% 32% h1% 12-15 Sh 51 h9 16 23 17 10 + v3=9.7; df=h; p<.os (92) (163) (76) 10~29 51% 33% 20% 30-h9 hl 50 50-70 8 N F Score 17 L i 2 I y3=39.2; df=hi p<.001 38 h2 . �TABLE IV InterhOSpital Differences in Treatment Variables ‘Menninger Hospital (100) N Type of Treatment Hillside Massachusetts Hospital Mental Health (173) Center (89) Psychotherapy 21% 36% 2b% Somatic h3 6h 68 Other 36 ~- 8 1 e a _ _u , xi:82.8: df=h: p<.001 N Duration of Hospitali— zation <7 months 7-11 months :il months (100) (173) (95) 22% 27% 67% 13 h? 27 65 31 S a ’ X2=9o.6; df=h§ p<.001‘ N Recovered, Improved Discharge Evaluation . Much (99) (172) (88) 1% 23% 28% Improved 80 62 61 Unimproved 19 15 10 lvwwy2=29.3; df=h; p<.001 m“ N Schizophrenia Discharge Diagnosis ” Affective Psychosis Psychoneurosis and Personality Disorder (95) (171) (85) h3% 52% 5h% 5 22 17 52 26 29 , X2=23-83 df=h; p<.001 �TABLE V Duration of Hospitalization BX,A§2 PERCENTAGE OF AGE GROUP STAYING OVER ONE YEAR £53 Menninger Hillside mag Below 20 81 h2 1h 20-29 73 36 30-39 61 30 h0-h9 30 20 50+ 36 �A? 9/7 . THE AMERICAN PSYCHOANALYTIC ASSOCIATION SUMMARY AND FINAL REPORT OF THE CENTRAL FACT-GATHERING COMMITTEE /f" ’4-4-‘"?;"é /L\ W2} The Central Fact—Gathering Committee was established by this Association in 1952 and charged with the responsibility Of setting up a method for pooling :the significant data of psychoanalytic practice. Starting modestly and testing a procedure that ensured professional secrecy, it was hoped that increasingly valid, meaningful data might be accumulated. However, the long-recognized difficulties -- diagnosis, nomenclature and measure of effectiveness -- all have led to increasing resistance and a resultant falling-Off in the number of completed questionnaires. Scarcely any reports are now being received. Therefore, it was recommended at the last meeting of the Association that this Committee be discharged and its materiel stored until such time as further developments warrant confidence in the use of the statistical method in psychoanalytic validation. \7 This summary of the material is being sent to you for your study and files. Although some members of the Committee thought otherwise, the Committee as a whole, the Executive Council and the membership at the last Business Meeting of the Association in December, 1957 approved the opinion that none of this material be published. It is not that the figures can be used to prove analytic therapy to be effective or ineffective, but that the material on which either opinion may be based is inadequately established, and controversial publicity on such material cannot be of benefit in any way. We trust that all will agree and will limit discussion of this ‘ material to those professionally qualified to recognize its serious limitations. is divided into two sections: Part I, the summary of the material from the Initial Questionnaires, and Part II, of the material from the Final Questionnaires. This summary ‘ PART I We received a total Of about 10, 000 Initial Questionnaires and 3, 000 Final Questionnaires, from about 800 participants. Of the 800, about 350 were members of the then total membership of 530, and 450 were senior candidates of the then total 600 senior candidates. SUMMARY OF DATA FROM INITIAL QUESTIONNAIRES 1. Sex: Male: 48%. 2. Race: v“ "114’ or i'TéIIW?“IMI—TNT 315' 51;; g L); (“lgﬂﬂIPV iﬂfﬂ uuunwﬂkz ”v, jQihﬁjﬁyrf HaAll. n F. F7! :~ , ,LCJHJE: . [2‘3 ,_ rf' 355:3 _ , White: 99%. Female: 52%. (U.S. Census: White: 89%. Colored: 11%.) �3. Age 9; patients: Percentage of total Up to 12 years: 2 2 13-18 14 48 27 19—25 26-35 36-45 ‘ 46 and over: 8 4. Highest educational level: 60% of all patients are at least college graduates. (25% college graduates, 8% attended graduate school, and 27% more completed (U.S.Census: 6% are college graduates.) graduate schooll) . : 5. income: 1—5 . % % ‘ 1 in analysis: in psychotherapy: 22 35 U.S.Census: 71 6-10 25 (In thousands) 11-15 28 16 13 23 6 ' 16-20 21-40 8 9 ' 1 16 13 41.69 4 2 Over 560,303 3 Z (over $10,000) 6. Previous treatment: Regardless of type of diagnosis, about 1/ 6 or 1/7 of all patients had had previous analysis. 1/3 of the cases of neuroses and 1/2 of the cases of psychoses had had previous psychotherapy. Some had had both. About half of the cases of psychoses had had previous psychiatric hospitalization, as did 1/10 of the cases of neurotic reactions and character neuroses. cases being re-analyzed (i.e. , 1/6 of all), only about 1/6 of them are being re.analyzed by the previous analyst. The other 5/6 chose another analyst . Of the group of. 7. Present treatment: 54% Of all cases in treatment are listed as being in analysis, and 46% in psycho. therapy. The percentage runs from 60-65% in analysis in the neuroses, to 40% in analysis in the borderline cases, and 20% in the schiZOphrenias, 8. Place of treatment: Private oﬁice: 94%. Out-patient clinics: 9 4%. Psychiatric & general hospital: 1%. . {reguency of treatment: % % in analysis: in psychotherapy: Per week: 1 2 3 4 5 1 6 29 41 20 7 42 33 13 3 6 or more < 2' Q1 10. use of psychological projective tests: The tests are reported as being carried out in approximately 25% of the cases. In 75% of the cases given psychological tests, the clinical diagnosis was in agree. ment with the tests . �II. -3... 213929§§§ Initial diagnoses: The following diagnostic listings are presented with full appreciation of and emphasis on their inadequacy, invalidity, uncertainty and probable insignificance. It reminds one of Freud's remarks when chided about the lack of statistics in psychoanalysis, in 1913: "To compile statistics is at present impossible. To begin with, we work with much smaller numbers than most other doctors who devote so much less time to individuals. Then, the necessary uniformity is lacking which alone can form a basis of any statistics. Should we really count together apples, peas, nuts? What do we call a severe case? Moreover, technique changes and what about the numerous partially analyzed cases and those whose treatment had to be discontinued for external reasons? " ORDER OF FREQUENCY OF GROUPS OF DISORDERS Psychoneuroses Personality trait disturbances (character neuroses) Per sonality pattern di sturba nce s (borderlines) Psychotic reactions Perversions Addictions All others Psychosomatic disorders co-exi stent in: _ Percent of total . 39 33 1 l 9 5 2 1 11 ' ORDER OF FREQUENCY OF SPECIFIC DISORDERS Pas sive-aggres sive personality Compulsive personality, & Anxiety reaction (each) 16 14 Depressive reaction SchiZOphrenias Phobic reaction, Obsessive-compulsive reaction, personality (each) Perversions Conversion reaction, 9 7 & Schizoid Emotionally unstable personality (each) Dissociative reaction, Inadequate personality, Cyclothymic personality, Paranoid personality, & Addictions (each) Paranoia, & Manic—depressive reactions (each) & Psychosomatic disorders co-existent in: Some additional data: Of the neurotic 6 5 3 2 1 11 reactions, dissociative, conversion, de— pressive and phobic reactions were much more frequent to times more) in females than in males . Obsessive-compulsive reactions were somewhat more frequent in males than in females. The diagnosis of anxiety reaction was made equally in males and females. (2 3 diagnosis of borderline disorders, "schizoid", "paranoid", etc. , and of schizophrenia was equally distributed between males and females. Homosexuality was diagnosed two to three times as frequent in males as in females, as were the other reported sexual deviations. The �We have received about 3, 000 Final Reports. These were on cases that had been in treatment at the time the CFC- program began, or that began treatment thereafter. As it became increasingly evident that significant figures could not be obtained because of the previous mentioned lack of uniformity, we confined our study 110 a more intensive investigation of the neurotic reactions that had ”completed" treatment. We cannot say what happened to all of the cases that were in treatment during this program, because only about 1/3 to 1/4 of the cases were terminated during this period. The following information from the Final Reports may be of interest. sis, We found that out of 595 cases of neurotic reactions which undertook analy- 306 were reported as having been "completely analyzed”, that is, approximately years. (W ere this study to be continued, this figure might be higher, as there might be a larger percentage of longer analyses. However, it would not be lower.) Follow—up questionnaires were sent to the participants who had sent in these 308 " completely analyzed" reports. We received a return of 210 replies, that is 70%. Below is a summary of the supplementary information on the above Final Reports of "completely analyzed" cases of neurotic reactions: 50%, and the average duration was 3~4 Is there any doubt in your mind regarding the diagnosis? Did you think there was an underlying psychosis at any time? Had the patient been in analysis previously? Was the patient in standard, or classical, analysis? Of 28% 25% 18% 90% these "cured" cases. 45 Yes: Yes: Yes: Yes: 210 supplementary questionnaires received, 80 were listed as In 35 of these, all of the symptoms were reported as "cured", and in residual symptoms remained. In the 130 questionnaires received on "improved" was moderate in 74 cases, great in 46, and slight in 10. From the above, one might draw the conclusion cases, the improvement that about 97% of patients who undertake analysis for neurotic reactions and "complete" it, are "cured" or "improved" . Of the 50% who do not complete their analyses in this group of disorders, about half discontinue apparently because they were improved. The other half discontinue for "external" reasons primarily, because they did not improve, or were consid— ered untreatable, transferred to other analysts, or required hospitalization. The most frequent reason given for discontinuing, apart from being improved, was " external reasons". �-5RESULTS IN COMPLETE ANALYSIS OF N EUROTIC REACTIONS Final In Analysis Reports Analysis Completed Cured Improved Unimproved Anxiety reaction - ‘ 1,120 cases 335 183 90 35 52 3 70 38 26 11 15 0 cases 85 46 23 11 11 1 Phobic reaction 000-X04 - 500 cases 200 104 61 17 42 2 170 108 43 14 28 1 250 116 63 29 34 0 14110 595 306 117 182 7 50 37 6O 3 OOO-XOl Dissociative reaction OOO-XOZ - 175 cases Conversion reaction GOO-X03 - 250 Obsessive-compulsive reaction OOO-XOS - 500 cases Depressive reaction 000—X06 - 700 cases TOTAL Average Per Cent: REPORTED RESULTS IN Depressive Reactions Total Final Reports: In analysis: Cured Improved Unimproved 000-X06 Compl‘d 29 34 Discont'd 30 7 4 Untreatable Transferred Hospitalized External reasons TOTAL 250 116 Anxiety Reactions OOO-XOl Phobic Reactions 000—X04 335 183 200 104 Compl'd Discont'd Compl'd Discont'd 35 52 43 42 12 3 9 2 4 1 7 5 2 7 1O 29 2 1 2 1 63 53 90 93 12 61 43 �-5REPORTED RESULTS IN Obsessive-Compulsive Total Final Reports In analysis Cured Improved Unimproved Untreatable Transferred Hospitalized External reasons TOTAL Reactions, Compl'd 14 28 OOO-XOS 170 108 Disoont‘d Cured Improved Unimproved 1 441 232 Disoont'd 31 72 0 5 8 2 22 Compulsive PersonalityJ 000-X53 365 237 Compl'd Discont'd 29 77 62 3 l7 4 4 10 10 2 37 135 11 43 65 OOO-XZI Compl'd X29 — 234 42 97 Schizoid Personality 000-X42 Disoont'd 4 3 2 * Compl 'd 5 8 6 3 5 28 Homosexuality 000—X63 82 Disoont'd l3 9 1 7 i 33 1 34 128 101 4 9 35 109 185 HOSpitalized TOTAL Compl'd OOO-XSZ 6O 1 Untreatable Transferred External reasons Personality, 23 Schiz0phrenia Total Final Reports In analysis Passive—Aggressive 65 CompchL Disoont'd 8 13 1 1 6 10 4 3 3 5 2 8 9 48 22 43 Inall these eight reported cures of homosexuality, follow-up communications indicated assumption of full heterosexual roles and functioning. * Thinking it might be of some interest to gather the opinions and general experience of the membership on the expectation of results, the following questionnaire was submitted to the membership about a year ago: "Given a young person, whom one could analyze four years or more, with all conditions favorable, what would be your expectancy of result, in percentage, of cure, improvement and failure" -- for a list of neuroses, char— acter disorders, schiZOphrenia, schizoid personality and homosexuality. were the opinions: We received 120 replies from the membership of about 650. These �-71. 45% expected no cure in any of the conditions. 2. 35% expected a 50-100% cure in the neuroses, less in the character 3. disorders, psychoses and perversions. expected a 5~40% cure in the neuroses, less in the other con- 20% ditions . those that expected no cure or a low percentage of cure, 50% expected moderate improvement, 45% great improvement, and 5% slight improvement. Of those that expected some cures in the various condtions, the average expectancy of cure was: Of . 50% in anxiety, conversion and phobic reactions. in dissociation, obsessional and depressive reactions. in schizophrenia. 4. 20% in homosexuality. 1 2. 3. 33% 10% If these figures are combined with the reports of those expecting the no cures, percentage of cure would be about half, i.e. , 25% in anxiety cases and phobias, 15% in dissociation, obsessional and depressive reactions, 5% in schizo— phrenia, and 10% in homosexuality. Our "findings" suggest a higher percentage of ”cures" than the above opinions. (Please note quotation marks!) All of the foregoing have been presented before closed meetings of the Association and to a number of the societies. Details are available to those members who request them. As Chairman of the Committee, I should like to thank the members of the Committee, the membership, and the participating candidates for their cooperation, advice and criticism. Respectfully submitted, HIW:as 1/5/58 Harry I. Weinstock, M.D. Chairman Central Fact—Gathering Committee different times during the past five years the Committee has included: Drs. Leo H.' Bartemeier, Roy R. Grinker, David Kairys, Lawrence C. Kolb, Lawrence S. Kubie, Alfred O. Ludwig, Milton L. Miller, Milton Rosenbaum, and George W . Wilson, and our consulting Statistician, Jack B. Chassan, Ph.D. At �Janusry 15; 19590 é :9: Br. n. rink art. R.£. Kuhn and H. 51:111 sunancrs ﬁneiul Payehidtrxa study gt manningcr reuadntien, 3.3“,’ 5‘10. 1959‘ yuan: arrived in rapuka rhmrudc ‘evnning, atnuary 7, ;nd ut tn. Paundttian nsrly t a nuxt sarning. Dr. Irving rupcrtud Kurt“: ta. Biractor of tho ﬁ.¥. Xanainqur Munorial Baupital, .1 panel: zraaious and eaoparativa 1n urtry way. Eu bud Ill proyurod the stat: tad patients hatarahand in untiakput1an'at var visit. 8t:f£ coapsrﬁtion at :11 1:101: wt: oxealltnt. rhnrn In: guaninc intsrcst in car :tudy and us had intnrusl Wu dincuaaiana with maths»: of tho stati. Br. Kurtuu Int us ans hi! 05:13: us air handgunrtcra In& and. nrrnnaauunﬂs tnr um kt lﬁﬁﬁrﬁ :11 nppoin$n¢ntc and obtain ‘11 rouardn ind ropcrtn that I: ﬁliirtdu Przar ta «at again; had tskud a: ta pruvidc him with ma iuiaruﬁtion uncut I. indinntin: I11 tun rocord data uttdiﬁ for nut thudy. the nonienl runawaulibrtrinn and he: auatntuat Iptnt fair 6‘}! conp1¢$1ng taut. turn: ta dotnil. siuau sat: a! thin inturuatian was net raudtly avuiltblu in tho ehtrﬁs, ﬁr. xtrtnu aunt t for: to all t». stat: «twist. in ob$u1n thin inxﬁrnnticn chart noqdnd. It w¢n1a havc takuu a: pnrh¢pl two nugka ta obtain :11.thu rneard intornﬁttan aurlclv¢t. ways. Thu a» “ the patiunts It! caninotud in two Iatull tasting of 60 worn aollantaé 1n the tharaday ubaut pttiantt $ha on and t¢utod an aging. :yuanuinn rlnuinlng attiﬁutu Pridny, tautcd indiviaunlly in thtir reams. baring the Friday tcnting tart a uﬂgtr nurt¢ nacnuytuiod at 3% all tinnt.ha that as short the various putauuta warn locatad and ta intradusu us ts Glah puticnt. Br. Kartun yartiaipatad in tha udniniutraﬁioa at thg test an the dinturhad ward and gran It?! 1% ta a to: pittantn himself. Arrangancntu atrn undo tar tho raeaxﬂulihwnriun ta sand an tau disahnrxc data can: a manta during ﬁhu next ynnr. an sgtarday neruxng, priar ta war dapnrturq, a: disuuaaod with m. 031‘an Murphy, Br. allay Gardner ”lurch tad Br. Rahart wallontttan. In tddi$1mn, aw dinunnnad garnet: z! ta: «linieal prusrnn with Dru. Rorbnrt auhlguingcr and Philip “that” “lﬁ‘ﬁnn or our Viuit thanks ortry objectiva to tha oxtrauraxntry eaaporttion a: tan manningar atntt, partinnlnrly Br. x;rtns. tun ltr¢et0r at tho huipxtnl and Eva. tauntu, thc modicul ruacrau 13hrnr1an. Ehuy war. ‘11 nuts xraaiaully httpitnblc and and. “a I‘ll-vulcanu and ut hunt. In unitary V0 uehiovod , 3&1143 �7‘, -. nay-u JIRU‘VV 1%: FRQH: Br. a. link art. svnaxata ﬁ¢L. Kuhn and I. 15; 1959; 5103:! antatl Ptrahiuhria study Jlnuury 5‘10; 1959* uﬁ nhnninsar-rvunégtiqn. a. arrivad in Tapaku Ehnrtdu atoning, January 7, and rqpurttd ut tau runndnttun curly' a ncxt attains. Br. Irving Itrtus ta: Biruetar of ﬁn. 6.3. thningar Hanurinl Balpitnl, was cx%rnmu1y grngiuuu mad weapcrntivn in OVQ?’ may. 30 haﬂ yrtynrtd sh: stuff gnu pat$nnt¢ butarokund an tnttaipntian ct an? vilit. ﬁturt aunyaratiaa at I11 Ivvalu in» axaalloat. tag». it: cnnutne inturast in an: Iﬁuty luﬂ a: hlﬂ tatarnal dinausttvnn with unabcrn o: tha staff. ﬁr. Kurtu: Int an nﬁo h1¢ oxttac I! an: hundquartorl aha and. arraugnnnnsa In: up %n tantra n11 uppaintncnts and abiain :11 rtearéu and ropnrtn that u: dusivgd.. trig? ta but G§I$ﬁ8 ha had ankud.uu tn pruvidn bin with an iniurnntiun nhutt inﬁiotting n11 tun rianvd alt: uoaéod tar mar ntndy. 2h: uptuﬁ :01: any: nudietl racirdnlibrnrinu and haw aasiat3nt «unwitting thcua turn: in datnil. $1300 can: 0: this information was nut ra:d£1y artil‘blc in sh. ahsrtc, nr‘ Rattan goat u tar: £9 :11 thc atatt dactarn ta abtuan than internatiun want. aci¢ad. I$~Vﬂﬂlﬁ hava ﬁakan 1‘ yarhupa tun wash: to obtain all tho roaord information ourscvaaa the aatual tuttinc at thu‘pnticntc wan gnuaucttd an in: nnyu. an fluvial: ukout 60 pntacntn vars eelltutaé in th. gylanpiun tag tpntoa gm amass. .an rrtany, «a; rcxnining'puttaatu thy wridty touting var. tantné ludtvadunlly in that: ragga. ﬂaring saaw $0 no they. in: taunt ﬁt neuonpnaicﬁ as all I uttti aura. variant patiuutl wart lﬁﬂltid qua to intraduau as to naah patient. Br. tartan partiaipntgd in Eh. téuiniatrution at thp tun! an tbs diatarbod ward and gran ggvc at ta a In: pntiantl hinant. Arringauantt wart ugd¢ tor tho rgeerdtlihrnritn ta 30nd In the dinahlrxa data «an: a lauth ﬁuring thu nmxt ymar. on antardny-morniux. print ta gar d¢purtnrc nu digcuuand rtactr¢b nativitlna with nr.0%x§mma'nurphy, Br. £11.: euranar aaa 9r. iﬂhltt waxlumataia. In .dditiau, I. dinuuaaca anptati giltho ulinietl procran with Dru. Earhart achltaiagtr tad ﬁhilip ‘ﬁﬂﬂﬂa In summary it anhicvnd_tvury ahagat1Vt or an: viast thunk: ta th: axtrtorainury anuparatgan g: tho Hunnincsr utatt, and Era. pnrtioulurly Br. Knrﬁmt. in: ﬂirtator a! :5. hospital moa£ $3: wart rhuy nodisul-rnaorﬁs all librartua. xntntu, [racinuuly hatyttgblt and and. In Incl tblaﬂlﬁ and at boat. ILK:JB ��wwwmgunm ﬁummﬁmmmhmmhwbmlw mswm‘mwmmmwwwmnwmw 2mm “WgLoW numm �Jun! 17’ 1959; Dr. Hilton Graanblatt, Haosachusetta Hontal Health Cantor, 72-7h Fonsood Road, Boston, 15, lane. Dear Kilt: I want to take thio opportunity to parsonally thank you and your Staff for the excellont cooperation shown the Billoide workers during their racont visit. They returned laden with considerable data and enthusiastic about the spirit and onthuaiasa manifested by your Staff. I an aoot grateful for your oooporation. / sincerely yours, , ,. éox Fink, H.D. foJB ��Q4: mmmnwm:mun.nm:mmw mamas ' " wMMummuanmmu _gm“, Mm. uuuwuﬁumnmuumazr- hunt“. " “mama. 7pm.; mm «m, a gm mm m mm: ' V»4,.ﬁ,_,§.,..r* 3. Age" A tu Miamiwnuanhmmummumh‘ ��1/” [W W J7 fké, fax»: .7 .2 =_7 adv/O gala; ,Afuuzs a CH“; ; NV/ g xY/ A A3 / ‘3~*‘~/7::¢4 - ls- 925“ '0’? 4a 9 09% W [W751 13.9140 4 dew/9,567 ) M42 ﬂF/ﬁf. J adeN‘ > .7 Fm”. MM 5% F A?” ﬂu— ﬁnk. fut. #mmduiui’ Fay: Q. �APR 5 I!!! HOSPITAL 1. nillnidt 2. nonningar 3. Hnn¢* nautil 2,3,k. PATIENT HUMBER 5. SE: 6,7. AGE Ectlth 1. Kilo a. Funnio --, on. Exact no Ago , intnrn;ti¢n RAGE 1. Whit. Euro 0th.:0. la inrornntien 2. 3. RILIGIGH 1. Pratauttnt 2. c;thalie 3. J¢ n 09. in“ r nu inxorattion 10. szArua‘ KARIYAL 1. Bingld 2. marriud 3. separated h. Divorecd 5. Widow‘d 6. la intaruttioa anueArIol 1. l¢n¢ 2. 1~6 yuarn 3. 7 h, . a s 9’11 ‘ o 6 . 12 7t 13-15 a . 16 9 . 17* e . nu internatiaa uma �«.2... 12. PLACE 1. 2. 0! 31313 USA reroitn tern: lagliah Bpatking ' ' 3. h. 5. 6. 7. 8. o. 13. 21‘38 1. 2. 3c . gammy ‘ ‘ 9‘- F‘ O C‘ U amrunwb 4t O . “”6 o‘ u 90 0. 15,/9 n * ' " I u * * ﬁ : x H I t I 1 countricl Girntnia & Scandiuu tvinn Ittly Prune. & aplin slavie natiaun Latin Ancriet ethnr In internation I! 9.5.A. lativv beta Lap: thua 1*h 1 S~9 10~19 29.29 30+ 30 infatuation 69 at 79»?! 89-69 1... 90~99 16¢~199 110~119 120~12y 1 0‘13? 1 0* Ia intarmation 163 A? FIRE! PSYCHIATRIC 363156! -.. lxaet Ag. inrornltion PATIEIT'S sachL CLASS 1. 61:” 1 2. class 2 00“ He 3o 01". h. 81:” §.v 91:0: 5 9. 5113301“! IBHIIR : OF PRIOR HOﬁPITALIﬁATIONB «a murmur-i 9. 0. «I 8* Ho intomuntion �.3... TOTAL PERIOD OF PRIOR xxrxnxxxczs Lola than 1 nonth 1-5 not. 6’11 ‘0. t HOﬁPITAL 1. 2. 3. h. 5. 6. 7. ‘Ow 0. 12~17 not. 1%-23 “58¢ 2h~35 non. 36-h? mac. h3~59 ”0‘. 5+ No year: internation COHDITION A? DISCHARGE 2. 3. Hueh‘inprovod; rocovarod Inprovod Unchangod or Ilightly wort. o. Ho 1. a. Docctncd informatien 913081861 OR DIAGH0313 l. 2. ESTABLISHED Psyahauis: Schiaephrcnic reaction Paychenia: Afroetiva rotations 3. Payeheniﬁz Dynamic h. Paychonnurotie Bisordcr 5. Pornonulity Dinardnr 6‘ Transient Situational Peranality ls 0 Ha inlermatian General Paychothornpy 30? TREATMEHT: +3 no internatian TREtTEEﬁTT IRELTHEBT: 1. 2. easia#¢—— Psychotherapy Payeheanulyais Paychethnrapy: ”.9. Psychethortpyc 0th.: Gran; Thcrnpy Unlpoaiticd Ho psy¢hethorapy lo infatuatien �“aTREATMENT: 1. 2. Hoprob., dopral, oqunnil h. 1 + 2 1 + 3 2 + 3 1 + 2 + 3 3. S. 6. 7. 8. 29/ ORGANIG Phonothyaninou (OP,P,Tr11 9 C O O Tafranil Gthor organic trcatunnt Ne intermatian Ho LENGTH 6F HOSPITALIZATION BEFORE GRGAHIC TREATMENT Lo:a than t‘ 11- 2 M?“ weeks menths k' 5:6 78 9-10 omwmmru 1 waak u " " 11 + months No 25. infcrmation LE GTE OF CURRENT HOSPITALIZATIE Under 1 menth t v- t o wmwmmrwmwu I 2 3 manths months h-S manths 6 months 7~8 months 9-11 month: 12 month: (1‘. 2?, 2- . .‘ 13+ months No informtticn "F" SCORE —-. a exact 00. ~ Ha scorn information ) �0 \, $550014’o s 0% 'P ~_/”‘ A § PA- N A M H G H ‘1” a f ‘64, . , '_ «a V ’4L Raﬁ» Psychiatric Group Association for Health Insurance Inc. Mental Health Association PROJECT SPRINO7-6000. Ext. 399 RESEARCH 22' FOURTH AVNUE. NEW VORK3N.V- (Invettigation Into the Insumbility 0f Pch/aiatric Treatments) Helen H. Avnet, Proiect Director November 28, ADVISORY COMMITTEE l 960 Harvey J. Tompkins, M.D. CHAIRMAN lea Perlis VICE-CHAIRMAN A. Oakley Brooks Martin Cherkasky, MD. John M. Cotton, M.D. Jack Elinson, Ph.D. Sylvan s. Furman David Goldstein, MD. Clarkson Hill Paul H_ ”och, M.D. William A. Horwitz, M.D. Lothar B. Kalinowsky, M.D. Mack Lipkin, M.D. Henry B. Makover, M.D. Martin E. Segal Leo Srole, Ph.D. Partic£9ating PSYChiatri-Sts FROM: Harvey P J. Tompkins , M. D. and John M. Cotton, 1...; Participating Psychiatrists, the Project, covering a sample group Of 76’ 000 Persons’ has been operating satiSfaCtorll-y Since July 1,1959 HarrYl.Weinstock,M.D. Bernard Wortis,M.D. Attached msma is a report pating psychiatrists, REPRESENTATIVE COMMITTEE Int erest 1‘18- MANHATTAN: John M. Cotton, M.D. CHAIRMAN An on our survey of particithink you will find Which we address recently made by ArthurHH. Harlow, Jr. PrESident of Group Health Insurance, Inc., on the first, year' 5 experience under the Project, will be summarized in the December issue of the Bulletin of the New York State District Branches of the American Psychiatric KINGS: Morton H. Hand, M.D. BRONX, Jacobo. S-Jaeger,M.D. QUEENS: ArthurW.Schappe|l,M.D. Association. NASSAU: Irving Chipkin, M.D. If SUFFOLK: Robert Wagner, M.D. WESTCHESTER: Miltiades Zaphiropoulos, MD. write us r equ est. you would like additional information please and we will be happy to comply with your NEw JERSEY: David Flicker, M.D. DEPARTMENT EXPERiﬁ'l {ﬁlial or ”ii PSYEW HILLSIDE HOSPITAL GLEN OAKS.N NOVZ 31960 M. D. sycuratric Research Pro;. ect Thanks to the cooperation of our S. APA T02 SUBJECT .. . . National American I 1 ulna! Illness (3 Me Financed by National Institute of Mental Health and Group Health Insurance, Inc. �QUESTIONNAIRE SURVEY OF PARTICIPAIING PSYCHIATRISTS possible aid in the eventual evaluation of results of treating Project professional qualifications and customs of participating psychiatrists. As a cases, a survey was conducted on the age, sex, and for participants, returned questionnaires. In addition, data on qualifications were obtained from the latest medical directories of the non-reSpondents. Of 1150 many 1008 In order to encourage the broadest possible response, the questionnaire was limited to one page with a dozen questions in all, mostly check-offs, and with space provided for comments. are: From the Project's point of View, the most important findings of the survey (1) The great majority of participating psychiatrists are well qualified, judging by accepted standards in the field. (2) Over three-quarters of participants regard themselves as primarily analytically and psychologically oriented in their approach to treatment. ‘ é‘EX, AGE;.,L9.CATION - (Tables 1 - 3) More than half the participants are between 35 and 49 years of age. About every tenth participant is a woman. The majority practice in Manhattan, although the suburbs are fairly well represented. TABLE 1 — SEX OFﬂgAgILQIPATING PSYCHIATR;§1§# Male Female TABLE 2 - AGE 1001 (88 per 138 (12 per cent) cent) Dl§IgIBUTION Age Group‘ Egmbgr 28-34 187 204 144 224 168 99 35-39 40-44 45~49 50-54 55-59 65 60-64 and over Total *excludes those who have resigned or in Group 71 42 1139* who have died ger Cent of Total 16.4 17.9 12.6 19.7 14.8 8.7 6.2 3.7 100.0 �Page 2. - AREA OF PRACTICE TABLE 3 Number Area Manhattan Brooklyn in Area Per Cent of Total 57.0 649 98 8.6 5.2 1.9 59 Queens Bronx 22 Staten Island New Jersey .4 5 6.4 73 7.0 79 Nassau Suffolk 4.3 5.8 49 Westchester 66 16 Rockland Other Total ~23 1.4 2.0 1139 100.0 TYPE OF PRACTICE participants confine their practice to hosPital work. The majority Forty-three per cent treat only in the treat office, referring their hospital cases to colleagues. Seven out of ten answering this question (1000) report that they also do out-patient clinic work. Only 17 both office and hospital patients. QUALIFICATIONS Of 1096 either participants for whom information is available, cent are 85 per Diplomates of the American Board of Psychiatry and Neurology or are ”Board per cent are qualified as psychiatrists, with an ”SI" rating, under the New York State Workmen's Compensation law. 0f the remaining 13 per cent, 6 per cent are accredited as psychiatrists by the New York State Department of Mental Hygiet e, with the "QP" rating, and 7 per cent meet the quali— fications for membership in the American Psychiatric Association. eligible." Another Table 4 shows TABLE two this over-all distribution, and Table 5 breaks it down by age: 4 - QUALIFICATIONS DPN* DPN ‘ . Number Per Cent Cumulative Per Cent 585 53. 