Appalachian Public Health Nursing: Mental Health Component in Eastern Kentucky David H. Looff, M.D.
ABSTRACT: The Manchester Project, and its attendant public health nursing activity, is described as a unique mental health program in the commonwealth of Kentucky. It continues to operate within the existing framework of four local county health departments in eastern Kentucky, and utilizes much public health technique, personnel, and methodology. By focussing upon the intrinsic mental health component of public health work, the project demonstrates an effective way of meeting community mental health needs in rural, impoverished areas. Many families in the economically stricken areas of Appalachia share with the poor elsewhere in our nation formidable, interrelated general and mental health problems. In eastern Kentucky, as elsewhere in Appalachia, the areas marked by poverty are likewise marked by disease, substandard housing, inadequate education, broken homes, and chronic unemployment. The State Health Department of Kentucky has ample statistical data to indicate that the poor in eastern Kentucky have higher morbidity and death rates for tuberculosis, cardiovascular-renal disease, influenza, pneumonia, and home accidents. There is empirical data to suggest that those in poverty areas have more mental illness and mental retardation, higher birth rates, more illegitimate births, more pregnancies with little or no prenatal care, an infant mortality rate two or three times as high as that in more affluent sections, more orthopedic and visual impairments, and a host of other similar conditions. Added to these general statistics is the suffering, despair, and apathy that exists among the Appalachian poor. THE MANCHESTER PROJECT: DEVELOPMENT, PROGRAM, AND PERSONNEL In eastern Kentucky, as elsewhere in the southern highlands, many Appalachian families turn to the local county health departDr. Looff is associate professor of child psychiatry, Child Psychiatry Division, Department of Psychiatry, University of Kentucky Medical Center, Lexington, Ky. This paper was presented at the annual meeting of the American Public Health Association, Miami Beach, Fla., October 26, I967, at a session on Mental Health Services Today in Rural Areas. Community Mental Hearth Journal, Vol. 5 (4), 1969 295
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Community Mental Health Journal
ments for medical attention because of the frequent absence or scarcity of local physicians. Concern for the total health needs of the families in their area led health department personnel in four eastern Kentucky counties to initiate organization for local mental health-mental retardation services in "r964.
For years the county health officer of Clay, Lee, Jackson, and Owsley counties and her staff of eight senior public health nurses had been identifying a group of troubled children and their families through the health departments' various nursing programs. These programs serve the four-county area's 49,000 residents, including 52,300 children. Community resources for the care of these children had been realistically limited. The xx general physicians in private practice in this area were faced with the almost overwhelming health needs of a population that included both a large group of children and a large group of the aged. Two regional state hospitals provided brief-contact aftercare clinics in the health departments for discharged adult psychiatric patients from these counties. Only indirect services for children were provided in the counties by the Kentucky Child Welfare Department and the public assistance programs. These factors combined, therefore, to produce a specific need for psychiatric services for children. After identifying this need, health department personnel invited the Department of Psychiatry of the University of Kentucky Medical Center to join them in developing these services in the four-county area. At the time of this request, the Department of Psychiatry recognized it needed a field laboratory to provide trainees with experience in community psychiatry. The service need of the health departments and the training need of the Department of Psychiatry met, therefore, in the cooperative formation of the Manchester Project. The Manchester Project has been in continuous operation since August 2964 . Serving the four-county area, the project operates community child psychiatry clinics every other Wednesday in the local health departments. These clinics include diagnostic-treatment services for emotionally disturbed children and their families; regular case consultations to schools, primary physicians, child welfare workers, and Head Start programs; and training seminars. Project personnel include the resident health department staffs, and a traveling component from the University of Kentucky consisting of the author, two psychiatric social workers, two third-year residents in general psychiatry, and several social work trainees. Each semester a group of from eight to ten senior nursing students are included in the project from the Berea College of Nursing. These students are assigned for three months for public health field experience in various nursing programs of the health departments. DEMOGRAPHIC DATA The staff of the project found that a broad sociocultural review of the people and their area was essential to understand in depth
David H. Looff
297
