http://exhibits.library.stonybrook.edu/mfp/files/original/9a3312b18cdf6e7ffc1390135fa8f24f.pdf 7ebf0740040bf69f9525e1f11a533ee3 PDF Text Text 20 Soci0psychological A3pects of Psychiatric Treatment A Report of Treatment in Three Voluntary Hospitals ROBERT L. KAHN, PhD, NEW YORK; MAX FINK, MD, ST. LOUIS; AND NATHANIEL SIEGEL, PhD, BETHESDA, MD IN THEIR STUDIES of the New Haven treated primarily by psychotherapy, and repsychiatric patient population, Hollingshead ceived poorer discharge ratings. These and Redlich reported significant relation— clinical factors were also related to a measscale.""5 California F the of in the individual’s stereotypy, ure position ships between an social—class structure and the incidence of Higher F scores, ie, greater stereotypy, were treated illness, types of diagnosed disorders, often found in patients diagnosed as inand kinds and duration of psychiatric treat— volutional psychosis who were referred for ment administered.1 The influence of the convulsive therapy, hospitalized for shorter economic status of the patient on the avail- periods, and were more often rated as much recovered. improved or of however, was personnel, treating ability It was suggested that differences in psy— not excluded. should chiatric hospitals treatment in the social factors of among Studies of the role social factors of influence in— similar reflect a of hospitalized patients treatment Hos— Hillside within noted for patients dependent of their financial status and the as decided it to this To was test suggestion pital. undertaken of treatments were availability 1957 Hillside the of the procedures 1957. employ this In in hospital, at Hillside Hospital Hosinstitutions—Hillside in three instudy a variety of treatment modes, including dividual psychotherapy, pharmacotherapy, pital, the C. F. Menninger Memorial Hosand convulsive therapies were available to all pital, Topeka, Kan, and the Massachusetts inThese Boston. Health Mental Center, patients regardless of their ability to pay. In our surveys 2'3 we observed that patients stitutions were selected with the expectation hospitalized for the shortest periods were that diverse treatment modalities were older, had less education, and were more equally available to populations of different often of foreign birth. These older, less- social classes. Each provided short—term educated patients were predominantly treated treatment of voluntary patients and did not by convulsive therapy and received more provide custodial care. Each is a residency favorable clinical discharge ratings. In con- training center with a full—time supervisory trast, younger, native—born, more—educated staff and active research units, emphasizing patients were hospitalized for longer periods, psychoanalytically-oriented psychotherapy. This study was designed to determine the Submitted for publication June 21, 1965. From the Department of Experimental Psychiatry, Hillside in— three the of characteristics population Hospital, Glen Oaks, Long Island, NY 1959-1962. Currently at the Department of Psychiatry, University of Chicago, social with class, to stitutions age, respect the of at the Psychiatry Department Chicago (Dr. Kahn); Missouri Institute of Psychiatry, University of Missouri and F score; and to relate these education, School of Medicine, St. Louis (Dr. Fink); and the National characteristics to treatment variables of type Institute of Mental Health, Bethesda, Md (Dr. Siegel). Reprint requests to 5400 Arsenal St, St. Louis, Mo 63139 of duration of hospitalization, treatment, (Dr. Fink). ' Arch Gen Psychial—Vol 14, Jan 1966 �EPIDEMIOLOGY—DUNHAM Small City,” in Epidemiology of Mental Disorder, B. Pasamanick (ed), \Vashington, DC.: American Association for the Advancement of Science, 1959, publication No. 60. 46. Hollingshead, AB, and Redlich, F.: Social Class and Mental Illness ew York: John Wiley & Sons, Inc., 1958. 47. Morris, ].N.: ealth and Social Class, Laneet 12303—305 (F 1959. 48. Dunham, Dis— “Anomie and Mental .. order,” in Anom and Deviant Behavior, M. B. Clinard (ed.), Ne k: The Free Press of Glencoe, a division of the acmillan Co., 1964. 49. Buck, C.; Wanklin, M.; and Hobbs, G.E.: Symptom Analysis of Ru l—Urban Differences in First Admission Rates, ] erv Ment Dis 122 280-82, ].A., and Kohn, M.L.: Social Isolation and Schizophrenia, Amer Soc Rev 20:265— 58. Clausen, 273 (June) 1955. 59. Stein, L.: Social Class Gradient in Schizo- phrenia, Brit J Prev Soc Med 11:181-195 (Oct) 1957. 60. Carstairs, G.M., and Brown, G.\V.: A Census . (July) 1955. M.B.: Al native Hypothesis for the Explanation of Some f Faris and Dunham’s Re— sults, Amer J Soc 47 48-52 (July) 1941. 51. Schroeder, C. : Mental Disorders in Cities, Amer Soc 47 :40-47 ( 1942. 52. @degaard, (3.: E igration and Insanity: Study of Mental Diseas Among Norwegian Born Population in Minnes , Aeta Psychiat Neural, 50. Owen, suppl 4, 1932. 53. @degaard, Incidence of Psychoses 0.31m in Various Occupations, Soc Psychiat, vol 2, No. 2 (Autumn) 1956. 54. Ekblad, M.; Psychiat c and Sociologic ‘ 19 , of Psychiatric Cases in Two Contrasting Communities, J Ment 5 ' 72—81 (Jan) 1956. 61. Dunha r .W.: Community and Schizo— phrenia : Epidemiological Analysis, Detroit: Wayne Sta University Press, 1965. 63. Leig lot: Comm Psychiatry, , lisher, 1960. 64. Leigh ger, New Y. 65. LClgh the Epidemi demiology bank Memori b , .H.: “A Proposal for Research in y of Psychiatric Disorders,” in Epi— ental Disorder, New York: Mil‘ o Fund, 1950, pp 128-135. 66. Krame M.; “Discussion of H. W. Dunham’s article”. 'n Causes of Mental Disorders: A Review of miologieal Knowledge, 1959, New York: Milban emorial Fund, pp 271—273, 1961. 67. Miles, H.C., et A Cumulative Survey of All Psychiatric Expe nce in Monroe County, New York: Summary of ata for the First Year (1960), Psychiat Quart 3| ‘ 58-487 (July) 1964. 68. Dohrenw , B., and Dohrenwend, B.: The Problem of Valio in Field Studies of Psychological Disorder, ] Abn Psyehol 70 :52-59, 1965. 69. Benedict, P.R., nd Jacks, I.: Mental Illness in Primitive Societie Psychiatry 17 :379—390 (Nov) . . ’ E.: Mental Ment Hyg (April) 1935. 55. \Vinston, M.; Compa t e Study of Disease Incidence in Admissions to ase Psychiatric Hospi— tal in Middle East, Men ei 922118—127 (Jan) 56. Simms, 1946. 57. JaCo, E.G.: The Social Isolation Hypothesis and Schizophrenia, Amer Soe Re-zv 19:567-577 (Oct) 1954. 1954. 70. Hollowell, Philadelphia 1955. : .A.: Culture and Experience, niversity of Pennsylvania Press, Arch Gen Psychiat—Vol 14, Jan 1966 �SOCIOPSYCHOLOGICAL ASPECTS OF TREATMENT—KAHN ET AL diagnosis, and discharge evaluation among the institutions. Method A census of all voluntary, adult patients in residence in the institutions was undertaken in January 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 evalua— tion or were members of a chronic schizophrenic state hospital group transferred for a specific research project. These patients were excluded from the study because of their nonvoluntary status. The California F scale was scored for each patient 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 two-factor index—a weighted score of education and occupation—was used.“’6 The study population consisted of 173 patients at Hillside, 100 at Menninger, and 95 at the Massachusetts Mental Health Center. The study included examination of the relations of the social to the psychiatric variables within each institution as well as between institutions. These comparisons were difficult, however, because of vari— 1959. ous methodological differences discussed below. These difficulties were most marked in the intrahos— pital 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, reflected in the tables by the varying population sample sizes. Results I. Methodological Problems—When re— porting studies from one institution, the structure of the hospital is taken for granted and either ignored or mentioned briefly. In TABLE 1.—Redesignation of Discharge Diagnoses Menninger Discharge Diagnoses Depressive reaction, narcissistic personality Anxiety reaction, narcissistic personality Narcissistic personality Narcissistic personality, alcoholism, chronic infantile personality Passive aggressive personality, alcoholism Infantile personality, schizophrenic reaction, schizoaiicctive type General Classification Psychoneurosis Psychoneurosis Personality trait disturbance Sociopathic personality disturbance Sociopathic personality disturbance Schizophrenic psychosis 21 gathering comparable data from multiple in— stitutions, however, the differences between institutions are accentuated. While these in— stitutions were selected as comparable in teaching, research, and treatment programs, they were functionally unlike in ways which influenced the data of the study. Specific differences were prominent in the designa— tion of type of treatment, diagnostic classifications, and the evaluation of treatment outcome. Designation of Type of Treatment: The criteria for designating that a patient , received “psychotherapy’ differed among the institutions, making comparisons (lif— 1. ficult. 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 a psychiatric resident physi— cian were considered part of routine ad— ministrative patient care. At Hillside Hospital psychotherapy was defined as treatment sessions with a psychiatric resident. Staff psychiatrists did not treat patients, but restricted their activities to supervising resident physicians. No additional fees were charged. At the Massachusetts Mental Health Center psychotherapy was designated as the activity of many disciplines—psychiatric residents, psychologists, social workers, nurses, and medical students. Formal records of such sessions were not routinely included in the patient’s record and to ascertain which patients received psycho— therapy it was necessary for members of the study team to interview the resident physi— cian responsible for each case. 2. Diagnosis: Individual institutional di— agnostic styles made comparisons difficult. At Menninger Hospital diagnoses employed the multiple evaluative scheme recommended by the American Psychiatric Association, while both Hillside and MMHC followed different unitary systems. Several examples of diagnoses from Menninger are listed in Table 1, with our suggested conversions into categories comparable to that of the other two institutions. These conversions provide a source of distortion. Arch Gen Psychz'al—Vol 14, Jan 1966 �SOCIOPSYCHOLOGICAL ASPECTS OF TREATMENT—KAHN ET AL 22 Discharge Ratings of Improvement: Ratings of improvement at the three hos— pitals varied in format and detail. The discharge rating at Menninger Hospital was tripartite with a separate evaluation for social, characterological, and syndrome changes. Hillside Hospital and Massachusetts Mental Health Center had global ratings making it difficult to assess the contribution of each factor of the Menninger system (Table 2). For this study the Menninger syndrome rating was compared to the global ratings of the other institutions. II. Interhospital Comparisons—1. Sociopsychological Variables: The distribution of the variables of social class, age, education, and California F scale score among the three institutions is presented in Table 3. A. Social Class. The anticipated differ— ence in social class composition of the three institutions was observed. At Menninger Hospital the population was predominantly upper class; at Hillside Hospital, middle class; and at Massachusetts Mental Health Center, predominantly lower class. B. Age. There were no differences in age distribution in the institutional populations. C. Education. The populations also differed in educational attainment, with patients having more years of education at Men— ninger Hospital than at Massachusetts Mental Health Center. While 41% of the patients at MMHC had not completed high school, only 32% at Hillside and 23% at Menninger did not graduate. D. F Score. Differences in the distribution of scores on the California F scale were also observed. Fifty-one percent of Menninger patients had F scores below 30, and only 8% with scores of 50 or above—the higher F scores being associated with higher degrees of stereotypy. In contrast, at Hillside 31% of the patients had F scores below 30 while at MMHC only 20% were be- 2.—Comparative Ratings of Clinical Condition at Time of Hospital Discharge TABLE 3. low 30. Menninger Hospital Thus, differences in social class, tional attainment, and performance on the F scale were observed. These differences permit a test of the hypotheses relating socio— psychological factors to the treatment variables among these institutions. 2. Psychiatric Treatment Variables: A. MM HC Improved Recovered Much improved Unimproved Improved Social adjustment Character structure Recovered Markedly improved Moderately improved Slightly improved Unimproved Unimproved Improved Unimproved Syndrome Complete remission Improved Unchanged (or worse) Selection of Treatment. Among the institu— tions, significantly fewer patients at Menninger Hospital (43%) received somatic therapy than at Hillside (64%) or MMHC (68%) (Table 4). B. Duration of Hospitalization. The three institutions differed with regard to patient’s length of stay (Table 4). Patients at Men— ninger Hospital were hospitalized longest, with 65% of the patients remaining for 12 months or more, compared to 31% of the Hillside patients and only 5% at the Massachusetts Mental Health Center. The modal stay of the Hillside group was beComparison: for 'Sociopsychological Variables TABLE 3.——Interhospital ' Hillside Hospital Menninger Hospital N 87 31 % I II III Social class l 17 13 28 28 O 5 20-39 40+ x2= N <12 12-15 16+ 121.5, df = 3.9, dr= 4, 100 23 % 54 23 x2 = 9.7, df = 4, [ F score { I N Arch Gen Psychiat—Vol 14, Jan 1966 x2 51 P % 41 8 = 39.2, (if = <0.001. 173 19 % 58 23 95 15 % 52 33 173 32 % 51 17 91 41 P: NS 92 10-29 30-49 50-70 L P 8, 100 19 % 59 22 <20 education 28 V = 72 3% 2O 1 x2 M M HC 51 IV N Age 133 7% 34 34 L Years of educa— Hillside Hospital 4, P % 49 10 <0.05 163 33 % 50 17 <0.001 76 20 % 38 42 �SOCIOPSYCHOLOGICAL ASPECTS OF TREATMENT—KAHN ET AL TABLE 4.—Inicrhospital Difi‘ercnccs in Treatment Variables Menninger Hillside Hospital Hospital MMIIC 100 Ty pe of treatment Psychotherapy [ Duration of hospitalization Somatic Other 21% 43 36 x2=82.,8 df=4, P <0.001 NMo <7 Mo >11 M0 7- 11 100 22 % 13 65 x3=90.,6 df=4, P RecoveNred,1 % evaluation much1m- proved Improved Unimproved x2=29.3, df= N Discharge diagnosis 80 19 4, 89 24 % 68 8 173 27 % 42 31 67 % 27 172 23 % 88 28 % 5 5 P 62 15 61 171 52 22 S5 54 10 <0001 95 43 % 5 Schizophrenia Affective psychosis Psychoneurosis 52 & personality disorder xa = 23.8, df = 4, P <0.001 % % 17 26 29 tween 7 and 11 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 4). At Menninger Hospital, however, a higher percentage (19%) of patients were rated as “unimproved” and only a single patient was scored “recovered” or “much improved.” The highest percentage of “recovered” or “much improved” ratings (28%) and the lowest proportion of “unimproved” (10%) were found at the Massachusetts Mental Health Center. D. Diagnosis. For statistical analysis three diagnostic groupings were made: TABLE 5.—Duration of Hospitalization, by Age Percentage of Age Group Staying Over One Year Age Below 20 20-29 30—39 40-49 50+ Menninger Hillside MMHC 81 73 61 30 36 42 14 6 6 0 0 36 30 20 0 schizophrenia, affective disorders, and psy— choneurosis and personality disorders (Table 4). The diagnostic proportions of patients within these groups were similar for Hill— side and MMHC, as slightly more than half were diagnosed as schizophrenia and one quarter as psychoneurosis or affective dis— order. In contrast, at Menninger Hospital psychoneurosis and personality disorder ac— counted for more than 50% of the popu— lation. III. Intrahospital Comparisons—The lack <0.001 99 Discharge 173 36 % 64 — 23 of meaningful criteria for the subdivision of populations, their homogeneity within each institution, and the limited sample size (several groupings were obtained which had fewer than five cases) precluded significant intrahospital comparisons. However, the trends appeared similar to those found in the earlier study. Age and F score were found related to the selection of treatment at Men— ninger 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 re— maining for the longest periods. While such relationships were significant in these two hospitals, a similar trend was noted at the MMHC (Table 5) where no patients over 40, but 14% of patients under the age of 20 remained longer than a year. Comment The patients of three voluntary psychiatric hospitals exhibited significant interinstitutional differences in social class and years of education, but not age; in distribution of California F Scale scores; and in each of the treatment variables—duration of hospital— ization, selection of treatments, and dis— tributions of diagnoses and discharge evaluations.7 Expectations based on our earlier intra-Hillside Hospital study were confirmed. The institution serving upperclass patients did have the longest duration of stay, a higher proportion of psychoneurotic diagnoses and more complex diagnostic schemata, a lower proportion of patients receiving somatic forms of therapy, and the poorest discharge ratings among the Arch Gen Psychiat—Vol 14, Jan 1966 �24 SOCIOPS‘YCHOLOGICAL ASPECTS OF TREATMENT—KAHN ET AL three institutions. Similarly, the institution serving lower—class patients did have the shorter periods of hospitalization, lower proportions of psychoneurotic diagnoses, and the better discharge evaluations. It is our impression that these differences in psychiatric treatment are related more to differences in staff attitudes and social class variables than psychiatric differences in populations. The contrasts between in— stitutions in duration of hospitalization are great, as are the complexity of diagnostic formulations, discharge evaluations, defini— tions of psychotherapy, and the details and amount of recorded data. While these stylistic differences may be dismissed as idiosyncratic, they follow a pattern related to social differences, and their consistency with expectations suggests a greater de— pendence on social class variables than ordinarily acknowledged. Such population and treatment variable relationships are interactive processes, de— termined both by the attitude of the physician and the administrative staff and by the constellation of symptoms or history which patients present. Such relationships are marked most in those psychiatric conditions where diagnostic criteria are least specific, ie, where objective criteria defining diseases of known etiology are absent, as in schizo— phrenia, psychoneurosis, personality and be— havior disorders. Under these conditions of perceptual and situational ambiguity, the ob— server’s attitudes and expectations become significant aspects of his perceptions, classi— fications, and decisions. A similar situation was clearly documented by Pasamanick et al 7 in their study of variations in diagnosis within a single institution. They observed that patients assigned at random to different wards (lid not differ in type of admission, marital status, education, age, or residence. Significant differences did occur, however, in the incidence of various diagnostic classifications among the three wards and among three administrators on one ward. As no differences in the popula— tions were demonstrated, we believe the different incidence of diagnoses reflect the attitudes of the examiners. Present psychiatric concepts of diagnosis and clinical evaluation have little meaning when transferred from one institution to another. Literal adherence to these concepts produces paradoxical results. For example, Menninger Hospital with more highly trained personnel conducting treatment, keeps its patients for the longest time, has the fewest patients diagnosed as schizo— phrenia, and yet, reports the poorest treat— ment results. At MMHC, in contrast, which is most inclusive in defining a therapist, keeps patients for the shortest periods, and has a higher proportion of the population classed as schizophrenia, reports the best treatment results. In the absence of independent criteria for the quality of care or the assessment of com— parability of populations for degree of ill— ness among the institutions, these findings do not reflect the relative therapeutic efficacy of the institutions. Since the evalua— tions are based on the institution’s own ratings, we believe that the differences reflect variations in the criteria used for evaluation of improvement rather than intrinsic psy— chiatric characteristics. In our initial Hillside study3 it was postulated that different criteria of improve— ment 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 been literally confirmed in the present study, with the staff of Menninger Hospital using a tripartite rating compared to the global rating of the other two institutions. Even considering the syndrome rating on which our comparative statistical analyses were based, it is our contention that for lower—class persons we are apt to assess improvement in relation to symptom relief or the patient’s capacity to resume work, while for upper—class persons the criteria emphasize such complex intangibles as “de— veloping insight,” or “working through one’s problems.” While these investigations have again demonstrated the role of social factors in psychiatric treatment, we have been greatly impressed by the methodological problems of studies across institutions. These institutions Arch Gen Psychiat—Vol 14, Jan 1966 �SOCIOPSYCHOLOGICAL ASPECTS OF TREATMENT—KAHN ET AL were selected for their educational leader— ship and the expectation that the recorded variables would be clearly defined. But dif— ferences in institutional style made it diffi— cult to obtain comparable data. This experience is a cue to the problems of the conventional use of comparative statistics, especially in the evaluation of psychiatric therapies. The use of discharge ratings, di— agnostic classifications, or length of hos— pitalization as criteria in therapeutic evaluations or the identification of comparable populations are subject to extensive error unless the institutions are clearly matched for staff attitudes and style as well as social class patterns in patient popula— tions. These difficulties also extend to the failures of scientists to confirm clinical or laboratory observations made in other labo— ratories, for the lack of confirmation may reflect differences in populations and psy— chiatric criteria as much as errors in the original hypotheses. The use of the terms “schizophrenia” or “psychoneurosis” to explore changes in psychological and biological features of mental illness has led to a science burdened by negative results. Even were a valid observation to be reported from one laboratory today, we do not have the methods to describe psychiatric populations adequately for a satisfactory test of the hypothesis. Increased attention must be paid to the classification of subjects by “objective” criteria rather than our present methods, so highly dependent on institu— tional and observer attitudes and the socio— psychological aspects of the therapist—patient interaction. 25 Summary Population characteristics, defined by social class, age, education, and F score; were related to treatment variables in three voluntary teaching hospitals. Treatment vari— ables included type of treatment, duration of hospitalization, diagnosis, and discharge evaluation. Interinstitutional differences were observed in patient social class, years of education, and distribution of California F scores, but not age. The variations in treatment characteristics among institutions were significantly differ— ent in the predicted direction. The institution serving upper-class patients did have the longest duration of stay, a higher proportion of psychoneurotic diagnoses, and more com— plex diagnostic schemata, a lower proportion of patients receiving somatic forms of therapy, and the poorest discharge ratings among the three institutions. Similarly, the institution serving lower-class patients did have the shorter periods of hospitalization, lower proportions of psychoneurotic diag— noses, and the better discharge evaluations. These variations in psychiatric practices followed a pattern consistent with the social class differences among the institutions and are not regarded as idiosyncratic. Such differences in institutional style make comparisons of diagnoses, duration of hos— pitalization, and treatment results between institutions difficult and tenuous, and the need for more objective criteria for the classification of psychiatric populations is emphasized. Aided, in part, by grants MY-2092 and MY-2715, of the National Institute of Mental Health, US Public Health Service and the Nassau County Mental Health Board. Dr. Max Pollack aided in gathering material for this study. REFERENCES Hollingshead, AB, and Redlich, F.C.: Social C lass and Mental Illness: A Community Study, New York: John Wiley & Sons, Inc., 1958. 