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Paraprofessional Child Therapists MILTON S. ADAMS, M.D., Director of Child Services, Hahnemnann Community Mental Health/Mental Retardation Center, Philadelphia, Pennsylvania
Over the past 10 years we have become increasingly aware of the lack of services, direct and indirect, which address the mental health needs of both children and adolescents. It is apparent that we shall never be able to meet current manpower needs by the professional or non-professional in providing the kind of services children need and deserve. Despite the fact that this country has 210 million people, there are only 25,000 adult psychiatrists. It is estimated that minority groups (primarily black) make up less than 5% of this group. We have at least 10 million people under the age of 25 who need some help from mental health workers, both professional and para-professional. Because of this situation, increasing attention has been given to the development and utilization of other mental health personnel other than the traditional trinity of psychiatrist, psychologist, and social worker. There have been some papers in psychiatric literature which have described the role of the paraprofessional in adult psychiatry. There have been few, if any, which describe the past, present, or future role of the para-professional who deals primarily with the mental health needs of children. Here we shall look at the para-professional as a child therapist based on the author's experience of five years in two different community mental health centers, three of which were spent recruiting, training, supervising, and evaluating the performance of nearly two dozen para-professional child therapists. The term para-professional has lost much of its specificity. In some centers, institutions, or schools, a para-professional is any-
one who has less than a master's degree or undergraduate degree in a specific discipline. The term, however, is commonly reserved for those who have a high school diploma or less in formal education, who have had some modicum of training-either formal or informal, and who work alongside and under the supervision of a professional. In the psychiatric field these people are frequently referred to as child care workers, child care aides, psychiatric technicians, mental health assistants, sub-professionals, new professionals, semi-professionals, child health associate, nurse practitioner, or even homemakers. SETTING
The Community Mental Health Center at Temple University, which was taken over by a Community Board in January of 1973, serves a catchment area of four square miles in which approximately 208,000 people reside. According to the 1970 Census, approximately 77.9% are black, 21.1% white, and 1.0% have Spahish surnames. At least 100,000 are under the ages of 18, with at least 10 to 15,000 of that number in need of mental health services. The name of the Center has changed to that of the North Central Philadelphia Community Mental Health/Mental Retardation Center. Temple University was one of the first Centers (1966) to pioneer in the recruitment and utilization of indigenous people as paraprofessional therapists. At this institution the role and function of the para-professional or mental health assistant has been tortuous, ambiguous, and confused at best. Indigenous people were recruited from the immediate
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catchment area which is an economically deprived area. Several years ago the Federal Government deemed the area a poverty one. This philosophy at the time was that in order to fill the gap in mental health personnel and to try new or innovative approaches to mental health delivery and mental health care, indigenous personnel, would be screened, trained, placed in the community mental health center, under the supervision of professionals, and would assume the role of "primary therapists." This idea, up until 1966, was generally unheard of, at least as to the concept of the para-professional as the primary therapist or "change person." The initial concept was noble. It has been the contention of many in the mental health field that the primary role of community mental health centers was to provide aftercare services for the thousands of state hospital patients who were subsequently deposited in the back wards of the "community." As these chronically impaired people were poured into nursing and boarding homes, they eventually found their way into the community mental health centers. It was felt that the emotional deficits and needs of such people could be adequately handled by mental health assistants with back-up support and training by professional staff. This was an interesting and revolutionary concept, particularly when it is realized that many of these patients had been institutionalized for as long as 40 years, and presented with severe psychological, social, and physical problems. While hospitalized, many were tested and therapeutized by a wide variety of mental health personnel with varying degrees of skill and interest. The results were often disappointing at best. Now these patients were to be cast into the community to be serviced by untrained and unskilled people. The mental health assistant was not only told that he or she had unique sensitivity, skills, and intuition to handle such patients, but as primary therapists they were indeed superior to any professional, especially psychiatrists. Unfortunately, many believed this and frequently were resistant to any form of organized training or traditional psychiatric concepts. When the inservice training was im-
SEPTEMBER, 1975
plemented, it was frequently poorly organized, irrelevant, fragmented, loosely monitored and out moded. It also was not interfaced with a career ladder program, or tied into increased salaries for increased skills. CHILDREN AND FAMILY UNIT
The Children and Family Unit, which developed initially as a consultative rather than a direct service program, gradually expanded to include a small group of mental health assistants which complemented the initial small core of professionals. Several of the para-professional staff were recruited from the original pool of mental health assistants. This meant that they would have to make the transition from that of primary adult therapist to primary child therapist. After this initial expansion it became quite apparent that additional training was required for those who were to work primarily with children-especially the six to 12-year-old group. One of the first things I did upon assuming the role of the Director of the Children and Family Unit (April, 1971), was to assess the needs of the para-professional staff. This meant a change and revision of job duties commensurate with the expanded direct service responsibilities of the Unit. Six months prior to my arrival, a mental retardation staffing grant had been acquired. We were now the only Mental Health Center in the city which had mental retardation services combined with a children's service. The implication of this was tremendous. Our new ''counselors" would also be expected to handle or manage both children and adults with varying degrees of mental retardation. Because the Center-wide training program was insufficient to meet our varied needs, the former director had already launched an inservice training program which would address the specific needs of our counselors. TRAINING
Fortunately, our initial group of paraprofessionals were men and women of unusual ability and tremendous dedication. They had spent two to three years as mental
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health assistants and were ready for the challenge of dealing with children-both retarded and emotionally disturbed. The majority had already taken college-related courses and were pursuing their own program of upward mobility. We sought out and were able to recruit several para-professionals who had or were in the process of completing a formal two year training progranm in child care. Upon my arrival as the new director, I felt that as we expanded our Unit and services both direct and indirect, it was necessary to revise, expand and update our own inservice training. The first year we took advantage of whatever inservice training, conferences, etc. were offered by the Center. New staff were oriented through a training program provided by the H.C.U.* of St. Christopher's Hospital, the pediatric hospital of Temple University Hospital. Since the Unit, as well as the Center employees were under the mantle of the University, many of our staff-especially para-professional took advantage of reduced tuition rates and pursued college courses in the evening. Recently, we were able to obtain work release time (three hours per week) for job-related courses at the University. We have made generous use of course work being provided by other agencies. An example is a 10 week course given by a local agency on the sexual needs, problems, and education of the retarded. Since we have a separate or identifiable budget, we have allocated a specific sum of money for staff training and development. In the beginning of September, we mapped out our inservice training as best we could for the next six months. Since we believe a health program should be subject to ongoing scrutiny and change, we have attempted to make our inservice training relevant, integrated (both mental retardation and mental health) with other Units, and one which comes from the needs and wishes of both professional and para-professional staff alike. Currently, we run two different groups or level of instruction. Group one is primarily designed for those staff who have had less than a year of experience in the mental health field*Handicapped Children's Unit- A special service for children with cerebral palsy. convulsive disorders, mental retardation and other developmental disabilities.