4 31. 8 2.1 53.4 85.2 87.3 7.1 100.0 eligibility only* 349 23 SI rating only** 61 QP rating only*** 78 APA membership only Total Known 1096 5.6 9239 100.0 *Diplomate, American Board of Psychiatry and Neurology **Qualified as psychiatrist under New York State Workmen' 3 Compensation Law " " *** by New York State Department of Mental Hygiene - �TABLE 5 - QUALIFICATIONS Page 3. AND AGE Per Cent of Age Group with Boards or Eligibility SI Rating Only Age Group 28-34 90 40-44 45-49 50-54 55-59 89 - 60-64 65 and over 'All Groups (Total Reporting1096) *less than 1 * * 80 35—39 2 87 90 3 86 2 71 68 8 10 85 2 * per cent ORIENTATION invitations to participate in the Project were issued, reasons for nonparticipation were also solicited. Most refusals were based on the practitioner's analytic orientation: The 15 sessions provided by the Project were felt to be far from adequate in terms of the respondent's usual ”A-P” (analytic and psychological) When approach to treatment. Since the "D-0" (directive—organic) and eclectic practitioners were more apt to be optimistic about the effectiveness of short-term therapy, there seemed a possibility that enrollment from these groups might dominate the list of participants. This theory was effectively demolished by the survey. Of over 1000 respondents, 77 per cent checked ”analytical and psychological” as their primary orientation, 10 per cent checked "directive and organic,” and 13 per cent checked "other", usually specifying "both” or a combination of the other two such as "organic and psychological.” Although the majority with the primary A-P orientation exists at every age level, it becomes less of a majority with each age increment, so that what starts out as a 92 per cent A-P orientation, in the youngest group, comes down to a 53 per cent A-P orientation in the over-60 group, as shown in Table 6. TABLE 6 - PRIMARY ORIENTATION AND AGE . Age Group Per Cent of Each Age Group with Specified Primary Orientation Other A-P D-O Combination 28-34 35~39 92 89 2 3 40-44 85 3. 50-54 55-59 60 and over 76 61 10 21 45~49 All Groups(Total Reporting 1002) 6 8 12 53 25 14 18 23 22 77% 10% 13% 59 18 �Page 4. A primary orientation toward one approach does not of course mean that an individual will always use that approach. A psychiatrist who is primarily A—P oriented may use organic approaches on occasion, as shown below. ATTITUDES TOWARD DRUGS,gSHOCK THERAPY, GROUP THERAPY Drugs appear to be almost a universal tool among psychiatrists (98 per cent). 0n shock therapy and group therapy, there were far fewer answers, and it is impossible to evaluate whether a non-response indicates a negative attitude or an oversight. But a comparison of the number responding to each question may in itself be indicative to some extent of the degree of acceptance achieved by each method of treatment. The total responses and the percentage of affirmative answers follow: Total QEEEEEQE Do " H you " drugs? prescribe ” I! Per Cent Affirmative 98 952 693 shock therapy? group therapy? H Number of Answers 75 51 69". A cross-tabulation of the answers to these questions with the primary practice orientation of the respondent shows that the use of drugs and shock treatment is not a distinguishing characteristic of any group, although the non-A-P's are much more apt to recommend shock therapy than their colleagues. - PERCENTAGE OF REPORTING PSYCHIATRISTS TABLE 7 AND GROUP WHO PRESCRIBE SHOCK THERAPY, DRUGS, THERAPY, BY PRACTICE ORIENTATION Per Cent of Each Orientation Who Prescribe - Practice Orientation Shock Therapy 68 A—P D-O 92 90 Combination Drugs Group Therapy 100 100 50 54 34 97 There appears to be no dearth of personnel ready to administer shock therapy this) or to conduct group therapy (208 checked this). (247 checked FEES A question was asked as to differentiation between fees for initial consultatior Of 981 respondents, 45 per cent do differentiate, 55 per cent do not. and treatment. The question as to the respondent's usual fee for a private office session brought 987 responses, of which 789 were explicit, 198 stated a range. In other words, 20 per cent of the respondents do not have a set fee. For most of these, the range indicated was either $15-$20 or $20-$25, but there were instances of a twentydollar spread in the usual fee - e.g.,"$lS-$35" or"$30—$50". For those stating a definite usual fee, the distribution is as follows: Usual Fee $15 $20 $25 $30 or more Per Cent Charging 11 49 36 4 �Addendum: PSYCHIATRISTS AND THE OPERATION OF THE PROJECT Because of the enthusiastic response of psychiatrists to the Project, one of the disappointments of the first year's Operations was the relatively small number who actually saw a Project patient - fewer than a third of the participating psychiatrists. This includes cases treated by more than one psychiatrist, and multiple cases in the same family (usually treated by the same psychiatrist). The number of psychiatrists and patients* seen by each was as follows: Number of Psychiatrists Number of 201 1 Each 1 63 21 15 8 4 Patients 2 3 4 5 6 each 7 ,8,9,10,11 *Excluding cases having hospital care only. Psychiatrists having a in relatively short supply. number of cases are usually child psychiatrists, who are all participating psychiatrists, the psychiatrists who treated on the whole somewhat better qualified (91% vs 87% having Boards eligibility) and somewhat less primarily A~P oriented (67% vs 77%). The Compared with Project cases were or Board treatment. they rendered was mostly individual office psychotherapy. Four per cent of the cases were hospitalized; seven per cent received shock therapy (including hos— pital cases); three per cent received group therapy; seven per cent received psychological testing. Ig_thi£ty-five per cent of the office drugs were prescribed at one time or another during the course of treatment. cases, 0n the basis of the few (36) Project cases treated by two or more doctors, it would appear that psychiatrists are rarely in exact agreement about the diagnosis of a particular case. In 12 cases there was a basic difference as to the severity of the condition, with one doctor calling it a psychosis, the other something less severe. In four additional cases there was a difference as to major category (usually neurosis or personality disorder). In another six, there was a partial difference as to major category, with one doctor calling it a mixed diagnosis; and in another 9, there was agreement as to major category but differences appeared in the sub-categories. cases there were identical diagnoses in 5. 36 Out of Another demonstration of the individuality of psychiatrists emerged during attempts to classify frequency of treatment under the Project. Although six specific classifications were available for coding purposes, 42 per cent of the cases fell into the ”other” or non-classifiable category. Pursuit of this led to a fascinating variety of frequencies of individual office visits, each adding up to exactly 15 visits (the Project limit). There are combinations extending from two months (6 visits one month, 9 the next), to seven months (4,1,2,2,2,3,1; or and in between come all sorts of combinations spreading the visits overl,5,4,2,l,1,1), 3 or 4 or 5 or 6 months. far as is to the Project administration, there has been a negligible unfair advantage of the Certain difficulties inevitably arise with thbse who do not read their mail orplan. and there instructions, are occasional misunderstandings resulting from patients belatedly identifying them— selves as Project-eligible. As far as can be determined, broken appointments are not a serious source of difficulty. In general, the Project has generated the enthusiasm and cooperation which sometimes characterize pioneering ventures. So known amount of abuse, or attempts to take GHI’APA—NAMH RESEARCH PROJECT (for the period 7/1/59~6/30/60) �I: 12/26/60 Social Glaxo, Diognooio, ond Irootnoht In Throo Psychiotrio Hospital: In 1958, Bolliugohood and Rodlioh pahliohod on influontiol voloto, (1); in ohipn botvoon mat it tho: roportOd roiotion- social class) diognooio, tad tho troot- or loan]. dioordon. and Pink (2) which During 1958, Kohn, Pout ok roportod studill tt not lhOﬂn that who: oduootioh or oooiol slain, Hilllido Hoopitol vhoro woo it It! roiotod to toad who on to iodox on: rotorrod for convulsivo thoropy, one to tho thoropoutic rouponto to this trootnont inotrunont. Tho Bollinglhood ohd Rodlioh study It: oorriod out bororo tho oo-oullod 'tronquili:inz“ drugs oohiovod wido populority. thoropy ooooo oloo demo Tho Kohn, at a facility, woo hood. roportod, for CSﬂIplﬂg thot drug tho prinéipol thoropy in only b.31 of tho tho: otudiod.; thoropy won it: It won whoro Pollock o rink study woo ot tho tino, oonvultivo tho major organic thorlpoutio dovioo which �i3Tvvor the heepitele were well The third was the research hospital of a state hospital system etteohed to e its ﬁetiente private facilities. known university medical center. Heat of were voluntary ednieeionl. Each of the heepitele were peyohoenelytieelly oriented and each institution maintained affiliations with local analytic institute. The hospitals were loceted reepectively in the aid-West. Riddle Atlantic, and The queetioee we e New England. wished to answer in relation to social classes for the different hospital settings were: (1) What is the relation of patient social class to (a) diagnosis, (b) treatment, and (o) length of he (2) hospitalisation. For these varieties, are there differences between heepitele vhioh treat different model close groups? Pppuletion a Hethodolegy: During the Winter 1958~1959, e research team each of the three hospitals. population of each hoapitﬂ. The who visited total adult in~petient were hospitalized on �~11» voluntary cartitieatan day. Each patient word was then at hi: hospitalizatien on studied in a given viaitatioh followed through the course and information regarding his treatmant, langth of hospitalization and discharge status was appended xjﬁlxiai to tha data ahaata for each patient studiad. All patients discharged tron this hoapital within aightaan months after the study began, were indluded in the sample. This included approximately minty per cent of the originally studied. Eollingahead position and was emphasised which aducational scores. farred to it two factor index of social utilizes Data for each Eollingshead cards to weighted occupational patient I? and V. trans~ on thc p u‘i.05 laval. Class Diatributian within Hogﬁitala: In Hospital "A“; 311 or the classes I was facilitata statistical analyaas. Significanccs were computed Results: patiaata and II, 12$ to Class In Haapital Claaaes I and II, 3&5 '3', III, 271 in Class patients warn aaaignad ta and 571 to 615330: at the patients ware in III, and 39% in Clauses IV and I. �-5- '0', In Hospital III, Glass modion 82% and 1‘ in Class IV. class patients have I and II, worn in Classes of Viowod 17% in in turns of the its pationts, Hospital the highest status (Rd: Cleo: A's II), Hospital G's, the lowest (Ed: Close 1!) and Hospital B's petionts fall between tho two, (Nd: Cleo: 1119.10r purpuo of olooo~ ifiontion we visualize Hospital A no treating primarily upper close groups of patients, Hospital close group, and Hospital 0, a lower B, a middle class group. Hospital and Diggnosis: Comparing the proportion of its patients which ouch hospital diagnosed as oithor psychotic or non-psychotic, we found oigniticnnt diagnostic differences between institu- tiono (:2 - 12.73; df- 2; tended to treat p4 .01). In the hospital which predominantly lower close petionto, 75 For cont of-ull the patients were considered psychotic; in-tho hoopitol treating predominantly the middle class group, 7h! per cent were diognoood as psychotic, while in tin hospital trusting predominlily the oppor class grow), par cont wore oollod psychotic. 53 �.5. Social Glace and Dielgceiea It in interesting to note some of the diagnoetic differences in hoepitele, when In Classes I and constant. II the class factor we found patients were called neurotic, in Class neurotic, and in classes IV and V, 20% 36% or the III, 29% wc-e kept was were neurotic. The direction of these statistics tanded to support the observation of Hollinguhcad and Redlich but for the hospitalized patients never theleaa, did not reach significance (12 - 5.99, p on . the 15 level (12 ' 5.77; df - 2; p e 3.8.) .05). Hospitals and Treatment: We found differences in the employment of organic therapies, 1.0., the peychotrcpic coupenndc therepiee p 1n u.; .01). and convulsive the three institutions (12 - 12.12, a: In the clue: patients; hSS facility which tended to at the petiente received tract some - 2, upper torn or organic treatment; in the institution treating middle clues petiente, abs; clean pattente, and in the th hoepitnl treating prinerily lover received crgenic therapy. �.7Social Clan, Dugout: ndtrutnnt: In combined pooulntions or the three hoapitulo, thoro are differences between the major forms of troahncnt that psychotic and neurotic patients experience (12 d: - 2; p ~$.001). compared with 205 of In It! 115$ of the neurotic were administered to tho psychotic cacao. 32% tho go Organic thcaapios of the nourotica and Patients or psychotherapy, constituted 1nd kg of can: the psychotic tacos, psychotherapy the dominant trcatmont modality. wag ' 69-7; the paychotic cocoa. who 23% It I! 76% of received neither organic of tho neurotic cocoa has been shown thot within hospital settings studied, organic forms of therapy worn frequently given to psychotic than nourotic patients. morc In touting tho hypothocoa that a higher proportion of lower class than uppor class patients rocoivo organic forms of trootnont, we round the hyyothosia not to be supported for oithor the neurotic or psychotic groups. Within each oocial clot: group, psychotic patients received organic trootnont more was frequently than uon—poychotic patients but social class not aigniticantly rclntod to whether or not potionta �-3... who were either psychotic or noorotio would receive organic thorooy. Social Class and Length of Hospitalizotion: When no combined hospitals, we for Class I & found the populttions from the three that tho II potionto hospitalization period aoan III 9.2 months, Class was and Class IV and V, 7.2 months. We found no 9.8 months, statistical difference between the lungth of hospitalization or Class I, II III patients (t- 1.66, and div 196, p - H.S.) but found significant differences botvoon Class I, II and patients (t - 7.69, df- 221, ptmm) IV and V . ggopitalo and Length of Treatment: The figures are rotlootod in the different hospitalization periods that hospitals. patients were found in the three In Hospital A, the upper class hospital, were hospitalized for in Hospital 8, the middle class an average of ll institution, for montha, and in Hospital C, the lower S.k months. mean months, 8.9 class facility, for �“9- Rocapitnlation and Conclusion: The primary purooao or this ctudy ha: been to study the rolationahio of social class and psychiatric diagnosis and treatment in hospitals which have available conparablo facilities. troutmont differences, class which have We know members may that baoauso of «coconic gravitate toward institutions available different kind: of therapy, have selected three hospitals which and thus we employ comparable ranges of therapy and which tend to treat nonbors or different socioeconomic groups. “what In affect, what is the hospital experience of oocioocononic groups where all we are thus asking is: members of different forms of thorapy are equally available?" Within the social class was hospital cutting described, we found not related to whothcr a person diagnosed as psychotic or nonvpsyohotio. Ho that was also found aooial class to be unrelated to the employment of ergonio therapy. We believe that the relatively wide use that �-10psychotropic ooopoundo now enjoy nay toad to blur tho sharper diotinotiono whihh oxiotod non. yours ogo than organic treatment was identified with the shook tad con: therapies. We that lower class position found length of time doooribod.Lowo; o was related to tho patient spent in the hospital settings class patients (Glaoaos IV & V) were hospitalized for anoruﬁormas a: time than Class I, II 0r III patients. Major The difroronoeo were found between the throo hospitals. hospital treating upper class patients tended to diognooo the higher proportion of its patients as non-psychotic, tended to employ a lower comporativo percentage of organic thoropy, and left its patients period oz time. in treatment for the longest In contrast, the hospital which tended to treat patients primarily from the lower portion of tho ocononio ooootrnu had the highest proportion of psychotically diagnosod patients, onyloyod organic treatment more often than the other hoopitalo describod, and tort patients in treatmont for the shortest period of tins. �.11. In an tar us tau thrac hospitals studind arc construed, 300131 61188 woulé appear to ho lass intimataly rclutad to dingnosis and trantuent than scald the naturu at th. hospitzl itatltg and the sacinl gruup tauhieh it tddraascs itself. �1: 1/3/61 . soaihl 61:13, DiIIROIil whrct Paychtatrto und trtaincnt 1; Ht‘pit‘lﬁ IITRODUCTXOHa Iva hundrtd and ninety patients in $hr¢a uoau cuetadinl aetivu trcntiunt ptyehiatria haupitnln, which ortcrad multipln tharnpicn, primarily ta typur, niddlo a: lawn: clnta ﬁcraoul var. Iﬁndaud during 1959*60. Questions utudicd were whothnr naninl clans £¢r haspitaltnad paticnta ﬁypm It: ralntod to (a) dingntsil, a: tr¢ntnen$, aha langﬁh at trautaunt tnd rahttamhtp at yum: suntan-nu» Cb) a nun “away", ’miﬁdla', and “tuner” «inns hospitals ta dznauuain, type a: treatment and longth a: traatnaat. W! Volautnurily udaittcd paticnta 1n thrtn kncvn xucxraphtnclly 47W“. u/Cc. f“ V: atpur:tc httntttll w¢11~ which itiﬂrlé �nan- : rung. if thnrup¢ut1¢ prnxruan. that. putioutu aura prtnnritr rdprutoutattv. at $§ﬁ§upptr, 3:831. at lunar ulnauoa, turn atudiud t! s.aluu d:y in thy wintsr, n! a 311.3 heapittl 19$8~1959 tuilunod thruushaut tacit suntan and if a Putiontl vcro hospitalitutsnu detail: caacorninc that: buneruund, truutuant nud dtusnunin wart rncurdcd* 33831.93: Seats}. 6183! was tau“ ta ha r-alaud to lung“: at notivu truatnnn‘ within tha hotpitnl aettingn. 015': I? and charm Y putt¢nta rtlainad 1n truntnsnt for pox-ands a: an. than. an" x. I: or m paticntu. Signittctnt rolutanuuhipc bctwnun 1031‘; clans, diaguoail ana trtntucut warn mat uhaarvcd. sacniticnut rol‘ticnathn war. found bntwu.n p;t1§nt néubtrthip an upytr,xmiédla and Instr 01‘3t �inﬂux: and dams“, “aunt. and has“ at hupiuluutom the nut» in tutwuomu mum at m "mun, "guitar at Vhﬂhtr a an: nutwumu m, that mm mm: tho "My“ ma M man.“ u magma-tun; mu rams." wan-am than”, and ”mi '56 Mpiullw tu- t!“ lmut yaw-1M at patio“ m I mum at ‘1‘. a a �1: 1/3/61 anuttl Gitul. nzlgntnia ;nd fruuﬁncat 1a Ebro. Puyuhtatric notpxt;1: 111302301103: tin hundrtd nut ninnﬁr patlnusc in thran nth. custodial ac‘iis trca‘lnnt'ptrchtaﬁrtu knupttnll, arrdrtd uvlﬁiplo thnrnpioa, ﬁrtaartlr ta appur, which gladlo or Inuit «1‘3: pirlﬁﬂl 2‘3. atudand during ‘ 19$9~60. Quautsnas tindiod war. whithar 300151 31.0: hsnv1%nliutﬁ pntlcntu it: rnlntad in (I) din¢n¢nts. at trausnunt «:90 a! ircatunat, 3nd 1¢Ig§h raln‘aonshgp a: Fttitn£ llﬂhirihip a: and Inngth $34 th... ‘ntddlc'. ‘ud ”lower“ cln¢a hmlpttnIu-to ﬂirt or £ruatnant tar (3) 'nppcr'. dianumwzt, a: trnatunnt. 930039332: Valuntslrily adsttttd pgtiunta knuwn geographiaally Iapnrttc 1n thr¢t wail- haipittll which uttarvd �.2. 3 ring. a! thnrtptutis progruun, Vhﬂri plttﬁuﬁi warn prtnlrlly roprcatntaﬁavu a: iﬁiEnppor, ngdéau er lowcr alumnus, aura Uti‘iid an at n ctvuu hmapitui «call: any in tht‘wiuﬁtr. tallauod thmaushtu‘ thttt and 6.13113 unncnrnxug and diltnllil l9$8~1959 BQIrlﬁ ¢ if Pnttonia var: hampttnlatuttuu that! h$ak¢round, trunﬁnnu‘ mutt ruocrﬁad. Ilﬂﬁlg§x Benin: ulna: vat fauna to ht rulatcd to langth at asttro trcntnnnt wt‘han «a; hompttal Ittﬁinsl. 015.: IV and V pattan‘u ruuutacd Ln trcntuont {or thurtar 9.3104: at téuo tuna clan! pttlthtl. Signifiauat I, I: at r¢1m§¢nanhapu 01:33, ﬂtlﬂﬂﬁﬂil nut tr‘aiuomt lira :11 bitwcun.taotn1 ﬁat dblorvnd. aacntttcant rolnﬁiaalhtpa new: round bntugnn patsaat nadburahip an uyptr, 31441. and luau: «13;: �human and «awn; ”Miami and loan» at h§Ip1£u1tsatioaa 2h. srnttnr it: uaataaiaonuntc Ituiua a: the hanpiQal, rug&raluns a: whither a puticut any n ninbnr gmaup, aha mart a: a aiv¢n aacauuaacnumia 11ktly the pat1.n¢ wanié h: diaznaaed gs nanwpnychoﬁin, wauln rgaeivv neawurgania therapy, and would be hunpitnliangQr the $130. inngsst patina of �II: 1/10/61 Social Clean, Diegnoeie end Treetnent in Three Psychiatric Hoepitele INTRODUCTIOH: Recent etudiee have indiceted e reletionehip between eociel clean end peychietric diegnoeie end treatment. preeent etudy wee The designed to study whether social cleee for hospitalised patients wee releted to diegnoeie, type of treatment end length of treatment, in three institutions vith differing eociel cleee membership of the patient populetione. PROCEDURE: Two hundred end ninety voluntarily admitted patients to the C.F. Menninger Memorial Hospital, Hilleide Hoepitel end the Heeeechneette Hentel Health Center were etudied ea or e given hoepitel cenene day in the Winter, l958~1959. Petiente were followed by-e reeeerch teen throughout their course of hoepitelieeticn end deteile concerning their beckground, treatment end diegnceie were recorded. �.2RESULTS: Sooisl clsss was found to bs mars significant in coup-risans bstwssn hospitals than in intsr-institutisn analysis. Within institutions socisl class was saluted to lsngth at hospitalisstian snly; class signiﬁicsntly IV and V patients rsnsinsd in trustmsnt tar shorter psriods thsn III. those in clsssss I, II hespitsls significant rslstienships bstvssn social showsd sud Csnpsrison bstwssn class and disgussis sud trustusnt ss vsll ss lsngth of hospitslisstion. The higher tbs class status of tbs hospitsl, ths morn likely tho pstisnt would be diagnossd as nonpsychotic, vauld not rsssivs samstic thsrspy and would bs hospitslissd for s longsr psriod. hospital was mars Tho class status or ths importsnt than tbs inﬂividusl patisnt's clsss msnbsrship in dotsrmining thoss rslstionships. liIIIUQ �Junntry 10, 1961. Dr. Gurdnzr Kurphy, Diroctor of Research, Hunningcr Foundition Hoapitnl, Topeka, Kansas. Dear Dr. Murphy: stat: In 1959, Dru. Siogcl, Kuhn and Pollack at thin arranzod with Dr. Ksrtuu, ta undarttkc a canpnrativa population staple study at the in-putiontu Haulaahulitta Hunts! Hunlth Hospitals. Tho dtta colltction ph‘l. at this atudy VII conplotod in Soptunbor, and V. have prone-sad a large part or the atntiaticn and and. Ian. prolininary audguonts. It in our dosiro tn proscnt a comptrativc stnicuont a: the "Social Class. Dingnoui- ind Trontuant in Thruu Paychittric Hanpitalt ta tho incriesn Sociolozianl Sacicty in Augnat. rho dutu bl! bath intlysod according ta hypothcucn undtr otudy in tho in-pationt sorvico at Hillido Hospital in 1957 and 1958. An abutrnct or this initial roport in enclosed for your Honninger Hoapital, It Cbntur and Hilllidu internatian. urn plonuod ta credit the cooparatinu of tho ill thrto institution: in enabling this utndy to bo incomplilhud. I: that. it :ny additional connunicntion W. atattu or noogatngy new as for thc prancntntiou or this data, Du; Robbins and hipyy ycar. Join: us in withing you a Sine-roly yourc, Enel. HFsJB m iInE H05. would you lot anccoasrul �Social Class, Diagnosis and Treatment Jar/a ‘ in Three Psychiatric Heepitals 9s [4 N p as, "Axum If “lips: his 62%;}; s . d/mAM ,/ I INTRODUCTION: as g fag / AL»; 4 Kata, Xvi/5k. we ,4 A . _, Recent studies have .1 / ”wk indicated/a'relationshiﬁ between social class l and psychiatric diagnosis MW“' treatment.I\ and The designed to study whether social class aunt for hOSpitalized patients was related to diagnosis, A type present study was oi—taeotment and length of treatment, in three institutions Withhdiffering social class membership,e£_:h¢_9a;§en¢_. popaiebfﬁﬁs. PROCEDURE: Two voluntarily admitted patients hundred and ninety to the C.F. Menninger Memorial HoSpital, Hillside Hospital the Massachusetts Mental Health Center were studied as and of a given Patients hospital census day in the Winter, 1958-1959. research team throughout their were followed by a course of hOSpitalization and details concerning their background, treatment and diagnosis were recorded. 