Children and Paraservices of the Community Mental Health Centers
Paul L. Adams, M .D.
A friend who was not given to hyperbole, but driven to it after her experiences in a supposedly child-oriented center in the slums of a southern metropolis, told me, "Children are the parapeople-the recipients of paraservices , assigned to paraprofessionals, and always reached indirectly, through parents , through teachers, through pediatricians, through courts, through anyone except children themselves ." My own impressionistic observations, made in numerous and var ied encounters with community mental health and mental retardation centers, I led me to concur with my friend that ch ild re n' s services are frequentl y token services, sham services, or, at best, indirect services and " paraservices." When the people who staff CMH/MRCs think of doing something for children, they quickl y resort to paroseroices, namel y, indirect approaches, and to verbal appeals in the name of the family system or of education, prevent ion , research, or consultation. This is not to say that so me CMH/MRCs do not provide worthwhile direct services to yo u ng people. Some do, but man y do not; and those centers which do not will often make vag ue claims of doing things on behalf of yo un g people. but the evidence they proffer is evidence of the paraservices they furnish . Since accessory services or "almost" services, herein called paraservices, are so frequentl y held up as the CMH/MRCs' longlasting contribution to children's mental health, it becomes admissible that we attempt to find out what they have contributed to date to our general knowledge (e.g., through research) about child re n and their mental health or illness. Furthermore, since consultation, prevention, and public education are frequently the o n ly ingredients D ,.. Adams is P rojessnr of Psychiat r», Ullil 'rnily of Louin -ill» S rho»! l.ouisuillr, K.\'. -/020 I , I Subsequenilv referred 10 as C M H /~I RCs.
18
of Mediri nr,
Box 1055,
Children and Paraseroices of the CMHCs
19
of centers' children's programs, it behooves us to try to see what their overall contribution has been in that paraservice realm. Glasscote et al. (1972) found that the seven principal types of preventive efforts that engaged their respondent CMH/MRCs were, in decreasing frequency (as shown in parentheses), "Lectures, seminars, courses, group discussions regarding child rearing and development, family life, sex education, 'marital enrichment,' etc. (24); Parents groups . . . (15); Speakers for a broad variety of groups, such as the Parent-Teachers Association, service clubs, church groups, child-study clubs, etc., on a broad variety of topics (15); Consultations to teachers and other school personnel (14); Drug education programs, mostly for students (13); Seminars and courses for expectant mothers (9); Seminars and courses for mothers of newborn children (8) . . ." (p. 49). The CMHCs reported 19 other types of preventive programs, but each by only a few centers; the programs ranged widely from baby-sitting courses to coffee-houses, worry clinics, and radio broadcasts. For Glasscote and his colleagues, the easy way to enumerate modes of "primary prevention" was to separate them from and contrast them with all therapeutic and remedial work done in a CMHC. Following the same uncomplicated course, Sheldon and Dolby (1971) wrote, "The functions of a community mental health center are twofold-education and treatment. The basic educational activities include: the training of a large number of volunteers to work directly with patients; helping the community understand the etiology and symptoms of mental illness; educating the community to accept and live with people who traditionally have been 'sent away' to state hospitals" (p. 34). We shall undertake to elicit some further information about consultation and research programs in CMH/MRCs. CENTERS MAKING IT IN A NONWELFARE SOCIETY
By 1970 there were 206 federally assisted CMHCs in operation throughout the United States. If each of these were to serve a catchment group of 250,000, only a total of 51.5 million people would be served." The Joint Information Service (Glasscote et al., 1972) attempted to poll these centers in 1970 and found that, of the 135 responding, only 16 percent had been in existence as complete CMHCs for more than three years, and half of them had been in existence for two years or less. Patently, the CMHCs are 2 By 1972. the number seemed to have grown to 228 (Silber. 1972). Using the same form~lla of I :250.000. we get a total of 57 million persons potentially served.