2. Kahn, R.L.; Pollack, M.; and Fink, M.; Social Factors in the Selection of Therapy in a Voluntary Mental Hospital, J Hillside Hosp 6:216—228, 1957. 3. Kahn, R.L.; Pollack, M.; and Fink, M.; Sociopsychologic Aspects of Psychiatric Treatments in a Voluntary Mental Hospital: Duration of Hospitali— zation, Discharge Ratings and Diagnosis, Arch Gen Psychiat 1:565—574, 1959. 1. al: The Authoritarian sonality, New York: Harper & Brothers, 1950. 4. Adorno, T.W., et Per— Kahn, R.L.; Pollack, M.; and Fink, M.; Social Attitude (California F Scale) and Convulsive Ther— 5. apy, J Nerv Ment Dis 130 2187-192, 1960. N.H., et al: Social Class, Diagnosis and Treatment in Three Psychiatric Hospitals, Soc Problems 10 :191-196, 1962. 7. Pasamanick, B.; Dinitz, S.; and Lefton, M.; Psychiatric Orientation and Its Relation to Diagnosis and Treatment in a Mental Hospital, Amer J Psychiat 116:127-132, 1959. 6. Siegel, Arch Gen Psychiat—Vol 14, Jan 1966 �26 Families of Children Wit nia hi hood SchizoPhr Early Sc ected Demographic Informajion L IS HENDRICKSON LOWE, MA, INDIANAPOLIS PREVIOUS STUDIjS regarding the etiological importance of l‘family background in childhood schizophr ia have produced Kanner4 i ressions. and diverse findings has stated that autistic hildren are usually found to have intellige , sophisticated pareducational attaine high have who 3a ents level. In his populatio 10f autistic patients, grad— school high the we of parents 94% and 49% fathers of while 74% uates, of the mothers had co 'pleted college. In another publication,3 he ‘emarked on a low incidence of divorce :1 ng these families. Bender,1 on the other h d, has noted that 'ong the parents no such trends exist of schizophrenic childre seen at Bellevue, " t " wide variety of backgrou It has also been rep ed that a fairly in is a s common to of ratio boys high these that and ion, schizophrenic pop children are freq fly the firstborn in their male-fe— the lists nder2 sibling group. 1 in a group of 142 male ratio as 7 of under chil age. en years schizophrenic autistic 27 of ulation with a Phillips,6 is which boys, that noted were children, also He 6:1. ratio male—female 0 early a autistic of ition ordina data on presents children. In the general opulation, the ex— is 44.12%.6 children firstborn of rate pected In a group of 635 disturbed (but nonautistic) children, Phillips found that 27 the of while firstborn, 76.38% were autistic children, 81.5% were firstborn. that to data these suggest Phillips interprets autistic children differ from the normal population in matters of sexual ratio and ordinal position as do lesser disturbed chil:1 of the suggestion out dren. He points continuum, with more vere childhood dis— turbances appearing cw comitantly with a higher ratio of boys 'l girls, and with a ‘l stborn children. It higher proportion of should be noted that ny data on ordinal position can be undistood better when viewed in conjunctio with maternal age at the birth of the chi these various re— Discrepancies amo ports of data may be due to disparities in om which samples patient populations were drawn. Bender nd Kanner, however, drew their patient ample from different population groups ,' ith respect to socio‘anner’s probably came economic status. largely from peopl in higher socioeconomic groups in a unive ity community while Bender had a wide population to draw from in New York ci . Since this poten— tial error is compounc d by the relatively low incidence of c'dhood schizophrenia in the general . The p pose of the present paper is to make .available pertinent information collected etween 1955 and 1963 in the Chil— dren’s S :VICC of LaRue D. Carter Me— morial Ho' ital, Indianapolis. The data on children is compared with that schizophre obtained on y-\turbed children given diag— childhood schizophrenia. noses other Since LaRue Hospital is the only nit for disturbed residential treatmen youngsters in the stat of Indiana, the patient population is probably representative of all geographic areas of the state as well as a variety of socioeconomic backgrounds. t Ca Method Subjects.—Included in the study were the children whose preadmission diagnosis was one of emotional disturbance, whether or not the child was admitted Arch Gen Psychiai—Vol 14, Jan 1966 Submitted for publication March 18, 1965. From the Indiana University Medical Center. . Reprint requests to 64 Mercury Ct, West Springfield, Mass 01089. �Sociopsychological Aspects of Psychiatric Treatment in Three Voluntary Hospitals Robert L. Kahn, Ph.D.*, Max Fink, M.D.**, Nathaniel Siegel, Ph.D.*** �This study was done when the authors were associated at the Department of Experimental Psychiatry, Hillside Hospital, Glen Oaks, L. I. New York, 1959— 1962. cooperation of Dr. Max Pollack and the staffs of the Massachusetts MEntal Health Center and the C. F. Menninger Memorial Hospital is gratefully acknowledged. The Aided, in part, by grants My—2092 and MY—2715, of the National Institute of Mental Health, U.S. Public Health Service; and the Nassau County Mental Health Board. * Present Address: Division of Psychiatry, Montefiore Hospital and Medical Center, 111 East 210th Street, New York, New York ** Present Address: 10467. ‘ Department of Psychiatry at the Missouri Institute of Psychiatry, School of Medicine, University of Missouri, 5400 Arsenal Street, St. Louis, Missouri 63139 *** MIP 2/1/65 Present Address: National Institute of Mental Health, Bethesda, Maryland �Sociopsychological Aspects of Psychiatric Treatment in Three Voluntary Hospitals Robert L. Kahn, Ph.D.*, Max Fink, M.D.**, Nathaniel Siegel, Ph.D.*** �In their studies of the New Haven psychiatric patient population, Hollingshead and Redlich have reported significant relationships between an individual's position in the social class structure hand the incidence of treated illness, types of diagnosed disorders and kindsand duration of psychiatric treatment administered (2), The influence of the economic status of the patient on the availability of treating personnel, however, was not excluded, Studies of the role of social factors in the treatment of hospitalized patients independent of their financial status and the availability of treatments were undertaken at Hillside Hospital in 1957. In this hospital, a variety of treatment modes, including individual psychotherapy, pharmacotherapy and convulsive therapies were available to all patients regardless of their ability to payu In these surveys (3,4) we observed that patients hospitalized for the shortest periods were older, had less education and were more often of foreign birth, These older, less educated patients were predom— inantly treated by convulsive therapy and received more favorable clinical discharge ratingsa In contrast, younger, native born and more educated patients were hospitalized for longer periods, treated primarily by psychotherapy and received poorer discharge ratingso These clinical factors were also related to a measure of stereotypy, the California F Scale (1,5)c Higher F scores, i.e,, greater stereo— typy, were often found in patients diagnosed as involutional psychosis, who were referred for convulsive therapy, hospitalized for shorter periods, and more often were rated as much improved or recovered, In the survey reported here, it was suggested that dif— ferencesin psychiatric treatment among hospitals should reflect the influence of social factors as noted for the patients within Hillside Hospital, To test this suggestion it was decided to employ the pro— cedures of the 1957 Hillside study in three institutions -‘ Hillside Hospital, the C. F° Menninger Memorial Hospital in Topeka and the Massachusetts Mental Health Center in Bostono These institutions were selected with the expectation that they had diverse treatment modalities equally available, yet served patients of different social classes° Each provided short-term treatment of voluntary patients and did not provide custodial care, Each is a residency training center with a full time supervisory staff and active research units, emphasizing psycho— analytically—oriented psychotherapy, This study was designed to determine the population character— istics of the three institutions with respect to social class, age, education and F score; and to relate these characteristics to treatment variables of type of treatment, duration of hospitalization, diagnosis and discharge evaluation among the institutions, �..2.~ METHOD A census of all voluntary, adult patients in residence in the institutions was 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 schizo— phrenic state hospital group transferred for a specific research project. These patients were excluded from the study because of their non—voluntary statuso The California F scale was scored for each patient 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 (3,4,7)o The study population consisted of 173 patients at Hillside, 100 at Menninger and 95 at the Massachusetts Mental Health Centero — study included examination of the relations of the social to the psychiatric variables within each institution as well as between institutionso These comparisons were difficult however, because of various methodological differences discussed below. These difficulties were most marked in the intrathospital comparisons, and accordingly, in the analyses of psychiatric variables emphasis will be placed on the differences between institutions with citation of intra—institutional trendso These difficulties also led to missing information for some data, which is reflected in the tables by the varying population sample sizeso The �RESULTS A. Methodological Problems reporting studies from one institution, the structure of the hospital may be taken for granted and either ignored or mentioned briefly. In gathering comparable data from multiple institutions, however, the many differences between institutions are accen— tuated. While these institutions were selected as comparable in teaching, research and treatment programs, they were functionally unlike in ways which influenced the data of the study. Specific differences were prominent in the designation of type of treatment, diagnostic classifications, and the evaluation of treatment outcome, When 1. Designation of Type of Treatment: The designating that a patient received "psychotherapy" the institutions, making comparisons difficult. criteria for differed among At Menninger Hospital psychotherapy was designated as treatment administered on a prescription basis by a staff psychiatrist for which the patient was charged a feeo Sessions with the psychiatric resident were considered part of routine administrative patient care. Hillside Hospital psychotherapy was defined as treatment sessions with a psychiatric resident. Staff psychiatrists did not treat patients, but restricted their activities to supervising res~ ident physicianso No additional fees were chargedo At At the Massachusetts Mental Health Center psychotherapy designated as the activity of many disciplines -- psychiatric residents, psychologists, social workers, nurses and medical students, Formal records of such sessions were not routinely included in the patient's record and to ascertain which patients received psycho— therapy it was necessary for members of the study team to interview the resident responsible for each case. was 2. Diagnosis: Individual institutional diagnostic styles made comparisons difficult. At Menninger HOSpital diagnoses employed the multiple evaluative scheme recommended by the American Psychiatric Association, while both Hillside and MMHC followed different unitary systemso 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 distortiono �Table I Discharge Ratings of Improvement: Ratings of im~ provement at the three hospitals varied in format and detail. The discharge rating at Menninger Hospital was tripartite with a sep— arate evaluation for social, characterological and syndrome changes. Hillside Hospital and Massachusetts Mental Health Center had global ratings making it difficult to assess the contribution of each factor of the Menninger system (Table II)a For this study the Menninger syndrome rating was compared to the global ratings of the other 30 institutionsw Table B. II Inter—hospital Comparison 1. Sociopsychological Variables The distribution of the variables of social class, age, California F Scale score among the three institutions education and is presented in Table III. Table a) Social Class: The III . anticipated difference in social class composition of the three institutions was observedo At Menninger Hospital the population was predominantly upper class; At Hillside Hospital, middle class; and at Massachusetts Mental Health Center, predominantly lower class. b) Age: There were no differences in age in the institutional populationso distribution �populations also differed in edu—' cational attainment, with patients having mOre years of education at Menninger Hospital than at Massachusetts Mental Health Center. While 41 per cent of the patients at MMHC had not completed high school, only 32 per cent at Hillside and 23 per cent at Manninger did not graduateo c) Education: The Score: Differences in the distribution of scores on the California F Scale were also observed. Fifty—one per cent of Menninger patients had F scores below 30, and only eight per~ cent with scores of 50 or above —- the higher F scores being associated with higher degrees of stereotypy. In contrast, at Hillside thirty—one per cent of the patients had F scores below 30 while at MMHC only twenty per cent were below 300 d) F Thus, differences in social class, educational attain— ment and performance on the F Scale were observed. These diff— erences permit a test of the hypotheses relating sociopsychologi- cal factors to the treatment variables 2. among these institutions. Psychiatric Treatment Variables a) Selection of Treatment: Among the institutions, significantly fewer patients at Menninger Hospital (43%) received somatic therapy than at Hillside (64%) or MMHC Hospitalization: (68%) (Table IV), three insti~ tutions differed with regard to patient's length of stay (Table IV)9 Patients at Menninger Hospital were hospitalized longest, with 65% of patients remaining for twelve months or more, compared to 31 per-cent of the Hillside patients and only 5 per-cent at the Massachusetts Mental Health Center. The modal stay of the Hillside group was between seven and eleven months while two-thirds of the MMHC patients were discharged within six months of hospitalization° b) Duration of The c) Discharge Evaluation: In each hospital, most patients were evaluated at the time of discharge as "improved" (Table IV), At Menninger Hospital, however, a higher percentage (19%) of patients were rated as "unimproved" and only a single patient was scored "recovered" or "much improved"e The highest percentage of "recovered" or "much improved" ratings (28%) and the lowest proportion of "unimproved" (10%) were found at the Massachusetts Mental Health Centerm nostic d) Diagnosis: For statistical analysis groupings were made: schizophrenia, affective three diag— disorders, and �psychoneurosis and personality disorders (Table IV). The diag— nostic proportions of patients within these groups were similar for Hillside and MMHC, as slightly more than half were diagnosed as schizophrenia and one—quarter as psychoneurosis or affective disordero In contrast, at Menninger Hospital psychoneurosis and personality disorder accounted for more than fifty per-cent of the population° Table IV C. Intra—Hospital Comparisons lack of meaningful criteria for the subdivision of populations, their homogeneity within each institution, and the limited sample size (several groupings were obtained which had fewer than five cases) precluded significant intra—hospital comparisonso However, the trends appeared similar to those found in the earlier study, Age and F score were found related to the selection of treatment at Menninger Hospital (older and higher F score patients more frequently receiving somatic therapy), and F score alone at Hillsidec Length of hospitalization and chron— ological age were related at both the Menninger and Hillside Hospitals - the younger patients remaining for the longest periods“ While such relationships were significant in these two hospitals, a similar trend was noted at the MMHC (Table V) where no patients over 40, but 14% of patients under the age of 20 remained longer than a yeare The Table —-—\ V �-7DISCUSSION patients of three voluntary psychiatric hospitals exhibited significant inter-institutional differences in social class and years of education, but not age; in distribution of California F Scale scores; and in each of the treatment var— iables duration of hospitalization, selection of treatments and distributions of diagnoses and discharge evaluations (7), The —— Expectations based on our earlier intra—Hillside Hospital were confirmed, The institution serving upper class patients did have the longest duration of stay, a higher proportion of psychoneurotic diagnoses and more complex diagnostic schemata, a lower proportion of patients receiving somatic forms of therapy, and the poorest discharge ratings among the three institutionso Similarly, the institution serving lower class patients did have the shorter periods of hospitalization, lower proportions of psychoneurotic diagnoses, and the better discharge evaluations. It is our impression that these differences in psy— chiatric treatment are related more to differences in staff attitudes and social class variables than psychiatric differences in populationso The contrasts between institutions in duration of hospitalization are great, as are the complexity of diagnostic formulations, discharge evaluations, definitions of psychotherapy, and the details and amount of recorded data, While these styl— istic differences may be dismissed as idiosyncratic, they follow pattern related to social differences, and their consistency with expectations suggests a greater dependence on social class variables than ordinarily acknowledged, a population and treatment variable relationships are interactive processes, determined both by the attitude of the physician and the administrative staff and by the constellation of symptoms or history which patients presento Such relationships are marked most in those psychiatric conditions where diagnostic criteria are least specific, gig}, where objective criteria de— fining diseases of known etiology are absent, as in schizophrenia, psychoneurosis, personality and behavior disorderso Under these conditions of perceptual and situational ambiguity, the observer's attitudes and expectations become significant aspects of his per— ceptions, classifications, and decisions. A similar situation was clearly documented by Pasamanick, Dinitz and Lefton (6) in their study of variations in diagnosis within a single institution. They observed that patients assigned at random to different wards did not differ in type of admission, marital status, education, age or residence. Significant differences did occur, however, in Such �the incidence of various diagnostic classifications among the three wards and among three administrators on one ward. As no differences in the populations were demonstrated, we believe the different incidence of diagnoses reflect the attitudes of the examiners, Present psychiatric concepts of diagnosis and clinical evaluation have little meaning when transferred from one institution to another, Literal adherance to these concepts produces paradoxical resultso For example, Menninger Hospital with the more highly trained personnel conducting treatment, keeps its patients for the longest time, has the fewest patients diagnosed as schizophrenia, and yet, reports the poorest treatment results. At MMHC, in contrast, which is most inclusive in defining a therapist, keeps patients for the shortest periods, and has a higher proportion of the population classed as schizophrenia, reports the best treatment resultso In the absence of independent criteria for the quality of care or the assessment of comparability of populations for degree of illness among the institutions, these findings do not reflect the relative therapeutic efficacy of the institutions° Since the evaluations are based on the institution's own ratings, we believe that the differences reflect variations in the criteria used for evaluation of improvement rather than intrinsic psychi— atric characteristics. initial Hillside study (4) it was postulated that different criteria of improvement were utilized for persons of different social background, It was suggested that the higher the person's social background the more complex the criteria employedo This has been literally confirmed in the present study, with the staff of Menninger Hospital using a tripartite rating compared to the global rating of the other two institutionso Even considering the syndrome rating on which our comparative statistical analyses were based, it is our contention that for lower class persons we are apt to assess improvement in relation to symptom relief or the patient's capacity to resume work, while for upper class persons the criteria emphasize such complex intangibles as In our "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 great— ly impressed by the methodological problems of studies across in— stitutions. These institutions were selected for their educational �leadership and the expectation that the recorded variables would be clearly defined. But differences in institutional style made it difficult to obtain comparable data. This experience is a cue to the problems of the conventional use of comparative statistics, especially in the evaluation of psychiatric therapies. The use of discharge ratings, diagnostic classifications or length of hos~ pitalization as criteria in therapeutic evaluations or the iden— tification of comparable populations are subject to extensive error unless the institutions are clearly matched for staff attitudes and style as well as social class patterns in patient populations. These difficulties also extend to the failures of scientists to confirm clinical or laboratory observations made in other labor— atories, for the lack of confirmation may reflect differences in populations and psychiatric criteria as much as errors in the orig— inal hypotheses. The use of the terms "schizophrenia" or "psycho— neurosis'l to explore changes in psychological and biological features of mental illness has led to a science burdened by negative results. Even were a valid observation to be reported from one laboratory today, we do not have the methods to describe psychiatric populations adequately for a satisfactory test of the hypothesis. Increased attention must be paid to the classification of subjects by "objective'' criteria rather than our present methods, so highly dependent on institutional and observer attitudes and the sociopsychological aspects of the therapist—patient interaction. �-10- SUMMARY AND CONCLUSION Population characteristics, defined by social class, age, education and F score, were related to treatment variables in three voluntary teaching hospitals. Treatment variables in— cluded type of treatment, duration of hospitalization, diagnosis and discharge evaluationw Inter—institutional differences were observed in patient social class, years of education and distribution of California F scores, but not age. variations in treatment characteristics among institutions were significantly different in the predicted direction. The institution serving upper class patients did have the longest duration of stay, a higher proportion of psycho— neurotic diagnoses and more complex diagnostic schemata, a lower proportion of patients receiving somatic forms of therapy, and the poorest discharge ratings among the three institutionsc \Similarly, the institution serving lower class patients did have the shorter periods of hospitalization, lower proportions of psychoneurotic diagnoses, and the better discharge evaluations, The variations in psychiatric practices followed a pattern consistent with the social class differences among the institutions and are not regarded as idiosyncratic. These differences in institutional style make comparisons of diagnoses, duration of hospitalization and treatment results between institutions difficult and tenuous, and the need for more objective criteria for the classification of psychiatric populations is emphasizedo Such �REFERENCES l. Adorno, T. W., Frenkel-Brunswik, E., Levinson, D. Sanford, Brothers, R. N. The New Authoritarian Personality° York, 1950, 990 pp. J. and Harper and 2. Hollingshead, A. B. and Redlich, F. C. Social Class and Mental Illness: A Community Study. John Wiley and Sons, Inc., New York, 1958, 442 pp. . L., Pollack, M. and Fink, M. Social Factors in the Selection of Therapy in a Voluntary Mental Hospital. J. Hillside Hosp., 1957, 6: 216—228. Kahn, R. L., Pollack, M. and Fink, M. Aspects of Psychiatric Treatments in a Hospital: Duration of Hospitalization, G Ps h' Diagnosis. 