Intake As a Conflict Area in Clinic Function Nancy Staver, M.S.S. and Elizabeth LaForge, M.S.W.
Individuals all have their characteristic ways of experiencing stress: different as to the area of life in which the stress is felt, what name is given to it, what defenses are used, and what aspect of the total person is most vulnerably reactive. Organizations, too, have characteristic ways of reacting to stress, ways that are part of the continuing "personality" of an organization. The stresses in a child guidance facility are bound to affect service functions in some way; and probably, as in any social system, points of interaction between the organization and its environment are subject to the greatest tension and thus may become the focus for staff concern or dissatisfaction. At the Judge Baker Guidance Center, the intake and referral service for some time was such an area of repeated concern. The Center used to be housed in a central city area where parking was almost impossible. When the clinic moved to a larger building with a parking area of its own, the staff felt a great sense of relief-short-lived, because the parking space was soon insufficient for the staff, let alone the patients. As demands on the limited space increased, there were constant debates about the basis for assigning parking spaces, alternative transportation, response to interlopers, and many other real uncertainties. For years, also, one could predict that when some thorny, but half-hidden issue needed discussion at staff meetings, the staff would soon find themselves engaged in heated debate about "the parking problem." A similar phenomenon seems to have occurred in relation to intake; that is, reality problems concerning intake arose from changing times, but were then magnified and distorted by displacement of feelings about many different issues in the life of the clinic. It was notable how often administrative or planning meetMiss Staver is Chief of Psychiatric Social Work and Miss LaForge is Intake Coordinator, Judge Baker Guidance Center, Boston. Reprints nuzy be requestedfrom Miss Staver, Judge Baker Guidance Center, 295 Longwood Avenue, Boston, Massachusetts 02115.
589
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ings at the clinic fell into fierce discussion of how intake was handled. Parking and intake both have to do with a clinic's interface with the community-with "how to get to the c1inic"-and perhaps this fact determines their both being foci of contention in a time of change. Policy development regarding parking and regarding intake also has some common elements, being determined by spatial and numerical realities, and by choices made by the organization about needs and priorities as these change over time. The rapidity of change and the adaptive demands that its pace places on individuals and organizations are no news to mental health professionals who are working in a field that has been experiencing its own revolution during the last 10 to 20 years. Internally, and in its relation to families, neighborhoods, government and human service organizations, child psychiatry has altered drastically. One might expect that such change would be reflected in the intake function just because that function connects the internal organization to the environment. Fifty years ago, the Judge Baker presumably had no intake problem. The clinic was started by Healy and Bronner in 1917 as a diagnostic and advisory service, primarily for the Boston Juvenile Court. There appear to have been no uncertainties about the population to be served or the nature of the service to be offered, since in addition to their concern about children coming before the court, Healy and Bronner were eager to be of service to children referred by the various agencies of society that were dealing with upset or maladjusted children. Over the next two decades, the clinic became independent of the court, offered service increasingly to the whole metropolitan area, and developed an extensive, skilled treatment function, supported by the growth of child analysis. Thus, by the early 1940s referrals were coming directly from families and from a network of health and welfare agencies as well as the court. That shift of function must have been reflected in painful and painstaking revisions of how referrals were dealt with, but we have no record of the process. The clinic was then small enough so that informal communication about availability of services was feasible. Supply and demand were well enough matched so that a mother could call on Monday, have an application interview on Wednesday, and start treatment for her child and herself the following week. Clinical staff were in general agreement that child guidance diagnosis or treatment should be available for anyone wanting it, with only such gross limitations as age and some misgivings about how much help could be given to retarded children. The clinic's intake at that time
Intake As a Conflict Area in Clinic Function
591
probably involved little conflict of values or priorities, and little tension between clinic and community. Following World War II, there was a great surge of civilian interest in emotional problems and psychiatric services. Demand for such services rapidly outstripped supply in a process which continued for many years, despite the multiplying of psychiatric services. The Federal government's support of training for mental health professionals also changed the service picture and moved the clinic into a dual role: training and service were both seen as major commitments of the agency (though training in the clinical disciplines had taken place throughout the life of the clinic, as had practice-based research). At this period, some tensions developed around intake. There were internal disagreements about training vs. service priorities, the social workers taking intake calls felt pressured by the needs of applicants for whom service was not available and by occasional use of "back doors" to service. There was resentment in the community toward the clinic over waiting lists or the alternative at that time of closed intake. One response to these strains was the clinic's setting up an interdisciplinary intake committee and more formal screening procedures. The 1950s were marked for our clinic, as for others, by development of more varied services--inpatient treatment, day care, group treatment-and by closer ties with medical institutions. The primary impact of these changes on intake was to complicate the relationship between intake decisions and assignment or treatmentplanning decisions. Partially separated intake channels developed for these different services. The possibility of referrals from one service to another within the clinic made more obvious some of the ways in which intake decisions might be influenced by the power of the sender or the receiver of the referral, or by the patient's already being known to someone in the organization and thus having his needs more vividly felt by the referrer. In the 1960s, society's renewed and more informed attention to the problems of poverty and of urban disorder was bringing to the fore a new set of pressures on clinic services. There began a steady, large shift to a preponderance of referrals of working-class or financially dependent inner-city families. The community made the clinic's intake sharply aware of clinic behavior or decisions that seemed to be in any way discriminatory. Within the clinic there were differences of view concerning feasibility and priorities in offering service to people whose expectations and needs often fit very poorly with our traditional expectations and knowledge. The late 1950s and 1960s saw the development of more social concepts
