Community Mental Health Centers and the Criteria of Quantity and Universality of Services for Children
Frank T. Rafferty, M.D.
Fifteen years ago it was popular to read and to hear of the failure of the child guidance movement, presumably after a 40-year life span. With life speeded up, the tenure of social movements may be shorter, since early obituaries arc announcing the critical, nearfatal sickness of the Community Mental Health Center, 1 after only 10 years. Fortunately, accuracy of obituaries of social movements is no more required than firmness of theoretical base to begin them (Rafferty, 1966). Service organizations and theories survive obituaries consistently; for example, state hospitals, psychoanalysis, private psychiatric practice. But whatever the state of vitality of the CMHC, it certainly has come to the end of a phase, of a period of development that was an exciting, frightening, satisfying, frustrating, infuriating, and illuminating period of psychiatric history. In reflecting on the fragmented choreographed interaction of the CMHC movement with the child mental health professionals, we observe one theme that appears to be central-the theme of quantity and scope of service. Clearly stated in CMHC guidelines, even if it was often circumvented in operation, was the assumption of responsibility to provide comprehensive service to a designated population defined by geographical boundaries. The responsibility and accountability for all types of mental health services needed by every kind of person in the specified population were the sine qua non of the CMHC idea. Although the child outpatient clinic, the child residential treatment program, and the private practitioner of child psychiatry Dr. Raffert." is Direct", of Institutefor Juvenile Research, Projrssor of Psychiatry. Abraham Lincoln School of Medicine, University of Illinois. Chicago, Illinois. Requestsfor reprint" should beforumrded to Dr. Raffnt)' at 907 Wolcott AVi'., Chicago, Ill. 60M2. I
Throughout this paper designated as eM He.
5
6
Frank T. Rafferty
never claimed to be comprehensive, it was nevertheless on the basis of this criterion that they were judged to be failures. The early 1960s marked a turning point in the national realization that a large segment of the population was not sharing in the American dream of individual economic independence, of a fair distribution of consumer goods, and of vertical mobility in a flexibly stratified society. All the established social institutions were indicted as failures: the schools, churches, families, social welfare organizations, legal services, the courts, health and mental health institutions. It is hard to remember, now, the unbridled optimism of the early 60s when there was an honest if naive expectation that money from a bountiful federal government could change the structure of poverty, of racism, of school failure, and of the delivery of health care. The CMHC was an early example of that effort: at least mental health services would be fairly and universally distributed. Fifteen years later, the child mental health institutions are still indicted on the charge that they serve a selected clientele. The best of the child professionals and elite of the organizations are for the most part still uncommitted to solving the problems of quantity and scope, or universality of service. A few urban or suburban areas may have reached a saturation point with private practitioners. A few states have widespread networks of excellent community-based clinics that still depend for the maintenance of their quality on a usually informal, sometimes invisible, filter system in referral of children, and a utilization rate below 2 percent. A few urban areas appear to have generated a complete blanket of CMHCs that have children's services of erratic quality. Some areas seem to have met their quantitative need for hospitalization of children and adolescents. A number of cities have at least one, occasionally two, major showpiece mental health programs, frequently university-affiliated. Many programs have at least one gem of a project that tauntingly promises to reach, to treat, and to manage a large or at least significant number of children, or to represent a new technique to manage a previously unmanageable problem category. THE PROCESS WHICH BUILDS IN FAILURE
There would appear to be little doubt, even without hard data, that nationally the child and adolescent mental health effort has increased significantly. Essentially this has been an expansion of the manpower, technology, and organizational system of the early 60s, without benefit of the wished-for revolution. For the most part, it
CMHC and Services for Children
7
has been an expansion without the comprehensive planning called for in the "planning for a plan" of the CMHC movement, nor the systematic restructuring of children's services imbedded in the report of the Joint Commission on Mental Health of Children (Visotsky et aI., 1973). The child mental health establishment abdicated that part of the expansion related to innovation in organization and technology. The vacuum was filled by personnel coming from diverse directions, but impelled by new belief systems such as the behavioral therapies, family therapy, encounter groups, crisis intervention, and the "hot line" youth for youth drug programs. These services, with the possible exception of crisis intervention, were informed neither by the developmental theories of child psychiatry nor by the nascent theories of community and social psychiatry. The energy, youthfulness, and abrasiveness of the social and clinical activism of the CMHC, combined with the undeniable inHuence of the funding procedure of NIMH, has to a great extent prevailed in numbers of personnel, programs, officially stated goals, and style, without actually destroying the central hard core of resistance by a sizable number of child mental health professionals, especially child psychiatrists whose training and experience cause them to avoid the activist CMHC. These clinicians cling stubbornly to hard-learned techniques of controlled individual or small group therapy with carefully selected patients in the context of an individually derived therapeutic contract. It is not an unusual scene for a child psychiatrist who basically is committed to careful individual treatment to act as a consultant to a CMHC. with both parties ignoring the philosophical disparity for different reasons. It is always difficult to evaluate the purely economic factor. Those more overtly hostile to child psychiatrists point out that it is the psychiatrist's desire to make money that causes him to avoid the salaried full-time position. Undeniably, the social worker and psychologist have been more dependent on salaried employment in the bureaucracy, and consequently the NIMH funding procedures influenced them more strongly to a conversion to the CMHC philosophy and style. The child psychiatrist has had an escape route in private practice modified by the economic parameters of his geographic locality. So here we are, 10 years later and still in the prelaunch period of comprehensive, universal services to children. Funding for service has gone through different forms, but has become increasingly public rather than private. Public funding, whether federal or state, increases the pressure for quantity and universality of ser-
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Frank T. Rafferty
vice. Public officials have grave problems justifying and rationalizing select or elite programs and frequently end up opting for no program at all. So the battle is joined between those public forces inchoately pressing for universal service-"whatever is needed for whoever needs it"-and the professionals who only slightly more articulately say we don't know how, more often saying it's not our problem; but hungering meanwhile for the public funds. National health insurance would appear to be the coming public trough; and characteristically it is immersed in massive technical, financial, and organizational problems totally removed from the issues presented by universal mental health services to children. This is a product of disillusionment. Government and the health establishment have failed to reorganize, redistribute, or to restructure health services, and now government seeks to organize first the financing, according to convenience of public funding, and to watch the chaotic, forced scrambling of the heretofore inert, resistant system. But what of some of the efforts made to meet the problems of quantity and scope in the past 15 years? Since no one appears to be proclaiming his success, can something be learned from the interesting failures? The following are only examples of what has occurred in many locales. For a few years it looked as if there would be a system of universal day care for all children who needed it. Preschool day care was especially interesting to the mental health field. Not only was there the opportunity to provide care for children whose parents were working, but there appeared to be the opportunity for real prevention of a variety of behavior disorders secondary to school failure, and even for group treatment of disordered behavior in the preschool child. The input of several years of group day care, 3 to 10 hours per day, the corrective and enriching experience of professionally led small groups of children, the opportunity for parental support, education, and treatment seemed to present a solution to a number of serious problems in the organization for delivering mental health services. The child psychiatric program at the University of Maryland had the opportunity in the early 1960s to participate deeply in the Day Care and Child Development Movement. Prior to the federal program of Head Start, the Baltimore School System had initiated a full year of school for 4-year-olds, called Early Admission. Also, the Department of Public Welfare had initiated a pilot comprehensive day care center in a housing project, Westport. In each of these programs, the administration initially recognized the crucial dif-