specifically child mental health. Group II is designed for those counselors or mental health staff who have had one or more years of experience. We stress a group format, encouraging mutual interchange rather than the traditional didactic "I'm the teacher you're the student approach." Although we obtain input from the entire staff before implementing the inservice program, we feel that for entry level or relatively inexperienced staff, there are certain basic concepts, principles, or techniques which have to be mastered if one is to provide an effective treatment program. We have also made liberal use of training films, outside speakers, agency visits and case conferences. Whenever a consultant is hired, e.g. pediatrician, developmental psychologist, speech therapist, etc. we try to maximize our use of these specialists. Besides having them scheduled to see or evaluate patients, we set aside a period for using them as teachers. This not only provides a welcome relief from the sometimes tedious monotony of their job, but provides additional input for our staff. Additional training is provided through individual supervision-more of which will be discussed later-and various city, state, and national conferences. Recently, our Center has been the recipient of a New Careers Grant. This is a program funded by N.I.M.H. The Center will make available to eighteen current staff para-professional and eight indigenous people a program which will allow them to attend school (community college) three days a week and work the other two days a week for two years while they earn an associate degree in mental health. These people will be screened by a committee of both professional and para-professional staff (including the Community Board) and will maintain their current salary level. Those who wish to, will be able to move on to a four year college program upon completion of the A.A. degree. CASELOAD
The caseload of the children and family counselors is indeed a varied one. Children
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and adolescents are referred from many sources-mostly from the area schools. Referrals are discussed once a week at a screening conference. At this time, a decision is made to either keep the referral for treatment or counseling in our own Unit, or refer back to a more appropriate service. Assignments are made on the clients retained in our service. The assignments are made on the basis of the current case load of the therapist, experience and skill of the para-professional, nature of the presenting problem, e.g. an aggressive, acting out adolescent male with sexual problems would not be paired with a young or inexperienced female therapist. Assignments are made to both professional and para-professional staff. All staff carry both retarded and non-retarded patients. We stress a variety in diagnostic problems, age group, and cultural background. Since we service a significant Puerto Rican population, we have found it invaluable to have a Puerto Rican, Spanish-speaking therapist on staff. We have one young male worker who has had considerable experience in dealing with delinquent adolescents, another who has had considerable experience in family therapy-this diversity of staff gives us considerable lattitude in therapist selection. Each counselor carries a caseload which may vary from 10 to 30 individuals. Each is seen according to the perceived need. Some two or three times a week, others once a month. SUPERVISION
Supervision is the essential ingredient for making the entire para-professional program workable. I view supervision as the coming together of a more experienced person with a less experienced to share and learn from each other. Each staff person is responsible to someone else. Supervisors generally meet once a week or twice a month with their supervisee depending on the needs of each. Some will require a progress report from each person on every case carried. Others will focus on problem cases, meet in a group, or supplement their supervision with
SEPTEMBER, 1975
small case conferences. We know that supervision causes problems for some. Supervisors, who usually are middle class in their orientation, must learn how to relate or provide supervision which is relevant for both para-professional and client. Age differences sometimes pose problems-especially when the supervisee is much older than the supervisor. Cultural and racial differences must be taken into account. Failure to do so, can frequently impede progress and result in poor case management. We have found it helpful to have two different groupings or seminars. Once a month a general counselors meeting is held, in which the counselors (approximately 20) sit down with the director and occasionally some of the other professional staff and have an open discussion of their problems, both intra and inter Unit. This not only provides a forum for emotional release, but allows the director and other administrative personnel an opportunity to listen to common concerns and grievances. It is hoped that these sessions may become more focused and problemsolving in the future. Every other week a "supervisors' meeting" is held, where the supervisory staff explore their common problems, concerns and ideas among each other. This has generally been a well received meeting and one in which everyone feels comfortable in expressing themselves. STRATEGIES
One of the unique features of our paraprofessional staff is their kiiowledge of the community and willingness to make home visits. Since many live or have resided in the catchment area, they are quite familiar with the different neighborhood schools and agencies. After a case is assigned, the therapist discusses it with his supervisor, contacts the family and conducts the initial intake. When a family is unable to come to the Center, home visits are made. This brings the service to the client, allows the therapist an opportunity to actually see the living situation, and lets the client or family know that they are willing to extend themselves in their behalf. There are disadvantages in home
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visits-they can be abused, by both therapist and client. However, we generally make judicious use of them, and in some cases, this can make the difference between service or lack of service. Visits are occasionally made on weekends or in the evening. Clients are often transported to an appointment (hospital, welfare, court, etc.). The therapist routinely contacts the school in most cases. They have become adept at meeting teachers, counselors, principals, making classroom observations, and generally maintaining the type of informative alliance so necessary for good clinical care. Supportive counseling is widely used as a technique; this is supplemented with play therapy for younger children. Since psychiatric, psychological, educational, and pediatric evaluations are so readily obtained, the para-professional (under close supervision) will frequently utilize some insight in their treatment armamentarium. One of the problems has been the frustration by some of the more inexperienced counselors of defining treatment goals. There is also a tendency at times to over-identify with the patient, or a tendency to be unduly critical of parents. The supervisors should operate in such a way that they encourage and help direct clinical potential and ability. Some have to resist the temptation of making "junior social workers" or "psychiatrists" out of paraprofessional staff. Whenever difficulties arise which cannot be worked out between supervisee and supervisor, the director will meet with both and try to help resolve the problem. We are currently experimenting with the "buddy system" and rotating or multiple supervisors. The "buddy system" is designed for new para-professionals who have just entered the job. They are assigned to a more experienced counselor the first few months to help them through the various forms, procedures, anticipated problems, etc. This alliance, in addition to the supportive one of their clinical supervision has proven to be very helpful. Since psychiatrists, social workers, and psychologists have different philosophies and case management styles, we feel it is more helpful for para-professional staff to rotate after a year to another disci-
