2. US PUBLIC INPATIENT 1830- 1955

3. PUBLIC INPATIENT 1955-2006

4. TRANSFORMATION IN 20th CENTURY CUCKOO’S NEST PUBLIC MENTAL HOSPITALS CENTRAL LONG INPATIENT STAYS – “CHRONICS” MORE SOCIAL CONTROL THAN TREATMENT NO PATIENT RIGHTS VOLUNTARIES INSTITUTIONALISM

5. NO PLACE ON EARTH FOR ME SYLVIA FRUMKIN SHORT HOSPITAL STAYS LONG STAYS IN COMMUNITY MUCH LESS SOCIAL CONTROL MORE PATIENT RIGHTS HARD TO ENTER VOLUNTARILY ANTI-INSTITUTIONALISM

6. TRANSFORMATION INCREDIBLY SHORT PERIOD - CUCKOO’S NEST IN 1963 (1975); FRUMKIN IN 1978 (1982) WHAT WAS TRANSFORMATION? REASONS FOR TRANSFORMATION.

9. I. 1800-1850 AROSE IN U.S. ABOUT 1800 PREVIOUSLY FAMILY RESPONSIBILITY IF NO FAMILY EXILED OR JAILED MENTAL HOSPITALS INITIALLY HUMANE REFORM

11. ENLIGHTENMENT PHILOSOPHY REMOVE PEOPLE FROM STRESSFUL ENVIRONMENT COUNTRY SETTINGS - ISOLATED FROM FAMILIES AND COMMUNITIES PROVIDE MORAL TREATMENT IN CALM AND RESTFUL ENVIRONMENT MAINLY MIDDLE AND UPPER CLASS CLIENTS

14. II. TRANSFORMATION GROWTH OF POPULATION HUGE BUREAUCRACIES

16. NO EFFECTIVE TREATMENTS MANAGEMENT AND CONTROL

18. PATIENTS 1850-1955 LOWER SES, IMMIGRANT, ELDERLY LONG STAYS, HIGH DEATH RATES CHRONIC CONDITIONS - SCHIZ., SYPHILUS, ALCOHOLISM INSTITUTIONALISM: APATHY, ADJUST, DON’T WANT TO LEAVE

19. SUMMARY AS OF 1955 LARGE ISOLATED INSTITUTIONS CUSTODIAL WITH LITTLE TREATMENT LONG STAYS, FEW RELEASES, MANY ELDERLY PATIENTS NO ALTERNATIVES

21. III. DI (1955 - PRESENT) REMOVE PATIENTS FROM HOSPITAL, ADMIT FEWER PATIENTS, USE OF COMMUNITY TREATMENT BEGINS IN 1955 - REVERSAL OF 150 YEAR OLD TREND HIGHLY CONTROVERSIAL - CRIME, HOMELESSNESS, NEGLECT

22. PUBLIC INPATIENT 1955-2006

23. RESIDENTS OF PUBLIC MENTAL HOSPITALS DRASTIC DECLINE IN RESIDENTS, 1955-2006 (“OPENING BACK DOOR”) 1955 - 560,000; 1970 - 450,000; 1980 - 140,000; 1990 - 100,000; 2006 - 80,000 INCREASE IN ADMISSIONS 1955-1970, DECREASE SINCE THEN (“CLOSING FRONT DOOR”)

24. PUBLIC MENTAL HOSPITALS NOW NO LONGER THE MAJOR PART OF SYSTEM PLACE OF LAST RESORT - VIOLENT, DIFFICULT TO TREAT (FRUMKINS) OR NOWHERE ELSE TO GO STILL 2/3 OF STATE EXPENSE FIXED COSTS, UNIONS, COMMUNITIES

25. CHANGE IN PATIENTS FROM ELDERLY, LONG-TERM, SCHIZ. AND BRAIN DISEASE TO YOUNG, SHORT-TERM, DRUG USERS (MICA) SAME: POOR, MINORITIES, MALES

26. INPATIENT TREATMENT NOW MOST IN GENERAL HOSPITALS GROWTH OF PRIVATE, SPECIALIZED HOSPITALS SHORT STAYS – 1 TO 2 WEEKS OR AS LONG AS HAVE INSURANCE WHITE, FEMALE, DEPRESSION, ALCOHOL, EATING DISORDERS ELDERLY NOW IN NURSING HOMES

27. SUMMARY OF CHANGES DRASTIC DECLINE IN NATURE AND CENTRALITY OF PUBLIC MENTAL HOSPITALS NOT LONG STAYS BUT SHORT STAYS WITH LONG SPELLS IN COMMUNITY MOST INPATIENT TREATMENT IN GENERAL OR PRIVATE HOSPITALS RISE OF NURSING HOMES

28. PATIENTS PATIENTS IN PUBLIC MENTAL HOSPITALS STILL POOR/ MINORITY NOW YOUNG, DRUG USING, HARD TO HANDLE; NOT OLD, COMPLIANT, AND INSTITUTIONALIZED

29. Grade distribution – 2 nd Hourly Exam GradeRangeN A 90-10077 B+8812 B80-8665 C+7820 C60-7663 D50-588 F<503