A Mental Health Consultation-Education Program with Group Service Agencies in a Disadvantaged Community Saul Scheidlinger, Ph.D. Anne Sarcka, M.S.
ABSTRACT: The consultation-education program described here worked with about ao community-based group service agencies in a severely deprived urban area. The agencies included: (a) traditional neighborhood houses, (b) recreational and "character-building" centers, (c) church-sponsored group programs, and (d) neighborhood service centers. The program involved: (a) a planning body of administrators of group service agencies, (b) a consultation service on problems of individuals or groups, and (c) training workshops for agency staff. The program was geared to both institutional change via enhanced integration of services and promotion of new skills, and to attitude change of individual psychosocial "caretakers."
One of the major objectives of any community mental health program is the formation of viable alliances with significant community agencies. Accordingly, these agencies are viewed as psychosocial "caregiving systems" for prevention of disability and for enhancing the personal and social competence of the citizenry (Rae-Grant, Gladwin, & Bower, 1966 ). The task of furthering this therapeutic potential of significant community figures and social systems assumes crucial importance in the urban ghetto with its well-known lack of community cohesiveness and its plethora of social and health problems. This paper depicts the first phase (three years) of a consultation-education project in a severely deprived urban area. The sponsoring mental health facility worked with about 20 community agencies. The aims of this mental health facility's overall program, which included varied hospital and community-based services as well as research, were described by Peck, Kaplan, and Roman (5966) in another context. Dr. Scheidlinger, a psychologist and social worker, is associate clinical professor, Department of Psychiatry, Albert Einstein College of Medicine, 333 Southern Blvd., Bronx, N.Y.; and group process consultant, Community Service Society, New York City. Miss Sarcka, a social worker, is assistant instructor, Department of Psychiatry, Albert Einstein College of Medicine, and community organization specialist at Lincoln Hospital Mental Health Services, Bronx, N. Y. The authors wish to acknowledge the help of Dr. Melvin S. Roman, Mr. EmanueI HaUowitz, and Mrs. Joan Margolis in the development of this program. Community Mental Health Journal, Vol. 5 (2), 1969
164
Saul Scheidlinger and Anne Sarcka
165
The collaborating agencies' common characteristic resided in their use of groups as a major mode of service. The agencies fell into the following four categories: (x) traditional neighborhood houses, (2) recreational and "character-building" centers, (3) church-sponsored group programs, and (4) indigenous neighborhood organizations. BEGINNING OF THE PROGRAM The initial effort involved individual visits by one of the authors to a number of institutions sponsoring group services. Each director was asked to tell about the community's and his institution's mental health needs. The emphasis was on the ways in which the recently founded mental health service could be of help to his program. The climate of these initial interviews was friendly yet frank, with the inevitable doubts expressed as to whether our mental health staff really intended to "get its hands dirty" by moving out of the hospital and into such a disadvantaged area, and whether the service was "here to stay" in the face of numerous earlier short-lived government-financed community programs. When the individual visits were concluded, the directors of the different institutions were invited to a meeting for an exchange of ideas and for a planning of collaborative operations based on the interview findings. Of the xz directors invited, nine attended the first meeting; four churches, three neighborhood houses, and two recreational centers were thus represented. Many of the directors were strangers to each other before this date. None had had any experience with a meeting model involving such a variety of agencies with different sponsorships, philosophies, and levels of professionalization. It was furthermore not uncommon that neighboring group service programs had previously had only vague impressions of, or not known of, each other's existence. The many church-sponsored group programs combining pastoral and social welfare aims tended to be especially unfamiliar even to our own professional staff. It soon emerged that these latter programs represented spontaneous developments in this deprived area, in which dedicated ministers and volunteers conducted a variety of groups which were open to everyone in the neighborhood. Characterized by considerable flexibility, these included groups for ex-hospitalized adolescents and for addicts, as well as paramilitary Cadet Corps for pre-teen youths who tended to avoid the more traditional youth programs (Scheidlinger, ~965). The directors assembled in this first meeting appeared to welcome the opportunity for getting together under the "neutral" auspices of a mental health organization which was eager to help with their expressed and similar needs. In response to these needs, two collaborative services were launched immediately: a Consultation Service on group or individual problems available to all staff of the group-service agencies; and Mental Health Training Workshops aimed at staff development. In addition, the directors agreed to hold regular meetings from then on for purposes of planning and evaluation of these consultation and training activities.