20
PauL L. Adams
not widespread, not a firmly fixed part of a nationwide net of human services, and not an important resource for young people (Koret, 1973). Their place of emphasis among child psychiatrists and others has been out of proportion to their actual numbers and their actual programs for children. The CMH/MRCs have had to fight to get established, to stay alive, and to develop. Few states, even by 1974, found their entire population blanketed by CMH/MRCs. The geographic distribution of centers is astonishing, moreover, because there is no strong correlation with urbanism, levels of prosperity, or other sociocultural circumstances. For example, Kentucky, it is frequently alleged, although poorer than average, was the first of the 50 states to deploy its funds in such a manner that every catchment group throughout the entire state was furnished with a CMH/MRC. Silber (1974) attributed that specific state's good fortune largely to its alert and talented "centralized technical assistance service," allowing each of the state's 22 CMH/MRCs to obtain funds from an average of 25 different sources. The origination and continuance of a community center is a precarious matter. The CMH/MRC shares many of the sociopolitical risks of any other human service project in the present dispensation with which we are faced in North America. Austin (1969) drew close analogies between antipoverty programs and the CMH/MRCs, and declared that the CMHCs are constrained to make adaptations and adjustments that consume much effort, especially in their beginning epoch. Austin traced a pattern of development in which the first phase is devoted to the center's fighting for its survival. He wrote that, "the factors of survival and legitimacy plague the initial phase, with program rationality and hopefully maturity found in the second phase" (p. 163). The thesis advanced by Austin presupposed that the average CMH/MRC gets engrafted onto local regions, that some resistance occurs from preexisting agencies, but that there results a winning over and, ultimately, an accommodating survival when the center staff has proved that it can fit in, and might even be useful to deliver more abundant services. For Austin's posited Phase I, prevention, research, consultation, training, and education are soft-pedaled. Only in Phase 2 is it safe to bring forth the original purposes and goals of the CMHC-including "more comprehensive and coordinated services to a geographically or functionally defined segment of the population, e.g., a neighborhood or children" (p. 161). The phasing suggested by Austin was a characteristic one for both antipoverty projects and for CMH programs. It was a style of acting now
Children and Para sennces ofthe CM HCs
21
and programming later on. Over and over, in recent yeal 's numerous spokesmen have emphasized the comparison of child mental health to antipoverty projects. Hetznecker and Forman (1971), among many others, made a plausible case for the common parentage of concerns for community child psychiatry, ra cial justice, economic changes, and other institutional reformations . In my opinion, Austin 's thoughtful exposition is an accurate statement of an existent developmental sequence , but I suspect that his account is applicable only to a "nonwelfare so ciety" where new programs emerge without a background of careful planning and where so many services originate as novel and faltering implants. Such implants have to struggle for survival and legitimacy within the established community system, for it is not given them to be well-supported upsurges or ground swells from within communities traditionally committed either to rational planning or to valuing and diligently promoting human welfare. The notion is intriguing, that there are parallels between CMH/MRCs and the short-Iived antipoverty programs of the I960s of Presidents Kenned y and Johnson . That the parallel is not complete (witness the greater durability of the CMH/MR programs as compared to antipovert y ones) has prompted considerable speculation that the MHC movement owes its greater acceptability to its being so much more congenial to the status quo than, for example, the community action programs against poverty . Radical critics, such as those who used the forum of Radical Them/Jist (Talbott, 1974) , attacked the "mental health establishment" of the CMH /MR variety 3 as much as they did the private practitioner, and those critics were particularly vocal against eM H consultations to schools and to police and yo u th correctional people. Such consultations, according to the radical spokesmen, were "co p-o u ts," e xe m p lifying a rhetoric of distrust that wa s well depicted by H irs ch (1974), for they did not (said the radicals) get to the roots of mental distress, namely, the society. Those who are more agreeable than the radical therapists might choose to rephrase the commentary, and