those troubled families referred to the clinic, or discussed in case consultations. The people living in southern Appalachia today are by no means socially homogeneous. In the area there is a middle class (teachers, shopkeepers, clerks), as well as a professional and upper class. These have much the same characteristics as these classes anywhere else. Many serve as community leaders and are considerably ahead of the total population in education, income, property ownership, and age. In his recent book Yesterday's People, Jack Weller (2965) describes them as activists and progressives, receptive to national values and contacts, and definitely ahead of the rank and file of people in pushing for change and development. They contrast with the lower, or folk-class, which exists side by side with them. Of the southern mountaineer in this folk-class much has ,been written by novelists, poets, sociologists, government researchers, politicians, and industrialists. These writers have told only a few aspects of the Appalachian story--the feuds, the inadequate agriculture, the harsh life of the mining towns, the terrible mining accidents, the shocking illiteracy rate, the poverty, squalor, and chronically high incidence of disease. Weller describes this group as the product of initial backwoods intransigenc~ followed by generations of isolation, poor schools, and government neglect. Impoverished by absentee ownership of the wealth from natural resources (coal, natural gas, timber, and limestone) and by an archaic agriculture, many southern highlanders are moving into the cities. This out-migration has been commented upon by Thomas Ford (2964), a University of Kentucky rural sociologist, in a recent monograph. There he summarizes much pertinent demographic data for Kentucky. Clay County (23,ooo population), the largest of the four counties served by the Manchester Project, can be taken as an index-area in a review of this data. Lying partly in the eastern coal fields, and partly in the eastern Kentucky hills area, Clay County has been economically dependent upon mining, small-scale agriculture, and lumbering. As small, marginal farms became unprofitable, and coal miners were displaced as a consequence of restricted mining production and the introduction of more efficient mining equipment, a surplus male labor force was created. Many out-migrated either alone or with their families to seek employment in the industrialized north central states. Many remained behind to increase the high rate of unemployed in Kentucky. A large part of the failure of those displaced to be employed in other occupations stems from their lack of basic education which serves as a barrier to retraining in other technical skills. In addition, new industries have not materialized in sufficient quantity to absorb the displaced workers and young people entering the labor force. Another aspect lies in the fact that many of these men have little or no experience living outside the mountains, and often no desire to leave the only home they have ever known. Weller aptly describes the psychological effect of these combined factors as the shock of unemployability.
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Community Mental Health Journal
However, within southern Appalachia not all are adversely affected by the economic difficulties of the region. James Brown, another University of Kentucky rural sociologist, has indicated: "Casual observers and, too often, trained social scientists as well, tend to view the populations of rural low-income areas as relatively homogeneous 'pockets of poverty.' Too often they fail to take into account that systems of social stratification exist within such depressed areas or, to phrase it another way, that families in such areas vary in their abilities to cope with the problems of survival and of assuring the well-being of family members in a situation of continual economiccrisis" (Brown, ~964, p. 2). REVIEW OF CLINICAL CASES FROM THE MANCHESTER PROJECT During the initial two and a half years of operation of the project, 525 children and their families were referred for diagnostic evaluation and treatment; an additional 208 children were discussed in case consultations. The majority of clinic referrals were made by the senior public health nurses from their caseloads in the four-county area. School personnel and the primary physicians also referred families, but always through the nursing staffs at the health departments. Referrals in this way took advantage of the nurses' intimate knowledge of and proximity to the community, its families, and its resources. Through traditional public health programs and their positions as school nurses, the public health nurses played a key role in early case finding, an outstanding feature of the project. Following the decision for referral of a particular child, the nurse in whose district of the county the child lived and attended school thoroughly reviewed the case prior to the family's being seen at the health department. In this initial or diagnostic phase of the case reviews, the nurse's role merged with the traditional role of the psychiatric social worker. The nurse visited the child in his school setting and conferred with his teachers. Current and past medical information was gathered from the child's local physician and from any social agencies with whom the family might have been involved. The nurse then visited each home. There she talked for several hours with the child and his family, and watched him at work and play in a variety of relationships. The nurse then arranged appointments for the family at the health department, presenting her findings to the traveling part of the project team on clinic days. Most of the families readily accepted referral. They viewed the mental health clinic as positively as the other public health programs, a view reinforced by the nurse's initial case review. Several families were reluctant to accept referral initially. Most families in this group were poor, and lived under chronic exposure to many kinds of impoverishment--economic, physical, emotional, and cultural. Like most poor families under severe and chronic stress, they lived in apathy, without hope, and perceived few alternative solutions to these problems. Hence they remained apathetic toward, openly apprehensive about, or even puzzled by
David H. Looff
299