166
Community Mental Health Journal
Except for the later addition of program (as differentiated from case consultation), the above-named two service components plus the bimonthly directors' meetings have continued to date. Though closely interrelated in practice, they will be described separately. CASE CONSULTATION SERVICE The Case Consultation Service involved discussions, generally initiated by agency workers, about problems presented by individuals, whether clients or staff. Following the usual model of case consultation (Haylett & Rapoport, z964), the emphasis was on helping the worker arrive at a way of handling the problem that was satisfactory to him. In most instances the attempt was made to resolve the difficulty by renewed intervention within the group service agency's structure. Where this was not feasible, referral of the individual to our own multipurpose clinical facility or to other resources was suggested. More than half of the consultations could be handled over the telephone. It is noteworthy that the number of requests for case consultations decreased significantly as agency staff members began to participate in the mental health training workshops where they were flee to present problems encountered in their daily practice. TRAINING WORKSHOPS As already noted, decisions regarding topics, duration, and composition remained under the aegis of the agency directors' planning body. However, in view of the inability to offer more than one of these workshops at a time, it was urged that the initial effort be directed at administrative and supervisory personnel (top management) with the expectation of a maximum payoff in terms of potential influence on lower echelon staff. Since by now most of the agency directors and supervisors have been exposed to this experience, regular staff currently make up the bulk of the membership. The following workshops of ten weekly sessions 'each have been completed during our first program phase: (a) Mental Health Needs of Pre-Teen Youths, (b) Mental Health Needs of Adolescents, (c) Short-Term Counseling of Children and Adults, (d) Advanced Workshop on Adolescence, (e) Group Work with Socially Disadvantaged Adults. The value placed on this workshop program by the participating agencies can be gauged by a number of factors. To begin with, in addition to sending members of their staff, more than two-thirds of the agency administrators themselves completed at least one workshop, while one-third of them participated in two or more. When directors chose not to participate, it was usually because they preferred that their program directors or other supervisory staff have this opportunity. Due to space limitations, each agency could send only two participants to any one workshop. Only three of the 2o agencies participating in the program failed to send any representative. Reversing the usual pattern, workshop registration continued to increase to the point where a current session, geared to a membership of ten, had 59 people attending.
Saul Scheidlinger and Anne Sarcka
167
In an effort to gauge more precisely the value of this experience, each group of workshop members was asked to fill out unsigned questionnaires in which they rated the workshop and made suggestions for changes. The ratings, ranging from "excellent" to "poor" on a four-point scale, were uniformly favorable and many of the suggestions for change which were brought back to the directors' group were acted on. The workshops were characterized by an air of informality and by a minimum of structure. The participants were encouraged to bring u p any items that interested them within the broad context of the chosen topic. The subjects would thus run the gamut from discussion of specific group experiences to problems presented by individuals (Berlin, 296o). The leader's role in these meetings was largely that of making free group discussion possible. He also acted as a resource for technical data, in nontechnical language, pertaining to specific knowledge or skills. He was always alert to any opportunities presented for enhancing the potential of the staff members as helping persons, especially in relation to the vulnerable youths of the inner city. As might be expected, much time was spent on the issue of how to reach the alienated adolescents; that such older adolescents in the community who were most in need of help tended to remain unreached, was readily acknowledged. In view of the requirement for utter sincerity on the part of the adult workers with such youths, workers earnestly examined their feelings and attitudes toward the younger generation in the workshops. The interaction was at times so lively that it was difficult to recollect who said what and how. There were many doubts and disagreements, as well as shifting alliances. Discussions regarding sex education produced especial ventilation of feelings and also considerable anxiety. A few people spoke of feeling helpless to engage young people meaningfully because the youths' personal values were so far removed from their own. Some extreme attitudes came to the fore as, for instance, those of a young white minister who asserted that sex outside of marriage was sinful. He felt, moreover, that unless a youth revealed some concern for morality "there was nothing to work with." A group worker from a nonsectarian agency countered with a much more tolerant attitude toward deviance. Pointing to the stark realities of sexuality in the ghetto, he stressed in his discussions with youths the importance of "caring," of a meaningful personal involvement as part of the sex experience, together with the responsibility for preventing unplanned pregnancies. When it became dear that many workers, despite fruitful discussions, did not feel ready to handle sex discussions with adolescent girls, a special training exercise was devised. The workshop leader offered to conduct a threesession demonstration series with a girls' group from an agency represented in the workshop. With the girls' permission, the workshop members observed these meetings without participating in the discussions. In addition to proving exceedingly helpful to the particular group of Negro adolescent girls and their worker, this demonstration vividly portrayed the desperate need for sex
168