to speculate in alternative terms, such as: The mental health movement was better conceived, connected, planned, manned, and more timely, then was a war against poverty in predominantl y capitalistic so ciety. Two facts remain, though. One is that the ce n te rs are not well favored, either by government or by private philanthropy (Silber, 1972). Another " Va lll{ha n e t al. (197:1) demonst rated that private prartiuoners themselves G ill co nd uc t a first-ra te CM HC if condition » are fa,'ora")e. Oz arin a nd Spane r :\h:NTAL HEALTII OF CIIII.IIRE:'> (197:~), The Mental Health 01 Children: ,)/'/1'iCI',I, Hrsearrh, and Alall!HIllIer. New York: Harper & Row. KOIlLER, ~1. (1971), The rights of children: an unexplored consuruenrv. ,)01'. Potu», 1::16-4:1, KORET, S. (\ 97:~), The children's community mental health center emerges. Child Psschiat. HUIII. Develpm., :~:24:~-2;'·1. Kiau; L. S. (1971), The retreat from patients: an unanticipated penalty of the full-time system. Arch. Cell. Psschiat., 24:9~I06. MARtE:'>, ~1. (1971 l, -Beyond credentialism: the future of social selection Soc. Policy, 2: 14-21. OZARIN, L. D. & SPANt:R, F. E. (\974), Mental health corporations. Hosp. COlli';'. Psschiat. 2;':22;'-227. PANZETTA, A. F" SLOANE, R. B., & ARONSO:'>, H. (197:~), A survev of attitudes of chairmen of departments of psychiatry toward community mental 'health. A 1111'1'. I Psvrhiat., isn. 17;'-17H. PASAMANICK, B (1972), Some comments on research in a state department of mental hYJ,(iene. Psvchiat. Quarl., 46:2:19-25:1. St:I;AL,.J., ed. (1971), The Mmtat Health of the Child: PropWII Re!JOr/1 ojthe National I nstitute 01 Menta! Hl'llllh. WashinJ,(ton, D.C.: U.S. (;o\,ernmelll Printing Office (PHS #216H). Sm:ALY, A. E. & WRIl;lfT, P. (1972), A state-wide epidemiological assessment of the effectiveness of community mental health sevvices.], Clin. Psschol., 2H:109-111. Sm:LlloN, R. & DOLBY,.J. (1971), Community mental health centers: fact and liction. Psvchiat. Opinion, H(ll)::H-:n. SII.BER, S. C. (1972), Private philanthropy: an untapped source for supportiug mental health proJ,(rams. Ho,p. COIIIIII. Psvchiat., 2:~: 1:n-I :~H. - - - (1974), Strategies for developing multisource funding I(Jr communirv mental health renters. Hasp. COlli III. Psvrhiat., 2;':221-22;'. SWAN:'>, T. R. (1972), Treauneut as a conununitv function and the responsibilitv of the mental health center as a community resource (Sununarv of Workshop). A III 1'1'. Orthopsvchiat. A,,". Nrtoslrttrr, l ti: lfi. SZASZ, T. S. (\ 970), Id,'olog)' and lnsanitv. New York: Doubleday Anchor Books, chap. II. TALBOTT,.J. A. (\974), Radical psychiatry.AIIIPr.I Psxchiat., 1:~1:121-12H. TOWNSEL, L. E., IR\'IN(;,.J., & STROO, H. H. (1974), Mobile Consultation: All l ntegratnie Approarh 10 Mmtal Health Sen lice/or Children, Columbus, Ohio: Child Mental Health Center.
Children and Paraservices of the CMHCs TRUAX, C. B. & LISTER, J. 1.. (1970), Effectiveness of counselors and counselor aides). srl. PI)·c/IOI.,
31 COIllI-
17:3:H
Paul L. Adams, M .D.
A friend who was not given to hyperbole, but driven to it after her experiences in a supposedly child-oriented center in the slums of a southern metropolis, told me, "Children are the parapeople-the recipients of paraservices , assigned to paraprofessionals, and always reached indirectly, through parents , through teachers, through pediatricians, through courts, through anyone except children themselves ." My own impressionistic observations, made in numerous and var ied encounters with community mental health and mental retardation centers, I led me to concur with my friend that ch ild re n' s services are frequentl y token services, sham services, or, at best, indirect services and " paraservices." When the people who staff CMH/MRCs think of doing something for children, they quickl y resort to paroseroices, namel y, indirect approaches, and to verbal appeals in the name of the family system or of education, prevent ion , research, or consultation. This is not to say that so me CMH/MRCs do not provide worthwhile direct services to yo u ng people. Some do, but man y do not; and those centers which do not will often make vag ue claims of doing things on behalf of yo un g people. but the evidence they proffer is evidence of the paraservices they furnish . Since accessory services or "almost" services, herein called paraservices, are so frequentl y held up as the CMH/MRCs' longlasting contribution to children's mental health, it becomes admissible that we attempt to find out what they have contributed to date to our general knowledge (e.g., through research) about child re n and their mental health or illness. Furthermore, since consultation, prevention, and public education are frequently the o n ly ingredients D ,.. Adams is P rojessnr of Psychiat r», Ullil 'rnily of Louin -ill» S rho»! l.ouisuillr, K.\'. -/020 I , I Subsequenilv referred 10 as C M H /~I RCs.