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9
ferences between kindergarten, nursery school, or proprietary day care, and the new concept of a comprehensive child development center. The latter, of course, involved changing one-disciplineoriented programs to accommodate informed techniques from health, mental health, and child development. Initially, about 40 to 60 children were involved in each program. Personnel consisted of child care workers, trained early education teachers, a social worker experienced in the health and mental health concerns of children and families, pediatric and public health nurse services, along with 8 hours per week of child psychiatric time. Unfortunately, even in those relatively uninflated times, the cost was approximately $2,000 per child per year. But the potential benefit appeared substantial. From the child psychiatric viewpoint there were enormous advantages. Preschool children could be observed, developmental strengths and vulnerabilities assessed, and interventions made without labeling the child, stigmatizing the family, or removing the child from the mainstream of child-caring institutions. The experience could be individualized to accommodate a wide range of problems, including the autistic and psychotic child, the mild to moderate retarded, those with speech, language, and specific learning disabilities, the behavior disorders, and the unsocialized. With small groups and adequately skilled personnel, the disordered child could be accommodated well in the group, and the developmental center could forego making referrals to other institutions. Although formal CMHC guidelines did not include or even suggest such treatment institutions, child development centers were exemplary of the best of community mental health theory and practice. It is necessary, though, to report what happened over the next 10 years. The Early Admission program expanded from 60 to 1,400 children. The Day Care and Child Development program expanded from 40 to 4HO with a mel'ger into Head Start. For a while, personnel, technological, and organizational aspects kept pace with the expansion. Leadership of the major educational, social service, health, and mental health componenls remained t he same, yet gradually became diluted beyond any effective implementation. It is not the same task to organize, staff, direct, and supervise 4 one-half-day classrooms of 15 children each in 2 schools and to organize, staff, direct, and supervise 70 classrooms of 20 children each in 25 schools. So many child mental health personnel have participated in this kind of debacle that we are reluctant to be banal, except that the dissolutions and failures have not been written of often in the professional literature.
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Frank T. Rafferty
The erosion process, though scarcely perceptible and administratively rationalized, is nevertheless obvious and devastating. A unit director is put in charge of two units. The social worker responds unselfishly to the request to cover a one-third larger caseload. No teacher with early child education training and experience is available, so a fourth-grade teacher is put into the vacancy. Involvement with parents and their participation in daily programming is attenuated because no one has the time to bring them along. Physical space and equipment are stretched beyond reasonable constraints. Soon the disordered child is the source of anxiety, arousing doubts in personnel of their competency to cope, and inevitably raising the question of referral to some other program "that can give him better, more appropriate service." Mental health personnel erodes with the rest. In the beginning we settle for only the best with close supervision for a really substantial program input; contact with and knowledge of each child; support, education, and collegiality of staff, which ranged from teachers and child care workers to cooks; program consultation to administration; and with trainees. But even a major increase in personnel is not able to meet the pressure for number of man-hours so that those of relatively less competency and peripheral commitment are involved. Concomitantly, the economic pressures reduced psychiatric inputs from 8 hours per week per center to 4 and then to 2, of necessity reducing the technical significance of participation. And all those even peripherally involved will recall with shudders of horror the vagaries of administrative and program support that day care and child development centers have gone through from federal and state government. There were the shifting and turnings of Head Start policy; the in and out of community action programs; the strivings for control of local, state, and federal agencies; the frequent changes in monitoring personnel; the ever-contracting Aexibilities in funding, and the promise and unfulfillment of programs like the 4C's (Community Coordinated Child Care). One of the most shattering of experiences, not limited to day care, is watching the phenomenon of the executive branch of the federal government mutilate a program at the height of public interest and support. There is a temptation to think of this as unique to the change in philosophy and personnel brought about by the 1968 national elections; but experience over a period of years with a variety of programs and with oneself as an administrator is strongly convincing that administrative and public support are analogous, not to rockribbed mountains, but to shifting sand dunes, and at times even to
CMHC and Seroices for Children
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the surf on a Hawaiian beach. Unfortunately, the closer one gets to public programs, and thus the political process, the more uncertain the dunes and surf. Can awareness of these realities be built into rational planning of human services, or must we be continually buffeted and surprised by the dynamics of the social and political process? CONSULTATION PUT TO THE TEST
But let us return to the core task of this paper, evaluating the technology, manpower, and organizational tactics of child psychiatry and of community mental health by the criteria of quantity and scope of service. One of the most fascinating, promising, and promoted technologies of the CMHC was consultation. The technique was not invented by the Community Mental Health Act, nor even by one person, and certainly not in the 1960s; it had evolved independently in a number of places, had been shaped by many practitioners, and had been utilized in a wide variety of agencies. But it was the CMHC legislation that canonized consultation as one of the five required services and submitted it to the tests of quantity and scope. To a major degree, it was the technique of consultation that gave substance to the expectation of success for the CMHC to serve the total population of a catchment area. The constraints of time, manpower, and training on direct service were appreciated, but by consultation or indirect service all other agencies-industry, welfare, general medicine, schools, housing projects, recreational facilities, law enforcement, churches, etc.-were to be converted to auxiliary mental health facilities. It was here that the siren lure of "community" was most seductive. Social psychiatric theory and data established that some social and economic structures, cultural patterns, and institutional organizations contributed positively or negatively to mental illness and/or mental health. Consultation was the instrument to convert the noxious institutional structure to a positive influence. Child psychiatrists have reported formally and informally on successful consultative experiences with schools, well-baby clinics, pediatric wards, special education programs, prisons, training schools, juvenile courts, residential treatment centers, orphanages, welfare departments, law enforcement agencies, family service agencies, day care centers, city and state governmental bodies, the Peace Corps, Vista, dental and law schools, and industry. In one instance of school consultation, School 95 in Baltimore became a thoroughly converted, positive mental health institution while ful-