1959, ., Kahn, R. Kahn, R. ifornia F L., Pollack, Sociopsychologic Voluntary Mental Discharge Ratings and is 565-574. Fink, M. Social Attitude (Cal— Scale) and Convulsive Therapy. .lefiflah_lkflflfi_Dlfi,, M. and 1960, lfifl: 187-192. Pasamanick, B., Dinitz, S. and Lefton, M. Psychiatric Orien— tation and its Relation to Diagnosis and Treatment in a Mental Hospital. Ameri_la_£sxchiat., 1959, 116: 127-132. Siegel, N. H., Kahn, R. L., Pollack, M. and Fink, M. Social Class, Diagnosis and Treatment in Three Psychiatric Hospitals. Social Problems, 1962, lg; 191—196. �TABLE I Redesiggation of Discharge Diagnoses Menninger Discharge Diagnoses Depressive Reaction Narcissistic Personality Anxiety Reaction General Classification Psychoneurosis Narcissistic Personality Psychoneurosis Narcissistic Personality Narcissistic Personality Personality Trait Disturbance Alcoholism, Chronic Sociopathic Personality Disturbance Passive Aggressive Personality Sociopathic Personality Disturbance Infantile Personality Alcoholism Infantile Personality Schizophrenic Reaction, Schizo—Affective Type Schizophrenic Psychosis �TABLE II Comparative Ratings of Clinical Condition At Time of Hospital Discharge MENNINGER HOSPITAL Social Adjustment Improved Unimproved Character Structure Improved Unimproved Syndrome Complete_Remission Improved Unchanged (or worse) HILLSIDE HOSPITAL MASSACHUSETTS MENTAL HEALTH CENTER Recovered Recovered Much Improved Markedly Improved Improved Moderately Improved Unimproved Slightly Improved Unimproved �TABLE Interhosgital Comgarisons for Sociogsxchological Variables MEnninger Hospital N I Social Class III Hillside Hospital Massachusetts Mental Health Center IIIIIKEEIIIIIIHIIIIIEIIIIIIIIIIIIIIIHEIIIIIIII 31% 7% II 51 20 III 17 34 . . IV 1 34 V O 5 X 2 = 121.5; df=8: p<.OOl IIIIIIIIIIIIIIIIHNIEIIIIIIIIIIIHHIIIIIIIIIIIIIIIJBHIIIIIIII 19/ Ag e 20- 39 IIIINIIIIIlllllflflddflllllIIIIIIIHHEIIIIIIIIIIIEHIIIIIIIII Years of Educatio < 12 41% 12-15 49 16+ 10 x2 = 39.2; df=4; p<.001 �TABLE IV Interhospital Differences in Treatment Variables jMenninger N Treatment Massachusett Mental Healt Center .m-m-mHospital Type of Hillside Psychotherapy Hospital Somatic Other =82 8 Duration of , Hospitallzatlon 7 df= 4 . .001 months 7-11 months ~11 months Discharge Improved Evaluation Unimproved X = Schizophrenia 29.3' df=4' .<.001 ' Discharge Diagnosis Affective Psychosis Psychoneurosis and Personality Disorder X = 52% 54% 22 17 26 29 23.8' df=4' -<.001 �TABLE V Duration of Hospitalization By Age PERCENTAGE OF AGE GROUP STAYING OVER ONE YEAR Ass Menninger Hillside Below 20 81 42 20-29 73 36 30—39 61 30 40-49 30 20 50+ 36 MMHC 14 �TABLE V Duration of Hospitalization By Age PERCENTAGE OF AGE GROUP STAYING OVER ONE YEAR Menninger Agg Below 20 Hillside 81 20-29 73 30-39 61 30 ho-h9 30 20 50 + MMHg �TABLE IV Interhospital Differences in Treatment Variables Menninger Hillside Massachusetts .m---Hospital N Psychotherapy Somatic of Treatment Type WW Other l Duration of Hospitalization Hospital Mental Health Center 9 21% 36% 2b% h3 6h 68 36 -- 8 » . _ . _..W.xi:82-8:.§_£:-hz P<-001 mud-Mm...“ w...» W 7-11 months x2=90.6; df=h; p<.OOl Recovered, Improved Discharge Evaluation f ‘> . 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Thane imfitndmmumfwfinbcmfiamlumpmdfln Wmmmdmbmmdmmmwmd. obtain mm Mammuammfinpmblmofflumdaulm 65.1ch data. But in style made it difficult to mmblc ofmantiwstafiatim,apocidlyinfiuommimofmmimie Mics. Mmofdismmfim,dimficfludflafimsor Mdmitmufimumminmmmwfiu to extensive of warm imtitutims mien countable popuhflms the m clan-1y m swim mm m for staff attitudn cad styhumllusocialclasspaminpatimtpomlafiom. cholicve mmfmmmommfiufaflmofmimfisummflm mbmmrmdmmimmmmmmmw sdmbmduudbymmiwmulu. Manudobmatimtobo Whamlnbomtmy,ttnmfimdsmmtavaflablctodaym mmmmmmmmrwmmmm. �-13- Inam‘asod attunticn must ho paid to tho althodblogiaal prcblumn of classifying mjom mlthads, so highly dnpgndant an m criteria institutional by ”objcativa" than the present and obonrvur attitudul mmmmmmmammm-pmmm. �Wmmnsxm 1. Infimowydmmic-mmmmgmfitnn, WWmmammmmmtm-hbm. Populatimsmdcflmdbyaomlelus,m,adumtimmfsm. mmmhmmtypoofumt,dmfimofhmpitmadm. Wwflmmmflm. 2. 3191131121“: inurhwfitutianl diffm m obscured in Wflmofpatimtsoahlelus,ymofodmutimm diuudbufimofcuifwml‘m,butmtago. mmmmmwummmum timmfmmbouigflfimflydifimtinmpmdicmd 3. dim. It. mmmmymammmnmnm mumtwithmmclusdflfmwmgimflmdmsmdm thuidiosynmtie. 5. matrmmmmmmummmof W,mumof)mpimnmim,mdmammultnbam mmwfimdtmmm,mmmdfmmobjwdw «imamimdmofmmfimsismim. �REFERENCES 1. Adorno, T.w., Frenkel-Brunswik, E., Levinson, D.J. and Sanford, & New Brothers York, Harper R.N.: The Authoritarian Personality, 1950. Two-Factor Index of Social Position, Hollingshead, A.B.: mimeo— graphed publication. Mental and Class Social F.C.: Redlich, & New John Sons, Inc., Wiley York, Community Study, Hollingshead, A.B. and Illness: A 1958. 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: §g_p., 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, Arch. Gen. Psychiat., l: 565—57h, 1959- (CaliM. M.: Attitude Social and Fink, Pollack, R.L., & Ment. Nerv. F Dis., J. and Convulsive Therapy, fornia Scale) Kahn, 122: 187-192, 1960. Pasamanick, B., Dinitz, Psychiatric OrientaTreatment in a Mental S. and Lefton, M.: tion and Its Relation to Diagnosis and 1959. 127-132, Amer. J. Psychiat., llé: Hospital, Siegel, N.H., Kahn, R.L., Pollack, and Treatment in Three M. and Pink, M.: Social Class, Diagnosis Psychiatric Hospitals, Social Problems, 10: 191—196, 1982. �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 HILLSIDE HOSPITAL MASSACHUSETTS MENTAL HEALTH CENTER Recovered Recovered Much Improved ~W‘_ Improved Moderately Improved Unimproved Slightly Improved Improved Unimproved Unimproved Syndrome .._.W Complete Remission Improved Unchanged (or worse) Markedly Improved W- �III TABLE InterhosEital Comparisons for SocioEsychological Variables Hillside Menninger ; Hospital Hospital Education 17 ’ (92) N 3 Score 1 i ’ F Massachusetts Mental Health ; 10-29 1 3o-h9 W7 51% i ’41 g (163) 33% 50 10 g i 76 20% 1 '1 38 } 50-70 8 1 i 17 g M �TABLE IV Interhospital Differences in Treatment Variables Massachusetts lHillside iMenninger Mental Health Center IHospital ‘Hospital ‘Psychotherapy of Treatment Type Somatic h3 Other Duration of Hospitalization 36 ’ 7-11 months 1 months Recovered, Improved Discharge Evaluation Much Improved 61 ’ . 'Unimproved 10 % I 9 . - _ mw.,,__,‘<2=29-3s df=1v fianQwawiwflj I Discharge Diagnosis tr-‘a-m-th-A _ ...-A.Wn‘.m Schizophrenia Affective Psychosis Psychoneurosis and Personality Disorde .W--- 85 Sh% 1? 26 29 ”- -.- —-”“— w- �TABLE V Duration of HosEitalization By Age PERCENTAGE OF AGE GROUP STAYING OVER ONE YEAR Menninger Hillside Below 20 81 h2 20-29 73 36 30-39 61 3O hO-h9 3O 20 50+ M9 �‘— ‘7 -w vuwlr-u'rflmmm —-u-- “Tm—“vii W Hm: W. 21, man 911.13. Hill-M- Wu}. P. 0. Dan: 33 man Odes. the You: W81 , mm. mm mmmlht: MWWIMBWMbyaWo-n I whammmm'mmmmmmrmunm. Midwinbutlmzldlfluewrymm IMMMM Mtfizhfwwblmw . Wumflulntdmfimfm Wh.metMtoajml,ImflAlihto$smm-d Hm,I mmmmwmuwmmm. singlubmmtittoamoffiujwmmmwm to . 81 FILE. ‘ ‘ mm,mmmqumummxwmt mwmumwtm-mmdtmjmw. WWW. ma: �flv psychiatric treatment, haMflm and research December 2h, l96h Dr. Max Fink Missouri Institute of Psychiatry Shoo Arsenal St. St. Louis, Missouri Dear Max: (E) / (:> let, the have reread I In reply to your letter to and objections my original paper on sociological aspects the skirts I feel no altered. it in way this paper are whole problem of diagnosis which Nat in a previous paperwhich and than social class, has shown to be more ;important True, variable. be crucial a VA showed to I in the paper disturbed more severely younger same institution within the of time period a and longer for kept patients are treated and all this is relative to the philosophy of the the in not reported at all is This viewpoint institution. paper. form. in present its of in publishing favor not it I am Should you have some specific need for seeing it published, removed. was name my providing no objection I would have collaborate to want should you authormanship, of Speaking variables and psychological EEG and psychiatric on the findings I would have no objection. My best wishes to you, Martha and the kids for a Joyous New Year. have him I and Turan to tell Please give my regards ordered a copy of his book. Sincerely yours, of the 10m»; MP:gp Pollack, Ph.D. Senior Research Associate Max �m 21, 196‘! mmmrmtmmmgm-ormw;md fdfluMdmmm-Jmlofwmommfia Mfllhdmlafhyuhhm. mfiwmhfin ”magma-mum. hmmhmyw. and: Enema-mu cc: Pollack Ph.D. Nathmial siegel, Ph.D. Max �MONTEFHMHCHUSPVRHJAND MEDHLMACENTER 111 EAST 210TH STREET. BRONX, NEW YORK 10467. TELEPHONE: 212/TU 1-1000 January 19, 1965 Fink, Director max M.D. Missouri Institute of Psychiatry suoo Arsenal Street St. Louis, Missouri 63139 Dear Max: I think the paper is fine, and would touch it as little as possible. Your choice of Journal is excellent. For my part, go ahead and submit it. The only change concerns the here - "Mbntefiore Respital and Mbdical Center" and the revised address as revised name shown on this letter. It to see you and I pleased that you are doing well. was good am Best regards to Martha. Sincerely, RLK:FB Rdbert L. Kahn, Ph.D. Head, Section on Psyology Division of Psychiatry �DEPARTMENT OF HEALTH. EDUCATION. AND WELFARE PUBLIC HEALTH SERVICE BETHESDA. MD. 20014 December 31, 1964 NATIONAL INSTITUTES OF HEALTH AREA CODE aoI TEL: ass—mo In reply refer to: M-TMR-SS AIRMAIL Dr. Max Fink, Director Missouri Institute of Psychiatry 5400 Arsenal Street St. Louis, Missouri 63139 Dear Max: I was pleasantly surprised to see the paper on "Sociosociological Aspects of Psychiatric Treatment in Three Voluntary Hospitals" again. I was really delighted that you resurrected it and have taken responsibility of submitting it to one of the journals that you listed. I have no real preference for one of various journals that you mentioned. I would think it would be most unlikely to be published in Psychiatry, but I am sure you share this opinion since you listed it last in your order. In all honesty, in rereading the manuscript, I found it to be much better than I remember it. Most of my comments are of a stylistic nature. Here, however, I would bow to you as the collator of the document to use the style that you prefer. My own penciled comments are, however, on the paper. V/ I think the main contribution that this paper has to make, and should make, has to do with the methodological problems that are involved in doing cross-hospital studies or in doing hospital studies within the same institution over a period of time. As you indicate in the paper, on page 4, that when one reports studies from one institution, the structure of the hospital is either taken for granted or ignored. Cer— tainly, we should be elaborating on this in great detail, and the methodological aspects of doing a study, such as the one we have done, Should occupy a major area of the report in its own right. For this reason, I am not sure I would report methodological problems as we have done on page 4. I think that it should either occupy a place of its own in the discussion or might indeed exchange status with "AH Interhospital Comparisons on page 4, and become the "A" category, or interchange and make Interhospital Comparisons the "#1" category. Most of the things that we want to say are in the paper but, as I have indicated, I am a �2. little unhappy about interweaving our "findings" with the "methodological not being our intent in the original investigation in the also, report. more I, important the I being think ...and, yet, would I of the author be try to should senior paper. believe that you own in and autonomy right its give problems it methodological the spotlight Section." 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MWuwa-mw. mammmmwmmummw m.mawunuum.newmum mmmtum.mmmmmwmdw B. wwwmmamnw �REFERENCES 1. and D.J. Sanford, Levinson, Adorno, T.W., Frenkel-Brunswik, E., & New Brothers York, Harper R.N.: The Authoritarian Personality, ' 1950. 2. Hollingshead, A.B.: Two-Factor Index of Social Position, mimeo— graphed publication. 3. Hollingshead, A.B. and Illness: A Community Redlich, F.C.: Social Class and Mental & New John Sons, Inc., Wiley York, Study, 1958. h. R.L., Pollack, Selection of Therapy in M. Kahn, Social Factors in the Voluntary Mental Hospital, J. Hillside and Fink, M.: a Hos2., g: 216-228, 1957. S. R.L., Pollack, M. and Fink, M.: Sociopsychologic Aspects of Psychiatric Treatments in a Voluntary Mental Hospital: and Diagnosis, Ratings Discharge of Duration HOSpitalization, Kahn, Arch. Gen. Psychiat., 6. l: 565—57h, 1959- (CaliAttitude Social R.L., Pollack, & Ment. Nerv. F J. Dis., and Convulsive Therapy, Scale) fornia M. Kahn, and Fink, M.: 129: 187—192, 1960. 7. Pasamanick, B., Dinitz, tion Hospital, and 8. and to Diagnosis Relation Its Amer. J. Psychiat., 116: 127-132, l9S9. Siegel, N.H., Kahn, R.L., Pollack, and Treatment Psychiatric OrientaTreatment in a Mental S. and Lefton, M.: M. and Pink, M.: Social Class, Diagnosis in Three Psychiatric Hospitals, Social Problems, 10: 191-196, 1962 �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 HILLSIDE HOSPITAL MASSACHUSETTS MENTAL HEALTH CENTER Recovered Recovered A Markedly Improved Much Improved Improved A ! Character Structure Improved Unimproved Syndrome Complete Remission Improved Unchanged (or worse) Unimproved Moderately Improved Slightly Improved Unimproved �TABLE Interhosgital Comgarisons for Sociopsychological Variables i I Social Class Years of Education III Menninger Hospital Hillside Hospital : I Massachusetts Mental Health �TABLE IV Interhospital Differences in Treatment Variables gMenninger Hillside Massachusetts Hospital Mental Health iHospital Center ' of Treatment ‘Psychotherapy Type 68 Somatic 8 Other 1 . _fl, __ Duration of Hospitali— zation 7-11 months 1 months Improved .--a-—u.~...w Much Improved 61 Unimproved lO a,” Discharge Diagnosis , months Recovered, Discharge Evaluation ~__imiu_i_.,i_.__.::- . ”13:29-33 W Schizophrenia Affective Psychosis Psychoneurosis and Personality Disorde df=h~ 5,1001 I ‘ ”WWW” 85 22 1? 26 29 ! I S2 1 �TABLE V Duration of HosEitalization BX Age PERCENTAGE OF AGE GROUP STAYING OVER ONE YEAR £52 Below 20 Menninger Hillsidg 81 he 20-29 73 36 30-39 61 30 ho-h9 30 20 3422219. �' > %> This study was done when the authors were associated at the Department of Experimental Psychiatry, Hillside Hespital, Glen Oaks, L.I., N.Y., 1959-62. Pal/sue aux! KIRIM“ cooperation of the staffs of the Massachusetts Health Center the is The acknowledged. and C.P, Menninger Memorial Hospital Mental gratefully Aided, in part, by grants MY—2092 and MEI—2715, of the National Institute of Mental Health, U.S. Public Health Service; and the Nassau County Mental Health Board. ** Present Address: Division of Psychiatry, Montefiore Hespitalaw* ’ ' {hxxfirtfiF-itfifr IO‘NAZI g“ QM? 1.14: 0M yNL nan : National Institute of Mental Health, 'M, -flflqmam pn--~~r~Ognv m. Bethesda, Md. Department of Psychiatry at the Missouri Institute of Psychiatry ef-the-SChool of Medicine, University ot’ Missouri, suoo Arsenal Street, St. Louis) an, Ma, 6399'"! ,4 :9, �In their studies of the psychiatric patient population, Hollingshead and Redlidh have reported significant relationships between an' individual's position in the social class structure and the of treated New Haven illness, types of diagnosed disorders administered.(;%. treatment patient . The and kinds and duration W of psychiatric influence of the economic status of the the availability of treating personnel, however, was not excluded. Studies of the role of social factors in the treatment of hospitalized on #‘Ffi‘ . ' IflL srflwu‘ patients independent of pateent‘s finances and the availability of treatments were undertaken at Hillside Hespital in 1957. In this hospital, a variety of treatment modes, including individual psydhotherapy, pharmacotherapy and convulsive therapies were available to . . . . all patients regardless of their ability to pay. (Eglgé In these surveys we observed that patients hospitalized for the shortest periods were older, had less education and were more often of foreign birth. These older, less educated patients were predominantly treated by convulsive therapy and received more favorable clinical discharge ratings. In contrast, younger, native born and more educated patients were hospitalized for longer periods, treated primarily by psychotherapy and received poorer discharge ratings. These clinical factors were also related to a measure of stereotypy, the ' California F ’15’ Scale (1333. Higher F scores, i.e., greater stereotypy, were often in patients diagnosed as involutional psychosis, who were referred for convulsive therapy, hospitalized fOr shorter periods, and more often were rated as much improved or‘recovered. hen, (gram) e' In thzs surveyglit was suggested that differences in psychiatric treat— ment among hospitals should reflect the influence of social factors as noted f0und fbr the patients within Hillside HOspital. To test this suggestion it was �decided to employ the procedures of the 1957 Hillside study in three institutions Hillside Hospital, the C.F. Menninger Memorial Hespital in Topeka and the Massachusetts Mental Health Center in Boston. These institutions were selected mm» Ww-Mans.:qum-W nag-MW : with the expectation that they served patients of different social classes.and- provide custodial care. Each supervisory staff and is a residency training center with a full active researCh units) time emphasiqgugsychoanalytically— They oriented psychotherqua This study was designed to determine the population characteristics of the three institutions with respect to social class, age, education and score; F to relate these characteristics to treatment variables of type of treatment, duration of hospitalization, diagnosis and discharge evaluation among the in— and stitutions. M'MWW,.,L..««Ila-mm?” W/ “”‘MW‘WWW ”‘W “’ m "' “ t4" "M" ‘flwwmwww ”‘ W “m «a , N, WWW‘W,MM —— �/ A METHOD census of all voluntary, adult patients in residence in the institu— in January, 1959. While Manninger 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 psydhiatric evaluation or tions was undertaken of a chronic schizophrenic state hospital group transferred for a from because excluded the These study were researdh patients project. specific of their non—voluntary status. The California F scale was scored for each were members patient on the census day. Eighteen months examined were of records the disdharged patients later to determine the social and psychiatric factors of the study. For a measure of social class, the Hollingihead 2—factor index a.weighted score of education used(g;ii;.The and occupation was study population consisted of 173 patients — — at the Massachusetts Mental Health Center. social of the to the The study included examination.of the relations psychiatric variables within each institution as well as between institutions. These comparisons were difficult however, because of various methodological differences discussed below. These difficulties were most marked in the intra— hcspital comparisons, and accordingly, in the analyses of psydhiatric variables emphasis will be placed on the differences between institutions with citation of at Hillside, 100 at Manninger and 95 intrainstitutional trends. These difficulties also led to missing infbrmation 1&6/34 6, #2, for some data, whidh is reflected in th varying population sample sizeslénrthe 4fififlxeu �RESULTS I Methodological Problems A‘ When reporting studies from one institution, the structure of the hospital maybe taken forgranted and either ignored or mentioned briefly. 'W 1,, e comparable gathering gr; m, _ M ”1111111....” institutions While were selected as these data from.multiple institutions, . in teaching, research and treatment programs, they were functionally unlike in ways which influenced the data of the study. Specific-problemscygf4LAt-Lk* comparable were prominent tions, in the designation of type of treatment, diagnostic classifica- and the evaluation of treatment outcome. criteria for designating that differed among the institutions, making come Designation of Eype of Treatment: 1) a patient received ”psychotherapy" [Sous parehti=ay The difficult. At Menninger Hospital psychotherapy was designated as treatment administered on a prescription basis by a patient was Charged a fee. staff psychiatrist for whidh the Sessions with the psychiatric resident were con— sidered part of routine administrative patient care. 'At Hillside Hospital psydhotherapy was defined as treatment sessions with Staff psychiatrists did not treat patients, but No additional resident physicians. restricted their activities to supervising a psydhiatric resident. fees were charged. At the Massachusetts Mental Health Center psychotherapy was designated aucha‘ functiggrof psydhiatric residents, psydhologists, social workers, nurses and medical students. Formal records of such sessions as the many disciplines -— �which ascertain and record to in the included patient's were not routinely team members the of study for was received necessary psydhotherapy it patients to interview the resident responsible for eadh case. made comparisons diagnostic styles Individual institutional Diagnosis: evaluative the multiple employed diagnoses At Menninger Hospital difficult. 10 dlil the American Psydhiatric Association)while both followed different unitary systems. Several examples of scheme recommended by Hillside and MMHC conversions with Table suggested in our I, diagnoses from.Menninger are listed con— These two institutions. other of the that into categories comparable to versions provide a source of distortion. at the detail. The discharge rating at Menninger and format varied in three hospitals Hospital was tripartite with a separate evaluation for social, characterological 53) e Rat' Disc s of rovement: Ratings of improvement Hillside Hespital and Massachusetts Mental Health Center had global ratings making it difficult to assess the contribution of each factor of the Menninger system (Table II). For this study the Menninger syndrome and syndrome Changes. rating 3. jfiflv was compared to the global ratings of the other institutions. "A, .16 (’30 waft/mm Co I. Sociopsychological Variables The distribution of the variables of social class, age, education �and California F Scale score among the three institutions is presented in Table III. a) Social Class: The institutions composition of the three the population anticipated difference in social class was observed. was predominantly upper At Menninger Hospital class; at Hillside Hospital, middle Massachusetts Mental Health Center, predominantly lower class; and at class. There were no differences b) ége; in age distribution in the institutional populations. c) Education: The populations also differed in educational attain- ment, with patients having more years of education at than at MassaChusetts Mental Health Center. While Ml patients at per cent of the had not completed high school, only 32 per cent at MMHC Hillside and 23 per cent at Menninger did not graduate. d) F Score: Califbrnia F patients had 50 or above below 30. Differences in the distribution of scores on the Scale were also observed. Fifty—one per cent of Menninger F —- of stereotypy. patients had Menninger Hospital F scores below 30, and only eight per cent with scores of the higher F scores being associated with higher degrees In contrast, at Hillside thirty—one per cent of the scores below 30 while at MMHC only twenty per cent were �Thus, thl=a=pa===d.differences in social attainment and performance on the #40; F class, educational Scale were observed. RELA'H u a. These differences permit a test ofkhypotheses oamannrnngdflxrirfiefifixwrtn? sociopsychological factors to the treatment variables among these institutions. 