71.9.3th )7 5/2, ”mg r [£1 44M” ‘2 I (’- ’3 1,1,4"; at. & “4.4140,,51‘: , 2:3; f.a.Aﬁ/_ 1.14931. 3 , j>gﬂ(‘""4" I) MM! 14.0741; 5&4: 4‘ I ”my 1:“ 2'33; 4» fall’g’ffrf (4“ {W4 / "w a? “3‘ ” . M was f. a a, ,x. aw Wm, f‘zl/“ié ”*Muwwt‘ .-' 7 “A,“ I ‘5 ’ 1,» . «min ad.“ an» g9 252‘. .6‘ - I J, £354 {V _ an , ' . �-k’ RESULTS: a . Social class was found comparisons between WM if ”54/ to be‘more significantnin hospitals than in inter—institution analysis. Within institutions social class was related to length of hospitalization only; class signiﬁicantly IV and V patients remained in treatment for shorter periods than 1132.? those in classes I,\II hospitals showed significant relationships between social class diagnosis and treatment as well as length of and hospitalization. The and Comparison between higher the class status of the hospital, the more likely the patient would be diagnosed as non- psychotic, would not receive somatic therapy and would be hospitalized for hospital was more a longer period. The class status of the important than the individual patient's class membership in determining these relationships. M �Mary 16, 1961. Dr. Hilton Greenbhtt, manhunt“ Rental Kuhn Center, 72-76 rammed Road, Bolton, Hen. Dear mm It In good talking to you in Wuhington. I think the meetings went very well and I eapociauy liked Shep Roma's raport location the VA, pnuont-paumt intonation. on also quite an Xurlmd and is little The many nit-moon in studios. more ammo good. bringing out the drug Comm oomtin and for phoebo control! now in and comparative efficacy tasks on saluting be who’s Mom to Encloud in our inltial abstract much to the Andean Sociological Society. we My best. regards. Sincerely you”, an: inn: mﬁ. Baal. HF: JB new drugs in order. am sending - �1. 3... W .‘ M753 . 2,3,8. z m» 5;. in. 5. 7 8 7. 4/44: m7 IAA/c M, m M4 n n "" If? ’é a , fl. "0 5 . .__n 22...} .JL A ~ MI Ag~nhﬁ ‘ 13. m. In" M ta man mum at “4.”. I. mmm ms WW!!!” m...“ “,.".“. -WA �at» mamount: ”a“ m I! 1: 'u‘n‘m 5. 19:19 6. 19-” 300 ,_ 15. N»?! 0M! 3. 5.a {@099 Ya 1'0‘1!’ #. ’1 a. 16. u km 6! .. ‘ ”-1” Rod” '9‘. h tumum Q‘tumﬂ sans. ems :1. 1 ’1 an. 3m. 5 "m m it ms mmum mm ii s g. 11,13. 316/”); I “a M‘. “O “1mm a A6311! as. 1’.”. ruemnn manna“ rm:is! ”I M‘ m. 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II IIIIIIIIIIIIIIIII IugtIgillz.‘:IIIIII m III 3Iml 1 I I / I. VIII 1. ' m I 1» . 5151*" 33%; MI 3* 3' i' .. : I. ‘: ‘.. . ,‘ > _,: \_ ‘ k A. J ... .‘A. Kuwr S‘ . A Jam-.1 I‘m-Hana; �4" man“: Fer-Chm: #7. M “in 3..1. mu ﬁrm My aa. aw‘33”: h «mm Q J m W i 1 I - MW‘ :1 Mill‘ W‘“;:J”*”' 4" N m3w x95? W a .. W a. a.. s. g. ; ’ .. la 1 ,1” 77W 3 a 9’ t 1 t. 595'? ,‘é/W . 3 «r ‘ 3 ”:3“ m . ﬂ/M/L 13% : £5 OI. V man nasuumm .. h 5 mm 6 min 7. ’41 mm: mu: 9% 13‘ mm 1.33893 1 at ,. :, = 18;. 151 ' - 1 . a ‘ m. so 31,, 1 a. St Mutation 1'" sea: *‘N 3 ea. I. intonation .Mm IW TM ill/M a ' ' LEW. ' :~ 1 44 �W ﬁﬁﬁB 6913:; 1. r 1953, 1. 1:1 Iﬂtyltll'5%lé195?. 2. Billaidt stuay, 1966. Its: 138. 3333? _ xearltAL '2. Kenninzur 3. East. ﬁcatanIQA1th S. 3:113:53, 195? 6‘ niilsidc, 1969 2,3’hc £121!!! lﬁﬁiﬁl 5. 831 6,1. an: 8. axe: iii: 1. 2. Ytntle Extst 3:. ~~. It 99. 15 infatuatiau Wits E. xogrc am: a. San: or 3. 9. 10. nu iaiaruatioa nxaxaxan 1. yrotOtttnt 2. Gathcli¢ 3* 3‘?in 6. 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' <20 E ' 20-39 , 5 van-1 ‘w-n— our man �wwmmemI TABLE Munich V XIV and Duration of no v .mmtm am» in awaits]. ,rw—mqw gPu-‘cantz ‘ vamww Manon < W." 12 3 ~11 12* A 23 13 a 87 ’ w.~h.‘.w-, 12-15 51 20 22 £5 254 35 8 .. 12 21 5h 25 12-15 19 13 33 164‘ 9 21 21 w: 12 7h 17 9 may 57 39 h , ’ “Wm—r «gV\_..n..w_u_l_... w.” _._.._w MC 16*, c ��Wm.vwvlp.~ .- TABIE 1' . 1' Score 141' H ' 30449 33 10-29 30-119 50-70, m0 10-29 304:9 ’0» 0 Nation of 1mm < in. Ho Mimam ta; Paula 7.11 12+ 17 57 V 1“? 0-70 Score and IV m 33 ‘ 26 21 7 5 47h 4f: 1/ 1*: Ma? #3 29 15 33 17 69 6h 77 15 no 38 28 9 31 32 2 5 d4! 4 5!" g 93 US 214 O h o V 4 df 7? Or y‘ Y 05 ��" 3 . . u r." ~w-wm-aw‘m ' —L~"K'.uuhll a 'V'wlm m‘wmww.‘ -wmwmm ��M. +MI o I821. LC] 81.? K o 72.7 = 2. x" =/.-IO /:~s 20.9] 22.5 31.0 HH. 55%. “‘3 $8.6 =4 =5£7 X P = N5 MMHC ZED 49.4 25.3 22.2. 6!.0 w =3? x / =/VS 44.7 ��W“!- Aft-5 p< .061 N'- wmmm" ‘m'W-mmn“mm rum. V":I’ﬁwmﬂlﬂhm 1». ::-.. r u'< ��‘18.? 35’] 59,2. (0.0 . IA’. ‘2’ O 54,7. 52.7 9’51? MM (4C. 39% X’V 5/: / 1 r. P ‘ 77.0 91.8" 13.5’ 39,5- (47.3 53.8 9,/ . 9.7 7.7 ‘ .56 N3 ‘ V53 ��f 70 2 lé HEN” /.. / {’1’ 141.4 ' $29 2 ~- 32- é .5" �’<ZZ _ . 7" 1 I7 ' 7 '22 7 HS’ 5/ _______2__ . 39 ‘ ‘ FINN <7 o 7-— 6 . __ 0 " 3 I 11+ M?! [IQ 5‘ €=N3 5 33 4 7-" /$‘ ‘2. [If 5' O g I? a \\ NS ��W6’m 3 m mtmGoLﬁ. REE. 26. macalo 26. mam. mthnnhhmoﬂaimdmtommiw’mo' Hamnﬂquind,m'mw&m mu'nm.1,mtmmmwmca1.1.,nc. lawman analysis, the «en Gel. bum wmmm.29. 11m col. 29/ will b- mum-following 1,2,;th 29/6,?3 691.22/3 9.’ cal-dim“ 29/0 1111 m ho m. 5. ma far 29f]...2,3, ,5; 29/63; 29/5,? m and com «:3 an 601. 23 and 601. 26. aud-u Inmmamthath. mum‘s-um. WW 11:91»th Bogart-ant at Lunar Psychiatry, amino‘nybomm um, 61m Oaks, I. I. nmm. Rommel, 1: than. my difficulties um: um. any“, I my 3:. roach-d a mm. 3—7”, Monica 235. this mm, My“. to: Dr. shun}: yum-I. nth-ma. '3. mp1, mm. �iua1apuruhoxnclcnt Aspu¢1n or 311.21 L. Kain. rn.n.*, ﬂhﬁﬁauAul Ptrtiaitriu trcaﬁnautle In: rulxauu, r119. 51.5.1, ra.n. tad ﬁlm yank, «a. Buymrtntut a: r:«. 01¢: 8.3. Expurmsaneax Purch1a$ry, 3111116. cult, 1.1., I.!. AAdnt 11 putt. h; ‘11:! 31.209: at tug Iattsutx Ianiisato acuith. and 150 1.3113 Pabltc Buntth innpitnt. v.5 8.5115 lonrd. at 3.11:1 strvincz ”unﬁt! Unna¢uhurot§n $113!: Innis: the unaporuﬁitn-ox if It: ti. Icalth 6.31:: :31 1h. c.r. uonniusar ﬁaaorstl aaapatux 1: ¢9m313 cratnthllr aukunmloduuﬁ1 ; it ’I& 31v1u1on Srozgatﬁtgdrutts 13 2/63 . at Ptyuhtntry, nontuttaro ﬂcnpltal, �In innit liuﬁr or sun luv pupuxmtttn, Rtlltacthmnd 5a! 83"; ynxuhzutrta patient ildlilh rtpnrtaa atnatttc£ut rolntioulhtpo bitumen In innavzdnaz‘a yactt£¢a in tha tuuinl clams Itrusﬁura 3nd tan yrgv:13aan at trantnd illausu. typun or dilﬁﬁﬁltd aka-rduru Inn kind. and ﬂurutiau a: puruhtntvxt trvutunut aﬁstuxstgwod ( ). Char indimutté, tar txuupla, tht§l‘hig§ur vruyirttiu «f 1¢§nr alutn puﬁtinto in troutnunt wart alanattata yumitnma at It purnhntaa uppur 91:5: nae pcvtunnzity will. attairteuntzr high.» pmn¢ patiuuit Viv. eluaattioa at nauto‘ic etuurdtra. Far all vatltnts, psyahqﬁharupy no: Ippitid 1n dalyriyoriiunutqu htnh itarnqa ta twp.» «Int. pattua‘a. within «tan dimgnﬁat&e granﬁ, yqyuhatharnpy was apylzcd unﬁt-afﬁne in npm§r ulna. yaiicmﬁa tad urinate ﬁhtrtptnn tn lunar ulna: nuha‘ntn‘ ﬁiaimmr It. ligaxr1canuu at ¢uinanic fantara at traitius paruannal dgtaralaiag thn and availability abnorvgd disrurauman tiuld at! ht uxtludaﬁ in $301: Iﬁudiii. to tutu ﬁho #010 u! �-2. ﬂﬁﬂihl fact!!! in tap $r¢ttuaa£ at hutpttniistd patinuti nadir noadition: axnluaing sh. ruutara a: p¢ti¢nt'n rtuinata Ind availability 0! trcltnuatn, an: «adtriakta it a yaticnt can‘t: try: aurvay 3111114. unnpitul in 1957* yitti. t Viritty at triatntut awn... ind Irzouio thortpiua at. 1st. at thﬁlr ability $9 pay. In inglndinn pszuhothtrtpy available to «11 pgtiautn r.¢nrd~ an abachtd $hut nan. odnaatsﬁn and 913:. a:¢n£t1u:utly aaluciutod ﬁith ﬁbﬁiﬁ. Quin hog. #3 at htrth tran‘naut, duratiun a! unﬂatt:11nnii¢a, altnzaul datahlrgc IvalunQiun daggnunta ( i. 91n¢r, iar'tgnwbara patiantu tarsal uduaattca wurn mart warn with ﬁnd {a lit‘lu Itkolr tn ruccsv. qu‘tiu thurtpy. var. kupt in tha hnspital for nhurtar pcrioda at tint, aura titan rttaa .0 rancvurgd «r gawk Saerth And an ditchurga. In nanié;at. tho rsuncar, buttot uduoltud and n.ttvc born paﬁtonta airs at ertsuunt, stimn raeatvud puy¢hothurtpy an wot; haapituiisad it. 001: turn tar tong.» parioas tad rancivud �.3. t3: yearc: cliniuul diauharcu rutinut. Show: obsorvitivna attrautypr :culitarnin 3 rarlactoﬁ ﬁnal. C v.3. 1n £139 raintud to noniurau or lubjnet': roaponaea to ). Bichar F a nadiriad asorau wart unloointcd with ditgnaicu at 1nv¢1utianal payahnlis, uhartnr parioda or hanpitaliuutiun. and»: tharnpy ( It ). who h$shmr inoiélubc a: roturrul tar nouutia canclndod thtt the atroets patterﬁa trulﬁmant at aauiua algal (us dutinud my an ysyahiutria Halliaatho£a tad analluh). tau, advantiaa birthplncn and dogreo at statue» ﬁypy «tru 33% u result «I aconontc itcigtl or tvuiluhilitr a: uuagilttan an: «luau. trnitpsnt wan tha$ the oblervntionu taﬁptutiou. rtrttcﬁioa at ditturunt naagl a: 8.2. : tian and uxpruntian. It conuu31¢5w u:a poztnlatai that anhsucta cf 108a: would ROI. 313th :ud uduaattau 1001:: fortian Ioninl ulucunl, in maker nou~varhu1, ar mangory lynptunu ninirunt trcqututly puttnrnas while uyper 015a: subjunts vauld of .xprnulion. utiliip vurhal :¢nnt �.3... A n¢e§nd titaa to ﬂho intirprttatlon, navthr, rc1:tnd th: tratinaat philauophicn tntiauul luadura and It wan anﬁ paraoanal. lantiiutioau what: ynyuhathhrapr Wﬁﬁ absurvuu ;ttitudu¢ at 13:81“ nuggsstod that in ilxhly vstund, uypcr Ginsu iudﬁvidunln wauld rauntvu inordinatu ruprtlcnta$$¢n in ski! ﬁhtrnyy. ﬁanilnrly, dinahara. ovtluntiouu ¢ad duration at hanyattlxaatioa ﬁtnld bu aflostté 195? «tat: at dittcring anciul ain‘t. unpnatntionn for individutln to twat this by nitraronaan in uu¢¢nd aucg¢utiou w. doaiicd Hillaido Iiﬂdy; to naplvy ¢h¢ to rtpcat uh. It». lrotudurnig Ind uon* ¢h§arvati¢na «ataad the to ta ta: oth¢r iantitntiont, currently shn 0.). nannincur Ronarinl Boupttul a: laaaachaaatta Manta: noalth Tupakt tad tho Conﬁar 0: Boston. In theta thlﬁt hauptinlu, inlﬁitutiaunl ptraonnvl nfxuot similar ttﬁitadus in trsatuuut tad education. Eaah I fall tin: Inpurwinory stat: 1a a $¢¢ohins hasxital with uni tutivu rtnnureh dapurtneat. thuy amphaaiaa yaychnnng13t1enXXynarianttd glychntharaﬁy but �m5.u yrovide uﬁhor traataantn 1nolud1ng nonttxu ﬁhortpiea «ad aetivp pragrlnt of utiiuu thurnyy. Bach ’trosuos chart- terﬁ traatmant of voluntary watiuuta, data tedial aura 39% provide gun» ta arav their paﬁiont papulntian Ira: and tend: aimilur an; graupa, excluding ehtldrun and thy aunilc ug.d. ﬂﬁjar inatiuuhznual dxtrcronaun 3:! gain in thoir cantata or iinnnaial anppart, airfarent institutional policies rnnnrd~ Sag lanath at stay ﬁnd ntﬁur¢¢tru. rho Huanuohuanttu Rental Health neuter (Mﬁﬁc) in a publin Itﬁﬁt tundu: Killstdc Hospital institutien suppartud (RR) 1: a nan~pvot£t veluntary hospitui with a ns3ar partinn of its incanc durlvnd and other aonmunity funds; tad Kanningur pr1v¢ta inntitutiun. taliuntiﬁn, «5:1. more Hﬁ at 33 tic: nit; nanpital (HIE) in a ha; I 90 day limit for haapiw I flotiblo on. yaar retina; kaharal attatuda. At urn $nd @ntpntiunt ulxaia urn while Thu Hana by maﬁa trail: trailnhla t and HIE, I dty hospital and to all vatznntag thdrela no 43a heapital and I uhopt tutu, limitld �45. tttovenrw proevnu is availabla to 2h: printry ruaaun I tun patinnts. far ouloettng tun tattitutaonu, havov¢r, lay in thy axpnctutiou thnt thuy vauld murvu pattants of differing acuinl alumnus {nae £5) lad that differuneui in this dtutaiicn vauld bu roxlnatad ta. ta trau$nnnt wurinblaa. rho speeifiu purpato cﬂ tutu stuﬂy wt: ta dotcraina papilla t1en dittnrcnaas betuuan tun ﬁbrin mustttnttant with raaptct to anclnl alman, :39, education and F utorc, na& to rolutn thaaa pttiunt chlraatcrtatica to sho trnntnnnt Ouvtnblun of type at treatmant, durntian or hospi$a111nt1an, diagnonau diuehawg. twilvatinn. Qua �.1. REEBOB A11 : pattoatn in rcaidcnco ia‘th¢un tnaﬁiﬁutiana givun dutu in January 1959 aura utuétod. R8 had mane on whiz. urn tan auuhar thoaa a at at duly, stall patients veluntlry Vtrt sultanua by an: uaurt: ta thu institutioa tor puynhiutria ovuluutian, or a chranis aahiuophrqula granp udn1t$¢¢ :nat. fro. in... a ottto hospitll for a Ip‘oific roaanrah pro- putisuta wit: oxuludud tron thy viva: bocauuc at thiir nan~vo1unttry ataxia. ntltnd a: 350h putt-nil ﬁt an, 113 patient wan givun The 100 study popu1¢tloa cou- at urn tad 1h. culitnrnSn P cauln 95 It ( nuns. ) on the agatgnntaa dtxt. Paticntt' roeovdn aura analyutd ﬁtter a ported at 15 nontha. which was the out~o££ vaint far the analyai: a! hut trontm¢nt vnrzuhloa. tor the dntcrninnuiau of toaitl clans, tau nailingthuad 2~ta¢tor inaux wua uncd ( ). �1. nutheaolegle Aaggata it ﬁt: tuna uhlurvod thtﬁ thc vary tautor: an var: inturcltoa in studying afroatﬁd thi aollcotiou tad organizt~ tin-u o! tn dun. Via-tutu” in “iguana“: a: tarp: of trantmant and axprausiens auad far dtuguoaia and trottuant awnluatann, mad: aanlyauu attriault, tnﬁ rcguirad ooastdsrublu sanrtion for unitarnity. I} 1'- at u ut_!r, taint: Among thy tast1§u~ had a tha that the dtslgnataon pattnnt for crituria tionn, rocuivcd 'gnyahothurtpy' aiztavad narkndly. asking autturuity in cluas1rieat1nn difficult. At nrﬁ‘ﬁaychatherapy win dot1g¢ nttad ta trautaunt udn1n1;tar04 atnfr paychsatrtst, tar additional i... on a which tha proaariptian basis by a puttont was obtreod tn acasinnu with tbs psyahittric rwsia-nt wart cansiﬁarud part at routina adninintrative pati-nt earn. At an psywhath¢rtpy Vt! dcfiaﬁd at trcatncnt anatiana with psychiﬁtria rcaiaﬁnt. 8‘33: puywhiatraat: do not treat #hn �.9. rationia dircotly, but ruatrlntud that! activitius to uup'ru ﬁtting the reticent th.rnpia$s. At the naac, 1n centrtat, paychotherapy Ina designatcd as a function at many diaciyliuua . payohiutric rustduuta, nurses, lidl¢§1 atudent¢, 3601.1 uorkorn 3nd piyuhalag1atu. Formal rueards at sneh nonstona warn ”Gt ruutﬁnc inaludgd in tun patannt': rauerd and to accurtttn watch patiynts were ranazving puynhethorapy, v1.3 the r-uadcnt in ohnrgo or each ta intcrw stat. Thor: aura individual b} migﬁuouia: we hmd institutional aestza 18:10:, uhzah and. nonpartaans dirtianlt. dinu~ At urn ata¢hnrgo diagnoaaa unployid tn: multiglq clanuificntian rsynhiﬁtrin Asaouantian whila both an tad nyittn.at tho shaving» nanc rallawad unitary indiganoua nywtims. at diagno¢ua tron urn goaﬁad convuruiona it. savcrul ax‘mplas Itutud in tabla , with *3: angu inté catcgoriaa campartble ta tn. athar tun inatitutiom, providing, how/var, an muvoidnbu sound: or d:stortian.. @iuilnr abaarvuﬁiona hit» bton rapartad and hit asaacintas ( ) who h&v& by Paanntniak chain thnt diaganac: within �411“ saniax aluau unngupition at thi karma institution: (Enhlt kt urn tho ycyulatioa artdoninantty‘uppar c1;ln with wan par cant of pntiuntn in annaea I at all»: 7. I»: «luau xv, and man. in 5% HR 82 i: uni! can viticut maﬁa!» «Inna praauuinttcd 31th acct patients in clnauan XII ind xv (éﬁ par cent}. At-HHHG, 57 It, ). pctianta «are «htafir from tha luwur a1u3;aa with pix eont la olnsans b) 532: Rhurc uué v. XV at: an ailturnaat in tan inutitatianal papnlnﬁioan in mg: diatribntxan. a rung: afloat fiﬁh sh» putiuutn an». undur the :3: at twnnty and on: quarter warn :orty yunru at oldgr. a} manuatagg: was populations éitrared 1n adunnﬁianal nttainnunt, with patienga at tiau gt ﬁhsn thguc 3x36 it KFH having worn yanra cﬂucau «use. Whit: k1 gar cunt at tho patiunﬁu ruilod ta camylcto high auhacl, only an and 23 ptra¢nt a: at Krﬁ did sat graduxta. 32 par aunt at aux» Sanding in. cauuxntunt with the anciul clan: diffnraugt, claws the ceaiul �113 8 Intur:uut1tu%1onat countriinu. for aeasnplrahalosiaul Viritb1¢a m 512. 2. 51 an 23 3. h. 17 3h 13 1 3h 29 5. 0 5 28 19% 19 22 1. anti-1 G1!!! 26 Q 315 7% ”we 3% . I 9-.001 ‘ 59 58 333 22 23 33 23 32 bl um m. 2.2.15 51: 51 a9 16 * 23 1? 1o radorn to«29 51 33 20 Sowhﬁ hi 90 38 Sa~7a & 18 a: Ag. a “121 5 d£~8 39.39 he * 4.12 > 12-3.9 d£*h phn'ﬂ'i ,2, mi .1 n~-0§ $g9.2 ;~.aox �.1a. alas» unnauru 1;, in part, buncﬂ an t6uani&§n. a) P Squat: 91:2.»¢ue¢¢ in tha diatrihution u: warn ubaurvc&‘ Fixiyuaun put buluw 30. and chi? It In cautraat. I aaala, A: ax tight par «an% at urn pntanutu fifty pi! want of the had accrua watiaatl 9:!" ma an“: a: 50 at mart. hna ? acorns in the hwe in: diaign «I an: study includad within stab r supra. sunk wath snarot mf an ar abuva. tad rurtyutwo par «ant "hum: had aunc tvauﬁy gar cunt uura halww 30 on tha 31461: runga bntwaaa 30 «ad tho r Ewart; m nxnuinntion at m myohutric an» 1.: inititntiaa, ta wall as butacun inatiiutioat. tutu uiupuriteaa pruvua difficult, in putt buaauuo a! difrtrw aueid in thy dotinitiun a: ﬁn: paychiatrac variabluu, ﬁnﬁ, in part, huaauau shins variables ranged so widuxy that «gnu paraﬁln answer: arxtﬁria anmlé «at b: autdrniuad. Far umnmpla, ‘o-conpart tautitutican tn relatimn tu Innath a: �«13‘- htlpitnl atty, vuriout eut~¢t£ poriaal any: triod‘but nan: sllnuut tar at 165 At than luau «.11 3150:. urn, cqulvslout putiauta audﬁr ho yuan: ringinnd 15.0 thin 7 non‘hi. At sane, 70! of All Ind 39$ aura than 12 unathi. runnintd 1.3: than ? ninth». ﬁnd 63 mar. thtn patilnti 12 manthn. Aauarﬂiugly, amphuaxa will bu pluaad on 1h; dirtcrunaul btawcan institutiana, with cttatiau wt rolcvnat intruuinuttw tatloatl rolntianthiyn. g) saw pnt1«nta 439 at xru i m: “autumn raw yuanivnd aauutiu thlrnpy than &t tan nthsr tau insﬁltutaani. Manning.» ' Gauaurrintly a twnllor parcuntasu of patiautc warn attuned a: rac¢ivla¢ payuhothurnyy, with 3 lawn; aunts: (36 vcr want) r-euivtng niltnu turn. a: trtntaaut. an At KR that. antiautt Hamid hut: bo:a «Inluitiud ﬁtting rgenived payahatyarupyﬁ x: can cuntruata tun pita owning. or 338 aamatac knurayy, reoniving patient: ahwvu oxanttieuntly lass than wither at tho ﬁthur tun inatztntiano. �.11.. niltvu , (13 Ethics yarsittin: a «catwalk Wﬁthxu wank it and plyﬂhﬂthlvariiﬂ wwrc cauhtuié. a: aunntlu :né taltituiion. trontaant at urn and F ?ut&unta why unto yuan: at pny¢h01¢¢1¢a1 thuruyivn.) nan wan waistla to nu10¢t£ua near: as xru $nd ER (Tablo ). uhnwa F a%oru VI! low rc¢c$v¢d pnyuhothurnyy with srcutnr trﬂqutaay $han gataouti who Vdra olétr or vha haé high F acoraa. Enua;t1¢nn1 achiavcnoa‘ and innit} eiaxn ﬁia not nigniticantlr atfcct soltutxan at ’30:: it any hauyéhnix Ana»: ﬁhn yuyohtatrxc Ulrimblmt, within naah aitgnasia twia%* wax inttitut&cn, higﬁly tun want rulatvd varinhlo ta aaltetxon at itcn%annt. 91l¢hl¥3ﬁ ovuluntiaa honpltuliuutana at 33 ﬁnd name it urn and aur‘tiaa u: “are :13. rolatcd ﬂu saloation at troatucnﬁ. than, aanataa truntaint an: :ataataﬁ for pa‘iiuﬁa clataiiicd nu sanitaphrania and attaativa dincrdlr hart nttna ﬁhnn urn; pafahaaanrntia. Lt that. «littnd an puﬁlunia rccaivtnc lattiiﬁ arnatntnt (prudnninaatly that: �’15. alaauid an nahisuyhrtntu) rililwﬂﬁ dalnhnrsc rating: at minus. pmyuhnﬁhcruny rn¢a1v1nc p¢i$¢nsa than ngtuprovoé With hyapaﬁnlu acupztuzx:xta¢n, ptticuta dtrtﬁiﬁﬂ tn a: rtcnrd ﬁnnﬁ tar langcr ptrlldi b) wtrn that: rtcuivtn: nunutie thcrﬁgy. eoaniwtrnb1u dittortunau g' vurﬁ #huwn bﬁtwnan «a. ﬁbrin inuttﬁatﬁvna with waapaat so paxatuﬁ‘a lungth a! stir 3; (rahlw 31a pasiuaﬁa VI?! han- ta§a¢wt, with 65$ 0: puﬁ¢¢atﬂ runniniag pi‘nxasud naathn 0r aura, «savanna tud-unly 5 it 31 9a: aunt that: ut gut auu$ a! H336. 93 it! tar twmlvu the 33 patinaﬁa aqua} uﬁny Inuit: at thy while twawthirat EB nxuvun and batuuua savtn ﬁﬁ! stony a: win within éiﬂﬁhﬂraﬁﬁ warn 3836 tan watasnta munQKa a: heapiﬁaliautiong urn uaﬂ ﬁn I! at. wan its luadh 9t haupi§altﬁtﬁ$¢n for tha 1nugust veriad. At sauznl tunttr unit alumni: rtlaadd ~~ yauutcr yatxcuﬁn rmmniutns Ovary :50 1Ith, hawavcr, that: �.16.. nt RIB rammiuud lanai: £hnn at an at Indand, an: mane. intnriuntihutiaanl diffuranous voru :9 grant that : putttat in the oldest as. group an: no». ltkniy to ho bospittlisud far trait. nanth: or yuanguat tau stony mart at tt Hana. urn thin war. pntinnta in an. At urn tad an tier. wan tile t aignificnnt relations batwenn durutiau a! honpitnlisutinn and F acara, tho lave: r uaora being atoneit‘od with lanai: in.» pitil atty. a) gigggniggu 1: thaw; t1. 1n rtblo 2h. diutribntion at diaehurgc attsnotnu . tar atatisttecl analysis three diagnaln ﬁery undue uabtsophranin, n£rautivv ditardﬁru 3nd grvnpiugn psyvh¢nouroaaa Iﬂﬂ ynrsonultty «Quaraorn. portiona warn similar for the an and tha HFK muse rho é:ngnoci§a prou povulnttons, but pt%1cata warn rngurdoé as having raver urinativa and Iahiaophrania éiuordcrs, but I larger haiku: or paymhanoutotia or ehnrtatar dixardaro. Intrttnetxtationul analyntn chauoa this at as both as. �.1?. and 3 suort ”ﬁr. rwlntnd to diﬁgnoaiu: at 3:3 as. clan: of tan sonata tgntart In: volataa to dinauouing whiz: at nuns a: tha senial variablnu war. trig vurinblgs, dingnoaaa can signifia&ntly so rolntcd. haupitnl ta unleatioa or trottmcnt &nd or maﬁa its rolttcd payouts- 1% «.mn durution at haapittilo nation; Ina val: at an tn aiaahtrgt ovuluutioa (gag: £££E£)~ a) 91353:: 0 Evuiuatiunt In sack heapital, nest patiouta ‘fi urtlnttud It A? the time a! disnharga as ”ingrovodﬁ (Tabl. ). 338. hatovnr, a higher ptreuatuga (19%) at patisntu warn ratad g. *uninprav¢d* and only I ainala puticnt wt: callud 'rucovnrod* er “hunk impru§ad'. rho highant porcantago at *rccovaro¢* at "Inch impruvod' rutxnga (28%) and thy lu‘nt haunt! at ”unimprovaéﬁ (165) wort $9334 at ”386. Anulyann within uaoh it an and Mann thqrt vitae haiku: than 1117 institution ﬁne a teuéancy ahavad vuriuhln rliﬁltl. for clan: pationta ta ywungcr ones, but thc b0 reunita urn Itntiatiaw significunt only at an. At a!“ that. run nu appositu trand, vita 014.! putxautt'uara liknly ta b. rutcd unimprovti. �__._._.._ u—mmmW__—m ��j w - 49:25 {0‘70 W “i a7 -31 2 5“ ”iii—“T- 7 '5 _ ��f ". ’qg" A comparactu a: Parahantwio truntnuut ta rant: Ybiuntary ntipstull nan-t an. an, Plum", nu mums, rum. lathgaxnl 81‘301. ?h.n. mu m: ’bwu Buapitul. nu, ma. Dmrtnoa‘ a: ta. #103 6th., L.I., znpnrtnnntux Plynhiuiry. laliuido l.!. II~2992 thy Inttunal Inntt‘utu grant a: by u.a. rublxu ﬁnnlth survtc.; &ad tho liuuau mﬁuilth at Xantul ﬁuuaiy nuns:1 ﬂutlth 30:96. a$ntt$ at tho lansnahsnntts luatnx I: it. ‘3‘ 0.3. Hummingur ﬁbuuriul ﬂutpiﬁnl 1n In. comptruiatn ﬁnalth Busty: an! gratutully ntkuaulodx¢d. Aﬁdraau: rrtltat 3.1. $7. 1.1. * 'VI: 3/5! niviuion a: rayuhautnr. Hau‘utinrc Bouptttl. �tn thoir 331$: at ﬁhw It» ﬁavuu ptrﬁhtatrau patilnt ﬂailingahund and anilinh rapovtla Itgntttnaui populnilon, valuisuauhipn baiwaun in xsdaviaumx‘: position in ﬁn. tilill $ti§tad alum: ptruoturc Ina £3. pravuluu¢t at illnaua. twycu of attsuaaud atturamru and kinds and duratica.¢r payahAatrtc truutnuat :anantuiarad ( ). tkgr thattntna. for umaupla. that ; hiahor prupowﬁann a: ions: aliin patient. in tvaatncat were alnncixtua Il~pl¥¢hﬁ§ﬁi whaln‘uignzrinnutlr hithi? ptﬁ~ .purttons a: uppar ulna: p;t1¢nth var: alanuaxand an nuuraiio and puritanlitr dailrdora. It! all at: inpldrmﬁ is ﬂiuyrnportaau:sity pnthonﬁu. acyuhutharupy high ditrtli with at: ugyuw ¢1§Is pnyuhoni ouch within «inunnutat Iran», gutiyutaa thirty? tduxnzut.r¢d um. its; Otitn ﬁt uppur exist p;t$amtt tad otntatu thnrupmuu in lunar 01a:- uabacatu. who cianiti‘nnst or iﬂiﬂﬁliﬂ tnc‘uvu at Granting «avid nah pavuunnnl dutaruinluc b. txaludod 1a and uvtilabaltiy it. obntrttd altxaruucau taunt iﬁudaua. In tact tau rﬁlu a: �.1. watts: raster! in tin trontuntt u: hutpitalssd& vutiantc 'udur otndttllai quludtnl tut (natty; at pustanﬁ‘a £1uauuei and availability at trttﬁuautly an! auditinknn t pISai. patlunﬁ acnaun sip: auvvqy at lillntdu niuptint 1a 1957. in $38: b0!» vnriuty a! ﬁrnntucut nudcu, Snalu¢1n¢ ptyﬁhmshuruyr or;¥nsc aha thnrwpiom irt a: ﬁhutr ability ta §u¢u u wt dbauruud availahiu ka all patauntu rustedn why. that use, Odiatilin and 911a; uf‘birth acre ’atgatritaﬁtmy automiftid with «intau «I trtutuon£. duration at hospitalautttua, arts: ( )a ultu1u¢x ninthnrtu cvnltatiom taa «luau furnauﬁubnru nanny. pattcn‘. with littlu Input! giauttiaa war. at». minim: ta rucuavu taunts: taartpy, viva taps in in. hatpattl it» churﬁar yariod. ﬂ! $aun, and new. nt‘uu ﬂirt vital in BIDUVIIid aw unit tuprtvcd on.d&nuh¢rtc. In Ionﬁrnta, tau yuuasur, buttur cﬁnuutod and natavm burn pasiunsa at»: titan ria¢1th purchaihurupy :3 tan saxo town a! trau*uou§. aura h¢3p£i511tvd 1hr teaser piriodi and tuuuivad �.3. ﬁhc‘poovur ciiniail dinuﬁuran rﬁtingg. Ehita uthrvnﬁttun turn 31:. ruxattd ﬁo'nauturat a: tiawnatrvy a: rurllctnd in nubaoais' vacuum... to a uyda~ {10¢ Gnltforuta I Butt. ( ). Haghnr 2 gotta: war: aasoaann tad v1$h ¢$uau0unl at tuvulutttaul psychouta. thawing purtoau a: htuyitnltl¢tian. and I highnr Lnuidcacu at votnrral 2i! aquatic thtrnpr ( ). 