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Frank T. Rafferty
filling its role as an all-black, poverty area ghetto school. Techniques to assess the developmental and social strengths and vulnerabilities of every child in school, and the ability to individualize instruction on the basis of this information, were demonstrated (Mackie et aI., 1967). Changes in educational philosophy, teacher attitudes, organization of pupil personnel services, size of class, utilization of teacher assistants, involvement of ghetto families, major changes in curriculum, class grouping, language programs, and reading were accomplished as well as stimulating and participating in changes of size of school, class size, personnel staffing. All children were contained in the school with a minimum of special classes, including children who were comparable to those in child psychiatric inpatient facilities. However, consultation failed when tested on quantity and scope. Just as the private psychotherapist achieves elegant success by a selection (perhaps informally and unwittingly) of patients appropriate for his technique, the consultant achieves impressive results when there is a happy congruence of the right child psychiatrist, the cooperative school system, the receptive principal, the welltrained staff, the available parents, and adequate financing for required manpower. The CMHC requires that every school district, every school in the district, every principal and teacher, every family and every child be served well by the mental health manpower available. In the example cited above, the project was initiated with two schools adjacent to the psychiatric facility and by the same techniques. The principal of one school simply could not support and sustain the changes and differentiation of his school within the system. He lived in constant fear and trepidation that headquarters would disapprove of the curriculum changes, of pupil discipline, of teacher participation in the program. This was probably without real grounds in this particular school district, in which principals were accorded tremendous autonomy, flexibility, and even budgetary control. The superintendent frequently complained that principals would not use the authority and autonomy given to them. But (to illustrate the complexity of public school systems) there may have been countervailing messages from assistant superintendents. In any event, the principal who did participate over a period of five years after her colleague opted out acquired considerable prestige and status within the system for the innovation. To continue with this example of the test of technology by quantity and scope, the original consultant team consisted of substantial portions of three professionals' time. As the 100 or so children of
CMHC and Seroicesfor Children
13
each kindergarten class were added, soon the number of children involved was over 400. Testing and observing children, interviewing parents, ordering data, feeding back information to teachers, managing crises, and carrying a relatively few individual cases had doubled the personnel time. As the negative effects of language problems in black children came to the fore, several specialists in speech and language pathology were added; furthermore, personnel had to acquire expertise in the Initial Teaching Alphabet reading system, which had not been systematically studied in black ghetto children. Finally, over ten mental health professionals plus trainees were involved. Reduction of class size and addition of teachers' assistants in the classrooms evolved as absolutely essential inputs from the school system. Fortunately, and unfortunately not repeatable in subsequent systems and times, the Federal Title I funds were at their peak flowing into the urban school systems, and School 95 was designated a model school with a reduction of population from 650 to 350, with class size reduced to 24, a teacher assistant in every classroom, a half-time psychologist, a full-time social worker, and nurse added to the school staff. But the expansion of service, the innovations in technology, the utilization of educational personnel were built on a house of cards. Compulsory retirement of the principal was a severe, yet not fatal blow. Funding needed to expand if service was to be extended to other schools; but certainly, the current level of funding had to be maintained. Interestingly, in the wisdom of a NIMH Study Committee, the project was not approved for funding because it was not innovative and represented only the practices present in all schools. However, the Grant Foundation was quite willing to fund the work as a research project. Unfortunately, research projects have goals different from service projects, and the end came into sight. When the project director moved to another city, another catchment area, and another school system, the fragile ecology of the techniques becomes apparent. The new, culturally embattled system, embroiled in politics, union conflicts, continuously on the defensive, with large deteriorating physical plants, provides few schools interested in and capable of developing the kind of partnership described above. Similarly, a child psychiatric service in the State Department of Mental Health, enduring the basic mistrust of the poor population of the catchment area, struggling with the emerging philosophical conflicts in psychiatry, and threatened by loss of training and research funding, is not capable of implementing the sophisticated, expensive procedures for that catchment area. At best, the schools are able to receive and utilize a comparatively un-
Frank T. Rafferty
14
complicated form of case consultation. Consultation, like psychotherapy, works effectively when the participants are not struggling with survival issues, and when the institutional analogues to ego strength are present. THE RHETORIC OF PREVENTION
One particular intellectual gambit has become commonplace when speaking of children and is frequently and inaccurately paired with the children's service of the CMHC. When someone has become enough aware of the impossibility of expanding current technologies, manpower, and organizations to meet the needs of comprehensive and universal mental health services, he frequently turns to the rhetoric of prevention. Some people even speak of prevention when talking in general about the child mental health services as if they were the same, and ignoring the fact that to prevent is a transitive verb, and requires precise delineation of what is being prevented by what specific set of operations. In absolute number, so few individual children are being treated effectively by present methods that the incidence or prevalence of any significant condition in a future population of adult or adolescents is certainly to go unaltered, even if the childhood condition is a true progenitor of the later condition. This statement must not be used to denigrate the personal, existential, and humanistic value of treating individual children. It simply suggests that programs of treatment of children not be sold on the basis of prevention, and, conversely that prevention not be sought by the treatment of individual children. With reference to the prevention of mental illness in children, it becomes apparent that relatively few conditions of behavioral deviance can meet criteria of the disease model, e.g., a differentiated etiology, specific expressive signs and symptoms, a characteristic pathology, specific treatment, and prognosis. More frequently, the phenomena are better conceptualized as individual variations from the developmental standards; or as long-standing patterns of adaptation to less than optimal economic, social, or interpersonal environments, or patterns of interaction of the individual variability with the interpersonal and political process that determines status in the social structure. Whatever the conceptualization, however, the transactional antecedents of behavioral deviance in children are seldom within the professional purview of psychiatric personnel, certainly not in significant numbers, and basically not under the mandate of CMHCs.