592
Nancy Staver and Elizabeth. LaForge
among psychiatrists and psychologists, and more treatment skills among social workers. The blurring of disciplinary boundaries as all clinical disciplines took on overlapping diagnostic and treatment roles probably also affected role definition and satisfaction in relation to the intake function. The greatly increased knowledge concerning organic factors in children's problems also had an impact on intake, both in terms of what parents and others were requesting and of how the tasks of the intake interview were conceived. The appearance of the community mental health clinics within the last decade in its turn brought new tensions to the intake function. For a clinic that was not part of a catchment area system, difficult issues about organizational responsibility and patients' rights arose. Philosophical and clinical issues about freedom of choice for patients became very practical decision problems when a mother said she would positively not return to her local clinic because such and such had displeased her there. Intake workers at a clinic like the Judge Baker worried lest they find themselves referring back to their local community mental health clinics the families with more serious problems or fewer resources, while intake workers at community mental health clinics were Hooded with the requests of great numbers of people whom they had a statutory obligation to serve. A greater variety of child mental health resources became available especially for suburban residents. Epidemiological and cultural changes were perhaps occurring as well, bringing a larger population of angry, action-oriented, and impatient sufferers to the doors of inner-city clinics, so that swift availability of service was often a deciding factor about handling referrals. The literature concerning intake naturally reflects these historical trends. For some reason, the intake literature has come more from adult psychiatry and social services than from child psychiatry, possibly because child patients do not usually refer themselves, complain about waiting lists, or demand equal treatment or a voice in intake decisions. Coleman et al. (1948) discussed the intake interview with a mother as in itself an actual treatment experience; those were the days of the developing waiting lists, and the authors saw a waiting period after the intake interview as providing an opportunity for a "consolidation of intent." Two years later, a Group for the Advancement of Psychiatry report (1950) on concepts in child psychiatry discussed the intrafamilial nature of the child's disorder, and stressed the parents' being free to choose not to use clinic services. During the years of enormous expansion of mental health services, Polansky and Kounin (1956), Frank et al. (1957),
Intake As a Conflict Area in Clinic Function
593
and Eiduson (1968) were undertaking studies of factors inHuencing the effectiveness of the initial contact as measured by continuance rates, expressed satisfaction, or outcome-factors such as hope, a sense of the competence of the helping person, and intelI~ctual preparedness for the nature of the psychotherapeutic interview. In the late 1950s and the 1960s, under stimulus of the fresh awareness of, and approaches to, problems of poverty and deprivation, there came a host of reports on newly based and designed clinical services intended for poor, alienated, or disadvantaged populations. These included discussions of intake procedures as these made help more or less available to previously seldom served communities. Gordon (1965), Fantl (1964), Kluger (1970), and others (Brager, 1965; Adams and McDonald, 1968; Collins, 1969) questioned traditional intake and referral procedures, some seeing these as a means of discouraging poor people from using clinics, others describing alternative intake procedures aimed at eliminating delay, money, strangeness, 01' motivation as barriers to offering service. Mayer and Timms (1969) did a vivid study of the frequent gross misunderstanding between social workers and prospective clients about what could constitute help. Articles concerned with the relationships between clinics and communities have appeared especially in the last few years. Reid (1972) and Lazare et al. (1972) at Massachusetts General Hospital raised new questions about whether the providers of service or the potential consumers should make the choices about what kind and what amount of help would be useful. Hansell (1967) conceives of intake as being the point at which linkages with formal and informal support systems are established or mobilized. Hirschowitz (1973) sees the intake person as "gatekeeper," and discusses sanctions, power, and loyalties within the organization as factors inHuencing the actual decisions about who gets served and by what means. The Judge Baker Guidance Center is one of three independent child guidance clinics, hospital-affiliated but essentially autonomous, serving children and families in a metropolitan area of nearly a million persons and offering clinical training to educators, nurses, and theological students as well as to the usual clinical disciplines. In addition to these three clinics, about twenty to thirty other facilities in the area offer general or specialized psychiatric services for children in general 01' psychiatric hospital settings, courts, community mental health clinics, etc. Despite the wealth of resources, the Judge Baker has been able in recent years to offer
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Nancy Staver and Eli zabeth LaForge
continuing service to fewer than half th e people who request help. Approximately one fourth of the clini c's ser vices at an y given time go to special groups, suc h as correctional syste m referrals, who are speciall y routed into th e clinic and do not e nter through the general child guidance intake service door. Intake se rv ice for general ch ild guidance referrals is provided by social work staff, with some minor participation of other departments. Th e social workers covering intake try to offer thoughtful and well-su p po r ted referral for people best served elsewhe r e, or for whom the clinic does not ha ve re sources at a given time. The general chi ld guidance referrals come at a rate of about 500 a year, with cons ider a ble seasonal variation. The majorit y of referrals are made directly by parents, and nearly half the referrals are from the city of Boston. What, then, are the conflicts that impinge on this function, which sounds so simple and com fo r table in a bri ef description? The historical statement ha s adumbrated some of th em . One unceasin g co n fl ict arises from the program choices that must alwa ys be mad e because personnel r eso u rc es ar e never unlimited , and becau