1t nun nanola¢u§ thnt thu uttuuta a: aoat‘z class. :31 Udllltilﬂ, biuhpinau and dcaroo at clarcaw Sway an purchaatrtc ﬁruuinnat patturuc war. not a rouuit t: ataaautn :Iu‘¢ru or awnainbilitw a: trunungut ilﬂnic 9a: dbﬁurvutiuna war. 3:3:tnttan val thus thg iudtviaunl astrircnnnl in and «uprtslian. X‘ month & ratlcutiou ax a: Iiuytutaon. nununaaaattan uni pcotulatcd that uwh3.¢tu t: taunt cocinl #Iﬁllﬂﬂ, lacinr‘wduuatiaa uaa turuttu birth wtuld aura trtquuutlr nanatalt lympiduu in nanwvorbul. tanner: a» II“? yt‘turuu, nﬁtn: whtlo upvav alas. If «upruisitnv Itbsattl wall uttiiiu varbnl �“a... t aanaud Lnturpritutiaa, huuuvor. ruluiud in; ubturutw taunt tn tht ﬁrnnﬁusnﬁ philaaaphiul tad xsfttada; ct talttm tnsaaunl lucdaml and yawnunnul. tilt: audzv1d3313 nudﬂ runnivo It Uta aaacaﬁtod that Ipptr inardiautn vupr.uwntahi¢n in psrahnthcrupr in 1a:t&%autoan what. yaymhntharanr vat highly vuluca. ataxitrly. ﬂiﬁlhtrtﬁ.§VIlﬁiﬁiﬁnﬂ and durailau a: knapitnlintﬁxan Imuld ha i33cttud u!pn¢$nt1¢nn tum Sﬂﬂ1VSdn§11 20 tons 195? allllléi my ditturaunh: in Ital! a: disrurtn; social «la... that scannd augguutioa an anulaad to ragga: the ntnay unplmrin: uh. u&nc pvuaaﬂuria ind nan» aurr.nslr t0 «stand it» ohnurvut1¢na to tun 6.3. naauaugim armorial Hatpataz at sun oﬁhur Ebpaku and inatttn‘ltuu. tha untanahucnttl nausnl Hﬂ‘lﬁh cuntlr a: vastnn. In that. ﬁhrao haupitnln, initttutianll piraunuol stitch :intlur tttttudai 13 trauﬁnunt and udusntxon. a full llth 13 a itaahta: haupttal with twig auplrvilory nt¢££ ﬁnd aetiva tumansh dvvarinont. rhuy lﬂphﬁtiﬁt purehtanalrtaﬁallywtrltntnd pnyuhnihurnpr but �«6m H35Iﬂﬁ 111 vulnatarr. nanlt paﬁa-ntn tn rnitdauou in than. inntituianuu an a civun dt£a in Jtuutry ﬂail: urn lad it than. it 1959 vurt ntuditd. an had volum$arr-patxtatn only, a R836 wart tcnigund hr It‘ll unnbur in. ataxia tar yuyuhittrtc avihnitin. or wurt sawhnrt at I otwouiu anhinwyhrunac ntntu haugi‘sl Iraﬁg ﬁrtnliurrnd to! I sycatriu riannrth prajutt. that¢.paidnn&a war. umoluand tram thn aiudr hanuvn. a: that: nanwvulnniary abutat. 2h: study pnpuln$1un-etnnlctud at 113 p‘ttnuan uﬁ an, 190 at K18 titan satin £ha ﬁnittaruia F In! C 9E at maﬁa. ) an tho zach pa‘tau‘ 8t! datttugtta aatg. lithtnon Illihl taint in. knit-utn‘ rauurdn var: nualriad. Jar an. dutarutnataoa at :cetul exams, «an Hullsngahaua ﬂoatatar iadax may ntnd ( ). �“a. Autthur tritium of the prtlnnoc it: atrtur'nt ruataruh 1‘ tan itau rcutzaau. alaninit altacttu: grnuraut, sh. ¢£ nuns ﬁx: at pavaunt vutiantn at tucaty upgrauanutaxr aurrny. wart ah:9a1u.lly 111 tad use Eta: hunptiuliﬁad far ulny Sﬁtﬁ a uwtap uuula «at annualir hnwu hunt inst tiny had Esau tranbturrnd tram yturt. in this hecpitu! inothtv skats.1uut1tu~ taou.tuw a Ip¢aiul uindr. rung. it vat anon apparant that £ht Vim: finiﬂfi war. inturauiod an Isndyiua ntrtcind thy atllua‘aon at nnﬁ in unite we». prdhlann ﬂat éxtn. spaaarie urgiutswtiaa 9! st. varin‘xouu an ﬁnnigan*xnua a: twp: a: troatuuat and exprnualcaa qud tar diuguonin trantn-ut uvnlun‘iau watch aunt .n:1:~ W! at. disfiault 3) and dualguuﬁtn: and viqntrid caaiiéovnblu wxorttau it‘s a puttuat than; sh: institutiouu, tut uni» m "um: for riuutv.d "unrahoth¢rupy* dittlrud making untSQrISty in clu:u$ti¢¢t$nn �.9. ditttailt. as an.par¢hoth¢rupr was davicuuttd nu trus‘uunt atlzulctornd on a yrnaurlyiton basis by tar thigh sh. A aunt: raruhtatrilt, pgﬁicut nu: churned an additional (cu. with tho ptyahtgtrle retidant were uonntﬂursd part at rﬁutiuu ti 3! wuywhn‘hornpy ill ulntntntrgttva pntxant oarc¢ to triatuont nunaionn with Station. ﬁha dart‘ud psychiatric rtnidcut. stuff paywhintritta did not tract pgtiunts diraetly, but raitrtutod thair sativitiom ta aapurviatns tau roaidouﬁ phywialnnn. Sb. lﬂﬁﬁ parehatharupr Wtﬁ a.t1gngz¢a g: a function Aluethiuoi-a~ parohtntrzu roatdouta. pmynholagittu. andauui xtudnnta. Formal workura. nuracu and station‘ war: not vau91noly ineiudod and ﬁn unaariaiu which v0 and to ‘b) 1n at uni, «#6131 rieard. a: tank tau paeicut'n roger! patients wart rucotviag puythvthqripy, tutorviov $30 ruttdun‘ in chart. or 'uah oats. < Itylaa his» 5% “atlas Individu31 ialtitutionnl diuunontla mud: uomparioanu atrxicult. At $13 dinuhnrgs dtgtnvuua anplaymd tha mulﬁapln awniuuﬁtve data lﬁhlﬂﬁ �.19. ruccnuundol by it. Annrtcnn Payuhtntrzo Attestation uhtlo tellauad unitary syatcun. 5.1.9:: nuanplou boﬁa an :nd luau at ﬁtnznalun Iron ark 3:. liutad in Tani. I, with our sug- gIatId uouvorniGnn into cathccrie: «caparablt to th. athar tua tuctztntlnna. 1h... canvosataau prcvido, hnwavur. an unuvotdahlt Iﬁﬂtﬁ. a: dis#¢rt1¢n. (sinilgr obgorvutian: htva erortud boon ’allntntok by and dioata thus itaananuu within us: anneaiuucd $hn «an; ( ) who in- taut1tut1¢u arc 3130 vulatruhln to individunl dittornuaas nuang nxgntntra.; ‘ “U ”G“ .v."~.-ﬁ fabll I ’ In a) Hunt vnracd :13 an: , tin ' a: I rovunnn I Rating: at zupravon in forum: ;nd actual. in. dischargc 1:113: tripattita with n tapnrgtc urulugtian churicturolocxual and axudrcn: chuncsa. global rbtluca 13 vital txihutlnn of ciah it tacit: HR it tar snaial. and Kane had In! dittiuult to saunas tan anu- 0! ‘ho Runniastr 3:06am (rail: 1!). �.11. tar tux; lwu&y sh: Hiuningar ta ta. slahnl raﬁiugt or rating at: ealwnrad syndrome an and 3533. it. “a. .”‘*¢ *‘U’ Tiblt I! maﬁmﬂbﬁdhaou. that. in: 391131 013.0 a narkcd dittcrunoo in tho tanpoci‘ton or an; $hrt¢ tuntatutaoua (tab). :31). it. povnluttdn nun prgdauinuutly*uppar sluts uiﬁh At urn pa! «tut O: pitiunin in dintucs 3 «lat: 1‘ an IV. :36 non. 1a «1‘0; v. rare in «1:539: 11! uavu'iu alannou ﬁ) 53;: and IV nnd XV. whzle a: 9r 1!, only one paﬁitnt 1: 3% 68 par onnt of patttat: $330 57 pcr aunt or pltisntt 9‘ rhura nut. no ﬂixxartuot. 1n .3. distribution :3 sh» annt1$uiioual panulgtiaan. an. firth tug paﬁiunta at»: this! tan use at tuuuty and one quart.» tor. tort: runrn or oldtr. e) ;:;i fan population: dittowad tn udlaatlaaul �Cwmf Mﬂ 2%} maxi?" ”an m“ 19$ 54cm 59 may £0 a?“ :- 2: _: ' 19s 53 a: 2‘33 3 13 33 , a:- ﬁ 1:25;; « �.1}. tﬁﬁalllmnt, $1». ihnu putttutn at a?! haviag nmri v&§h that. iﬁ Illa. as Ilia 1.11.! In ca& $0 camplcia a) pat «out at 0inlxutunt while ht par aunt rat! in: a: %&0 a: ﬁﬁuﬂiﬂ pt£1tuta blah iChOOI, tax: 33 par ctn‘ III as: at: u¢oaa1 IUIF£ nﬁ graauut¢. thin finding :- alga. dittorauua, :lnaa tho aoainl clan: nitsuru in, in putt, husta an education. a) g;§§gggs nirruroueon in the dictrabutiou at hoards «a th‘ salitavngn r Seal: an». ohuurvud. Pittyvonc par a¢a$ at mra patitnts kid with taunt: G! 59 i «mart: htluw J0, uud aux: at short .. an. Eight: r tith‘ pur aaa$ aeorta buing ntmun tinted with hiahav agaruuu a: uturuetypy. In ountraat. $336 ﬂunnty par 91v oonﬁ ﬁt. h.¢ «iii sworwa putaan$u has t var: hclnu 30 an at 50 or wars. ta. At an 9 it Quilt, and tartrwtua titty pt: aunt at 1009:: in tho maﬁa}. rung» botuaan 30 nna E9. 3. Wag It: Vggbxq candy inclnﬁad .xauiautinn admin: ‘9 ﬁn. a! th¢ rulutioua at 1!. ylythidttiﬂ vﬁrinhlnn within nauh inatiauﬁioa, �~13- I3 v.11 an Butane: inatituﬁannu. Thwli noupnrilonn provud dixricult hangar. or dirtortnain in tho attiuitioa rtynhiatriq 1§v1nh1un. tn. *urxahlnu rung.d 01 th* tidal: @ and achw parnhlc wutaoxt ovltarin eeulﬁ an: by a¢t§r333td. and varying itarcta or ulsaingdntt. .rar'uaaupza, ta canparc tnoﬁltmﬁiani in ralntian an xgugﬁh at hatp1%‘l stay, variant cutuott p¢rtodi auto triqd but man. allowed 33%. :5: aqutv¢1¢at «.11 11:... At an. gatrtaa of tha patituts ranatnad fawn: tug: 3".» nau‘hs. and sleuthzrﬁu “‘3. than twozsa‘aonthu. aeutt$nt, 70$ at .11 aha auly d! any. ﬁh;a #13:. thus: wax pa$iuuﬁo runninad 1... at mass. 13 thin atvun Ioniht, twilia annthu. In ﬁttuvuiutug social informatxan nvailnhlu far 292 a: 371 patioaﬁﬁ. unalannitiahla at!!! at». ﬂﬁlt otian ﬂair! thu nduaatsuu at tbs knahnnd at in. {athar at a haaaowtxn «w ntnor wag nwt rnaﬁrde¢¢ aonarainxzy, in the antiwaau cf ysywhzntrﬁc variable: euphaaaa H111 ha plmoad on the ditfmroueun botv~¢u inattﬁutanls. �.15.. with citattun at vii-want tutruutut‘ituttonnl ralntannthipa (!Ih1c IV).' a) ﬁgggggggg_gg~gzgg!§gggs tutu: lnltltntianu, tawﬁr patatnsa it xx: r§a¢1v04 Inuitao ﬁharnpy ﬁhnn tun instituﬁsvuu (2:31. 1). canenrrantxy 3:: or launsngur plﬁilnta instant, 8193 & anallnr parcau‘» act. allllid at rcaaavias paruhau lurta aunts: (as pursuit) raooavtu; allitu turn: at trautaoaﬁ. I: t at $3. uthnr tt a 9:13.17 ﬁruntnon‘ an patiunts r¢ciivanx then: ‘htr:ptua It! claaaltioﬁ to raaciving psyuhau thavupy utn¢u unuh 1- conventﬁauttr again: taint. If on: ann‘rnat ﬁhu aanuﬁau thgrupy. urn about t rniidals pnyuhtn- paranutlsa a: pt‘ltﬂtﬂ vttalvln; atauattuuuttr loan ‘83: 01th.: at tho 038:: in» institutinnu. tibia ﬂtthsu V uncut harn ouuh xnu$1t1t&on, ‘30 I‘i ralntud ﬁa=a¢1aat1uu �.15. a: trautunn‘ ut urn (I: Ihtln 1V, mitt-I and r taut. at both urn «ad I! (tibln If), and plynhnthurtptun aura semiautd, para hittsac a awntrnut u! inattaa Putatuta KFﬁ who W0?! yuan; it thtftpitﬂ.) ané puyuhclostnsl urn hr who‘s r nuara was 19: it or 33 ruoetvnd plychothnrxpy 91th sveltar rrnquanay than pattonil who var. altar or ihﬁ hid task achAQvunan£ and cua$u1 r ttﬁtti. Eduagtiannl alas: did not axgntxluanﬂly artist culucticn at tromﬁuautlut nay huupit¢1. luau; in: plyuhittriu vurlablau within ﬁlah inntitnttuu, iigsnuuta ﬁgs ﬁha unit highly rnlattﬂ variabzo $e sultatioa a: traaﬁnnkt. aquatic trot‘nnat wt: natcutud tar p‘tiuntn clunoittod t: auhtuoyhrauiu ind nttqctavo diaardur mare than the-y utttoud I! purchonn§r¢tl¢. Bituhtrﬁa avuiugtton n5 urn and aurgtioa at hanyitgliuat$uu at an rathid s. at trtntuant. ulna titan culmntion At and annc wow. MPH, p:t1natn rceoivtac anun$¢c trnnwn¢nt (pradunlnnntxy that. «lann§é as �“17. hnucvur. than. nt :33 rcnuluua lencur ihnu ﬁt as Iudnnd. ‘3. 1nt¢rtunc1tut1au§1 dalxnruaupt n pataaaﬁ ta ta. «lanai .2: pitalistd tar chIVd 1a the ytuncclt .3. at to :rtaﬁ taut an: airy 112.1: cramp aonthn or new. group worn at at lHRGQ $0 ha ha». £18 than wuru paﬁiuutl Hana. ﬂuwtmﬁnuudaﬁma «tr-bun an '- Emﬁlc v thwut hath a) Diuggggzgz 3h. d$a%ributtou o: dtnchuraa titanium! 1: shown $u lﬁblu VII. Fur ututtutionl uuuiyail three diugv rustic grasping: warn undo: nahtiuphvania, attactlvn attoraara, aaa yirﬁhﬁh¢VFIi5§ and ysrioualtty ﬁtuordarn. 1k: diuunuutiu pvupovitoaa nur‘ ttntlnr for in. El tat popuxntiona, but H330 sh: urn pa‘imatd warn rncnrﬁad at having f$WIr tttnattva and unhatuphrunit diavrdaru and a luvs.» nuuh‘r a: ptrahununrwtla a: pgrnannlity datnrdors. Intriinliitntiiuui and 3 unuiyuts nhnmnd near. cur. allitad ta «13:30.10: that it :t an bath mat urn us. glow: of �.18.. it. aaaaal tuuﬁuru «at ruiatad to atununoiug non; a: ‘h; I'd!!! VtrtlbIQi have ckintrta vaviabltu. diagnnuil tutu hmnpital ‘0 atlcoﬁtoa pitalahntawn; and duty it. is um, r:%ad It at ham», it. 4; picniltuuntty rtln‘uﬂ at 711 tr huna (via. In ouch knupttul. rant pttttnts ”mm. um “ingrovnd' (ink). VIII). (195) 9: ”an“ 'tniupruvtd' lad calr a taunt. pltwtus ’rauovawad‘ at ihtut barn tau. at diuahurgi mum-v dwra‘lun £0 «Inuhnruv ovtlunﬁaon d) gigggg;§g_§ggggg3§ggs ¢1tluutnﬂ u. rdlutcdt or ‘ha para a: $rotiuan$ Ian 1% H8 1:51: who that: at lure “math tupanvud'. mu van c.1125 the highest para-ntata a: ”rtcuvurad” at “unit isprovna' rating: (255) and tht luwaut (10;) with sauna at muse. prupawstcu a: "unimpruvwd‘ Antlynau vi‘han Utah anlﬁtﬁuttan giant: varinhlb rulnlil. �.19” At 8! and Inna that: III C sinncuay tgr cldir putluaﬁt if b. rutnd butt.» tan: ytuatar «uni. hut tut renal.» illr lilnitiﬂiai Quty-ut us. At awn trend, with ulnar pttituti intrt an!» lxkuly tr. atatxnttuu vat tn upwtsitu is h. ruﬁud unimpravnd. �~29» m mum In ibis unvpar‘ntn at ihro¢ vuluutary garuhittric httpitala Vt havu-abttrVad sartoransua q: cannttlun and uninitiuaat tutarxnstituttounl varaubloa 3.61:1 tho in at yuavs a: pt‘itnti tutti: Illﬂi, but 00$ u¢.; ta diutriiustou a: ﬁulttuvniu I‘Eaalu trawli; and in unﬁt of tun triniulnt wart» $51.0 ditivtbxttnn a: aansuauuu sud dinohnrgu tvnlnaﬁtana. In and quxinal atlltlai ‘33 in .. dnrnﬁatn a! havpitaltsutzan. tdiauistn or transnaaia it: §1r£oraacou naapxtnl diner tbs «Enutha alyahtairac vtrlannu rut. nuarthnd ta airinruuaul an sunuclﬁiud and wins: the nacial ttctarn at causatiun Ina utavio~ iapy n‘ raxlo¢tta in ya. v mourn. In ﬁhn trimhgapttux atair, tntnrtautatattausl-aﬁnyaritanu a: the pirahtttrta Vitib «big: I!!! thaw uiguitiannt sixtaruuogu, and §h§na rulluw nupuatsa «attributiaa thﬁ its. tars a: ﬁt!&l1_.1ﬂll, aduuntaaa tinnisiodnﬁ Vast at tat hryathutis 1a: inaﬁitut&nua1 caapuriaaat, wharc it um: and 1a Oh! r naorng in. iaﬂvuu tutiaiputgd {ant iocttl �.21” wartu in puythtu§r10 bu valntad ulna ulna: ditturtucau vault cvuravlltng uh: 1n ;ty1an. dxusnaaitu But vuranttdna whiuu. in3$1ﬁut£¢ua1 varlnttnnt 1n cud hamytiuiiuatxtu duratinu at Affautad anﬂ «unvaritau: thaiu vatautad diuchsvgu rattan: tho signatscun¢¢ 0% tbs inturhinuittutianil.aunpnrisauu 3! ﬁn iﬁliiﬁﬂiiiﬂl'ﬂ¢* aaltcttun at tracing: It? idlﬂﬂiid taint ﬁhru: institution: a: bqing aduparuhid in “‘11; Int, acaaamta, rotuntitie nué th¢rap¢utia aﬁ$aa£pattus rigor. printiynt ditttruntui ninth nampaaisAou await} in the thair putaaaﬁa. run: were atrtaruni in whatnl alts! puttivni prﬁhiana aathaﬂuiuczcal thu bu‘ nest Itriktus sure Vida dinsrdp;ua10u a: mm in: in tha atrialﬁtuus a! tha plvuhtttrla wiriuhloa. can aaa¢1usian qoalé be that t§c dh‘nrvnd difzurauacc in purahiatric Viridhlut uqrﬁ littln act. 1dianyasr:a1n¢. wt: «untrant ta in hnapihglxsod urn ptttuatt ta; than aéninxntr‘iﬁon laughs ¢t tam: taut 33% 3nd name in an arm‘s, �n22» havuvir th¢$.1$ in $53 1£k01?‘§h be a raiiccﬁiou a: mixturiuaui ta 5h: ﬂip: in it «nah aduluiu§rut1va :avquﬁtiuu tanturcu an noupluniﬁy u: diachiutta hnﬁ dtuahurnu avalaataon, tinny a: tharipiti lVI11£31l uni thy énfiaitlou and sauna “kink :: fin atttarnncut quuttﬁy or uaatnl niiarahr. airiiuiaa at garchothurany are arcat dsxturunaoc £«11nu n gntturn. canttstant vath.9ruvioun randinxn A -. yatturu and hypuuhunal on tan rataﬁann.at toaiai :actaxi $9 pxyuhst‘rzu «a»; at hampxiﬁln tlid ﬁttinntt. It is palsahtu taan, that tau oabﬁky a! ﬁn inatitution in aawivnd ta t trauﬁnnnt putt. stuntsiatnt uxtint sociajmyahalmaintl tautuvna ﬁt in» pliiunﬁ Ivan thn prcdoutnant popnlntxan partly in rolatinn in the proatpticun, uttiﬁudcu. identificatian rulatian to darivud and asparntsaas {ha nxpcatationa thcir nuainl a: tha ntnrf and pnrtly 0: tbs patient: and that! 1n fililiti buekground. rhino nothﬁdalagical dittieultiou «nu the ntgnxtiaant arrant or gdmsniptrnﬁivc and stat: uttttndua on pnyuhtatrto �.93” vuraiblcn «r. vuluvnni it She cauvunﬁtaaal was itVt utntavtacg. ugpa¢iu117 thuvapius. The rrtqnaut in: 1a may a: avu1§;ﬁ$nn or aaup¢rn~ at ynynhtstrda 4£I¢hargQ vuiinga, diuwaantic algaanu or I-agth a! heaptttlixntioa us arisiria o: $h¢rtpvutlc valuua ar computability or aubzacts and pﬁﬁﬂlltiaui 3.3% ta .xailutvo arrnr unlit: ugtahoé sawing It: ﬁn: at. inatitttaena are olanrly aauini¢trattvc philoncphy uni l9¢1l1 «1:0: a! papulntiua nut variablgt .. ta nﬁutznn 9:1: at that study. ruiluvt in naeiuat to: thilt litnral tatirprctution of Thu saﬁw ﬁne in. paraéexiaal mast 91.13:. altar. at : variablus is in bu Cut abanrvatioa nonpu« noun 1: a at that atuiy. 1h. tub hawk highly trutand reactant! «and!¢t1as tyeaiuaut ﬁ?!‘htn an or iiunx puriod: (unlinitcd) shiah is appliud tar aptiutl pepulntians with in: luau: prapcrtint alaguusnﬁ in In untuv¢r* uh1¢ pragnautic gravy (cdhisephruuiu) item a: ttvaruhls trvnﬁuaut fﬂltl‘. .- and sat, «a. proparv it iho pomrtct. it Hand, in cantraci, «hat: tug 1¢nst trusuta tharnpiutt 13:1: trnntuauﬁo �u’hu to: tho attrt¢r periods, to a yapulutita with a higher pam- pnrtann daugucuta nchxsopkvautn (v‘po¢r yrngnosua 1) tau pvuportiou or ttvurt§10 Jiaahlxca rttiaga 1a artuturl ahibualr. thtta obturvutltan an act uizutfitaatlr rail-It thy itarapuuttc hfftcacr a: th¢au tantatntainu. but indiuutun tn. dartbwuat 1&1: critarta a: inprwvcnaat. Inc! or «barity in diagnostic unhona‘a sud incompar~ ability at paychtntrto trantnuat variation Ital: pants to :tttlwtud calpurattvu «$3613: or paywhigtric thavapiun. Iii I!» txanpla, thu vacant failure: by wiricua kaolactcnl natuut1¢ta to confirm ubuartatiana 3:66 in ether laburntlvan: hay'bu an much a raxluotian a! diffuranaiaa in populations, pavuﬁtu atria «attoriu, 233. rha'waéaayraad asa at an £311u¢1oa 1n the numb original hypnthaucu. turn: ‘3 “Inhinophrantuﬁ an '9»:ahou¢na¢sau* to unplaro eh. uhancot 1n payuhologsenl a: bialagiatl roaturca with anntnl illnouu h;n 1.4 ta a scaled. burdcnad by acautivc result: (3.11:3). hast u;rkaa rauuutly �.3... an in. tantztnting railing at tn. rnacc a: «taunts cud paywhulngatul a unrun ruvtav an cﬁhiiaphrnatn: fit in. whiz: thnripitu or ﬁne transnatarinn if aauaatu inuuqruvakxltty.ot Git phywznzaganaz *~ huhnriuraz corvulattnun an aunt an (Fuuktnat§zn) and tadattan thruahala ﬁaaks¢ Erna it. uuaholrl «art : vaxtd ﬁbulrvusiua in hi rtvurtad traa tug alxntt, do w: hhva nuthtd! avn$lub1n $9 «uteri»; yepalntﬁaus.aduquataiy sauna num£Xraation? .Wu.ha11¢vu not, mad ta gravid: a nunnludo tron ﬁhnﬁi «bairvatiuuu that incruuugd attuatiua aunt bu ynxd ta tha suathodnluwiani yrnblnud mm“, mm a: alunuzﬁyias nubauaia by “ubgnaﬁavu‘ ma. um mum: mama no hﬁahly ﬁuyaudunt on inatiﬁntianal and and tau zun£ap¢y¢hu1nainal tapuwtx which «was: to to «bauwwir att1$aﬁula at in. ﬁhurtpiahmyntimuﬁ intirauatmng what aw tha ralmilan at again: ﬂlﬁiﬁ t¢»psyeh1x%r1a trantnunﬁ an t§aﬂa pdyulutiamx? aﬁgnzfitant dittiraaaaa it trcutwant anttavn taint betwoun thaau anntatu$aans, nné thqr ‘ �~26» ds-auﬂdr ﬁg dilrgmnuﬂ moat: Inuiul attuvam, utthﬁdalauiaal limitliauan umtlinaﬂ wan-no gruuﬁar a dcﬁawninuni hit with!» ﬁhc ilviitv, iaﬁinl atuti pirkhtnﬁvia Sh! Vittthiun if «athin any inititutznu than «or: aha «ﬂan» varidblam‘ ﬁn «nuns «may. hauuvur, that m: away” 1» ﬂay ianaiduraiaun «him «a. m we a: vctturna or at in. may, &&:¢nosin and ﬂitting. tharimx unnuaﬁ laniri I! it that-in that! haupxtalu, patiunt twain! tiara graﬁmhau thn phitnaqphy twcuﬁnua% as an intruahaapisal thutar. 11 Ian: tutanttatr malttnd tn diigniﬂxl «nu try: bf ﬁruiinuuﬁ than int naturt a: vﬁduti hﬁnpiial uni uh» iﬂﬂill canny aaaraaanu tum iaaim it wh£th it‘prtalriir :t-azr. an: paraaunbl a: mazxnaaa lbuyiiil, tantra», likb thmt a: in: sunningar‘ﬁhnaraal awn: mm“ mm unsp1$a1 wad ﬁn. laxtauhuutttu m: WIN: a In institution: with 31f£¢v¢ni ﬁxmmm trt‘tntut iriunﬁatiﬁnu. pntaibta taut eitrarint witntiuhu hutw&ua it in theta vurtibtni �wa?ﬁ any ”a ‘h“r“‘i In hntpitnli. gar ixuaplé. whﬁwl trnutnant n‘=‘¢£&Iru¢ urn pvﬁnarilr auutnatuz or «um-tic, or «hurt nut: nuns” mun anagum m inﬂiviauui tacit} alas» it in: in:$itt$&uu may auﬁ xxx cm Win-mat awn, diiiﬁngﬁiah‘ﬁrtihﬁtni grwapte x$ azatt uua aﬁministwuiivt attitgdat urn a ﬁriﬁiﬁl Vﬂrzabla in auﬁarnintae tan pa‘iani‘n dinnnnitl; irauﬁnuut, qua tiawtk at haupiaaligaﬁica. �culpartnoa a: Suctopuyuhaloglcgl Virtublos nan Psychiatric frnniuunt 1n rite. 'blult‘ry laopltalu A ru.».‘; In: Rdbart L. xnhn. ramnnsk, rn.n. la‘hautcl 311.01. 95.9. and In: Iris 113k, 8.3. tho nontriuont or lxportncltnl Paychtntry, ltllaido loupatnl, Glen Oaks, 3.1., 1.2. £1404 in part, by grant nxuaoyz u: tho lhtlounl Innt1$u60 or lontal ﬁatl‘h, 8.8. P3511. Health survlco; and the luau.» county ﬂoutnl Ioal‘h Basra. tho oooporaﬁtoa at tho stutto «t tho Intiuchuaotta ﬂau$a1 lonlth Gout-r and tho c.r. loaning-r nunartul loapi‘nl 1o stat-fully : acknoulodcod. Division or Hvutcfloro Psychiatry, ﬁnnpttnt. ;;U:;ut'tgdruaas ! ’ I C v11: Q 3/62 �I: that: at in. law lav¢u psychiatriu put10n% populutauu, lollinxphcaa and iodlxch r-porﬁud Iicn1ttonut utuﬁy rotatloanhlpc hair‘s: nu individua1’u pantttou in tho tacit! 01:3: struottro :34 tn. provalanoc It treat-d 111-03., £ypcn at diagnouod dalorduru and usual 03¢ duratxan a: puyahttﬁvtu trcntucut ndntatu‘orod ( ). tiny indicatod that proportionntoly nor. 10rd: 0130. pasxnutu in stout-cut vow. clalilfitd an psych-‘10 whtiu ‘ppar clas- pattcu‘a vow. Iﬂfllttil ulna-1ttod an noarotto nud parannnltir disordcra. n-unrdloll at digglouiu, plyuhciharupy was Inplcv.d 1a diaproyorttoaa$cly high 4.:rooa with tho uppor at... pntloutu. and annual. thtrnpto: with lcvcr clans subjects. 1h. Stilt-no. or cacnunio Iﬁnt‘u :34 the availability §0I1d or ﬁroa‘iug POIIOIIII not in cauludcd 1n £hou¢ t‘Idlﬁl. to tout the 901. or noctll_tnctoru 1: tin trcsiacut :1 ho:pitalxnod puﬁaon‘a indopusdoat a: plutont's tinnncuu and :vuilubxllty at tro:tnon$u. n yntlca‘ turvoy val undtrtakuu 1951.,x: u:at nan-u. a «rut: :of treatment nod... including ildavsdual paychothnrapy ans orgnuau ‘hnrnpiou ‘90 nvnilnbln ta :11 ptt1ant: rccnrdlcsn mun: ct ‘htir ablli‘r maul, t. guy. In ﬁhnﬁ tauplo. 33s. tduuutton and plant or birth var. otgnsrinnntlr luuoutntod with chain. ot.‘rautnont, durataoa at hilplﬁtllll‘illg allutnal discharge ivuluatiou ‘30 �lllﬁntlii ( ). it. gltatcul factor: war. 11-. ralltod to a non-Ira a: utorootrpy. tho calttorntu 1 Seal. ( ). ltxhcr r acoran tor. turn ur‘on round in pilliatl dauguoaoi a: tuvolntaouul parlhnlzl rctqrrod for sciatic thirty: and hours. taliiod to: a shortcr yuriod ( ). It It. concluded that ti. extant. a: postal altar, uno. ldi'ttiol. htrthplaaa and dagrco a: atarnotrpy on psyohtu‘ric ﬁrtatnca‘ pnt‘uvnu VII. uoﬁ a roault at cannanta tno‘orn at availgbtlttr of troutlunt .10... On. tugxon‘iun was that 3001.1 :hcﬁ'rl tuIquu-od diagnouin :ad tronsncat by atrociing the varbsl and avg-vnrsnl nynptc- pattarnl at pats-It behavior. It was puntnla‘cd tha‘ nubauo£l at lcvor lusts! all-sou. Inna-r oduot‘tua :34 £03.13. Birth vault nartroqnontly'unuttcnt lynptuun non-Vtrbal. IOBIOPI or IOtO! pnttnruq cud «avast phyolonl noﬁsa or thurapy. Huger ulna. subject. will! utiltic Vtrhal non-n at gunman-10:, and patintputn paycholngioal turn: at troninun‘. A non-ad xn‘crprctataon rilnﬁod plynh11$r1¢ trnutnont ‘0 tho philosophinn and uttxﬁnduu or individutl payuhtatrints and hatptttl ntat! nttttudou. II 1&3‘1‘n‘10ll what. patch.» thartpy Ill hluhlr vulucd. typo: 011-0 pnttunin vculd b. ‘rontod dispruyorttountcly with ptyuhath'rnpr. ataxllrly. dischargc ovuluattonn tad durut1on a: honpttalltntaon U'lld 1n it'll be uttcctcd by itttaroncol :u o‘ttt unpootutioau tor individlu all or distortu; noctal «13.3. �.3. In to“ m. «and menu“ I. «cum: u up.“ $0 lillaldo (ll) :tudy unploytns tin can. proctdurcl :ud tons-trout}: to attend thu diacrquIGnl to in. 0th.: taut:tu‘tonl. ‘hu 0.1. leanings! nuuurtnl inapltll at tarot. (If!) and tho llaunoinncttc lautal lcnlth cantor a: loaton tultt‘uﬁtann worn loloaﬁod in tho Impoo‘nttan (ulna). ‘In$ tiny servo putt-at: .8 ditrursux 30.1.1 clunuou and 1951 It... thnt ditfcrOIcoc an ‘hta dinanatuu uculd ho rofinotod in tho trnatucnt vurtdblou. In that. houulnlu $huro 10 a minim lnrlty 1n attitudo £OUIrdI ‘rcntnaut aad oduna‘tou. Inch 1: a ‘oaoltug haapt‘ox with n {:11 $hlo Inpcrvtaorr utntt and out£v0 research dapar€n0a$. tiny 0:93.013. plythae t-nlrttcalxy-orlontod payohttharupr but gravid. 0‘30: trcnt~ lint. inslnlan; taunts. thcrcptou and activ. prosrnss or I111ﬁl £harnpy. Each :troinlt Ihlrtutarl troutnont or valuntnrr puttautl, does an‘ gravid. cuuﬁodial car. and toads t. d!!! 1‘: pu‘aont pcpnla‘tou trim 01:11:: as. groups. It. Ipouttio till a! £hxl study var. ﬁt duttrntna popu13‘103 airfares-Ia toﬁvccu th- thrlc lun‘tﬁltioan with roupcct to social 01..., a... cantatlol und 1 learn, and to roln$a ‘hunc patient attractorta‘tcn to tho trouﬁuca‘ variables c: twp. o: ‘rauinout. durut1on or hanpitaltua‘ton, ligament: Ind iililltta uvnlnniitu. �.5. am vuluntnry. adul‘ putiuntn 1n rustic... In ‘htll tuntttuttanl on a 31v.- dn‘c ta Ignutrr 1959 new. studiod. “£11. Ill and as had vnllntary 9a‘1cn‘l only. 3 0:311 nuniar a: ‘Inuc It also not. nultlnad by tho court: tor paychtntrtc ovulittton. or war. numb-r. a: a chronic achtsnphroatc utt‘o holpttul group transforrud for u upocltlo ranoarnh p30500‘. than. pataousn aura «natal-d tram tin Itudy b¢¢uulo of tuna: Ian-vnlunﬁcry status. !Ia I‘I‘V population nountntnd a: 113 patinata at II, 100 a‘ Its sad 9S ut ulna. tutu pattcu‘ III ¢1vcn sh. calitorntn r 00.1: ( ) on tin doatgnntod data. Bastian: mouth: taint the paﬁtcntl’ rccurda war. anulynod (hr Oh: variant social and payshinﬁrl: taster. If sh. titty. 