in competing for federal funds and opposing state federal programs that they considered detrimental the rights of former drug abusers. Such
groups
often
provide
support
and to
to professionals
as
well. A group called Parents of Adult Schizophrenics opposed staff cutbacks that would have reduced treatment services in a county mental health program in California. Group members made a determined visit to the local hoard of supervisors to tell them so. As a result of that visit the board decided not to make the cuthacks, much to the satisfaction of the professional staff, who had tried unsuccessfully to have the policy reversed. My experience with self-help groups has involved consultation to a group active in burn prevention. The group, the Northern California Burn Council, was started in 1975 by Andrew McGuire, the former director of a similar group in Boston. The Boston group, Action for Prevention of Burn Injuries to Children, had received its initial Support from John Locke, a government demographic expert in burn injuries, and John Crawford, M.D., chief of pediatrics at the Shriners’ Burns Institute in Boston, who collaborated with parents of some children who had been burned and with other individuals who themselves had been burned when they were children. The group’s development benefited from the early support of these professionals. The Northern California Burn Council has been effective in educating the public about the efficacy of using flame-retardant clothing, in introducing burnsafety information into schools, in working with recent burn victims, and in educating professionals who deal with burn victims. My consultation work has been flexihle and informal. It has involved planning for the clinical aspects of the council’s program of group meetings of recent burn victims, participating in the board of directors’ meetings, and writing statements of support for grant requests. The group has made good use of limited professional time and has had impressive impact. However, work with self-help groups is not exempt from the normal kinds of problems mental health professionals often experience in more traditional consultation roles. Requests for consultation are often ambivalent; some members of an agency or group may oppose having consultation, while other members may arrange for it. In addition, the consultant may be used by one subgroup for its own political purposes. The psychiatrist may become the object of suspicion, since it is a common misconception that psychiatric consultants use their knowledge of psychology to stir up emotional problems or to make embarrassing revelations.4 Furthermore, the power of psychiatric consultation is at times oversold, leading to disappointment in the consubtant’s
In
actual
comparison
4 D. Spiegel and Services Agency.”
accomplishments.
to
large
B. Naparstek, Psychiatric
HOSPITAL
5
A.
Help
Low, Mental in Psychotherapy
Boston, 6
M.
February
Health Through as Practiced
Will-Training: by Recovery,
“ Psychiatric Opinion, Vol.
agencies,
Consultation 11,
August
self-
to a 1974,
&
COMMUNITY
“
Alcoholics
1975,
Anonymous,
I,”
Psychiatric
Annals,
Vol. 5,
pp. 22-61.
SOME RETROSPECTIVE IMPRESSIONS OF PSYCHIATRIC PROGRAMS FOR TREATING CHILDREN Louis
Fairchild,
Ph.D.
#{149}Whena person
is involved on a full-time basis with a and is so much a part of its operation, he has difficulty being completely objective about its strengths and weaknesses. Since leaving the staff of a children’s psychiatric facility, I have spent several years in an academic position, which possibly has provided me with a more objective perspective. Since I am a part-time consultant and spend more time observing, I have had even more opportunity for reflection. The first impression to surface was the realization that there is no single best way to run a treatment program for children. As there is no only’ way to rear or educate children, neither is there any one way to treat them in an institutional setting. The authoritarian treatment
program
‘
Legal
pp.
PSYCHIATRY
A System of Selfinc., Christopher,
1950. Bean,
‘ ‘
government
30.
772
help groups tend to be relatively transient and fluid, with less clearly established patterns of leadership and funding. Their members may be less interested in or respectful of professional support. Nevertheless, many self-help groups want such assistance. The classic example is Recovery, Inc., a large self-help group for former mental patients, founded by psychiatrist Abraham Low. Dr. Low is revered by the group and his writings are read religiously.5 Other groups, such as Alcoholics Anonymous, are officially critical of the medical profession in general and the use of drugs in particular, but most chapters, nevertheless, cultivate good relationships with physicians in their areas.6 Professional consultation to a self-help or mutualsupport group offers an important alternative to traditional agency consultation. However, such a role has limitations. What one loses in his contact with self-help groups is a sense of omnipotence. One is able to advise and suggest but not to decide which course of political action is to be taken. That is the prerogative of the citizens. Mental health professionals may well be advocates, hut ought not to be political leaders. While we may use our expertise to try to improve the life of the community and of the individual patients with whom we work, we cannot and should not decide issues of social policy based on technical, therapeutic, or political considerations. Such approaches may seem enlightened and humanitarian, but they have a tendency to become elitist and autocratic.