385
pline. The other plan which is informally operative, is that of meeting with several different supervisory staff to discuss case management of unusual or difficult problems. We have encouraged the use of short term or time-limited treatment. This not only allows the Unit and staff to see a larger number of children, but reduces dependency, forces the therapist to rapidly organize his thinking and work on realistic goals. Group therapy has been increasingly advocated as a treatment approach that many of our paraprofessionals use. Some have served as cotherapists of both latency-aged and adolescent groups. They have done this in the Center and in some instances in schools where we have a formal mental health program. Again, supervision is a must-especially in group work, where you are dealing with many children and multiple problems. Family therapy has been utilized by some. Some have become quite adroit in using family therapy on home visits with broken or one parent families. Behavior therapy is one technique that many of our para-professional staff have resisted using. Perhaps our training program has not met the challenge of how to present it effectively. Another possibility is that it frequently makes repetitive demands on both therapist and patient, and there is still some resistance on the part of both. We are now experimenting with the use of using more experienced and capable paraprofessionals as supervisors. So far, we are reasonably optimistic and feel that this may be another use for skillful counseling staff. PROFILES Ms. L is a 24-year-old black woman who has recently completed twenty-two months as a child care workers. This is a position which pays less than a regular counseling position, and requires an ability to relate to and get along with preschool children. Ms. L. had completed high school and one year of working in a nursery school as a teacher's helper. Her particular position was locked into a specific program and depended on an increasing number of referrals of pre-school retarded children. Over the months, we found that these referrals virtually dried up. Her position was the only one of its kind; there was no chance for upward mobility. As the months wore on, and Ms. L. became increasingly discontented with her work and her supervisor, she came to me for advice. After meeting with her and different people who were involved with her work, it was decided to do two different things: 1) Change her supervisor; 2) Change her job title to a more relevant one-one that provided more responsibility, but also afforded
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her an opportunity for more money and career mobility. Her new position is not rigidly tied to a specialized program, and hence should give her a more useful and varied work experience. Ms. A.F. is a 47-year-old divorced, black woman who had had three years of experience as a mental health assistant before coming to the Children and Family Unit as a counselor. She has had a long series of personal tragedies, but has been able to perform amazingly well. She has unusual clinical sensitivity, can rapidly size up the essential problems of a given case, and in many instances out performs some of our professional staff. Recently she has been able to galvanize her resources and is vigorously pursuing a college degree in social work. Mr. G. is a 30-year-old black male, who had previously worked for eight years as a child care worker in one of the more prestigious state hospitals. He has developed a clinical competence and practical approach to children's problems that would have to be seen to be believed. Although he has completed two years of college course work with outstanding grades, he is ambivalent about what mental health career to pursue. CONCERNS
The para-professionals have many concerns, even in a facility which has demonstrated its support of them. Many feel that they are doing the work of "professionals" and should be paid accordingly. Some feel that there is not a city-wide, much less statewide, commitment to these "new careerists." This means that should they leave their prescnt job, where will they go? What will they do? How much will they be paid? All these are provocative and important questions. There has been a constant cry for a relevant career ladder program. As I-have mentioned earlier, the Center has taken some initial steps in this direction. Many want more clinical support; some feel that they are on the firing line, and should have more input into case selection. Some want to obtain degrees and move into more traditional mental health professions. Since many are middle aged, they do not have the luxury of time and money; hence they want credit (academic) for time spent as mental health workers. They feel that free tuition or low interest loans should be made available. In short they want the dignity, recognition, and security that their professional counterparts demand and receive. The professionals have some concerns. Although most of our professional staff have progressed beyond the "threatened" stage, there are many who jealously guard their
SEPTEMBER, 1975
own disciplines and credentials. This, of course, restricts the mobility and options of professional and para-professional alike. Both groups have much to give to each other in the common goal of providing quality mental health services for children. This exists whenever services and skills are not defined or updated. This leads to uncertainty, discontent, poor communication, questionable job performance and ultimately inadequate service. Clients have occasionally expressed some concern about either the para-professional or the job which he performs. Many community people are physician-oriented when it comes to health care-physical or mental. Some are referred by a well meaning school official or family doctor to a community mental health center to see the "doctor." The "doctor," however, is frequently not the first person they will see. Until the client can really understand the nature of the para-professional's role, he is frequently suspicious, resistant and distainful. In some cases there are distinct personality clashes which would occur no matter who the helping person was. Generally, we find that the para-professional staff can identify with many of the multiple problems that children and family present; that they will extend themselves and follow through. When family conferences are held, the psychiatrist, social worker, or psychologist is present and assures the family of their support of both client and counselor. The professional mental health staff is, of course, available to all the families. It is gratifying that the number of legitimate complaints against professional and para-professional staff have been relatively minor. Agencies, both social service and educational, have expressed some concern over the role of the para-professional. In situations where the agencies feel secure, avoid generalizing and can discuss their concerns, we have usually been able to correct any deficiencies either in the operation of the Unit, or the clinical style of individual counselors. SUMMARY AND CONCLUSIONS
