Community Mental Health Journal
Volume 2, Number 4, Winter, 1966
A CASE FOR RANGE AND VERSATILITY W I T H I N AGENCIES IN PLANNING MENTAL HEALTH SERVICES DONALD A. DEVIS, M.A.*
Agencies that provide mental health services have a continuing responsibility for program review and re-examination of policies, procedures, and methods that limit their helping capabilities. Intra-agency planning and administration offer a fruitful area for both improv•ng and increasing treatment and intervention for distressed individuals and families. Range in services and treatment methods and versatility in staff skills are proposed as important aspects of the organization and administration of services. Four aspects of internal organization are examined as possible critical points where improvement could be effected.
In planning mental health programs for communities, much attention is given to the provision of comprehensive community services and to clarity about agency func. tions aimed at preventing overlapping services. This is an appropriate area for major emphasis, as most community organizing effort is intergroup work, leaving agencies a great deal of autonomy in defining their own functions and services. Both mental health and social agencies are free to decide when and to whom they will offer their services. In doing this, they characteristically use a
variety of formulas to determine such variables as eligibihty, need, motivation, treatment potential, prediction of movement, and so on, to sort out, on some rational basis, those persons to whose needs they will attend. Unfortunately, this process produces a rather coarse screen through which many individuals or families fall without receiving the help they so urgently need. Or, more mysteriously, a longneeded new service is finally provided only to have referrals dry up completely. It is the suggestion of this discussion that
*Lt. Col. Donald A. Devis, a psychiatric social worker, is Chief, Clinical Social Work Service, Brooke General Hospital, Fort Sam Houston, Texas. This article was originally prepared as a resource paper for the Annual Meeting of the American Psychiatric Association, May 4-8, 1964, at Los Angeles, California.
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THE COMMUNITYMENTAL HEALTH JOURNAL
a n area of p l a n n i n g that needs c u r r e n t att e n t i o n is intra-agency p l a n n i n g and practice i n contrast to interagency or commu. nity planning. It is believed that the developm e n t of range and versatility by individual agencies, clinics, or i n s t i t u t i o n s is a key notion i n providing a good deal more service with existing facilities. Modification of intake procedures; range i n t r e a t m e n t methods offered, to include new methods of conjoint group and family therapy processes; versatility on the part of caseworkers and therapists through ongoing training and retraining; flexibility i n applying motivational, m e a n s and needs tests; careful, regular reexamination of so-called time-tested operational hypotheses; and recognition that administrative decisions a b o u t service are often generated from a defensive st~/nd by the agency--all offer fruitful areas for exploration of possible i m p r o v e m e n t i n both q u a n t i t y and quality of mental health and social services. More specifically, some of the intraagency practices warranting examination and clearheaded re-evaluation are the following:
Assumptions about time and effort required for treatment response. Despite m o u n t i n g evidence to the contrary, there still exists a strong i n v e s t m e n t i n the belief that longterm treatment is needed for most social and mental health difficulties, with a corollary that no service can be offered short of the goal of personality renovation. It is often a presumption that mental health is a discrete entity that is hard to effect by therapeutic i n t e r v e n t i o n b u t once attained is a p e r m a n e n t condition. One might wonder how our dental colleagues would survive with such a concept of dental hygiene and treatment. The reality is that periodic, short-term treatment or counseling efforts at critical points in development or maturation or i n psychosocial stress situations is quite often a more efficacious i n v e s t m e n t of professional time t h a n long-term treatment. Certainly, reported results i n multiple impact therapy and family therapy point our attention i n this direction. Yet agencies and clinics still behave i n the following manner:
A general hospital with a psychiatric department received a frantic call from a pediatrician some 400 miles away. He reported that an eight-year-old girl who had recently joined her father and stepmother after living for a number of years with her grandmother was involved in a great deal of masturbatory behavior and sexual play with her younger siblings. This led to great alarm on the part of her father and stepmother, and the pediatrician had not been able to deal effectively with this child and her family. Because of the distance factor, the parents and the child were invited to come to the general hospital for a two-day stay, where a multiple impact therapy approach to the problem was designed. Unfortunately, the mother did not arrive with the father and the child, because arrangements could not be made for the care of the other children in the family. Despite this disadvantage, the two days were devoted to periodic evaluations and sessions with the child and her father. It was soon learned that the child was a very timid and forlorn little girl who was at a great loss as to how to relate to her stepmother and her siblings. She saw the stepmother as preferring her own children, who were below school age, and as requiring the stepdaughter to behave in a much more mature and adult-like manner than the other children. She had been separated from her father for nearly four years following the death of her own mother and had lived in the home of a grandmother, where rather loose sexual practices abounded. Sensing reject/on by both parents and siblings, she resorted to