25-
Dr. Fairchild is an associate psychology at West Texas
professor
State
and
University,
head of the department of Canyon, Texas 79016.
and the permissive approach may be equally effective in a parental role since the personality, warmth, and consistency of the parent have a strong bearing on the over-all impact that will be made on the child. The institutional setting is an even more complex milieu with many variables converging simultaneously on the child. It may be that these different variables will be arranged differently from one program to another with equal effectiveness. A second impression involves the need for a developmental base for treatment. Strong, steady parent figures should be available with whom the children can work through the developmental conflicts and stresses. This is not to disregard more technical behavioral approaches, but to suggest that specific techniques should be couched in a relationship. Two aspects of the relationship must be accessibility and acceptance. It is essential that the therapist-parent figures be available to the children and that the nature of the availability be warm and accepting. Too often programs and scheduling can create barriers that prevent patients from having adequate contact with their therapist, and programs can lapse into harshness and border on rejection. A third impression acknowledges the significant role of the child-care attendants who are continually in contact with the children. This role can be enhanced through the shared responsibility of personnel. It is questionable whether the professional can completely separate himself from the functions normally carried out by the child-care worker. On occasion the professional as well as the over-all treatment milieu might profit from the professional’s participation in wiping noses, giving baths, or having to enforce discipline. On the other hand, the child-care worker must be incorporated into the decision-making of the institution. His impressions must be solicited and his input encouraged. In other words, in the disposition of cases we must take advantage of those who have so much invested in the children. The European Educateur Program is a good demonstration of this function of the child-care worker.’ The educateur’s role is that of a highly trained child-care worker who uses craft, vocational, recreational, and other practical activities to achieve a close personal relationship with a small group of children. A basic assumption of the program is that the adult closest to the children is the one who spends the most time with them. Thus that person is the central agent in the treatment of the disturbed child and is given a responsible voice in decisions made about the child. A fourth impression concerns the need for program structure. The program must be carefully planned and organized; treatment days and hours must not be left to chance. However, with careful organization and planning, there is the danger that detail and structure will become an end unto itself. It is important that children
not be servants of the structure but be allowed to explore and find themselves within it. Well-designed activities are good boundaries of participation, but freedom of movement must be encouraged within the schedule, lest children be coerced to fit the schedule. A fifth impression underscores the importance of education. Rutter, Greenfeld, and Lockyer found that many treatment approaches with psychotic children show discouraging results.2 However, individualized educational efforts appear to be encouraging. Two points are rather basic in emphasizing the importance of education. First, the role of fundamental academic skills must not be disregarded. It is essential that children be helped to achieve basic abilities if they can. However, for other children education may have to progress to more applied, vocational skills. Many children require this more functional kind of learning. Going beyond the two basics, however, education must also entail some degree of moral or character training. Other authorities have pointed out that the way the American educational system differs most significantly from primitive societies and other contemporary societies is the lack of emphasis that we give to spiritual or moral kinds of learning. Character-shaping is an aspect of treatment to which children’s programs must be sensitive. Again, that does not mean that we should force children into a rigid code of morality. But children must be encouraged to examine right and wrong, and they must be exposed to the reality that in every society standards of behavior and conduct do exist. A final impression is that children’s treatment programs must make a major effort to confront poverty and racism. The report of the Joint Commission on Mental Health of Children emphasizes that nearly 25 per cent of our children are victims of poverty and that racism is a major public health problem.3 It is impossible to allow our mental health treatment programs for children to ignore those issues. Treatment program staff cannot allow themselves to indulge in removed, esoteric topics at the expense of the hard realities that affect the lives of one-fourth of our children. Many treatment programs may need to develop an extramural thrust and make an effort to extend the delivery of services to areas long neglected. Psychiatric treatment programs must be untiring in their efforts for child advocacy. These considerations will not add up to a best” program for children. Better programming, however, is both realistic and necessary. I hope that these perspectives may in some situations result in services that are more thoughtful and sensitive.U ‘ ‘
2
1
T.
Linton,
“
The
American 125-133.
European Journal
Educateur
of Orthopsychiatry,
Program
for
Disturbed
D. Greenfeld,
Study British
Outcome,” pp. 1183-1199. 3
Children,” 1969, pp.
M. Rutter,
Follow-up
Joint
Mental
of
Journal
Commission
Health,
on Harper
and
Infantile
L. Lockyer,
Psychosis:
of Psychiatry, Mental & Row,
Health New
“
A Five
II. Social Vol. 113,
York
of
to Fifteen
Crisis
Children, City,
Year
and Behavioural November 1967, in
Child
1969.