18
of Mediri nr,
Box 1055,
Children and Paraseroices of the CMHCs
19
of centers' children's programs, it behooves us to try to see what their overall contribution has been in that paraservice realm. Glasscote et al. (1972) found that the seven principal types of preventive efforts that engaged their respondent CMH/MRCs were, in decreasing frequency (as shown in parentheses), "Lectures, seminars, courses, group discussions regarding child rearing and development, family life, sex education, 'marital enrichment,' etc. (24); Parents groups . . . (15); Speakers for a broad variety of groups, such as the Parent-Teachers Association, service clubs, church groups, child-study clubs, etc., on a broad variety of topics (15); Consultations to teachers and other school personnel (14); Drug education programs, mostly for students (13); Seminars and courses for expectant mothers (9); Seminars and courses for mothers of newborn children (8) . . ." (p. 49). The CMHCs reported 19 other types of preventive programs, but each by only a few centers; the programs ranged widely from baby-sitting courses to coffee-houses, worry clinics, and radio broadcasts. For Glasscote and his colleagues, the easy way to enumerate modes of "primary prevention" was to separate them from and contrast them with all therapeutic and remedial work done in a CMHC. Following the same uncomplicated course, Sheldon and Dolby (1971) wrote, "The functions of a community mental health center are twofold-education and treatment. The basic educational activities include: the training of a large number of volunteers to work directly with patients; helping the community understand the etiology and symptoms of mental illness; educating the community to accept and live with people who traditionally have been 'sent away' to state hospitals" (p. 34). We shall undertake to elicit some further information about consultation and research programs in CMH/MRCs. CENTERS MAKING IT IN A NONWELFARE SOCIETY
By 1970 there were 206 federally assisted CMHCs in operation throughout the United States. If each of these were to serve a catchment group of 250,000, only a total of 51.5 million people would be served." The Joint Information Service (Glasscote et al., 1972) attempted to poll these centers in 1970 and found that, of the 135 responding, only 16 percent had been in existence as complete CMHCs for more than three years, and half of them had been in existence for two years or less. Patently, the CMHCs are 2 By 1972. the number seemed to have grown to 228 (Silber. 1972). Using the same form~lla of I :250.000. we get a total of 57 million persons potentially served.
20
PauL L. Adams
not widespread, not a firmly fixed part of a nationwide net of human services, and not an important resource for young people (Koret, 1973). Their place of emphasis among child psychiatrists and others has been out of proportion to their actual numbers and their actual programs for children. The CMH/MRCs have had to fight to get established, to stay alive, and to develop. Few states, even by 1974, found their entire population blanketed by CMH/MRCs. The geographic distribution of centers is astonishing, moreover, because there is no strong correlation with urbanism, levels of prosperity, or other sociocultural circumstances. For example, Kentucky, it is frequently alleged, although poorer than average, was the first of the 50 states to deploy its funds in such a manner that every catchment group throughout the entire state was furnished with a CMH/MRC. Silber (1974) attributed that specific state's good fortune largely to its alert and talented "centralized technical assistance service," allowing each of the state's 22 CMH/MRCs to obtain funds from an average of 25 different sources. The origination and continuance of a community center is a precarious matter. The CMH/MRC shares many of the sociopolitical risks of any other human service project in the present dispensation with which we are faced in North America. Austin (1969) drew close analogies between antipoverty programs and the CMH/MRCs, and declared that the CMHCs are constrained to make adaptations and adjustments that consume much effort, especially in their beginning epoch. Austin traced a pattern of development in which the first phase is devoted to the center's fighting for its survival. He wrote that, "the factors of survival and legitimacy plague the initial phase, with program rationality and hopefully maturity found in the second phase" (p. 163). The thesis advanced by Austin presupposed that the average CMH/MRC gets engrafted onto local regions, that some resistance occurs from preexisting agencies, but that there results a winning over and, ultimately, an accommodating survival when the center staff has proved that it can fit in, and might even be useful to deliver more abundant services. For Austin's posited Phase I, prevention, research, consultation, training, and education are soft-pedaled. Only in Phase 2 is it safe to bring forth the original purposes and goals of the CMHC-including "more comprehensive and coordinated services to a geographically or functionally defined segment of the population, e.g., a neighborhood or children" (p. 161). The phasing suggested by Austin was a characteristic one for both antipoverty projects and for CMH programs. It was a style of acting now