se fu nc tio ns never r em ain sta tic. These program cha nges- mo re se rv ice to delinquent or to negl ected or abused ch ild ren, to ch ild re n in fost er care or ch ild re n with severe psychosomatic di sordcrs-s-ncccssitatc diminution o f serv ice to some other population and crea te a need for readjustm ent in the clinic's rel ationship with th e co m m u nity and its access to the clinic. New programs ma y call for differential handling of intake. For instance, when a mobile crisis intervention team goes into a co mmunit y, th e clini c must ensure access to th e clini c for the families served by th at team but needing in-clin ic se rv ices in addition . Whether tr aining or serv ice has priorit y in th e clinic's go als is a source of confl ict a t th e point of intake . So meone with broad training responsibilities is con cerned to have work re ad y and waiting when trainees arri ve, but patient needs d o not usually time themselves neatly to fit a training calendar, nor d o most applicants these days find it tolerable to wait a long tim e for service . Referrals d o not come arranged to provide well-mixed experience for trainees, yet we do not want to train clinicians through working only with latency-age learning-problem children or with delinquent adolescents. There are also com peting views abo u t the amount and kind of clini cal experience that provides optimal learning, so that one supervisor ma y be more co ncern ed for his trainees to work with people whose neu roti c problems make clear th e nature of internal co nflict, while a no ther su pe rvis o r believes that a primar y ingredient in good learning experience is th e necessit y to cope with the
Intake As a Conflict Area in Clinic Function
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needs of people who are suffering through the worst disorders of the modern city, with apathy or violent action seeming to them their only options. Still another supervisor may believe that every experience in service delivery provides valuable training and that trainees must learn to cope creatively with whatever problems are brought to them. Fiscal survival for nongovernmental human services organizations has an urgency which bears on intake and priorities in service delivery, both by increasing pressure toward allocation of resources to specialist services delivered on a contractual basis, and by confronting us with the reality that we no longer have the philanthropic base to be able to give as much free service as the community may wish, and that third-party payment does not always accompany the greatest need. Intake workers feel these fiscal wolves at the door, even though clinic policy does not set ability to payor Medicaid coverage as a criterion of acceptance for service. (There is some logic in support of the latter position, when a generally very deprived population can be served with Medicaid coverage, and when psychiatric services are available through community clinics, so that a private clinic's free service is equivalent to subsidizing the public services.) Another series of conflicts has to do with clinical issues in the intake and referral system. The medical model which dictates an intake process based on description and history of an illness to be assessed and prescribed for by an expert comes into increasing competition with interactional models based on ego concepts (Bennett, 1973) or on some theories of family functioning, or of social causes of personal malfunctioning (Ewalt, 1973). These divergencies of view are linked with differences about whether treatment is seen as separated from intake and diagnosis, or as beginning-for long or for short, for better or for worse-with the first exchange on the telephone. What parental collaboration needs to be ensured by the intake process is differently viewed, as people have differing concepts of the nature of the child's problem. Disagreement is heard, too, about the extent to which the applicant is seen as entitled to make his own choice about where he goes for help and the kind of help he needs. If we offer a family an opportunity to sort out the problems of growing up and the hassles that the parents get into with their teen-ager, and the family, referred by the juvenile court, says the boy needs a doctor with some authority to lay down the law to him about normal and deviant behavior, are we to accept the family's prescription? Do we believe that a family who is aggrieved with
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another mental health organization should be free to shift to our services instead? The problem of choice of service is further complicated by the fact that the "patient" is a child and usually has no effective vote in the intake process. The intake worker may hear in the parents' account the story of a child who needs psychological help, and there may be disagreement about the parents' right to refuse that help. Another clinical and service-ethic disagreement is about the clinic's obligation toward applicants to whom it cannot provide direct service. Are they like shoppers for a TV set who are expected to continue to shop until they find what they want and can afford, or are they like the hurt arrivals at a hospital's doorway for whom the hospital will, one hopes, feel responsible until another plan is prepared? If the latter view is accepted, administration must commit adequate time and skill of the agency to deliver an intake and referral service matched to that concept of responsibility. Another problem relates to clinical issues and to issues concerned with decision-making. Intake and assignment machinery of child guidance clinics operated for many years with the presumption that treatment was carried out through individual interviews. Now that family, group, and educational therapies are frequently used, we must sort out how consideration of such alternative interventions should affect the intake process (e.g., whether the intake interview should be wholly or in part a family interview; whether one data base suffices for taking the steps that may lead to one or another type of intervention; at what point and by whom the initial decisions about choice of therapeutic approach should be made). Poor articulation and communication between the intake system, the assignment system, and the system for planning training have considerable effect on the quality and ease of the intake service. Indeed, who is responsible for making decisions about intake is a central and often prickly question, the more prickly if a clinic does not have a clear intake policy or is in process of changing it. For many years a high-level interdisciplinary committee at the Judge Baker screened those applications that social workers and others doing intake thought should be considered for service or felt undecided about. Often this system worked well, but it sometimes meant that a worker would have found with a family some hopeful sense of what the clinic could make available, only to have to go back to the family with a refusal of service or an unanticipated alternative plan. In any event this system imposed a stop on the path into the clinic that was often not intelligible to distressed people. A few years ago, a senior social worker was designated as intake coordinator. Intake responsibility is now rotated among several