Vol. 39, January
VOLUME
28
NUMBER
10 OCTOBER
1977
773
groups
often
provide
support
and to
to professionals
as
well. A group called Parents of Adult Schizophrenics opposed staff cutbacks that would have reduced treatment services in a county mental health program in California. Group members made a determined visit to the local hoard of supervisors to tell them so. As a result of that visit the board decided not to make the cuthacks, much to the satisfaction of the professional staff, who had tried unsuccessfully to have the policy reversed. My experience with self-help groups has involved consultation to a group active in burn prevention. The group, the Northern California Burn Council, was started in 1975 by Andrew McGuire, the former director of a similar group in Boston. The Boston group, Action for Prevention of Burn Injuries to Children, had received its initial Support from John Locke, a government demographic expert in burn injuries, and John Crawford, M.D., chief of pediatrics at the Shriners’ Burns Institute in Boston, who collaborated with parents of some children who had been burned and with other individuals who themselves had been burned when they were children. The group’s development benefited from the early support of these professionals. The Northern California Burn Council has been effective in educating the public about the efficacy of using flame-retardant clothing, in introducing burnsafety information into schools, in working with recent burn victims, and in educating professionals who deal with burn victims. My consultation work has been flexihle and informal. It has involved planning for the clinical aspects of the council’s program of group meetings of recent burn victims, participating in the board of directors’ meetings, and writing statements of support for grant requests. The group has made good use of limited professional time and has had impressive impact. However, work with self-help groups is not exempt from the normal kinds of problems mental health professionals often experience in more traditional consultation roles. Requests for consultation are often ambivalent; some members of an agency or group may oppose having consultation, while other members may arrange for it. In addition, the consultant may be used by one subgroup for its own political purposes. The psychiatrist may become the object of suspicion, since it is a common misconception that psychiatric consultants use their knowledge of psychology to stir up emotional problems or to make embarrassing revelations.4 Furthermore, the power of psychiatric consultation is at times oversold, leading to disappointment in the consubtant’s
In
actual
comparison
4 D. Spiegel and Services Agency.”
accomplishments.
to
large
B. Naparstek, Psychiatric
HOSPITAL
5
A.
Help
Low, Mental in Psychotherapy
Boston, 6
M.
February
Health Through as Practiced
Will-Training: by Recovery,
“ Psychiatric Opinion, Vol.
agencies,
Consultation 11,
August
self-
to a 1974,
&
COMMUNITY
“
Alcoholics
1975,
Anonymous,
I,”
Psychiatric
Annals,
Vol. 5,
pp. 22-61.
SOME RETROSPECTIVE IMPRESSIONS OF PSYCHIATRIC PROGRAMS FOR TREATING CHILDREN Louis
Fairchild,
Ph.D.
#{149}Whena person
is involved on a full-time basis with a and is so much a part of its operation, he has difficulty being completely objective about its strengths and weaknesses. Since leaving the staff of a children’s psychiatric facility, I have spent several years in an academic position, which possibly has provided me with a more objective perspective. Since I am a part-time consultant and spend more time observing, I have had even more opportunity for reflection. The first impression to surface was the realization that there is no single best way to run a treatment program for children. As there is no only’ way to rear or educate children, neither is there any one way to treat them in an institutional setting. The authoritarian treatment
program
‘
Legal
pp.
PSYCHIATRY
A System of Selfinc., Christopher,
1950. Bean,
‘ ‘
government
30.
772
help groups tend to be relatively transient and fluid, with less clearly established patterns of leadership and funding. Their members may be less interested in or respectful of professional support. Nevertheless, many self-help groups want such assistance. The classic example is Recovery, Inc., a large self-help group for former mental patients, founded by psychiatrist Abraham Low. Dr. Low is revered by the group and his writings are read religiously.5 Other groups, such as Alcoholics Anonymous, are officially critical of the medical profession in general and the use of drugs in particular, but most chapters, nevertheless, cultivate good relationships with physicians in their areas.6 Professional consultation to a self-help or mutualsupport group offers an important alternative to traditional agency consultation. However, such a role has limitations. What one loses in his contact with self-help groups is a sense of omnipotence. One is able to advise and suggest but not to decide which course of political action is to be taken. That is the prerogative of the citizens. Mental health professionals may well be advocates, hut ought not to be political leaders. While we may use our expertise to try to improve the life of the community and of the individual patients with whom we work, we cannot and should not decide issues of social policy based on technical, therapeutic, or political considerations. Such approaches may seem enlightened and humanitarian, but they have a tendency to become elitist and autocratic.
