Community Mental Health Journal Volume 3, Number 1, Spring, 1967
COMMUNITY MENTAL HEALTH CENTERS AND SERVICES FOR THE MENTAILY RETARDED HENRY DUPONT, PH.D.*
In the past, community mental health centers have often had a policy of not providing services to the mentally retarded. In view of the many needs of the retarded child and his parents this policy is unfortunate. A review of the four-year period caseload of one small community mental health center that offered services to the retarded shows that 14% of all admissions involved the problem of mental retardation. In 70% of these cases diagnosis and counseling were provided; in 18%, casework was provided; in 12%, psychotherapy was provided to the parents. The complications involved in these latter cases are discussed. It seems clear that many of the services needed by the mentally retarded and their parents can and should be provided at community mental health centers.
It is difficult to dispute the contention that the typical child guidance clinic and the community mental health centers of the past decade or two did not meet the needs of the mentally retarded child or his parents. As a rule, the parents of the retarded had the right to feel rejected and that there was little interest in their retarded child, be. cause this was true. Some clinics, in fact, had a policy of refusing service to the re. tarded. One cannot defend this policy. Where it existed it often reflected a rejection of the retarded; it was also frequently based on the realistic recognition that, while the clinic staff could make the diagnosis of mental retardation, they had little knowledge or understanding of the retarded child and his needs. It is only in the last few years that courses in mental retardation and the experience of working with the retarded have been offered as part of the curriculum at professional training schools. Now that many of us are receiving more adequate training, training that embraces
both mental illness and mental retardation, it seems tragic that there is such a cry for clinics to serve the mentally retarded exclusively. While there seems to be a need for more highly specialized diagnostic services, the notion that the mentally retarded must be served only at clinics that specialize exclusively in mental retardation seems foolhardy. It is especially so for sparsely populated areas where there is a general shortage of professional personnel, for as Beck (1959) has pointed out: "Many of the problems that occur in connection with mental retardation are common to families of handicapped children in general." The emphasis on special clinics for the retarded also seems to encourage a neglect of the needs of parents, and parents have a nonending responsibility in the guidance, treat. ment, and education of their retarded child. Parents of the mentally retarded are first of all people. They may be well adjusted or poorly adjusted before they discover that their child is mentally retarded. What a parent may need in the way of service may
*Dr. Dupont, a clinicalpsychologist,is Coordinator of Psychological Services and Program Evaluation, Division of Mental Hygiene, Department of Public Welfare, Madison, Wis.
33
34
TH~ COMMUNITYMENTALHEALTHJOURNAL
vary depending upon the age of the child, tal retardation is involved and the parents the services previously obtained, and the have emotional problems. parents' general state of maturity and menSix COMPLEXCASES tal health. Case I. Mrs. B requested a n a p p o i n t m e n t ONE CENTER'SCASELOAD for her child but then could n o t bring him The kind of services often needed and to the center for study. She seemed to be used by parents of the mentally retarded is both asking for help and at the same time inillustrated by a review of the caseload of sisting that she didn't really need it. She one small community mental health center was reluctant to accept an appointment for that offered services to both the emotionally herself but finally did so. She canceled several of her first appointments but was finally disturbed and the mentally retarded. Over a four-year period, 14% of all ad. able to keep an appointment. In her interviews she immediately talked missions involved the problem of mental retardation. In 70% of these cases, there about herself; she had numerous symptoms were no complications. The parents wanted of anxiety. She felt smothered and had the a diagnostic study, and they wanted to know sensation of choking. She reported being their child's assets and disabilities so they extremely depressed and having the feeling could make plans for his education, train- that something was going to happen. She ing, or institutionalization. Many of the said she had lost interest in everything. It diagnostic studies were completed with the became clear that she could not face the cooperation of two local pediatricians. The guilt she felt because of the accident in department of neurology and the depart- which her son sustained the head injury ment of pediatrics of a nearby medical that caused his retardation. She blamed school were also used in several instances herself for the accident, because she had when difficult diagnostic problems were en- gone to work just a few days before it occountered. curred. In five treatment interviews her sympIn 18% of the cases involving retardation, the retardation had been previously toms disappeared, and she came to face this established, but the retardate was manifest. guilt constructively and was able to accept ing an adjustment problem. In most of these the need for a diagnostic study and plancases treatment involved working with the ning. Case 2. Mrs. C, a mother of three children, family in casework, helping them to handle the child in a way more consistent with their and her husband requested a diagnostic retardate's needs, and in several cases help- study of their five-year-old child. One of her ing them to accept placement in a residen- other children was severely mentally retial school. tarded. Her oldest child was gifted. They In 12% of the cases (six cases) diagnosis, had suspected for some time that their interpretation, and planning were hampered youngest child might be mentally retarded. considerably by the parents' emotional prob- The mother warned the worker at the end lems. In three of the six cases