Community Mental Health Journal
Volume2, Number4, Winter,1966
T H E CHALLENGE OF COMMUNITY CHILD P S Y C H I A T R Y MORTON B. NEWMAN, M.D.* of health, etc., the staff finds that the area is served by three family service agencies, three state hospitals, three associations for retarded children, three municipal courts, and two regional offices of the Division of Child Guardianship. Although the following observations might be thought (with some justification) to apply only to Mystic Valley, it is suggested that from this example general principles can be formulated that have a much wider application.
The effective practice of community child psychiatry requires an understanding of the reality in which the work is performed. Programs and practices result as much from the requirements of the situation as from the mental health workers' preformed notions of good professional work. The various realities of a specific community psychiatric clinic for children are described and their impact on clinical practice noted. How community child psychiatry is influenced by the various realities in which it operates may be illustrated by the experiences of the staff of a small psychiatric clinic for children, organized through a partnership arrangement between the Division of Mental Hygiene of the Massachusetts De. partment of Mental Health and the local voluntary citizens' mental health association. The Mystic Valley Children's Clinic with a professional staff of six full-time and two half-time workers serves an area in Massachusetts containing 150,000 people that includes the suburban towns of Arlington, Bedford, Lexington, Winchester, and the city of Woburn. The population is composed of a wide socioeconomic, ethnic, and cultural spectrum with a fairly large proportion of middle-income, psychologically sophisticated families who are extremely invested in their children. A special feature of the community is that it is composed of five separate autonomous municipalities, each of which possesses a unique character, with little or no tradition of working together. A further complicating factor is the lack of coordination with, and correspondence to, other social service areas. Thus, in addition to working with five school systems, five police departments, five boards
THE REALITIESOF COMMUNITYCHILD PSYCHIATRY In psychiatry, as in medicine generally, the realities of the situation, as well as the ideas of the practitioner, determine the character of clinical practice. The professional works in a physical and human environment; the pressures emanating from this milieu are as important in determining what is done as are the practitioner's preformed notions of good professional work. The environmental reality--what it is and what it expects or demands--is nowhere more important than in the field of community psychiatry. The staff of the small clinic mentioned works within five types of realities, identified as: l. 2. 3. 4. 5.
political-economic geographic administrative professional clinical
SOME MAJOR CHARACTERISTICS OF THESE REALITIES 1. An important aspect of the politicaleconomic reality is that the clinic is a public facility whose financial support comes from state and local tax funds.
* Dr. Newman, a child psychiatrist, is Director of the Mystic Valley Children's Clinic, Lexington, Massachusetts, and is ClinicalInstructor in Psychiatry, Tufts University School of Medicine, Boston. A version of this paper was read at Tufts University School of Medicine on May 12, 1966, at a psychiatry staff meeting on the topic "Meeting the Challenge of Community Child Psychiatry." The author wishes to express his gratitude to Lucile N. MeMahon for her valuable editorial assistance. 281
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THE COMMUNITYMENTAL HEALTH JOURNAL
2. The geographic reality is that the clinic is located, not within the protected walls of a teaching hospital or on the grounds of a state hospital, but on a street in a suburban town among the patients it serves. (One of the first families to apply for service lived next door to the clinic.) 3. The administrative reality is that while the clinic is part of the Department of Mental Health, its basic support is provided by local citizens who, interested in mental health, serve voluntarily on boards and committees. 4. One aspect of the professional reality is that the clinic staff is not alone in the business of providing service to emotionally disturbed children. Departments of youth service and school guidance departments, for example, are also involved with patients, although the patients may not be so identified and the practitioners usually have a very different orientation toward, and professional view of, the problems involved. 5. The basic and inescapable clinical reality is that enormous numbers of people request service from a small staff of trained professionals. IMPLICATIONSOF THE REALITIESFOR COMMUNITYCHILD PSYCHIATRICPRACTICE
The dependence on public tax funds and the requirement to report the amount of service given (the political-economic reality) to each of the five communities in terms of number of cases, interviews, and hours makes it almost mandatory to maintain an open intake policy and to shift emphasis from the intensive treatment of a few to the provision of service to all those who apply. The clinic must maintain an image of helpfulness and service, not one of exclusiveness, frustration, and mystery. Because the clinic is so close to the people (the geographic reality), they come there much earlier than they might to a more distant facility and have not always clearly identified themselves as patients, i.e., sick people needing treatment. Consequently, they must be approached, not with the formality of the hospital, but with the relaxed interest that one shows to neighbors who come to discuss problems.