1hr tho daﬁuruinatton a! social claua. t5. lulltngshaad autuc‘ar luau: was hand ( ). rho utudr thalidod ulnnxan‘aon a: the rolntacua or ﬁhn 0001.1 to it; payahtaﬁrtc vurtublot within tack tau.atu‘lon. .3 3.11 a: tutu-on tnuti‘attonl. otnpurtnonl pravnd dttttcnlt basin-o at littoral... 1: the dutinttton at the paychtnﬁric vurinbloa. ‘Io variabloa ranged #11017 lad cnnparnhlo cutout: orttarta 00:16 30‘ to d0$urnanua, and varying dour-on at 31:31:. 41“. lb: uuunplo, to acnpnru tnctatuttonl in rola‘son to length of haupltnl u.ny. Vlrlitl ouﬁoott potion. wore ‘raod but I... IIIIIOG for gilpurnbln dtnttlbuianun. At III, on. Q‘nrtnr or the pattuata tonuilcd raw-r this cart: nouths. tad wwvo‘hlrdo L11 it... �.5“ than twtivu nan‘hn. A: Illa. :3 contract. 701 at :11 61 only Inca ‘htu rauntnad nor. 00"! nath:. I.‘ pitiilil that ﬁnalv. mantra. I: inturututug coats: 01:1. ‘haro vac IGIO 08 89! for uVIilabll lltlrlaﬁtul union accurrad what. thy 06‘3ct10n wit. .r in. tn‘hnr at I ulnar Pittoatl. Incluluttinhlo‘ of tho hm:hand of a not... 371 not ruccrdod. Anacrdtus, 1n ﬁho auolyann or payuhaasrto variation ouphunia will be glucod on tho asst-runaun botvacu sastzﬁutlouu. with ostnttuu a! rutnvnnt antrn-tnttstnttaunl roln‘ioashtpa. was �~6- 3mm: I. tn no Whoa riparian; Itndtal 3:1: I hano’inlsatuttou, £30 ltruttlro if it. hanpt‘nl 1| takcu for nrnntod, and ui‘h-r ilﬂﬁf04 I? 8.ﬁ*1‘ild brinrly. luvtvur. 1n atnaytuc a cuupnrabia Gut: 13¢ gather nttaupttag Itransn tlntitutian t. 1::51tn-V butt-an tho differ-nae: many 1at tﬂhrd 3.4: II. $103.. It. hosp1§a1 organisatsun a: a datnruianat a: grantnout in on: nothndolocie prohlcu. Far oxnnplo. bu‘h £h. mane and III havu dny houpttal unttc, while an doc. 39‘. A. name the ﬁeottias phwuxciun can our. tar a patioat an In Qho and an sitar-taro any tbs in hacpt‘ul. tacpattuut, clinic. II Inch a ustttnn, ha 0‘! Ital tree t0 «tachnrgo the pntlont tron tho Ioupital at tn curlxsr «sit. kl¢V1lﬂ that he v11: still bu ranycnsitil £09 hi: pntxont's c;rn; what-an at In, dischargd lint! tnwuinnﬁiou «I shut putiost- 1. I rclttionlhtp. tu-thar probluu an: cu. princnea «I dittoront ruuourch the .2 ‘15. routines. ¢1$i10a1 ti. attoctin: it progra-u. the 91810.1. at a: porcont tunity upprcutnatnly IIIVQI. sane acre chroszaally 111 and had but: haupl‘nlttoa for hnvo ban: in unrn:XIr u such act that! zrc‘p nan: y-arl. thin honpttnl hit tiny and icon trtatturrﬁd Iran anathur donﬁer Ittt- Anntttl§£un for That, it. t lytiill silty. vary tactqrn to war. tut-routed in Itn£rin¢ �.7“ situated ‘ho coll-ataoa and arguaisa‘:¢a .: tit dttn. ap.o::1- grails-l var. noted :- do.1¢ua.1¢an 0: try: a: trout-tut, (sag-nattc torn. and actlnntlouwor troutucnt outta... .) naggiggtigg at 3:23 2; rrggﬁucntc 2h. crttorit tor looignntlng that I past-It r¢ouivud 'parohothornyy' dirtorod anon; tun tastttntioul, waking unitarnltr in olntlttscatsuu difficult. At Iii p:yohothcrnpy tru;;nant 34.1.II ‘ stat: paychintrtat, was dal13n1§od tttoroa on a pronurtpttoa banxl by lb: uhxch tin patiunt was citrate a ton. sonbaaan with the payohia‘rio rnnidoa‘ v.20 countdnrod part a! rcutxao nintnlutrattvv yaﬁinnt Giro. At In plythothcrtpy Ill dcttnod at trtntnqnt caution. vith ‘ho plyohto‘rtu raaiduat. Stat! payohattrtn‘o dtc not trgut pl‘ltuﬁl. but rootrlcsad that: cctavt:aos to cupcrva-tag tho téﬂlﬂOi‘ phylacxaao. At tho lune pnythc‘hornpy val dalxcnasud an a (tactic; of Ian: diocipltaca ~~ pnyshtu‘rio rusadoatu, psychololiatu. Iactal Iurkorn, strata and nodical students. III-n1 accords at such stations vow. n9$ routtnoxy taclndoa 1n the pntlonﬁ'u rouurd and to :lcurtain thigh pu‘iontu roociv¢d piytho§lurapy, tn. rouidnn‘ tn charge at oath a... van lu‘trviovtd. h) Diagnaaaus ludividUll 1::‘1tn‘10na1 dtugnoittc atria. ﬁll. and. ocupcrisnnn litticult. At K!B din-barn. �diagnouol nuptqycd tut nultipin cvnlnn‘ivn dn‘n sch-no raculncadod hr thy tntrtouu Paychlu‘rtl 1.00:11‘1uu whilc both in .36 male rolllvod unt‘ury ayutana. anvural 11:191.. at IJI arc iihlo I, vl‘h our in:sootcd convurliona tutu catuturica eunyurthlo to tho 0th.: 11.130000 tru— ltuﬁod in fags; convvrizoas provtdc, havcvar, tn unavnidabla taste: .3 diutartioa. (31:11:: aboarvntluau havb-nn roperﬁnd by Pas-Inuit: and him tauoetstad ( ) wha indicat. that dilzuntaa Within tho tine tantitutloa Ira db. vulnnrnhlo to individunl titraruacua Ilia: examaacraa ﬁve lunﬁiﬁuﬁlouu. u--O-“.““. {thin I ”’W‘.ﬂ u... c) gtlobnrlg Ragggln a: Ingggvcmcut: Rating: 0: invrQVOo aunt wart-é 1n (splat and dotall. It. discharge rating at nil was $r1purt$£o with a inparu§a cvaIunilun tor soatal. ottrac‘urololttal and Irndrona canteen. RI and tune End clubs: ratings in which 1‘ VII difficult ta attain the can. ‘rtbuﬁton at such tuct¢~ n: tn: 1!! Iyltuu (rnhic 11). Fur than ntuiy gt. 3!! lyndrawc rating van unwanted to it: global rgttuc' a: an and line. C-” t .“G‘”. Q Tibia XI ”“ﬂ“Q‘O” a. Booicgtzphologgggl Virgabloc �‘9. Scotti amp-u; that. at: a ngrkad dixttrcuuu ta ta. .0013} alas! count-$Qton at ‘bn tire. annta$nttonl (tibia 111). g} at. .t as praduninnutly “pvt? 0130!; nxddlc .1333; and at mane, produatnauttr loan! 01‘33. h) ﬁgs: Thar. war. no daltcroiaul in 01' itl‘cihltina in tho tus£1sntiounl popula‘aonﬁ. o) pdn¢uﬁgggc The nopuln%toas dittarod in oduaataounl attstauant, with pniitu£l at If! havtuu not. glut: a: sinustiou than than: at 3:36. ﬁhlin k1 per aunt of ‘hl pusiunﬁl 3‘ Hana tutled to aauplotn high cahool. only 32 par canﬁ at an tud 23 par cant aﬁ urn did not grndutta. d) r Sacra: natturuuaaa 3. tin ata‘rlbnslcn a: metro. an tau calitnruiu ! 3131. war. oblorvcd. Itrth-oao pot ennﬁ at urn pattaaﬁa had I soar-n hcldv 30, and eat: ctgh‘ not «out wi‘h start. 0! 50 or thaw. ~~ tn. highnr ? neuron 3.1:; .8..egatnd with higher 6.3!... at sgurcoiypy. In coa‘raut, at unnc tumuﬁy par ccnﬁ var. halo! 30 at tho 2 30.10, .Id fortytuo par cant hnd intro. 9: 50 or more. At an titty par coat 0! it. patiuatu hnd r an.rua in £hu utddln rgagc botutoa 30 and £9. 3. szph§ggg$g Vutiuhlgt In‘rnainutttuttunnl oonparinoau urn counotidatod 1: tabla 1', while tutaroinlt1£u§10nal unitartitul It. prancu‘od indiviﬁnullr 1n llih not$tcn. In ttbl. IV, ntlbu and payohou thcrnptoo var. cnnbtnad, parntﬁtana I oontract a: 30-311: uni At 81! the population �pcycholcglaal tharaplnu. 3) 8.1.0.1.: or troatunu‘: ‘80:; inn$1tu.1ona, lunar 6% fOOOSVDd ulna, $hat naught. or thornny I! I?! at yl‘iontu (iuhlo V). OOIOIBIOC‘IV suallcr various... at tho urn pu‘tontl taro 31:35.6 :3 rootivis¢ paynhoﬁhorapy, with u largo tank.» (36 putt-at) ratotvxna 31110: torso at ‘roa‘o tout. 1t an patsonta rocotvtn. nilxou thnrnptou at. Clﬂliltic¢ an raoniviu: plyluothoragy no i yrs-3:1 Iroatnuut ItIQO sank pattnntil cantonxtanily 3.01:; 3 3.014033 ply-htnsrict. 003331. or rnuctvtnx tho plﬁtuu‘a pcrnonﬁtnc ion‘ruct on: I: thornpy, urn ﬂhl'. nighttlctntly loo- thlu intact 02 .3. o‘htr tun anlﬂ1£itaona. . ”U“. d.-.”ﬁ-‘.”.’..~” £311. 1 abuu‘ barn ao¢1a1«paynholoui¢a1 P Old acorn nun Alon; fuotlro, nannisieantly rolatad tn sraawnout nsloc‘ioa (0160» and highsr r Basra patzom‘a at ups; and 9 ant. froqucntlr'vccosvtna somatic therapy) 8.0:. can tainted to troaincnt ooloo‘ton n‘ 33. athar taa‘ora utrc Itgnaticauﬁ. Ian. of ti. '001n1psychological factor: II. rclntta ta try. at trottaon‘ at nuns (tabla IV). Luau. ﬁn. purchx‘tric vurtabios vi‘hin ouch inntttutiou. diagnosit at: ntgnitso:ntzy‘rolntod 1a '11 tutu. hospital-x discharge ovaluntton ‘t I?! only. had dura$1an or hocyt‘nltunttoa I. �.11.: it an and nano. sonata. troaanan‘ nun aolaotol for pattunta clnnuittud nu ochisnphr-nta titan that $hoa¢ cluaaod tad attactivu diacrdar “or. a; paychgnnlzotio at oath htartt;1. urn. pataanﬁ: roootvinu acnatxn truaﬁuont (prudnnilaatly that. tlaa¢ad as Ichanophrontn) raeulvcd ditahnrso rattncu at Iniupruvud nor: artua than pntianta rnnttvini payohoth-rspy At nlonn. b) BI!&I&I! a: BIG 1it11 'zttat 1k. fir-c 11¢t1$ut1¢ul dittorod with roaptot to pnticu“: ltauth at utly (2‘51. 71). ”an“ was mat-nu: 19‘s.", um 65$ at gaunt. taunt-1n. tar traits «oath. .r usrc, compare: ta 31 par cnn£ at ‘ta 1! puttonta and only 5 par aunt 0! than. at nuns“ 2h. an andul aﬁﬁy st ‘30 In group it: bctvnoa save: and nl¢vnn noatha I311. tau-thirac at the anus pattun‘n var. diach§r¢od within '1! uoathl a: houpttnlinnﬁtou. 8.01.1 oinnu and 3 $3020 we». utt rnlutod id aurution at nay tultltutiou. ti. psy¢h1n£rio vurinblua. III! 613330.13 coula ht rtlntod . ﬁg ﬁhnao diuanantd ll achtsorhrouia utro bnlpttalaucd tar inncor puriaﬂi .t each instii‘tscn. at «vary .3. 1.7.1, it... a: at urn ran-incd loagar tuna Qt 38 av Hana. Iadctd. tun lituriantieutiontl dirrcronuon turn a. gruat that a yattcnt in m clan-tn an» m m. lit-11 u be mutant“ “r tulovt manta: or more ut urn thug war. putaautn in ﬁne "II‘II‘ ts. Irv!) at x386. Within initiﬁatﬁnns. as. andauducu‘1oa at xxx tad an �a“. war: wizntad ‘0 lsucht a: honpitnliﬁatzuu -« runagir tad 1.0: olucutnd pstanntn rinninits for tho linxca‘ porioi tail. 1! dsdnt atrt a) Qgggggggg_gzg;33§;gga In ough hacpitnl. Kilt patient. .32 um um mum“ u. ”wwma" (ran. are cnlutoé u. (19%) 1; a" var. peanut panamWW. Ultli nu ”uninprovaa" and 0&1: ‘ 31331: patient Hus antlua 'rcgovnrod” or .Iﬁﬁh taprovid‘. tum highcat pareaataec at 'rotovur-d“ a» ”tank inprovud' 31:13:: (20:) :51 an. tenant propurtion a: ”Ininyruvvd’ {101) «0:. Stand at aunc. Lnalyuua within such auntttnaioa uhcutn vurtnbln rouulto. A‘ an and nunc thsrc an: n tandungy IQ! )Iaar putauntn to ho Iltcd hctﬁor ‘3‘: yolaanr anal, but ‘kc ratnita tr: l‘a.1|$1t~ was m. ma on than n. may aimltisaant awn”. um rm‘cd to 5! with Iatupruvlla oléar likely an». pstinntu trend, tut ‘hia did not aahsava a‘sttltlcni tignittaanno. n m, an. mm a “‘3'“ :9.“‘ﬂl”..”rhbgo VII wa-oonhwﬁcumahha d) btgsnnuila Fur u‘atiattnul analytic $hrnn dinsnontal l¢h38iphliu1¢, arxostavc dsnurdaro. and poyzh¢ncnron15 and tﬂrlﬂnllltr ditirdlrt ($351. '11:). nuns and 31-11:: ﬁt: I! disgn¢at1¢ proyorticnn It! It!» It. groupcinsu Ina. 544:: �.13. pcptlnttonn. but it. Ill ’iﬁiﬁlﬁﬂ «or. rcunrdod an invanu and and a 13:30: Iahtuophrcntc nttacttvo 1130:4023 tart: nn-pur a: purchanouroﬁtc or per-duality dilornora. Intrailltitutlnutl ntalrlta Ibiuid that tt I! tot! l1. tad r loot. wore rolstad to It‘sntuan; 1‘ III an. at... a: £h. nacitl tltttrr was rolntca to dsnxnootng null. as 1386 iii? I! it. 30:13! vuradbla¢ war. no ralatod. at tho p31» Ohllttll var1thlos, it‘snoata val nignitiaantly rtlstnl gt enth hoiyital te tg1:¢tica 01 trnuitcnt llﬁ durati¢n of sad only at IE to diauh‘wxo artlaatiau. hanpt‘nltuation; .ﬂuﬂwﬁ Q. .DI.C“M”O“ flhla V111 dbaut hart U-“OD‘““Om--.ﬁ-“”“~.- �.15. n . 10! In this courtrtaon It ﬁhroa vutun$nrr paychintriu houpa‘alt a. hat. dbuorvud tisaatlonat tn‘orinutitntionnl atttuvuunol I! rattantl 1. ‘ho noctnl vurtlblta a: rtura at oduca‘ioa and 1.01:1 slant, but not ugu; :- distribution at cnlstorutu r acalovan¢rnsy ‘nd 1: oath of tin truntnmat durntaon a: knapst:11uatton. ccluctton o: vurtlbluu trdut-c-tl and atltrtbutton at 1113.0... and danuhnrct ovuluattlua. It. tilt-routs: in ‘rontncnt variable. butt-nu £ho Lia‘stuttuns nay roc‘l‘ Iron man: flitlrl. including £ho 30.1.1 aspoo$o highlightod 13 an! tntﬁstl ain‘t-t. 2' dttinc tho r01: a: sedan! tho‘oro taro olonvly, vb IIICIiotk tho 1n£r‘~$nlttttt1¢nu1 nulparinOIt. Iron into. aﬁulyioa. ﬁt» :gok a: cnlutltcnt ralaGloashtpu land: dent: n: in tho v.1. at putlcut nottal tuaiars u‘ priallpil actorntnnnta 1a £routnal£ vtlhln than. tittin... It via an‘tcipatud that wi‘hin ouch tusﬁltnttoa. pnﬁlonin at hichur 00.1.1 clays, turn: r not». ans hat‘ar causation, would to croutud prcrcru tg‘luXXV by pcrthntb¢V£vrg clnsnttiod as nourotio, tuna:tnr shorter partodl and r:¢¢1v. botﬁ-r danchargo rats-an. wl‘hxn in. :uli1iut10n, an irrtstlnr unsootnﬁloa bc‘vtta tn. 1;). (ram. mun-u «I wan. no sauna-n. it. Illa. not. at tin Inuit: $323.51.. var. rotatod tn any cum at: at. tacit! alga: Itliilttc;117 rotataa to 3:: trontnomt vnrlubln at otshcr I! or 313. o: a ﬁrouﬁuout turtnblus �$3313 3 ___, by nun-qutuuml ”hunch”. Manta“ on Sam. ”I - haunt aoluﬂ“ ' '- mun O: thuuﬂl ' - Duncan 11“ch suit-nun mutton . man or Inﬂuuuuu I an" - ”can“ sun“." . Mam” " ii‘lﬁ 3;: - n. I. “nun-up in- ti mo. m «I» 4» am...» he mu: am0 u r: .05 p< .0). on W .001 �.15. pcccthlc he rclccaccchtpc hchucch ccctcl ccc trcctccnt vhrachlcc, clcvcn crc chctﬁcttcclly nightttocat. fhc dirtcrcnccc 1c tho an cud It! dctc ucy hc a» rctlcchlcc ct thcir pcpclclhdch atttcrcccccu thc rclccicu at 13c cc d1cchcr;c cvclccttcn, ccd r cccrc tc 41c¢nccic at an rctlccticcihc htchcr prcpcrticn c: dcprcccivc illccccccp uhtlc hhc rclcctcc ct cuc cc hrcchucct cclccticn cc urn rctlccttcs choir highcr prcpcwttcc c: {cc-t pcrcccc clccciw tic! pcychcncurcclc cud chcrcchcr itccrdcr. rho ctnilcrthtcc :- I! and Ill much In: rctlcct ctnilcr trcchccut philcccphtcc, which crc littcrcct rrcn thct ct Illa. ccudtttcac c: clcchivc trcchucht ccd clccttvc dcrctxcn ct hccpitclxcchlch catch ct ll cud HIE. and th may hc thin tlcllhtlihy thch pcrcttc tho inhcrccticc ct tho cccicl vcrtchlcc. 1% lane, hcvcvcr. tho lththcd cccy cud cccd tcr rcpid trcctccch rcculhc ta h tctlcrc hc dchchctrchc cc 1ctcrcch1cc ct cccicl vcrichlcc vtch tho trcchhhct prccccccc. Similarly. thc rclchtcc ct cccihl clccc vcrichlcc hc trcchhcht varichlcc 1c hhc lcllxccchccd ccd nclltuh ctndicc Icy rctlcct hhctr dctc cclcchtca, vhtch vac cvcr thc hrccd rccxc ct c11 ccnuhcatw :cctltctcc cud cll trccthcah portcdc. within thcsahcttcnc, hcvcvcr, thccc cccthl thctcrc cppccr lccc «Incl-.111" ct trcchcct ruichlcc. accusing): cvmcvcrcd by tctrcccrcl cdhtctccrcttvc ct {sunsctcl ccccccthtcc. 1c hhc ccrltcr Iillctdc lccpthcl chcdacc ( ) thc rclcttcc ct �~16- vnrtubloc trooinant ‘0 thtad cit-atlas 0: u... r 3019:, 13 u rdlnation of the krona ndnantn‘rativu 1a£1ta¢ua avntlnhlo defined broadly lrtnﬁnout. var. tans. that a‘ tn pnﬁlnu‘ car. with cengﬁtc, nzltou :34 paychoﬁhurnpautto undo. annuity ‘vniznhlo. ”III‘SOQ Ir Incpt‘nlinotton an. broadly duttnod Anni-lion policy 1 raga-atod. 19:31: or to up i: your, at was {113151. and thh taught and purntt‘od tun Ianxslaon or paﬁtuu‘n ‘1‘» a I10. 933;. a: pcylhlatrxa laouraorc. the proacnt an Isudy than: (out: locial-trantnont'rctn‘tono con-ﬁr‘o‘ttn 195? a parka»: ‘ha rollocttuc than s‘uay. nit»! Lu avgilabiliﬁy a! trcaﬁuont :hoiooa. ta popu1t£1on 33¢ a uniturn us‘cnnton-cl ditl‘lil at heapttcllulttoa. lit. new ad-tntn‘rnliﬁh a can‘nlyorcsoouslr thatlsltad pitta... with closer no narkud a Granting axillarity in clonal: $10., the Mt! nodal. Such administruttvo discus-10:. arc iosu no prtutcpal dctorntnlltl or tn. Clorﬂlllﬂ or dist-lutton a: social vurinbloa, n. ltl‘lrl ta tho trantncnt prostlu. A lacuna aspect at that. I‘udtoo an: tun Icthodoloctoul problems In 6011.13: tho ‘roatnon‘ Vtrtnbloo. That. last:tltSOan wort toloctod to: that: cantattouni loudnruhtp and be vanld roomrd¢d £ho vurtuono 01¢:rly tha‘ clygctattoa it. uglinod. OI: dirttcultzao in arriving at comparable Asia oouvuattonnl at a: $ht-prdblnn to one! in. tupcrtant tit at. OOIplrﬁﬁiyi it;$ia£ion. 0330015117 1- £3. ovulustton a: psychiatric therapiou. rho trnquun‘ nu. at dilahnrco ratings, �-17- dtncnolttc .11.... or Iongth at houpisaltnatton an ortturta or thorlpputic vnluou at conpnrubtltty or nuts-ct: and poppItttona urn Iibaoct £0 can-031v. array pal... tho inuttﬁnctono puraduxtn naschnd adulatutrntivo patparuu. tar clourly It. It. cal uupuro at a :atluru ts anounat for this vurinhlo 1- to be 6511 dbucrvnﬁtoa ‘hc of a in tutprprctataon lttcrnl t: Iii! cindy. an. urn hi! it: most highly train! per-canal oondutttnu troainunt think is applxud for indivicunlly tottaoﬁ,¢ptxan1 portods o: ‘llis it populations with it. 1...‘ propurtion danunouod 1p nu unfavorabls pritlll‘it group (achilophronin) - 1. uncultl (cvorlblo tracing-t a: rot. th. pOOIOIt. At Illa, 1n contranﬁ, tilt. in: lonat traluod shtruptacﬁ apply transient. for nu adutntutrativnly llutsnd patina, ‘0 t papnlattou ‘1‘! a tight! prcportlon dtnuuoacd Ichisophrpnia. tho proportten or tnvorablo itscharxt rating: in lixutticnutlr grouper: It 1- prubsblo thnt thun- ohlcrvuu £303: a. sop rutloc£ thy tharapcusac atticppy 0: photo snap:1n inﬁtcatodb ortsorta o: tuprvvo~ attics-loan tu‘ttul, 3" ~- tad tho proportion uonﬁ. this lack a: alsritv in «tacuautta achcunﬁ¢ and lacunpnrtbiltﬁy or psychiatric trou‘upnt variably. all. landpallc to th. t‘tcnptnd acuparupivc studio: or payohtntria thorpptca. Pb: asunplo. tho rank at rooont failurns or biolcgtcal Ioaonticsu to Courtru ubacrvutioan Ill. 1: «that labor-tartan rip he I: unch a rutloctinn 0: 11:10:03... In �.18. popnlnﬁsoul. paynhaatrin orssortu,lggg. an tullaniou it tho or131ua1 hip-thus... tin vtdnspmoad no. or tank turns :- ”Ichzscphroaiu' or "plynh'aamtoaiu' to unplarc £hn shuns-n 13 pnyubutagtoal or biological toninraa with nouﬁaz ilincsc has 106 it a Icioaea burdonod by ungattvu rctaign (Iellak), nont narkod rocuntly 1n tho nontliettng studio: at I tdrll false: in auhaauphroutn, :3d the tact-pur‘btltty or the yhyutologtoul -. hohnvtorcl corrcluttnn: scan in tun u0choly1 (Fulton-toau) and sedatiau thr¢lholﬁ tnakt. Esta nor. 3 valzd abourvn‘tou to be ropuriod :rcu on. clinic, dc a. havo' nothtdi available ‘0 deliriho poputlilonl manqua‘nzy £0 providc ‘ sound nontlrnatlon? w. haltovu hat, and nonoludc from thugs dbnurvuttcls that incranacd attention unst be paid to she uathodolaaaaal prnblun: o: alttsityina uuhjocta hy 'vb:oot&vo“ cratcriu, rather than ﬁns prosoat untied! whack appear to b: a. hichiy dopoadont a: institutionnl ;ad otuarvar nttittana. In: the oouiopaychological 339.0%. .2 ‘3. thﬂllptltupl§103‘ tltcrtctiou. �IleI I can? a nu at Bil: WW 1. nnprunaav‘ rouctson Surciaozntlo Puruonnlitr 1: no: WM“ 1 61-1- “mm Payohcncnrostl 2. Auxtuty Roaution larttnntutia Parlounlaﬁr Payohnaonrootl 3. larcttsiutia ?urlcan11my tartan-11:: $ h. lurcatﬂiutlc Par-annlstr. Alcohcttun chronic Intintilo PartinIISty I acuiuputhic Put-onaltty Btuturhusoo S. Pausivn Augrcuuive P¢rsoun1$ﬁy Alcoholiun Suctcpcthic Purcoanllty Disturhllco 6. Inthn‘iln rarncnnlzty Schauophrtntu Ronltton StuttOphronlo vaychoail , Suhiﬁl-Aflloﬁ1Vi*2¥pl frtit 31I£I§bnnio �TAELE c 1 5‘ 1 of I: on g; gaggs‘nl aacahnrgo 8a.: tin. Ii u , Illa ﬂoats: tgguai-ant Ruusvuroi luouvavud Inpmuvod Bach Inprvv‘d unrkodly InprQV'I Untaprovvd Invrdvnd lodurntolr Improvul alllprcvod 81133‘17 Inprovod Hltnprcvud couplate Ronanaign 2aprov.d v‘ahnugcd (u: wits.) �ans-$3 :33»! . i: on ., w W M . - V. ma w, ,-.M , u. x n Ha ‘ a WE w m V m Vino W4 m .w Vacs. gm H1 II ”Sup-32a a I'_I"II 3.33.. V mﬁuﬁﬁﬁm .63. I; Eu. as PH. no in �EQELE V :2! an kl 173 we v’-82.8; 39 dtwhx p¢.061. ’ 21 h: 36 36 6h 0 ah 68 a ! principalxr lilies thsrtplio �me 95 x'.?0.6; “'1” V5.09! �331.8 quttt‘u I an g! m ‘ ’ Rum“, rum n '1; «huand d 1 c ﬁ Imprond ﬂux-yam! 99 1 an 1.9 17: 23 6: 15 as 61 10 mc- x*-29.3; «rub; p«.oat. �Y Ilstttntaau . V I WM). l achtgophrtnia Puyuhonguronia and E' 7 ml m1 male 171 . 85 t"13.8h1 43-h; pﬁoanl.‘ far-onaliﬁy O; !' J££o¢ttvo 33 $2 5 52 26 :92 SL 29 16 �A Couporioon o: sooioplyoholoaiool Voriobloo and Poyohlotrlo trootnout 1o Throo Voluntary Hoopitolo Robort L. Kuhn, Ph.D.', no: Pollock, Ph.D. lothoniol Siogol, Ph.D. oud m ﬂak, um. tron tho noportuont of Suporinootol Poyohiotry, Hilloido Hoopitol, ﬁlo: Oaks, L.I., 5.1. Aidod, in port, by grout HI-ZOQI of tho lotionol Inotituto o: Kontol Koolth, 0.8. Publio BooIth Sorvloos ond tho loooou County Kontol Hoolth Hoard. tho cooperation of tho ototto of tho Hooooohuootto Montol Hoolth Contor and tho 0.1. Hoaninlor Houoriol Hoopitol 1o lrototuily ooknovlodcod. o Prooont Addrooo: Divioion o: Poyohiotry, Houtottoro noopttol, I.!. 67, 3.2. VII: 3/62 �In thair atndy a: tha lav lavas payahiatria patiaat populatiaa. lailingahaad and Badliah rapariad aignitiaant raiaiiouahipa batwaan an individuai'a paaitian in tha aohial aliaa airuatura and tha pravaianaa a: traatad iilaaaa, typaa at diaguaaad diaardara ind kinda and duration at payahiatria traatnaat adniaiaiarad ( ). Thay indiaaiad that prapartian~ ataiy aura lava: aiaaa paiiaata in traataant vara aiaaaitiad aa payahatia whiia uppar alaaa patianta vara naraattan alauaitiad aa naaratia and paraaaality diaordara. ﬁagardiaaa at diagnaaia, payahatharapy waa anplayad in diaprapartianataly high dagraaa with iha uppar alaaa patianta, and urgauia iharapiaa with iavar alaaa aahjaata. W” Tha intiuanaa at aaanaaia atatua tha availability aau‘gviat lﬁkaualndad in thaaa atudiaa. at traating paraanual fa iaat tha raia at aaeiai taatara in tha traatnant at hoaa finanaagfaui iadapaudani at patiant patiant' pitaliaad M“: JJ’availabilityat iraataauta;a patiant aarvay vaa undertakaa at Biliaida laapiial in 1951. In thia haapitai, a variaty at traatlant nodal, inailding individual payohatharapy and organic tharapiaa at. availabia to .11 patianta ragardlaaa 3”“ at thair ability to pay. In that ....!G. aga, adnaatian and piaca at birth var. aignitiaauiiy aaaaoiatad viih ahaiaa at traatuaai, duratiau at haapiiaiiaatian, aliniaal diaaharga avaiuatian and �.2diecneeie ( ). The elinieel teetere were elee releted to e eeeenre e: etereetypy, the celiternie F snele ( ). Higher r eeeree eere nere etten round in petiente diegneeed en invelntienel peyeheeie referred for eeuetie therepy end heepi~ telieed fer e eherter peried ( ).i 11..., mﬁﬂﬂ‘iv W” It eee eenelnded thet the elGIItI-et eeeiel eleee, ege, education, birthpleee end degree or etegzgggpy en peyohietrie i:3§::§:7gi eeeienie treeteent petterne were not teetere er eveilebility er treeteent eleee. One eezgeetien wee thet eeeiel teetnre influenced dieueeeie end treeteent by etteetin: the verhel end nen-verhel eynpten petterne e: petient behevier. It wee peeteleted thet eehjeete et lever eoniel eleeeee, lee-er edneetien end tereicn hirth would eere frequently eeniteet eyepteee in nen-verbel, eeneery or enter pettnrne end would expeet phyeieel eedee e: therepy. Upper eleee eehjeete eenld etiliee verhel neene e: expreeeien, end eetieipete peyehelegieel teree er treeteent. A eeeend interpretetien releted peyehietrie treeteeet to the phileeephiee end ettitedee at individnel peyehietriete end heeyitel etet: ettitedee. In inetitntiene where peyehetherepy wee highly velned, upper eleee petiente would he treeted dieprepertienetely with peyehetherepy. Sieilerly, dieeherge eveleetiene end deretiee e: heepitelieetien weeld he etteeted by dittereneee in etet: expeetetiene for individuele of differing eeeiel eleee. ”Sikhs/W! �toot thio ooooad hypothuio no dooidod to "put to Hilloido (an) otody ouployinx tho Iona prooodoroo out l'o 1957 oonoorroatly to oxtoud tho oboorvotiono to two othor institutions, tho 0.}. nounio‘or Honoriol loopitol of fopoko (HIE) ond tho looooohoootto Hootol ﬂoolth Cantor of Bolton (ulna). rhooo inotitntiooo not. oolootoo in tho oxpoototioo that they oorvo potionto o! ditroriag oooiol olooooo and that ditrorooooo in thin di-oooiou would ho rotlootod in tho trootnont variation. In thooo hooptolo thoro in o oinia lority in ottitndo souordo trootooot and oduootiou. Each in o tooohinc hoopitol with a toll tin. ooporvioory ototr and ootivo rooooroh doportooot. rho: onphooino poyohoonolytioolly-oriontod porohothoropy but provido othor trottuonto including oonotio thoropioo ond ootivo procro-o o: nilioo thoropy. Book otrooooo chart-torn trootoont o: voluntary potionto, dooo not provido oootodiol ooro and tonde to draw ito potiont populotioo tron oinilor ozo croopo. tho opooitio tin; of this study voro to dotornino population dittoroaooo botwoou tho throo institution: with roopoot to oooiol olooo, ago, oduootion too I oooro, nod to roloto tho-o potioot ohorootoriotioo to tho trootnont voriooloo or typo or trootnoot, duration or hoopitolilotiou, diagnooio and dioohorxo ovoluotioo. �Uh. HEIIOD valaatary, adult pattanaa 1a validaaaa in thaaa taattauttaaa an a titan data in January 1959 wara aaad£ad. whsla 8!! and El had valaatary paataata only, a aaall nuabar a: thaaa at zinc vara aaatsaad by aha eaarta tar payahiatrta avalaaataa, at wara aanbara at a abrania aahtaaphraaio ataaa hospital group tranatarrad for a apaattia raaaarah proJaat. Thaaa patlanaa vara aaa}gaa§mgaan tho atudy baaauaa at that: aaa-valaaﬁary atataa. fha laud: popu1;‘1.§“;;hai§£;§”;g:§i3 tag-“ice at m and 95 at me. nub van W~_MM' W._~.»M~_~-w gtvan tha calitarnia I aaala ( ) an aha daaigaatad aaaa. is 0!“ ”Univ; MM Eightaaa aoutha later tha-paﬁtaata' raaar ‘Awara aaaiyaad. to. MMML and tho aha variaua aaatal taatara at payahtatria atady. )far a£3~3:::::2:;tton tar at aaazal alaaa, tho Ballingahaad 2-taatar tad-x was aaad ( ,). Tho atady inaladad aaaatnaaiaa at tha ralatiana of tha aacial ta tha payahiatrta variablaa within aaah inaattatian, as wall aa batwaaa inattantiana. ‘rhaaa aaaparlaana provad difficult baaauaa at airfaranaaa in tha dattataian of tha paychiatrta variahlaa, aha variablaa L11 mung"; pl;;t cut-at: aritaria could not ha dataraiuad, and varying dagraaa at ataatag data. Far axaapla, ta aaapara inatitutiana in ralatiaa to laacth a! haapital raucad widaly and camparahla atay. variaaa nag-or: pariada vara ariad but aana allowad rat aaaparahla diatributtaaa. At Hyﬁ, ana quartar a: an. pattaata raaaiaad ravar thaa aavan aaatha. aad awa-ahlrda a �.5. Into tuna twclvo acuthu. At ulna, in contract, 701 at .11 pation‘t rcnntnod 1... than IOVOI noaths. tad onzy 61 not. than 3201?. angina. In actor-intng 0.01:1 .1... that. van tarnrnnttou availnbll for 292 of 371 patiouta. Unclaucitxablo Ctlll accurrtd whoro tn. educ‘tion or the unaband or a honouwtto If the tathnr or a liner VII nut rouordod. Loonrdinu, 1n $ho nutty... a: paychiatrio vnrinblot inphllll V111 bu plaacd on tho dittcrcncoo botvoou tuititu‘lonn, with c1t:txon or rolovnnt tnttu-inatltnttonal rolntaonnhtpa. �Katharina“! “no.