Community Mental Health Journal
guidance in this community. The gifts, all of whom came from poor though relatively stable Negro families, insisted that they would not dare taik to their mothers about sex because it was a taboo subject. In fact, not a single one of them had been prepared by her mother even for menstruation. The confusion on the subject of sexuality was extreme, with questions about pregnancy and venereal disease being interspersed with fatalistic statements about marriage as connoting seduction, coercion, fights, and desertion. The girls insisted they had never seen real love and could not comprehend that love could be a part of sex. Cynical notions reflecting the street morality with which they were surrounded existed side by side with naive beliefs, such as that the "stork story" was the best way to answer their younger siblings' questions about sex. At the conclusion of this workshop, the staff participants felt ready to initiate similar work at their own agencies. There were many expressions of a desire to emulate the example offered and to share feelings and attitudes with others in similar circumstances. It should be mentioned here that the process notes taken of each workshop session by a research assistant were mimeographed and sent to the participants, as well as to all the agency directors. This served to reinforce the impact of the training experience. PROGRAM CONSULTATION While the training workshops and case consultations undoubtedly served to enhance the agency staff's sensitivity and skills in dealing with their daily problems of practice, they did not in themselves sufficiently stimulate innovative group programs geared to high-risk populations. Accordingly, agencies were encouraged recently to experiment with new program modalities, with regular consultative help to supervisors and staff members available for as long as necessary. As part of this approach, a settlement house sponsored two paratherapeutic activity groups for latency-age children under the leadership of indigenous nonprofessional workers. In contrast to clinical activity groups, the emphasis here was on offering the children adult identification models in a structured environment. The parents' and children's response to the idea of such "clubs" was most favorable, and attendance patterns exceeded the staff's expectations. As a means of dealing with a marked increase in unwanted pregnancies, four agencies (two churches and two settlement houses) were involved with the program in the development of sex guidance discussions for adolescent gifts and their parents. The model called for three concurrent sessions with the gifts and three with the parents. This was to be followed by two joint sessions of girls and parents. During the project, the group workers conducting the sex discussions participated in weekly meetings with the mental health consultants where experiences with the groups were compared and discussed. As might be expected, not only was each leader's style different but, also, in line with the overall approach of the sponsoring agency, there were differ-
Saul Scheidlinger and Anne Sarcka
169
ences in the degree of structure and the amount of emphasis on the moral and spiritual aspects of sexuality. Little of the anticipated resistance to such a program from parents was found. On the contrary, almost all were grateful that the agencies were offering sex guidance discussions. As was the customary experience with meetings for adults in the community, the actual attendance of the parents was poor. In two agencies only about half of the girls' mothers came to at least one meeting. In the other two, still fewer mothers attended, despite the fact that the leaders had managed to establish positive individual contacts with a nmnber of them. Although the fathers were also invited, none put in an appearance. The workers felt that more parents could have been involved had they had time to visit more homes prior to the beginning of the discussion series. It was interesting that some of the mothers who did attend sought guidance and information on sexual issues for themselves--quite apart from the primary aim of enhancing parental communication with the girls. Needless to say, when mothers did come to the meetings their empathy with the girls was visibly deepened. The value of this kind of cooperative program resided not only in the fact that a workable short-term group guidance approach came into being. Perhaps even more important was the demonstration that agency staff members without a professional background could be trained to conduct such discussions. They are now ready to help other staff repeat this experience with different groups. The work on this project revealed a lamentable lack of audiovisual educational aids for young people in poor neighborhoods. The directors' group, which had previewed some sex education films, found them of dubious value for their programs, intended as the films were for an audience of middle-class youth. They decided then to explore the possibility of sponsoring a new film based on life in this community, with Negro and Puerto Rican youths as actors. In addition to the above developments, there is a newly initiated consultation service to paramilitary Cadet Corps groups which tend to attract especially vulnerable latency-age children. There is also a pilot program underway with the aim of utilizing the creative arts as a means of reaching disadvantaged youths. It is too early to evaluate these preliminary undertakings. There are strong indications, however, that expanded work in this sphere of program consultation is desirable if more group approaches designed to meet the special characteristics and needs of low income populations are to be developed. DIRECTORS OF GROUP SERVICE AGENCIES Viewed initially as a means of promoting the collaborative planning and evaluation aspects of our mental health consultation and training activities, the directors' group (now almost doubled in size) evolved into a viable entity with a marked creative momentum of its own. The directors now exchange information and ideas in the group about the services of their respective agencies. There is also considerable interchange about the
170
Community Mental Health Journal