The administrative reality supports this approach in a situation where one may find that one's patient of today becomes a board member the following night. The situation requires that the staff be educators and translators, that it be able to communicate what it knows to a variety of audiences and to convert its knowledge into usable, palatable information. The professional reality requires establishing and building good relationships with other caretakers in the community. To borrow a phrase from political science, dialogues must be established with other professionals in order to learn what they expect from the clinic staff and let them discover what the psychiatric team is able to provide. At a later stage they may learn what it expects from them. A system of mutual continuing education is thus established. The clinical reality that derives from, and is a consequence of, the other realities demands that available staff time be used most efficiently. To put the matter more exactly: rapid, accurate diagnosis of the child's problem and the family pathology must be coupled with a clearly defined determination of what changes need to occur in the child or in his existing environment if symptoms are to be removed. There is the further need that there be frank assessment of the reasonable likelihood that such changes can be brought about by various types of therapeutic intervention and varying degrees of therapeutic investment. ACTIVITIESOF A CHILD PSYCHIATRIC CLINIC WITHINTHESE REALITIES
The policies at the Mystic Valley Children's Clinic and the specific activities of its staff can be seen as a function of the realities mentioned above and of the implications of these realities. Intake has been held open for the past three years despite the continuing enormous demand for service. The staff has participated in public discussions of issues ranging from delinquency and alcoholism to preschool education and the role of the clergy in mental health, always with the underlying aim of providing for the listeners a glimpse
MORTON B. NEWMAN of psychiatric thinking and of stimulating them to seek closer contact with psychiatry in general and with the local clinic in particular. The staff has actively collaborated with others in the community in organizing summer Head Start programs and community councils. Again, the aim is not only to engage in worthwhile community projects per se but also to point up the central relevance of psychiatric thinking, how it is not simply an amusing diversion but rather a crucial ingredient of any community project whose goal is to change human behavior. The hope is to transmit the message to the community that what the clinic professionals have to say about issues is valuable, useful, and understandable, an important service that the community will want to use again and that must, of course, be actively supported. Outside the clinic walls the staff's major activities involve consultation for other caretakers in the community, principally school guidance personnel, and more recently, with the addition of a psychiatric nurse to the staff, for nurses in the community. School guidance counselors, adjustment counselors, school psychologists, and social workers comprise the largest group of professionals working with, or potentially able to work with, emotionally disturbed children in the community. It was thought initially that regular consultation with these counselors would not only improve their skills and the mental health climate of the school but would also reduce the clinic intake load to manageable proportions. It was hoped that encouraging these people to work with emotionally disturbed children in the schools would result in decreasing the need for referral of children to the clinic from the schools, which are, after all, the greatest single referral source. Matters have turned out, however, to be more complicated than it at first appeared. Although the consultation program has been very well received, it has not had the effect of reducing our clinic intake. The staff has learned to appreciate the apparently obvious fact that others, such as school adjustment counselors, work in a very different environment than that of the clinic
283
and have different needs and values. It is pointless, for example, to discuss psychodynamics if their major concern is with disposition. It has been realized that the needs of the consultee, while sometimes different, are as important as those of the consuhant. These realizations have led to a broader, more flexible, and more tolerant view of the whole matter of consultation, attempting on the one hand to meet the immediate needs of the consultees (be it for reassurance, removal of problem cases, or rescue) while slowly, hopefully with patience, trying over time, using a variety of methods, to bring them into a closer, more trusting professional relationship with the clinic. Methods of clinical diagnosis have become more varied, while diagnostic aims have become increasingly focused. To traditional history taking and individual evaluation have been added observation of parents and children in groups, family interviewing, home visiting, and nursery school observation. The opinions of others who have observed the child and his family are sought