“ what! "parts.“ tn: hatun I tnutuuou, “at” 11 and “icon for of tho “that hospital crust“, "not”. 1. 4*“ 2y“ 1,: ,7) § )3 § Pg « § 3 studying in brieﬂy. “attend ﬂavour, {LR $ Q 1:”er 77W ', 0”] M and author Guplrlbli d». 44W stunting inﬂation 3:. ﬁg .W' 3'. M” batvua tho undo 1at q dirt-rue” luuumm. any m\ an 3N M ”1:1” (Md “on. ﬂu hospital. org-nuts.» u a dour-tun at twat-x § Q1: 9. 3* ”3%: both sh. pr-Obltl. 03mph, )W tumultuous hr no“ Q‘s an u ‘ Mﬂg 3 3g an do“ not. 7“ MM 1mm and am In" in: lupin]. nun, while (ft; Q 3‘ mfg?” At me the trotting phynuua u: can for a pttuu u a ‘E Q“k and tho as 1n é day the utter-nu hospital, W‘ﬁjw Min-pun“, x i to In tool 1% In ;.1. 1,, no): a auburn «a in. “tuna. cunts. w k“ g M"; knowing tho at hoopla! the «run“to, patient in: ”ﬁle/:4 , a WV 15%”, 11111 ha hi: tar patint'u to ruponltblo «to; um can % 1;. 'bj’whuuﬁ up») gt an, “sour” nun urination or “at puunA” MW auto:relation“?W M” Jr 1M Vb 5 0: the Authcr $4, III pubic: 51/” “than prune. running m. {Lu u} NM 5”” w” M. use tbs .2 _.., 011““). an. "nun“. ‘y prurun, “tuna: W” w g‘éﬂm w tho at approximately pan-nu “any para." u «may, W { to:111 had and bun chronically hospitals!“ mo var. “wwizof rb Mara would not normally 1: luv. bun Sun group I yuan. any ﬁg Wu; MW" thin nuptial bit they had bun trmtornd tron author m O | 9' 1,. . |. “0: ax- . in 8 v 8 ”L e , A _ . Mk M ‘ 3 ‘35 ’ 3 \ g , . x ‘ W” ,5 l i ' W" . l at.“ human“ for a ”001.1 ““1. Thu, tho vary not." no In" int-tutu / in studying ,4"ch ‘ �~80 diagnssol unpluynd tho unltipIo avnl‘ativu d.ta Ichuuo rootuaondod by tin Anortcna Psychiatric LIIOOIQ‘itl will. both an and nuns rollovod Iaiﬁary nyuﬁunl. 8.7.!!! uxanploo a: dllﬂlllll tram I)! are liatod 1n Idblo I, with on: on;goutod oonvoruioaa into ottngoricn coaparablo so the cthor two institutiona. {hone aonvorlioul provide, horcvcr, an unavaidnblc neuron of dfstartaon. (31-11nr ebonrvntinln havban rap-rut! by Pun-nut and his uuetntoj ( ) who indicts. th.t diagnoous riﬁhin the can. tantikutiou arc die valuarnblo to individual ditturoncoc anon; anguinnr-J -“--I‘-----QTtblu I c) Dilahsr 0 anti 3 at In rovcm¢n%: Ratings at inpravc:ont varind in (grant and detail. the dischargo rating It KPH In: triparti‘o with a liptruto cvalustion for social, attractorcloliual and cyndrouo Chlnloto an and Kane had glob-1 ratings in which it was dirtiault to .0303: the con— trtbution or cash factor at th: urn tyntan (rubl- II). For this Itudy the urn urndrono rating VII compared to tho glqbll ratings of an and mane. T‘bla 2. Socioglzeholoitcal Variable. II �-9“ a) Socitl Gina-z that. val I narkod dittoronoc in tho lociil ulna: oonpouition of tho thro- iuttitttions (Table 111). 3% an BEE 01:00; tho produninaltly population uppar In. it niddia olaun; tad at axle. pradcninaatly lava: Ola-u. b) 5.3: Thor. turn as dittaruncun in In. dilirihutiou in the institutional popuiitiano. 0) Education: Tho populitionl dirtorod in cduantioual 1% HIE with having nor. yoirl or adieupaticatt utttinncni, tion than that. it HERO. While kl p02 aunt of tho pttiontl HERO ttilod to cosploto high annual, only 32 par cent at it KPH UK and 23 par cont it did ant ‘raduntc. d) F Sacra: Dittoruncon in the diuiribuiion of scar-I on tho Gilitornia r 80.1. not. obsorvod. ritth~ono par coat or urn paticntl had P score: below 30, cad only eight var cent with IBOrCI or 50 or abuvo -- the higher P acorns being O0..cintod with high-r dugrtul o: sturuotypy. In contrast, at 3336 tittty per cont not. Euler 30 on the F 30.1., and tort Knigz;::;pnr—ttnt $0 two per scat and IBOIII at or nova. it bb¢”»130 chad eﬁnuau~ P&c&¢r véu<_z or the pntiuntl hid F 3002.: ia—ihn—nidd%¢arcntu-huﬁwuuu—3O '0'”?ch My Sowua «Jan, 50m 0 3. Pozohiatric Variablu: Intrgoinutitutionnl «satirinonl urn connoiidatod in Tabla IV, wail. iuicr-inutituiional ounparinont are proacntad iadividquly in tack auction. In tibia IV, nirhu uni psychotherapi.a act. conhiuod, parlitting p «cairn-t or countie ind �.11. at an and rune. 3.3.310 two‘s-ant uni uolootna for pattea‘u clan-itlcd an achisaphroain and atfcotivo disorder not. titan than than. Illlﬂid an paychonuurmszo u$ Illh hoapitll. At HFH, pattou‘a rocolvtll unantio troaiannt (prodcninautly than. 01.8.06 an nthiaoyhrania) rocnlvod dinohsrso ratingot uninprevnd nor. ofton thus putiuata roooivina psychathcrapy alone. b) Duration of Boagitaliuttiona 23. turn. instituticua agitated with roapott t0 ptticnt'o longth of ctny (Tabla VI). MPH patients VII. haupitnliscd leascls, with 65$ of pat1¢atl runtiniag t0: twelvo lanth- or torn. cenpatua ‘0 31 par cont 0: patioutl and 0:1: 5 par coat a: that. it nuns. rho 3.4.1 ttay .1 it. i3 group was hottocn IIVOI and «lurch nonthn Hull. twenthirén of tho XHHC patioata wort diachuracd within six 393th: at hoapttnlisatton. 3031.1 «1::- and F acorn worn 30‘ rnlutod té dira‘ion at any institutian. or tea psyghiatrio variabloa, only diazuoaia 00‘1d b. taint-d - in. HE as tho». diagnonod a. achinaphron1n war. hospttnlaund to: longer porlodn It sunk inutttution. At avury at. 10701, that. at RFE rouninaé $0.30: th¢a It 33 or Mlle. Ind-oi, tho in‘cr- institutionul ditturonotl rat. to grant ‘hat 3 pttiont in th- oldut go pup nu It" 11h): up In lac-punts“ :cr tvlov. tenths cw not. at KPH ‘htl war. pntioats in tho yonncont as. graup at HXKO. Within ill‘iilt10nl..‘IO nudmodnoatton As xv: and an �-12u honpttnltnatiaa ~- youaxnr lid 10!: oducatod putt-at! rinutntng for tho lingolt period worn roln‘od to lunght of Q-.-“-O-QC“-- .O-”--. rabzo V1 abuut her. -U.---'...--’--Q-ﬁ--.~ a) Diuoharlc Evaluation: In cash helpitnl, ants patiouta are ovnluatnd ut th. time o: disaharto :& "taprovcd" (Tabl. VII). 9: pattnntl worn a IIQEI. p¢t1¢nt who call-d At KPH, hoV¢vnr, u high-r porountaun (19$) rntud a: ”unimprovcd” and «317 ”gooovorad" or ”much improvad”. Tho hiahu:£ purncntago or ”roeovorod" or ”such 13336706" r;:1nsa (28$) :ud tha lowcat NHEC. (10%) "unimprvved” {tuna a: ct war. proportian Analya¢a within «ash institution Chalid Ttriiblﬂ roanltc. At an tad H336 thorn was t tondonay far 9140: puticuta to ho ratcd hatter than youaanr onus, but uh. results arc ut:ttlt1¢33. Aﬁ H33 thorn wan II OppOlt$O anly at aixnirieant all? trund, with older pationta nor. ltkoly to ho rctcd nutupruvod; but this 616 net aahiove ntatiuticaI signiftclnao. -ﬂ‘----‘-ﬁ-“ﬂﬂﬂ’.9351: VII -O.--’.-‘-.ﬁ-¢--. d) Diauneais: Fer neltiutiaal annlyulu thrco diltnﬁi‘lt groupfingc were mudo: achisophrouit, tffottivo aiaordcru. disardora (Tublt VIII). Th. alcgnontie propertians «or. similar for tho an tad Hana und puychoneurcsin anﬁ pnr¢¢aa11ty �.13. purulntaonu, but it. It! patluuta wort tiﬂlrdol s. h:v1:¢ tow-r atttattvo ate oohasophrcnto 1100:4013 and n.13rxcr author a: plyohcnonrotic or port's-11:; disordatl. Intrainatitutianal nnulylis abound that at RH both as. tad F 000:. not. rclatcd to ditcntats; &% HER use alone at thu nociul factorx uni ralstad to diaguoais; while at EMHG hﬁﬁﬁ 0f ﬁle social varigbloa were so related. 0f ha payohzattiu variables, diagnoatl wan significantly rulnhad at Ollh hospital to solootion or tdnatnant aha auratian of and(§ging:iélta diucharge ev‘luttien. haspitalinttioag "'----’“-”-ﬂ”. u-~u~q~a25310 VIII about barn u---~-‘n---—-h-~n”ca—umu—Mﬂn �~1hDISCUSSION In this comparison of throo voluntary psychiatric hospitals as havo obsorvod significant intorinstitntional dirtoroncos of pationts in tho social varioblos of yoars o: oducaticn and social class, but not ago; in distribution or California F Scalo scoros; and in oach of tho troatnont variablos -- duration of hospitalisation, soloction of troatnonts and distribution of diagncsos and dischargo ovaluatinns. pTho littoroncos in troatnont variablos botwoon tho institutions nay rosnlt from many factors, including tho social aspocts highlighted in our initial studios. To ,.__ Ar 7-“, dotino tho rols of social factors noro cloarly, no nndortook tho intra-institttional comparisons. Fron thoso analysos, tho lack of oonsistont rolationships londs doubt as to tho rclo o: pationt social factors as principal dotorninants in troatnont within thsso sottinss. It was anticipatod that within oach institution, pationts or highor social class, lowor F sccro and hottor oducaticn, would ho trootod proton-4 ontially by psychothorapy, classitiod as nourotic, romain for shortor poriods and roscivo bottor disshargo ratings. Within tho institution, an irro ular association botwoon tho (Tablo:;§;). variablos was obsorvod Within ono institution, tho HHHC, ncns of tho social variablos woro rolatod to any ...-- v troatnont variablo; nor was social class statistically ro~ latod to any troatnont variablo at sithor KB or MFR. Of a �-15- ’51, > possible h8 relationships between social and treatment variables, eleven are statistically significant. The differences in the HE and NPR data nay be at reflection of their popnlaltion differences: the relation of age to discharge evaluation, and Fiscore to diagnosis at hH reflectingthe higher proportion of depressive illnesses; while the relation of age to treatment selection at MIR reflecting their higher proportion of young persons classified psychoneurosis and character disorder. The similarities, in HR and HFH uata may reflect similar treatment philosophies, which are different from that at MHHC. Conditions of elective treatment and elective duration of hospitalisation exist at HE and MPH, and it may be this flexibility that pernits the interaction of the social variables. it HHHC, however, the limited stay and need for rapid treatment results in a failure to denonstrate an interaction of social variables with the treatment processes. Similarly, the relation of social class variables to treatnent variables in the Hollingshead and Rellioh studies may reflect their data selection, which was over the broad range of all community facilities and all treatment periods. Within institutions, however, these social factors appear less determining of treatment rariahles, seemingly overpowered by intramural edninistrative or financial necessities. In the earlier Hillside Hospital studies ( ) the relation of �.16. svoru, an: cducataul tn tin ‘routnnu‘ Vtrtttloc in t valuation a: ﬁt. brand adntala‘ruﬁtvo latitudes tvntlnhlo £011.04 broadly ltoutnon‘o not. tans. tn plttcnt 0.20 t‘ that with nonattu, natto‘ cad puythoﬁlnrupuut1n Ind-I aquaixy i'ISXIUIGo Duro§aou at hingt‘ultsattou was tread}: tuttnod gs up ‘u 1 1I¢r, If longs: at rotunl$nd. hints-1's p.131: tun .1 and udnislttu and bath IOIIk$ par-titan (Icntblo II. dtnordorn. at var'hlasrto vtth runs. '1‘. I pattian f01§$$OI~ socxnlutronincn£ (out: In titan In: prtnott I‘l‘! constructxon a 1951 rotlac£1nl parity. Itndr. aha»: its: than tvusluhtlitr a: urinal-at ch¢1¢¢l. in pavulnttun and a intturu cu‘auliou at d§ru610| at hocrtttitlutxol. this with nan :dn:nlttracultauporaacauslr tuttxiutcd : prion-I. itﬁt clout: marina a Itntlnraty 070.11.: at tics. is nio-zlr adutaautruﬁivo daucasaioua as Buck III! Iodci. 8!! It. tn. it. dinuolutltn at or Itﬁcrnxnnnta thoracic. tr yrtnzcvll 0061.1 Vilil‘ltig ca titttri 1: tin trolmnont prcacal. A loalnd tlpoot c: that. Ituiica 3:3 tin nathodcloctonl prdﬁloun In dottnln; tun traits-at vurtﬁbioa. Thai. tact:ﬁuﬁaous var. Iclootoa it! ‘hoir causatisngl ltuanrahty and ‘ho capacﬁa‘ton that tbs rooardul variable! wouId ho altar}: dofiutd. OI: dirttauiticc in Ittlvtts as Odlibrtilirdtil $h¢ cauvcatlosal'uno a: anon at ‘0 sh. gratin: .r. tap-rtaut cuuparntagu o‘ttintlnu. alpuntuIXI 1: ﬁt. ovuluu£1oa a: purch3n%rlc thornpxnu. it: truancnt II. It diachnzao ratings. .3 ago. D �-17ae or criteria hoapiteliaation length diaguoetio cleaner/or of therapeutic valnee or oouparability or aubjeeta and populationa are subject to oxeeeoive error unless the inatitutione The paredoxipa+torna. adninietrativo notched for are clearly '7 be to ie oal nature of a failure to aooouht aeon in a literal interpretation of the observation or this HFH conducting boo personnel The highly the traini loot etudy. treatment which ie applied for individually defined,eptina1 periods or tine; in populatione with the least proportion diagnoeod in an unfavorable prognoa io group (aohiaophronia) ie roenlte treatment and the proportion yet, -o5\£avorabla the poorest. At HMKG, in contrast, where the laaet trained therapioot apply trootnente for an adniniotrativaly limited period, to a population with a higher proportion diagnosed eohioophrenia, the proportion of favorable discharge ratings in eignifioantly greater! It is probable that thoaa observationo do not reflect tho therapeutic ottioaoy or theoo inotitutiona, but indieataﬂi dittoronoee in criteria of improve- for@ Iont. Thie laok of clarity in diagnostic aohomata and incom- lendo a1ae variables treatnont e: payohiatrio peribility pauae to the attempted comparative etudioa of psychiatric t ranioe. For example, tho raeh of roeont failure: 0! made confirm other in to aoientiate ‘/h(c£jﬁau!§iolozioal obaorvettfno laboratories may be as each a reflection of dittoronooa in �-18.. fallooioo in tho on such torus of The use widospzood hypothoaoo. original “oohioophronio” or "poyohononrooio" to oxploro tho chongoo in poyohologiool or biological rooturos with nontol illnooo hos lod to o ooionoo burdonod by negotivo rooulta (Bollok), noat marked roosntly in the conflicting studios of o serum factor in schizophronio, and tho inconporobility of the tho nooholyl in soon oorrolotions hohovioral physiological -(Funkonstoin) and sodation throohold tasks. Even were a havo' do wo from ono be clinic, roportod valid oblorvotion to nothodo available to doooribo populations odoquately to ooncludo Ho and holiovo sound confirmation? not, a provide from thaso obaorvotiona that increased ottontion nuot ho paid to hho nothodologiool problono of olooolfying aubjooto mothodo tho than presont rathor "ohjootlvo" by criteria, which oppoor to bo so highly dopondont on institutional and ohoorvor ottitndoo, and tho oooiopayohologiool oopooto of tho therapist-pationt intoraotion. populations, poyohiotrio oritorio, 323. Uﬁﬁ})*l 1" t no �”ﬂu“ Wing mun. nupwum: 1V. Beneﬁt.» Mun“. rmuw AnzacQV mm“ 3. magnum: Puumu‘y rum-nut. running mu h. l'mmuty mus-u: nub-1m em. f 8001me Imus)... Formula” S. 6. I'm“. Farm “mun in tau-nu rwmuw Batu” nun-pm. Baum-ulna" W - 1’me “than” Winn rumba“ Pmbmuw annual-n1. Ply-haul �z§gLs g; W W Ithovod Inst Inprovud Untnvrnvud coupluia nonalciao Ihwruvud Btuhtngad (or aura.) �am 1 M9 m. m “mu on mm ' i ‘ h). sa 5 want“ In".. cm W 33 3: mm“ an m �am um: 0) U) a g a: g . H auton,ann . .m.m So. E? So. 0&5» an a llllll'llglllllllll in CO E3 nonansao>m a“. o H‘ad .m.m Mina-«n can» an m “no no. 3E Hand pm a . an n 8. —:o«a~uwnu¢«.uom and. guaoﬂanncm .8. we ncvd.lomcuhnaH nodunuvm «uncanny . am «a So.“ ma mo. «nonvooua M. no. mm . nauaeadcm 3. mu . . «6 nuddo “;o«anu«n¢aumuom mouoauﬁahm aoaaanuun Queen n«uo:uu«n ouudaunun newcauun “Canon a: h �m1 . u“ m �‘ * M1” .4 m H m . a: It 3? , 67 Innsh OM: $.00), ' 13 $5 a ’1 an s �ms X"2’a3i ‘ as «mush: mum. u a: 10 �Inattﬁuttau I schlnophr-ntt rayuhtuanrosiu it}; m n me ‘ 171 - as x'-8)~3h1 ﬁrth; p¢.60m. Pursuant: and 8 .1. .. 1* _ 5’ 5’ 53 35 51; V art-1‘11. .99 s > 22 1‘ �ms]: Mutts-ant awn-«um: human on stun m" haunt 01' lap-11.13““!!9mm . ant-cum - " - W1- mum xumm at man mm "ﬁnalising " .. ~ 1 8m mud» " . n: - W 5.10.“..- uts-«mug W ti m. n- w m u m E ‘0' M 0" '3' m a a a 00 IWmﬁ tar man a... a 94. .05 H vs: .01 �IAﬂLE G0 vnasxox 0! 333313033 BISCRARGﬂ BIAGEEﬂES 1- n¢prota1v¢ raaatinn ﬂarciiatatic Portannlity 2. Anxioﬁy Rotation 6. I IﬁCﬁARGE E AﬂBBSEB GEIIRSL CL‘ﬁﬁIFICAT . ?nyohanaaraa15 narcissistic Forv¢aa11ty Plyahounurccﬁw Hareienistzc rattannlity Faruuaultty fruit Diuﬁurbcuc. Strainalutia rtrlantlity Alcahaltsn 0hrnu1¢ Infantile Pattonalihr; Sﬂﬂiﬁﬁn$h1¢ Paaaiva Aggrnaaivc Parsonllity Aleeholian ﬂociopnzh1¢ Parawnnlity . Infantila Pernanality schisephrenio ﬁnaniion s¢h$ao~1££¢ut1vo typo Parsannlity Disturhiuua Diuturbanca schizophrenia Payabalin �IABLE ‘Gnﬂraattlvz 8311308 0? OLIRIGAL ﬁDRBITIﬁﬂ oa- Rauniugor 39¢IAL ADJEEIEEYT 7 it QIKB 3 3a Killeida ﬁﬂﬁﬁ Raaavnrﬁé atauvartd Inprnvad narxodly Inpravud Improvwﬁ Rumh ﬁninpravwﬁ Imyruvnd nodnrntuly Inpruvul ﬂainprovod slightly Inpretnﬂ ‘~ stancruax Imarnvad Uniaproved agggaena. ¢auwlnﬁn Rtmianinu :upmuvsa ﬂuthuaaud (yr werua) Uninprovid �Iutnrinatitutiuuul ntfturauea in Solaatiuu at Iggltmnng . - .wt_ _m1e . w. m 21 h: :5 I! 33 6h 6 mm as 53 a x2 «52.3 a: ”guru 9 .1, �taggg Inﬁorinstatution’l Ditrcrnneil (5 o! 1n itiliilti Duratiuu of not thjuatu) month: in gougital natitutian x? 7*11 1? 0 aka 22 13 65 ”K 27 h? 31 unac 6? 2? 5 :90.6 a: -k n �taggg Intarinatttutional Birrnrcnuau in Dinahargu Ditgnaoin Dingnaatte ﬁatcgarius (Par agnt) Iantitutlou ﬂ at; me :3 '23.8h a: sh ﬁ { t 001 Payahoncnroaia aha Purtunuiity Disardvr Atrsuttru b3 52 s 952 ‘ an schitophronis 171: 85 V ‘ 52 as 22 Sh 29 16 �ﬁtgﬁﬁ Inttrinotiﬁntiennl Ditruranuts X 1n niachar a Evaluattan niacharga Evaluatiau {?ar cunt) Institution W RIB ﬁﬂﬂﬁ x2 «29.3 df 'h p,§.001 linororeé, Inpravgd Buinpruvod 1 80 19 :3 62 15 nnd Each 1 srgvod �. I. . ,2 ' ‘1‘ ’ , . ' ‘ .. ' ‘ ‘ v I 6) z 'u m 1&1 tum-au< 2" ‘ �WW“ m m, rum. tuna, m my» my. Int-m 1.. mm, mm», “I 3.9. mmwwww maxim, “My m, hM;WMﬂ~mdﬁ-meam mammals-nun; m, mmmmmmam. lulu .10 mwammamwmmam ume.r.wmwmumw am.» am Palm mm, W ‘w W T 01’ n.’ : 4‘bv at 1.2. �MWWMuM“WMW¢(Mm mmmﬂ)mmmnmmmm nmmammmmmmmm, wmaummnmmmmumm umw,mwwmnummm “Mama-mm“). ummmam mnmwxmwm wthatwm‘w Wmmwwmmu ammmum. hmmmmmwortm mummmwwmumwuw. hmmswdmnnmmmmzmmm* «.me mwmm mu �“w- 'ml‘tvﬂivamu «mtmummmtmwm mawwm‘mmmmm I. “mummumummum. mmwuumummwmmu umumwmummmm,w' ¢J.rwmmmwm.u'mmm mummmnummmmm mmW-umummmammcm nmwmummmmum mm smwummmwmmm. mu. mmmuunwmmmumw mmmwwm m,mmmmmumwn~mm .am‘m. ”mmmammm “.mummm mmummmmuammumm, m,mm3m,mummmwmruuu ’ummmuwaw,mamm mtmmmum-m. mama-rum �mmmmmummmmm (an ummmmmmamm. mamm,mwmmmmm. mm~Wmemmalm,mu ::*:W~*”M1m*~” “WW MWWW:WWW,W3W «mmm‘umwm madam-Worm ,I. W W,um.mmummmm �mam-.nmmmmmumm. wmmmumuwum, t.) W ;_ :' 'm ”A a m “1% M W mmwummt ammmmmmum . . «mumu‘m mum-«mm maﬁa-Wum‘ mmmumm mm,mmmmmmumm «WWWWMxm-uuwmm Wuamuwmmmm, maummmmumutm mmmummmwmm'mu ‘ E§~ �lvmmm.—v m- n. 5) mm mmmmmmmmmm ummmmwmm mmmmmmmmmmw. meta-am. mmammwmmumuvm ww_mmwmwutnam mmmﬂm. MWWummm «um. nun-mm mm'mumowmnmum. uwmnmmmmuumuwlmmm. mummuaamw. mamumum mummammlmmmwumammmmt ummmmwamdmmwmmmmm mmmwmrmmmmm «mmmummrmmm. (1mm. WI! mmammamm,m,m �, mwrm—W“ W" mmrsuummmmmumum gammy. W: Mm‘mﬂﬂmuthmiu maximammmmm. mwmmm I») Wm'mumam;nmunmm Mgumwummum,mwm. a: mumummummmuw s) m: m,uummnwmmmmmormm mum-m umammmum ummmnmmmwww,maﬂmm mmmmmuW-mmm a) ' nummammnwmmm.(ma: (1)9393 . ”gm: awdmnmumm mma‘mWIMMW. mini-muse: mmmr'mwnatwmprmuu masoummmmrmcnummmnmm‘ “tn-“aw hm,anpx-mtd wmmmrmwwmnmm-Mmum mm”! m,m>mwmmmmmuenu mmumm,uwnu¢mmmmmum 1 mummmmmrm. WWW“ 'msmmmwummormmm �mwmmwmumm mammal WQMMiWMWM“ wmmmmmmmmum m, ma—mwwmmnmmmmm‘ mummmuu‘mmmmwu mmmm,mwmm. mmmwmm,mmwm“ mummm-Wmm,mmnmmw ummgmmmaomwwm. 'ummumuw, mm,murm mwmuwmm(mwm rmmwwmﬁmmmxrm «mummnw,uapnwmp WWW hummus.anme Wit:Mwumwmmmamum MM? Mawuﬁamﬁ #mée twat HS? MMWWWQ WWQM Wﬁﬂﬂﬂ 9W“. �MI ‘ . o‘lo'u mammmmummammm vamwmu-Wnamhuwum WW,‘WM1§WIIW{WUMMW www.mm-ammmmmmwm;m. W? m mummammmm mummmmmmmmmmm mum y‘ ammmmmummmmsm. mm mwmmmmmm,mmwmmuw mmmmewmuw,ummm �WW # mustmwmumunutmormnw. mmnzaurwmuumumummuua, “snowman-Man. mmmumnmutum Wqummxmot-ounmuumuuu o: than 'wmm.m Willi-Ind mam, um mum m toners, It mthmnhtmumutmlmttmm M m,mmmmamxuutmuhrzmmu the of exam mid. new swam M, mm mswhmnmmwmsm'smm,emm, mmm‘m,um,m.,mwwmmu,mm tnmwmmmumumummmo: ﬂu mam mm tom of W new new. th; 13 .mwumanmummmumrmmth-thum‘mmmmmmm “Wummmmnmmmuuutm mew,mmmmmwwmmu unmummmmwmmmtua wuawmumuummmmmmmw If utmmm-mumnmmutwmmmr. mwmmuummmummmm mam,mmmmwmtma mm. WQMtMW,h-mttmmmmmm �gm. anmuquw. Mmumwntmmmwm nm,umm,mnmmmﬁmmuum. um,uuuu MMWMtwnmmm,dmahusm deMW‘Iﬁ-Wamum m,mmmmm~mm«m mnmummtm Mmmumu mmmmmnnmmmmmm,n mmnw.m¢mmmmumm. hwmw tin-mmmmmmmmmuwm gamma mmmwmmm mmmumwa mummw mmm,uuwmmtmmummm ma “stumwmmm'wammnmmw ammuuxmmaw'm‘ammmmw WWMH‘WW,‘WWWWK �”V 1 “.17.. —-m_ — mmmmummmmum- -Wamwwmmm gunman -w—rv-v-rvv a. 7—WWVVWWW_W—.__. ummnmmmm ”.mumww,‘ mmwwwwuwmm 7m "— WWW—v N . 0w _ “A .W ..,_,.mw_.—....,.r,.,.- ww-v. ”u'mm*w “Mwumw (M‘m‘ m W‘i ”thawum W mmmnmmwm,mwwmmm mmamnmmmammm mmmmmmummmw «mnwammmm,m~wmm awmmm,m,mmum “at mmm,mmmmmumm J t; " �",wwww w .7"- wry—«W... ..”___,__, » «- .w‘ 3...; Amwmmmnmmwm, umamwmmmmnmm www‘wvwa WW «p—w‘wmmvw—WW mmammm,mmmum WWW-w ”.7“ ~ .— WW. �TABLE I - Redesignation of Discharge Diagnoses r . .m. ._...- in... Menninger Discharge Diagnoses 1. Depressive reaction Narcissistic Personality General Classification Psychoneurosis & reaction Narcissistic Personality Psychoneurosis Narcissistic Personality Personality Trait 2. Anxiety Narcissistic Personality Alcoholism Chronic Infantile Personality Passive Aggressive Personality Alcoholism Disturbance ' Sociopathic Personality Disturbance Sociopathic Personality Disturbance Infantile Personality Schizophrenic Reaction Schizo-Affectige Type ~ " Schizophrenic Psychosis *4 . r ., . ' ~ �TABLE II Comparative Ratings of Clinical Condition At Time of Hospital Discharge MENNINGER HOSPITAL HILLSIDE HOSPITAL ' Social Ad ustment Recovered ‘1’ MASSACHUSETTS MENTAL HEALTH CENTER Recovered Improved Much Unimproved Improved Moderately Improved Unimproved Slightly Improved Character Structure ﬁproved Markedly Improved Improved Unimproved Unimproved Szgdrome' Complete Remission Improved Unchanged (or worse) �TABLE III InterhosEital Comparisons for Sociogsychological Variables Hillside Massachusetts Menninger Hospital Mental Health Hospital Center 7% 20 Social ’=121.S df=8 p<. 001 3h Class 3b 5 1970 : . ‘ _ - Age 58 _ _ S2 Y3=3o 9 dfuh p- n.s. 12—15X2'9 <12 Years of Education 16 ” 32% df-h + p<. 51% F 7 OS X"3 2 df-h9 ‘ WWW Score hl SO p<. 001 8 -‘ - --‘” ~ ~ -~ .. x “hm-ave - x-r' row-'t-t'r. «ma-Iv: «cr-r\+:w.-:.wv-'--vvwz- ~‘rwrwg ,..\IQ‘W~("" w my 3‘"5‘WM»WMP �TABLE IV Intel-hospital Differences in Treatment Variables Heminger Hospital Psychotherapy Treatment Duration of Hospitalization Sanatic -(-19— 21% Hillside Hospital -ﬂl)- Husachnsetts Mental Health Center —(-D 36% h3 6h 36 -- 7-11 months 27 11 months Discharge Evaluatim Improved Improved 80 62 Unimproved 19 15 Affective Psychosis Diagnosis 28% Psycheneurosis and Personality Disorder 61 10 �:5” HOSPITAL STAY K ONE YEAR ;P.sTA¥ING,OVER ‘Pﬁ 8‘1 . 20329 I ~ 6 36' “ ‘ M M - 73 A_ w Hillside Menhinger -‘ . , '61 in I ' BY AGE j :‘35 ~7f 6 I I ‘ 3,0 2.5,; - . 2’0 , 0 . . , 0 0 �7142b, ’- ”‘7‘; aceiopsyuhelogieal 13:11:00 of Pnyuhintric Trontnoat in fire. Voluntary loupttuls Robert L. Iain, P&.D.ﬁ, in: Pollack, Ph.D. lathauxol stag-1, Ph.D. and an: Pink, 3.5. tho Bcpartlont of InpurtHOItal fuybhtntry, lillutdn fro. 61¢: Oaks. L.I., 3.1. loapttnl, Atdud, in parﬁ. by 29.3% lt-IOOI or the latiounl InItStn‘c’ of labial It‘l‘h. 8.8. ,ublic Inllth aorticag and tho Iguasu County Keats: Bealth Beard. the cacpcrntion of tho stuff. a: the nan-nonalctta mantel Italth Ccntar and the C.?. Hanninacr Nauorial ﬂospital 13 grutctully nokaculodcod. irresant Address: Rivision of Paynhiatry, Haatofioro Hoapital. l.!. 67, l.!. 7!!!! h/62 �In pruvioua coat-payohologionl s‘udioa or leapitcl papulntion a. obncrvcd educatiou,plutu of birth aenlu rut. Iignitiountly 01 galact1on and th‘t scar. ﬁt. 3:11.1do tuck a-pccta an :30, on the calitoruiu I Pointed ‘0 tbs trcntncut variation or trontumut. «11:10.1 disuse-1.. dura‘iou o: hacpitaliuatton gut treatment cytltation. It was ltggoutad at thut tins that tho can. influenco or noelal variation on the treat-cut process Inuit b. observed upon: institutions. to tact this auggontion a: wall as to roylieuto the stud: within inntitutiona, tho prusont study of three hoapitell val undattakta. In a. their study or ﬂu Baron panhin‘ric mutant populsticu. Holliaguhoad and Budlizh rapertud alanifiiaat rtlntlonthlyu button» smut” an individual'a vanities 1n thu 0001.1 pmduu tented 111”". two: at amend uurdcra a: nu- ma «nu-n or pay-untu- duo troatnont cdnintutarod economic status or and tho ( upon tho ). fl. influoaeo o: patton‘ availability or trcnt1ag peruouuol �.-9. van nut ﬁxalndod in this. :tudlua. 