Intake As a Conflict Area in Clinic Function
597
social workers and social work students. These workers, with whatever consultation with the intake coordinator they consider appropriate, are free to make case-by-case intake decisions within the reality of shifting personnel resources of the clinic and programmatic changes. The intake procedure, since it does not include anything like an open case conference, has a rather low visibility in the clinic; and that may contribute to some uneasiness in the clinic about how intake decisions are arrived at. Follow-ups of families referred elsewhere and of terminations against advice among cases given service beyond intake indicate less attrition than is usually reported in the literature, and show most parents satisfied about referrals elsewhere. One unfortunate consequence of strains around intake may be that the intake and referral function is not much enjoyed and tends to become a low-status function which is handed down from more to less experienced people, despite a preponderant view that it calls for a high degree of skill. When intake policy is unclear or in process of changc, decisions about referrals may be made on the basis of intake workers' feelings toward applicants, with the workers then concerned about whether they are acting on countertransference bases. A recital of complexities and problems calls for a prescription for change. Here, unfortunately, an analogy with the parking problem breaks down. The parking problem was taken in hand with one decisive act; it was turned over to a garage company, with an administrative person from the clinic setting priorities for claim on the more convenient or lower-priced parking spaces. While there is still complaint over parking, there is no longer a "parking issue" to come up at staff meetings. Questions and conHicts about intake cannot be settled in that way, however. The organization's very life is seen in constant change, which has to mean constant change in whatever functions tie the clinic's work to the surrounding world; and intake is one of these functions. Our intake workers must, as Toffler (1970) recornmends, learn how to live with change. What contributes to and is part of a good intake and referral service? Of first importance is an intake policy that is an appropriate expression of the clinical service goals of the organization, that provides a clear framework within which the intake service can function, and that takes reasonable account of both the clinic's resources and other resources in the community. The policy should be realistic with regard to the clinic's knowledge and capacities, but open to experimentation and change. The intake service needs to
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constitute a means of communication and adaptation between the clinic and its community. A good intake and referral service requires time for the process of listening thoroughly to people in trouble, clarifying what they want and where it can be found, and responding sensitively to their anxieties about seeking mental health services. Another component is the capacity of the intake service to "hear" underlying meanings, the broader implications that specific requests may have for previously unrecognized community need. Time should be available for staying with the process of referral elsewhere when that is called for. Time and skill are required for building good knowledge of resources. A training component helps to maintain high quality in the service, and a research component stimulates and guides needed change. These conditions for, and qualities of, a good intake service are much like those that contribute to a good intake process for a family or individual. The individual intake worker must listen as the clinic listens, to hear accurately the expressed need, and to grasp something of the implications and roots of this need. The mutual process of seeing how the family might utilize the clinic's resources and how the clinic's resources might be adapted to the family's need resembles the mutual process in which the clinic as an organization through its intake service negotiates the fit between community need and clinic program. In both the organizational service and the case-by-case intake process, an alliance with positive resources is sought and fostered, and a sense of mutual responsibility encouraged (Group for the Advancement of Psychiatry, 1961). The intake service, like the individual clinical intake, should be monitored by regular systematic assessment of how well the service is working, including its flexibility and openness to new developments. Such study is of importance in enriching conceptualization of clinical issues, and thereby improving teaching and practice in an area demanding specific kinds of art and knowledge-the sensitive and effective response to people who are seeking help because they are suffering or frightened or furious and don't know what to do.
REFERENCES ADAMS. P. L. & McDoNALD, N. F. (1968), Clinical cooling out of poor people. Amer.). Orthopsychiat., 38:457-46:i. BF.NNF.TT. I. B. (1973), Use of ego psychology ('(lIKepts in family service intake. Soc. Caseuik,
54:290-293.
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BRAGER, G. ( 1965) , Pape r read a t sy m posi u m o n work with unmoti vated clien ts, Floren ce H eller Sc hoo l, Brand eis U niversi ty. CO LEMAN , J., SHORT, G . B., & HIRSCHB ERG, .J. C . ( 1948) , T he inta ke interview as th e begin ninK of ps ychi atr ic treatment in ch ildre n's ca se s. Amer. j. Psvchiat., 105 : 183-186. COLLINS , A . H . ( 1969), The Lallely and Af raid. Ne w York : Od ysse y. EIDUSON, B. T. ( 1968), Ret reat from help . A mer. ], Orthopsychiat., 38 :9 10-92 1. EWAl.T, P. 1.. ( 1973), T he crisis- trea tm e nt approach in a chi ld g u ida nc e clinic. Soc. Casruik, 54 :406-4 II . FANTl., B. ( 19Ii4), Inleg ral in g soc ial a nd p sycholo gical th eo r ies in soc ia l work pract ice . Smith Coli. Stud . Soc. Wk, Vo l. 34, No.3. FRANK, J. D., G LlmMAN, 1.. H ,; btRER , S. D ., NASH, E. lL , J Roo & STONE, A . R. ( 195 7), Wh y p atients lea ve psych o th erapy. Arch. NruTOI. Psvrhiat., 77 :2It~-299 . GORDON , S. ( 1965), Arc we seei n g the right patients? C hi ld g ui da nce inta ke : the sacred co w. Amer .]. Orthop"ychiat., 35 : 131-1 37 . GROUP FOR THE ADVAN CEMF.NT OF PSYCHtATRY (1950), Basic Concepts in Child Psychiatry. Ne w York: Group for the Adv ancem ent of Psychiatry, Repo rt N o . 12. - - - (1961), lnitial lntervin os. New York: Group for the Advancement of Psychiatry, Rcport No. 49. HANSELL, N. (1967), Pat ient predicament and clinical se r vice . Arch. Grn. Psychiat., 17:204-210. HtR SCHOWITZ , R. (197 3 ), Pe rsonal co m m u n ica tio n , KLUGER, J. M . (1970), T he u ni ns u la ted case load in a ne ighhorhood mental health center. Amer .], Psschiat., 126 :14 30-1 436 . LAZARE, A., COHEN , r., J ACOBSON, A. M., WIl .l.IAMS, M. W ., MIGNONE, R. J., & ZISOOK , S. ( 1972) , T h e walk-in patie nt as a "c us to m er." A m", ]. Orthopsychiat.• 42 :87 2-883. MAYER , J. E. & TI MMS, N . ( 1969), C lash in p erspect ive be tween wo r ker and client. Soc.
Caseiok,
5 0 ::~ 2-4 f).