25-
Dr. Fairchild is an associate psychology at West Texas
professor
State
and
University,
head of the department of Canyon, Texas 79016.
and the permissive approach may be equally effective in a parental role since the personality, warmth, and consistency of the parent have a strong bearing on the over-all impact that will be made on the child. The institutional setting is an even more complex milieu with many variables converging simultaneously on the child. It may be that these different variables will be arranged differently from one program to another with equal effectiveness. A second impression involves the need for a developmental base for treatment. Strong, steady parent figures should be available with whom the children can work through the developmental conflicts and stresses. This is not to disregard more technical behavioral approaches, but to suggest that specific techniques should be couched in a relationship. Two aspects of the relationship must be accessibility and acceptance. It is essential that the therapist-parent figures be available to the children and that the nature of the availability be warm and accepting. Too often programs and scheduling can create barriers that prevent patients from having adequate contact with their therapist, and programs can lapse into harshness and border on rejection. A third impression acknowledges the significant role of the child-care attendants who are continually in contact with the children. This role can be enhanced through the shared responsibility of personnel. It is questionable whether the professional can completely separate himself from the functions normally carried out by the child-care worker. On occasion the professional as well as the over-all treatment milieu might profit from the professional’s participation in wiping noses, giving baths, or having to enforce discipline. On the other hand, the child-care worker must be incorporated into the decision-making of the institution. His impressions must be solicited and his input encouraged. In other words, in the disposition of cases we must take advantage of those who have so much invested in the children. The European Educateur Program is a good demonstration of this function of the child-care worker.’ The educateur’s role is that of a highly trained child-care worker who uses craft, vocational, recreational, and other practical activities to achieve a close personal relationship with a small group of children. A basic assumption of the program is that the adult closest to the children is the one who spends the most time with them. Thus that person is the central agent in the treatment of the disturbed child and is given a responsible voice in decisions made about the child. A fourth impression concerns the need for program structure. The program must be carefully planned and organized; treatment days and hours must not be left to chance. However, with careful organization and planning, there is the danger that detail and structure will become an end unto itself. It is important that children
not be servants of the structure but be allowed to explore and find themselves within it. Well-designed activities are good boundaries of participation, but freedom of movement must be encouraged within the schedule, lest children be coerced to fit the schedule. A fifth impression underscores the importance of education. Rutter, Greenfeld, and Lockyer found that many treatment approaches with psychotic children show discouraging results.2 However, individualized educational efforts appear to be encouraging. Two points are rather basic in emphasizing the importance of education. First, the role of fundamental academic skills must not be disregarded. It is essential that children be helped to achieve basic abilities if they can. However, for other children education may have to progress to more applied, vocational skills. Many children require this more functional kind of learning. Going beyond the two basics, however, education must also entail some degree of moral or character training. Other authorities have pointed out that the way the American educational system differs most significantly from primitive societies and other contemporary societies is the lack of emphasis that we give to spiritual or moral kinds of learning. Character-shaping is an aspect of treatment to which children’s programs must be sensitive. Again, that does not mean that we should force children into a rigid code of morality. But children must be encouraged to examine right and wrong, and they must be exposed to the reality that in every society standards of behavior and conduct do exist. A final impression is that children’s treatment programs must make a major effort to confront poverty and racism. The report of the Joint Commission on Mental Health of Children emphasizes that nearly 25 per cent of our children are victims of poverty and that racism is a major public health problem.3 It is impossible to allow our mental health treatment programs for children to ignore those issues. Treatment program staff cannot allow themselves to indulge in removed, esoteric topics at the expense of the hard realities that affect the lives of one-fourth of our children. Many treatment programs may need to develop an extramural thrust and make an effort to extend the delivery of services to areas long neglected. Psychiatric treatment programs must be untiring in their efforts for child advocacy. These considerations will not add up to a best” program for children. Better programming, however, is both realistic and necessary. I hope that these perspectives may in some situations result in services that are more thoughtful and sensitive.U ‘ ‘
2
1
T.
Linton,
“
The
American 125-133.
European Journal
Educateur
of Orthopsychiatry,
Program
for
Disturbed
D. Greenfeld,
Study British
Outcome,” pp. 1183-1199. 3
Children,” 1969, pp.
M. Rutter,
Follow-up
Joint
Mental
of
Journal
Commission
Health,
on Harper
and
Infantile
L. Lockyer,
Psychosis:
of Psychiatry, Mental & Row,
Health New
“
A Five
II. Social Vol. 113,
York
of
to Fifteen
Crisis
Children, City,
Year
and Behavioural November 1967, in
Child
1969.
Vol. 39, January
VOLUME
28
NUMBER
10 OCTOBER
1977
773