earlier patterns of self-gratification and on occasion sought out other adults in the neighborhood with affectionate overtures. The stepmother was so alarmed that she isolated her own three children in her bedroom and left this girl very much alone. It was possible to discuss the causative nature of these events with the father, and although he had limited insight, he began to understand that affection displayed openly toward his daughter would be an important step toward resolving the difficulty. Because of his limited verbal capabilities, he requested that someone inform his wife about this as she was so upset that she was saying that the child would have to leave the home. At this point, it was learned that a child guidance clinic existed some 50 miles from his place of residence but that they had refused to work with the family because they were in a different county. It was thought useful if a social worker from that child guidance clinic could spend some time with the mother to explain some of the behavioral dynamics involved in this situation. A complete summary of the findings was forwarded to that child guidance clinic, with the request that they make an exception to their geographic limitations and see this mother for at least one exploratory interview. Some days later, a reply was received from this clinic, indicating that a conference had been held between the social work and psychiatric staff and that the conclusion was that "this mother needs long term treatment" and the clinic was unable to provide it
DONALD A. DEvls because the family lived beyond the geographic limits served by the clinic. A second request was forwarded to the clinic, pointing out that the only service requested was a one-time interview with the mother to interpret and discuss with her some of the findings of the psychiatric evaluation and the meaning of the child's behavior. A second negative response was received. Four months later, the general hospital wrote to the family, particularly the mother, indicating their continued interest in the child's adjustment in the home and received the following response: "I deeply appreciate your interest and concern in this matter now and during the time she was there. I am very happy to say T has overcome these problems and we are having nothing more than is normal or could be expected for kids her age. She is doing well in school and has greatly improved in every way." I n the face of such evidence, which can be replicated in every clinic, it seems inappropriate to continue policies about giving services and treatment that are based on assumptions of clairvoyance about response to treatment, whether brief or long term.
Administrative or operational procedures that waste professional staff time. A recent report by a highly respected university psychiatric clinic states that it sets aside an entire day for the evaluation of new patients and has 29 per cent failure to keep first appointments. It is hard to understand why some drastic alteration of procedure is not initiated to reclaim this wasted but very precious staff time. A vast number of remedies could be arrived at with a little thought and some ingenuity. Another questionable practice is the investment of a team of three or more professional persons for evaluation of chil. dren's problems. While no one would question that children deserve the most careful and comprehensive kind of attention, m a n y agencies are getting good results by unilateral evaluations with consultation from colleagues as needed rather than as standard procedure. W h e n the team--or the Holy Trinity, as Redl (1962) calls it--is used so rigidly and profligately for evaluation, the end result is all diagnosis and no treatment. One clinic reports that only 18 per cent of patients referred are seen beyond five interviews. I n one city with seven child guidance clinics, m u c h time is spent asking one another to treat cases they have evaluated,
341
always with the same reply: " N o time." I n other areas, many agencies or clinics adhere very stringently to " n o treatment" policies of service and write voluminous studies that are beautifully phrased and carefully filed in charts--for colleagues to admire and emulate--but give precious little ongoing counsel to families, m u c h less treatment to children or adults.
Treatment requirements that lead to defections or early discontinuances. It seems that once an agency arrives at what it believes is an effective treatment method, it becomes very dogmatic that the client or family must submit to treatment by that method or not be offered service. The couch, EST, the spouse, the group, both parents, and, more recently, the siblings all have been at one time or another the sine qua non for help from often esoteric programs. While workers usually disagree among themselves about the validity of such requirements and treatment approaches, very little is done to move toward developing versatility or to offer a range of possible helping methods to clients. It is an easy defense for the typical overloaded clinic to set up a presumptive test for motivation based on a bias toward a particular treatment method, but most agencies are very uneasy behind this facade. An agency may well be missing out with the adolescent in deep trouble when it requires both parents to participate in the treatment process. It is not too difficult to find eases where marital compatibility is enhanced by service to one spouse; yet all too often intake is closed when husbands demur. W h e n m u c h time and a diagnostic conference are devoted to an evaluation and group therapy is decided to be the "treatment of choice," agencies are hard put to accept a rejection and to proffer other help. The weekly hour also may not be sacrosanct, and there is some beginning evidence that seeing a family four to six times in a two-week period is more helpful and more likely to get continuance than weekly visits stretched out over one or two months. Agencies talk a great deal about the right of the client for self-determination but often deny it under the guise of "knowing what is best."