a clinic referral as a potentially helpful aid in problem-solving. Thus it was apparent these tensions had to be eliminated before the clinic could render regular services for these families. By virtue of her shared cultural background, her proximity to families, and her availability in other, actionoriented public health programs, the nurse became the most effective member of the mental health team in overcoming these tensions. Time-consuming though it was, frequent home contacts by the nurses with these families were generally effective in breaking through the barriers of apathy and resistance to render them more receptive to the next, or clinic phase, of needed mental health services. Several families, because of the nature of the shared family psychopathology (as in several school phobia reaction cases), remained fearful of the referral. Their fears were expressed by missing initial clinic appointments. If this occurred, the nurse, the socal worker, and the psychiatrist promptly visited the family in their home. Often this was successful in overcoming initial resistance and moving the families toward the health department for succeeding appointments. At the health department, parents were interviewed jointly by the social worker while the child was being seen by the psychiatrist. Data on the first 52 families referred for evaluation were recently reviewed and presented by the author (Looff, ~966, ~967). Socioeconomic data obtained from these families placed them in the three-class social system characteristic of the southern Appalachian region. Psychiatric data on the children were not strikingly different from that on children seen at many child psychiatry clinics, with two exceptions: (a) because of early case finding by the nursing staff, more children were seen with developmental problems or adjustment reactions than is true in many university or urban community child psychiatry clinics, and (b) family functioning in most instances was markedly interdependent; their orientation was a strongly familial one, often with extensive kinship ties. Related to these dynamics was the increased incidence of dependency-related psychiatric syndromes (acute and chronic school phobic reactions, a relatively pure form of symbiotic psychosis in one young child, and various psychophysiologic reactions) in the project's child cases measured against comparable data from a successive group of cases at the child psychiatry clinic at the University of Kentucky Medical Center. Furthermore, no cases of early infantile autism or primary behavior disorder (both generally considered to be based on extreme emotional deprivation in infancy) were found in project children. Collaboration between all members of the project team concluded the initial interviews with each family at the health department. Team members' findings were discussed, leading toward an initial dynamic understanding of the child's and family's problems. Decisions were made for interim and longterm treatment planning. The nurses carried out many of these initial and final case recommendations. They were responsible for prompt follow-up reports to the primary physicians, and for follow-up reports and future con-
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Community Mental Health Journal
sultations around the children to the schools. A n d in m a n y instances they worked with the children and their parents directly. Several case-examples are presented to illustrate the o n g o i n g diagnostictreatment role of the public health nurses in the project: Case z : Tony (z3) was from a poor, marginal-farm family torn by recent divorce. His open anxiety, marked rebelliousness toward his mother, running away from home, and occasional stealing occasioned the referral by the family's nurse. Nearly a year of regular subsequent casework contacts with the project's social worker failed to alter the suffering, martyred views of Tony's mother, who expected Tony and his older brother Leonard to act out aggressively. Concurrently, the two boys became increasingly abusive at home. An aggressive family crisis erupted. The nurse, understanding the underlying case dynamics, and the family setting as incapable of modification, moved swiftly to intervene. She supported the mother's jailing of Tony, recognizing the boy's need for separation from home and for firm, kind external controls. Simultaneously she visited Tony daily in jail, openly discussing his needs and her future planning for him. The jailer was encouraged to support and befriend the boy during his five-day stay. Quickly the nurse brought her full knowledge of the case to the awareness of the local child welfare worker, and with her obtained prompt commitment of Tony to the evaluation-residential center of the Kentucky Department of Child Welfare in Louisville. Simultaneously the nurse supported the boys' mother at home, relieving her guilt and clarifying crisis-planning for the family. The nurse concluded her crisis-intervention by arranging for boarding school in the region for fifteen-year-old Leonard. During the ensuing year Tony and Leonard made good progress in their separate settings, and their mother was now free to utilize nursing and casework support of her strengths in less conflicted handling of her younger children. Case 2: Shelia (7) developed an acute school phobic reaction shortly after entering first grade. The nurse, following her case review, formulated the family's close interdependent functioning, chronic concerns over illness and accidents, and the immediate stress on entering school as responsible for Shelia's and her mother's mutual separation anxiety. The nurse volunteered to be the prime mover in the family's treatment plan. She listened to mother and daughter in their home, brought their mutually reinforcing fears into focus, clarified reality with them, and enlisted support for a gradual plan of separation for both. She arranged with school authorities that Shelia and her mother attend school together, initially in the same room. Later, Shelia's mother worked elsewhere in the building, and gradually left the setting altogether. Helped in this crisis situation, the family continued to function as separated individuals.