1b tact the :01. of coats: factors in tho triatunnt.or hoapttaltaod patients inﬂaptnddnt or puticnt'l tibiae-a 3nd dvcalnbillty of trnatacnta, I patiout burv.y In: undortakcn It lillolda 1§§7. in Ia thza‘hcapita\. a variaty’ct ﬁrockuuut Ibmyiﬁtl ptychoéhnrnpy and organic Ind-n, including individual thorupiua are attllahlo to all pattints rlgardlosu or tags: abilzhy ﬁe pay. In in. tillaido study. Ian. canonﬁton and 31-00 at birth cur. utgnttlnuaﬁly nouontatcd ut‘h chain. of trudaaont, duration at honpatglicntaan. alsuxeul diachnrxo aval‘ntiou Ind diagnonlt ( ). It Ill ohncvvod that patiuntn hounltnliuod for th- Ihortnus plrild aura the oldest, had tn. loant cane.» tic: :36 «are taut liktly to bats hut: foreign hnvu. The: wit. prudoulnnntly £rc-ﬁnd by ouuvulutvo ‘horipy and rocuivnd it. not. fuvauahla diachnrsn ratinga. Ibnngur. unttv. horn and not. sdnaatcd paticnza.uuro hospitalinod ﬁho lenzuce. puyahoﬁhcrnéy and goaorallr roaotvod trantnd prilntlly ﬁr it: 90020! dischargo rattaga. it. 011310.: (Inter: 0‘3. 51:0 rtluted ta n I.nauru of starcatrpy, tn. culttornia r 80.1. ( ). lxahar I canton Int. tor. o:%ca tound an pu$1onts diagnccod an invalullannl pagthcutn, ruturrua far nonntto shorapy. and hasvttaltaad :91 unartor parted, and nor- Qtttu Uﬂfi vitae as much Anymovod or roger-rod. it in. 6.01301 to tupont tin 195? .111016. study uuployiug tha nan. procaaursu nnd nongurrtntly ta axteué who obstrvutaona I _ . �.3lnatitnttenu vtth roopact to social alsas. 33o. oduottioa and I to tho scorn. ﬁnd to relate than. pats-at charactorlttica trtct-ont variahlqs of type if troutsont. duration at hospitalisation, diagnosis A and Ginsburg. evaluation. m enact: a! :11 voluntary. .dult patient. in roatdoaco in than. tuititattona was nadortakou in January 1959. ﬂh$10 lcln1n¢¢r and Hillatdo Hospitals hnd ‘luatary pationta aalr. t 3:311 avatar at tho-e at Danton were anntguod by tho tor psychiatric avalnntton, or war. nc-bcta at aohisophroaxe stat. hounttql group tralalorrod 3 can’t- annual. ter a optoitia ruloarch product. Thane pationta war. cxoludad from the study banana. at tacit non-vuluntcry ntntun. Inch pnttent III :17.» th- cglitoraiu ligation tutti: lctar r 39.1. ( ) on the OOBIII any. the rooordo or dilohnrgod patient- voro untlyucd to dotorninu tho c.0131 and psychiatric factor- ar the otudy. For a mutant. of $03111 glass, the ﬁclliucahoud �.‘5- 2-tuetor ind-x was 3.06 t of 173 putllatn at ). Thu 81113140. zoo study population consisted at lbaalncor and 95 at ti. rnlationu or Untouchuootta Haltnl ﬂcalth cantor (nuns). Tho study inelndcd «lamination a: in. social to th- paychlutrtu wart-hlcu within each institution, 2h... as wall as butunua inaﬁltatlons. difficult, hcunvor, boon-no fora-con discunncd below. comparisons were at variouqnnthodologlenl d1:- 9h... difficulttca var. nosQ Infkﬂd 1n the iatrnhaupitnl anupnrasean, and accordingly, in tin unnlynou a: p-yuhlntpta varinhloc emphasis will be lantttutiana, with citation plannd on tho daft-ronaus §atvoen or lb. intra-tnotltutiannl tronde. Whoa tho otruotnru rcportlnc studs-u fro! a lone institution, at tho houpltul 1- %ahoa tar grunt-d. and 01th:: ignored or Icnttunud briefly. Houwvur, in studying a atranco �a. institutien I“. “at will. I. and author t6 :ttcuptias canaarablo ant: ya. in of tho my allot-«cu but.” “autumn. tclcotod than. tuttituttont an eolpurablo in ‘bnchlag, rtaoarch, and troatunut pryxruuu, we tinc that tho: are unalika atrnct‘rolly in v.11 think influanca tn. data at the study. specific prohlona were notcd 1n dastgnatioul or type a: trnstu-nt, diaguont1a turns and avuluatiau or trontnnnt outcono. a) 90:1 ation a! a at cntlant: Th- critorin for danagatting that a paticut raceiv'd 'pcychotharupy' dirt-90¢ along an natiwtulu, Idling “Remus: «uniﬁcation aux-nun. At ﬂoaningcr Hospital puyuhothurtpy use designated a trogtnaat qdninictcrod an a pro-criytiou ball: by a stat! pcyvhiaﬁriat, for which th- pattont via chtrgud a too. ﬁenatone with tho ptynhintrta rnnidunt were considered or routine unaiaiutrattva pationt aura. part .0 �.j. it Hillside lsspiisl psyshsthsrspy was astinsd ss viih tho psychistrio rssidsnt. star! trsstasut ssssioas psychiatrisss.¢id not trssii patisuts, but rsstristsd thsir activities to supervising tbs residsnt physicians. it was ths Massachusetts xsntsl ﬁsslth csntsr payohothsrspy assignstsd ss s functiea or many disoiplinss -- psyuhu istris rssidsnts, psychologists. socisi worksrs. nurses sad msdiasi studsats. Portal records a: sash ssssions wars nos routinely insiuded in the patisnﬁ's rscorﬁ and to ssesrisin which pstisnts rseoivsd psychotherapy. it was nocsssnrr for this study toss to intorviss tbs reaidsuis in churns washers of o: ssch cssa. b) n ' asis: individual institutionsl disguostic stylus slso Isds soupsrissns difficult. it lbsnisgsr lsspitsl disgussss supisysd ths sultipis svslustss ﬁsts caucus asses-sadsd by ths Aussiosn Psychisiric Association hsih Hillsids sad asstsu sun-piss sails toil-Ila usicsry systsss. assorsl st discussss tron lsssiussr sss listsd in 2:51. I, �-3with our ausgaatad aonvarazana into catacortaa nonparabla to that of tha nth-r tan inatttationa. Thaaa convaratona at. an unavoidahla aaaraa of distortion. (statlar abaarva- taona hava baan rapartad by Paaaaaatak and hia aaaocxataa ( ) who indicata that diagnoaaa within tho aaaa inatitatiaa ara alao valnarabla to individual dixtaraacaa anon: ataxiaara). Tabla I ﬁ---“3) ntgoggg‘a gating; of Igggovaaaatn gravalant varied 1n Iattnga a: 1n— foraat and datatl. rho diauharga rating at nanninaar loapxtal aaa tripartite with a aaparata avaluattaa for social aharaatarolaalaal and ayndraaa ahanaaa. I111a1da > Raapttal and ﬂaaaaahnaatta aantal Iaalth cantor had aloha: ntiuga I! in at aaeh which it "a difficult to aaaaaa the ontﬁbatton taetcr of tha Haaaiaxar ayutaa (Tabla II). for this atudy tho Iaaningar ayudraua rating aaa couparad to tha global ratinaa of tha athar iaatltattana. �.9. fibl. I! 2. aootgzgzggologiog; Vagiablaa Ina diatrtbattan at the variation of aooial 01a... aga, adacattoa and calttornia institution: in praaautad 1n r saala scar: along tha taro. tabla III. a) ﬁgg§.;_g;§ggn tiara uaa a Iarkad dittaranaa in tho aaaial clans coup-attic: at tho thraa inatttattona. Nautilus: loapttal tha reputation was At pradantnantly app-r class; at Hillatda laapttal Itddla alas-3 and at laaaaahuaatta lantal Baalth cantar, pvadaainantly 101a: alaaa. h) 553: that. war. as airfaronaaa in ago «attribu- patulattaao. tion in tho institutional a) Eduggtions rho populatzoaa dxttarad 1: tanta- ttaaal attatnlaat, 11th pattaata at naauiagar leapital having not. yaara at educattou than than. at Baa-annuaatta lautal laalth Cantat. 33110 kl ya: want at tho pattanta at also �-19- ha: aat couplutad high ottool, only and 23 per cent 32 par cont at Hillsidt nt loaningur did not graduate. Bittﬂrcnccs é) {nggggy in ‘3. distributtcu or can on tho annoy-nu I 80.1.. mo obs-nu. titty-cu V 9.: can: or lbnnancor puttautn had only night par cont I In coor¢n below 30, gnu scorn. of 50 or show. ~- thn higher accrue 5.13: associated with highor dcgruos or stereotypy. eaatraat, gt I Inuit, At '1‘! I Boston trout: 9.! coat unto hula: and forty-two par 3.9% had scores Hillside thirtybonc paw at 30 on tho 50 or nor¢. south! the vationta had I uaorol bolaw 30 sad otzhtatn por goat ubOVt 50. In nun-cry, .09131 class ' its a: the ptpllatiun val oblorvcd :3 uncut arr-nun on anticipatod dittorouetu in prudaninalt ﬁt. r 30:10. 2h. 1a ago mutual dtutrlhatioa d1£rtrcnoon thus par-1t tho the institationa. hum-cat «14 not I011 on cigo an: mum“ 11:20:. Then. stair a: troutncut variables along �sum Wm ﬁeduaigﬂgtion a; D§ge§gggg gag‘noggs M" an mmm nuproncivo reaction I. ﬂnrczsaiatic Foraonality Payehanuaroniu 8. Anxiety reaction larezsalatto Personality 3. lavas-oistto Personality #- latoisoaltac Puruonaltty tlaoholiuu Chronic Infantilo Portolnlity S. Fusttvc Asgruacivc ’oroonality Alaaholxaa 6. Infantila Personality Sohiuophrunsc Ioaotaun antitanltfucttg. typo Psynhalturoais ' Poruouulity fruit niatnrhanco sociopathic Paraanality niuﬁlrbunoo Seatapnthio Pirwnxrllﬁy ﬁiaturbanao achisnphrauic Flywheels �aggzggattvo ﬁgttugg gt glgngog; geudition IIIIIHGII BOSPIZIL 33218132 HOSPITAL ﬁllﬂlﬁﬂﬂalfiﬂ gg‘bfﬁ CENTRE locovurnd loaovorod Each lproved Eark¢d1y Improved Ingrovod Hadnratoly Inprovod Unznprevod slightly Inprovcd Enimproved 60I§10to admission Ilprlvud Fuehnnged {or were.) HEHYIL �ammonia). muggy»souguzcholoﬁut 1'3; Yuan“ Hanna. ’nuluhmutn Ear-pun luau). Rum: liming" 30-pin). Gum 31$ 75 3% ' Saul c1». . Au 51 20 as 1? 35 13 1 3h 28 0 S 28 19$ 19! se 59 22 , p-n.l. 23 at Ian “mutton 33-9.? - ' 5.0!. W005 X..3909 did: 9‘ a 001 �m m. _ . i typo of '1'th Psychotherapy W mum t £10,111th manhunt:- mmani 215 Sal-nu 1:3 mm» 36 H1111“. Baum. ’ ; my. mm 36% 21a: 63; 68 - . B �.113. 7:23;;gt510 frogtysnt Vagiuhlog a) Soloetton or front-onto than: tultltucionn, taunt yattoutn 3‘ Ian-13:0: uoapttal rucctvcd sciatic thornpr than n$ ﬂail-14. or "Ric, (fable 2'). caucnrron£1y a cnnllur parenting. or the nuaatuucr patttnia vita 013.004 to rocctvlng payche‘horupyp with a 132:. author (36 Iilica tor-- of treats-at. was an £111.14. lotpttnl - that. spacial doutcuataon tor Itliou therapies sud pationtn are 01:13:21.6 :- rocolvtuc payoho‘hcrapy Iont also. Iaﬁh pattbnt psychiatrist for at nook. 1% pit cant) rteotving :- 10.1% II n priusry trout- tohcdnlod to so. u valid-mt tar... ouoohalt hour session: per 2h; pcrooaﬁacc 0: pa‘tou‘o rocotvtnu lunatic thorupy, at louatuscr natpltnl (3h!) 1. Isgntttcan‘ly 1-3: than n‘ ot‘hor at tho 0th.! in. houpttalu. lﬁbﬂt patient. ulnacad II cahtxophrcntn. thnr. was no atrrurunoo along houpltalo. for 10.30; a: such pationt' at each hospital recoivod notatio for.» of troatnont during �-13. It. hpnplltllsnﬁlon. 1: hated on $ho thé altroroaogu anon: laltlﬁutloua dittorlng attitude. lounrdo gallant; oloacltlod a. puyohonourotlo, bahavlor diaordor sad dcprocnlvn payohoaln. its turn. llotltutlonl b)‘a3glgggg_g‘_lglg;§.;§g§§§ggs «11:09.4 with racy-ct lo pullout'n lcnuth 0: its: (2331. IV). loaning-r Hospital patlualo v.9. hocpltalluod least-t. with 653 a! pntlnnta rounlnlln for witlvu mouth. or loan. cou- ‘1 93304 to 31 par cant lb. 8111.140 pattcntl and only 5 91-: cast or £30.. Qt the lhcauohnnottn lontal loalth Ooutnr. ﬂi- Iodd any of tho clovgn tenth: lull-id. group II but»: urea will. two-thirds of the diachgrsod within Boston and valiant: cor. .1: tenth: of hoayllalllatlaa. In cash hospital. tout pntlanta arc ovqltatod uﬁ tho tan. or discharuu ca 'lnprovcd* (tnblo 11). ll lounlugar loopttal. havuvur. a blunt: poroautnco (l9!) 0: pttluutn turn rated II 'Inluprovud* and only a tingle psﬁluat �.13. woo oollod 'sosovosod' or 'sooh ispsovod'. rho hishost possontoso or “rooovosod' or “soon iopsovod' sstinas (881) sod tho ioooot provostioo st at ‘osiopsovod' (10$) ooso (bond Boston. d) ggg‘ggggg; For otstistissl ossiysis throo diogaostis groupings soso nods: sohioophrouis, ottostivo disosdoss, sad poyohonoorosis sud porosasiity disssdoss (roblo IV). tho diocoostio proportions of pstiosts within thoso groups loss sinilss tor lilisido sad lostoo in that slightly ovor holt discussod as sshisophssnio sad oppsouiootoiy oso-qoostor os psychooonrosio or ottootivo disordos. In sootssst ot Housings: loopitoi, poyoholsosooio sad possouslity dioosdor to: oooooatod . ovos n 1. lo titty pot O 0 o i coat of tho popslstion. 1 Probl Vsriols nothodoiosieol problsss vitistod intro-hospital ototi'otisol sou-potions. lost pro-issue. on tho has of loosinxtul out-or! ssitorio for subdivision or populstions. �-m- ft: oxaaplc. in ecuparo instituiioau in rpiniiou to Inacth or hospital Iiay, vuriouu eat-ct: varied: var. iriod uni n03. it lanaiacar lonvisui. Clio-04 for coupIr-blo distributioao. oat-quarto: at tho pationto runaiaod turn: Ina SII~thrdl taro than tunivo Inathu. its: auto: suntan, it Insoashtlottn ncnini laaiih easier, in couttuot. 70! at :11 paiioatu ro- ttinod 103! ill: ncvca months, and only 6’ :99. than tapivc Ionian. Anothtr aspect III tho oouatriotica of tutoroconoity or the population sulpic. In in. Boston group, tho crucial rooturoh patient. and th- uonrt roturrais sure hath dnlotod. in contra-tins tho_1957 and 1959 xiii-id. papuiutioa, II ob-orvad n uicaitieant accr.ano in it. an. o: oomvuinivo ihorapy its and an at pniiulia under tho :3. o: to. II. number a: cit-r patiouta, inure... in the coupurnhiiiiy a: as. group: in tho turn. halpitulo in this I‘Id’ lakes ihat similar pron-cunt lay lattes rumba! have oocarrod in it 113.17 in. ﬁre-cat and lonuiacor populatioan. than ducrcioina tn. rang. �.13., e: ﬁle diecueetie, treatment In verieblee. end ecneetieuel elnttleu, Iteeiug tutorletlea eeelel oleee an leﬁerntuetaeqlee e teeter in vitietlng £ntre-heep1te1 eelperteeae with sate variable. In deteretetux eeetel eleee enere wee tater-eeiee W eveileble for 29! e! petieute. thleeetrteble eeeee 371 occurred where the edncetlen o: the huebend e! e heueea site Or the tether e: e miner wee ne‘ reeorded. alibi: these letheeelegteel ltnttettene. e number 0: the latte-heepltel eelperleele rare of eizatfleenee. With recerd to selection or treetleut. age end I eeere were significantly releted et Healteger Ieepltel (elder higher r aom pan-nu therapy) end 1 Score wee were frequently end unsung eon“. releted te zreetnen‘ eeleetion et I111e14e. In “eaten-u evaluation. t. ere an e teatime: tor older petten‘e te be re‘ed better then younger euee et lilletde' end Benton; but at leantncer there wee en eppeette trend. �-15... with oldcr ptttoato nor. likely $0 be rated tninprovud; finial: 0: .3. Loasth n: haupttalllnzttn and tho causation III. loup¢tols . rolutod st .ai Itll-tdo tho youugur IB“XCOI oduoatod putts-ta riulntu; tar tin luacont parted. that. dunonatrntod In in Danica (13b1pa$1sa$s Ind-r rilntionahipn 1% bo‘h tho Honnlatcr un‘ V) Whiz- such ruluttoanhtpn two hoart‘nla, riot. a. vnttcatl I 01:11:: it. trail 070: be. but 13 noted 1&1 a: as. to taunt: loucor than/n 70.2. 31.11:: It. for education, and for diacuousl. 30%04 abusinzor noupttcl the poroautaco at pationtn with ﬁho dinxnoain at ouhtaophrausu.uho wore hoapttalinod ova: an. yin: II. 911. at ltlllld. [capital laltal luulth cantor 7!. C...”rablo V 35‘ and at luaucshlcotto �# .W IGRPI‘I‘IL ”ﬁll“a; 0: 53! an. Mon to 3H! 3'! £63 21! £32 6501!? 8131136 0785 W . ‘0 .35...“ M 81. ha 73 36 6 30*” 61 30 6 ho-M so to o 50 o 36 o o tan-29 11: �.17In thin nonpartgon of this. vquatary payhhtntria hocpt‘alc we have obs-trad significant tu$ar1act1tutzoanl diff-roast. or puﬁtcu:a tn ‘hc social vurxabznt or want. a: oduaa$1on tad .00131' .1305, But not .50: a: itaﬁribuﬁinu o: calitoruta r anal. sacral; Ind ta ouch a! ﬁho irnuIn-n$ variation ~~ duration at haupl‘oltunitaa, noloo‘ton at invaalsl§a and dia‘rtbutaona a: (taunt... uni dischargu Isuzunttnnt. in. oxpoctn‘ion ﬁhat the institutton carving «99¢! G1.il pattnuts vault but. the long-at durattou o: otur: I uschu! pvoporttan a: payuholourotao Gianna... and nor: ooupluu diagnosﬁﬁc nah-nuts; lunar preporttoa a! patients requiring organs. turn. or thavnpwa and peasant ditchuruu 1:31:30 use. each contarlnd. 81-41331!) tho tuctttution serving lav-r clan- putioata lvtnoad Ibortar purtoda at hocpttnllnutita, 10w proportaaua at pay-honaurotio cinema-us. and bot‘ar 41:03.13. uvnllaﬁaonl. In addition, tho diatrihitt-II at r 30.1. scorn. anon; tho that. hn0p1%aln tollaund tic arising: atllaidc it‘d: in that low accruuurc lost uhnrtn%¢rtnt1u at tho upper :1... group, and high score: at the lava! 0130-. 1951 mam. n: mu»by ropltoaﬁaon 3% Islamic; $ﬂ 1959. a: null no tntvn—tua‘ttuttonal ‘ a. “mg a «m:- m am analysts 5‘ tbs oﬁh'r ﬁn. holpttalo. '0 VII. intuucooutul. It. ‘33. tuttod to anhlcv: a‘a‘tn‘ionl Itgnittonacu. in part huaunuo at variomy or no‘hodologtcal prohluun. bnﬁ th- trcudu of tho laﬁa I?! 01-11:: to the ortxtaal study. . �.18. wall- theee etedlee have egeln eupheeleed the rele et eeeiel tedbre 1n peyehletrle tees-eat, we neat. have been lepreeeed by eke letheeelezleel preble-e e: etedleepereee laeeltetlene. theee leetltelleee were eeleeted tee their edeeetlenel leederehlp end eke expeetetlea thee the recorded vertehlee would be eleerly defined. our dirtteelelee 1a errlvtec et eoapereble dete ere invertent euee to the preblee o: the eeeventlenel eee e: eeeperettve eeetletloe. eepeelelly treqeene in the evelietlel e: peyehleerie thereplee. ihe eee e: dleeherze retinal, alecueeele eleeeee or length or heepltelleetlen ee craterle in therapeutic eveluetleue er ldeatltleetlen the e: eeepereblle populetloae ere enhaece te exceeelve error enleee eke tee stainletrettve peteerne. lnetlteeleee ere eleerly eetehed The peredexleel neenre e: e fellere te eeeeent for tneeltelleeel idleeyaereelee be eeea 1: e llterel :nterpretetlee e: the 1e to observation or sale etedy. fhe Reﬁnance! neepllel bee the leet highly trelued �.19. par-onuol conducting trontuant thick to applied fur iudtvtda Optimal port-dd utlly Outta-a. ti. 10:33 propnrticn at tinny in population. with diagnaaud 1: an unfavorahlo prognostic grasp (nahtnophron1n1 . - and rut. tn. proportion of ruportod (ivornblc traatlont rouulta 1. tin recruit. It lintll lanlth 10.3% cantor, 1a contra-t, that. th-rnpiltn apply trout-nuts tor its atlluahunuttu an administruttvaly t'utnod lilatod potted, to a populntlou with a hithcr pruportton diagnouud an tahtuophrunta. the propor$1ou or Ihorco raﬁanaa :- than. dhnIrVn$£ann tarornhlc III-It: 41-- otgnatto-ntly grants!) 1‘ to yrobnhlo do not garlogs %hu% the thirapoutlo efficacy a! «a... tnltatuttann. but ludioutnn differ-aces 1n oritnrtn or ilprﬂvnncat. this luck of clarity in dilanos%1c Ichcuatn and 130.!- pnrthtlity or pnyuhiatrac truinant 1:31.310: :10. load. panic tn tn. attc-ptcd comparative stanzas 0: psychiatric tbcrapioa. for tun-win. tho rlIh or roounﬁrntlurcn o: �.26- hioleslatl caloutlltl to contlrn obnorvatloaa and. 1: othor laboratorlou In: bu as such a rotlcntlau o: dittoruaec. in popnlttloau. payehlnlrlo orltarln,'g§g, an fallout.- 1: the original hapothcuon. the widcaprhad “cohltophr'uln' or ‘puyahououroslu' II. £0 at Utah turn. as caplet. tho ohnngoa in payuhdbatonl or blclogluol tosGIrOI with mental 111:... ha. 1.! to a totals. burdcnod by nasatSVI result: (lullnk). coat Ijrkad ruouutly in lb. atatlletlng stadium at taste: in anhinophruals. physiological ~~ and tho lneonparnblllty bohuvlornl corrolntlona Icon 1. (runkuuulnln) and meantiou threshold tutti. Sven I It'll at the t3. Incholyl turn I 1.111 ohnurvntloa to b. roportod from on. allnlo. in v. is!- II‘hOdl twillablo to doccrlba povulctluno adoquntol: lo provido 1 00.34 ountlrun‘lon? 270: than. obocrvntiaal at icllavu ao‘, and concludn tint lucrtnuoa attention list to p.16 to the nothodlocloal problana of clnaaltylix substatby 'objoativo' criteria. rcthor thus ta. pro-oat lathe!- uhlnh,uppo-r to ho so highly dcponloat an inatttutlonnl �-g1. :ad ohatrvur nttiiudul, and tho nociepoyuhoiegieul nspuctc or it. thorupintapnsiont intcraction. studio: :13. highlight the situate of changing !hnuu populatidns on Iinilnr mind: than italics. lillnido lbnpitsl rho peasant that: rich! soaiopayuholocicai~troatlcat rclntioachipu it. 1957. rufloo‘inc. I. btliovu, a constriction in tho typo. ﬁt trout-out. and th- .30 runs. at tho patiuntu. flora in; a nicnitiegnt rnduoiiou in the inure... in Icflocting anon oduontionai iovdi an 13010... in noun use, and as o: its population, it. nunbar of aJQIOlotnt and 33.33 aduli patients. baring in. in. yaw! purine, that. can 31.0 a untied voduoiion in tho incruasc in czalndnd was iii. it. nan u:- o: couvuluivv ihar:py chain. in the 1957 Itudy, wail. tho aoliacnt lunatic truatloat or thin study. at in. pvt-ant study, and a z: at poyuhatropic 4213!. art; ihorupy In. :- s irontlaat ‘OOOp‘QEQO and dittttcat ii had both a crcntcr it it the stuff psychological mooning than can. vulaivu incrlpr. Ind hearing, parhapc a diff-punt mulbioachip to attic! variablnn. its availability at an ottoctivcihorupy �9.2;. (or viauruua tout tor sinusitiaation) nay liaidbo in. intin-uco or uoeial «in-I vurinhlcu lliiin‘ahnad Ina lodiich (bund clans aad typo a: truttnayt did for tho oehiuophroaiaa. 317.3 dial-cu, than in n rolatittly ottaoiivu, n0 on iruatnnut. Etna. rulntion intros: loci-1 tar attentivt 'fhil payohoni: but tho: aﬁccontc that trail-at mils“. it, which inaxp-nnivu and tachaically for a i. lilplo. 01.0: ditfnruueun nay ho Podtcld, but not niiuiaaﬁod‘. 2:11. that. inter-hospital dittoroncoo 8‘! he loak¢d initial liliallc inirn-houpitai ‘ um. um peanuts.» and It. iatcrauiin DIOOOIIOI and expectation! of tho atndy. Xt_io our i-pr03Ii0I. tron-out mm “bun-hip. 1.9301: Invited iron tint: and authoriticu it. .ttiiudoo uiilil 0.83 institution.‘ thug. duration or patient tiny. Ginsburg. rating, type or transient anniniotcrod ind diagnosis are In �-52.. dutcrltuod an Inch by ‘30 attitude 6! the phyuiotnn and thy hanpttal niltcn 1a which tho‘pcsinlt rind: hilonlt. a: In: acuitollntion o: uyupttu or history which in In: pros¢nt. snob ralntionshapa ooaditlna tiara will he host lurkod in than. psychiatric that. diagnostic critnrin at. lunn‘ 39.01119. 5‘3‘, tho obaaoQavu «9:53:13 aloostntod with 4300.... hats: arcs-10 inpuirI-nt arc ahacnt, at an an achisuphrcuin. plynhancurolsn, and pcraouazt‘y and bohavior disordcrc. Vain: conditacnn or anbtcnitr tbs obcurvor'l internal can. (ntttwudal. alpoctttionl) hood-o and by clansiticatton hamlet, ( tic ball. for pyrotptton ). this via: 31.1%: and 1.1!“! 1!: was clonrly douonu$rutcd ﬂair study of vandal in dingao¢1u within a £13315 institution. Th0: dbuurvod that 1: pnttnuts rials-1: assign-d to ditturoaf lords inns powulattonl d1! not 6111.: in sang it Idlllltin, Inrttal otntnn. vasecttla. as. or contain... stxusftoaa$ 41:211-300. 41¢ occur, hcvcvnr. 1- 13014030. of diagnoses anon; tItIO �5""? mg “m ammuuun- in on an. u that unman- mo notably at “he.“ in the mmu». I. an.“ they at largely "nuan- of tho “«Nu. and uts“: at the Ian-1:0". �Sociopsychological Aspects of Psychiatric Treatment in Three Voluntary HoSpitals Robert L. Kahn, Ph.D.*, Max Pollack, Ph.D. Nathaniel Siegel, Ph.D. and Max From M.D. the Department of EXperimental Psychiatry, Hillside Hospital, N.Y. L.I., Aided, in part, Mental U.S. ‘Glen Oaks, Fink, Health, Mental Health Board. by grant MY-2092 of the National Institute of Public Health Service; and the Nassau County cosperation of the staffs of the Massachusetts Mental Health Center and the C.F. Menninger Memorial Hospital is gratefully The acknowledged. NOYI * Present Address: Division of Psychiatry, Montefiore HOSpital, NOYO 67, �Recent community studies have demonstrated relationship between social factors and psychiatric treatment. In their study of the New Haven psychiatric patient population, Hollingshead and Redlich reported significant relationships between an individual's position in the social class structure and the prevalence of treated illness, types a of diagnosed disorders and kinds and duration of psychiatric treatment administered (3). The influence of patient economic status upon the availability of treating personnel, however, was not excluded in these studies. To test the role of social factors in the treatment of hospitalized patients independent of patient's finances and availability of treatments, a survey was undertaken at Hillside Hospital in 1957. In this hospital, a variety of treatment modes, including individual psychotherapy and organic therapies are available to all patients regardless of their ability to pay. In the Hillside studies (h,S) it that patients hospitalized for the shortest period were the oldest, had the least education and were most likely to have been foreign born. The older, less educated patients were predominantly treated by convulsive therapy and received the more favorable discharge ratings. Younger, native born and more educated patients were hospitalized the longest, treated primarily by psychotherapy and generally received the poorer discharge ratings. The clinical factors were also related to a measure of stereotypy, the California F Scale (1,6). Higher F scores, i.e., greater stereotypy, were often found in patients was observed �-2diagnosed as involutional psychosis who were referred for somatic therapy, hospitalized for a shorter period, and more often were rated as much improved or recovered. Another hypothesis developed at this time was that differences in various aspects of psychiatric treatment among hospitals should show the same relationship to social factors as noted within Hillside Hospital. To test this suggestion it was decided to employ the procedures of the 195? Hillside study in three institutions -Hillside Hospital, the C.F. Menninger Memorial Hospital of Topeka and the Massachusetts Mental Health Center of Boston. These institutions were selected with the expectation that they served patients of different social classes. It was anticipated that in these hospitals there would be a similarity in attitude towards treatment and education. Each is a teaching hospital with a full time supervisory staff and active research departments. They emphasize psychoanalytically-oriented psychotherapy but provide other treatments such as somatic therapies and active programs of milieu therapy. Each stresses short-term treatment of voluntary patients and does not provide custodial care. The specific aims of this study were to determine the population characteristics of the three institutions with respect to social class, age, education and F score: and to relate these characteristics to the treatment variables of type of treatment, duration of hospitalization, diagnosis and discharge evaluation among the institutions. �-3METHOD these in residence in adult patients census of all voluntary, and Menninger While 1959. institutions was undertaken in January, of number small a only, Hillside Hospitals had voluntary patients (MMHC) assigned were Center Health Mental those at the Massachusetts chronic a of members Or were by the courts for psychiatric evaluation a for specific transferred group schizophrenic state hospital from the study excluded These were research project. patients A the patient because of their non-voluntary status. the months later F Eighteen California scale on the census day. social the determine to examined were records of discharged patients and psychiatric factors of the study. For a measure of social class, Each was given and education of score the Hollingshead 2-factor index - weighted 173 of consisted The study population occupation - was used (2). 