12. Psychiatric Treatment Variables a) Selection of Treatment: Amongfiinstitutions, significantly at Menninger Hospital (”3%) received somatic therapy than at Hillside (64%) or MMHC (68%) (Table IV). fewer patients b) DUration of H05pitalization: The three institutions differed with regard to patient’s length of stay (Table IV). Patients at Menninger Hospital were hospitalized longest, with 65% of patients remaining for twelve months or more, compared to 31 per cent of the Hillside patients and only per cent at the MassaChusetts Mental Health Center. The modal stay of the Hillside group was between seven and eleven months while two-thirds of the MMHC patients were disdharged 5 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 Hospital, however, a higher percentage (19%) of were rated as "unimproved" and only a single patient "recovered" or "much improved". or "much The was patients scored highest percentage of "recovered" inproved" ratings (28%) and the lowest proportion of "unimproved" (10%) were found d) Diagnosis: groupings were made: at the Massachusetts Mental Health Center. For statistical analysis three diagnostic schizophrenia, affective disorders, and psycho- neurosis and personality disorders (Table IV). The diagnostic propore tions of patients within these groups were similar for Hillside and MMHC, �as slightly more than half were diagnosed as schizophrenia and one- In contrast , at Menninger quarter as psychoneurosis or affective disorder. Hospital psychoneurosis and personality disorder accounted for more than fifty per cent of the population. 6. Intra—Hospital Comarisons lack of meaningful criteria for the subdivision of populations, 1......an size and 1:: the sample each within institution homogeneity their dgghb A $31“ Lou-T precluded adequate intra—hospital comparisons . everal groupings were The WW Jr”) W obtained which had fewer than five cases) . . . . 94 z 5/ the trends appeared similar to those found in the earlier study. Age and F score were found related to the selection of treatment at Menninger Hospital (older and higher more and somatic therapy), receiving frequently F P score patients score alone at Hillside. both the related at and were chronological of age hospitalization length Hillside Hospitals - the younger patients remaining for the longest periods, While such relationships were significant in these MMHC V) where no (Table noted the was at trend similar two hospitals, a Menninger and patients over 40 , but 1% of patients under the age of than a year. ————_———_—— 20 remained longer �DISCUSSION Q , M daM SOClal variables—95 1:11: differences in Significant interinstitutional of distribution in not but age; years of education/W97 ; F ? {”1238 MN 3 WI } kw of eva‘aaeed periods shorter lower class patients the institution serving Eta and fieportions diagnoses of low psychoneurotic “better , hospitalization, discharge evaluations. \ ment are fiuw $7, memm‘ ; (M I and complex more diagnoses of psychoneurotic of stay, a higher proportion a forms somatic receiving of patients diagnostic schemataalower proportion “in Similarly, yere-eaeh-eonflmed. ratings and discharge of therapy, poorest r“ “3 {2/ MW W , ”fl 033°” “5: f Wtuw W —variables treatment the each of and F in California Scale scores; duration of hospitalization, selection ff treatments and distributions “MM: Mafia—5’ in— e of diagnoses and discharge evaluations. ..._v,.__~__~_.'/l\——".~W-v J! A . . . . duration the longest class patients stitution serVing upper ' f""\ 9’ «mean related Ato differences in staff attitudes than—to— “errences in populations . 'Ihe contrasts between institutions in duration of hospitalization are great, as are the complexity of diagnostic and of evaluations psychotherapy, formulations , discharge , definitions lflese differences recorded data. amount and stylistic of details the W wwfi‘sfissed as slinky idiosyncratic1am they follow a pattern M, W related to social {W WW; meabmx/Wm fig “W434. differences] consistent7with . �-10- Such population and treatment variable relationships are Cf the physician attitude the both determined by interactive processes , and the administrative staff and by the Such constellation of symptoms or relationships are marked most history which patients present. least are criteria where diaglostic conditions those in psychiatric known of diseases defining criteria where objective i.e. specific, , fl personality schizophrenia, in psychoneurosis/ etiology are absent, as AAA-0L of conditions perceptual a: Under these disorders. and behavior and expectations attitudes observer's the situational ambiguity) Ak444~0u4, become 5 I4 v "uufi situation was Eris his perception classification) 6 . . . . study their and (1) lefton in Dmitz Pasamanick, clearly emanated-by observed They institution. within a single of variations in diagnosis in did differ wards not type different to assigned“ that patients g4en¢bh ' o dew S ’and' ~qu réaedéup _ M ’1 Significant residence. education, or age marital status, of admission, diagnostfié Cewif‘UI-Lflvarious of incidence differences did occur, however, in the among the three wards and m ' believe thefi reflect the among differences attitu W ward. one on administrators three As (“E in the populations/ we es 0 the examiners. ”atclinical evaluation Present psychiatric concepts of diagnosis par” another. to institution have little For results . roduces paradoxical literal adherance to these concepts meaning when example, Menninger transferred from one M mhighly trained personnel Hospital has—themes; con— 3% has “fewest the for longest patients its keeps time/and ducting treatment, the poorest Ad reports yI.’ yet, as diaglosed schizophrenia, patients I i I �-11- treatment results. ,fit'MMHC, in contrast, whiCh is most inclusive in defining a therapist, which keeps patients for the shortest periods, and whéeh-has a higher-proportion of the population classed as schizophrenia, OV’ quality of carefnnop the assessment of comparability of populations for degree of illness among the institutions)‘ Since the evaluations are based on the institution's own ratings, we believe that the differences reflect variations in the criteria used for evaluation of rather than.§gy intrinsic psychiatric Characteristics. In our criteria of initial Hillside it was postulated that different utiliZed fer persons of different social suggested that the higher the person's social improvement were It baCkground. study (‘) improvement was the more complex the cr1ter1a.enm3i?:§é*£lgis has‘::§&;1 background literally confirmed in the present study, WithAMenninger‘EluSIng a to the global rating of the other two institu— considering the syndrome rating on whidh our comparative tripartite rating tions. Even statistical compared analyses were based, it is our contention that fOr lower class persons we are apt to assess improvement in relation to symptom relief or the patient's capacity to resume work, while for upper class persons the criteria emphasize sudh complex intangibles as "developing insight", or "working through one's problems." �-12_ demonstrated the role of While these investigations have again social factors in psychiatric treatment, we have been greatly impressed by the methodological problems of studies across institutions. These selected for their educational leadership and the expectation that the recorded variables would be clearly defined. But differences in institutional style made it difficult to obtain comparable institutions were data. This experience is a cue to the problems of the conventional use of comparative statistics, especially in the evaluation of psychiatric therapies. The use of disdharge ratings, diagnostic classifications or length of hospitalization as criteria in therapeutic evaluations or the identification of comparable populations are subject to extensive error unless the institutions are clearly matched for staff attitudes and style as well as social class patterns in patient populations. fikrtefiéeve——— difficulties also extend to the failures of scientists to clinical or laboratory observations made in other laboratories, lack of confirmation may reflect differences in populations and criteria as much as errors in the original hypotheses. The use confirm ’Ehese for the psychiatric of the terns "schizophrenia" or "psychoneurosis" to explore changes in psydhological and biological features of mental illness has led to-;:;1mnanadrthgr 6;Z;é science burdened by negative results. a valid observation to be “40W reported from one laboratory{ the methods armhamfiaafieélable—teéay to Judy.” «(no—c..- (adeduately)describe psychiatric populations for an=adiqnuta==nnfinm==éan. //*~—~.“www.m“imm. “WM.,.,.--M—«~~WW" c M 4;,Aaanéigzgedai7 . : 54; fggfi"JR;¢”;' 2%;7*"/;? E �~13. fzar Increased attention must be paid to thenaathedniogéoairprebiemSuei—-V4-’ 3 w, a by "objective" criteria rather than the present methods, so highly dependent on institutional and observer attitudes and the sociopsychological aspects of the therapist-patient interaction. $nn“ g cla881fyiag sub ects ‘ . o a 9 a �-1u- WW SUMMARY and “Wu-I 2 @1 MW VoLu u'! three CONCLUSION MWHw.» m...» (A a. teaching hospitals, W,~.mm~__1_ ""“"Wm.m...“ mmwv— vm l.»/ fiopulation characteristicsjig-ererelated to treatment variables W ,.. . ., wwmm MN defined by social class, age, education and F score , W type of treatment, duration of hospitalization, TfZM (W Washed-#0 W diagnosis and discharge evaluation. Z interinstitutional :da— differences were observed in patient social class , years of education and California F scores , but not age. distribution of @ variations in treatment characteristics among institutions were found—$0.435; significantly different in the predicted ‘2, The direction. '% 6 “Q variations in psychiatric practices follow a pattern among’f‘institutions withgocial and are consistent class differences These not regarded as idiosyncratic. 6g ‘Eae differences in institutional style make comparisons of between and treatment duration results of diagnoses, hospitalization, institutions difficult and tenuous , and the need for more objective criteria 4w 4C1 ff classification ( 0 ne‘kfi‘m‘v) emphasized. is pppulations A �REFERENCES Adorno, T. W., Frenkel-Brunswik, Authoritarian Personalitz. The 990 pp. 3. Communit238tudz. J. and Sanford, R. N. Harper and Brothers, New York, 1950, D. Class and Montal Illness: John Wiley and Sons, Inc., New York, T933, KHZ pp. Hollingshead, A. B. and A E., Levinson, delich, F. 0. Social L., Pollack, H. and Fink, M. Social Factors in the Selection of Therapy in a Voluntary Montal Hospital. J. Hillside Hos ., 1957, Q; 216Kahn, R. 228. h. Kahn, R. L., Pollack, M. and Pink, M. Sociopsychologic Aspects of Psychiatric Treatments in a Voluntary Montal Hospital: Duration of Hospi- talization, ;: 565-5714. Discharge Ratings and Diagnosis. Arch. Gen Ps hiat., 1959, S. Kahn, R. L., Pollack, M. and Fink, H. Social Attitude (California F Scale) and Convulsive Therapy. J. Nerv. Mont. Dis., 1960, 1;_: 187—192. Pasananick, 3., Dinitz, s. and Lofton, M. Psychiatric Orientation and its Relation to Diagnosis and Treatment in a Mental Hospital. Amer. J. P hiat., 1959, gig: 127-132. 7. Siogel, N. H., Kuhn, R. L., Pollack, M. and Fink, H. Social Class, Diagnosis and Treatment in Three Psychiatric Hospitals. Social Problems, 1962, 19: 191-196. �TABLE I Redesignation of Discharge Diagnoses Menninger Discharge Diagnoses Depressive reaction Narcissistic Personality Anxiety reaction General Classification Psychoneurosis Narcissistic Personality Psychoneurosis Narcissistic Personality Personality Trait Disturbance Narcissistic Personality Alcoholism, Chronic Infantile Personality Sociopathic Personality Disturbance Passive Aggressive Personality Alcoholism Sociopathic Personality Disturbance Infantile Personality Schizophrenic Reaction, Schizo-Affective Type Schizophrenic Psychosis �TABLE II Comparative Ratings of Clinical Condition At Time of Hospital Discharge MENNINGER HOSPITAL Social Adjustment Improved Unimproved Character Structure Improved Unimproved Syndrome Complete Remission Improved Unchanged (or worse) HILLSIDE HOSPITAL MASSACHUSETTS MENTAL HEALTH CENTER Recovered Recovered Much Improved -WM_W_ Markedly Improved Improved Moderately Improved Unimproved Slightly Improved Unimproved �TABLE InterhosEital III Comparisons for Sociopsychological Variables Menninger Hospital I Hillside Hospital 1 Massachusetts Mental Health s 2 § a 3 1 1 Social Class III E 17 3b ‘ z g i g 1 i i 3 i l ! z ~, Years of Education llZ—lS ; % i a 3 I F Score 5h '13 �TABLE IV Interhospital Differences in Treatment Variables ;Menninger [Hillside Massachusetts {Hospital [Hospital Mental Health of Treatment Type 'Psychotherapy Somatic 68 Other 8 I Duration of 7-11 months Hospitali— W zation months WWW..-”— mmm -w - 1 *- Recovered, Improved Discharge Evaluation Much Improved 61 Unimproved 10 . i Discharge Diagnosis . , I mewmm 001 -.......’32_.L.__.......B< _.... Schizophrenia Affective Psychosis Psychoneurosis and Personality Disorde (95) (171) I (85 5h% 17 �TABLE V Duration of HosEitalization BX Age PERCENTAGE OF AGE GROUP STAYING OVER ONE YEAR l» mm Below 20 Menninger Hillsidg 81 he 73 36 61 30 3O 20 �Sociopsychological Aspects of Psychiatric Treatment in Three Voluntary Hospitals Robert L. Kahn, Ph.D.*, Max Fink, M.D.**, Nathaniel Siegel, Ph.D.*** �Sociopsychological Aspects of Psychiatric Treatment in Three Voluntary Hospitals Robert L. Kahn, Ph.D.*, Max Fink, M.D.**, Nathaniel Siegel, Ph.D.*** �This study was done when the authors were associated at the Department of Experimental Psychiatry, Hillside Hospital, Glen Oaks, L.I. New York, 195941962. cooperation of Dr. Max Pollack and the staffs of the Massachusetts Mental Health Center and the C.F. Menninger Memorial " Hospital is gratefully acknowledged. The ‘ Aided, in part, by grants My—2092 and MY—2715, of the National Institute of Mental Health, U.S. Public Health Service; and the Nassau County Mental Health Board. Present Address: Division of Psychiatry, Montefiore Hospital and Medical Center, 111 East 210th Street, New York, New York *9': Present Address: 10467. ‘ Department of Psychiatry at the Missouri Institute of Psychiatry, School of Medicine, University of Missouri, 5400 Arsenal Street, St. Louis, Missouri 63139 *** MIP 2/1/65 Present Address: National Institute of Mental Health, Bethesda, Maryland �In their studies of the psychiatric patient pop— ulation, Hollingshead and Redlich have reported significant relationships between an individual's position in the social class structure and the incidence of treated illness, types of diagnosed disorders and kindsand duration of psychiatric treatment administered (2), The influence of the economic status of the patient on the availability of treating personnel, however, was not excluded, New Haven Studies of the role of social factors in the treatment of hospitalized patients independent of their financial status and the availability of treatments were undertaken at Hillside Hospital in 1957. In this hospital, a variety of treatment modes, including individual psychotherapy, pharmacotherapy and convulsive therapies were available to all patients regardless of their ability to pay“ In these surveys (3,4) we observed that patients hospitalized for the shortest periods were older, had less education and were more often of foreign birthc These older, less educated patients were predom— inantly treated by convulsive therapy and received more favorable clinical discharge ratings. In contrast, younger, native born and more educated patients were hospitalized for longer periods, treated primarily by psychotherapy and received poorer discharge ratings, These clinical factors were also related to a measure of stereotypy, the California F Scale (1,5)o Higher F scores, i.e,, greater stereotypy, were often found in patients diagnosed as involutional psychosis, who were referred for convulsive therapy, hospitalized for shorter periods, and more often were rated as much improved or recovered. In the survey reported here, it was suggested that dif— ferencesin psychiatric treatment among hospitals should reflect the influence of social factors as noted for the patients within Hillside Hospital, To test this suggestion it was decided to employ the pro— cedures of the 1957 Hillside study in three institutions -— Hillside Hospital, the C. Fo Menninger Memorial Hospital in Topeka and the Massachusetts Mental Health Center in Boston» These institutions were selected with the expectation that they had diverse treatment modalities equally available, yet served patients of different social classesc Each provided short-term treatment of voluntary patients and did not provide custodial care, Each is a residency training center with a full time supervisory staff and active research units, emphasizing psychoanalytically-oriented psychotherapyo istics This study was designed to determine the population characterof the three institutions with respect to social class, age, score; and to relate these characteristics to treatment variables of type of treatment, duration of hospitalization, diagnosis and discharge evaluation among the institutions” education and F �-2“ METHOD A census of all voluntary, adult patients in residence in the institutions was 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 schizo— phrenic state hospital group transferred for a specific research project. These patients were excluded from the study because of their non—voluntary statusc The California F scale was scored for each patient 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 (3,4,7)o The study population consisted of 173 patients at Hillside, 100 at Menninger and 95 at the Massachusetts Mental Health Center» — study included examination of the relations of the social to the psychiatric variables within each institution as well as between institutionso These comparisons were difficult however, because of various methodological differences discussed below. These difficulties were most marked in the intra—hospital comparisons, and accordingly, in the analyses of psychiatric variables emphasis will be placed on the differences between institutions with citation of intra—institutional trends" These difficulties also led to missing information for some data, which is reflected in.the tables by the varying population sample The sizes, fl... �RESULTS A. Methodological Problems reporting studies from one institution, the structure of the hospital may be taken for granted and either ignored or men— tioned briefly. In gathering comparable data from multiple institu~ tions, however, the many differences between institutions are accentuated. While these institutions were selected as comparable in teaching, research and treatment programs, they were functionally unlike in ways which influenced the data of the study, Specific differences were prominent in the designation of type of treatment, diagnostic classifications, and the evaluation of treatment outcome; When *— 1. Designation of Type of Treatment: The designating that a patient received "psychotherapy" the institutions, making comparisons difficult, At Menninger criteria for differed among Hospital psychotherapy was designated as basis by a staff psychia— treatment administered on a prescription trist for which the patient was charged a feeo Sessions with the psychiatric resident were considered part of routine administrative patient care. Hillside Hospital psychotherapy was defined as treatment sessions with a psychiatric resident“ Staff psychiatrists did not treat patients, but restricted their activities to supervising res— ident physicians, No additional fees were charged, At At the Massachusetts Mental Health Center psychotherapy was designated as the activity of many disciplines -- psychiatric residents, psychologists, social workers, nurses and medical students, Formal records of such sessions were not routinely included in the patient's record and to ascertain which patients received psycho~ was necessary for members of the study team to interview therapy it the resident responsible for each case. 2. Diagnosis: Individual institutional diagnostic styles made comparisons difficult. At Menninger Hospital diagnoses employed the multiple evaluative scheme recommended by the American Psychiatric Association, while both Hillside and followed different unitary systemsa 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 distortiono MMHC �Table I 3. Discharge Ratings of Improvement: Ratings of imr provement at the three hospitals varied in format and detail. The discharge rating at Menninger Hospital was tripartite with a sep— arate evaluation for social, characterological and syndrome changes. Hillside Hospital and Massachusetts Mental Health Center had global ratings making it difficult to assess the contribution of each factor of the Menninger system (Table II). For this study the Menninger syndrome rating was compared to the global ratings of the other institutions. Table B. Inter-hospital II Comparison 1. Sociopsychological Variables The distribution of the variables of social class, age, California F Scale score among the three institutions education and is presented in Table III. Table in. a) Social Class: The III . anticipated difference in social class composition of the three institutions was observed. At Menninger Hospital the population was predominantly upper class; At Hillside Hospital, middle class; and at Massachusetts Mental Health Center, predominantly lower class. b) Age: There were no differences in age in the institutional populationso distribution �populations also differed in edu—' cational attainment, with patients having more years of education at Menninger Hospital than at Massachusetts Mental Health Center. While 41 per cent of the patients at MMHC had not completed high school, only 32 per cent at Hillside and 23 per cent at Menninger did not graduatec c) Education: The Score: Differences in the distribution of scores on the California F Scale were also observed. Fifty-one per cent of Menninger patients had F scores below 30, and only eight per— cent with scores of 50 or above -— the higher F scores being assoc— iated with higher degrees of stereotypy. In contrast, at Hillside thirty—one per cent of the patients had F scores below 30 while at MMHC only twenty per cent were below 300 d) F Thus, differences in social class, educational attainment and performance on the F Scale were observed, These differences permit a test of the hypotheses relating sociopsychologi- cal factors to the treatment variables 2a among these institutions. Psychiatric Treatment Variables Selection of Treatment: Among the institutions, significantly fewer patients at Menninger Hospital (43%) received somatic therapy than at Hillside (64%) or MMHC (68%) (Table IV). a) three institutions differed with regard to patient's length of stay (Table IV)Q Patients at Menninger Hospital were hospitalized longest, with 65% of patients remaining for twelve months or more, compared to 31 per-cent of the Hillside patients and only 5 per—cent at the Massachusetts Mental Health Center. The modal stay of the Hillside b) Duration of Hospitalization: The 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)o At Menninger Hospital, however, a higher percentage (19%) of patients were rated as "unimproved” and only a single patient was scored "recovered" or "much improved"e The highest percentage of "recovered" or "much improved” ratings (28%) and the lowest proportion of "unimproved” (10%) were found at the Massachusetts Mental Health Centero nostic d) Diagnosis: For statistical analysis groupings were made: schizophrenia, affective three diagdisorders, and �psychoneurosis and personality disorders (Table IV)w The diag— nostic preportions of patients within these groups were similar for Hillside and MMHC, as slightly more than half were diagnosed as schizophrenia and one-quarter as psychoneurosis or affective disordero In contrast, at Menninger Hospital psychoneurosis and personality disorder accounted for more than fifty per—cent of the populationo Table IV C. Intra—Hospital Comparisons lack of meaningful criteria for the subdivision of populations, their homogeneity within each institution, and the limited sample size (several groupings were obtained which had fewer than five cases) precluded significant intra—hospital com— parisonso However, the trends appeared similar to those found in the earlier study, Age and F score were found related to the selection of treatment at Menninger Hospital (older and higher F score patients more frequently receiving somatic therapy), and F score alone at Hillsideo Length of hospitalization and chron— ological age were related at both the Menninger and Hillside Hospitals - the younger patients remaining for the longest periods, While such relationships were significant in these two hospitals, a similar trend was noted at the MMHC (Table V) where no patients over 40, but 14% of patients under the age of 20 remained longer than a year. The Table V �the incidence of various diagnostic classifications among the three wards and among three administrators on one ward. As no differences in the populations were demonstrated, we believe the different incidence of diagnoses reflect the attitudes of the examinerso Present psychiatric concepts of diagnosis and clinical evaluation have little meaning when transferred from one insti— tution to anothere Literal adherance to these concepts produces paradoxical resultso For example, Menninger Hospital with the more highly