REVIEW OF S C H O O L C O N S U L T A T I O N S The project's psychiatrists and social workers, accompanied 'by the public health nurse in her role of school nurse, regularly provided case consultations to schools, and to regional Head Start or D a y Care programs. Two hundred and eight maladjusting preschool and school-age children were discussed with teachers during the initial 30 months of the project's operation. The nurse's participation in the consultation p r o g r a m was crucial for the success of each of the several phases in individual case consultation, as follows. The initial phase involved the consultant's coming to understand the teacher's background, her classroom functions, and h o w she had come to feel about the particular child being discussed. It was found, as Millar did in his work (5966), that the consultant's first concern was with the teacher's feelings
David H. Looff
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for, until these had been dealt with, she was not in a position to accept another view of the child--the dynamic one accounting for his particular behavior. In this situation, as in her clinic work with families, the nurse's shared cultural background with the teacher often enabled her to quickly empathize with her. This enabled the consultant to encourage the teacher to express her frustrations more directly. It was found that after the teacher had dissipated some of her accumulated feeling, and had been assured of the competence and interest of the consultant (fostered by the nurse's working relationship with the consultant), she was ready to understand the child in different terms. The second phase of everyone's coming to understand the child's behavior received a powerful impetus from the nurse's knowledge of his home background and its psychological, economic, and cultural forces. The teacher and nurse shared their respective data, often reaching a conclusion of real clarity about a child. The consultant team was then in a position to make more effective classroom management proposals for the teacher in helping the child. Sometimes these proposals involved a role for the nurse as Well, in her direct work with the child's family. She on occasion neutralized chronic parental concerns about separation, illness, death, and violence which taken together fostered chronic anxiety expressed in classroom belligerence of several children, to cite one example. Occasionally it was found necessary to have the nurse follow up the regular consultation by visits with the teacher in her classroom. This was done in instances in which the teacher's changed attitudes toward a child began to fade. The nurse's continuing supportive consultation with the teacher tended to reinforce desirable attitude change, with accompanying more effective classroom management of the child. TRAINING FUNCTIONS OF THE MANCHESTER PROJECT Within the community clinic and school settings, the residents in general psychiatry learned to work collaboratively with children and families, public health nurses, school personnel, public assistance workers, and primary physicians. The social work students and the senior nursing students were afforded similar collaborative field training and experience. A training seminar for project personnel conducted by the author and the psychiatric social worker concluded each clinic. DISCUSSION Two general themes are characteristic of the Manchester Project. The first is that in some respects the project resembles a traditionally organized community child psychiatry clinic. Retained are the elements of collaborative work in evaluations, community consultations, and treatment methods shared by all community clinics.
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The second theme is that in other, important respects the project makes a major departure from the more traditional community clinic model by taking its place with other public health programs in a county health department setting. Four elements of this setting are of crucial importance in the formation, ongoing operation, and projected development of the project. (5) The four health departments lead in comprehensive planning in the four-county region for all health services. (z) The health departments, their staffs and programs, have strong professional and public acceptance. (3) The public health nurses represent what Forstenzer (5965) calls the most effective, community-oriented technological agents present in the region for modifying the amount of mental disorder in the population served. (4) The health departments' programs have broad implications for primary, secondary, and tertiary prevention of mental disorders. The third-named point, that of the public health nurse's role as a mental health agent, merits additional comment. In their work the nurses have a flexibility, mobility, and proximity to people and their health needs of crucial importance in community mental health programs. As a result of their shared cultural background, they generally have great empathy for their people, and therefore can much more easily establish rapport with them than can other middle-class professionals. Accordingly the public health nurses, through personalizing clinic services, counter or offset many Appalachian families' traditional reluctance to seek help for problem-solving in outside agencies or clinics. These observations indicate that the public health nurse has been an effective sociocuhural as well as a medical bridge between national standards of health care and those families served by the health departments. This parallels Schwarzweller and Brown's thesis (5962) that education serves as a cultural 'bridge between American society and the eastern mountain region of Kentucky. Thus both health care practices, including mental health, and education can be viewed as inseparably bound complexes that span the gap between two cultural systems. Both are concerned with the integration of the folk-class subculture of eastern Kentucky with the culture of American society. REFERENCES Brown, J. S. Social class origins, migration and economic life chances: a case study of a rural-urban migration system. Paper read at the Rural Sociological Society Meeting, Montreal, Canada, 5964. Ford, T. R. Health and Demography in Kentucky. Lexington: University of Kentucky Press, 5964. Forstenzer, H. M. Planning and evaluation of community mental health programs. In Concepts in Community Psychiatry. National Institute of Mental Health, Public Health Service Publication No. 5359, 5965. Looff, D. H., Gabbard, Mildred B., and Miller, Dorothy A. The Manchester Project: a child psychiatry clinic in a county health department. Paper read at the Southeastern Division Meeting of the American Psychiatric Association, Hollywood, Fla., October 24, 5966.
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Looff, D. H. Psychiatric perspective on poverty in America: subsidiary review of mental health problems in Eastern Kentucky. In T. Weaver and A. Magid (Eds.), Interdisciplinary Perspectives on Poverty in America. San Francisco: Chandler Publishing, in press. Millar, T. P. Psychiatric consultation with teachers. Journal of Child Psychiatry, ~966, 5, z, z34-z44. Schwarzweller, H. K., and Brown, J. S. Education as a cuhural bridge between Eastern Kentucky and the Great Society. Rural Sociology, x962, 27, 4, 357-373. Weller, J. E. Yesterday's People. Lexington: University of Kentucky Press, z965.