POLA NSKY , N . & KOUNIN, J. ( 1956) , Clie n ts' react ion s to ini tia l interviews. Hum. Rel., 9 :237 - 264 . REID, P. N . ( 1972), Ref o rm in g the socia l se rvic es monopol y. Soc. W k, 17(6 ):44-54 . T OFFl.ER, A. ( 1970), Futu re Shock. Ne w York : Rand om H o use ,
Individuals all have their characteristic ways of experiencing stress: different as to the area of life in which the stress is felt, what name is given to it, what defenses are used, and what aspect of the total person is most vulnerably reactive. Organizations, too, have characteristic ways of reacting to stress, ways that are part of the continuing "personality" of an organization. The stresses in a child guidance facility are bound to affect service functions in some way; and probably, as in any social system, points of interaction between the organization and its environment are subject to the greatest tension and thus may become the focus for staff concern or dissatisfaction. At the Judge Baker Guidance Center, the intake and referral service for some time was such an area of repeated concern. The Center used to be housed in a central city area where parking was almost impossible. When the clinic moved to a larger building with a parking area of its own, the staff felt a great sense of relief-short-lived, because the parking space was soon insufficient for the staff, let alone the patients. As demands on the limited space increased, there were constant debates about the basis for assigning parking spaces, alternative transportation, response to interlopers, and many other real uncertainties. For years, also, one could predict that when some thorny, but half-hidden issue needed discussion at staff meetings, the staff would soon find themselves engaged in heated debate about "the parking problem." A similar phenomenon seems to have occurred in relation to intake; that is, reality problems concerning intake arose from changing times, but were then magnified and distorted by displacement of feelings about many different issues in the life of the clinic. It was notable how often administrative or planning meetMiss Staver is Chief of Psychiatric Social Work and Miss LaForge is Intake Coordinator, Judge Baker Guidance Center, Boston. Reprints nuzy be requestedfrom Miss Staver, Judge Baker Guidance Center, 295 Longwood Avenue, Boston, Massachusetts 02115.
589
590
Nancy Staver and Elizabetb LaForge
ings at the clinic fell into fierce discussion of how intake was handled. Parking and intake both have to do with a clinic's interface with the community-with "how to get to the c1inic"-and perhaps this fact determines their both being foci of contention in a time of change. Policy development regarding parking and regarding intake also has some common elements, being determined by spatial and numerical realities, and by choices made by the organization about needs and priorities as these change over time. The rapidity of change and the adaptive demands that its pace places on individuals and organizations are no news to mental health professionals who are working in a field that has been experiencing its own revolution during the last 10 to 20 years. Internally, and in its relation to families, neighborhoods, government and human service organizations, child psychiatry has altered drastically. One might expect that such change would be reflected in the intake function just because that function connects the internal organization to the environment. Fifty years ago, the Judge Baker presumably had no intake problem. The clinic was started by Healy and Bronner in 1917 as a diagnostic and advisory service, primarily for the Boston Juvenile Court. There appear to have been no uncertainties about the population to be served or the nature of the service to be offered, since in addition to their concern about children coming before the court, Healy and Bronner were eager to be of service to children referred by the various agencies of society that were dealing with upset or maladjusted children. Over the next two decades, the clinic became independent of the court, offered service increasingly to the whole metropolitan area, and developed an extensive, skilled treatment function, supported by the growth of child analysis. Thus, by the early 1940s referrals were coming directly from families and from a network of health and welfare agencies as well as the court. That shift of function must have been reflected in painful and painstaking revisions of how referrals were dealt with, but we have no record of the process. The clinic was then small enough so that informal communication about availability of services was feasible. Supply and demand were well enough matched so that a mother could call on Monday, have an application interview on Wednesday, and start treatment for her child and herself the following week. Clinical staff were in general agreement that child guidance diagnosis or treatment should be available for anyone wanting it, with only such gross limitations as age and some misgivings about how much help could be given to retarded children. The clinic's intake at that time
Intake As a Conflict Area in Clinic Function
591
probably involved little conflict of values or priorities, and little tension between clinic and community. Following World War II, there was a great surge of civilian interest in emotional problems and psychiatric services. Demand for such services rapidly outstripped supply in a process which continued for many years, despite the multiplying of psychiatric services. The Federal government's support of training for mental health professionals also changed the service picture and moved the clinic into a dual role: training and service were both seen as major commitments of the agency (though training in the clinical disciplines had taken place throughout the life of the clinic, as had practice-based research). At this period, some tensions developed around intake. There were internal disagreements about training vs. service priorities, the social workers taking intake calls felt pressured by the needs of applicants for whom service was not available and by occasional use of "back doors" to service. There was resentment in the community toward the clinic over waiting lists or the alternative at that time of closed intake. One response to these strains was the clinic's setting up an interdisciplinary intake committee and more formal screening procedures. The 1950s were marked for our clinic, as for others, by development of more varied services--inpatient treatment, day care, group treatment-and by closer ties with medical institutions. The primary impact of these changes on intake was to complicate the relationship between intake decisions and assignment or treatmentplanning decisions. Partially separated intake channels developed for these different services. The possibility of referrals from one service to another within the clinic made more obvious some of the ways in which intake decisions might be influenced by the power of the sender or the receiver of the referral, or by the patient's already being known to someone in the organization and thus having his needs more vividly felt by the referrer. In the 1960s, society's renewed and more informed attention to the problems of poverty and of urban disorder was bringing to the fore a new set of pressures on clinic services. There began a steady, large shift to a preponderance of referrals of working-class or financially dependent inner-city families. The community made the clinic's intake sharply aware of clinic behavior or decisions that seemed to be in any way discriminatory. Within the clinic there were differences of view concerning feasibility and priorities in offering service to people whose expectations and needs often fit very poorly with our traditional expectations and knowledge. The late 1950s and 1960s saw the development of more social concepts