trained personnel conducting treatment, keeps its patients for the longest time, has the fewest patients diagnosed as schizophrenia, and yet, reports the poorest treatment results, At MMHC, in contrast, which is most inclusive in defining a therapist, keeps patients for the shortest periods, and has a higher proportion of the population classed as schizophrenia, reports the best treatment resultso In the absence of independent criteria for the quality of care or the assessment of comparability of populations for degree of illness among the institutions, these findings do not reflect the relative therapeutic efficacy of the institutionso Since the evaluations are based on the institution's own ratings, we believe that the differences reflect variations in the criteria used for evaluation of improvement rather than intrinsic psychi— atric characteristics. initial Hillside study (4) it was postulated that different criteria of improvement were utilized for persons of different social backgroundo It was suggested that the higher the person's social background the more complex the criteria em— ployed° This has been literally confirmed in the present study, with the staff of Menninger Hospital using a tripartite rating compared to the global rating of the other two institutionso Even considering the syndrome rating on which our comparative statistical analyses were based, it is our contention that for lower class persons we are apt to assess improvement in relation to symptom relief or the patient's capacity to resume work, while for upper class persons the criteria emphasize such complex intangibles as In our "developing insight," or "working through one's problems.” While these investigations have again demonstrated the role of social factors in psychiatric treatment, we have been greatly impressed by the methodological problems of studies across institutions. These institutions were selected for their educational �leadership and the expectation that the recorded variables would be clearly defined. But differences in institutional style made it difficult to obtain comparable data. This experience is a cue to the problems of the conventional use of comparative statistics, especially in the evaluation of psychiatric therapiese The use of discharge ratings, diagnostic classifications or length of hospitalization as criteria in therapeutic evaluations or the iden— tification of comparable populations are subject to extensive error unless the institutions are clearly matched for staff attitudes and style as well as social class patterns in patient populationso These difficulties also extend to the failures of scientists to confirm clinical or laboratory observations made in other laboratories, for the lack of confirmation may reflect differences in populations and psychiatric criteria as much as errors in the orig— inal hypotheses. The use of the terms "schizophrenia" or "psycho— neurosis" to explore changes in psychological and biological features of mental illness has led to a science burdened by negative results. Even were a valid observation to be reported from one laboratory today, we do not have the methods to describe psychiatric populations adequately for a satisfactory test of the hypothesis. Increased attention must be paid to the classification of subjects by "objective" criteria rather than our present methods, so highly dependent on institutional and observer attitudes and the sociopsychological aspects of the therapist-patient interaction. �-10- SUMMARY AND CONCLUSION Population characteristics, defined by social class, age, education and F score, were related to treatment variables in three voluntary teaching hospitals. Treatment variables included type of treatment, duration of hospitalization, diagnosis and discharge evaluation, Inter-institutional differences were observed in patient social class, years of education and distribution of California F scores, but not age. variations in treatment characteristics among institutions were significantly different in the predicted di— rection. The institution serving upper class patients did have the longest duration of stay, a higher proportion of psychoneurotic diagnoses and more complex diagnostic schemata, a lower proportion of patients receiving somatic forms of therapy, and the poorest discharge ratings among the three institutions, ~Simi1arly, the institution serving lower class patients did have the shorter periods of hospitalization, lower proportions of psychoneurotic diagnoses, and the better discharge evaluations. The variations in psychiatric practices followed a pattern consistent with the social class differences among the institutions and are not regarded as idiosyncratic. Such differences in institutional style make comparisons of diagnoses, duration of hospitalization and treatment results between institutions difficult and tenuous, and the need for more objective criteria for the classification of psychiatric popula— tions is emphasized° These �REFERENCES E., Levinson, D. J. and Authoritarian Personality. Harper and 1. Adorno, T. W., Frenkel—Brunswik, Sanford, Brothers, R. N. The New Hollingshead, Mental Inc., York, 1950, 990 pp. A. B. and Illness: A Redlich, F. C. Community Study° New York, 1958, 442 pp. Social Class and John Wiley and Sons, L., Pollack, M. and Fink, M. Social Factors in the Selection of Therapy in a Voluntary Mental Hospital. Kahn, R. J. Hillside Hosp., . 1957, 6: 216-228. L., Pollack, M. and Fink, M. Sociopsychologic Aspects of Psychiatric Treatments in a Voluntary Mental Hospital: Duration of Hospitalization, Discharge Ratings and G Ps Diagnosis. A a ., 1959, A; 565—574. Kahn, R. Kahn, R. ifornia F L., Pollack, Social Attitude (CalScale) and Convulsive Therapy. ligjfiuabhlkuug_jn§,, M. and Fink, M. 1960, 13Q5 187—192. Pasamanick, B., Dinitz, S. and Lefton, M. Psychiatric Orientation and its Relation to Diagnosis and Treatment in a Mental 1959, 116: 127—132. Hospital. Whig” Siegel, N. H., Kahn, R. L., Pollack, M. and Fink, M. Social Class, Diagnosis and Treatment in Three Psychiatric Hospitals. Social Problems, 1962, lg; 191—196. �TABLE I Redesignation of Discharge Diagnoses Menninger Discharge Diagnoses Depressive Reaction Narcissistic Personality Anxiety Reaction General Classification Psychoneurosis Narcissistic Personality Psychoneurosis Narcissistic Personality Personality Trait Disturbance Narcissistic Personality Alcoholism, Chronic Infantile Personality Sociopathic Personality Disturbance Passive Aggressive Personality Alcoholism Sociopathic Personality Disturbance Infantile Personality Schizophrenic Reaction, Schizo—Affective Type Schizophrenic Psychosis �TABLE II Comparative Ratings of Clinical Condition At Time of Hospital Discharge MENNINGER HOSPITAL Social Adjustment Improved Unimproved Character Structure Improved Unimproved Syndrome Complete Remission Improved Unchanged (or worse) HILLSIDE HOSPITAL MASSACHUSETTS MENTAL HEALTH CENTER Recovered Recovered Much Improved Markedly Improved Improved Moderately Improved Unimproved Slightly Improved Unimproved �TABLE III InterhosEital Comgarisons for Sociogsxchological Variables Menninger Hospital I Class "I“ Hospital 7% II 20 III 34 IV 34 V 5 x2 = 121.5; df=8: I Massachusetts Mental Health lllllflaiflllllllIlllflflflflfllllll N Social Hillside _ p:(.001 “M“-0__-____—_‘-.i-____.__..1-____—___ 19% 20- 39 Years of Educatio <12 41% 12-15 49 16+ 10 x2 = 39.2; df=4g p<.001 �TABLE IV Interhospital Differences in Treatment Variables §Menninger N T Massachusett Mental Healt Center mum-.mHospital Type of Hillside Psychotherapy Hospital 36% re atment Somatic Other =82 8 df=4 100 N Duration of Hospital— ization 7 months 7-11 months . ~11 months Recovered, Much .001 173 95 22% 27% 67% 13 42 27 65 31 5 90. 6 df= 4 X2= . .001- Improved Discharge Improved Evaluation Unimproved X = Schizophrenia Discharge Diagnosis Affective Psychosis Psychoneurosis and Personality Disorder X = 2903' df=4. U<n001 52% 54% 22 17 26 29 23.8' df=4° .<.001 �Duration of Hospitalization By Age PERCENTAGE OF AGE GROUP STAYING OVER ONE YEAR Age Menninger Hillside Below 20 81 42 20-29 73 36 30-39 61 30 40—49 3O 20 50+ 36 MMHC 14 �Sociopsychological Aspects of Psychiatric Treatment in Three Voluntary Hospitals Robert L. Kahn, Ph.D.*, Max Fink, M.D.**, Nathaniel Siegel, Ph.D.*** �This study was done when the authors were associated at the Department of Experimental Psychiatry, Hillside Hospital, Glen Oaks, L. I. New York, 1959— 1962. Pollack and the staffs of the Massachusetts Mental Health Center and the C. F. Menninger Memorial Hospital is gratefully acknowledged. The co.operation of Dr. Max Aided, in part, by grants My—2092 and MY-2715, of the National Institute of Mental Health, U.S. Public Health Service; and the Nassau County Mental Health Board. * Present Address: Division of Psychiatry, Montefiore .Hospital and Medical Center, 111 East 210th Street, New York, New York ** Present Address: 10467. ‘ Department of Psychiatry at the Missouri Institute of Psychiatry, School of Medicine, University of Missouri, 5400 Arsenal Street, St. Louis, Missouri 63139 *** MIP 2/1/65 Present Address: National Institute of Mental Health, Bethesda, Maryland �In their studies of the New Haven psychiatric patient pop— ulation, Hollingshead and Redlich have reported significant relationships between an individual's position in the social class structure and the incidence of treated illness, types of diagnosed disorders and kindsand duration of psychiatric treatment administered (2), The influence of the economic status of the patient on the availability of treating personnel, however, was not excludeda Studies of the role of social factors in the treatment of hosPitalized patients independent of their financial status and the availability of treatments were undertaken at Hillside Hospital in 1957. In this hospital, a variety of treatment modes, including in— dividual psychotherapy, pharmacotherapy and convulsive therapies were available to all patients regardless of their ability to pay, In these surveys (3,4) we observed that patients hospitalized for the shortest periods were older, had less education and were more often of foreign birtho These older, less educated patients were predom— inantly treated by convulsive therapy and received more favorable clinical discharge ratingso In contrast, younger, native born and more educated patients were hospitalized for longer periods, treated primarily by psychotherapy and received poorer discharge ratingsm These clinical factors were also related to a measure of stereotypy, the California F Scale (1,5)o Higher F scores, i;gf, greater stereotypy, were often found in patients diagnosed as involutional psychosis, who were referred for convulsive therapy, hospitalized for shorter periods, and more often were rated as much improved or recoveredu In the survey reported here, it was suggested that differencesin psychiatric treatment among hospitals should reflect the influence of social factors as noted for the patients within Hillside Hospital» To test this suggestion it was decided to employ the procedures of the 1957 Hillside study in three institutions -- Hillside Hospital, the C. F, Menninger Memorial Hospital in Topeka and the Massachusetts Mental Health Center in Bostono These institutions were selected with the expectation that they had diverse treatment modalities equally available, yet served patients of different social classeso Each provided short-term treatment of voluntary patients and did not provide custodial care. Each is a residency training center with a full time supervisory staff and active research units, emphasizing psychoanalytically-oriented psychotherapya istics This study was designed to determine the population characterof the three institutions with respect to social class, age, score; and to relate these characteristics to treatment variables of type of treatment, duration of hospitalization, diagnosis and discharge evaluation among the institutionsa education and F �METHOD A census of all voluntary, adult patients in residence in the institutions was 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 schizo- phrenic state hospital group transferred for a specific research project. These patients were excluded from the study because of their non-voluntary status. The California F scale was scored for each patient on the census day. Eighteen months later the records of discharged patients were examined to determine the social and psychiatric factors of the study. For a measure of social class, the Hollingshead 2—factor index a weighted score of education and occupation was used (3,4,7)o The study population consisted of 173 patients at Hillside, 100 at Menninger and 95 at the Massachusetts Mental Health Center, — study included examination of the relations of the social to the psychiatric variables within each institution as well as between institutions, These comparisons were difficult however, because of various methodological differences discussed below. These difficulties were most marked in the intra—hospital comparisons, and accordingly, in the analyses of psychiatric variables emphasis will be placed on the differences between institutions with citation of intra—institutional trendso These difficulties also led to missing information for some data, which is reflected in the tables by the varying population sample The sizes, �RESULTS A. Methodological Problems reporting studies from one institution, the structure of the hospital may be taken for granted and either ignored or men— tioned briefly. In gathering comparable data from multiple institutions, however, the many differences between institutions are accen— tuated. While these institutions were selected as comparable in teaching, research and treatment programs, they were functionally unlike in ways which influenced the data of the study. Specific dif— ferences were prominent in the designation of type of treatment, diagnostic classifications, and the evaluation of treatment outcome, When 1, Designation of Type of Treatment: The designating that a patient received "psychotherapy" the institutions, making comparisons difficult. At Menninger criteria for differed among Hospital psychotherapy was designated as basis by a staff psychia— treatment administered on a prescription trist for which the patient was charged a fee, Sessions with the psychiatric resident were considered part of routine administrative patient care. Hillside Hospital psychotherapy was defined as treatment sessions with a psychiatric resident, Staff psychiatrists did not treat patients, but restricted their activities to supervising res— ident physicianso No additional fees were chargedu At At the Massachusetts Mental Health Center psychotherapy designated as the activity of many disciplines -- psychiatric residents, psychologists, social workers, nurses and medical studentso Formal records of such sessions were not routinely included in the patient's record and to ascertain which patients received psychotherapy it was necessary for members of the study team to interview the resident responsible for each case. was 2. Diagnosis: Individual institutional diagnostic styles made comparisons difficult. At Menninger Hospital diagnoses employed the multiple evaluative scheme recommended by the American Psychiatric Association, while both Hillside and followed different unitary systemso 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 distortiono MMHC �‘1 Table I Discharge Ratings of Improvement: Ratings of imw provement at the three hosPitals varied in format and detail. The discharge rating at Menninger Hospital was tripartite with a separate evaluation for social, characterological and syndrome changes. Hillside Hospital and Massachusetts Mental Health Center had global ratings making it difficult to assess the contribution of each factor of the Menninger system (Table II)o For this study the Menninger syndrome rating was compared to the global ratings of the other 39 institutions. Table B. II Inter—hospital Comparison 1. Sociopszchological Variables The distribution of the variables of social class, age, California F Scale score among the three institutions education and is presented in Table III. Table a) Social Class: The III . anticipated difference in social class composition of the three institutions was observedo At Menninger Hospital the population was predominantly upper class; At Hillside Hospital, middle class; and at Massachusetts Mental Health Center, predominantly lower class. b) Age: There were no differences in age in the institutional populationso distribution �populations also differed in edu—' cational attainment, with patients having more years of education at Menninger Hospital than at Massachusetts Mental Health Center. While 41 per cent of the patients at MMHC had not completed high school, only 32 per cent at Hillside and 23 per cent at Menninger did not graduate, c) Education: The Differences in the distribution of scores on the California F Scale were also observed. Fifty-one per cent of Menninger patients had F scores below 30, and only eight per— the higher F scores being assoc— cent with scores of 50 or above iated with higher degrees of stereotypya In contrast, at Hillside thirty-one per cent of the patients had F scores below 30 while at MMHC only twenty per cent were below 30, d) F Score: —— Thus, differences in social class, educational attainfi ment and performance on the F Scale were observed. These diff— erences permit a test of the hypotheses relating sociopsychological factors to the treatment variables among these institutionse 2. Psychiatric Treatment Variables Selection of Treatment: Among the institutions, significantly fewer patients at Menninger Hospital (43%) received somatic therapy than at Hillside (64%) or MMHC (68%) (Table IV)c a) three institutions differed with regard to patient's length of stay (Table IV)O Patients at Menninger Hospital were hospitalized longest, with 65% of patients remaining for twelve months or more, compared to 31 per-cent of the Hillside patients and only 5 per—cent at the Massachusetts Mental Health Center, The modal stay of the Hillside b) Duration of Hospitalization: The group was between seven and eleven months while two—thirds of the MMHC patients were discharged within six months of hospitalization. c) Discharge Evaluation: PA In each hospital, most patients were evaluated at the time of discharge as "improved" (Table IV). At Menninger Hospital, however, a higher percentage (19%) of patients were rated as "unimproved" and only a single patient was scored "recovered" or "much improved", The highest percentage of "recovered" or ”much improved" ratings (28%) and the lowest proportion of "unimproved" (10%) were found at the Massachusetts Mental Health Centero nostic d) Diagnosis: For statistical analysis groupings were made: schizophrenia, affective three diagdisorders, and �psychoneurosis and personality disorders (Table IV). The diagnostic proportions of patients within these groups were similar for Hillside and MMHC, as slightly more than half were diagnosed as schizophrenia and one-quarter as psychoneurosis or affective disorder, In contrast, at Menninger Hospital psychoneurosis and personality disorder accounted for more than fifty per-cent of the populationo Table IV C. Intra—Hospital Comparisons lack of meaningful criteria for the subdivision of populations, their homogeneity within each institution, and the limited sample size (several groupings were obtained which had fewer than five cases) precluded significant intra—hospital comparisonso However, the trends appeared similar to those found in the earlier study, Age and F score were found related to the selection of treatment at Menninger Hospital (older and higher F score patients more frequently receiving somatic therapy), and F score alone at Hillside. Length of hospitalization and chron— ological age were related at both the Menninger and Hillside Hospitals - the younger patients remaining for the longest periodso While such relationships were significant in these two hospitals, a similar trend was noted at the MMHC (Table V) where no patients over 40, but 14% of patients under the age of 20 remained longer than a year. The Table V �-7DISCUSSION patients of three voluntary psychiatric hospitals exhibited significant inter'institutional differences in social class and years of education, but not age; in distribution of California F Scale scores; and in each of the treatment variables -- duration of hospitalization, selection of treatments and distributions of diagnoses and discharge evaluations (7)¢ The ,r‘ Expectations based on our earlier intra—Hillside Hospital were confirmedo The institution serving upper class patients did have the longest duration of stay, a higher proportion of psycho— neurotic diagnoses and more complex diagnostic schemata, a lower proportion of patients receiving somatic forms of therapy, and the poorest discharge ratings among the three institutions” Similarly, the institution serving lower class patients did have the shorter periods of hospitalization, lower proportions of psychoneurotic diagnoses, and the better discharge evaluations. It is our impression that these differences in psychiatric treatment are related more to differences in staff attitudes and social class variables than psychiatric differences in populations° The contrasts between institutions in duration of hospitalization are great, as are the complexity of diagnostic formulations, discharge evaluations, definitions of psychotherapy, and the details and amount of recorded data, While these styl— istic differences may be dismissed as idiosyncratic, they follow pattern related to social differences, and their consistency with expectations suggests a greater dependence on social class variables than ordinarily acknowledged, a population and treatment variable relationships are interactive processes, determined both by the attitude of the physician and the administrative staff and by the constellation of symptoms or history which patients presento Such relationships are marked most in those psychiatric conditions where diagnostic criteria are least specific, 3223, where objective criteria defining diseases of known etiology are absent, as in schizophrenia, psychoneurosis, personality and behavior disorders, Under these conditions of perceptual and situational ambiguity, the observer's attitudes and expectations become significant aspects of his perceptions, classifications, and decisions. A similar situation was clearly documented by Pasamanick, Dinitz and Lefton (6) in their study of variations in diagnosis within a single institution, They observed that patients assigned at random to different wards did not differ in type of admission, marital status, education, age or residenceo Significant differences did occur, however, in Such �the incidence of various diagnostic classifications among the three wards and among three administrators on one ward. As no differences in the populations were demonstrated, we believe the different incidence of diagnoses reflect the attitudes of the examinerso Present psychiatric concepts of diagnosis and clinical evaluation have little meaning when transferred from one insti— tution to another, Literal adherance to these concepts produces paradoxical results, For example, Menninger Hospital with the more highly trained personnel conducting treatment, keeps its patients for the longest time, has the fewest patients diagnosed as schizophrenia, and yet, reports the poorest treatment results, At MMHC, in contrast, which is most inclusive in defining a therapist, keeps patients for the shortest periods, and has a higher proportion of the population classed as schizophrenia, reports the best treatment results, In the absence of independent criteria for the quality of care or the assessment of comparability of populations for degree of illness among the institutions, these findings do not reflect the relative therapeutic efficacy of the institutions, Since the evaluations are based on the institution's own ratings, we believe that the differences reflect variations in the criteria used for evaluation of improvement rather than intrinsic psychi— atric characteristics. initial Hillside study (4) it was postulated that different criteria of improvement were utilized for persons of different social background, It was suggested that the higher the person's social background the more complex the criteria em— ployed, This has been literally confirmed in the present study, with the staff of Menninger Hospital using a tripartite rating In our compared to the global rating of the other two institutionso Even considering the syndrome rating on which our comparative statis— tical analyses were based, it is our contention that for lower class persons we are apt to assess improvement in relation to symptom relief or the patient's