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ORGANIZATIONAL WORKING RELATIONSHIPS
Taking note of a few outstanding exceptions, we must observe that the child psychiatric establishment and the CMHCs have been extraordinarily and reciprocally wary in their approach-avoidance behavior. Perhaps the existence of the free-standing outpatient child clinic in many communities provided a pseudomutual escape for both parties. The CMHC could contract with the child clinic for service and thus satisfy the not too precisely monitored requirements of the NIMH for comprehensiveness, and the child clinic could equally tentatively participate in the tempting funding and not really alter its operations. This was a most popular solution, providing protection for the territorial concerns of both sides. Part of the concerns of the child institutions was that a sizable segment of child mental health professionals were already using the various technical procedures that were being trumpeted as new and expected to be comprehensive for the CMHC. These included working in multidisciplinary teams, consultation and community education, community boards, and working with the system rather than the patient, as in family therapy . It is important to recognize that not only had this group of child mental health professionals been involved with these techniques for some years and thus felt territorially trespassed when others discovered them, but in a perhaps inarticulate and intuitive way. many had a thorough awareness of the limitation of theory and practice. So there was a conservatism in the ambitions and claims, a rigor in the selection of patients, and a meticulousness of application that became antithetical to the ambience of the CMHC. The goals of a comprehensive. universal mental health service available to everyone who needed it not only demonstrated great gaps in technology, organization, and manpower, but unceremoniously activated the unresolved philosophical, professional, and political question of "what is mental illness?" When the clientele of mental health services were either a sophisticated, select segment prepared to seek out voluntarily and to pay [01' their own service, or a neglected, alienated, rejected, and forgotten population that society was fully prepared to have stored away, the concern with defining mental illness was strictly academic and stirred little passion in people's hearts . But when everyone in the community was to be involved in some way, and perhaps be subject to efforts to change attitudes about mental illness, then the definition becomes acutely personal. Many of the presenting problems of definition are primarily of forensic or legal interest, but for children's
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Frank T. Rafferty
services the definition of mental illness will determine which bureaucratic agency will be responsible, how funds will be distributed, and which professional dis cipline will receive the mandate to care for the mentally ill or behaviorallv deviant. If a particular cluster of phenomena in children can be defined as mental illness, then th e medical insurance should pa y for its treatment at the eM He. I I' a constellation of symptoms in children can be defined as mental illness. then the educational agency. the child care agency. or the correctional institutions can, with some reasonableness, seek to tr ansfer the child to the community mental health clinic. However, the overworked personnel at the underfunded community mental health facility are equally desperately looking for ways to keep the child in his own home, school. or other institution and do so by denying the specific mental illness component, while emphasizing the educational or child care components. These questions and many more are usually precipitated by a specific case and involve only a few personnel from different agencies, but they are substantive questions about how to manage the enormous number of behaviorally deviant children. Those who ultimatel y must make de cisions about funding and organization of services apparentl y prefer to scapegoat the personnel of the agencies. to argue about accountability and responsibility, to split hairs about definition, or to philosophize on the dangers of labeling, rather than to confront themselves and the voting public with the actual numbers, varieties, and realities of deviance. COMMENT AND SUMMARY
That the CMHC has had an impact on child mental health is undeniable . but the evaluation of a national social movement is at least as subjective as the evaluation of individual psychotherapy. Things have changed; the number of personnel involved in the child mental health system has certainly increased several times, while the kind of personnel involved has multiplied, as have the settings for service. At the same time, the dogmas presumably guiding the operations have proliferated. The general public has become more involved in child mental health . But how do we assess the specific impact of the CMHC program. especially when more powerful social and economic forces were at work, the directions , effects, and magnitudes of which were only dimly anticipated by framers of the Community Mental Health Act? Who among those influencing and preparing President Kennedy's message to Congress anticipated his precipitous assassination , the style and results of the Civil
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Rights movement, the tragic mistaken commitment in Vietnam, the massive social legislation of President Johnson, the political polarization and radicalization of some segments of the society, the inflationary process of guns and butter, the anti psychiatry effects of the denial of legitimacy of authority, of the Civil Liberties movement, the continued failure of the educational institutions, and so forth? In many respects, the development of the CMHC has been itself a victim of these powerful oceanic swells in the national matrix of life, demanding the attention of the electorate and of government. In summary, we have pointed out that a central feature of the CMHC was comprehensive care of a geographically defined population, and that this mandate presented the task of delivery of service to a quantity of children with a range of problems far beyond existing technological competence, manpower resources, and organizational capacity. Not only did the CMHC movement fail to generate the necessary theoretical, technical, and organizational innovations, but it has failed thus far to win the loyalty of the child psychiatric establishment. The child mental health specialist found numerous reasons to avoid commitment to the CMHC and to the problems of quantity and universality. Not the least of these was the inherent understanding of the constraints on direct service to a large number of children of widely varying behavioral conditions. Several examples of pushing procedures or organizational innovations to the limit were described. Finally, the rhetorical refuge of speaking loosely of "prevention" as an answer to the problems of quantity and universality was described as an empty vessel in the present state of theory and technology. The definition of mental illness is expected to assume a larger and more passionate role as the pressures for quantity and universality continue to mount with expansion of public funding.
REFERENCES MACKIE, ./., RAFFERTY, F. '1'., & MAXWEl.l., A. n. (19li7), The dia!{nostic check point for COIllmunity child psychiatry. Psvchiat. RI's. RI,!'., 22: 171-192. RAFn:RTY. F. T. (19lili), Thl' community is becoming. Amer. J. Orthopsvchiat., 36: 102-110. VISOTSKY. H .. SCHON, D., & RAH'ERTY, F., eds. (1973). Organization, administration, and financing of services for emotionally disturbed children. In: The Mental Health of Children: Services, Research, lind Manpower, by the Joint Commission on Mental Health of Children. New York: Harpel' & Row, pp. 87-238.