The roles of the para-professional child therapist in an urban community mental
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Child Therapists
health center have been presented. An attempt has been made to show both the advantages and disadvantages of employing such personnel as primary therapists. It is felt that our unit has made a modest attempt to maximize the strength and talent of our para-professional staff. In so doing, we have tried to provide a clinical service which is meaningful and effective in alleviating the mental suffering of our children. To quote Arnhoff, Rubenstein and Speisman with whom I disagree on some points (commenting on matching tasks with the capabilities of those available to perform them): "Often there seems little choice of who is to be trained, particularly, in as lowpaid an area as mental health service has traditionally been. Efforts to use the abilities of the underprivileged, the elderly, the unskilled, and the dropout must recognize both their strengths and their weaknesses."' The authors note that the sensitivity and compassion of many of these individuals are particularly appropriate to working in "custodial" institutions, often with children and usually with the retarded. I feel that there is a significant place for para-professionals outside of institutions. In fact, one could argue
2.
3. 4. 5.
6. 7.
387
that more, not less sophistication, sensitivity, and compassion are required to work with children and retardates both in and outside of custodial settings. We, as child psychiatrists, have a tremendous responsibility for supporting and structuring child care occupations, especially at the para-professional level. Para-professional manpower must not be wasted through overlap, inadequate training, lack of career mobility, or preparation for irrelevant occupations or already obsolescent skills. LITERATURE CITED
1. ARNHOFF, F. and E. RUBENSTEIN, and J. SPEISMAN, (eds.). Manpower for Mental Health. Chicago: Aldine, 1969. SEE ALSO 1. FEIN, R. The Doctor Shortage: An Economic Diagnosis. Washington, D.C.: Brookings Inst., 1967. 2. NATIONAL INSTITUTES OF MENTAL HEALTH, Public Information Branch, and Center for Studies of Child and Family Mental Health. Mental Health Services for Children. (Public Health Service Publ. No. 1844.) 1968. 3. PEARL, A., and F. RIESSMAN, (eds.). New Careers for the Poor: The Non-professional in Human Service. New York: The Free Press, 1965.
(Brown, from page 377) Considerations. Arch. Phys. M. and Rehab., 40: of Orthopedic Surgeons, Vol. XIV. Ann Arbor: 387-9, 1959. J. W. Edwards, 1957. 8. MICHELE, A. A. and J. J. DAVIES, F. J. JACKSON, R. The Cervical Syndrome. 2nd ed. GRUEGER, and J. M. LICHTOR. ScapulocosSpringfield, Ill.: Charles C Thomas, 1958. GRANT, J. D. B. An Atlas of Anatomy. 5th ed. tal Syndrome (Fatigue-Postural Paradox). N. Y. Baltimore: Williams and Wilkins, 1962. State J. Med., 50:1352p.6, 1950. INMAN, V. T., and J. B. de C. M. SAUN9. JOHNSON, E. W. and R. M. Wells, and R. J. DERS. Referred Pain from Skeletal Structures. J. Duran. Diagnosis of Carpal Tunnel Syndrome. Nerv. Ment. Dis., 99:660-7, 1944. Arch. Phys. M. and Rehab., 43:414-9, 1962. 10. McKeever, D. C. The So-called Whiplash Injury. SANDLER, B. Cervical Spondylosis as a Cause of Spinal Cord Pathology. Arch. Phys. M. and Orthopedics, 2:1960. 11. CAILLIET, R. Hand Pain and Impairment. Rehab., 42:650-660, 1961. Philadelphia, Pa.: F. A. Davis Co. 1971. ODOM, G. L. and W. FINNEY, and B. 12. CAILLIET, R. Neck and Arm Pain. Phil. Pa. WOODHALL. Cervical Disk Lesions, J. Am. Med. Ass., 166:23-8, 1958. F. A. Davis Co. 1971. 13. GRAY, H. Anatomy of the Human Body. 26th RUBIN, D. Head, Neck, and Arm Symptoms ed. Phil. Lea and Febiger, 1954. Subsequent to Neck Injuries: Physical Therapeutic
SUPPORT THE SCHOLARSHIP FUND
381
Paraprofessional Child Therapists MILTON S. ADAMS, M.D., Director of Child Services, Hahnemnann Community Mental Health/Mental Retardation Center, Philadelphia, Pennsylvania
Over the past 10 years we have become increasingly aware of the lack of services, direct and indirect, which address the mental health needs of both children and adolescents. It is apparent that we shall never be able to meet current manpower needs by the professional or non-professional in providing the kind of services children need and deserve. Despite the fact that this country has 210 million people, there are only 25,000 adult psychiatrists. It is estimated that minority groups (primarily black) make up less than 5% of this group. We have at least 10 million people under the age of 25 who need some help from mental health workers, both professional and para-professional. Because of this situation, increasing attention has been given to the development and utilization of other mental health personnel other than the traditional trinity of psychiatrist, psychologist, and social worker. There have been some papers in psychiatric literature which have described the role of the paraprofessional in adult psychiatry. There have been few, if any, which describe the past, present, or future role of the para-professional who deals primarily with the mental health needs of children. Here we shall look at the para-professional as a child therapist based on the author's experience of five years in two different community mental health centers, three of which were spent recruiting, training, supervising, and evaluating the performance of nearly two dozen para-professional child therapists. The term para-professional has lost much of its specificity. In some centers, institutions, or schools, a para-professional is any-
one who has less than a master's degree or undergraduate degree in a specific discipline. The term, however, is commonly reserved for those who have a high school diploma or less in formal education, who have had some modicum of training-either formal or informal, and who work alongside and under the supervision of a professional. In the psychiatric field these people are frequently referred to as child care workers, child care aides, psychiatric technicians, mental health assistants, sub-professionals, new professionals, semi-professionals, child health associate, nurse practitioner, or even homemakers. SETTING