social problems in the community, about resources and other possibilities for joint action. Despite the high turnover rate---of the nine directors who attended our first meeting in March z965, only two are still at their posts tod a y - t h i s body's cohesiveness and level of sophistication regarding mental health problems have steadily risen. In this connection most of the zo currently participating agencies have demonstrated a readiness to build more individualization and "reaching out" efforts into their programs. At the directors' initiative, a directory was distributed, listing the participating agencies and the services of the mental health facility. A number of agencies also expressed a willingness to work with the program's Rehabilitation Services, employing ex-hospitalized patients in volunteer jobs; one church has had two such volunteers. More would have participated had there been need for them. The directors were eager to collaborate with other components of the mental health organization. For example, they were extremely helpful when youngsters in treatment at the clinic required group services in the community. They also participated with the program's Neighborhood Service Centers (Hallowitz, z968 ) in community action efforts, particularly in several campaigns to obtain improved health services in the area. They are increasingly interested in working with adults through tenants' councils, narcotics education programs and, most recendy, through welfare rights groups. All these developments represent a substantial departure from earlier approaches to programming. IMPLICATIONS The unique aspects of this mental health consultation and education program reside in the combination of elements of community organization with those of individual and institutional change in a low income area. While the objective assessment of the efficacy of such work will have to await specific research endeavors, the reactions of the participating agencies and the evaluations by the workshop participants and observers have been uniformly encouraging. What stood out to begin with was the way effective working relationships and collaborative program planning could be fostered among heterogeneous agencies, agencies with secular and religious as well as with professional and nonprofessional staffs. Status and autonomy issues were almost nonexistent. It was perhaps the very enormity of the common task of working in an underserved community with extremely limited resources, as well as the "neutral" nature of the mental health sponsorship, which made this possible. The program's major attitudinal stance on fostering initiative, flexibility, and autonomy of the agencies--helping them develop programs of their own of the highest quality--played a major role. As in all collaborative endeavors, there was much mutual learning. The consultants learned a good deal about the character of the community, including its unmet needs, and much about each individual institution, its leader-
Saul Scheidlinger and Anne Sarcka
171
ship and staff. Especially impressive was the agencies' responsiveness to the ongoing service program, this in the face of the heavy demands made upon them with limited funds, largely untrained workers, and an unusually high rate of staff turnover. It is quite likely that the gradual drop in requests for case consultations was due not only to the staff's greater skill in dealing with special problems but also to the sense of support offered by the consultants' demonstrated availability in case of need. The ongoing training workshops, always open to new members, were of course especially useful in this connection. In terms of Caplan's (~964) three levels of mental health prevention, the major emphasis in these initial endeavors was on primary prevention. This is a considerable achievement, keeping in mind that in such an inner city area, most if not all youths can be considered vulnerable. Through case and program consultation, the secondary and tertiary prevention levels were brought into play. In this connection, true rehabilitation endeavors and special group programs for "fringe" and high-risk populations require considerable consultation staff time. If accompanied by effective documentation and, whenever possible, evaluation (Struening & Peck, ~967), the collaborative evolution of such new group intervention measures not only serves to meet client needs but also adds to the armamentarium of group treatment modalities for low income populations. This aspect of the work is slated for expansion in the near future, induding the use of nonprofessional staff whenever feasible. While local circumstances and staff preferences will dictate specific emphases (Yolles, 1967), there is little doubt that this kind of consultationeducation pattern, addressed to heterogeneous group service agencies viewed as "caretaker" systems, represents a model uniquely suitable for community mental health programs in disadvantaged areas. REFERENCES Berlin, I. N. The theme of mental health consultation sessions. American Journal of Orthopsychiatry, i96o , 30, 827-828. Caplan, G. Principles of Preventive Psychiatry. New York: Basic Books, 1964. Hallowitz, E. The role of a neighborhood service center in a community mental health program. American Journal of Orthopsychiatry, I968, 38, 7o5-714. Haylett, C. H., & Rapoport, L. Mental health consultation. In L. Bellak (Ed.), Handbook of community psychiatry and community mental health. New York: Grune & Stratton, I964. Peck, H. B., Kaplan, S., & Roman, M. S. Prevention, treatment and social action: a strategy of intervention in a disadvantaged urban area. American Journal of Orthopsychiatry, I966, 36, 57-69. Rae-Grant, Q. A. F., Gladwin, T., & Bower, E. Mental health, social competence, and the war on poverty. American ]ournal of Orthopsychiatry, 1966, 36, 652-664. Scheidlinger, S. Three group approaches with socially deprived latency-age children. International Journal of Group Psychotherapy, 1965, ~5, 434-445Struening, E., & Peck, H. B. The role of research in evaluation. In R. H. Williams & L. D. Ozarin (Eds.), Community mental health. San Francisco, California: Jessey-Bass, I967. YoIles, S. F. Community mental health services: the view from I967. American Journal of Psychiatry Supplement, 1967, 124,1-7.