95 Massachusetts the and at 100 Menninger at patients at Hillside, a Mental Health Center. social the of of the relations examination included study to the psychiatric variables within each institution as well as The between institutions. These comparisons were difficult however, These below. discussed differences because of various methodological and comparisons, marked the most in intrahospital difficulties were will emphasis variables of the in analyses psychiatric accordingly, be placed on the differences between institutions with citation of to missing led also These difficulties trends. intrainstitutiOnal information for some data, which is reflected in the varying population sample sizes in the tables. �RESULTS A. Inter-hosEital Comparisons l. Methodological Problems institution, the reporting studies ignored and either granted for taken is of the hospital structure institution a strange studying in or mentioned briefly. However, the of made aware is one data comparable and attempting to gather these selected we While institutions. between differences many pro— treatment and research teaching, in comparable as institutions wh ways in structurally unlike were they found that we grams, in noted were problems Sp‘cific the of study. influenced the data the and classes diagnostic of treatment, of type the designation outcome. treatment of evaluation desigfor The criteria 8) Designation of 212s of Treatment: the among differed "psychotherapy" received a nating that patient When from a home difficult. classification in uniformity institutions, making treatment as designated was At Menninger Heepital psychotherapy for a psychiatrist staff by basis a on prescription administered the psychiatric with Sessions a fee. which the¢patient was charged care. patient administrative of routine considered part were resident treatment as defined was At Hillside Hospital psychotherapy did Staff psychiatrists resident. sessions with the psychiatric to supervising activities their not treat patients, but restricted charged. were fees No additional the resident physicians. �-5At the Massachusetts Mental Health Center psychotherapy was designated as a function 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 in charge of each case. b) Diagnosis: Individual institutional diagnostic styles made comparisons difficult. At Menninger Hospital diagnoses employed the multiple evaluative data scheme recommended by the American PsychiaMMHC and both while followed unitary Association Hillside tric 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 source of distortion. c) Discharge Ratings of Improvement: Ratings of improvement at the three hospitals varied in format and detail. rating at Menninger Hospital was tripartite with discharge separate evalua- The a tion 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-tho Meaninger syndrome �rating was c Sociopsychological Variables age, of social class, variables the of The distribution institutions three the among F Scale score and California education 2. is presented in Table III. M social the in difference a) Social Class: Hospital Menninger At institutions. three the of class composition Hospital, Hillside at class; upper predominantly was the population There was a marked predominantly Center, Health Mental Massachusetts and at middle class; lower class. b) Age: There were no differences in age institutional populations. distribution in the attaineducational in differed 0) Education: The populations Menninger at education of more years having with patients ment, hl While per Center. Health Mental Massachusetts than at Hospital 32 only school, high MMHC completed not had Cent of the patients at not Menninger graduate. did cent at 23 and per Hillside at cent per of distribution the in differences F Score: Significant d) cent per Fifty-one observed. F were Scale California the scores on �-7cent and eight per only below 30, scores of Menninger patients had associated F being scores with scores of 50 or above -- the higher thirtyHillside at In contrast, with higher degrees of stereotypy. MMHC while at 30 below F had scores one per cent of the patients F 30. below were cent only twenty per the of class social the in differences Thus, the anticipated These differScale. educational attainment and performance of relation the concerning the hypothesis testing permit ences insti— the among variables treatment the to factors sociopsychological on the F tutions. 3. Variables Treatment Psychiatric Among Treatment: of a) Selection institutions, significant- therapy somatic received Hospital Menninger at fewer patients ly IV. Table shown in MMHC (68%) as than at Hillside (6h%) or differed The institutions three b) Duration of Hospitalization: IV). (Table of stay markedly with respect to patient's length longest, hospitalized were Menninger Hospital patients cent 31 to compared per months or more, twelve for remaining patients the of those at 5 cent of the Hillside patients and only per Hillside the of modal The stay Massachusetts Mental Health Center. the of two-thirds while months was between seven and eleven (h3%) group of months hospitalization. six within MMHC patients were discharged were most patients each In hospital, c) Discharge Evaluation: At IV). (Table “improved“ evaluated at the time of discharge as �-3(19%) of patients percentage a higher Menninger Hospital, however, called was patient a single and only were rated as "unimproved" "recovered" of The percentage highest "recovered" or "much improved". of lowest proportion and the (28%) "much ratings improved" or Health Mental Massachusetts the "unimproved" (10%) were found at Center. groupdiagnostic three analysis d) Diagnosis: For statistical and psychodisorders, affective ings were made: schizophrenia, The diagnostic IV). (Table disorders neurosis and personality Hillside for similar were these groups within of patients proportions schizophrenia as diagnosed were and MMHC in that slightly over half disorder. affective or psychoneurosis as one-quarter and approximately and personality psychoneurosis Hospital In contrast, at Menninger the of population. cent than per fifty disorder accounted for more B. Intra-Hospital Comparisons Problems Methodological l. by limited were comparisons The intra—hospital statistical lack the was Most prominent problems. methodological of a variety of subdivision the for criteria cut-off statistical of meaningful within the of population due to the homogeneity populations, in part analyses the In statistical size. each institution and to the sample had which obtained were cells several within a single institution �-9- either none or fewer than five cases, thus not permitting a satisfactory intrahospital test of the hypothesis. 2. Intra-Hospital Comparison With this methodological limitation some trends similar to that found in the earlier study were observed, although few were of statistical significance. With regard to selection of treatment, for example, age and F score were found related at Menninger Hospital (older and higher F score patients more frequently receiving somatic therapy), and F score alone at Hillside. Length of hospitalization and chronological age were related at both the Menninger and Hillside Hospitals - the younger patients remaining for the longest period. While such relationships were trend two a in these was noted at the significant hospitals, similar MMHC (Table V) where no patients over ho, but lb% of patients under the age of 20 remained longer than a year. -—-_------- �-10.. DISCUSSION we hospitals psychiatric of voluntary three In this comparison of differences patients interinstitutional have observed significant but and social of education class, of in the social variables years of each and F in Scale scores; not age: in distribution of California hospitalization, selection of the treatment variables treatments and distributions of diagnoses and discharge evaluatimﬁh The expectation that the institution serving upper class patient! would have the longest duration of stay, a higher proportion of psychoneurotic diagnoses and more complex diagnostic schemata,10W6r proportion of patients receiving organic forms of therapy, aM'poorest discharge ratings were each confirmed. Similarly, the ﬂﬁtitution serving lower class patients evinced shorter periods of howitaliza— disand betwr low of diagnoses, psychoneurotic proportions tion, charge evaluations. It is our impression that these differences in psycuatric treatment are more related to differences in staff attitﬂes than to differences in population samples. The contrasts betweeninstituthccomplexity. tions in duration of hospitalization are great, as are of diagnostic formulations, discharge evaluations, definiﬁons of details and amount of recorded data These and the psychotherapy, stylistic differences cannot be dismissed as merely idiosywratic since they follow a pattern related to social differences mnsistent with previous findings. —- duration of �-11- treatment variable relationships appear to be interactive processes, determined both by the attitude of the physician and the administrative staff as by the constellation of Such population and history which a patient may present. Such relationships will be most marked in those psychiatric conditions where diagnostic criteria are least specific, 343., where the objective criteria symptoms or defining diseases of known organic impairment are absent, as in schizophrenia, psychoneurosis and personality and behavior disorders. Under conditions of perceptual or situational ambiguity the observer's attitudes and expectations become the basis for perception and classi- fication. This clearly demonstrated by Pasamanick, Dinitz and Lefton (7} in their study of variations in diagnosis within a single institution. They observed that patients randomly assigned to different wards did not differ in type of admission, marital status, education, age or residence. Significant differences did view was occur, however, in diagnoses among the three wards and among three administrators on one ward. As it is highly unlikely that these differences were inherent in the population, we believe they are reflections of the attitudes of the examiners. largely It is clear that many of the present psychiatric concepts of diagnosis or clinical evaluation have relatively little meaning when transferred from one institution to another. If these concepts are taken literally the results become paradoxical. For example, Menninger Hospital has the most highly trained personnel conducting treatment, keeps its patients for the longest time and has fewest �-12- patients diagnosed as schizophrenia. And yet, despite these resources At treatment results. the poorest and favorable factors, it reports MMHC, in contrast, which is most inclusive in defining a therapist, which keeps patients for the shortest periods, and which has a higher the reported classed asschizophrenia, of the population proportion treatment results are the best. the does relative not reflect study this that probable is It Our no furnishes data of the institutions. therapeutic efficacy the which provides hospital for determining independent criteria better care; nor for assessing the comparability of the population the based on evaluations the Since are of the in degree illness. institution‘s own ratings, we believe that the differences reflect variations in the criteria used for evaluation of improvement rather than any intrinsic psychiatric characteristics. In our initial Hillside study (5) 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 has This employed. the complex the criteria more social background Manninger‘s using with the confirmed study, in been literally present two other of the the global rating a tripartite rating compared to which our on Even syndrome the rating considering institutions. contention our is were based, it analysis comparative statistical in improvement to we assess lower apt class are that for persons work, resume to capacity the symptom patient's relief or relation to while for upper class persons the criteria stress such complex �-13- intangibles as "developing insight", or "working through one's problems." investigations have again demonstrated the role of social factors in psychiatric treatment, we have been considerably impressed by the methodological problems of studies across institutions. These institutions were selected for their educational leader— ship and the expectation that the recorded variables would be clearly defined. But the differences in institutional style making it diffi— cult to obtain comparable data are important cues to the problem of the conventional use of comparative statistics, especially in the evaluation of psychiatric therapies. The use of discharge ratings, diagnostic classifications or length of hospitalization as criteria in therapeutic evaluations or the identification of comparable populations are subject to considerable error unless the institutions are clearly matched for social class patterns in patient population and for staff attitudes and style. These difficulties may also extend to the failures of scientists to confirm observations made in other laboratories, for the lack of confirmation may be as much a reflection of differences in populations and psychiatric criteria as to errors in the original hypotheses. The wideSpread use of such terms as "schizoWhile these phrenia" or "psychoneurosis" to explore the changes in psychological or biological features with mental illness has led to a science burdened by negative results. Even were a valid observation to be laboratory, we do not have methods available to describe populations adequately to provide a sound confirmation. reported from one �~1h- Increased attention classifying subjects must be paid to the methodological problems of criteria rather than the present and on institutional dependent highly by "objective" methods which appear to be so of the and aspects the sociopsychological observer attitudes pist-patient interaction. thera- �-15.. SUMMARY and CONCLUSION hospitals, variables. treatment to related were characteristics population F and education score, social by defined age, class, were Populations and were related to type of treatment, duration of hospitalization, diagnosis and discharge evaluation. in observed were differences 2. Significant interinstitutional and education of characteristics of patient social class, years F of California scores, but not age. distribution 3. The variations in treatment characteristics among instituthe in predicted different be found to significantly tions were direction. a follow pattern practices in psychiatric h. These variations and are institutions among differences class with social consistent not regarded as being idiosyncratic. of make comparisons S. The differences in institutional style between results and treatment diagnoses, duration of hospitalization, need more objective for and the and tenuous, institutions difficult emphasized. is of populations of classification criteria 1. In three psychotherapantic-oriented teaching �REFERENCES l. Adorno, T.W., Frenkel-Brunswik, E., Levinson, D.J. and Sanford, & New York, Harper Brotherg R.N.: The Authoritarian Personality, 1950. 2. Hollingshead, A.B.: Two-Factor Index of Social Position, mimeo- graphed publication. 3. Mental and Class Social F.C.: Redlich, & Sons, Inc., New John Wiley York, Community Study, Hollingshead, A.B. and Illness: A 1958. h. R.L., Pollack, Selection of Therapy in M. Kahn, Social Factors in the Voluntary Mental Hospital, J. Hillside and Fink, M.: a 1957. 216-228, g: 2., Kahn, R.L., Pollack, M. and Fink, M.: Sociopsychologic Aspects of Psychiatric Treatments in a Voluntary Mental HOSpital: Duration of Hospitalization, Discharge Ratings and Diagnosis, Ho 5. Arch. Gen. Psychiat., 6. l: 565-57h, 1959. (CaliM.: M. Attitude Social and Fink, Pollack, R.L., & Ment. Nerv. F Dis., J. and Convulsive Therapy, Scale) fornia Kahn, 130: 187-192, 1960. 7. OrientaM.: and Psychiatric S. Lefton, Pasamanick, B., Dinitz, Mental a in and Treatment to Diagnosis tion and Its Relation Heapital, Amer. J. Psychiat., 116: 127-132, 1959. �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 HILLSIDE HOSPITAL MASSACHUSETTS MENTAL HEALTH CENTER Recovered Recovered Much Impr oved Markedly Improved Improved Moderately Improved Unimproved Slightly WW- Unimproved Syndrome Complete Remission Improved Unchanged (or worse) ~———-————-—-——— Improved Unimproved �TABLE III Comparisons for Sociopsychological Variables Interhosgital Menninger Hospital ' Hillside Hospital t I Massachusetts Mental Health ! i t t Social Class EIII % 17 3h 13 i g § IV v 1 E t 28 �TABLE IV Interhospital Differences in Treatment Variables gMenninger Hillside Massachusetts Hospital Mental Health {Hospital Psychotherapy Somatic of Treatment Type 68 Other 8 1 . as”ii.ii.ii_wmm.mi“iiiiiiiiii.i,__ Duration of Hospitalization i:QﬁiéimﬁifAL_R$;991MW_WWWW“a. _-._~ _-_rmi...._i__.mwt 7-11 months 1 months “—W.W - came-u «rr Recovered, Improved Discharge Evaluation Much 61 Improved 10 'Unimproved I .. , m Discharge Diagnosis ..—W_-»lnw w-‘W a . df=h§ B<.OOl.~W___ y3é29.3; ..... Schizophrenia Affective Psychosis _ “p M 1? Psychoneurosis and Personality Disorde x2=23-83 df‘h? P<-001 29 *__,m_.__". �TABLE V Duration of Hosgitalization BX Age PERCENTAGE OF AGE GROUP STAYING OVER ONE YEAR i» mm Below 20 Menninger Hillside 81 73 61 3O 30 20 2422219. �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 �.0". m an.» "mm ”turn M m «trauma in a Want a mu “am“. m. to m: Imitation mums It“ ”'01:“! 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Rejec’t' “1 ram 13 0 ~ 1 o 7 11 3 ° ° 9 11 O1 1 ll] o 57 - 70 7 8 001.23/3 35 > li $7, 2312 Col. 1 ‘1 IJ" | 1 7/01.} TALLY SHEEP 601.26/1 ‘7 ,..,2 Deckf - D11 1 0 1 1 ‘ 0 . / 9 4 . 75" 0011.29/8,9. {Mama 1%‘5‘5 I! I 2 391 3 5 1h 0 o Reject O 5‘3 20111.11 X 11601.26/1 // 2 3 _ — 0. Asa .0 as: 1 111: 1 1 1 35‘ 115 a - r 16 - _ o 1 W—‘i— 01.1 Re I .9.— 1. 9‘ 11 .3- " M-w—«eﬁm 0 H ect 1mm. 01 77 1 55 “_~_ 53 f �Dock: I , “BALL! Qilvcéév 31‘ comes/1 . , 2 a?” sum sol-23k ,Gol.23/1 ” _ 001-23/3 17 3 O l 20 6 . O , O mutt» ‘00“ 6 3 o 3 3 O 33 3 o Reject ICE“. 7 O 3-- o �f x 7“ ,/;.!,/, ﬂ _ TALLY SHEEP g/ 001.2611 ‘7 57‘7“.”— ' 001,237.! 7‘1"" 1" a ! 'i , /’ , 16 h ’* J 5 u ﬂ 7 ,. . ”J--. ., x . . o. V- o . o 2 ~_ - V 0 . 7.1.07 , 0 _-. J ‘1‘ 36 7 , 0 a “I, 74.,47445 Co1.23/3 ‘ 7 ,. Q- . V I 5 7 35"“! 7,001.23/2' 1...,_ 27 . J ﬁYlI ‘, 2 " bro" Decks" I 16 , i t. .. . . - 57 . . 0 0 , - 13. O I [4' 7 7 II 8 9. 7-07 ll l V 0 I. iii Owﬁl" Reject H warm. ” “I": aﬁa’ .. ‘ , , . I V. O 0. II. 3 0 O ~ A - D _ .. ~ - , . O , , . - H 4 ’9. {IV/J '11.: farm/1:22.— , , , , .16. , 9 69.19.2311... - . 2 .39.-. 3 S - -h- .0 o Reject MAL X 5‘3 // 2 not“ - .3 - .0 V J.» V. 5 . .35‘ - 0 8' 7 ‘ C? .o . m____9__ 0 f _. - Reﬂect - __ . . 43 ,a .0 _._V ., 3 , O A -601026/1 - limo), 001.29/8,9. Duh“ - ,, 55 .9— .V 9‘ - .. ,3- «wag—m... 53 / �-3Menninger Hospital, however, a higher percentage (19%) of patients called rated as "unimproved" and only a single patient was "recovered" or "much improved". The highest percentage of "recovered" or "much improved" ratings (28%) and the lowest proportion of "unimproved" (10%) were found at the Massachusetts Mental Health were Center. d) Diagnosis: For statistical analysis three diagnostic groupings were made: schizophrenia, affective disorders, and psychoneurosis and personality disorders (Table IV). The diagnostic proportions of patients within these groups were similar for Hillside in that slightly over half were diagnosed as schizophrenia and approximately one-quarter as psychoneurosis or affective disorder. In contrast, at Menninger Hospital psychoneurosis and personality disorder accounted for more than fifty per cent of the population. and MMHC -‘---------’ Table B. Intra-Hospital Comparisons l. Methodological Problems The a IV intra-hospital statistical comparisons variety of methodological problems. of meaningful statistical cut—off were limited by Most prominent was the lack criteria for the subdivision of populations, in part due to the homogeneity of the population within each institution and to the sample size. In the statistical analyses within a single institution several cells were obtained which had �Page 5. COMMENTS BY PSYCHIATRISTS Most of the unfavorable (1) (2) more insufficient " criticism can number of " " be divided into two complaints: sessions per patient paid for by Project patients point, many apparently feel the Project should advertise itself to its eligible subscribers, reminding them of the availability of coverage. 0n the second Favorable criticism was in general directed at expressing approval of the idea of testing psychiatric insurance. There were in addition a surprising number of complimentary remarks about the planning or administration of the Project. SUMMARY typical participating psychiatrist is a man between 35 and 50, practicing in Manhattan. He treats patients in the hospital as well as in his private office, and he also does some clinic work. He has his "Boards" in psychiatry. His usual office fee is $20 or $25. His primary orientation in his practice is analytical and psychological. This does not preclude his prescribing drugs or shock therapy. The interest in the Project is demonstrated by the fact of his participation. If he has some adverse criticism, it is apt to be directed at the number of sessions allowed, which he regards as insufficient, or at the small number of patients who have sought care, which he regards as a reflection of an inadequate educational program. In short, his criticism is generated by his tendency to view the Project as a social rather than an insurance experiment. He feels the Project, Operating in an area where the supply of private psychiatric time apparently exceeds the demand, is in a unique position to promote more psychiatry for more people, which is what he really wants - insurance or no. His APA-NAMH-GHI RESEARCH PROJECT August 30, 1960 �MWQQIPWZMMMWMS. mmuummmumuaumm umm-mmmyutnwmuum mmmummmammw «mummy-"um. mmumtmmmuwm mmnm.mumn nun-1 mm m "WW nu» M m mnﬂMmMWmuumu-m ml; Wax. m- 1: m», W‘s: ”.mtunmwmmtm.mm Mnmw‘um. mam. uanwmmum.nm ��~19. tut Oil. innﬁltution urn vniulruhla ‘u individual dittorunaai among uxaainera.) uwdﬂﬂﬂh‘b an“ “it Tabla ﬁttings at inﬁrOth neat variad in tornat uad antltl. MIR #3: triptrtit¢ Yb: diaahtrmc with a toynrtta cvtlnntion aburnctaralugi¢nl and buhnvtoral changnt. it wan dattianlt tar rating at toc&31, 3R and name had cltbnl ratings in which tribution at taator a: th‘ ﬂdngiaaar ﬁrst.» (tabla II). 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E ﬂ m” he 4, ~ ' :'*13I:§ ‘ «a 9".”‘ 1“ 31-3 9 ”‘03:: at" .1 it'We” it”$001 “it" 90. � 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 Social aspects of psychiatric treatment in three hospitals: methodological problems. VA Cooperative Studies in Psychiatry, 6:202-6. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-004-59-001 Date A point or period of time associated with an event in the lifecycle of the resource 1961 Creator An entity primarily responsible for making the resource Pollack, Max; Siegel, Nathaniel; Kahn, Robert L.; <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Published Works -- Articles and Reviews Relation A related resource The Max Fink Collection Description An account of the resource 9 items. 1: Photocopy of publication with Q & A. 2: [preprint]. 3: Draft. 4: The Identification of Patient Populations: Comparability of Subjects in Evaluating Therapies Among Institutions by Max Fink, M.D. 5: The American Psychoanalytic Association Summary and FInal Report of Central Fact-Gathering Committee. 6: Correspondence. 7: Handwritten notes. 8: Social Class. Diagnosis, and treatment In Three Psychiatric Hospitals. 9: Research, drafts, and letters. Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Published