Frank T. Rafferty, M.D.
Fifteen years ago it was popular to read and to hear of the failure of the child guidance movement, presumably after a 40-year life span. With life speeded up, the tenure of social movements may be shorter, since early obituaries arc announcing the critical, nearfatal sickness of the Community Mental Health Center, 1 after only 10 years. Fortunately, accuracy of obituaries of social movements is no more required than firmness of theoretical base to begin them (Rafferty, 1966). Service organizations and theories survive obituaries consistently; for example, state hospitals, psychoanalysis, private psychiatric practice. But whatever the state of vitality of the CMHC, it certainly has come to the end of a phase, of a period of development that was an exciting, frightening, satisfying, frustrating, infuriating, and illuminating period of psychiatric history. In reflecting on the fragmented choreographed interaction of the CMHC movement with the child mental health professionals, we observe one theme that appears to be central-the theme of quantity and scope of service. Clearly stated in CMHC guidelines, even if it was often circumvented in operation, was the assumption of responsibility to provide comprehensive service to a designated population defined by geographical boundaries. The responsibility and accountability for all types of mental health services needed by every kind of person in the specified population were the sine qua non of the CMHC idea. Although the child outpatient clinic, the child residential treatment program, and the private practitioner of child psychiatry Dr. Raffert." is Direct", of Institutefor Juvenile Research, Projrssor of Psychiatry. Abraham Lincoln School of Medicine, University of Illinois. Chicago, Illinois. Requestsfor reprint" should beforumrded to Dr. Raffnt)' at 907 Wolcott AVi'., Chicago, Ill. 60M2. I
Throughout this paper designated as eM He.
5
6
Frank T. Rafferty
never claimed to be comprehensive, it was nevertheless on the basis of this criterion that they were judged to be failures. The early 1960s marked a turning point in the national realization that a large segment of the population was not sharing in the American dream of individual economic independence, of a fair distribution of consumer goods, and of vertical mobility in a flexibly stratified society. All the established social institutions were indicted as failures: the schools, churches, families, social welfare organizations, legal services, the courts, health and mental health institutions. It is hard to remember, now, the unbridled optimism of the early 60s when there was an honest if naive expectation that money from a bountiful federal government could change the structure of poverty, of racism, of school failure, and of the delivery of health care. The CMHC was an early example of that effort: at least mental health services would be fairly and universally distributed. Fifteen years later, the child mental health institutions are still indicted on the charge that they serve a selected clientele. The best of the child professionals and elite of the organizations are for the most part still uncommitted to solving the problems of quantity and scope, or universality of service. A few urban or suburban areas may have reached a saturation point with private practitioners. A few states have widespread networks of excellent community-based clinics that still depend for the maintenance of their quality on a usually informal, sometimes invisible, filter system in referral of children, and a utilization rate below 2 percent. A few urban areas appear to have generated a complete blanket of CMHCs that have children's services of erratic quality. Some areas seem to have met their quantitative need for hospitalization of children and adolescents. A number of cities have at least one, occasionally two, major showpiece mental health programs, frequently university-affiliated. Many programs have at least one gem of a project that tauntingly promises to reach, to treat, and to manage a large or at least significant number of children, or to represent a new technique to manage a previously unmanageable problem category. THE PROCESS WHICH BUILDS IN FAILURE
There would appear to be little doubt, even without hard data, that nationally the child and adolescent mental health effort has increased significantly. Essentially this has been an expansion of the manpower, technology, and organizational system of the early 60s, without benefit of the wished-for revolution. For the most part, it
CMHC and Services for Children
7
has been an expansion without the comprehensive planning called for in the "planning for a plan" of the CMHC movement, nor the systematic restructuring of children's services imbedded in the report of the Joint Commission on Mental Health of Children (Visotsky et aI., 1973). The child mental health establishment abdicated that part of the expansion related to innovation in organization and technology. The vacuum was filled by personnel coming from diverse directions, but impelled by new belief systems such as the behavioral therapies, family therapy, encounter groups, crisis intervention, and the "hot line" youth for youth drug programs. These services, with the possible exception of crisis intervention, were informed neither by the developmental theories of child psychiatry nor by the nascent theories of community and social psychiatry. The energy, youthfulness, and abrasiveness of the social and clinical activism of the CMHC, combined with the undeniable inHuence of the funding procedure of NIMH, has to a great extent prevailed in numbers of personnel, programs, officially stated goals, and style, without actually destroying the central hard core of resistance by a sizable number of child mental health professionals, especially child psychiatrists whose training and experience cause them to avoid the activist CMHC. These clinicians cling stubbornly to hard-learned techniques of controlled individual or small group therapy with carefully selected patients in the context of an individually derived therapeutic contract. It is not an unusual scene for a child psychiatrist who basically is committed to careful individual treatment to act as a consultant to a CMHC. with both parties ignoring the philosophical disparity for different reasons. It is always difficult to evaluate the purely economic factor. Those more overtly hostile to child psychiatrists point out that it is the psychiatrist's desire to make money that causes him to avoid the salaried full-time position. Undeniably, the social worker and psychologist have been more dependent on salaried employment in the bureaucracy, and consequently the NIMH funding procedures influenced them more strongly to a conversion to the CMHC philosophy and style. The child psychiatrist has had an escape route in private practice modified by the economic parameters of his geographic locality. So here we are, 10 years later and still in the prelaunch period of comprehensive, universal services to children. Funding for service has gone through different forms, but has become increasingly public rather than private. Public funding, whether federal or state, increases the pressure for quantity and universality of ser-
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Frank T. Rafferty
vice. Public officials have grave problems justifying and rationalizing select or elite programs and frequently end up opting for no program at all. So the battle is joined between those public forces inchoately pressing for universal service-"whatever is needed for whoever needs it"-and the professionals who only slightly more articulately say we don't know how, more often saying it's not our problem; but hungering meanwhile for the public funds. National health insurance would appear to be the coming public trough; and characteristically it is immersed in massive technical, financial, and organizational problems totally removed from the issues presented by universal mental health services to children. This is a product of disillusionment. Government and the health establishment have failed to reorganize, redistribute, or to restructure health services, and now government seeks to organize first the financing, according to convenience of public funding, and to watch the chaotic, forced scrambling of the heretofore inert, resistant system. But what of some of the efforts made to meet the problems of quantity and scope in the past 15 years? Since no one appears to be proclaiming his success, can something be learned from the interesting failures? The following are only examples of what has occurred in many locales. For a few years it looked as if there would be a system of universal day care for all children who needed it. Preschool day care was especially interesting to the mental health field. Not only was there the opportunity to provide care for children whose parents were working, but there appeared to be the opportunity for real prevention of a variety of behavior disorders secondary to school failure, and even for group treatment of disordered behavior in the preschool child. The input of several years of group day care, 3 to 10 hours per day, the corrective and enriching experience of professionally led small groups of children, the opportunity for parental support, education, and treatment seemed to present a solution to a number of serious problems in the organization for delivering mental health services. The child psychiatric program at the University of Maryland had the opportunity in the early 1960s to participate deeply in the Day Care and Child Development Movement. Prior to the federal program of Head Start, the Baltimore School System had initiated a full year of school for 4-year-olds, called Early Admission. Also, the Department of Public Welfare had initiated a pilot comprehensive day care center in a housing project, Westport. In each of these programs, the administration initially recognized the crucial dif-