it was not pos- of the intake interview that she did not want sible to proceed with the planning for the any bad news about her child. When the child until the parents had been helped with diagnosis was completed and they were told their emotional problems. In two cases it their child was retarded, the mother dewas not possible to complete a diagnostic veloped a rather severe depression. In the study of the child until one parent had been interviews that followed, it became clear treated, and in one case the parents were that she had considerable repressed anger unable to profit from anything the center about the way they were told about their had to offer. This finding was somewhat sur- other child's retardation. She was also angry prising. A review of these six cases will il. at the way the community regarded mentallustrate how complex the request for serv- ly retarded children. She had a strong need ice may become when the diagnosis of men. to deny the second child's retardation. After
HENRYDUPONT several interviews, she was able to plan for the child's training, but her depression remaine& She refused further casework but obtained some relief from drug therapy obtained from her family physician. Case 3. Mrs. D requested an interview to describe her problems that centered around her mentally retarded daughter. She immediately demanded that we write a letter to her husband's commanding officer describing their retarded child and the mother's need for the husband's help in caring for her. She hoped this letter would result in the cancellation of the orders for overseas duty her husband had recently received. In this telephone contact and several that followed, she was extremely demanding and hostile. She seemed to want an interview but would not accept one, seemingly because the center would not promise her beforehand that it would meet her demands. After numerous telephone calls, she finally accepted an appointment. In her first several interviews she was extremely defensive and anxious. It developed that a diagnosis had been made several years earlier at an army hospital overseas. Apparently the findings had been presented in a cal-, loused way, for the mother repeated many times, "We were told she would never be more than an animal." Both parents were puzzled and troubled by this prognosis, since their child was now eight years of age, an attractive, talkative, friendly child. From numerous things the mother said about the child, it did sound as though the child was retarded. She refused, however, to bring the child in for a diagnostic evaluation. The mother's extreme anxiety and panic suggested that she had an anxiety neurosis. She finally accepted the psychologist's offer of treatment interviews for herself. She improved considerably during the psychotherapy, which lasted a little over one year. At this time, with her anxiety very much reduced, she requested that the center do a complete diagnostic study of her child. A study was completed. She and her husband were able to accept the findings as a realistic basis for planning for the child. Case 4. Mrs. W was a mother of three girls. Her youngest child of five had been
35
previously diagnosed as schizophrenic. After a complete study and review of previous studies, the center staff felt it had to change the diagnosis to mental retardation. Mrs. W became very upset and could not accept this diagnosis. She did, however, accept her need for help. In her therapy interviews she came to face constructively the anger she felt toward her husband for his lack of reinterest and sympathy" and the guilt she felt. Her oldest daughter had a play accident in early childhood while the mother was away from home and is, as a result, a physically handicapped child. Mrs. Wseemed to relate her oldest child's accident and her youngest child's retardation in some causal way that suggested to her that she was a r162 mother." She improved considerably after a year and a half of psychotherapy and was able to accept her child's enrollment in a class for the educable mentally retarded. Case 5. Mrs. Y was the mother of a fiveyear-old child who had been diagnosed as mentally retarded because of brain damage. A diagnostic study revealed the child was severely retarded. In the interpretation conference her husband seemed to accept the findings, but Mrs. Y appeared apathetic and depressed. She declared they did not plan to have any more children so she could devote all of her time to this retarded child; all of our suggestions about home care and training seemed to be rejected. The offer of treatment interviews was, somewhat to our surprise, accepted. In these interviews Mrs. Y revealed that she felt sometimes that her child was a demanding little monster and that she was ashamed of how angry she often felt toward her child. When these feelings were clarified, accepted, and discussed, her apathy and depression disappeared. She was able to talk about seeing her family doctor to talk with him about having another child. Case 6. Mr. G was the father of two children. He and his wife sought help in planning for the advanced training of their brain-damaged mentally retarded adolescent boy. The boy was recently also manifesting many behavioral problems. It became clear in the parent's interview that the father had serious emotional problems. He
36
THE COMMUNITYMENTALHEALTHJOURNAL
rejected our findings and was critical of his wife and son. He was having financial difficulties and seemed to be projecting the blame for this onto his wife and son in some obscure, illogical way. Mr. G also made it clear that having a retarded son was a severe blow to his self-esteem. Good planning clearly was not possible. Therapy was offered to the father, and after several interviews he complained of symptoms suggesting some organic problems. He rejected the suggestion tlaat he get a thorough diagnostic workup or even a physical examination, and he broke off his therapy relationship. His wife was aware of his symptoms and his emotional problems, but she could not get him to accept the help he really needed. It was our strong impression that his problems and his behavior with his retarded son were considerably aggravating his son's adjustment. It was not possible to help either Mr. or Mrs. G in planning for their retarded son.