Center for Psychological Studies Established Wayne State University has announced the formation of a Center for Psychological Studies of Dying, Death and Lethal Behavior. Organized as a unit of the Department of Psychology, the interdisciplinary center will undertake research, and correlate and distribute information on death and lethal behavior. Further information is available from Dr. Robert Kastenbaum, director, 42o Mackenzie Hall, Wayne State University, Detroit, Mich. 48202
ABSTRACT: The Manchester Project, and its attendant public health nursing activity, is described as a unique mental health program in the commonwealth of Kentucky. It continues to operate within the existing framework of four local county health departments in eastern Kentucky, and utilizes much public health technique, personnel, and methodology. By focussing upon the intrinsic mental health component of public health work, the project demonstrates an effective way of meeting community mental health needs in rural, impoverished areas. Many families in the economically stricken areas of Appalachia share with the poor elsewhere in our nation formidable, interrelated general and mental health problems. In eastern Kentucky, as elsewhere in Appalachia, the areas marked by poverty are likewise marked by disease, substandard housing, inadequate education, broken homes, and chronic unemployment. The State Health Department of Kentucky has ample statistical data to indicate that the poor in eastern Kentucky have higher morbidity and death rates for tuberculosis, cardiovascular-renal disease, influenza, pneumonia, and home accidents. There is empirical data to suggest that those in poverty areas have more mental illness and mental retardation, higher birth rates, more illegitimate births, more pregnancies with little or no prenatal care, an infant mortality rate two or three times as high as that in more affluent sections, more orthopedic and visual impairments, and a host of other similar conditions. Added to these general statistics is the suffering, despair, and apathy that exists among the Appalachian poor. THE MANCHESTER PROJECT: DEVELOPMENT, PROGRAM, AND PERSONNEL In eastern Kentucky, as elsewhere in the southern highlands, many Appalachian families turn to the local county health departDr. Looff is associate professor of child psychiatry, Child Psychiatry Division, Department of Psychiatry, University of Kentucky Medical Center, Lexington, Ky. This paper was presented at the annual meeting of the American Public Health Association, Miami Beach, Fla., October 26, I967, at a session on Mental Health Services Today in Rural Areas. Community Mental Hearth Journal, Vol. 5 (4), 1969 295
296
Community Mental Health Journal
ments for medical attention because of the frequent absence or scarcity of local physicians. Concern for the total health needs of the families in their area led health department personnel in four eastern Kentucky counties to initiate organization for local mental health-mental retardation services in "r964.
For years the county health officer of Clay, Lee, Jackson, and Owsley counties and her staff of eight senior public health nurses had been identifying a group of troubled children and their families through the health departments' various nursing programs. These programs serve the four-county area's 49,000 residents, including 52,300 children. Community resources for the care of these children had been realistically limited. The xx general physicians in private practice in this area were faced with the almost overwhelming health needs of a population that included both a large group of children and a large group of the aged. Two regional state hospitals provided brief-contact aftercare clinics in the health departments for discharged adult psychiatric patients from these counties. Only indirect services for children were provided in the counties by the Kentucky Child Welfare Department and the public assistance programs. These factors combined, therefore, to produce a specific need for psychiatric services for children. After identifying this need, health department personnel invited the Department of Psychiatry of the University of Kentucky Medical Center to join them in developing these services in the four-county area. At the time of this request, the Department of Psychiatry recognized it needed a field laboratory to provide trainees with experience in community psychiatry. The service need of the health departments and the training need of the Department of Psychiatry met, therefore, in the cooperative formation of the Manchester Project. The Manchester Project has been in continuous operation since August 2964 . Serving the four-county area, the project operates community child psychiatry clinics every other Wednesday in the local health departments. These clinics include diagnostic-treatment services for emotionally disturbed children and their families; regular case consultations to schools, primary physicians, child welfare workers, and Head Start programs; and training seminars. Project personnel include the resident health department staffs, and a traveling component from the University of Kentucky consisting of the author, two psychiatric social workers, two third-year residents in general psychiatry, and several social work trainees. Each semester a group of from eight to ten senior nursing students are included in the project from the Berea College of Nursing. These students are assigned for three months for public health field experience in various nursing programs of the health departments. DEMOGRAPHIC DATA The staff of the project found that a broad sociocultural review of the people and their area was essential to understand in depth
David H. Looff
297