out, and these observations are evaluated and useful material extracted. While more flexible in accepting what is regarded as useful diagnostic data, the clinic is more specific in its aims: to obtain an accurate description of the child's symptoms and behavior, a working theory of its meaning, an assessment of the nature of parental concern and of the possibilities of therapeutic intervention. We are interested in strengths as well as in weaknesses, in existing relationships and how they can be made more salubrious, in capacities for change in parents and child, in what can be manipulated, redirected, guided, replaced, or provided. This approach to therapeutic intervention is essentially conservative. It is limited in goal and in time and does not strive for major revision of personality. The aim must be to do what can be done briefly as well as effectively. Parental anxiety is used to build a problem-solving alliance, and an attempt is made to shift parental attitudes and behavior individually or in groups, sometimes without the child being seen at
284
THE COMMUNITYMENTALHEALTHJOURNAL
all. The staff works collaboratively with principles and who are able to feel comother caretakers who may see one family fortable enough to try out adaptations and member while another is treated at the new combinations and flexible enough to clinic. The trend is to be more directly meet a variety of demands both within and clarifying with both parents and children, without the clinic walls. The need for longmore ready to make suggestions, freer to term psychotherapy has not been elimiadvocate external change when significant nated; rather, as a larger, more varied, and internal change seems unlikely. more heterogeneous population with widely There is more that could be said about different expectations and capacities comes the clinic's approach to treatment and a within the clinical domain, additional great deal more that needs to be discovered methods should be added. Again, to borrow about its nature and effectiveness. It must a phrase from the language of contemporary be remembered that the clinic population political science, a variety of options is is relatively unselected, with varying de- needed. Long-term and short-term, ingrees of motivation, psychological minded- dividual and group psychotherapy, manipuhess, readiness to use psychotherapy, and lation, direct suggestion, and indirect capacity to profit from it. An attempt is treatment through consultation all have a made to give patients, not simply what it place in the armamentarium of the comappears they need, but what they want and munity psychiatrist. Continuing efforts find palatable and useful. People come to must be devoted to attempting to underus in great numbers asking for service; stand where, to what patients, and in which this does not necessarily mean and, indeed, situations each method can most usefully usually does not mean a request for long- be applied. term psychotherapy. Notwithstanding these Community child psychiatry challenges facts, it is felt most important to keep a mental health professionals in a variety of place for long-term conventional psy- ways. It tests their stamina and patience, chotherapy and casework, even in an over- competence and flexibility. It requires them crowded and understaffed clinic. The im- to be adaptable and clearly aware of what portance of long-term psychotherapy de- they are doing as well as why and how they pends, first of all, on the fact that some pa- are doing it. The training of medical stutients can be helped by nothing else. Fur- dents, social workers, and psychologists at thermore, it is only through a thorough the Mystic Valley Children's Clinic has understanding of personality, achieved by been found to help the staff give better conducting long-term psychotherapy, that service, for the need to define what is being staff members can become sufficiently done is reinforced by the obligation to exskilled to use shorter, more active, and plain to others. more experimental methods. The experience gained from the practice of community child psychiatry has, it is CONCLUDINGREMARKS suggested, relevance also for the planning Many things are said about community of community mental health programs. psychiatry these days--usually with a great While there must of course be some basic deal of breathless excitement. Some en- preplanning, a truly viable community thusiasts see in it the answer to the twin psychiatric program must evolve from a problems of shortage of trained psychiatric dialogue between the clinic professionals personnel and of the high cost of investment and representatives of the community, both in long-term psychotherapy. The complexi- lay and professional. In the public sector ties of the work, however, require not so of community psychiatry the wishes of the much the energies of those with little train- community are as relevant as the needs of ing or experience but rather the highly de- the professionals. Ideally, despite the in. veloped skills of those psychiatrists, psy- evitable frustrations and disappointments, chologists, and social workers who are a process of mutual education is initiated thoroughly trained and grounded in basic out of which programs and practices evolve.