ABSTRACT: The consultation-education program described here worked with about ao community-based group service agencies in a severely deprived urban area. The agencies included: (a) traditional neighborhood houses, (b) recreational and "character-building" centers, (c) church-sponsored group programs, and (d) neighborhood service centers. The program involved: (a) a planning body of administrators of group service agencies, (b) a consultation service on problems of individuals or groups, and (c) training workshops for agency staff. The program was geared to both institutional change via enhanced integration of services and promotion of new skills, and to attitude change of individual psychosocial "caretakers."
One of the major objectives of any community mental health program is the formation of viable alliances with significant community agencies. Accordingly, these agencies are viewed as psychosocial "caregiving systems" for prevention of disability and for enhancing the personal and social competence of the citizenry (Rae-Grant, Gladwin, & Bower, 1966 ). The task of furthering this therapeutic potential of significant community figures and social systems assumes crucial importance in the urban ghetto with its well-known lack of community cohesiveness and its plethora of social and health problems. This paper depicts the first phase (three years) of a consultation-education project in a severely deprived urban area. The sponsoring mental health facility worked with about 20 community agencies. The aims of this mental health facility's overall program, which included varied hospital and community-based services as well as research, were described by Peck, Kaplan, and Roman (5966) in another context. Dr. Scheidlinger, a psychologist and social worker, is associate clinical professor, Department of Psychiatry, Albert Einstein College of Medicine, 333 Southern Blvd., Bronx, N.Y.; and group process consultant, Community Service Society, New York City. Miss Sarcka, a social worker, is assistant instructor, Department of Psychiatry, Albert Einstein College of Medicine, and community organization specialist at Lincoln Hospital Mental Health Services, Bronx, N. Y. The authors wish to acknowledge the help of Dr. Melvin S. Roman, Mr. EmanueI HaUowitz, and Mrs. Joan Margolis in the development of this program. Community Mental Health Journal, Vol. 5 (2), 1969
164
Saul Scheidlinger and Anne Sarcka
165
The collaborating agencies' common characteristic resided in their use of groups as a major mode of service. The agencies fell into the following four categories: (x) traditional neighborhood houses, (2) recreational and "character-building" centers, (3) church-sponsored group programs, and (4) indigenous neighborhood organizations. BEGINNING OF THE PROGRAM The initial effort involved individual visits by one of the authors to a number of institutions sponsoring group services. Each director was asked to tell about the community's and his institution's mental health needs. The emphasis was on the ways in which the recently founded mental health service could be of help to his program. The climate of these initial interviews was friendly yet frank, with the inevitable doubts expressed as to whether our mental health staff really intended to "get its hands dirty" by moving out of the hospital and into such a disadvantaged area, and whether the service was "here to stay" in the face of numerous earlier short-lived government-financed community programs. When the individual visits were concluded, the directors of the different institutions were invited to a meeting for an exchange of ideas and for a planning of collaborative operations based on the interview findings. Of the xz directors invited, nine attended the first meeting; four churches, three neighborhood houses, and two recreational centers were thus represented. Many of the directors were strangers to each other before this date. None had had any experience with a meeting model involving such a variety of agencies with different sponsorships, philosophies, and levels of professionalization. It was furthermore not uncommon that neighboring group service programs had previously had only vague impressions of, or not known of, each other's existence. The many church-sponsored group programs combining pastoral and social welfare aims tended to be especially unfamiliar even to our own professional staff. It soon emerged that these latter programs represented spontaneous developments in this deprived area, in which dedicated ministers and volunteers conducted a variety of groups which were open to everyone in the neighborhood. Characterized by considerable flexibility, these included groups for ex-hospitalized adolescents and for addicts, as well as paramilitary Cadet Corps for pre-teen youths who tended to avoid the more traditional youth programs (Scheidlinger, ~965). The directors assembled in this first meeting appeared to welcome the opportunity for getting together under the "neutral" auspices of a mental health organization which was eager to help with their expressed and similar needs. In response to these needs, two collaborative services were launched immediately: a Consultation Service on group or individual problems available to all staff of the group-service agencies; and Mental Health Training Workshops aimed at staff development. In addition, the directors agreed to hold regular meetings from then on for purposes of planning and evaluation of these consultation and training activities.