those troubled families referred to the clinic, or discussed in case consultations. The people living in southern Appalachia today are by no means socially homogeneous. In the area there is a middle class (teachers, shopkeepers, clerks), as well as a professional and upper class. These have much the same characteristics as these classes anywhere else. Many serve as community leaders and are considerably ahead of the total population in education, income, property ownership, and age. In his recent book Yesterday's People, Jack Weller (2965) describes them as activists and progressives, receptive to national values and contacts, and definitely ahead of the rank and file of people in pushing for change and development. They contrast with the lower, or folk-class, which exists side by side with them. Of the southern mountaineer in this folk-class much has ,been written by novelists, poets, sociologists, government researchers, politicians, and industrialists. These writers have told only a few aspects of the Appalachian story--the feuds, the inadequate agriculture, the harsh life of the mining towns, the terrible mining accidents, the shocking illiteracy rate, the poverty, squalor, and chronically high incidence of disease. Weller describes this group as the product of initial backwoods intransigenc~ followed by generations of isolation, poor schools, and government neglect. Impoverished by absentee ownership of the wealth from natural resources (coal, natural gas, timber, and limestone) and by an archaic agriculture, many southern highlanders are moving into the cities. This out-migration has been commented upon by Thomas Ford (2964), a University of Kentucky rural sociologist, in a recent monograph. There he summarizes much pertinent demographic data for Kentucky. Clay County (23,ooo population), the largest of the four counties served by the Manchester Project, can be taken as an index-area in a review of this data. Lying partly in the eastern coal fields, and partly in the eastern Kentucky hills area, Clay County has been economically dependent upon mining, small-scale agriculture, and lumbering. As small, marginal farms became unprofitable, and coal miners were displaced as a consequence of restricted mining production and the introduction of more efficient mining equipment, a surplus male labor force was created. Many out-migrated either alone or with their families to seek employment in the industrialized north central states. Many remained behind to increase the high rate of unemployed in Kentucky. A large part of the failure of those displaced to be employed in other occupations stems from their lack of basic education which serves as a barrier to retraining in other technical skills. In addition, new industries have not materialized in sufficient quantity to absorb the displaced workers and young people entering the labor force. Another aspect lies in the fact that many of these men have little or no experience living outside the mountains, and often no desire to leave the only home they have ever known. Weller aptly describes the psychological effect of these combined factors as the shock of unemployability.
298
Community Mental Health Journal
However, within southern Appalachia not all are adversely affected by the economic difficulties of the region. James Brown, another University of Kentucky rural sociologist, has indicated: "Casual observers and, too often, trained social scientists as well, tend to view the populations of rural low-income areas as relatively homogeneous 'pockets of poverty.' Too often they fail to take into account that systems of social stratification exist within such depressed areas or, to phrase it another way, that families in such areas vary in their abilities to cope with the problems of survival and of assuring the well-being of family members in a situation of continual economiccrisis" (Brown, ~964, p. 2). REVIEW OF CLINICAL CASES FROM THE MANCHESTER PROJECT During the initial two and a half years of operation of the project, 525 children and their families were referred for diagnostic evaluation and treatment; an additional 208 children were discussed in case consultations. The majority of clinic referrals were made by the senior public health nurses from their caseloads in the four-county area. School personnel and the primary physicians also referred families, but always through the nursing staffs at the health departments. Referrals in this way took advantage of the nurses' intimate knowledge of and proximity to the community, its families, and its resources. Through traditional public health programs and their positions as school nurses, the public health nurses played a key role in early case finding, an outstanding feature of the project. Following the decision for referral of a particular child, the nurse in whose district of the county the child lived and attended school thoroughly reviewed the case prior to the family's being seen at the health department. In this initial or diagnostic phase of the case reviews, the nurse's role merged with the traditional role of the psychiatric social worker. The nurse visited the child in his school setting and conferred with his teachers. Current and past medical information was gathered from the child's local physician and from any social agencies with whom the family might have been involved. The nurse then visited each home. There she talked for several hours with the child and his family, and watched him at work and play in a variety of relationships. The nurse then arranged appointments for the family at the health department, presenting her findings to the traveling part of the project team on clinic days. Most of the families readily accepted referral. They viewed the mental health clinic as positively as the other public health programs, a view reinforced by the nurse's initial case review. Several families were reluctant to accept referral initially. Most families in this group were poor, and lived under chronic exposure to many kinds of impoverishment--economic, physical, emotional, and cultural. Like most poor families under severe and chronic stress, they lived in apathy, without hope, and perceived few alternative solutions to these problems. Hence they remained apathetic toward, openly apprehensive about, or even puzzled by
David H. Looff
299