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THE COMMUNITYMENTAL HEALTH JOURNAL
Inertia and timidity of clinics and therapists or workers in so-called specialization areas. A director of a family service agency recently stated that they could not hope to learn family therapy techniques because their workers were "not at ease with children." Other clinics or agencies display similar hesitancy in giving service to mentally retarded, aged, alcoholic, schizophrenic, delinquent, adolescent, or preschool-age applicants. There is no question that the economics of agency time demands good judgment about many variables. Yet everyone can cite a number of instances where the most unlikely cases show the greatest movement. The brief here is not against good clinical judgment but against blanket exclusions based on lack of experience or, worse yet, unwillingness to enter into selfdevelopment. Inservice training, staff development, and consultation concepts leave an agency little excuse today to say it "can't do" because it doesn't have "know how." "Know how" is ours for the asking or the reaching. This is not the time for retrenchment and ossification but rather the time for
bold thrusts and ventures into lifelong learning of method and process. Research and specialty training should serve to extend the range and versatility of the generalist rather than provide him with an easy avenue to "referral to some more appropri. ate medical, psychiatric, or social agency." In summary, this discussion points out essentially intra-agency areas for greater attention from planners. They may admittedly be difficult to get at because of ideas about agency and individual professional autonomy, but they nevertheless offer extremely fruitful pockets for improvement of mental health and social services. Administrative management, range in treatment methods, staff versatility, and willingness to reexamine, adapt, and learn are all facets of service that can provide greater capacity for coping with ever increasing mental health needs. REFERENCE REDL, F. President's Annual Address, American Orthopsychiatric Association, April 1962, Los Angeles, California.
Volume 2, Number 4, Winter, 1966
A CASE FOR RANGE AND VERSATILITY W I T H I N AGENCIES IN PLANNING MENTAL HEALTH SERVICES DONALD A. DEVIS, M.A.*
Agencies that provide mental health services have a continuing responsibility for program review and re-examination of policies, procedures, and methods that limit their helping capabilities. Intra-agency planning and administration offer a fruitful area for both improv•ng and increasing treatment and intervention for distressed individuals and families. Range in services and treatment methods and versatility in staff skills are proposed as important aspects of the organization and administration of services. Four aspects of internal organization are examined as possible critical points where improvement could be effected.
In planning mental health programs for communities, much attention is given to the provision of comprehensive community services and to clarity about agency func. tions aimed at preventing overlapping services. This is an appropriate area for major emphasis, as most community organizing effort is intergroup work, leaving agencies a great deal of autonomy in defining their own functions and services. Both mental health and social agencies are free to decide when and to whom they will offer their services. In doing this, they characteristically use a
variety of formulas to determine such variables as eligibihty, need, motivation, treatment potential, prediction of movement, and so on, to sort out, on some rational basis, those persons to whose needs they will attend. Unfortunately, this process produces a rather coarse screen through which many individuals or families fall without receiving the help they so urgently need. Or, more mysteriously, a longneeded new service is finally provided only to have referrals dry up completely. It is the suggestion of this discussion that
*Lt. Col. Donald A. Devis, a psychiatric social worker, is Chief, Clinical Social Work Service, Brooke General Hospital, Fort Sam Houston, Texas. This article was originally prepared as a resource paper for the Annual Meeting of the American Psychiatric Association, May 4-8, 1964, at Los Angeles, California.