592
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among psychiatrists and psychologists, and more treatment skills among social workers. The blurring of disciplinary boundaries as all clinical disciplines took on overlapping diagnostic and treatment roles probably also affected role definition and satisfaction in relation to the intake function. The greatly increased knowledge concerning organic factors in children's problems also had an impact on intake, both in terms of what parents and others were requesting and of how the tasks of the intake interview were conceived. The appearance of the community mental health clinics within the last decade in its turn brought new tensions to the intake function. For a clinic that was not part of a catchment area system, difficult issues about organizational responsibility and patients' rights arose. Philosophical and clinical issues about freedom of choice for patients became very practical decision problems when a mother said she would positively not return to her local clinic because such and such had displeased her there. Intake workers at a clinic like the Judge Baker worried lest they find themselves referring back to their local community mental health clinics the families with more serious problems or fewer resources, while intake workers at community mental health clinics were Hooded with the requests of great numbers of people whom they had a statutory obligation to serve. A greater variety of child mental health resources became available especially for suburban residents. Epidemiological and cultural changes were perhaps occurring as well, bringing a larger population of angry, action-oriented, and impatient sufferers to the doors of inner-city clinics, so that swift availability of service was often a deciding factor about handling referrals. The literature concerning intake naturally reflects these historical trends. For some reason, the intake literature has come more from adult psychiatry and social services than from child psychiatry, possibly because child patients do not usually refer themselves, complain about waiting lists, or demand equal treatment or a voice in intake decisions. Coleman et al. (1948) discussed the intake interview with a mother as in itself an actual treatment experience; those were the days of the developing waiting lists, and the authors saw a waiting period after the intake interview as providing an opportunity for a "consolidation of intent." Two years later, a Group for the Advancement of Psychiatry report (1950) on concepts in child psychiatry discussed the intrafamilial nature of the child's disorder, and stressed the parents' being free to choose not to use clinic services. During the years of enormous expansion of mental health services, Polansky and Kounin (1956), Frank et al. (1957),
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and Eiduson (1968) were undertaking studies of factors inHuencing the effectiveness of the initial contact as measured by continuance rates, expressed satisfaction, or outcome-factors such as hope, a sense of the competence of the helping person, and intelI~ctual preparedness for the nature of the psychotherapeutic interview. In the late 1950s and the 1960s, under stimulus of the fresh awareness of, and approaches to, problems of poverty and deprivation, there came a host of reports on newly based and designed clinical services intended for poor, alienated, or disadvantaged populations. These included discussions of intake procedures as these made help more or less available to previously seldom served communities. Gordon (1965), Fantl (1964), Kluger (1970), and others (Brager, 1965; Adams and McDonald, 1968; Collins, 1969) questioned traditional intake and referral procedures, some seeing these as a means of discouraging poor people from using clinics, others describing alternative intake procedures aimed at eliminating delay, money, strangeness, 01' motivation as barriers to offering service. Mayer and Timms (1969) did a vivid study of the frequent gross misunderstanding between social workers and prospective clients about what could constitute help. Articles concerned with the relationships between clinics and communities have appeared especially in the last few years. Reid (1972) and Lazare et al. (1972) at Massachusetts General Hospital raised new questions about whether the providers of service or the potential consumers should make the choices about what kind and what amount of help would be useful. Hansell (1967) conceives of intake as being the point at which linkages with formal and informal support systems are established or mobilized. Hirschowitz (1973) sees the intake person as "gatekeeper," and discusses sanctions, power, and loyalties within the organization as factors inHuencing the actual decisions about who gets served and by what means. The Judge Baker Guidance Center is one of three independent child guidance clinics, hospital-affiliated but essentially autonomous, serving children and families in a metropolitan area of nearly a million persons and offering clinical training to educators, nurses, and theological students as well as to the usual clinical disciplines. In addition to these three clinics, about twenty to thirty other facilities in the area offer general or specialized psychiatric services for children in general 01' psychiatric hospital settings, courts, community mental health clinics, etc. Despite the wealth of resources, the Judge Baker has been able in recent years to offer
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continuing service to fewer than half th e people who request help. Approximately one fourth of the clini c's ser vices at an y given time go to special groups, suc h as correctional syste m referrals, who are speciall y routed into th e clinic and do not e nter through the general child guidance intake service door. Intake se rv ice for general ch ild guidance referrals is provided by social work staff, with some minor participation of other departments. Th e social workers covering intake try to offer thoughtful and well-su p po r ted referral for people best served elsewhe r e, or for whom the clinic does not ha ve re sources at a given time. The general chi ld guidance referrals come at a rate of about 500 a year, with cons ider a ble seasonal variation. The majorit y of referrals are made directly by parents, and nearly half the referrals are from the city of Boston. What, then, are the conflicts that impinge on this function, which sounds so simple and com fo r table in a bri ef description? The historical statement ha s adumbrated some of th em . One unceasin g co n fl ict arises from the program choices that must alwa ys be mad e because personnel r eso u rc es ar e never unlimited , and becau se fu nc tio ns never r em ain sta tic. These program cha