a clinic referral as a potentially helpful aid in problem-solving. Thus it was apparent these tensions had to be eliminated before the clinic could render regular services for these families. By virtue of her shared cultural background, her proximity to families, and her availability in other, actionoriented public health programs, the nurse became the most effective member of the mental health team in overcoming these tensions. Time-consuming though it was, frequent home contacts by the nurses with these families were generally effective in breaking through the barriers of apathy and resistance to render them more receptive to the next, or clinic phase, of needed mental health services. Several families, because of the nature of the shared family psychopathology (as in several school phobia reaction cases), remained fearful of the referral. Their fears were expressed by missing initial clinic appointments. If this occurred, the nurse, the socal worker, and the psychiatrist promptly visited the family in their home. Often this was successful in overcoming initial resistance and moving the families toward the health department for succeeding appointments. At the health department, parents were interviewed jointly by the social worker while the child was being seen by the psychiatrist. Data on the first 52 families referred for evaluation were recently reviewed and presented by the author (Looff, ~966, ~967). Socioeconomic data obtained from these families placed them in the three-class social system characteristic of the southern Appalachian region. Psychiatric data on the children were not strikingly different from that on children seen at many child psychiatry clinics, with two exceptions: (a) because of early case finding by the nursing staff, more children were seen with developmental problems or adjustment reactions than is true in many university or urban community child psychiatry clinics, and (b) family functioning in most instances was markedly interdependent; their orientation was a strongly familial one, often with extensive kinship ties. Related to these dynamics was the increased incidence of dependency-related psychiatric syndromes (acute and chronic school phobic reactions, a relatively pure form of symbiotic psychosis in one young child, and various psychophysiologic reactions) in the project's child cases measured against comparable data from a successive group of cases at the child psychiatry clinic at the University of Kentucky Medical Center. Furthermore, no cases of early infantile autism or primary behavior disorder (both generally considered to be based on extreme emotional deprivation in infancy) were found in project children. Collaboration between all members of the project team concluded the initial interviews with each family at the health department. Team members' findings were discussed, leading toward an initial dynamic understanding of the child's and family's problems. Decisions were made for interim and longterm treatment planning. The nurses carried out many of these initial and final case recommendations. They were responsible for prompt follow-up reports to the primary physicians, and for follow-up reports and future con-
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sultations around the children to the schools. A n d in m a n y instances they worked with the children and their parents directly. Several case-examples are presented to illustrate the o n g o i n g diagnostictreatment role of the public health nurses in the project: Case z : Tony (z3) was from a poor, marginal-farm family torn by recent divorce. His open anxiety, marked rebelliousness toward his mother, running away from home, and occasional stealing occasioned the referral by the family's nurse. Nearly a year of regular subsequent casework contacts with the project's social worker failed to alter the suffering, martyred views of Tony's mother, who expected Tony and his older brother Leonard to act out aggressively. Concurrently, the two boys became increasingly abusive at home. An aggressive family crisis erupted. The nurse, understanding the underlying case dynamics, and the family setting as incapable of modification, moved swiftly to intervene. She supported the mother's jailing of Tony, recognizing the boy's need for separation from home and for firm, kind external controls. Simultaneously she visited Tony daily in jail, openly discussing his needs and her future planning for him. The jailer was encouraged to support and befriend the boy during his five-day stay. Quickly the nurse brought her full knowledge of the case to the awareness of the local child welfare worker, and with her obtained prompt commitment of Tony to the evaluation-residential center of the Kentucky Department of Child Welfare in Louisville. Simultaneously the nurse supported the boys' mother at home, relieving her guilt and clarifying crisis-planning for the family. The nurse concluded her crisis-intervention by arranging for boarding school in the region for fifteen-year-old Leonard. During the ensuing year Tony and Leonard made good progress in their separate settings, and their mother was now free to utilize nursing and casework support of her strengths in less conflicted handling of her younger children. Case 2: Shelia (7) developed an acute school phobic reaction shortly after entering first grade. The nurse, following her case review, formulated the family's close interdependent functioning, chronic concerns over illness and accidents, and the immediate stress on entering school as responsible for Shelia's and her mother's mutual separation anxiety. The nurse volunteered to be the prime mover in the family's treatment plan. She listened to mother and daughter in their home, brought their mutually reinforcing fears into focus, clarified reality with them, and enlisted support for a gradual plan of separation for both. She arranged with school authorities that Shelia and her mother attend school together, initially in the same room. Later, Shelia's mother worked elsewhere in the building, and gradually left the setting altogether. Helped in this crisis situation, the family continued to function as separated individuals.