The Community Mental Health Center at Temple University, which was taken over by a Community Board in January of 1973, serves a catchment area of four square miles in which approximately 208,000 people reside. According to the 1970 Census, approximately 77.9% are black, 21.1% white, and 1.0% have Spahish surnames. At least 100,000 are under the ages of 18, with at least 10 to 15,000 of that number in need of mental health services. The name of the Center has changed to that of the North Central Philadelphia Community Mental Health/Mental Retardation Center. Temple University was one of the first Centers (1966) to pioneer in the recruitment and utilization of indigenous people as paraprofessional therapists. At this institution the role and function of the para-professional or mental health assistant has been tortuous, ambiguous, and confused at best. Indigenous people were recruited from the immediate
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JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
catchment area which is an economically deprived area. Several years ago the Federal Government deemed the area a poverty one. This philosophy at the time was that in order to fill the gap in mental health personnel and to try new or innovative approaches to mental health delivery and mental health care, indigenous personnel, would be screened, trained, placed in the community mental health center, under the supervision of professionals, and would assume the role of "primary therapists." This idea, up until 1966, was generally unheard of, at least as to the concept of the para-professional as the primary therapist or "change person." The initial concept was noble. It has been the contention of many in the mental health field that the primary role of community mental health centers was to provide aftercare services for the thousands of state hospital patients who were subsequently deposited in the back wards of the "community." As these chronically impaired people were poured into nursing and boarding homes, they eventually found their way into the community mental health centers. It was felt that the emotional deficits and needs of such people could be adequately handled by mental health assistants with back-up support and training by professional staff. This was an interesting and revolutionary concept, particularly when it is realized that many of these patients had been institutionalized for as long as 40 years, and presented with severe psychological, social, and physical problems. While hospitalized, many were tested and therapeutized by a wide variety of mental health personnel with varying degrees of skill and interest. The results were often disappointing at best. Now these patients were to be cast into the community to be serviced by untrained and unskilled people. The mental health assistant was not only told that he or she had unique sensitivity, skills, and intuition to handle such patients, but as primary therapists they were indeed superior to any professional, especially psychiatrists. Unfortunately, many believed this and frequently were resistant to any form of organized training or traditional psychiatric concepts. When the inservice training was im-
SEPTEMBER, 1975
plemented, it was frequently poorly organized, irrelevant, fragmented, loosely monitored and out moded. It also was not interfaced with a career ladder program, or tied into increased salaries for increased skills. CHILDREN AND FAMILY UNIT
The Children and Family Unit, which developed initially as a consultative rather than a direct service program, gradually expanded to include a small group of mental health assistants which complemented the initial small core of professionals. Several of the para-professional staff were recruited from the original pool of mental health assistants. This meant that they would have to make the transition from that of primary adult therapist to primary child therapist. After this initial expansion it became quite apparent that additional training was required for those who were to work primarily with children-especially the six to 12-year-old group. One of the first things I did upon assuming the role of the Director of the Children and Family Unit (April, 1971), was to assess the needs of the para-professional staff. This meant a change and revision of job duties commensurate with the expanded direct service responsibilities of the Unit. Six months prior to my arrival, a mental retardation staffing grant had been acquired. We were now the only Mental Health Center in the city which had mental retardation services combined with a children's service. The implication of this was tremendous. Our new ''counselors" would also be expected to handle or manage both children and adults with varying degrees of mental retardation. Because the Center-wide training program was insufficient to meet our varied needs, the former director had already launched an inservice training program which would address the specific needs of our counselors. TRAINING
Fortunately, our initial group of paraprofessionals were men and women of unusual ability and tremendous dedication. They had spent two to three years as mental
Vol. 67, No. 5
383
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health assistants and were ready for the challenge of dealing with children-both retarded and emotionally disturbed. The majority had already taken college-related courses and were pursuing their own program of upward mobility. We sought out and were able to recruit several para-professionals who had or were in the process of completing a formal two year training progranm in child care. Upon my arrival as the new director, I felt that as we expanded our Unit and services both direct and indirect, it was necessary to revise, expand and update our own inservice training. The first year we took advantage of whatever inservice training, conferences, etc. were offered by the Center. New staff were oriented through a training program provided by the H.C.U.* of St. Christopher's Hospital, the pediatric hospital of Temple University Hospital. Since the Unit, as well as the Center employees were under the mantle of the University, many of our staff-especially para-professional took advantage of reduced tuition rates and pursued college courses in the evening. Recently, we were able to obtain work release time (three hours per week) for job-related courses at the University. We have made generous use of course work being provided by other agencies. An example is a 10 week course given by a local agency on the sexual needs, problems, and education of the retarded. Since we have a separate or identifiable budget, we have allocated a specific sum of money for staff training and development. In the beginning of September, we mapped out our inservice training as best we could for the next six months. Since we believe a health program should be subject to ongoing scrutiny and change, we have attempted to make our inservice training relevant, integrated (both mental retardation and mental health) with other Units, and one which comes from the needs and wishes of both professional and para-professional staff alike. Currently, we run two different groups or level of instruction. Group one is primarily designed for those staff who have had less than a year of experience in the mental health field*Handicapped Children's Unit- A special service for children with cerebral palsy. convulsive disorders, mental retardation and other developmental disabilities.