Volume2, Number4, Winter,1966
T H E CHALLENGE OF COMMUNITY CHILD P S Y C H I A T R Y MORTON B. NEWMAN, M.D.* of health, etc., the staff finds that the area is served by three family service agencies, three state hospitals, three associations for retarded children, three municipal courts, and two regional offices of the Division of Child Guardianship. Although the following observations might be thought (with some justification) to apply only to Mystic Valley, it is suggested that from this example general principles can be formulated that have a much wider application.
The effective practice of community child psychiatry requires an understanding of the reality in which the work is performed. Programs and practices result as much from the requirements of the situation as from the mental health workers' preformed notions of good professional work. The various realities of a specific community psychiatric clinic for children are described and their impact on clinical practice noted. How community child psychiatry is influenced by the various realities in which it operates may be illustrated by the experiences of the staff of a small psychiatric clinic for children, organized through a partnership arrangement between the Division of Mental Hygiene of the Massachusetts De. partment of Mental Health and the local voluntary citizens' mental health association. The Mystic Valley Children's Clinic with a professional staff of six full-time and two half-time workers serves an area in Massachusetts containing 150,000 people that includes the suburban towns of Arlington, Bedford, Lexington, Winchester, and the city of Woburn. The population is composed of a wide socioeconomic, ethnic, and cultural spectrum with a fairly large proportion of middle-income, psychologically sophisticated families who are extremely invested in their children. A special feature of the community is that it is composed of five separate autonomous municipalities, each of which possesses a unique character, with little or no tradition of working together. A further complicating factor is the lack of coordination with, and correspondence to, other social service areas. Thus, in addition to working with five school systems, five police departments, five boards
THE REALITIESOF COMMUNITYCHILD PSYCHIATRY In psychiatry, as in medicine generally, the realities of the situation, as well as the ideas of the practitioner, determine the character of clinical practice. The professional works in a physical and human environment; the pressures emanating from this milieu are as important in determining what is done as are the practitioner's preformed notions of good professional work. The environmental reality--what it is and what it expects or demands--is nowhere more important than in the field of community psychiatry. The staff of the small clinic mentioned works within five types of realities, identified as: l. 2. 3. 4. 5.
political-economic geographic administrative professional clinical
SOME MAJOR CHARACTERISTICS OF THESE REALITIES 1. An important aspect of the politicaleconomic reality is that the clinic is a public facility whose financial support comes from state and local tax funds.
* Dr. Newman, a child psychiatrist, is Director of the Mystic Valley Children's Clinic, Lexington, Massachusetts, and is ClinicalInstructor in Psychiatry, Tufts University School of Medicine, Boston. A version of this paper was read at Tufts University School of Medicine on May 12, 1966, at a psychiatry staff meeting on the topic "Meeting the Challenge of Community Child Psychiatry." The author wishes to express his gratitude to Lucile N. MeMahon for her valuable editorial assistance. 281
282
THE COMMUNITYMENTAL HEALTH JOURNAL
2. The geographic reality is that the clinic is located, not within the protected walls of a teaching hospital or on the grounds of a state hospital, but on a street in a suburban town among the patients it serves. (One of the first families to apply for service lived next door to the clinic.) 3. The administrative reality is that while the clinic is part of the Department of Mental Health, its basic support is provided by local citizens who, interested in mental health, serve voluntarily on boards and committees. 4. One aspect of the professional reality is that the clinic staff is not alone in the business of providing service to emotionally disturbed children. Departments of youth service and school guidance departments, for example, are also involved with patients, although the patients may not be so identified and the practitioners usually have a very different orientation toward, and professional view of, the problems involved. 5. The basic and inescapable clinical reality is that enormous numbers of people request service from a small staff of trained professionals. IMPLICATIONSOF THE REALITIESFOR COMMUNITYCHILD PSYCHIATRICPRACTICE
The dependence on public tax funds and the requirement to report the amount of service given (the political-economic reality) to each of the five communities in terms of number of cases, interviews, and hours makes it almost mandatory to maintain an open intake policy and to shift emphasis from the intensive treatment of a few to the provision of service to all those who apply. The clinic must maintain an image of helpfulness and service, not one of exclusiveness, frustration, and mystery. Because the clinic is so close to the people (the geographic reality), they come there much earlier than they might to a more distant facility and have not always clearly identified themselves as patients, i.e., sick people needing treatment. Consequently, they must be approached, not with the formality of the hospital, but with the relaxed interest that one shows to neighbors who come to discuss problems.