capacity to resume work, while for upper class persons the criteria emphasize such complex intangibles as "developing insight," or "working through one's problems." While these investigations have again demonstrated the role of social factors in psychiatric treatment, we have been greatly impressed by the methodological problems of studies across institutions. These institutions were selected for their educational �f’. leadership and the expectation that the recorded variables would be clearly defined. But differences in institutional style made it difficult to obtain comparable data. This experience is a cue to the problems 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 extensive error unless the institutions are clearly matched for staff attitudes and style as well as social class patterns in patient populationso These difficulties also extend to the failures of scientists to confirm clinical or laboratory observations made in other labor— atories, for the lack of confirmation may reflect differences in populations and psychiatric criteria as much as errors in the original hypotheses. The use of the terms "schizophrenia" or "psychoneurosis" to explore changes in psychological and biological fea— tures of mental illness has led to a science burdened by negative results. Even were a valid observation to be reported from one laboratory today, we do not have the methods to describe psychiatric populations adequately for a satisfactory test of the hypothesis. Increased attention must be paid to the classification of subjects by "objective" criteria rather than our present methods, so highly dependent on institutional and observer attitudes and the socio— psychological aspects of the therapist—patient interaction. �-10- SUMMARY AND CONCLUSION Population characteristics, defined by social class, age, education and F score, were related to treatment variables in three voluntary teaching hospitals. Treatment variables in" cluded type of treatment, duration of hospitalization, diagnosis and discharge evaluation, Inter-institutional differences were observed in patient social class, years of education and distribution of California F scores, but not age. variations in treatment characteristics among institutions were significantly different in the predicted di— rection. The institution serving upper class patients did have the longest duration of stay, a higher proportion of psycho— neurotic diagnoses and more complex diagnostic schemata, a lower proportion of patients receiving somatic forms of therapy, and the poorest discharge ratings among the three institutionso »Similar1y, the institution serving lower class patients did have the Shorter periods cf hospitalization, lower proportions of psychoneurotic diagnoses, and the better discharge evaluations, The variations in psychiatric practices followed a pattern consistent with the social class differences among the stitutions and are not regarded as idiosyncratic. These in— differences in institutional style make comparisons of diagnoses, duration of hospitalization and treatment results between institutions difficult and tenuous, and the need for more objective criteria for the classification of psychiatric popula— tions is emphasizedo Such �REFERENCES E., Levinson, D. J. and Authoritarian Personality. Harper and 1. Adorno, T. W., Frenkel—Brunswik, Sanford, R. N. The Brothers, New York, 1950, 990 pp. Hollingshead, Mental Inc., . A. B. and Illness: Redlich, F. C. John Wiley and Sons, Community Study. New York, 1958, 442 pp. A Social Class and L., Pollack, M. and Fink, M. Social Factors in the Selection of Therapy in a Voluntary Mental Hospital. J. Hillside Hosp., 1957, 6: 216-228. Kahn, R. L., Pollack, M. and Fink, M. Sociopsychologic Aspects of Psychiatric Treatments in a Voluntary Mental HOSpital: Duration of Hospitalization, Discharge Ratings and G PS h 565—574. 15 Diagnosis. 1959, ., Kahn, R. Kahn, R. ifornia F L., Pollack, M. and Fink, M. Social Attitude (Ca1- Scale) and Convulsive Therapy. .lLJkflubnlkflug_DLi-, 1960, 139; 187-192. Pasamanick, B., Dinitz, S. and Lefton, M. Psychiatric Orien— tation and its Relation to Diagnosis and Treatment in a Mental Hospital. Am£I4_Ja_2£¥£hiaL., 1959, 116: 127—132. Siegel, N. H., Kahn, R. L., Pollack, M. and Fink, M. Social Class, Diagnosis and Treatment in Three Psychiatric Hospitals. Social Problems, 1962, 195 191—196. �TABLE I Redesiggation of Discharge Diagnoses Menninger Discharge Diagnoses Depressive Reaction Narcissistic Personality Anxiety Reaction General Classification Psychoneurosis Narcissistic Personality Psychoneurosis Narcissistic Personality Narcissistic Personality Personality Trait Disturbance Alcoholism, Chronic Sociopathic Personality Disturbance Passive Aggressive Personality Sociopathic Personality Disturbance Infantile Personality Alcoholism Infantile Personality Schizophrenic Reaction, Schizo—Affective Type Schizophrenic Psychosis �TABLE II Comparative Ratings of Clinical Condition At Time of Hospital Discharge MENNINGER HOSPITAL Social Adjustment Improved Unimproved Character Structure Improved Unimproved Syndrome Complete Remission Improved Unchanged (or worse) HILLSIDE HOSPITAL MASSACHUSETTS MENTAL HEALTH CENTER Recovered Recovered Much Improved Markedly Improved Improved Moderately Improved Unimproved Slightly Improved Unimproved �TABLE III InterhosRital Comparisons for Sociogsychological Variables Menninger Hospital N I Social Class ‘“ Hillside Hospital Massachusetts Mental Health Center IllllflliillllllllIIIIIIIHEIIIIIIIIIIIIIIIIZIIIIIIIII 31% 7% II 51 20 III 17 34 IV 1 34 V 0 5 x2 = 121.5; df=8: p<(.001 “M 1IIIIiIifliiIIinjflfiniiiiifliiiifliijfiiiiiiIIIIIIIMIBIIIIIIIII 19/ 20- 39 = Years of Educatio 3. 9; df= 4; p=n. s. < 12 41% 12-15 49 16+ 10 x2 = 9.7; df=4; p<.05 IIIIEIIIIIIIIIIIIEIIIIIIIIIIIIIIIIIIIIIIIIIIIIIEflIIIIIIII F Score x2 = 33% 20% 50 38 17 42 39.2; df=4; p<.001 �W TABLE IV Interhospital Differences in Treatment Variables {Menninger Hospital N Type of Treatment Psychotherapy Somatic Other Duration 0t Hillside Hospital Massachusett Mental Healt Center 21% 36% 24% 43 64 68 36 -— 8 7-11 months Hospitallzatlon ~ll months Recovered, Much Improved Discharge Improved Evaluation nimproved X = Schizophrenia 2903. df=4.'<0001 52% Discharge Diagnosis Affective Psychosis 22 Psychoneurosis and Personality Disorder 26 X = 23.8. df=4. .<0001 54% 17 29 �Duration of Hospitalization By Age PERCENTAGE OF AGE GROUP STAYING OVER ONE YEAR Ass Menninger Hillside Below 20 81 42 20-29 73 36 30-39 61 30 40-49 30 20 50+ 36 MMHC 14 �Herch 12. 1965 Dr. Hetheniel Siegel. Ph.n. lecionel Institute of Hentel Beelth Bethesde. Ketylend Deer nets: I have sooepted ell your recommendations end heve redone this report. Enclosed ere e for copies which, while they still may hsve e typographiosl error, ere in e for: which ooold he sent to s publisher. I have taken the liberty of running this off on Colitho pletos. so the: if it is not published, we may still have some copies for our friends. Unless I hes: from you or receive s stop order. I will send e copy of this to the Archives of Geoersl Psychiatry. My best regards. Sincerely yours. Me: Pink. H.D. H131- Professor of Psychiecry �Hutch 12. 1965 Dr. Robsrt L. Kuhn, Ph.D. Division of Psychiatry antstiora Hospital and Medical Cents: Ill Esau 210th 8tssst Riv York, flaw York 10667 Dear Bdb: Following all tha recommendations in our last discussion, I have accepted the full responsibility for this draft. Recognizing the snotionsl problems involvsd. I hsvn deleted nsas. In this drsft. I have sssuusd tbs senior authorship insofar as you seen to be ralactsnt to do anything with the doeumsnt. It you would lihs, I will has. the first psgs radon. sad hsvs this subnictsd to tbs Archivss of Gsuarsl Psychiscry. with you ss senior author. st's It I tsctory. My do not has: from you. and submit ss is it it I will assume that this drstc is satisto Dr. Grinksr. best rsgsrds. Sincerely yours, Iink, H.D. frofsssor of Psychistry Ms: 31:3: �MONTEFIORE'HOSPPTAL.AND MEDICAL UHETHR 111 EAST 210TH STREET. BRONX. NEW YORK 10467. TELEPHONE: 212/TU 1-1000 March 15, 1965 Fink, M.D. Professor of Psychiatry Department of Psychiatry Missouri Institute of Psychiatry University of Missouri 5h00 Arsenal Street St. Louis, Missouri Max Dear Max: Thank you for sending me the draft of the "Three Hospitals" paper. I can understand your deleting Max's name since he never seemed able accept this organization of the material. I would appreciate however, if my name were restored as senior author when the paper is submitted for publication. I do not, in fact, feel "reluctant" it, to handle it, and if you wish, I am quite prepared to arrange for publication. I have no objections, however, if you wish to submit it to Dr. Grinker first with myself as the senior author. I notice from your letterhead that you are now a professor at the university of Missouri. I hope this change will be beneficial to your professional interests. You certainly have my best wishes. Regards to Martha. Sincerely, 34;, Hebert L. Kahn, Ph.D. Head, Section of Psychology Division of Psychiatry RLK:DCS to �April 1, 1965 Robert L. Kain, Ph. D. Division of Paydmiatzy Hmtefiom Hospital and Hndical Cantor 111 East 210th Strut Bronx, Haw York 10%? DurBob: Mummftisenclmod.andithasgmctonn Wrinthisfom Idohopohaceeptait,becauseit is me of tho intcmsting nm-biolofieal studies in m participated. MWMWMW.mImfindmlf inapooitimsimilartomatmichlheldinmsa. whidx we have Waterman burdms The are minimal and palate exclusively to mymstudiu. Immhawadaiewdawdmofindepondmca fwmamhwithamatdulofauflmvityoverpatimtn. staff.md£acilitius. WMIcm-mhemflxingofthis Ihaveafew excellent oomrkcm,but mlytimwill tell. have none the stimulation and imginatim that you exhibited. Max 14?: fun Fink, PLD. Professor of Pug/wintry �DEPARTMENT OF HEALTH, EDUCATION. AND WELFARE PUBLIC HEALTH SERVICE BETHESDA. MD. 20014 NATIONAL INSTITUTES OF HEALTH AREA aoI TEL: ass—mo coo: March 17 2 1965 In reply refer to: M-TMR-SS AIRMAIL Dr. Max Fink Professor of Psychiatry Missouri Institute of Psychiatry ‘ University of Missouri 5400 Arsenal Street St. Louis, Missouri 63139 Dear Max: for the colitho copies of the "Sociopsychological" It looks fine and I hope that it will be accepted by Thank you paper. the Archives of General Psychiatry. I have been in touch with some of our training grantees in Missouri, making the Missouri Institute of Psychiatry more visible to them as a research source. I hope that some cooperative endeavor may result in the not too distant future. Please keep in touch, and give my best regards to Martha. Sincerely, Nathaniel H. Siegel, Ph. D. Acting Chief, Social Sciences Section Training and Manpower Resources Branch National Institute of Mental Health �April 1. 1985 Mamie). a. 31.91, PM). Acting Chief, Social 801m Sectian Training and Hammer Ramon Bunch National Institute of bats). Health Dapu'mmt of Health, Edtmtim. md Welfm Bethesda, Maryland Dar Nat: After- scnfing copies of the aociopsychological paper to Bob, he indicated apnfomce forbeing the scalar auflm. Implmodtocxooodtohiswish,mdmcloeediaaoopy offite “pm wiflatmmvisod fact sheets. Ampysimmrto this has gone to the Amhim. 811ml}; yaks, Max HP-zjn Pink, 1-1.1). Manor of. Psychiatry �March 30. 1965 lobbins, stis Msdicsi Dirscror Hillside Hospital Dr. P. O. Box 38 Glsn Oaks, Haw K. D. York Dost Lev: During ths wists: usstings discussed this study and esrion. we Bob Xshn, I for publi- Nst Sisgcl and ssrssd to prepsrs it linsl drsft is enclosed for your infornstian. Vs hsvs tsksn rhs liberty of sabnirring this to Dr. Grinksr for his A consideration for publication in tbs copy I! to Agghgve . it sdvissbls. I would be plesssd to ssnd you dssl snyons you sugzsst st tbs Heaninxsr Foundation. Sincsrsly yours. link, H. D. Protsssor of Psychiatry Ms: first, s �Hatch 30. 1965 Dr. Jack Ewslt, H. D. Prefessor of Psychistry Massachusetts Hunts! Esslth Cantor 72~76 Yenwood Rosd Boston, Hassschnsstts Dear Dr. Ewslt: s conpsrsttve study was undertsksn with the Massachusetts Mental Baslth Conner as s coopsrstins institution. A finsl copy of tbs ropes: of thst study is sneloscd. we have tsceLvsd psruisston to publish this inforustion from Sons years ago, Dr. Grssnblstt. WW- I an writing to tell for consideration I would bu by tho you tbs: us hsvs submittsd this drst: plssssd to hsvs your con-sacs. Sinesrsly yours. Ms: rink, u. D. Profsssor of Psychiatry lltkp �March 30, 1965 as. Roy R. Grinkar, Sr. lbpartnent of Psychiatry Michael Reese Hospital micago, Illinois 60616 Dear Dr. Grizflcer: I the opportmity to enclose two copies of a report "Socioysychological Aspects of Psychiatric Tmatmnt in Emma Voluntary Hospitals" for your consideration for publicatim in the Archives. am tall-dug We report mmmts a study mdertaken some years ago by my associates and myself at the Hillside Hospital. We have decided to submit 'ti'xis for publicatim, in View of the continued interest in the social aspects of diamonis and manhunt. Sincerely yours, Max Pixflc, M. I). Professor of Psychiatry 3‘? �Harvard Medical School Department of Psychiatry Boston Fenwood Road, 021 I 5 74 l l l Massachusetts Mental Health Center [plllllllllllllllllll3M“; ljlllllllllll!!llfllH . ugfifirflifi a: g 2:” l (Boston Psychopathic Hospital) ill Department of Mental Health W” ”H" u: ‘ Flak-.215 .-:::.!'1| " x2.mumuillméw JACK R. EWALT, M.D. 3mm PROFESSOR or PSYCHIATRY SUPERINTENDENT April 5, 1965. Dr. Max Fink Professor of Psychiatry Mi ssouri Institute of Psychiatry 5400 Arsenal Street St. Louis, Missouri 63139 Dear Max: Thank you for the copy of your study of the Hillside Menninger's MMHC. I found it very interesting and, considering the differences particularly between this place and Menninger's, I am impressed with the way you could tease out comparable elements. I would hope some energetic person would about ten years after the first study do a repeat on the same three institutions, using as near as possible the same criteria to see what directions or shifts if any had taken place be would directional changes that there I them. strongly suspect among in all three but the differences you found would probably persist. Si ely �w. -. m. .V 1n: vv “ quI’V—nw W", waw w':——'-1.17W . VF... s ”pamn— w...“ -mrmwmwv 4w-uw1-w‘rr ,_....v , . — Jun. 3, up. lbbart 1.. New . .4, , .«.—-~w "w ‘v.'rr .. «q many 1965 Rain Division of Psychiatry Hawaiian Win). and 1.11 East 210th 3m“: M York, ”fin—“W. hated. Cantor York 16%? DaanublndNat: Hm: Firm, 1!. 1). Professor of Paydfiatry many an: HAW Sign. Hm}. Mimi Imam of m1 Knuth m, mm a“ m:«mv-:~,<muvw; vn‘w‘u‘w‘rv v V .. ,... �PROCESSING OF ACCEPTED MANUSCRIPTS Each accepted manuscript is processed in the Chicago Editorial Offices of the Archives of General Psychiatry bringing together all elements of the printed pages of the final published article. You will receive a reproduction of the typescript, edited according to the official AMA Style Book, for final review and approval. There will be no galley proof. is accepted with the understanding that it may be necessary to make minor revisions, or to request changes in illustration or text. Your manuscript The Editors �SAMPLE DETACH SAMPLE AUTHOR(S) (AND ONE ADDRESS): R. K. Merchant and .I. P. Utz 1200 Blank Street, Chicago, Illinois 60610 TITLE: Familial Sarcoidosis (Name of) JOURNAL: Archives of Internal Medicine Sarcoidosis was observed in a mother and her daughter. The criteria for this diagnosis included (1) a compatible clinical picture, (2) granulomatous inflammation with little or no necrosis and the absence of demonstrable microorganisms to specially stained sections of biopsy material, (3) negative cultures, particularly'for acid-fast bacteria and fungi, of appropriate body fluids, exudates, and surgically excised granulomatous tissue, and (4) apositive Kveim test. These cases of sarcoidosis, together with 73 others involving more than one member of each 32 families, suggest the possibility that a complex hereditary trait is operative in the pathogenesis of Sarcoidosis. �w DETACH . INVITATION...TO PREPARE AN ABSTRACT OF YOUR COMMUNICATION WHICH WILL BE CONSIDERED FOR PUBLICATION .IN THE JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION. Suggestions: .7. 1. Type name(s) of author(s) (also address of one of the authors), title of article and name of journal in which the original article appears. 2. 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Type abstract on attached card and mail promptly: a) Indicate purpose, extent, kind of study, materials and methods used. b) Refer chiefly to new data—the high points—informational, not descriptive; e.g., new statistics,new apparatus, new technics, new diagnostic criteria, new evidence, new preventive measures, a new theory,new treatment.Do not use abbreviations. 3. The abstract should not exceed 200 words. NOTE: Accepted article. PLEASE TYPE abstracts will be printed concurrently with publication} of the original THIS IS THE ONLY REQUEST PLEASE RUSH �SAMPLE DETACH SAMPLE ——————————-———————‘_ AUTHOR(S) (AND ONE ADDRESS): R. K. Merchant and J. P. Utz 1200 Blank Street, Chicago, Illinois 60610 V. TITLE: Familial Sarcoidosis (Name of) JOURNAL: Archives of Internal Medicine Sarcoidosis was observed in a mother and her daughter. The criteria for this diagnosis included (1) a compatible clinical picture, (2) granulomatous inflammation with little or no necrosis and the absence of demonstrable microorganisms to specially stained sections of biopsy material, (3) negative cultures, particularly'for acid-fast bacteria and fungi, of appropriate body fluids, exudates, and surgically excised granulomatous tissue, and (4) apositive Kveim test. These cases of sarcoidosis, together with 73 others involving more than one member of each 32 families, suggest the possibility that a complex hereditary trait is operative in the pathogenesis of Sarcoidosis. �*Kahn, R.L., Fink, , dd d THOR s *‘blijvisioé 3f(?3yc?1'i%€ryf°figntefiore “ M. and Siegel, N. 10467) Hospital, St., TFFLE:Sociopsychological Aspects of Psychiatric Treatment in Three JOIHHWAL: Archives of General Psychiatry Voluntary HOSpitals. Population characteristics, defined 5y social class, age, education and F score, were related to treatment variables in three voluntary teaching hospitals, Hillside Hospital (N.Y.), C.F. Menninger Memorial 111 E 210 NY Hospital (Topeka), and Massachusetts Mental Health Center (Boston). Treatment variables included type of treatment, duration of hospitalizaThe and evaluation. institutions differed in discharge diagnosis tion, of education and distribution of California class, years patient social 1 but not age. EF scores, had the The class longest g patients serving institution upper p psychoneurotic diagnoses > quration of stay, a higher proportion of lower of patientg Idand a schemata, complex proportion more diagnostic (I) the dischar e of fo oorest an somatic ther rati receivi Eamong tfié three instfgfitions. €¥§i1ariy, thg institution sgrving “gs m of had the shorter hospitalization, periods class patients glower m lower proportions of psychoneurotic diagnoses, and the better discharge evaluations. Psychiatric treatment and management practices differ among institutions according to the prevailing social class characteristics of their populations. �F‘ . “‘ ““ <4, FIRST CLASS Permit No. 1876 CHICAGO 10, ILL. VIA AIRMAIL MAIL REPLY BUSINESS No Postage Necessary if Mailed in the U.S. Postage . W111 be paid by— . American Medical Association 535 North Dearborn Street Chicago, Illinois 60610, U.S.A. Z. Danilevicius, MD _ — '— — — — — — — — — — — _ ~ �ARCHIVES OF GENERAL PSYCHIATRY EDITORIAL BOARD ROY R. GRINKER SR., M.D., Chief Editor American M€dical ASSOCiation June Institute for Psychosomatic andPsychiatticReseatch 29th Street and Ellis Avenue Chicago, Illinois 60616 EATON W. BENNETT, M.D., San Antonio EUGENE L. BLIss, M.D., Salt Lake City GEORGE E. GARDNER, M.D., Boston EDWARD O. HARPER, M.D., Cleveland M. RALPH KAUFMAN, M.D., New York HAROLD I. LIEF, M.D., New Orleans FREDERICK C. REDLICH, M.D., New Haven, Conn. MORTON F. REISER, M.D., New York DAVID MCK. RIOCH, M.D., Washington, D.C. JURGEN RUESCH, M.D., San Francisco 3 , 1965 Fink, M.D. University Of Missouri Max Medicine 5400 Arsenal Street St. Louis, Missouri JOHN H. TALBOTT, M.D., Director DIVISION OF SCIENTIFIC PUBLICATIONS SChOOl Of GILBERT S. COOPER, Managing Editor T. F. RICH, Assistant Managing Editor 63139 ' re: Manuscript Number 3836 Sociopsychological Aspects of Psychiatric Treatment in Three Voluntary Hospitals by KAHN, Fink, and Siegel Dear Doctor Fink: I am very pleased to inform you that your paper has been accopted by the Editorial Board for publication in the ARCHIVES OF GENERAL PSYCHIATRE, Yours very ROY truly, R. GRINKER, 311., NJ). Chief Editor iknczbr �’ ARCHIVES OF GENERAL PSYCHIATRY EDITORIAL BOARD ROY R. GRINKER SR., M.D., Chief Editor American Medical ASSOCiation Institute to: Psychosomatic andPsychiatticReseatch 29th Street and Ellis Avenue Chicago, Illinois 60616 EUGENE L. BLISS, M.D., Salt Lake City GEORGE E. GARDNER, M.D., Boston EDWARD O. HARPER, M.D., Cleveland M. RALPH KAUFMAN, M.D., New York HAROLD 1. LEE, M.D., New Orleans FREDERICK C. REDLICH, M.D., New Haven, Conn. MORTON F. REISER, M.D., New York DAVID MCK. RIOCH, M.D., Washington, D.C. JURGEN RUESCH, M.D., San Francisco June 149 1965 Max Fink, M.D . JOHN H. TALBOTT, M.D., Director DIVISION OF SCIENTIFIC PUBLICATIONS Department Of PSYChiatry Executive Managing Editor GILBERT S. COOPER, Managing Editor T. F. RICH, Asszstant Managmg Edttor ROBERT W. MAYO, Missouri Institute Of Psychiatry University Of Mi ssouri 5400 Arsenal Street St. Louis, Missouri 63139 re: Manuscript SOciopsychological Aspects of Psychiatric Treatment in Three Voluntary Hospitals by KAHN, Fink, and Siegel Dear Doctor Fink: I Number 3326 very pleased to inform you that your paper has been accepted by the Editorial Board for publication in the ARCHIVES am OF GENERAL PSYCHIATRY. Yours very ROY truly, R. GRINKER,SR., M.D. Chief Editor RRG3br P.S. We will, Of spaced throughout. Course, need three cepies of the manscript, doubled �re: Manuscript Number 3836 Sociopsychological Aspects of Psychiatric Treatment in Three Voluntary Hospitals by KAHN, Dear Author: et a1 Your paper has been received and is being considered by the Editorial Board. A decision will be given to you as soon as possible. Yours very truly, ROY R. GRINKER, Sr., MD. Chief Editor ARCHIVES OF GENERAL PSYCHIATRY �IS ROYR. GRINKER, Sr., M 5 c) Pan ‘ _HIS 29th STREET AND ELLIS AVENU CHICAGO, ILLINOIS, 60616 SIDE OF CARD FOR ADDRESS Fink, M.D. University of Missouri Dept. of Psychiatry at Missouri Institute of Psychiatry 5400 Arsenal Street St. Louis, Missouri 63139 Max �June 15, 1965 Dr. Roy R. Grinkcr, Sr. , Chief Editor- Archivna of General Psychiatry Institute for Paymomtic and Psychiatric Paaeamh 29th Strut and Ellis Avenue Chicago. Illinois 60616 Dnar Dr. Grinkcr: Enclosed am thme copies of thc mmcxipt entitled "Sociopsycl'nlogical Mpocts of Psychiatric '15:!th in That. Voluntary Mitch," as mmtcd in ymr recent letter. I am also enclosing the Mical abstract card. I have pmvimuly cm to Dr. Dmilevicim, as he had rcqunstcd this about ten days ago. mt man: you very much for your interest. Sincamly yours, Pink, H.D. Professor of Psychiatry Max Hrzkp encloms �Sociopsychological Aspects of Psychiatric Treatment in Three Voluntary Hospitals Robert L. Kahn, Ph.D.*, Max Fink, M.D.**, Nathaniel Siegel, Ph.D.*** �w. .-..w‘ww.."“mmmmn—pw MWCALWSOP WCWWWWWW mm L m. 31.9... ”I! My Katmai.“ Sing-1. Rub)“ “ODD... �Wt Oaks, Thisutudyunduuwmmnutmmassocimdatthe Hillside Hospital. Glen of L.I. Expodmul Pawmutry, New Yak. 1959452. MWmdfluataflsoffln meimofIr. CJ‘. «ad 1:): Manta). Henningnr Cantor hath Mutant“ mm l-bmitnl in gratefully W. Aidcd, in part. by grams M24092 and HY~2715. of the National Hulth, 0.8. Public malt}: Serving; and tho Instituu of mun Bond. Rum County mm m1 O Pun-mt Adams” East 210th York 1mm. “ I’m-mt Adan": W SM. mvidm of Psychiatry, Hmmfim 111 0mm, New Howitd and Wt ram New York. of Psychiatry at the Instituu o: Psyehhuy, Missouri School of of Mmity sum m1 Strut. Win... 8t. Inuit, Missouri 63139. no HIP 2/1/65 Present Adda-u; Nutimal Institutc of brutal Knuth, Wadi. mma. �. V.— ,___‘V ... auvn-m. rm. .whwwvr... _w.. .vaw.‘w 3w.-- - .-.—u--r.. .'>rlm' 'v' r q— “n... v-A‘Hnwwvwv‘V-vvv' )w-p—w' vrwumwrl—‘"W':"'V"V""-*‘VL'I'W-lw-v ‘.'._.,.._wv mmmdfluflummmcmmpop- ulntim. 8011111351356 and hdlich Imported significant relation- Mphmnmhmm'spmldminmsodalchssnmmtm mmmddmceofmatndillmas,typesof¢iagmoddism mmmmotmudammtmmmm. mainflumceoftmmcstmoffiumientmthe availabilityofmating pummel. m,mmtmm¢ Stmiasoffinmbofaodalfwminthomxmnof of their fixmial status and tho hospitalized paints Wt m mast-tam at Huma- Hospital in availability of mutant: 1957. In this hospital, anxiety of manhunt modes, incluling individual payabafinmpy, were WW thompiu available to all patients regardless of melt” ability to pay. and convulsive hmamys (mummizhat patimts hospitdiudforfln Wm‘iodsmmoldar.hadlmedtmimmdmmoftm 011mm. Mom,mmwmimmpm inmtlymmdbyomvulsiwfinmpymdmoeiwdmfavumbh WWW. mum W Myhypaydaathu‘pyujdmiwdpoomdim mm mm.mr.miv¢m. mhoopitlliud for Impurioda, tmtad ratings. Thuclmimlfwmwnmmmamof‘sumtypy, mmmnmrSa-hu.s).mwrm.w Mrstomn mmmofmmmdinmlmtadimduinvolutiaalpmis WWWMMWDMN thrupyfltocpitaliud‘fom amt- m,mmmmmumwwm. �_-..