service given to a client whose mental retardation had been previously established. Each of these clients, who were of various ages, was manifesting behavioral problems. Casework with the families of several older retardates resulted in training school placements. In 12% of the cases it was necessary to treat the parents for their emotional problems before the retarded child's needs could be attended to. As the experience of this one small community mental health center suggests, when a community mental health center stafftrained in mental retardation offers services to the mentally retarded, the service will be used. While the services of other specialists may be needed to complete diagnostic studies, the need for diagnosis, counseling, and casework is typical of all mental health center clients, and the work with the parents, which may include psychotherapy, is similar in character to the work done with any parent concerned about his child. BASIC SERVICESSHOULDBE PROVIDED While centers that specialize in the diagThis review of the services rendered to nosis, prevention, and treatment of mental mentally retarded clients by one community retardation are certainly needed, the commental health center shows how the render. munity mental health center can provide ing of these essential services can be an in. the general basic services needed by many tegrated part of the center's program. In of the mentally retarded and their parents. 70~o of the cases, diagnosis, interpretation, and help in planning were the services pro. REFERENCE vided. In 18% of the cases treatment BECK, HELENL. Counseling parents of retarded through family casework was the important children. Childr~, 1959, 6, 225--230.
COMMUNITY MENTAL HEALTH CENTERS AND SERVICES FOR THE MENTAILY RETARDED HENRY DUPONT, PH.D.*
In the past, community mental health centers have often had a policy of not providing services to the mentally retarded. In view of the many needs of the retarded child and his parents this policy is unfortunate. A review of the four-year period caseload of one small community mental health center that offered services to the retarded shows that 14% of all admissions involved the problem of mental retardation. In 70% of these cases diagnosis and counseling were provided; in 18%, casework was provided; in 12%, psychotherapy was provided to the parents. The complications involved in these latter cases are discussed. It seems clear that many of the services needed by the mentally retarded and their parents can and should be provided at community mental health centers.
It is difficult to dispute the contention that the typical child guidance clinic and the community mental health centers of the past decade or two did not meet the needs of the mentally retarded child or his parents. As a rule, the parents of the retarded had the right to feel rejected and that there was little interest in their retarded child, be. cause this was true. Some clinics, in fact, had a policy of refusing service to the re. tarded. One cannot defend this policy. Where it existed it often reflected a rejection of the retarded; it was also frequently based on the realistic recognition that, while the clinic staff could make the diagnosis of mental retardation, they had little knowledge or understanding of the retarded child and his needs. It is only in the last few years that courses in mental retardation and the experience of working with the retarded have been offered as part of the curriculum at professional training schools. Now that many of us are receiving more adequate training, training that embraces
both mental illness and mental retardation, it seems tragic that there is such a cry for clinics to serve the mentally retarded exclusively. While there seems to be a need for more highly specialized diagnostic services, the notion that the mentally retarded must be served only at clinics that specialize exclusively in mental retardation seems foolhardy. It is especially so for sparsely populated areas where there is a general shortage of professional personnel, for as Beck (1959) has pointed out: "Many of the problems that occur in connection with mental retardation are common to families of handicapped children in general." The emphasis on special clinics for the retarded also seems to encourage a neglect of the needs of parents, and parents have a nonending responsibility in the guidance, treat. ment, and education of their retarded child. Parents of the mentally retarded are first of all people. They may be well adjusted or poorly adjusted before they discover that their child is mentally retarded. What a parent may need in the way of service may
*Dr. Dupont, a clinicalpsychologist,is Coordinator of Psychological Services and Program Evaluation, Division of Mental Hygiene, Department of Public Welfare, Madison, Wis.