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ferences between kindergarten, nursery school, or proprietary day care, and the new concept of a comprehensive child development center. The latter, of course, involved changing one-disciplineoriented programs to accommodate informed techniques from health, mental health, and child development. Initially, about 40 to 60 children were involved in each program. Personnel consisted of child care workers, trained early education teachers, a social worker experienced in the health and mental health concerns of children and families, pediatric and public health nurse services, along with 8 hours per week of child psychiatric time. Unfortunately, even in those relatively uninflated times, the cost was approximately $2,000 per child per year. But the potential benefit appeared substantial. From the child psychiatric viewpoint there were enormous advantages. Preschool children could be observed, developmental strengths and vulnerabilities assessed, and interventions made without labeling the child, stigmatizing the family, or removing the child from the mainstream of child-caring institutions. The experience could be individualized to accommodate a wide range of problems, including the autistic and psychotic child, the mild to moderate retarded, those with speech, language, and specific learning disabilities, the behavior disorders, and the unsocialized. With small groups and adequately skilled personnel, the disordered child could be accommodated well in the group, and the developmental center could forego making referrals to other institutions. Although formal CMHC guidelines did not include or even suggest such treatment institutions, child development centers were exemplary of the best of community mental health theory and practice. It is necessary, though, to report what happened over the next 10 years. The Early Admission program expanded from 60 to 1,400 children. The Day Care and Child Development program expanded from 40 to 4HO with a mel'ger into Head Start. For a while, personnel, technological, and organizational aspects kept pace with the expansion. Leadership of the major educational, social service, health, and mental health componenls remained t he same, yet gradually became diluted beyond any effective implementation. It is not the same task to organize, staff, direct, and supervise 4 one-half-day classrooms of 15 children each in 2 schools and to organize, staff, direct, and supervise 70 classrooms of 20 children each in 25 schools. So many child mental health personnel have participated in this kind of debacle that we are reluctant to be banal, except that the dissolutions and failures have not been written of often in the professional literature.
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The erosion process, though scarcely perceptible and administratively rationalized, is nevertheless obvious and devastating. A unit director is put in charge of two units. The social worker responds unselfishly to the request to cover a one-third larger caseload. No teacher with early child education training and experience is available, so a fourth-grade teacher is put into the vacancy. Involvement with parents and their participation in daily programming is attenuated because no one has the time to bring them along. Physical space and equipment are stretched beyond reasonable constraints. Soon the disordered child is the source of anxiety, arousing doubts in personnel of their competency to cope, and inevitably raising the question of referral to some other program "that can give him better, more appropriate service." Mental health personnel erodes with the rest. In the beginning we settle for only the best with close supervision for a really substantial program input; contact with and knowledge of each child; support, education, and collegiality of staff, which ranged from teachers and child care workers to cooks; program consultation to administration; and with trainees. But even a major increase in personnel is not able to meet the pressure for number of man-hours so that those of relatively less competency and peripheral commitment are involved. Concomitantly, the economic pressures reduced psychiatric inputs from 8 hours per week per center to 4 and then to 2, of necessity reducing the technical significance of participation. And all those even peripherally involved will recall with shudders of horror the vagaries of administrative and program support that day care and child development centers have gone through from federal and state government. There were the shifting and turnings of Head Start policy; the in and out of community action programs; the strivings for control of local, state, and federal agencies; the frequent changes in monitoring personnel; the ever-contracting Aexibilities in funding, and the promise and unfulfillment of programs like the 4C's (Community Coordinated Child Care). One of the most shattering of experiences, not limited to day care, is watching the phenomenon of the executive branch of the federal government mutilate a program at the height of public interest and support. There is a temptation to think of this as unique to the change in philosophy and personnel brought about by the 1968 national elections; but experience over a period of years with a variety of programs and with oneself as an administrator is strongly convincing that administrative and public support are analogous, not to rockribbed mountains, but to shifting sand dunes, and at times even to
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the surf on a Hawaiian beach. Unfortunately, the closer one gets to public programs, and thus the political process, the more uncertain the dunes and surf. Can awareness of these realities be built into rational planning of human services, or must we be continually buffeted and surprised by the dynamics of the social and political process? CONSULTATION PUT TO THE TEST
But let us return to the core task of this paper, evaluating the technology, manpower, and organizational tactics of child psychiatry and of community mental health by the criteria of quantity and scope of service. One of the most fascinating, promising, and promoted technologies of the CMHC was consultation. The technique was not invented by the Community Mental Health Act, nor even by one person, and certainly not in the 1960s; it had evolved independently in a number of places, had been shaped by many practitioners, and had been utilized in a wide variety of agencies. But it was the CMHC legislation that canonized consultation as one of the five required services and submitted it to the tests of quantity and scope. To a major degree, it was the technique of consultation that gave substance to the expectation of success for the CMHC to serve the total population of a catchment area. The constraints of time, manpower, and training on direct service were appreciated, but by consultation or indirect service all other agencies-industry, welfare, general medicine, schools, housing projects, recreational facilities, law enforcement, churches, etc.-were to be converted to auxiliary mental health facilities. It was here that the siren lure of "community" was most seductive. Social psychiatric theory and data established that some social and economic structures, cultural patterns, and institutional organizations contributed positively or negatively to mental illness and/or mental health. Consultation was the instrument to convert the noxious institutional structure to a positive influence. Child psychiatrists have reported formally and informally on successful consultative experiences with schools, well-baby clinics, pediatric wards, special education programs, prisons, training schools, juvenile courts, residential treatment centers, orphanages, welfare departments, law enforcement agencies, family service agencies, day care centers, city and state governmental bodies, the Peace Corps, Vista, dental and law schools, and industry. In one instance of school consultation, School 95 in Baltimore became a thoroughly converted, positive mental health institution while ful-