‘._ i It as ,. m." .... 7.." ‘r».:- — -~~-- um» 7.“ , suggested that differences in paydxiatr-io treatnmxt afloat a similar influence of social factors along hospitals should as noted for patimts within Hillside Hospital. To ewtion it was decided to wloy the Hillside study in three institutions cm. lhmin'ger Mental Health mm enter in - test this procedures of the 195? Hilleide Hospital, the Hospital in Topeka and the Maoeadmoetta Boston. Those with the expectation that diverse available to population of institutions were selected tnataent modalities diffemt social classes. were equally Each provided ohm—ten treatment of voluntary patients and did not provide custodial care. Each is a residency training center with a full time supervisory staff and active march mite, mixing peydnomalytioallycoriented psychotherapy. 'Ihia study wm designed to detemine thepopulatim character- ietioe of the three inetitutim with respect to social class. age, echoatim and 1' some; lid to relate these dmmcteriatios to treatment variables of type of treatment, duration of hospitalization, diamoeia and discharge evaluation mg the inetitutiom. tvwrw— w v �w J"- -A.».—. v ...v. m-uwwa. ... ,ur» In.‘,._(...._,..n .,.‘,.“___,‘ .- warm—Mr...“ . .VN.... .v- , ‘ ,7...” .... .... NM”, x..." ‘rwm'.tq'(1.'rm'“>1flr-r.ny\w ”rm—"w.“fivn v..._ mu Ammofmwlmtuy.am1tpafimtsinmimin mum adminidnflonpitalslndvolmtuypafimsmly,amnnmr WWquuminmeylaso. ofthoocatfluWMthfimethflflQmm mimdbyfinmtsprsymcovalmfimormm dadmionwimmicnmmitummfmdfwn specifiampmjwt. Mmflmflmmmfmflu studybocmofthcirmwmuy 3m. mmimeIMwasmndformImtimtmm mundu.‘ memmofdismdmimfi mummmmmmmwmmcrma 1110M. PornmofsoddclumflnfloWZ-fwtw im-aWMsdemmmmim-mmd of Hillside, at patients (3.“,7). mist-d M MORWWDSKWWWWMmCmtw. mmmmmflmoffinnmofflusml The W 173 mmmdmcmiabluwifldnmmnimflmumnm batman institutions. mu. maxim mm difficult. lunar, MmeofvuMBquiffWWbem. W www.mmwymoepaymcvamm diffimltiu were most mined These in the intm-hospital will be placid on the diffomw batman imtitutiau with citatim difficulties also no to o: mwmmmm m m. mummfomdmfwm‘dau,mfhmdintbeubmbythé ' vmpawmimsaploaigs. ‘ pvt—u u �A. WMCAL mums M Rpm ofthehoapitalis r studies from an. instituticn, tho stmctm fwmtedmdeimrimdorm~ tel-am timed bflafly. In suturing amenable data from nultiplc institutimo, hmwr, the durum between institutions are «mutated. R111- thele institutims were sol-cred as mental: invading, mom and Mt m. unlflm in ways which inflummd the data they a! the m 8m. fmctimdly Specific Mt, mutant «Item. differences were manhunt in the deeimtim of type of (lunatic mutants. and th- evaluation of m Raw designating that a pationt miwd of 1. the institutim, making 01' Mutant: The ”1:”de cum-rim difficult. oxitcria for diffemd mg hazing-r Hospital psychoflmpy was duimatod as mutant basis by a staff psychiatrist for Want-d on a At Mum mmpafimtwudmmdafui Wwithapsyddmic ruidunt physicim wen midst“ part a! rmtino mutmiw paint an. arm a Hillsid- ibopitn payMampy was mutant main»! with a psychiatric mid-at. Staff poydmictrim did not A1: matplthnta, mmmactivitiutowpoming midmtphysicim. Nomitimdfmwemmd. W mm MW 3 At tht th- mtivity Hum: Gutter pnyehothcrupy was ofmy disciplines --~- We �“am < -v u w“ -w “KN..." .... ,.. v... -. .7 r,r.,,..-....r...m~ rm.“ \w‘wur-m 7.. , .mvmwvrwmw—w ”v, w... H r. v. -_.'wm.-_..r.,.“,...m_,,‘,,.._w_..,. ,,._r_~‘l.,,_. w mm,pydnlosisu.sochlm,nms wwwwdzmsimmnmtmflmlyimmainm mdmdioal students. mt'smmmmmmummmm Witmmmfwmoffluammminm unmidmtplmidmmpmnibh farewells... W: Wm: 2. and. Indivichal imtitutimal difficult. At diamtic styles cums WWtal Whmlflphuvmmiwsmmdbytmmdw and music:we row mum diffmtufimaym. Scwnlmwofdimm W. W Wmmudinhbul,wmhmmsumutodmmm thWmMflfiWmhflmfim. Mmmmamflmm. 3- m WW=WMW mummmitmmwinrmmmm. m WWatWpritnmtdpar-dtewitham «31min: Max:111, W011 and syndm W. mmmimmmmmmmmmmam difficult to assess the ammunim of cad: it tutor offinlhminearsymfl'nblan). Pwfifiss‘mdyflnmmw rating making smmmmmmmmotwm intimation. m A... 7w.. �, .,__n..-. 7‘..-‘._._.‘._..-..W‘..v...‘ w...—,.,-v.,mx-,~_..V“-.."w.u "Wm.”w r9.w‘_v . .r,_..-——w.w ”w. ._»,.,.r,, — ._.__ .m‘...-..v..‘~,.\" »......—-....—-v— "m..- w w ——.~.. ".V...», v...“ - mmmmumoruummamum,m.m mmmrmmmmmmuumm in III. W Table I) W mattinmfiaipuaddflfnmin mm" mommmmormmmmmw. ”Wm-pimfiupwflaflmmpmuywm; «mumm.mm;mnmmmmm www.muymam. b) msnmmmdifminmdimibutim ammumwmmm. Wammmaflu‘dhm _mmm.mmmummmamdm «WWmmummmmnmmmm. mulmmammummmmmw 3M.uuya2parmtdtmmidcmd23permtatfllmimr c) didmtm. d) Wswfminmdlstfibutimat mmfinmifthSed-mmmd. Fifty-em mmtdmmmrmhlwm.mmy oimtmmwimmofSOwabw-wmhlmfm hum InWt. �, ”.7 . v Nv‘,—' ~ v , v... v. ‘v" —.~,~.~..-m ”11"!“ “we ,-.. ~.<.., .._ ~--r“~..,—a,<.»~mprv-. —. ~~pw~mmmw-w~mn m.” a... j." -r..-‘...,.1~.v» nymI-rznu at Hillside thirty-me per cent of the patients had 1" scores 30 while at WHO only twenty per mt mm belcw 30. mus, differences in social perfume: an the below clan, edumtional attaimxt P Scale were observed. and These diffexemee permit test of the hypotheses relating sociopsydsological factors to the mam-at variables mg these institution. 2. gleam-1c Than-ant Variables a n) Selectim of rm uimifimtly W: Manna the institutions, patimts at Naming” Hmpitel 043*.) received sciatic therapy than at Hillside (6%) or 11116 (68$) (Table IV). 1:) V Wm at Hoegiteliznticn: ‘lhe three insti— tutims differed with mm: to patient's length of my (m1. IV). Pedant: it Hlminw Mini was hospitalized lamest, with 65‘ cf patients mining far twelve month: or mated to m. alparwrtofflnflillnidepatientsMmlySpercmtatthe Pin-mm Hentnl thalth Center. 'Ihe mdal stay of the Hillside mmbetweeneemmdelmmfiu while tm-thirds ofthe WC patients were a) W Evalutim: diam Diem within six In and! petients were evaluated at the time of (Table IV) . At (191!) thinger Hoapitel. of patients wen rated patimt was a of hoapitelizatim. mini, mot dimmer-3e no "iuprmd" however, a higher percentage “miwmved” and only a single scared ”uncured" or “max iwmved." The percentage of ”mounted" an "mm harmed" rating him (2810 and the �_ _ v. “v ~_.v_..‘._.......p.r "anv “:wu—"mw-nr -17.": WNWV. ”.wuwwn mm My .-.._‘ n-wwn-y—wy ..~—r 7— —-,__.y vwri'ai.W"YV-wwmrnw. Mmportimofwumwd”(mt)wmfamdnmmuo mwmmm. W3 minimum: W, d) nostic For satiation analysis uffccdw Mmmiamdpomuuntymnflabh than: diag— diam, IV). Trading- Mamdmmmmmmm mmmm.usum1ymmmenaiW "Wmmrwmmhwdfwdw centrist. at paydmmia WW1“). disorder. In and memmdfwmflmfiftypwmdm W161. c. ’ m W.» mmammmmmmmmmmf ”Alum W.finflrhmpmiflwifldnudaimfituflm.mdm mm m].- siu (neural mine Maud: had was («or than than was) maimed significant intru-l’mpital mn- pm. Humor-.mmappomummtommmm thou-lineman MMmeMnWmm ulwddefatWHo-piulwwwhiMF accumumfmmuymaimwmm‘py).md Pamalematlfllhide. mamimmmm~ Wmmmnmnmmmmmmm Wm~mwmmmfmetm. mmmmmummtmmmmmm, �asmmmndwamudummmbuwmmmmn mummusotpmmmummmonomm Mam. W m DISCUSSIW mmormmmymmnmcmm mind significant inter-institutional cum in social mwmofmum.mtmtm;indiatflbutimof ammrsmammmmmormmmm win~mmothosp1unudm.ahctimo£mmts mammarmmamwmum maul-mm“. Hmpitnlatudy WWmmmmr (7). marina-d. 'nuimtitutimmvingwmpatiom mmmmmwmyummw paydmdodimmdmmdiwflcm,a �-rw .-,. a... h -... w ‘ purvm .. “.V 7—-.. w. tux—0.... V" - ,7". "7‘-.. - "\‘w' . -. -h. -Vw—l m.—....‘——wn~. V . m .w._-—zu—«——~....'_~Wm,- u...“ -10.. form of therapy. mtic mim and the poorest discharge ratings mg the three institutims. smmxy. the 1:31:in serving mg. class patients did have Mr proportion of patients the shorter pew of hoe:pi.t:eliaa1:i.tm,~ peydmmtic diamond, ad lover proportions bf the better discharge evaluations. Itumiwmeimflmtmdflfeminpeydumc W durum in staff ettitudes and are related more to lock]. alas variables than peydniatric differences in populetiom. The are We greet. as between m the mututime in dwetim 0f hapitaliutim mucky of climatic foundations. diam-rye evaluations. deflnitima of peydwthempy, and the detail- md aunt of differences W date. mm. these stylistic idiosynmtic, they follow! a social related to diffemoes, aid finir'miemncy mum with emeoteticm laments e meter dependence on social class may be dismissed as Wiedgad. Sud! mulatim and metnnt variable variables than outwardly intemtive processes, physicim and the of an 15th determined both by mum‘s staff relatimships are the attitude of the me! by the matellatim or history which patients present. Such relationships mined mat in than psychiatric conditions where diwtic criteria are leeet specific, a,an fining diseases of Imam etiology where objective criteria de- absent. as in schizophmie. peyoimmuis, personality md beluvior W. Under these �- ——-»~.—.. . 0 . .... Twp... -‘-- ~vv-ul'~w 5" 1m -.——.rw~‘~_.r “mp—m...“ "m”. . v~-_.v...‘.. ... m «um”www.m—mrwv.r.w-‘.,r-r.—,.m.~ Nut-aw..." I"-~nr~rl’-' Irav’r VW'FV‘wW-Pf'lm‘"- ._ mmwpomwthainiguity.m¢oh«mr's mmwmmmuwmumormm classified“, «Md-claims. osmium. 1:313:11»qu chalydoamudbyl’umidc,mnitxmdhfm (6)1ntha1r studyafmiatimiadimiuwithinasinghimtitutim. 'nuyobuzwdflutputiummimdatrmmdiffcmtm admtdifhrintypoofmm,mitalm,e¢mim. mermaid-non. Simiflcmtdiffcmasdidm,m,in “demmicwvimfimmm Mm “wwwmmmmwm. wtmmmmmmmmm.mumwm wmmammotdimmmmmitmIoffln W. WWWofmmismdmniml mmnnhmwmmfcmdmmimb tutimmmflm. unmmmammaemm mimic-insults. Farminlhmimmtdwiflxm Wyudmdpcmlmmfingmmnknpcimpmmto fwfinlamttiu,huflufmtpatiem$mdu W.mm.mflupmatmtmulu. Arm,inmt.miahismstimlmiwindufininga Wat.kmpaflmufwfindmtpoflw.Mhma mmamWWme Whhaatmammults. �mmmotmmmmmmqmny olmwflnmmtofmwutyofpopumamfw dogmofilhmsmgmeimtimfims, these {Wand We «fleet the mhtiva efficacy of the institutions. Simfincvalmfimsmbaudmtmmfimdm’sommfings, arm Mfmmmofimmmmrfiminmicpsyw- we mum that tho rennet variaticm in the criteria Mam“. Inwinimlfiflhidoatudym)itmpoamhmthat M WWW. mam criteria of were utilized {or mom of Itwmsuggastedfimttmmmr flumm'asodubwmdfinmmlexflthefiaw ployad. with mmmumlymmmmmtsm. flu cuff of flaming-r ibupital min; a tripartite rating Em Wmmemmgdmmmmum. mmmemmfingmmmmmmtiwamim fimnlmmbmd.itisourmumtmtorlmr duapommwapttcumiwinnuumto Wamfwfinpafimt's mpmitytomm wrigmile for uppor ulna panama the criteria aphasia: such mien intangiblmm”avnloping insight,"or"mfld.nng‘a pmbm." mmmmmmmmmmmmu ofwdnfminpaymem.mhmbemgrufly mmwmmmmmormm_mumm. �Midesmmwamedmflmllnad-nhip mamamimmmmmwmmnucmuy defined. But diffm in instituflmal style and: it diffimlt toebtlincmpambhdata. Mmdmisnmmmpmblm Wiml Wu meofwdxinmcmm. memormm of the use of statistics, «Many in W,mewmwlmnthm umitwiainmmwalmmwmidmfiflmimof Whpopuladmmauhdecttomiwmmnum institutions m charly mm for staff attitudu md atyla wmlluminmminpafimrtwpumm. Thu-o diffimltiwalaouflndtoflnfdlmdscimflahmomflm mmwmymmmmmMuMm-m. mmmammmwmmmu. mmmdfimmmuMqummm hypotm. flamofthcm”adfiaophmnia"or”paydw- W18” to explore chm in paydnologial and biological futuresofmtdfllmnhulodmascimww Manama oboewatimtobanpoma Mmmwzoday,mmmthmmmtom negatiw malts. paydkalc munitions Manly fwamfm tut of the be must paid, to the elusificutim Imam Music. mum m, wmymmmmmmmmnflmm of aubjwts by "abjectiw" criteria tamer than our present the oodnpoydxologiml aspects of fin unmist-padom: Wm. �v. ...., A. n. ‘v ....._.—ur————‘.v—. muw ‘ «m Two—u..— -..—.—v. .r. vvn<~>ww~wmfl‘rmew~——uir—I .—~ . am WMWW Was, Mmmdrsm,mm1mammamntvaflablaoin dufimd by social class, age, Fopuluflm on. ”may tanning hospitals. typo of mm. W variablas incluad dmutim of hmpitulimtim, diagnosis md diuduma evaluation. Imimtitmimal diffaranous mm in mint nodal class, yum of and distri- m mam Monofculifmiufums,butmtsga. Wins Thu tions m in W Gamma“ mg institu- uimifioumly diffamt in the pmdictad dimctim. The imtitutim sawing class patients did have the longest Minn of stay, a higher pmportim of paydxmam'otic diagnoses and W m min: diagnostic am, W, a lower proportion of diam and the poorest too-Mag mastic fans of ratings can; tho imtttutim. Similu‘ly, the m patina imitutim ummmmmdidmmmrpemcr houpitulisutim, 1m proportion of psydxmamdc diagnoses, and the discharg- evaluations. Wvariation on ma mm m muss with W mm not and Such dim, Wm hum institutimo objwmdam is in psychiatric practices followed u pattern class <11!qu mg thu momma. as idiosyncratic. in institutions! style make madam of of houpitalizatim and treatment mats {:1th ma tea-nuts, and the mad for m «item m:- the classification: of psymiati'ic populu~ mind. �REFERENCES and D. J. T. Levinson, Frenkel-Brunswik, W., E., Adorno, and The N. R. Harper Authoritarian Personality. Sanford, Brothers, New York, 1950, 990 pp. Hollingshead, Mental Inc., A. B. and Illness: Redlich, F. C. Community Study. New York, 1958, 442 pp. A Social Class and John Wiley and Sons, M. M. and Social Factors in Fink, Pollack, L., the Selection of Therapy in a Voluntary Mental Hospital. Kahn, R. J. Hillside Hosp., 1957, 6: 216—228. M. M. and Sociopsychologic Fink, Pollack, L., Mental in Treatments a Voluntary of Psychiatric Aspects and Ratings of Discharge Duration Hospitalization, Hospital: Diagnosis. Argh, Gen Psyghia§., 1959, A; 565-574. Kahn, R. Kahn, R. ifornia F L., Pollack, M. and Fink, M. Social Attitude (Ca1— Scale) and Convulsive Therapy. J4_Nexy&_mgntg_flls,, 1960, 1395 187—192. . Pasamanick, B., Dinitz, S. and Lefton, M. Psychiatric Orientation and its Relation to Diagnosis and Treatment in a Mental 116: 127-132. 1959, Ameza_J‘_£a¥£hiat., Hospital. 7. Siegel, N. H., Kahn, R. L., Pollack, M. and Fink, M. Social Class, Diagnosis and Treatment in Three Psychiatric Hospitals. Social Problems, 1962, lg; 191-196. �TABLE I Redesiggation 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 Sociopathic Personality Disturbance Passive Aggressive Personality Sociopathic Personality Disturbance Infantile Personality Alcoholism Infantile Personality Schizophrenic Reaction, Schizo—Affective Type Schizophrenic Psychosis �TABLE II Comparative Ratings of Clinical Condition At Time of Hospital Discharge MENNINGER HOSPITAL HILLSIDE HOSPITAL MASSACHUSETTS MENTAL HEALTH CENTER Recovered Recovered Much Improved Markedly Improved Improved Moderately Improved Unimproved Slightly Improved ______.____——————-——— Social Adjustment Improved Unimproved Character Structure Improved Unimproved Syndrome Complete Remission Improved Unchanged (or worse) Unimproved �TABLE Interhosgital Comparisons for Sociopsychological Variables Hillside Menninger Hospital Hospital N Class WM” Massachusetts Mental Health Center IllllfliilllllllIIIIEEEEHIIIIIIIIIIIIflflZflIIIIIIII I Social III 31% 7% 3% II 51 20 28 III 17 34 13 H IV 1 34 28 V 0 5 28 ”'1‘" " x2 = 121.5; df=8: p<{.001 ,,_-_1_A_s-__1.______ 19% 20— 39 =3. 9; Years of Educatio <12 41% 12-15 49 16+ 10 --—--—-— x2 = F Score df= 4; p=n. s. = 9.7; df=4; p<.05 §3z 20% 50 38 17 42 39.2; df=4; p<.001 �TABLE IV Variables Treatment in Differences InterhOSpital EMBnninger Hospital Treatment Psychotherapy 21% 36% 24% Somatic 43 64 68 Other 36 -— 8 x2 Duration . 0? HOSpltal— lzat1°n Hospital Massachusett Mental Healt Center IlfiflflflflllllIIIlflEflIIIIIIIIZIIIIIII N Type of Hillside = 82.8- df=4 -m** 7 months 7-11 months ' .11 months 22% 27% 67% 13 42 27 65 31 5 Discharge Improved Evaluation nimproved X = 29.3' df=4' -<.001 85 54% Schizophrenia Discharge Diagnosis Affective Psychosis 17 Psychoneurosis and Personality Disorder 29 X = 23.8' df=4‘ -<.001 �Duration of HOSpitalization By Age PERCENTAGE OF AGE GROUP STAYING OVER ONE YEAR Age Menninger Hillside Below 20 81 42 20-29 73 36 30—39 61 3O 40—49 3O 20 50+ 36 MMHC l4 �AMA SPECIALTY JOURNALS ' ' lC ' Am 6 r1 C a n M e d al A S S O C l at] O n 535 NORTH DEARBORN STREET - ' CHICAGO, ILLINOIS 60610 wa— AREA CODE 312 527-1500 910-221-0300 November 2 , 19 65 Archives of Dermatology . um 0 an i:Chialldr:n Sinse;ses Archives Of Envir nrnent al Heal I h .° Archives °f General Psychiatry Archives of internal Medicine Archives of Neurology Archives of Ophthalmology Arc ives o ‘0‘ o l a ‘V n g o ‘ o 3’ "_ Arcthes of Pathology A'c h'was ° f S“ '3 eW JOHN H. TALEOTT, MD, DIRECTOR DIVISION OF SCIENTIFIC PUBLICATIONS ROBERT W. MAYO, EXECUTIVE MANAGING EDITOR NORMAN D. RICHEY, MANAGING EDITOR Fink , MD Department of Psychiatry Missouri Institute of Psychiatry University of Missouri 5400 Arsenal St. St. Louis, Mo. 63139 Max Dear Doctor Fink: edited copy of your manuscript entitled, ”SociopsychoA Treatment: of Aspects Report of Psychiatric logical Treatments in Three voluntary Hospitals,” is enclosed for your final checking and approval. Also enclosed is a layout that shows placement of title, copy, and illustrations. Please indicate any necessary changes in a covering letter rather than on the edited typescript. we will be responsible for checking your material against proofs. An manuscript has been edited according to present AMA style. For example, most abbreviations appear without periods. The are currently striving for brevity in article titles. If the modified title of your paper is not satisfactory, please \/ supply another that will fit into two lines of no more than 40 characters and Spaces each. we L ,ZU Chi, for reprint purposes, the one Is address at end of article, you will be using on a relatively long-termlaasis? 1 Specialty Journals publish acknowledgments only to personsbfi1p P have aided in that a a study or organizations major way, as, for example, by supplying drugs or funds, making statistical analyses, or doing pathological studies. AMA references have been renumbered to conform to our rule requiring numerically consecutive citation. Your �Fink, St. Louis, Max MD -2- Mo. 11/2/65 According to our calculations,the paper will occupy 6 printed pages. Please note that any new material you may wish to submit at this time will be acceptable only if it can be compensated for by deletion of an equal amount of copy now included. have retyped the references so that an accurate copy estimate could be made. Although we have reread the typescript, we request that you also check for any errors of omissions that may have slipped through. we correction and return of your typescript will help us get it into print as fast as possible. Please return it, along with the layout, in the enclosed self-addressed envelope no later than November 9. For your convenience we are also enclosing a reprint order form with the correct number of pages indicated. Prompt Yours very amh , udith M. truly, Kiolbassa �. "luau—“new .- , . H- MW. -1 ~ »~v - we. w re ,-_....‘--—-~~w—~- «V... WP v,“ mm“- "WWW. w. 1“. - -.. .. . 5. 1965 Judith H. Kiolbesse Mariam Medical Association 535 North Deerbom Street Chicago, Illinois 60610 Dear flies Kiolbesse: Myouwrymdafcrymmletterofflovemrz. I shelltrytomreechitenineeqmnoe. The article title is satisfactory, elthcugh I think the "A Mt sub-heed should reed in Three Voluntary Report of Hospitals.“ 'me word "treetlsents" end "treetsent" are probably interminable, but in this inetmoe, I think the singular {on is preferable. However, both eve acceptable. While the address at the end of the erticle is one that will be used for e lmg~tem basis, I would prefer that you and that is the Depertnmt of change this for Dr. Psychiatry. University of axioego. Chicago, Illinois. m. edmouledgmt included the name of Dr. Max Pollack. In ell the studies done at Hillside, Dr. Pollack was e coper'tioipmt. In this study he was one of the three people she visited eech of the institutions. Hmever, in writing this report, there were some disagreements as to the omclusims, mdheelectednottobeeoo—euthoroftheetudy. Hy essccietes and I. wild, however, like to indicate his assistance, and for this meson, I think a statusent, "me cooperation of Dr. Mex Polleok is gratefully edmwledged" “me would be appropriate. met. numbered refermces are I m assuming thet the Jamel limits the timer of authors to three, and The metthieisthereesmmythatintwooftheoitetions the co~euthore are omitted. If this is not e gmerel rule, perhaps in this instance the oo—wthcrs could be listed. page la, in addition to the notation regarding the coopemtim of Dr. Pollack, would you please damage the address of Dr. Kern from Hontifiore Hospitel to: Department of Psychiatry, University of Omicego, Chicago, Illinois. On .uw vs.— ‘ =. 2.. .: “may.“ . .,.. �Miss Kiolbassa -2- Also, the dates 1959-1952 , which follow the statement donoeming the origin of the study, are immutable by themelvee. In our original report, we used the sentence, "his study was dorm when the authors were associated at the Department of Experimental Psychiatry, Hillside Hospital. 19594962." If 30m full sentence offluiekindionottobeinoluded,thmlwmldouggestthat the dates 1959-1982 be omitted. I have read the text carefully, and find two small corrections midxlhavemked. mm2,naarfimbotton, theoomotimo putaolashlinethmwfithemwerS, mdthiemaybemolmto 1’ the printer. It should read "the California Scale. 03,5) page 10, mfemoe 7 should be number 6, and mmked this copy. cm I have so is a table. and them is a symbol which I do not mderatmd. In the first oolm."omplete remission"is aplit with a synbol mien to me would indicate that the word “mission” should be under "ooeplete." If that is so, this may be molear. I do not know how this will be not, but ”oanplete minim," "amicedly homo," "mdemtely normed” are each word pairs that should not be split. If this is too long for the oolmn, than I hope you will indicate féthat "markedly mmved” fit Page 19 together by appropriate spacing. Tfiis is the first time that I have had the opportunity to edit a mmxmoz-ipt in this fashion, and I must say that I found it quite helpful. opportunity toworkwithyou, andI Myouforthe look forward to the final results. Sincerely yours . Pink, NJ). Professor of Psychiatry Max HP : in �Sociopsychological Aspects of Psychiatric Treatment in Three Voluntary Hospitals Robert L. Kahn, Ph.D.*, Max Fink, M.D.**, Nathaniel Siegel, Ph.D.*** �Sociopsychological Aspects of Psychiatric Treatment in Three Voluntary Hospitals Robert L. Kahn, Ph.D.*, Max Fink, M.D.**, Nathaniel Siegel, Ph.D.