166
Community Mental Health Journal
Except for the later addition of program (as differentiated from case consultation), the above-named two service components plus the bimonthly directors' meetings have continued to date. Though closely interrelated in practice, they will be described separately. CASE CONSULTATION SERVICE The Case Consultation Service involved discussions, generally initiated by agency workers, about problems presented by individuals, whether clients or staff. Following the usual model of case consultation (Haylett & Rapoport, z964), the emphasis was on helping the worker arrive at a way of handling the problem that was satisfactory to him. In most instances the attempt was made to resolve the difficulty by renewed intervention within the group service agency's structure. Where this was not feasible, referral of the individual to our own multipurpose clinical facility or to other resources was suggested. More than half of the consultations could be handled over the telephone. It is noteworthy that the number of requests for case consultations decreased significantly as agency staff members began to participate in the mental health training workshops where they were flee to present problems encountered in their daily practice. TRAINING WORKSHOPS As already noted, decisions regarding topics, duration, and composition remained under the aegis of the agency directors' planning body. However, in view of the inability to offer more than one of these workshops at a time, it was urged that the initial effort be directed at administrative and supervisory personnel (top management) with the expectation of a maximum payoff in terms of potential influence on lower echelon staff. Since by now most of the agency directors and supervisors have been exposed to this experience, regular staff currently make up the bulk of the membership. The following workshops of ten weekly sessions 'each have been completed during our first program phase: (a) Mental Health Needs of Pre-Teen Youths, (b) Mental Health Needs of Adolescents, (c) Short-Term Counseling of Children and Adults, (d) Advanced Workshop on Adolescence, (e) Group Work with Socially Disadvantaged Adults. The value placed on this workshop program by the participating agencies can be gauged by a number of factors. To begin with, in addition to sending members of their staff, more than two-thirds of the agency administrators themselves completed at least one workshop, while one-third of them participated in two or more. When directors chose not to participate, it was usually because they preferred that their program directors or other supervisory staff have this opportunity. Due to space limitations, each agency could send only two participants to any one workshop. Only three of the 2o agencies participating in the program failed to send any representative. Reversing the usual pattern, workshop registration continued to increase to the point where a current session, geared to a membership of ten, had 59 people attending.
Saul Scheidlinger and Anne Sarcka
167
In an effort to gauge more precisely the value of this experience, each group of workshop members was asked to fill out unsigned questionnaires in which they rated the workshop and made suggestions for changes. The ratings, ranging from "excellent" to "poor" on a four-point scale, were uniformly favorable and many of the suggestions for change which were brought back to the directors' group were acted on. The workshops were characterized by an air of informality and by a minimum of structure. The participants were encouraged to bring u p any items that interested them within the broad context of the chosen topic. The subjects would thus run the gamut from discussion of specific group experiences to problems presented by individuals (Berlin, 296o). The leader's role in these meetings was largely that of making free group discussion possible. He also acted as a resource for technical data, in nontechnical language, pertaining to specific knowledge or skills. He was always alert to any opportunities presented for enhancing the potential of the staff members as helping persons, especially in relation to the vulnerable youths of the inner city. As might be expected, much time was spent on the issue of how to reach the alienated adolescents; that such older adolescents in the community who were most in need of help tended to remain unreached, was readily acknowledged. In view of the requirement for utter sincerity on the part of the adult workers with such youths, workers earnestly examined their feelings and attitudes toward the younger generation in the workshops. The interaction was at times so lively that it was difficult to recollect who said what and how. There were many doubts and disagreements, as well as shifting alliances. Discussions regarding sex education produced especial ventilation of feelings and also considerable anxiety. A few people spoke of feeling helpless to engage young people meaningfully because the youths' personal values were so far removed from their own. Some extreme attitudes came to the fore as, for instance, those of a young white minister who asserted that sex outside of marriage was sinful. He felt, moreover, that unless a youth revealed some concern for morality "there was nothing to work with." A group worker from a nonsectarian agency countered with a much more tolerant attitude toward deviance. Pointing to the stark realities of sexuality in the ghetto, he stressed in his discussions with youths the importance of "caring," of a meaningful personal involvement as part of the sex experience, together with the responsibility for preventing unplanned pregnancies. When it became dear that many workers, despite fruitful discussions, did not feel ready to handle sex discussions with adolescent girls, a special training exercise was devised. The workshop leader offered to conduct a threesession demonstration series with a girls' group from an agency represented in the workshop. With the girls' permission, the workshop members observed these meetings without participating in the discussions. In addition to proving exceedingly helpful to the particular group of Negro adolescent girls and their worker, this demonstration vividly portrayed the desperate need for sex
168
