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
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
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
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
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>.▪