nges- mo re se rv ice to delinquent or to negl ected or abused ch ild ren, to ch ild re n in fost er care or ch ild re n with severe psychosomatic di sordcrs-s-ncccssitatc diminution o f serv ice to some other population and crea te a need for readjustm ent in the clinic's rel ationship with th e co m m u nity and its access to the clinic. New programs ma y call for differential handling of intake. For instance, when a mobile crisis intervention team goes into a co mmunit y, th e clini c must ensure access to th e clini c for the families served by th at team but needing in-clin ic se rv ices in addition . Whether tr aining or serv ice has priorit y in th e clinic's go als is a source of confl ict a t th e point of intake . So meone with broad training responsibilities is con cerned to have work re ad y and waiting when trainees arri ve, but patient needs d o not usually time themselves neatly to fit a training calendar, nor d o most applicants these days find it tolerable to wait a long tim e for service . Referrals d o not come arranged to provide well-mixed experience for trainees, yet we do not want to train clinicians through working only with latency-age learning-problem children or with delinquent adolescents. There are also com peting views abo u t the amount and kind of clini cal experience that provides optimal learning, so that one supervisor ma y be more co ncern ed for his trainees to work with people whose neu roti c problems make clear th e nature of internal co nflict, while a no ther su pe rvis o r believes that a primar y ingredient in good learning experience is th e necessit y to cope with the
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needs of people who are suffering through the worst disorders of the modern city, with apathy or violent action seeming to them their only options. Still another supervisor may believe that every experience in service delivery provides valuable training and that trainees must learn to cope creatively with whatever problems are brought to them. Fiscal survival for nongovernmental human services organizations has an urgency which bears on intake and priorities in service delivery, both by increasing pressure toward allocation of resources to specialist services delivered on a contractual basis, and by confronting us with the reality that we no longer have the philanthropic base to be able to give as much free service as the community may wish, and that third-party payment does not always accompany the greatest need. Intake workers feel these fiscal wolves at the door, even though clinic policy does not set ability to payor Medicaid coverage as a criterion of acceptance for service. (There is some logic in support of the latter position, when a generally very deprived population can be served with Medicaid coverage, and when psychiatric services are available through community clinics, so that a private clinic's free service is equivalent to subsidizing the public services.) Another series of conflicts has to do with clinical issues in the intake and referral system. The medical model which dictates an intake process based on description and history of an illness to be assessed and prescribed for by an expert comes into increasing competition with interactional models based on ego concepts (Bennett, 1973) or on some theories of family functioning, or of social causes of personal malfunctioning (Ewalt, 1973). These divergencies of view are linked with differences about whether treatment is seen as separated from intake and diagnosis, or as beginning-for long or for short, for better or for worse-with the first exchange on the telephone. What parental collaboration needs to be ensured by the intake process is differently viewed, as people have differing concepts of the nature of the child's problem. Disagreement is heard, too, about the extent to which the applicant is seen as entitled to make his own choice about where he goes for help and the kind of help he needs. If we offer a family an opportunity to sort out the problems of growing up and the hassles that the parents get into with their teen-ager, and the family, referred by the juvenile court, says the boy needs a doctor with some authority to lay down the law to him about normal and deviant behavior, are we to accept the family's prescription? Do we believe that a family who is aggrieved with
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another mental health organization should be free to shift to our services instead? The problem of choice of service is further complicated by the fact that the "patient" is a child and usually has no effective vote in the intake process. The intake worker may hear in the parents' account the story of a child who needs psychological help, and there may be disagreement about the parents' right to refuse that help. Another clinical and service-ethic disagreement is about the clinic's obligation toward applicants to whom it cannot provide direct service. Are they like shoppers for a TV set who are expected to continue to shop until they find what they want and can afford, or are they like the hurt arrivals at a hospital's doorway for whom the hospital will, one hopes, feel responsible until another plan is prepared? If the latter view is accepted, administration must commit adequate time and skill of the agency to deliver an intake and referral service matched to that concept of responsibility. Another problem relates to clinical issues and to issues concerned with decision-making. Intake and assignment machinery of child guidance clinics operated for many years with the presumption that treatment was carried out through individual interviews. Now that family, group, and educational therapies are frequently used, we must sort out how consideration of such alternative interventions should affect the intake process (e.g., whether the intake interview should be wholly or in part a family interview; whether one data base suffices for taking the steps that may lead to one or another type of intervention; at what point and by whom the initial decisions about choice of therapeutic approach should be made). Poor articulation and communication between the intake system, the assignment system, and the system for planning training have considerable effect on the quality and ease of the intake service. Indeed, who is responsible for making decisions about intake is a central and often prickly question, the more prickly if a clinic does not have a clear intake policy or is in process of changing it. For many years a high-level interdisciplinary committee at the Judge Baker screened those applications that social workers and others doing intake thought should be considered for service or felt undecided about. Often this system worked well, but it sometimes meant that a worker would have found with a family some hopeful sense of what the clinic could make available, only to have to go back to the family with a refusal of service or an unanticipated alternative plan. In any event this system imposed a stop on the path into the clinic that was often not intelligible to distressed people. A few years ago, a senior social worker was designated as intake coordinator. Intake responsibility is now rotated among several