33
34
TH~ COMMUNITYMENTALHEALTHJOURNAL
vary depending upon the age of the child, tal retardation is involved and the parents the services previously obtained, and the have emotional problems. parents' general state of maturity and menSix COMPLEXCASES tal health. Case I. Mrs. B requested a n a p p o i n t m e n t ONE CENTER'SCASELOAD for her child but then could n o t bring him The kind of services often needed and to the center for study. She seemed to be used by parents of the mentally retarded is both asking for help and at the same time inillustrated by a review of the caseload of sisting that she didn't really need it. She one small community mental health center was reluctant to accept an appointment for that offered services to both the emotionally herself but finally did so. She canceled several of her first appointments but was finally disturbed and the mentally retarded. Over a four-year period, 14% of all ad. able to keep an appointment. In her interviews she immediately talked missions involved the problem of mental retardation. In 70% of these cases, there about herself; she had numerous symptoms were no complications. The parents wanted of anxiety. She felt smothered and had the a diagnostic study, and they wanted to know sensation of choking. She reported being their child's assets and disabilities so they extremely depressed and having the feeling could make plans for his education, train- that something was going to happen. She ing, or institutionalization. Many of the said she had lost interest in everything. It diagnostic studies were completed with the became clear that she could not face the cooperation of two local pediatricians. The guilt she felt because of the accident in department of neurology and the depart- which her son sustained the head injury ment of pediatrics of a nearby medical that caused his retardation. She blamed school were also used in several instances herself for the accident, because she had when difficult diagnostic problems were en- gone to work just a few days before it occountered. curred. In five treatment interviews her sympIn 18% of the cases involving retardation, the retardation had been previously toms disappeared, and she came to face this established, but the retardate was manifest. guilt constructively and was able to accept ing an adjustment problem. In most of these the need for a diagnostic study and plancases treatment involved working with the ning. Case 2. Mrs. C, a mother of three children, family in casework, helping them to handle the child in a way more consistent with their and her husband requested a diagnostic retardate's needs, and in several cases help- study of their five-year-old child. One of her ing them to accept placement in a residen- other children was severely mentally retial school. tarded. Her oldest child was gifted. They In 12% of the cases (six cases) diagnosis, had suspected for some time that their interpretation, and planning were hampered youngest child might be mentally retarded. considerably by the parents' emotional prob- The mother warned the worker at the end lems. In three of the six cases it was not pos- of the intake interview that she did not want sible to proceed with the planning for the any bad news about her child. When the child until the parents had been helped with diagnosis was completed and they were told their emotional problems. In two cases it their child was retarded, the mother dewas not possible to complete a diagnostic veloped a rather severe depression. In the study of the child until one parent had been interviews that followed, it became clear treated, and in one case the parents were that she had considerable repressed anger unable to profit from anything the center about the way they were told about their had to offer. This finding was somewhat sur- other child's retardation. She was also angry prising. A review of these six cases will il. at the way the community regarded mentallustrate how complex the request for serv- ly retarded children. She had a strong need ice may become when the diagnosis of men. to deny the second child's retardation. After
HENRYDUPONT several interviews, she was able to plan for the child's training, but her depression remaine& She refused further casework but obtained some relief from drug therapy obtained from her family physician. Case 3. Mrs. D requested an interview to describe her problems that centered around her mentally retarded daughter. She immediately demanded that we write a letter to her husband's commanding officer describing their retarded child and the mother's need for the husband's help in caring for her. She hoped this letter would result in the cancellation of the orders for overseas duty her husband had recently received. In this telephone contact and several that followed, she was extremely demanding and hostile. She seemed to want an interview but would not accept one, seemingly because the center would not promise her beforehand that it would meet her demands. After numerous telephone calls, she finally accepted an appointment. In her first several interviews she was extremely defensive and anxious. It developed that a diagnosis had been made several years earlier at an army hospital overseas. Apparently the findings had been presented in a cal-, loused way, for the mother repeated many times, "We were told she would never be more than an animal." Both parents were puzzled and troubled by this prognosis, since their child was now eight years of age, an attractive, talkative, friendly child. From numerous things the mother said about the child, it did sound as though the child was retarded. She refused, however, to bring the child in for a diagnostic evaluation. The mother's extreme anxiety and panic suggested that she had an anxiety neurosis. She finally accepted the psychologist's offer of treatment interviews for herself. She improved considerably during the psychotherapy, which lasted a little over one year. At this time, with her anxiety very much reduced, she requested that the center do a complete diagnostic study of her child. A study was completed. She and her husband were able to accept the findings as a realistic basis for planning for the child. Case 4. Mrs. W was a mother of three girls. Her youngest child of five had been