specifically child mental health. Group II is designed for those counselors or mental health staff who have had one or more years of experience. We stress a group format, encouraging mutual interchange rather than the traditional didactic "I'm the teacher you're the student approach." Although we obtain input from the entire staff before implementing the inservice program, we feel that for entry level or relatively inexperienced staff, there are certain basic concepts, principles, or techniques which have to be mastered if one is to provide an effective treatment program. We have also made liberal use of training films, outside speakers, agency visits and case conferences. Whenever a consultant is hired, e.g. pediatrician, developmental psychologist, speech therapist, etc. we try to maximize our use of these specialists. Besides having them scheduled to see or evaluate patients, we set aside a period for using them as teachers. This not only provides a welcome relief from the sometimes tedious monotony of their job, but provides additional input for our staff. Additional training is provided through individual supervision-more of which will be discussed later-and various city, state, and national conferences. Recently, our Center has been the recipient of a New Careers Grant. This is a program funded by N.I.M.H. The Center will make available to eighteen current staff para-professional and eight indigenous people a program which will allow them to attend school (community college) three days a week and work the other two days a week for two years while they earn an associate degree in mental health. These people will be screened by a committee of both professional and para-professional staff (including the Community Board) and will maintain their current salary level. Those who wish to, will be able to move on to a four year college program upon completion of the A.A. degree. CASELOAD
The caseload of the children and family counselors is indeed a varied one. Children
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and adolescents are referred from many sources-mostly from the area schools. Referrals are discussed once a week at a screening conference. At this time, a decision is made to either keep the referral for treatment or counseling in our own Unit, or refer back to a more appropriate service. Assignments are made on the clients retained in our service. The assignments are made on the basis of the current case load of the therapist, experience and skill of the para-professional, nature of the presenting problem, e.g. an aggressive, acting out adolescent male with sexual problems would not be paired with a young or inexperienced female therapist. Assignments are made to both professional and para-professional staff. All staff carry both retarded and non-retarded patients. We stress a variety in diagnostic problems, age group, and cultural background. Since we service a significant Puerto Rican population, we have found it invaluable to have a Puerto Rican, Spanish-speaking therapist on staff. We have one young male worker who has had considerable experience in dealing with delinquent adolescents, another who has had considerable experience in family therapy-this diversity of staff gives us considerable lattitude in therapist selection. Each counselor carries a caseload which may vary from 10 to 30 individuals. Each is seen according to the perceived need. Some two or three times a week, others once a month. SUPERVISION
Supervision is the essential ingredient for making the entire para-professional program workable. I view supervision as the coming together of a more experienced person with a less experienced to share and learn from each other. Each staff person is responsible to someone else. Supervisors generally meet once a week or twice a month with their supervisee depending on the needs of each. Some will require a progress report from each person on every case carried. Others will focus on problem cases, meet in a group, or supplement their supervision with
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small case conferences. We know that supervision causes problems for some. Supervisors, who usually are middle class in their orientation, must learn how to relate or provide supervision which is relevant for both para-professional and client. Age differences sometimes pose problems-especially when the supervisee is much older than the supervisor. Cultural and racial differences must be taken into account. Failure to do so, can frequently impede progress and result in poor case management. We have found it helpful to have two different groupings or seminars. Once a month a general counselors meeting is held, in which the counselors (approximately 20) sit down with the director and occasionally some of the other professional staff and have an open discussion of their problems, both intra and inter Unit. This not only provides a forum for emotional release, but allows the director and other administrative personnel an opportunity to listen to common concerns and grievances. It is hoped that these sessions may become more focused and problemsolving in the future. Every other week a "supervisors' meeting" is held, where the supervisory staff explore their common problems, concerns and ideas among each other. This has generally been a well received meeting and one in which everyone feels comfortable in expressing themselves. STRATEGIES
One of the unique features of our paraprofessional staff is their kiiowledge of the community and willingness to make home visits. Since many live or have resided in the catchment area, they are quite familiar with the different neighborhood schools and agencies. After a case is assigned, the therapist discusses it with his supervisor, contacts the family and conducts the initial intake. When a family is unable to come to the Center, home visits are made. This brings the service to the client, allows the therapist an opportunity to actually see the living situation, and lets the client or family know that they are willing to extend themselves in their behalf. There are disadvantages in home
