Policymaking in APA: From Propositions to Position Papers

APA and its predecessor organizations, the Association of Medical Superintendents of American Institutions for the Insane (1844-93) and the American Medico-Psychological Association (1894-1921), have been stating their policies since their early meetings through resolutions, which were expressions of professional opinion, and propositions, which were principles for future action.

The early resolutions dealt with, for example, the avoidance of political bias in hiring superintendents, the removal of insane persons from almshouses, and support for Dorothea Dix's efforts to obtain federal support for asylums.

At the founding meeting in 1844, propositions carried greater weight than resolutions. There the 13 superintendents passed a proposition that restraint of patients applied judiciously was necessary in asylums.

Probably the most important of the early propositions dealt with the construction, organization, and management of asylums. These were set forth principally by Thomas Kirkbride, M.D., of the Pennsylvania Hospital, whose name was given to the type of buildings that dominated the construction of mental hospitals into the 20th century. Another early proposition stated that asylums should be no larger than 250 beds to ensure that superintendents could get to know all the patients. After 1866 this no longer held, and asylums increased their capacities as rising admissions increased the demand for beds.

In the monumental 1916 work “Institutional Care of the Insane in the U.S. and Canada,” the chair of the committee that produced the opus, Henry Hurd, M.D., wrote that the superintendents who set forth the propositions believed they embodied the only proper methods to care for the insane. Over time, however, the growing number of younger superintendents who joined the Association expressed their belief that conditions had changed so much that the propositions were too rigid and outworn.

At the annual meeting in 1888, Kirkbride's propositions were rejected. Hurd wrote, “Mistakes are made by elderly men who seek in vain to arrange the world and to set it in order for all time.” The last proposition was adopted in 1875 and dealt with proper provisions for inebriates.

As it changed names and membership, the Association continued to pass resolutions. In 1884 a resolution was passed pleading with Congress to deny admission of “insane” and “defective” immigrants to the United States.

An 1890 resolution expressed the Association's gratification that New York would provide for dependent insane persons, and an 1897 resolution recommended that aftercare be provided for patients discharged from mental hospitals.

In an address at the Association's 1898 meeting, T.E. Eskridge, M.D., a neurologist on the Board of Commissioners of the Colorado Insane Asylum, outlined mentalhospital requirements and proffered staffing ratios—one assistant physician for every 50 patients, one resident physician for every 25 patients, a staff psychologist, trained nurses, and attendants.

The matter of staffing ratios for mental hospitals was to plague APA over the next 50 years. APA was importuned to set staffing standards but was well aware of the hospitals' worsening conditions, especially over-crowding and understaffing, and data were needed upon which to base standards. In 1936 a grant from the Rockefeller Foundation to the National Committee for Mental Hygiene allowed APA to conduct a hospital survey. In 1945-46, APA issued standards that included recommendations for the organization and administration of mental hospitals and staffing ratios: one psychiatrist for every 30 patients, and one graduate nurse for every four patients in acute units.

Revision of the staffing standards gave rise to disagreements among psychiatrists and other experts. By 1954 numerical ratios were no longer in the standards and never appeared again. Instead, the standards stated principles for the provision of quality care, and each hospital was left to develop its own staffing ratios. By 1974 a nonmedical administrator was permissible in psychiatric hospitals if there was a psychiatrist medical director.

In 1948 APA began to issue official policy statements called position papers. The first dealt with aggression, violence, and war. The second, approved in 1949, dealt with electroshock therapy.

Many of APA's position statements are posted online at<www.psych.org/public_info/libr_publ/position.cfm>.▪