*** �~ This study was done when the authors were associated at the Department of Experimental Psychiatry, Hillside Hospital, Glen Oaks, L.I. New York, 19591-1962. cooperation of Dr. Max Pollack and the staffs of the Massachusetts Mental Health Center and the C.F. Menninger Memorial " is acknowledged. Hospital gratefully The . ‘ Aided, in part, by grants My-2092 and MY—2715, of the National Institute of Mental Health, U.S. Public Health Service; and the Nassau County Mental Health Board. * Present Address: Division of Psychiatry, Montefiore Hospital and Medical Center, 111 East 210th Street, New York, New York ** Present Address: 10467. ‘ Department of Psychiatry at the Missouri Institute of Psychiatry, School of Medicine,-University of Missouri, 5400 Arsenal Street, St. Louis, Missouri 63139 *** MIP 2/1/65 Present Address: National Institute of Mental Health, Bethesda, Maryland �In their studies of the New Haven psychiatric patient pop— ulation, Hollingshead and Redlich hast reported significant relation— ships between an individual's position in the social class structure .and the incidence of treated illness, types of diagnosed disorders and kindsand duration of psychiatric treatment administered (2), The influence of the economic status of the patient on the availability of treating personnel, however, was not excluded. Studies of the role of social factors in the treatment of hospitalized patients independent of their financial status and the availability of treatments were undertaken at Hillside Hospital in 1957. In this hospital, a variety of treatment modes, including individual psychotherapy, pharmacotherapy and convulsive therapies were available to all patients regardless of their ability to paye In anr thsae surveys (3,4) we observed that patients hospitalized for the shortest periods were older, had less education and were more often of foreign birtho These older, less educated patients were predominantly treated by convulsive therapy and received more favorable clinical discharge ratings, In contrast, younger, native born/aim? more educated patients were hospitalized for longer periods, treated primarily by psychotherapy and received poorer discharge ratingsa These clinical factors were also related to a measure of stereotypy, the California F Scale (1,5)o Higher F scores, i.eo, greater stereotypy, were often found in patients diagnosed as involutional psychosisf who were referred for convulsive therapy, hospitalized for shorter periods, and more often were rated as much improved or recoveredo in-ehe-survey—rEpUTtEd-hETE)[it was suggested that dif— "’4”“’A“' ferencesin psychiatric treatment among hospitals should reflect the influence of social factors as noted for iht patients within Hillside Hospitala To test this suggestion it was decided to employ the pro— cedures of the 1957 Hillside study in three institutions -¢ Hillside HosPital, the C. Fo Menninger Memorial Hospital in Topeka and the Massachusetts Mental Health Center in Boston, These institutions were selected with the Fr:ec£3£ipn that hing-had diverse treatment modalities h’&Y‘ available,;d££:eoi¥ed-paeients of different social classeso equally Each provided short—term treatment of voluntary patients and did not provide custodial care, Each is a residency training center with a full time supervisory staff and active research units, emphasizing psychoanalytically-oriented psychotherapyo This study was designed 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 treatment variables of type of treatment, duration of hospitalization, diagnosis and discharge evaluation among the institutions, �_2_ METHOD A census of all voluntary, adult patients in residence in the institutions was 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 schizo- phrenic state hospital group transferred for a specific research project. These patients were excluded from the study because of their non—voluntary status? The California F scale was scored for each patient on the census day. Eighteen months later the records of discharged patients were examined to determine the social and psychiatric factors of the study. For a measure of social class, the Hollingshead 2-factor index a weighted score of education and occupation was used (3,4,7)o The study population consisted of 173 patients at Hillside, 100 at Menninger and 95 at the Massachusetts Mental Health Centero — study included examination of the relations of the social to the psychiatric variables within each institution as well as between institutionso These comparisons were difficult/however, because of various methodological differences discussed below. These difficulties were most marked in the intraehospital comparisons/.and accordingly, in the analyses of psychiatric variables emphasis will be placed on the differences between institutions with citation of intra-institutional trendso These difficulties also led to missing information for some data, which—ie-reflected in the tables by the varying population sample The sizes, �RESULTS A. Methodological Problems repgfting studies from one institution, the structure of the hospital guanine taken for granted and either ignored or mentioned briefly. In gathering comparable data from multiple institu~ tions, however, the.mnny;differences between institutions are accen— tuated. While these institutions were selected as comparable in teaching, research and treatment programs, they were functionally unlike in ways which influenced the data of the study. Specific differences were prominent in the designation of type of treatment, diagnostic classifications, and the evaluation of treatment outcomeo When l. Designation of Type of Treatment: The criteria for designating that a patient received "psychotherapy" differed among the institutions, making comparisons difficult, At Menninger Hospital psychotherapy was designated as basis by a staff psychia- treatment administered on a prescription trist for which the patient was charged a feeo Sessions with the ‘2 psychiatric residentfiyere considered part of routine administrative patient care. fkysa4.¢ Hillside Hospital psychotherapy was defined as treatment sessions with a psychiatric resident, Staff psychiatrists did not treat patients, but restricted their activities to supervising res— ident physicianso No additional fees were chargedo At At the Massachusetts Mental Health Center psychotherapy was designated as the activity of many disciplines -- psychiatric residents, psychologists, social workers, nurses and medical students, Formal records of such sessions were not routinely included in the patient's record and to ascertain which patients received psychowas necessary for members of the study team to interview therapy it the residentgresponsible for each case. fkjsKJAu Individual institutional diagnostic styles made comparisons difficult. At Menninger Hospital diagnoses employed the multiple evaluative scheme recommended by the American Psychiatric Association, while both Hillside and MMHC followed different unitary systems, Several examples of diagnoses from Menninger are listed in Table I, with our suggested conversions into categories comparable to that of the other two institutions. These conversions provide a source of distortiono 2° Diagnosis: �Table I Discharge Ratings of Improvement: Ratings of improvement at the three hosPitals varied in format and detaily The discharge rating at Menninger Hospital was tripartite with a sep— arate evaluation for social, characterological and syndrome changes. Hillside Hospital and Massachusetts Mental Health Center had global ratings making it difficult to assess the contribution of each factor of the Menninger system (Table II)o For this study the Menninger syndrome rating was compared to the global ratings of the other 30 institutionsa Table Q M’s _———"’ Inter-hos ital <:; B.fi~~,»n--__ "M..- {§_‘ 10 The Com II arisonSN Sociopsychological Variables distribution of the variables of social class, age, California F Scale score among the three institutions education and is presented in Table III. Table a) Social Class: The III . anticipated difference in social class composition of the three institutions was observed, At Menninger Hospital the population was predominantly upper class; /AE Hillside Hospital, middle class; and at Massachusetts Mental Health Center, predominantly lower class. b) Age: There were no differences in age in the institutional populationso distribution �populations also differed in edu—” cational attainment, with patients having more years of education at Menninger Hospital than at Massachusetts Mental Health Center. While 41 per cent of the patients at MMHC had not completed high school, only 32 per cent at Hillside and 23 per cent at Menninger did not graduateo 0) Education: The Score: Differences in the distribution of scores on the California F Scale were also observed. Fiftynone per cent of 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 thirty-one per cent of the patients had F scores below 30 while at MMHC only twenty per cent were below 30. d) F Thus, differences in social class, educational attainment and performance on the F Scale were observed, These diff— erences permit a test of the hypotheses relating sociopsychologi- cal factors to the treatment variables \“"2. among these institutions. Psychiatric Treatment Variables a) Selection of Treatment: Among the institutions, significantly fewer patients at Menninger Hospital (43%) received somatic therapy than at Hillside b) Duration of (64%) or MMHC Hospitalization: (68%) (Table IV), three insti— tutions differed with regard to patient's length of stay (Table IV)o Patients at Menninger Hospital were hospitalized longest, with 65% of patients remaining for twelve months or more, compared to 31 per-cent of the Hillside patients and only 5 per—cent at the Massachusetts Mental Health Center. The modal stay of the Hillside group was between seven and eleven months while two-thirds of the MMHC patients were discharged within six months of hospitalization. The c) Discharge Evaluation: In each hospital, most patients were evaluated at the time of discharge as "improved" (Table IV), At Menninger Hospital, however, a higher percentage (19%) of patients were rated as "unimproved" and only a single patient was scored "recovered" or "much improved"o The highest percentage of "recovered" or ”much improved" ratings (28%) and the lowest proportion of "unimproved" (10%) were found at the Massachusetts Mental Health Centerm nostic d) Diagnosis: For statistical analysis groupings were made: schizophrenia, affective three diagdisorders, and �psychoneurosis and personality disorders (Table IV). The diagnostic proportions of patients within these groups were similar for Hillside and MMHC, as slightly more than half were diagnosed as schizophrenia and one—quarter as psychoneurosis or affective disordero In contrast, at Menninger Hospital psychoneurosis and personality disorder accounted for more than fifty perncent of the populationo zx Table IV ‘“ CLJLRS ."” C: Intra—Hos s-‘wa. ~~ r“ e~ ital Com arisons ‘h53 lack of meaningful criteria for the subdivision of populations, their homogeneity within each institution, and the limited sample size (several groupings were obtained which had fewer than five cases) precluded significant intra—hospital com— parisons, However, the trends appeared similar to those found in the earlier study, Age and F score were found related to the selection of treatment at Menninger Hospital (older and higher F score patients more frequently receiving somatic therapy), and F score alone at Hillside. Length of hospitalization and chronological age were related at both the Menninger and Hillside Hospitals - the younger patients remaining for the longest periodst While such relationships were significant in these two hospitals, a similar trend was noted at the MMHC (Table V) where no patients over 40, but 14% of patients under the age of 20 remained longer than a year, The Table V �DISCUSSION patients of three voluntary psychiatric hospitals exhibited significant inter-institutional differences in social class and years of education, but not age; in distribution of California F Scale scores; and in each of the treatment var— iables -- duration of hospitalization, selection of treatments and distributions of diagnoses and discharge evaluations (7)“ swudy Expectations based on our earlier intra—Hillside Hospitaufifi;;:’ confirmed. The institution serving upper class patients did have the longest duration of stay, a higher proportion of psychoneurotic diagnoses and more complex diagnostic schemata, a lower proportion of patients receiving somatic forms of therapy, and the poorest discharge ratings among the three institutionso Similarly, the institution serving lower class patients did have the shorter periods of hospitalization, lower proportions of psychoneurotic diagnoses, and the better discharge evaluations. The It is our impression that these differences in psychiatric treatment are related more to differences in staff attitudes and social class variables than psychiatric differences in populationso The contrasts between institutions in duration of hospitalization are great, as are the complexity of diagnostic formulations, discharge evaluations, definitions of psychotherapy, and the details and amount of recorded data. While these styl— istic differences may be dismissed as idiosyncratic, they follow a pattern related to social differences, and their consistency with expectations suggests a greater dependence on social class variables than ordinarily acknowledged, population and treatment variable relationships are interactive processes, determined both by the attitude of the physician and the administrative staff and by the constellation of symptoms or history which patients presento Such relationships are marked most in those psychiatric conditions where diagnostic criteria are least specific, Egg}, where objective criteria defining diseases of known etiology are absent, as in schizophrenia, psychoneurosis, personality and behavior disordersq Under these conditions of perceptual and situational ambiguity, the observer's attitudes and expectations become significant aspects of his perceptions, classifications, and decisions. A similar situation was clearly documented by Pasamanick, Dinitz and Lefton (6) in their study of variations in diagnosis within a single institution. They observed that patients assigned at random to different wards did not differ in type of admission, marital status, education, age or residence. Significant differences did occur, however, in Such �the incidence of various diagnostic classifications among the three wards and among three administrators on one ward“ As no differences in the populations were demonstrated, we believe the different incidence of diagnoses reflect the attitudes of the examinerso Present psychiatric concepts of diagnosis and clinical evaluation have little meaning when transferred from one institution to another, Literal adherance to these concepts produces paradoxical resultso For example, Menninger Hospital with the more highly trained personnel conducting treatment, keeps its patients for the longest time, has the fewest patients diagnosed as schizophrenia, and yet, reports the poorest treatment results. At MMHC, in contrast, which is most inclusive in defining a therapist, keeps patients for the shortest periods, and has a higher proportion of the population classed as schizophrenia, reports the best treatment results, In the absence of independent criteria for the quality of care or the assessment of comparability of populations for degree of illness among the institutions, these findings do not reflect the relative therapeutic efficacy of the institutionso Since the evaluations are based on the institution's own ratings, we believe that the differences reflect variations in the criteria used for evaluation of improvement rather than intrinsic psychi- atric characteristics. initial Hillside study (4) it was postulated that different criteria of improvement were utilized for persons of different social backgroundc It was suggested that the higher the person's social background the more complex the criteria em— ployedo This has been literally confirmed in the present study, with the staff of Menninger Hospital using a tripartite rating compared to the global rating of the other two institutionso Even considering the syndrome rating on which our comparative statistical analyses were based, it is our contention that for lower class persons we are apt to assess improvement in relation to symptom relief or the patient's capacity to resume work, while for upper class persons the criteria emphasize such complex intangibles as In our "developing insight," or "working through one's problems." While these investigations have again demonstrated the role of social factors in psychiatric treatment, we have been greatly impressed by the methodological problems of studies across institutions. These institutions were selected for their educational �leadership and the expectation that the recorded variables would be clearly defined, But differences in institutional style made it difficult to obtain comparable data. This experience is a cue to the problems of the conventional use of comparative statistics, especially in the evaluation of psychiatric therapieso The use of discharge ratings, diagnostic classifications or length of hos— pitalization as criteria in therapeutic evaluations or the iden— tification of comparable populations are subject to extensive error unless the institutions are clearly matched for staff attitudes and style as well as social class patterns in patient populationso These difficulties also extend to the failures of scientists to confirm clinical or laboratory observations made in other laboratories, for the lack of confirmation may reflect differences in populations and psychiatric criteria as much as errors in the orig— inal hypotheses. The use of the terms "schizophrenia" or "psycho— neurosis" to explore changes in psychological and biological features of mental illness has led to a science burdened by negative results. Even were a valid observation to be reported from one laboratory today, we do not have the methods to describe psychiatric populations adequately for a satisfactory test of the hypothesis. Increased attention must be paid to the classification of subjects by "objective" criteria rather than our present methods, so highly dependent on institutional and observer attitudes and the socio— psychological aspects of the therapist-patient interaction. �-10- SUMMARY AND CONCLUSION Population characteristics, defined by social class, age, education and F score, were related to treatment variables in three voluntary teaching hospitals. Treatment variables in— cluded type of treatment, duration of hospitalization, diagnosis and discharge evaluation, Inter-institutional differences were observed in patient social class, years of education and distri— bution of California F scores, but not age. variations in treatment characteristics among institutions were significantly different in the predicted di— rection. The institution serving upper class patients did have the longest duration of stay, a higher proportion of psychoneurotic diagnoses and more complex diagnostic schemata, a lower proportion of patients receiving somatic forms of therapy, and the poorest discharge ratings among the three institutionse Similarly, the institution serving lower class patients did have the Shorter periods of hospitalization, lower proportions of psychoneurotic diagnoses, and the better discharge evaluations. The variations in psychiatric practices followed a pattern consistent with the social class differences among the in— stitutions and are not regarded as idiosyncratic. Such differences in institutional style make comparisons of diagnoses, duration of hospitalization and treatment results between institutions difficult and tenuous, and the need for more objective criteria for the classification of psychiatric populations is emphasizedo These �REFERENCES 1. Adorno, T. W., Frenkel—Brunswik, E., Levinson, D. Sanford, R. N. The Authoritarian Personality. Brothers, New York, 1950, 990 pp. Hollingshead, Mental Inc., Illness: New Redlich, F. Community Study. A. B. and A C. J. and Harper and Social Class and John Wiley and Sons, York, 1958, 442 pp. L., Pollack, M. and Fink, M. Social Factors in the Selection of Therapy in a Voluntary Mental Hospital. J. Hillside Hosp., 1957, 6: 216-228. Kahn, R. . L., Pollack, M. and Fink, M. Aspects of Psychiatric Treatments in a Hospital: Duration of Hospitalization, Diagnosis. Arch, Gen Psychia;., 1959, Kahn, R. Kahn, R. ifornia F L., Pollack, M. and Fink, M. Sociopsychologic Voluntary Mental Discharge Ratings and 1; 565—574. Social Attitude (Cal- Scale) and Convulsive Therapy. 14_lkuahhlkuxLL_Disu, 1960, llQ: 187—192. Pasamanick, B., Dinitz, S. and Lefton, M. Psychiatric Orien— tation and its Relation to Diagnosis and Treatment in a Mental Hospital. AmeIa_J4_E£¥£hiaL., 1959, 116: 127-132. Siegel, N. H., Kahn, R. L., Pollack, M. and Fink, M. Social Class, Diagnosis and Treatment in Three Psychiatric Hospitals. Social Problems, 1962, 1Q; 191-196. �TABLE I Redesignation of Discharge Diagnoses Menninger Discharge Diagnoses Depressive Reaction Narcissistic Personality Anxiety Reaction General Classification Psychoneurosis Narcissistic Personality Psychoneurosis Narcissistic Personality Narcissistic Personality Personality Trait Disturbance Alcoholism, Chronic Sociopathic Personality Disturbance Passive Aggressive Personality Sociopathic Personality Disturbance Infantile Personality Alcoholism Infantile.Personality Schizophrenic Reaction, Schizo—Affective Type Schizophrenic Psychosis �TABLE II Comparative Ratings of Clinical Condition At Time of Hospital Discharge MENNINGER HOSPITAL Social Adjustment Improved Unimproved Character Structure Improved Unimproved Syndrome Complete Remission Improved Unchanged (or worse) HILLSIDE HOSPITAL MASSACHUSETTS MENTAL HEALTH CENTER Recovered Recovered Much Improved Markedly Improved Improved Moderately Improved Unimproved Slightly Improved Unimproved �TABLE III InterhosEital Comparisons for Sociopsxchological Variables Menninger Hospital I Class 31% 7777 7 7 7% II 51 20 III 17 34 IV 1 V O 34 . 5 l||||||||||||||||||||||||||||||||||||||||||||||||||| x2 77 Hospital Massachusetts Mental Health IIIIIflBiflIIIIIIIIIIIIIIEIIIII N Social Hillside 7 7N7 777—777 7 = 121.5; df=8: p’{.001 7m__-— -77777777—77 20 39 Years of Educatio <12 41% 12-15 49 16+ 10 x2 = 39.2; df=4; p<.001 �TABLE IV Interhospital Differences in Treatment Variables iMenninger Hospital Treatment Psychotherapy 36% 21% Somatic Other um— =82 8' N Duration 0? Hospital Massachusett Mental Healt Center IIIIIIIHIIIIIIIIKIIIDIIIHIIIIIIJJIIIIII N Type of Hillside 7 months 7—11 months Hospitallzat1°n .11 months df= 4 . .001 Z ' A 70 13 42 27 65 31 5 52% 54% 22 17 26 29 Discharge Improved Evaluation Unimproved Schizophrenia Discharge Diagnosis Affective Psychosis Psychoneurosis and Personality Disorder X = 23.8' df=4' -<.001 �TABLE V Duration of Hospitalization By Age PERCENTAGE OF AGE GROUP STAYING OVER ONE YEAR Age Menninger Hillside Below 20 81 42 20—29 73 36 30-39 61 3O 40—49 3O 20 50+ 36 MMHC l4 �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". mm»... can“ b. awn-u a mi: “tum-Ma in a M an“ ”MI "in“ am: tm‘nt It“ ”mm van-mm pap-nun ”humbly! m trams m um to but! up»: u “mun" pram-I. «Wu! h by no “at: m pints“: m “um. a n manna" u. wanna» .1 Wm at hum: mu 1 ”tint up mm“. In! mumm- Irin h nut mm in m than Mm m. pmmuu I!" ”not“ Mt “am“: Mm hut with, $1334, than “I “scan" ufinu «flung «In». or knu- uum Mum-mt an that. a n W“ mchm“ ”than”2le at numb”, nnflnn. “than” an and «mutton o: a“ nun»’M“” a: citation! «yuan-n tum v3.01: 2» a» mu pmmuu «a «mausuun. In. an flatly Imam“ hr tun-much, an“: and um (7) u that it“: of «than: as “was: um: a am. in“. huh. 3.; than“ it“. ”mm mum}! animal! to 551’:an an m mm in m. t: await», mm: sum, man, an 0: awn-mt «um-«m m mm. m m mthmulnhhiutmummd. u “unawaI“ am, bum, 11:01: «In “no in “and“ it. and. as! “St-rm mu tub-rut 1: m ywmfln. �SociopsydholOgical Aspects of Psydhiatrie Treatment in Three Voluntary Hospitals ;R0berrt L, .lfiahn, 1311313332! Nathaniel Siegel, Ph.D.*** ‘— NEIIIIiiiiIIiE§E¥§ �-7- ’4‘, DISCUSSION patients of three voluntary psychiatric hospitals exhibited significant inter—institutional differences in social class and years of education, but not age; in distribution of California F Scale scores; and in each of the treatment variables -— duration of hospitalization, selection of treatments and distributions of diagnoses and discharge evaluations {7}, The Expectations based on our earlier intra—Hillside Hospital were confirmeda The institution serving upper class patients did have the longest duration of stay, a higher proportion of psychoneurotic diagnoses and more complex diagnostic schemata, a lower proportion of patients receiving somatic forms of therapy, and the poorest discharge ratings among the three institutionsc Similarly, the institution serving lower class patients did have the shorter periods of hospitalization, lower proportions of psychoneurotic diagnoses, and the better discharge evaluations. It is our impression that these differences in psychiatric treatment are related more to differences in staff attitudes and social class variables than psychiatric differences in populationso 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 datae While these styl— istic differences may be dismissed as idiosyncratic, they follow pattern related to social differences, and their consistency with expectations suggests a greater dependence on social class variables than ordinarily acknowledged. a population and treatment variable relationships are interactive processes, determined both by the attitude of the physician and the administrative staff and by the constellation of symptoms or history which patients presento Such relationships are marked most in those psychiatric conditions where diagnostic criteria are least specific, i;gf, where objective criteria de— fining diseases of known etiology are absent, as in schizophrenia, psychoneurosis, personality and behavior disorderso Under these conditions of perceptual and situational ambiguity, the observer's attitudes and expectations become significant aspects of his perceptions, classifications, and decisions. A similar situation was clearly documented by Pasamanick, Dinitz and Lefton (6) in their study of variations in diagnosis within a single institution. They observed that patients assigned at random to different wards did not differ in type of admission, marital status, education, age or residence. Significant differences did occur, however, in Such �Sociopsychological Aspects of Psychiatric Treatment in Three Voluntary Hospitals Robert L. Kahn, Ph.D.*, Max Fink, M.D.**, Nathaniel Siegel, Ph.D.*** � 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 Sociopsychological aspects of psychiatric treatment in three voluntary hospitals. A.M.A. Arch Gen Psychiat. 14:20-5. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-004-59b-002 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 Kahn, Robert L.; <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a>; Siegel, Nathaniel 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 Reprint, [preprint], drafts, letters, review board postcard, 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