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visits-they can be abused, by both therapist and client. However, we generally make judicious use of them, and in some cases, this can make the difference between service or lack of service. Visits are occasionally made on weekends or in the evening. Clients are often transported to an appointment (hospital, welfare, court, etc.). The therapist routinely contacts the school in most cases. They have become adept at meeting teachers, counselors, principals, making classroom observations, and generally maintaining the type of informative alliance so necessary for good clinical care. Supportive counseling is widely used as a technique; this is supplemented with play therapy for younger children. Since psychiatric, psychological, educational, and pediatric evaluations are so readily obtained, the para-professional (under close supervision) will frequently utilize some insight in their treatment armamentarium. One of the problems has been the frustration by some of the more inexperienced counselors of defining treatment goals. There is also a tendency at times to over-identify with the patient, or a tendency to be unduly critical of parents. The supervisors should operate in such a way that they encourage and help direct clinical potential and ability. Some have to resist the temptation of making "junior social workers" or "psychiatrists" out of paraprofessional staff. Whenever difficulties arise which cannot be worked out between supervisee and supervisor, the director will meet with both and try to help resolve the problem. We are currently experimenting with the "buddy system" and rotating or multiple supervisors. The "buddy system" is designed for new para-professionals who have just entered the job. They are assigned to a more experienced counselor the first few months to help them through the various forms, procedures, anticipated problems, etc. This alliance, in addition to the supportive one of their clinical supervision has proven to be very helpful. Since psychiatrists, social workers, and psychologists have different philosophies and case management styles, we feel it is more helpful for para-professional staff to rotate after a year to another disci-
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pline. The other plan which is informally operative, is that of meeting with several different supervisory staff to discuss case management of unusual or difficult problems. We have encouraged the use of short term or time-limited treatment. This not only allows the Unit and staff to see a larger number of children, but reduces dependency, forces the therapist to rapidly organize his thinking and work on realistic goals. Group therapy has been increasingly advocated as a treatment approach that many of our paraprofessionals use. Some have served as cotherapists of both latency-aged and adolescent groups. They have done this in the Center and in some instances in schools where we have a formal mental health program. Again, supervision is a must-especially in group work, where you are dealing with many children and multiple problems. Family therapy has been utilized by some. Some have become quite adroit in using family therapy on home visits with broken or one parent families. Behavior therapy is one technique that many of our para-professional staff have resisted using. Perhaps our training program has not met the challenge of how to present it effectively. Another possibility is that it frequently makes repetitive demands on both therapist and patient, and there is still some resistance on the part of both. We are now experimenting with the use of using more experienced and capable paraprofessionals as supervisors. So far, we are reasonably optimistic and feel that this may be another use for skillful counseling staff. PROFILES Ms. L is a 24-year-old black woman who has recently completed twenty-two months as a child care workers. This is a position which pays less than a regular counseling position, and requires an ability to relate to and get along with preschool children. Ms. L. had completed high school and one year of working in a nursery school as a teacher's helper. Her particular position was locked into a specific program and depended on an increasing number of referrals of pre-school retarded children. Over the months, we found that these referrals virtually dried up. Her position was the only one of its kind; there was no chance for upward mobility. As the months wore on, and Ms. L. became increasingly discontented with her work and her supervisor, she came to me for advice. After meeting with her and different people who were involved with her work, it was decided to do two different things: 1) Change her supervisor; 2) Change her job title to a more relevant one-one that provided more responsibility, but also afforded
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her an opportunity for more money and career mobility. Her new position is not rigidly tied to a specialized program, and hence should give her a more useful and varied work experience. Ms. A.F. is a 47-year-old divorced, black woman who had had three years of experience as a mental health assistant before coming to the Children and Family Unit as a counselor. She has had a long series of personal tragedies, but has been able to perform amazingly well. She has unusual clinical sensitivity, can rapidly size up the essential problems of a given case, and in many instances out performs some of our professional staff. Recently she has been able to galvanize her resources and is vigorously pursuing a college degree in social work. Mr. G. is a 30-year-old black male, who had previously worked for eight years as a child care worker in one of the more prestigious state hospitals. He has developed a clinical competence and practical approach to children's problems that would have to be seen to be believed. Although he has completed two years of college course work with outstanding grades, he is ambivalent about what mental health career to pursue. CONCERNS
The para-professionals have many concerns, even in a facility which has demonstrated its support of them. Many feel that they are doing the work of "professionals" and should be paid accordingly. Some feel that there is not a city-wide, much less statewide, commitment to these "new careerists." This means that should they leave their prescnt job, where will they go? What will they do? How much will they be paid? All these are provocative and important questions. There has been a constant cry for a relevant career ladder program. As I-have mentioned earlier, the Center has taken some initial steps in this direction. Many want more clinical support; some feel that they are on the firing line, and should have more input into case selection. Some want to obtain degrees and move into more traditional mental health professions. Since many are middle aged, they do not have the luxury of time and money; hence they want credit (academic) for time spent as mental health workers. They feel that free tuition or low interest loans should be made available. In short they want the dignity, recognition, and security that their professional counterparts demand and receive. The professionals have some concerns. Although most of our professional staff have progressed beyond the "threatened" stage, there are many who jealously guard their