Children and Para sennces ofthe CM HCs
21
and programming later on. Over and over, in recent yeal 's numerous spokesmen have emphasized the comparison of child mental health to antipoverty projects. Hetznecker and Forman (1971), among many others, made a plausible case for the common parentage of concerns for community child psychiatry, ra cial justice, economic changes, and other institutional reformations . In my opinion, Austin 's thoughtful exposition is an accurate statement of an existent developmental sequence , but I suspect that his account is applicable only to a "nonwelfare so ciety" where new programs emerge without a background of careful planning and where so many services originate as novel and faltering implants. Such implants have to struggle for survival and legitimacy within the established community system, for it is not given them to be well-supported upsurges or ground swells from within communities traditionally committed either to rational planning or to valuing and diligently promoting human welfare. The notion is intriguing, that there are parallels between CMH/MRCs and the short-Iived antipoverty programs of the I960s of Presidents Kenned y and Johnson . That the parallel is not complete (witness the greater durability of the CMH/MR programs as compared to antipovert y ones) has prompted considerable speculation that the MHC movement owes its greater acceptability to its being so much more congenial to the status quo than, for example, the community action programs against poverty . Radical critics, such as those who used the forum of Radical Them/Jist (Talbott, 1974) , attacked the "mental health establishment" of the CMH /MR variety 3 as much as they did the private practitioner, and those critics were particularly vocal against eM H consultations to schools and to police and yo u th correctional people. Such consultations, according to the radical spokesmen, were "co p-o u ts," e xe m p lifying a rhetoric of distrust that wa s well depicted by H irs ch (1974), for they did not (said the radicals) get to the roots of mental distress, namely, the society. Those who are more agreeable than the radical therapists might choose to rephrase the commentary, and to speculate in alternative terms, such as: The mental health movement was better conceived, connected, planned, manned, and more timely, then was a war against poverty in predominantl y capitalistic so ciety. Two facts remain, though. One is that the ce n te rs are not well favored, either by government or by private philanthropy (Silber, 1972). Another " Va lll{ha n e t al. (197:1) demonst rated that private prartiuoners themselves G ill co nd uc t a first-ra te CM HC if condition » are fa,'ora")e. Oz arin a nd Spane r :\h:NTAL HEALTII OF CIIII.IIRE:'> (197:~), The Mental Health 01 Children: ,)/'/1'iCI',I, Hrsearrh, and Alall!HIllIer. New York: Harper & Row. KOIlLER, ~1. (1971), The rights of children: an unexplored consuruenrv. ,)01'. Potu», 1::16-4:1, KORET, S. (\ 97:~), The children's community mental health center emerges. Child Psschiat. HUIII. Develpm., :~:24:~-2;'·1. Kiau; L. S. (1971), The retreat from patients: an unanticipated penalty of the full-time system. Arch. Cell. Psschiat., 24:9~I06. MARtE:'>, ~1. (1971 l, -Beyond credentialism: the future of social selection Soc. Policy, 2: 14-21. OZARIN, L. D. & SPANt:R, F. E. (\974), Mental health corporations. Hosp. COlli';'. Psschiat. 2;':22;'-227. PANZETTA, A. F" SLOANE, R. B., & ARONSO:'>, H. (197:~), A survev of attitudes of chairmen of departments of psychiatry toward community mental 'health. A 1111'1'. I Psvrhiat., isn. 17;'-17H. PASAMANICK, B (1972), Some comments on research in a state department of mental hYJ,(iene. Psvchiat. Quarl., 46:2:19-25:1. St:I;AL,.J., ed. (1971), The Mmtat Health of the Child: PropWII Re!JOr/1 ojthe National I nstitute 01 Menta! Hl'llllh. WashinJ,(ton, D.C.: U.S. (;o\,ernmelll Printing Office (PHS #216H). Sm:ALY, A. E. & WRIl;lfT, P. (1972), A state-wide epidemiological assessment of the effectiveness of community mental health sevvices.], Clin. Psschol., 2H:109-111. Sm:LlloN, R. & DOLBY,.J. (1971), Community mental health centers: fact and liction. Psvchiat. Opinion, H(ll)::H-:n. SII.BER, S. C. (1972), Private philanthropy: an untapped source for supportiug mental health proJ,(rams. Ho,p. COIIIIII. Psvchiat., 2:~: 1:n-I :~H. - - - (1974), Strategies for developing multisource funding I(Jr communirv mental health renters. Hasp. COlli III. Psvrhiat., 2;':221-22;'. SWAN:'>, T. R. (1972), Treauneut as a conununitv function and the responsibilitv of the mental health center as a community resource (Sununarv of Workshop). A III 1'1'. Orthopsvchiat. A,,". Nrtoslrttrr, l ti: lfi. SZASZ, T. S. (\ 970), Id,'olog)' and lnsanitv. New York: Doubleday Anchor Books, chap. II. TALBOTT,.J. A. (\974), Radical psychiatry.AIIIPr.I Psxchiat., 1:~1:121-12H. TOWNSEL, L. E., IR\'IN(;,.J., & STROO, H. H. (1974), Mobile Consultation: All l ntegratnie Approarh 10 Mmtal Health Sen lice/or Children, Columbus, Ohio: Child Mental Health Center.
Children and Paraservices of the CMHCs TRUAX, C. B. & LISTER, J. 1.. (1970), Effectiveness of counselors and counselor aides). srl. PI)·c/IOI.,
31 COIllI-
17:3:H