339
340
THE COMMUNITYMENTAL HEALTH JOURNAL
a n area of p l a n n i n g that needs c u r r e n t att e n t i o n is intra-agency p l a n n i n g and practice i n contrast to interagency or commu. nity planning. It is believed that the developm e n t of range and versatility by individual agencies, clinics, or i n s t i t u t i o n s is a key notion i n providing a good deal more service with existing facilities. Modification of intake procedures; range i n t r e a t m e n t methods offered, to include new methods of conjoint group and family therapy processes; versatility on the part of caseworkers and therapists through ongoing training and retraining; flexibility i n applying motivational, m e a n s and needs tests; careful, regular reexamination of so-called time-tested operational hypotheses; and recognition that administrative decisions a b o u t service are often generated from a defensive st~/nd by the agency--all offer fruitful areas for exploration of possible i m p r o v e m e n t i n both q u a n t i t y and quality of mental health and social services. More specifically, some of the intraagency practices warranting examination and clearheaded re-evaluation are the following:
Assumptions about time and effort required for treatment response. Despite m o u n t i n g evidence to the contrary, there still exists a strong i n v e s t m e n t i n the belief that longterm treatment is needed for most social and mental health difficulties, with a corollary that no service can be offered short of the goal of personality renovation. It is often a presumption that mental health is a discrete entity that is hard to effect by therapeutic i n t e r v e n t i o n b u t once attained is a p e r m a n e n t condition. One might wonder how our dental colleagues would survive with such a concept of dental hygiene and treatment. The reality is that periodic, short-term treatment or counseling efforts at critical points in development or maturation or i n psychosocial stress situations is quite often a more efficacious i n v e s t m e n t of professional time t h a n long-term treatment. Certainly, reported results i n multiple impact therapy and family therapy point our attention i n this direction. Yet agencies and clinics still behave i n the following manner:
A general hospital with a psychiatric department received a frantic call from a pediatrician some 400 miles away. He reported that an eight-year-old girl who had recently joined her father and stepmother after living for a number of years with her grandmother was involved in a great deal of masturbatory behavior and sexual play with her younger siblings. This led to great alarm on the part of her father and stepmother, and the pediatrician had not been able to deal effectively with this child and her family. Because of the distance factor, the parents and the child were invited to come to the general hospital for a two-day stay, where a multiple impact therapy approach to the problem was designed. Unfortunately, the mother did not arrive with the father and the child, because arrangements could not be made for the care of the other children in the family. Despite this disadvantage, the two days were devoted to periodic evaluations and sessions with the child and her father. It was soon learned that the child was a very timid and forlorn little girl who was at a great loss as to how to relate to her stepmother and her siblings. She saw the stepmother as preferring her own children, who were below school age, and as requiring the stepdaughter to behave in a much more mature and adult-like manner than the other children. She had been separated from her father for nearly four years following the death of her own mother and had lived in the home of a grandmother, where rather loose sexual practices abounded. Sensing reject/on by both parents and siblings, she resorted to earlier patterns of self-gratification and on occasion sought out other adults in the neighborhood with affectionate overtures. The stepmother was so alarmed that she isolated her own three children in her bedroom and left this girl very much alone. It was possible to discuss the causative nature of these events with the father, and although he had limited insight, he began to understand that affection displayed openly toward his daughter would be an important step toward resolving the difficulty. Because of his limited verbal capabilities, he requested that someone inform his wife about this as she was so upset that she was saying that the child would have to leave the home. At this point, it was learned that a child guidance clinic existed some 50 miles from his place of residence but that they had refused to work with the family because they were in a different county. It was thought useful if a social worker from that child guidance clinic could spend some time with the mother to explain some of the behavioral dynamics involved in this situation. A complete summary of the findings was forwarded to that child guidance clinic, with the request that they make an exception to their geographic limitations and see this mother for at least one exploratory interview. Some days later, a reply was received from this clinic, indicating that a conference had been held between the social work and psychiatric staff and that the conclusion was that "this mother needs long term treatment" and the clinic was unable to provide it
DONALD A. DEvls because the family lived beyond the geographic limits served by the clinic. A second request was forwarded to the clinic, pointing out that the only service requested was a one-time interview with the mother to interpret and discuss with her some of the findings of the psychiatric evaluation and the meaning of the child's behavior. A second negative response was received. Four months later, the general hospital wrote to the family, particularly the mother, indicating their continued interest in the child's adjustment in the home and received the following response: "I deeply appreciate your interest and concern in this matter now and during the time she was there. I am very happy to say T has overcome these problems and we are having nothing more than is normal or could be expected for kids her age. She is doing well in school and has greatly improved in every way." I n the face of such evidence, which can be replicated in every clinic, it seems inappropriate to continue policies about giving services and treatment that are based on assumptions of clairvoyance about response to treatment, whether brief or long term.