Community Mental Health Journal
guidance in this community. The gifts, all of whom came from poor though relatively stable Negro families, insisted that they would not dare taik to their mothers about sex because it was a taboo subject. In fact, not a single one of them had been prepared by her mother even for menstruation. The confusion on the subject of sexuality was extreme, with questions about pregnancy and venereal disease being interspersed with fatalistic statements about marriage as connoting seduction, coercion, fights, and desertion. The girls insisted they had never seen real love and could not comprehend that love could be a part of sex. Cynical notions reflecting the street morality with which they were surrounded existed side by side with naive beliefs, such as that the "stork story" was the best way to answer their younger siblings' questions about sex. At the conclusion of this workshop, the staff participants felt ready to initiate similar work at their own agencies. There were many expressions of a desire to emulate the example offered and to share feelings and attitudes with others in similar circumstances. It should be mentioned here that the process notes taken of each workshop session by a research assistant were mimeographed and sent to the participants, as well as to all the agency directors. This served to reinforce the impact of the training experience. PROGRAM CONSULTATION While the training workshops and case consultations undoubtedly served to enhance the agency staff's sensitivity and skills in dealing with their daily problems of practice, they did not in themselves sufficiently stimulate innovative group programs geared to high-risk populations. Accordingly, agencies were encouraged recently to experiment with new program modalities, with regular consultative help to supervisors and staff members available for as long as necessary. As part of this approach, a settlement house sponsored two paratherapeutic activity groups for latency-age children under the leadership of indigenous nonprofessional workers. In contrast to clinical activity groups, the emphasis here was on offering the children adult identification models in a structured environment. The parents' and children's response to the idea of such "clubs" was most favorable, and attendance patterns exceeded the staff's expectations. As a means of dealing with a marked increase in unwanted pregnancies, four agencies (two churches and two settlement houses) were involved with the program in the development of sex guidance discussions for adolescent gifts and their parents. The model called for three concurrent sessions with the gifts and three with the parents. This was to be followed by two joint sessions of girls and parents. During the project, the group workers conducting the sex discussions participated in weekly meetings with the mental health consultants where experiences with the groups were compared and discussed. As might be expected, not only was each leader's style different but, also, in line with the overall approach of the sponsoring agency, there were differ-
Saul Scheidlinger and Anne Sarcka
169
ences in the degree of structure and the amount of emphasis on the moral and spiritual aspects of sexuality. Little of the anticipated resistance to such a program from parents was found. On the contrary, almost all were grateful that the agencies were offering sex guidance discussions. As was the customary experience with meetings for adults in the community, the actual attendance of the parents was poor. In two agencies only about half of the girls' mothers came to at least one meeting. In the other two, still fewer mothers attended, despite the fact that the leaders had managed to establish positive individual contacts with a nmnber of them. Although the fathers were also invited, none put in an appearance. The workers felt that more parents could have been involved had they had time to visit more homes prior to the beginning of the discussion series. It was interesting that some of the mothers who did attend sought guidance and information on sexual issues for themselves--quite apart from the primary aim of enhancing parental communication with the girls. Needless to say, when mothers did come to the meetings their empathy with the girls was visibly deepened. The value of this kind of cooperative program resided not only in the fact that a workable short-term group guidance approach came into being. Perhaps even more important was the demonstration that agency staff members without a professional background could be trained to conduct such discussions. They are now ready to help other staff repeat this experience with different groups. The work on this project revealed a lamentable lack of audiovisual educational aids for young people in poor neighborhoods. The directors' group, which had previewed some sex education films, found them of dubious value for their programs, intended as the films were for an audience of middle-class youth. They decided then to explore the possibility of sponsoring a new film based on life in this community, with Negro and Puerto Rican youths as actors. In addition to the above developments, there is a newly initiated consultation service to paramilitary Cadet Corps groups which tend to attract especially vulnerable latency-age children. There is also a pilot program underway with the aim of utilizing the creative arts as a means of reaching disadvantaged youths. It is too early to evaluate these preliminary undertakings. There are strong indications, however, that expanded work in this sphere of program consultation is desirable if more group approaches designed to meet the special characteristics and needs of low income populations are to be developed. DIRECTORS OF GROUP SERVICE AGENCIES Viewed initially as a means of promoting the collaborative planning and evaluation aspects of our mental health consultation and training activities, the directors' group (now almost doubled in size) evolved into a viable entity with a marked creative momentum of its own. The directors now exchange information and ideas in the group about the services of their respective agencies. There is also considerable interchange about the
170
Community Mental Health Journal