The administrative reality supports this approach in a situation where one may find that one's patient of today becomes a board member the following night. The situation requires that the staff be educators and translators, that it be able to communicate what it knows to a variety of audiences and to convert its knowledge into usable, palatable information. The professional reality requires establishing and building good relationships with other caretakers in the community. To borrow a phrase from political science, dialogues must be established with other professionals in order to learn what they expect from the clinic staff and let them discover what the psychiatric team is able to provide. At a later stage they may learn what it expects from them. A system of mutual continuing education is thus established. The clinical reality that derives from, and is a consequence of, the other realities demands that available staff time be used most efficiently. To put the matter more exactly: rapid, accurate diagnosis of the child's problem and the family pathology must be coupled with a clearly defined determination of what changes need to occur in the child or in his existing environment if symptoms are to be removed. There is the further need that there be frank assessment of the reasonable likelihood that such changes can be brought about by various types of therapeutic intervention and varying degrees of therapeutic investment. ACTIVITIESOF A CHILD PSYCHIATRIC CLINIC WITHINTHESE REALITIES
The policies at the Mystic Valley Children's Clinic and the specific activities of its staff can be seen as a function of the realities mentioned above and of the implications of these realities. Intake has been held open for the past three years despite the continuing enormous demand for service. The staff has participated in public discussions of issues ranging from delinquency and alcoholism to preschool education and the role of the clergy in mental health, always with the underlying aim of providing for the listeners a glimpse
MORTON B. NEWMAN of psychiatric thinking and of stimulating them to seek closer contact with psychiatry in general and with the local clinic in particular. The staff has actively collaborated with others in the community in organizing summer Head Start programs and community councils. Again, the aim is not only to engage in worthwhile community projects per se but also to point up the central relevance of psychiatric thinking, how it is not simply an amusing diversion but rather a crucial ingredient of any community project whose goal is to change human behavior. The hope is to transmit the message to the community that what the clinic professionals have to say about issues is valuable, useful, and understandable, an important service that the community will want to use again and that must, of course, be actively supported. Outside the clinic walls the staff's major activities involve consultation for other caretakers in the community, principally school guidance personnel, and more recently, with the addition of a psychiatric nurse to the staff, for nurses in the community. School guidance counselors, adjustment counselors, school psychologists, and social workers comprise the largest group of professionals working with, or potentially able to work with, emotionally disturbed children in the community. It was thought initially that regular consultation with these counselors would not only improve their skills and the mental health climate of the school but would also reduce the clinic intake load to manageable proportions. It was hoped that encouraging these people to work with emotionally disturbed children in the schools would result in decreasing the need for referral of children to the clinic from the schools, which are, after all, the greatest single referral source. Matters have turned out, however, to be more complicated than it at first appeared. Although the consultation program has been very well received, it has not had the effect of reducing our clinic intake. The staff has learned to appreciate the apparently obvious fact that others, such as school adjustment counselors, work in a very different environment than that of the clinic
283
and have different needs and values. It is pointless, for example, to discuss psychodynamics if their major concern is with disposition. It has been realized that the needs of the consultee, while sometimes different, are as important as those of the consuhant. These realizations have led to a broader, more flexible, and more tolerant view of the whole matter of consultation, attempting on the one hand to meet the immediate needs of the consultees (be it for reassurance, removal of problem cases, or rescue) while slowly, hopefully with patience, trying over time, using a variety of methods, to bring them into a closer, more trusting professional relationship with the clinic. Methods of clinical diagnosis have become more varied, while diagnostic aims have become increasingly focused. To traditional history taking and individual evaluation have been added observation of parents and children in groups, family interviewing, home visiting, and nursery school