Administrative or operational procedures that waste professional staff time. A recent report by a highly respected university psychiatric clinic states that it sets aside an entire day for the evaluation of new patients and has 29 per cent failure to keep first appointments. It is hard to understand why some drastic alteration of procedure is not initiated to reclaim this wasted but very precious staff time. A vast number of remedies could be arrived at with a little thought and some ingenuity. Another questionable practice is the investment of a team of three or more professional persons for evaluation of chil. dren's problems. While no one would question that children deserve the most careful and comprehensive kind of attention, m a n y agencies are getting good results by unilateral evaluations with consultation from colleagues as needed rather than as standard procedure. W h e n the team--or the Holy Trinity, as Redl (1962) calls it--is used so rigidly and profligately for evaluation, the end result is all diagnosis and no treatment. One clinic reports that only 18 per cent of patients referred are seen beyond five interviews. I n one city with seven child guidance clinics, m u c h time is spent asking one another to treat cases they have evaluated,
341
always with the same reply: " N o time." I n other areas, many agencies or clinics adhere very stringently to " n o treatment" policies of service and write voluminous studies that are beautifully phrased and carefully filed in charts--for colleagues to admire and emulate--but give precious little ongoing counsel to families, m u c h less treatment to children or adults.
Treatment requirements that lead to defections or early discontinuances. It seems that once an agency arrives at what it believes is an effective treatment method, it becomes very dogmatic that the client or family must submit to treatment by that method or not be offered service. The couch, EST, the spouse, the group, both parents, and, more recently, the siblings all have been at one time or another the sine qua non for help from often esoteric programs. While workers usually disagree among themselves about the validity of such requirements and treatment approaches, very little is done to move toward developing versatility or to offer a range of possible helping methods to clients. It is an easy defense for the typical overloaded clinic to set up a presumptive test for motivation based on a bias toward a particular treatment method, but most agencies are very uneasy behind this facade. An agency may well be missing out with the adolescent in deep trouble when it requires both parents to participate in the treatment process. It is not too difficult to find eases where marital compatibility is enhanced by service to one spouse; yet all too often intake is closed when husbands demur. W h e n m u c h time and a diagnostic conference are devoted to an evaluation and group therapy is decided to be the "treatment of choice," agencies are hard put to accept a rejection and to proffer other help. The weekly hour also may not be sacrosanct, and there is some beginning evidence that seeing a family four to six times in a two-week period is more helpful and more likely to get continuance than weekly visits stretched out over one or two months. Agencies talk a great deal about the right of the client for self-determination but often deny it under the guise of "knowing what is best."
342
THE COMMUNITYMENTAL HEALTH JOURNAL
Inertia and timidity of clinics and therapists or workers in so-called specialization areas. A director of a family service agency recently stated that they could not hope to learn family therapy techniques because their workers were "not at ease with children." Other clinics or agencies display similar hesitancy in giving service to mentally retarded, aged, alcoholic, schizophrenic, delinquent, adolescent, or preschool-age applicants. There is no question that the economics of agency time demands good judgment about many variables. Yet everyone can cite a number of instances where the most unlikely cases show the greatest movement. The brief here is not against good clinical judgment but against blanket exclusions based on lack of experience or, worse yet, unwillingness to enter into selfdevelopment. Inservice training, staff development, and consultation concepts leave an agency little excuse today to say it "can't do" because it doesn't have "know how." "Know how" is ours for the asking or the reaching. This is not the time for retrenchment and ossification but rather the time for
bold thrusts and ventures into lifelong learning of method and process. Research and specialty training should serve to extend the range and versatility of the generalist rather than provide him with an easy avenue to "referral to some more appropri. ate medical, psychiatric, or social agency." In summary, this discussion points out essentially intra-agency areas for greater attention from planners. They may admittedly be difficult to get at because of ideas about agency and individual professional autonomy, but they nevertheless offer extremely fruitful pockets for improvement of mental health and social services. Administrative management, range in treatment methods, staff versatility, and willingness to reexamine, adapt, and learn are all facets of service that can provide greater capacity for coping with ever increasing mental health needs. REFERENCE REDL, F. President's Annual Address, American Orthopsychiatric Association, April 1962, Los Angeles, California.