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filling its role as an all-black, poverty area ghetto school. Techniques to assess the developmental and social strengths and vulnerabilities of every child in school, and the ability to individualize instruction on the basis of this information, were demonstrated (Mackie et aI., 1967). Changes in educational philosophy, teacher attitudes, organization of pupil personnel services, size of class, utilization of teacher assistants, involvement of ghetto families, major changes in curriculum, class grouping, language programs, and reading were accomplished as well as stimulating and participating in changes of size of school, class size, personnel staffing. All children were contained in the school with a minimum of special classes, including children who were comparable to those in child psychiatric inpatient facilities. However, consultation failed when tested on quantity and scope. Just as the private psychotherapist achieves elegant success by a selection (perhaps informally and unwittingly) of patients appropriate for his technique, the consultant achieves impressive results when there is a happy congruence of the right child psychiatrist, the cooperative school system, the receptive principal, the welltrained staff, the available parents, and adequate financing for required manpower. The CMHC requires that every school district, every school in the district, every principal and teacher, every family and every child be served well by the mental health manpower available. In the example cited above, the project was initiated with two schools adjacent to the psychiatric facility and by the same techniques. The principal of one school simply could not support and sustain the changes and differentiation of his school within the system. He lived in constant fear and trepidation that headquarters would disapprove of the curriculum changes, of pupil discipline, of teacher participation in the program. This was probably without real grounds in this particular school district, in which principals were accorded tremendous autonomy, flexibility, and even budgetary control. The superintendent frequently complained that principals would not use the authority and autonomy given to them. But (to illustrate the complexity of public school systems) there may have been countervailing messages from assistant superintendents. In any event, the principal who did participate over a period of five years after her colleague opted out acquired considerable prestige and status within the system for the innovation. To continue with this example of the test of technology by quantity and scope, the original consultant team consisted of substantial portions of three professionals' time. As the 100 or so children of
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each kindergarten class were added, soon the number of children involved was over 400. Testing and observing children, interviewing parents, ordering data, feeding back information to teachers, managing crises, and carrying a relatively few individual cases had doubled the personnel time. As the negative effects of language problems in black children came to the fore, several specialists in speech and language pathology were added; furthermore, personnel had to acquire expertise in the Initial Teaching Alphabet reading system, which had not been systematically studied in black ghetto children. Finally, over ten mental health professionals plus trainees were involved. Reduction of class size and addition of teachers' assistants in the classrooms evolved as absolutely essential inputs from the school system. Fortunately, and unfortunately not repeatable in subsequent systems and times, the Federal Title I funds were at their peak flowing into the urban school systems, and School 95 was designated a model school with a reduction of population from 650 to 350, with class size reduced to 24, a teacher assistant in every classroom, a half-time psychologist, a full-time social worker, and nurse added to the school staff. But the expansion of service, the innovations in technology, the utilization of educational personnel were built on a house of cards. Compulsory retirement of the principal was a severe, yet not fatal blow. Funding needed to expand if service was to be extended to other schools; but certainly, the current level of funding had to be maintained. Interestingly, in the wisdom of a NIMH Study Committee, the project was not approved for funding because it was not innovative and represented only the practices present in all schools. However, the Grant Foundation was quite willing to fund the work as a research project. Unfortunately, research projects have goals different from service projects, and the end came into sight. When the project director moved to another city, another catchment area, and another school system, the fragile ecology of the techniques becomes apparent. The new, culturally embattled system, embroiled in politics, union conflicts, continuously on the defensive, with large deteriorating physical plants, provides few schools interested in and capable of developing the kind of partnership described above. Similarly, a child psychiatric service in the State Department of Mental Health, enduring the basic mistrust of the poor population of the catchment area, struggling with the emerging philosophical conflicts in psychiatry, and threatened by loss of training and research funding, is not capable of implementing the sophisticated, expensive procedures for that catchment area. At best, the schools are able to receive and utilize a comparatively un-
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complicated form of case consultation. Consultation, like psychotherapy, works effectively when the participants are not struggling with survival issues, and when the institutional analogues to ego strength are present. THE RHETORIC OF PREVENTION
One particular intellectual gambit has become commonplace when speaking of children and is frequently and inaccurately paired with the children's service of the CMHC. When someone has become enough aware of the impossibility of expanding current technologies, manpower, and organizations to meet the needs of comprehensive and universal mental health services, he frequently turns to the rhetoric of prevention. Some people even speak of prevention when talking in general about the child mental health services as if they were the same, and ignoring the fact that to prevent is a transitive verb, and requires precise delineation of what is being prevented by what specific set of operations. In absolute number, so few individual children are being treated effectively by present methods that the incidence or prevalence of any significant condition in a future population of adult or adolescents is certainly to go unaltered, even if the childhood condition is a true progenitor of the later condition. This statement must not be used to denigrate the personal, existential, and humanistic value of treating individual children. It simply suggests that programs of treatment of children not be sold on the basis of prevention, and, conversely that prevention not be sought by the treatment of individual children. With reference to the prevention of mental illness in children, it becomes apparent that relatively few conditions of behavioral deviance can meet criteria of the disease model, e.g., a differentiated etiology, specific expressive signs and symptoms, a characteristic pathology, specific treatment, and prognosis. More frequently, the phenomena are better conceptualized as individual variations from the developmental standards; or as long-standing patterns of adaptation to less than optimal economic, social, or interpersonal environments, or patterns of interaction of the individual variability with the interpersonal and political process that determines status in the social structure. Whatever the conceptualization, however, the transactional antecedents of behavioral deviance in children are seldom within the professional purview of psychiatric personnel, certainly not in significant numbers, and basically not under the mandate of CMHCs.