REVIEW OF S C H O O L C O N S U L T A T I O N S The project's psychiatrists and social workers, accompanied 'by the public health nurse in her role of school nurse, regularly provided case consultations to schools, and to regional Head Start or D a y Care programs. Two hundred and eight maladjusting preschool and school-age children were discussed with teachers during the initial 30 months of the project's operation. The nurse's participation in the consultation p r o g r a m was crucial for the success of each of the several phases in individual case consultation, as follows. The initial phase involved the consultant's coming to understand the teacher's background, her classroom functions, and h o w she had come to feel about the particular child being discussed. It was found, as Millar did in his work (5966), that the consultant's first concern was with the teacher's feelings
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for, until these had been dealt with, she was not in a position to accept another view of the child--the dynamic one accounting for his particular behavior. In this situation, as in her clinic work with families, the nurse's shared cultural background with the teacher often enabled her to quickly empathize with her. This enabled the consultant to encourage the teacher to express her frustrations more directly. It was found that after the teacher had dissipated some of her accumulated feeling, and had been assured of the competence and interest of the consultant (fostered by the nurse's working relationship with the consultant), she was ready to understand the child in different terms. The second phase of everyone's coming to understand the child's behavior received a powerful impetus from the nurse's knowledge of his home background and its psychological, economic, and cultural forces. The teacher and nurse shared their respective data, often reaching a conclusion of real clarity about a child. The consultant team was then in a position to make more effective classroom management proposals for the teacher in helping the child. Sometimes these proposals involved a role for the nurse as Well, in her direct work with the child's family. She on occasion neutralized chronic parental concerns about separation, illness, death, and violence which taken together fostered chronic anxiety expressed in classroom belligerence of several children, to cite one example. Occasionally it was found necessary to have the nurse follow up the regular consultation by visits with the teacher in her classroom. This was done in instances in which the teacher's changed attitudes toward a child began to fade. The nurse's continuing supportive consultation with the teacher tended to reinforce desirable attitude change, with accompanying more effective classroom management of the child. TRAINING FUNCTIONS OF THE MANCHESTER PROJECT Within the community clinic and school settings, the residents in general psychiatry learned to work collaboratively with children and families, public health nurses, school personnel, public assistance workers, and primary physicians. The social work students and the senior nursing students were afforded similar collaborative field training and experience. A training seminar for project personnel conducted by the author and the psychiatric social worker concluded each clinic. DISCUSSION Two general themes are characteristic of the Manchester Project. The first is that in some respects the project resembles a traditionally organized community child psychiatry clinic. Retained are the elements of collaborative work in evaluations, community consultations, and treatment methods shared by all community clinics.
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The second theme is that in other, important respects the project makes a major departure from the more traditional community clinic model by taking its place with other public health programs in a county health department setting. Four elements of this setting are of crucial importance in the formation, ongoing operation, and projected development of the project. (5) The four health departments lead in comprehensive planning in the four-county region for all health services. (z) The health departments, their staffs and programs, have strong professional and public acceptance. (3) The public health nurses represent what Forstenzer (5965) calls the most effective, community-oriented technological agents present in the region for modifying the amount of mental disorder in the population served. (4) The health departments' programs have broad implications for primary, secondary, and tertiary prevention of mental disorders. The third-named point, that of the public health nurse's role as a mental health agent, merits additional comment. In their work the nurses have a flexibility, mobility, and proximity to people and their health needs of crucial importance in community mental health programs. As a result of their shared cultural background, they generally have great empathy for their people, and therefore can much more easily establish rapport with them than can other middle-class professionals. Accordingly the public health nurses, through personalizing clinic services, counter or offset many Appalachian families' traditional reluctance to seek help for problem-solving in outside agencies or clinics. These observations indicate that the public health nurse has been an effective sociocuhural as well as a medical bridge between national standards of health care and those families served by the health departments. This parallels Schwarzweller and Brown's thesis (5962) that education serves as a cultural 'bridge between American society and the eastern mountain region of Kentucky. Thus both health care practices, including mental health, and education can be viewed as inseparably bound complexes that span the gap between two cultural systems. Both are concerned with the integration of the folk-class subculture of eastern Kentucky with the culture of American society. REFERENCES Brown, J. S. Social class origins, migration and economic life chances: a case study of a rural-urban migration system. Paper read at the Rural Sociological Society Meeting, Montreal, Canada, 5964. Ford, T. R. Health and Demography in Kentucky. Lexington: University of Kentucky Press, 5964. Forstenzer, H. M. Planning and evaluation of community mental health programs. In Concepts in Community Psychiatry. National Institute of Mental Health, Public Health Service Publication No. 5359, 5965. Looff, D. H., Gabbard, Mildred B., and Miller, Dorothy A. The Manchester Project: a child psychiatry clinic in a county health department. Paper read at the Southeastern Division Meeting of the American Psychiatric Association, Hollywood, Fla., October 24, 5966.
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Looff, D. H. Psychiatric perspective on poverty in America: subsidiary review of mental health problems in Eastern Kentucky. In T. Weaver and A. Magid (Eds.), Interdisciplinary Perspectives on Poverty in America. San Francisco: Chandler Publishing, in press. Millar, T. P. Psychiatric consultation with teachers. Journal of Child Psychiatry, ~966, 5, z, z34-z44. Schwarzweller, H. K., and Brown, J. S. Education as a cuhural bridge between Eastern Kentucky and the Great Society. Rural Sociology, x962, 27, 4, 357-373. Weller, J. E. Yesterday's People. Lexington: University of Kentucky Press, z965.
Center for Psychological Studies Established Wayne State University has announced the formation of a Center for Psychological Studies of Dying, Death and Lethal Behavior. Organized as a unit of the Department of Psychology, the interdisciplinary center will undertake research, and correlate and distribute information on death and lethal behavior. Further information is available from Dr. Robert Kastenbaum, director, 42o Mackenzie Hall, Wayne State University, Detroit, Mich. 48202