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own disciplines and credentials. This, of course, restricts the mobility and options of professional and para-professional alike. Both groups have much to give to each other in the common goal of providing quality mental health services for children. This exists whenever services and skills are not defined or updated. This leads to uncertainty, discontent, poor communication, questionable job performance and ultimately inadequate service. Clients have occasionally expressed some concern about either the para-professional or the job which he performs. Many community people are physician-oriented when it comes to health care-physical or mental. Some are referred by a well meaning school official or family doctor to a community mental health center to see the "doctor." The "doctor," however, is frequently not the first person they will see. Until the client can really understand the nature of the para-professional's role, he is frequently suspicious, resistant and distainful. In some cases there are distinct personality clashes which would occur no matter who the helping person was. Generally, we find that the para-professional staff can identify with many of the multiple problems that children and family present; that they will extend themselves and follow through. When family conferences are held, the psychiatrist, social worker, or psychologist is present and assures the family of their support of both client and counselor. The professional mental health staff is, of course, available to all the families. It is gratifying that the number of legitimate complaints against professional and para-professional staff have been relatively minor. Agencies, both social service and educational, have expressed some concern over the role of the para-professional. In situations where the agencies feel secure, avoid generalizing and can discuss their concerns, we have usually been able to correct any deficiencies either in the operation of the Unit, or the clinical style of individual counselors. SUMMARY AND CONCLUSIONS
The roles of the para-professional child therapist in an urban community mental
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health center have been presented. An attempt has been made to show both the advantages and disadvantages of employing such personnel as primary therapists. It is felt that our unit has made a modest attempt to maximize the strength and talent of our para-professional staff. In so doing, we have tried to provide a clinical service which is meaningful and effective in alleviating the mental suffering of our children. To quote Arnhoff, Rubenstein and Speisman with whom I disagree on some points (commenting on matching tasks with the capabilities of those available to perform them): "Often there seems little choice of who is to be trained, particularly, in as lowpaid an area as mental health service has traditionally been. Efforts to use the abilities of the underprivileged, the elderly, the unskilled, and the dropout must recognize both their strengths and their weaknesses."' The authors note that the sensitivity and compassion of many of these individuals are particularly appropriate to working in "custodial" institutions, often with children and usually with the retarded. I feel that there is a significant place for para-professionals outside of institutions. In fact, one could argue
2.
3. 4. 5.
6. 7.
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that more, not less sophistication, sensitivity, and compassion are required to work with children and retardates both in and outside of custodial settings. We, as child psychiatrists, have a tremendous responsibility for supporting and structuring child care occupations, especially at the para-professional level. Para-professional manpower must not be wasted through overlap, inadequate training, lack of career mobility, or preparation for irrelevant occupations or already obsolescent skills. LITERATURE CITED
1. ARNHOFF, F. and E. RUBENSTEIN, and J. SPEISMAN, (eds.). Manpower for Mental Health. Chicago: Aldine, 1969. SEE ALSO 1. FEIN, R. The Doctor Shortage: An Economic Diagnosis. Washington, D.C.: Brookings Inst., 1967. 2. NATIONAL INSTITUTES OF MENTAL HEALTH, Public Information Branch, and Center for Studies of Child and Family Mental Health. Mental Health Services for Children. (Public Health Service Publ. No. 1844.) 1968. 3. PEARL, A., and F. RIESSMAN, (eds.). New Careers for the Poor: The Non-professional in Human Service. New York: The Free Press, 1965.
(Brown, from page 377) Considerations. Arch. Phys. M. and Rehab., 40: of Orthopedic Surgeons, Vol. XIV. Ann Arbor: 387-9, 1959. J. W. Edwards, 1957. 8. MICHELE, A. A. and J. J. DAVIES, F. J. JACKSON, R. The Cervical Syndrome. 2nd ed. GRUEGER, and J. M. LICHTOR. ScapulocosSpringfield, Ill.: Charles C Thomas, 1958. GRANT, J. D. B. An Atlas of Anatomy. 5th ed. tal Syndrome (Fatigue-Postural Paradox). N. Y. Baltimore: Williams and Wilkins, 1962. State J. Med., 50:1352p.6, 1950. INMAN, V. T., and J. B. de C. M. SAUN9. JOHNSON, E. W. and R. M. Wells, and R. J. DERS. Referred Pain from Skeletal Structures. J. Duran. Diagnosis of Carpal Tunnel Syndrome. Nerv. Ment. Dis., 99:660-7, 1944. Arch. Phys. M. and Rehab., 43:414-9, 1962. 10. McKeever, D. C. The So-called Whiplash Injury. SANDLER, B. Cervical Spondylosis as a Cause of Spinal Cord Pathology. Arch. Phys. M. and Orthopedics, 2:1960. 11. CAILLIET, R. Hand Pain and Impairment. Rehab., 42:650-660, 1961. Philadelphia, Pa.: F. A. Davis Co. 1971. ODOM, G. L. and W. FINNEY, and B. 12. CAILLIET, R. Neck and Arm Pain. Phil. Pa. WOODHALL. Cervical Disk Lesions, J. Am. Med. Ass., 166:23-8, 1958. F. A. Davis Co. 1971. 13. GRAY, H. Anatomy of the Human Body. 26th RUBIN, D. Head, Neck, and Arm Symptoms ed. Phil. Lea and Febiger, 1954. Subsequent to Neck Injuries: Physical Therapeutic
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