social problems in the community, about resources and other possibilities for joint action. Despite the high turnover rate---of the nine directors who attended our first meeting in March z965, only two are still at their posts tod a y - t h i s body's cohesiveness and level of sophistication regarding mental health problems have steadily risen. In this connection most of the zo currently participating agencies have demonstrated a readiness to build more individualization and "reaching out" efforts into their programs. At the directors' initiative, a directory was distributed, listing the participating agencies and the services of the mental health facility. A number of agencies also expressed a willingness to work with the program's Rehabilitation Services, employing ex-hospitalized patients in volunteer jobs; one church has had two such volunteers. More would have participated had there been need for them. The directors were eager to collaborate with other components of the mental health organization. For example, they were extremely helpful when youngsters in treatment at the clinic required group services in the community. They also participated with the program's Neighborhood Service Centers (Hallowitz, z968 ) in community action efforts, particularly in several campaigns to obtain improved health services in the area. They are increasingly interested in working with adults through tenants' councils, narcotics education programs and, most recendy, through welfare rights groups. All these developments represent a substantial departure from earlier approaches to programming. IMPLICATIONS The unique aspects of this mental health consultation and education program reside in the combination of elements of community organization with those of individual and institutional change in a low income area. While the objective assessment of the efficacy of such work will have to await specific research endeavors, the reactions of the participating agencies and the evaluations by the workshop participants and observers have been uniformly encouraging. What stood out to begin with was the way effective working relationships and collaborative program planning could be fostered among heterogeneous agencies, agencies with secular and religious as well as with professional and nonprofessional staffs. Status and autonomy issues were almost nonexistent. It was perhaps the very enormity of the common task of working in an underserved community with extremely limited resources, as well as the "neutral" nature of the mental health sponsorship, which made this possible. The program's major attitudinal stance on fostering initiative, flexibility, and autonomy of the agencies--helping them develop programs of their own of the highest quality--played a major role. As in all collaborative endeavors, there was much mutual learning. The consultants learned a good deal about the character of the community, including its unmet needs, and much about each individual institution, its leader-
Saul Scheidlinger and Anne Sarcka
171
ship and staff. Especially impressive was the agencies' responsiveness to the ongoing service program, this in the face of the heavy demands made upon them with limited funds, largely untrained workers, and an unusually high rate of staff turnover. It is quite likely that the gradual drop in requests for case consultations was due not only to the staff's greater skill in dealing with special problems but also to the sense of support offered by the consultants' demonstrated availability in case of need. The ongoing training workshops, always open to new members, were of course especially useful in this connection. In terms of Caplan's (~964) three levels of mental health prevention, the major emphasis in these initial endeavors was on primary prevention. This is a considerable achievement, keeping in mind that in such an inner city area, most if not all youths can be considered vulnerable. Through case and program consultation, the secondary and tertiary prevention levels were brought into play. In this connection, true rehabilitation endeavors and special group programs for "fringe" and high-risk populations require considerable consultation staff time. If accompanied by effective documentation and, whenever possible, evaluation (Struening & Peck, ~967), the collaborative evolution of such new group intervention measures not only serves to meet client needs but also adds to the armamentarium of group treatment modalities for low income populations. This aspect of the work is slated for expansion in the near future, induding the use of nonprofessional staff whenever feasible. While local circumstances and staff preferences will dictate specific emphases (Yolles, 1967), there is little doubt that this kind of consultationeducation pattern, addressed to heterogeneous group service agencies viewed as "caretaker" systems, represents a model uniquely suitable for community mental health programs in disadvantaged areas. REFERENCES Berlin, I. N. The theme of mental health consultation sessions. American Journal of Orthopsychiatry, i96o , 30, 827-828. Caplan, G. Principles of Preventive Psychiatry. New York: Basic Books, 1964. Hallowitz, E. The role of a neighborhood service center in a community mental health program. American Journal of Orthopsychiatry, I968, 38, 7o5-714. Haylett, C. H., & Rapoport, L. Mental health consultation. In L. Bellak (Ed.), Handbook of community psychiatry and community mental health. New York: Grune & Stratton, I964. Peck, H. B., Kaplan, S., & Roman, M. S. Prevention, treatment and social action: a strategy of intervention in a disadvantaged urban area. American Journal of Orthopsychiatry, I966, 36, 57-69. Rae-Grant, Q. A. F., Gladwin, T., & Bower, E. Mental health, social competence, and the war on poverty. American ]ournal of Orthopsychiatry, 1966, 36, 652-664. Scheidlinger, S. Three group approaches with socially deprived latency-age children. International Journal of Group Psychotherapy, 1965, ~5, 434-445Struening, E., & Peck, H. B. The role of research in evaluation. In R. H. Williams & L. D. Ozarin (Eds.), Community mental health. San Francisco, California: Jessey-Bass, I967. YoIles, S. F. Community mental health services: the view from I967. American Journal of Psychiatry Supplement, 1967, 124,1-7.