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ORGANIZATIONAL WORKING RELATIONSHIPS
Taking note of a few outstanding exceptions, we must observe that the child psychiatric establishment and the CMHCs have been extraordinarily and reciprocally wary in their approach-avoidance behavior. Perhaps the existence of the free-standing outpatient child clinic in many communities provided a pseudomutual escape for both parties. The CMHC could contract with the child clinic for service and thus satisfy the not too precisely monitored requirements of the NIMH for comprehensiveness, and the child clinic could equally tentatively participate in the tempting funding and not really alter its operations. This was a most popular solution, providing protection for the territorial concerns of both sides. Part of the concerns of the child institutions was that a sizable segment of child mental health professionals were already using the various technical procedures that were being trumpeted as new and expected to be comprehensive for the CMHC. These included working in multidisciplinary teams, consultation and community education, community boards, and working with the system rather than the patient, as in family therapy . It is important to recognize that not only had this group of child mental health professionals been involved with these techniques for some years and thus felt territorially trespassed when others discovered them, but in a perhaps inarticulate and intuitive way. many had a thorough awareness of the limitation of theory and practice. So there was a conservatism in the ambitions and claims, a rigor in the selection of patients, and a meticulousness of application that became antithetical to the ambience of the CMHC. The goals of a comprehensive. universal mental health service available to everyone who needed it not only demonstrated great gaps in technology, organization, and manpower, but unceremoniously activated the unresolved philosophical, professional, and political question of "what is mental illness?" When the clientele of mental health services were either a sophisticated, select segment prepared to seek out voluntarily and to pay [01' their own service, or a neglected, alienated, rejected, and forgotten population that society was fully prepared to have stored away, the concern with defining mental illness was strictly academic and stirred little passion in people's hearts . But when everyone in the community was to be involved in some way, and perhaps be subject to efforts to change attitudes about mental illness, then the definition becomes acutely personal. Many of the presenting problems of definition are primarily of forensic or legal interest, but for children's
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services the definition of mental illness will determine which bureaucratic agency will be responsible, how funds will be distributed, and which professional dis cipline will receive the mandate to care for the mentally ill or behaviorallv deviant. If a particular cluster of phenomena in children can be defined as mental illness, then th e medical insurance should pa y for its treatment at the eM He. I I' a constellation of symptoms in children can be defined as mental illness. then the educational agency. the child care agency. or the correctional institutions can, with some reasonableness, seek to tr ansfer the child to the community mental health clinic. However, the overworked personnel at the underfunded community mental health facility are equally desperately looking for ways to keep the child in his own home, school. or other institution and do so by denying the specific mental illness component, while emphasizing the educational or child care components. These questions and many more are usually precipitated by a specific case and involve only a few personnel from different agencies, but they are substantive questions about how to manage the enormous number of behaviorally deviant children. Those who ultimatel y must make de cisions about funding and organization of services apparentl y prefer to scapegoat the personnel of the agencies. to argue about accountability and responsibility, to split hairs about definition, or to philosophize on the dangers of labeling, rather than to confront themselves and the voting public with the actual numbers, varieties, and realities of deviance. COMMENT AND SUMMARY
That the CMHC has had an impact on child mental health is undeniable . but the evaluation of a national social movement is at least as subjective as the evaluation of individual psychotherapy. Things have changed; the number of personnel involved in the child mental health system has certainly increased several times, while the kind of personnel involved has multiplied, as have the settings for service. At the same time, the dogmas presumably guiding the operations have proliferated. The general public has become more involved in child mental health . But how do we assess the specific impact of the CMHC program. especially when more powerful social and economic forces were at work, the directions , effects, and magnitudes of which were only dimly anticipated by framers of the Community Mental Health Act? Who among those influencing and preparing President Kennedy's message to Congress anticipated his precipitous assassination , the style and results of the Civil
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Rights movement, the tragic mistaken commitment in Vietnam, the massive social legislation of President Johnson, the political polarization and radicalization of some segments of the society, the inflationary process of guns and butter, the anti psychiatry effects of the denial of legitimacy of authority, of the Civil Liberties movement, the continued failure of the educational institutions, and so forth? In many respects, the development of the CMHC has been itself a victim of these powerful oceanic swells in the national matrix of life, demanding the attention of the electorate and of government. In summary, we have pointed out that a central feature of the CMHC was comprehensive care of a geographically defined population, and that this mandate presented the task of delivery of service to a quantity of children with a range of problems far beyond existing technological competence, manpower resources, and organizational capacity. Not only did the CMHC movement fail to generate the necessary theoretical, technical, and organizational innovations, but it has failed thus far to win the loyalty of the child psychiatric establishment. The child mental health specialist found numerous reasons to avoid commitment to the CMHC and to the problems of quantity and universality. Not the least of these was the inherent understanding of the constraints on direct service to a large number of children of widely varying behavioral conditions. Several examples of pushing procedures or organizational innovations to the limit were described. Finally, the rhetorical refuge of speaking loosely of "prevention" as an answer to the problems of quantity and universality was described as an empty vessel in the present state of theory and technology. The definition of mental illness is expected to assume a larger and more passionate role as the pressures for quantity and universality continue to mount with expansion of public funding.
REFERENCES MACKIE, ./., RAFFERTY, F. '1'., & MAXWEl.l., A. n. (19li7), The dia!{nostic check point for COIllmunity child psychiatry. Psvchiat. RI's. RI,!'., 22: 171-192. RAFn:RTY. F. T. (19lili), Thl' community is becoming. Amer. J. Orthopsvchiat., 36: 102-110. VISOTSKY. H .. SCHON, D., & RAH'ERTY, F., eds. (1973). Organization, administration, and financing of services for emotionally disturbed children. In: The Mental Health of Children: Services, Research, lind Manpower, by the Joint Commission on Mental Health of Children. New York: Harpel' & Row, pp. 87-238.