35
previously diagnosed as schizophrenic. After a complete study and review of previous studies, the center staff felt it had to change the diagnosis to mental retardation. Mrs. W became very upset and could not accept this diagnosis. She did, however, accept her need for help. In her therapy interviews she came to face constructively the anger she felt toward her husband for his lack of reinterest and sympathy" and the guilt she felt. Her oldest daughter had a play accident in early childhood while the mother was away from home and is, as a result, a physically handicapped child. Mrs. Wseemed to relate her oldest child's accident and her youngest child's retardation in some causal way that suggested to her that she was a r162 mother." She improved considerably after a year and a half of psychotherapy and was able to accept her child's enrollment in a class for the educable mentally retarded. Case 5. Mrs. Y was the mother of a fiveyear-old child who had been diagnosed as mentally retarded because of brain damage. A diagnostic study revealed the child was severely retarded. In the interpretation conference her husband seemed to accept the findings, but Mrs. Y appeared apathetic and depressed. She declared they did not plan to have any more children so she could devote all of her time to this retarded child; all of our suggestions about home care and training seemed to be rejected. The offer of treatment interviews was, somewhat to our surprise, accepted. In these interviews Mrs. Y revealed that she felt sometimes that her child was a demanding little monster and that she was ashamed of how angry she often felt toward her child. When these feelings were clarified, accepted, and discussed, her apathy and depression disappeared. She was able to talk about seeing her family doctor to talk with him about having another child. Case 6. Mr. G was the father of two children. He and his wife sought help in planning for the advanced training of their brain-damaged mentally retarded adolescent boy. The boy was recently also manifesting many behavioral problems. It became clear in the parent's interview that the father had serious emotional problems. He
36
THE COMMUNITYMENTALHEALTHJOURNAL
rejected our findings and was critical of his wife and son. He was having financial difficulties and seemed to be projecting the blame for this onto his wife and son in some obscure, illogical way. Mr. G also made it clear that having a retarded son was a severe blow to his self-esteem. Good planning clearly was not possible. Therapy was offered to the father, and after several interviews he complained of symptoms suggesting some organic problems. He rejected the suggestion tlaat he get a thorough diagnostic workup or even a physical examination, and he broke off his therapy relationship. His wife was aware of his symptoms and his emotional problems, but she could not get him to accept the help he really needed. It was our strong impression that his problems and his behavior with his retarded son were considerably aggravating his son's adjustment. It was not possible to help either Mr. or Mrs. G in planning for their retarded son.
service given to a client whose mental retardation had been previously established. Each of these clients, who were of various ages, was manifesting behavioral problems. Casework with the families of several older retardates resulted in training school placements. In 12% of the cases it was necessary to treat the parents for their emotional problems before the retarded child's needs could be attended to. As the experience of this one small community mental health center suggests, when a community mental health center stafftrained in mental retardation offers services to the mentally retarded, the service will be used. While the services of other specialists may be needed to complete diagnostic studies, the need for diagnosis, counseling, and casework is typical of all mental health center clients, and the work with the parents, which may include psychotherapy, is similar in character to the work done with any parent concerned about his child. BASIC SERVICESSHOULDBE PROVIDED While centers that specialize in the diagThis review of the services rendered to nosis, prevention, and treatment of mental mentally retarded clients by one community retardation are certainly needed, the commental health center shows how the render. munity mental health center can provide ing of these essential services can be an in. the general basic services needed by many tegrated part of the center's program. In of the mentally retarded and their parents. 70~o of the cases, diagnosis, interpretation, and help in planning were the services pro. REFERENCE vided. In 18% of the cases treatment BECK, HELENL. Counseling parents of retarded through family casework was the important children. Childr~, 1959, 6, 225--230.