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social workers and social work students. These workers, with whatever consultation with the intake coordinator they consider appropriate, are free to make case-by-case intake decisions within the reality of shifting personnel resources of the clinic and programmatic changes. The intake procedure, since it does not include anything like an open case conference, has a rather low visibility in the clinic; and that may contribute to some uneasiness in the clinic about how intake decisions are arrived at. Follow-ups of families referred elsewhere and of terminations against advice among cases given service beyond intake indicate less attrition than is usually reported in the literature, and show most parents satisfied about referrals elsewhere. One unfortunate consequence of strains around intake may be that the intake and referral function is not much enjoyed and tends to become a low-status function which is handed down from more to less experienced people, despite a preponderant view that it calls for a high degree of skill. When intake policy is unclear or in process of changc, decisions about referrals may be made on the basis of intake workers' feelings toward applicants, with the workers then concerned about whether they are acting on countertransference bases. A recital of complexities and problems calls for a prescription for change. Here, unfortunately, an analogy with the parking problem breaks down. The parking problem was taken in hand with one decisive act; it was turned over to a garage company, with an administrative person from the clinic setting priorities for claim on the more convenient or lower-priced parking spaces. While there is still complaint over parking, there is no longer a "parking issue" to come up at staff meetings. Questions and conHicts about intake cannot be settled in that way, however. The organization's very life is seen in constant change, which has to mean constant change in whatever functions tie the clinic's work to the surrounding world; and intake is one of these functions. Our intake workers must, as Toffler (1970) recornmends, learn how to live with change. What contributes to and is part of a good intake and referral service? Of first importance is an intake policy that is an appropriate expression of the clinical service goals of the organization, that provides a clear framework within which the intake service can function, and that takes reasonable account of both the clinic's resources and other resources in the community. The policy should be realistic with regard to the clinic's knowledge and capacities, but open to experimentation and change. The intake service needs to
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constitute a means of communication and adaptation between the clinic and its community. A good intake and referral service requires time for the process of listening thoroughly to people in trouble, clarifying what they want and where it can be found, and responding sensitively to their anxieties about seeking mental health services. Another component is the capacity of the intake service to "hear" underlying meanings, the broader implications that specific requests may have for previously unrecognized community need. Time should be available for staying with the process of referral elsewhere when that is called for. Time and skill are required for building good knowledge of resources. A training component helps to maintain high quality in the service, and a research component stimulates and guides needed change. These conditions for, and qualities of, a good intake service are much like those that contribute to a good intake process for a family or individual. The individual intake worker must listen as the clinic listens, to hear accurately the expressed need, and to grasp something of the implications and roots of this need. The mutual process of seeing how the family might utilize the clinic's resources and how the clinic's resources might be adapted to the family's need resembles the mutual process in which the clinic as an organization through its intake service negotiates the fit between community need and clinic program. In both the organizational service and the case-by-case intake process, an alliance with positive resources is sought and fostered, and a sense of mutual responsibility encouraged (Group for the Advancement of Psychiatry, 1961). The intake service, like the individual clinical intake, should be monitored by regular systematic assessment of how well the service is working, including its flexibility and openness to new developments. Such study is of importance in enriching conceptualization of clinical issues, and thereby improving teaching and practice in an area demanding specific kinds of art and knowledge-the sensitive and effective response to people who are seeking help because they are suffering or frightened or furious and don't know what to do.
REFERENCES ADAMS. P. L. & McDoNALD, N. F. (1968), Clinical cooling out of poor people. Amer.). Orthopsychiat., 38:457-46:i. BF.NNF.TT. I. B. (1973), Use of ego psychology ('(lIKepts in family service intake. Soc. Caseuik,
54:290-293.
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BRAGER, G. ( 1965) , Pape r read a t sy m posi u m o n work with unmoti vated clien ts, Floren ce H eller Sc hoo l, Brand eis U niversi ty. CO LEMAN , J., SHORT, G . B., & HIRSCHB ERG, .J. C . ( 1948) , T he inta ke interview as th e begin ninK of ps ychi atr ic treatment in ch ildre n's ca se s. Amer. j. Psvchiat., 105 : 183-186. COLLINS , A . H . ( 1969), The Lallely and Af raid. Ne w York : Od ysse y. EIDUSON, B. T. ( 1968), Ret reat from help . A mer. ], Orthopsychiat., 38 :9 10-92 1. EWAl.T, P. 1.. ( 1973), T he crisis- trea tm e nt approach in a chi ld g u ida nc e clinic. Soc. Casruik, 54 :406-4 II . FANTl., B. ( 19Ii4), Inleg ral in g soc ial a nd p sycholo gical th eo r ies in soc ia l work pract ice . Smith Coli. Stud . Soc. Wk, Vo l. 34, No.3. FRANK, J. D., G LlmMAN, 1.. H ,; btRER , S. D ., NASH, E. lL , J Roo & STONE, A . R. ( 195 7), Wh y p atients lea ve psych o th erapy. Arch. NruTOI. Psvrhiat., 77 :2It~-299 . GORDON , S. ( 1965), Arc we seei n g the right patients? C hi ld g ui da nce inta ke : the sacred co w. Amer .]. Orthop"ychiat., 35 : 131-1 37 . GROUP FOR THE ADVAN CEMF.NT OF PSYCHtATRY (1950), Basic Concepts in Child Psychiatry. Ne w York: Group for the Adv ancem ent of Psychiatry, Repo rt N o . 12. - - - (1961), lnitial lntervin os. New York: Group for the Advancement of Psychiatry, Rcport No. 49. HANSELL, N. (1967), Pat ient predicament and clinical se r vice . Arch. Grn. Psychiat., 17:204-210. HtR SCHOWITZ , R. (197 3 ), Pe rsonal co m m u n ica tio n , KLUGER, J. M . (1970), T he u ni ns u la ted case load in a ne ighhorhood mental health center. Amer .], Psschiat., 126 :14 30-1 436 . LAZARE, A., COHEN , r., J ACOBSON, A. M., WIl .l.IAMS, M. W ., MIGNONE, R. J., & ZISOOK , S. ( 1972) , T h e walk-in patie nt as a "c us to m er." A m", ]. Orthopsychiat.• 42 :87 2-883. MAYER , J. E. & TI MMS, N . ( 1969), C lash in p erspect ive be tween wo r ker and client. Soc.
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POLA NSKY , N . & KOUNIN, J. ( 1956) , Clie n ts' react ion s to ini tia l interviews. Hum. Rel., 9 :237 - 264 . REID, P. N . ( 1972), Ref o rm in g the socia l se rvic es monopol y. Soc. W k, 17(6 ):44-54 . T OFFl.ER, A. ( 1970), Futu re Shock. Ne w York : Rand om H o use ,