observation. The opinions of others who have observed the child and his family are sought out, and these observations are evaluated and useful material extracted. While more flexible in accepting what is regarded as useful diagnostic data, the clinic is more specific in its aims: to obtain an accurate description of the child's symptoms and behavior, a working theory of its meaning, an assessment of the nature of parental concern and of the possibilities of therapeutic intervention. We are interested in strengths as well as in weaknesses, in existing relationships and how they can be made more salubrious, in capacities for change in parents and child, in what can be manipulated, redirected, guided, replaced, or provided. This approach to therapeutic intervention is essentially conservative. It is limited in goal and in time and does not strive for major revision of personality. The aim must be to do what can be done briefly as well as effectively. Parental anxiety is used to build a problem-solving alliance, and an attempt is made to shift parental attitudes and behavior individually or in groups, sometimes without the child being seen at
284
THE COMMUNITYMENTALHEALTHJOURNAL
all. The staff works collaboratively with principles and who are able to feel comother caretakers who may see one family fortable enough to try out adaptations and member while another is treated at the new combinations and flexible enough to clinic. The trend is to be more directly meet a variety of demands both within and clarifying with both parents and children, without the clinic walls. The need for longmore ready to make suggestions, freer to term psychotherapy has not been elimiadvocate external change when significant nated; rather, as a larger, more varied, and internal change seems unlikely. more heterogeneous population with widely There is more that could be said about different expectations and capacities comes the clinic's approach to treatment and a within the clinical domain, additional great deal more that needs to be discovered methods should be added. Again, to borrow about its nature and effectiveness. It must a phrase from the language of contemporary be remembered that the clinic population political science, a variety of options is is relatively unselected, with varying de- needed. Long-term and short-term, ingrees of motivation, psychological minded- dividual and group psychotherapy, manipuhess, readiness to use psychotherapy, and lation, direct suggestion, and indirect capacity to profit from it. An attempt is treatment through consultation all have a made to give patients, not simply what it place in the armamentarium of the comappears they need, but what they want and munity psychiatrist. Continuing efforts find palatable and useful. People come to must be devoted to attempting to underus in great numbers asking for service; stand where, to what patients, and in which this does not necessarily mean and, indeed, situations each method can most usefully usually does not mean a request for long- be applied. term psychotherapy. Notwithstanding these Community child psychiatry challenges facts, it is felt most important to keep a mental health professionals in a variety of place for long-term conventional psy- ways. It tests their stamina and patience, chotherapy and casework, even in an over- competence and flexibility. It requires them crowded and understaffed clinic. The im- to be adaptable and clearly aware of what portance of long-term psychotherapy de- they are doing as well as why and how they pends, first of all, on the fact that some pa- are doing it. The training of medical stutients can be helped by nothing else. Fur- dents, social workers, and psychologists at thermore, it is only through a thorough the Mystic Valley Children's Clinic has understanding of personality, achieved by been found to help the staff give better conducting long-term psychotherapy, that service, for the need to define what is being staff members can become sufficiently done is reinforced by the obligation to exskilled to use shorter, more active, and plain to others. more experimental methods. The experience gained from the practice of community child psychiatry has, it is CONCLUDINGREMARKS suggested, relevance also for the planning Many things are said about community of community mental health programs. psychiatry these days--usually with a great While there must of course be some basic deal of breathless excitement. Some en- preplanning, a truly viable community thusiasts see in it the answer to the twin psychiatric program must evolve from a problems of shortage of trained psychiatric dialogue between the clinic professionals personnel and of the high cost of investment and representatives of the community, both in long-term psychotherapy. The complexi- lay and professional. In the public sector ties of the work, however, require not so of community psychiatry the wishes of the much the energies of those with little train- community are as relevant as the needs of ing or experience but rather the highly de- the professionals. Ideally, despite the in. veloped skills of those psychiatrists, psy- evitable frustrations and disappointments, chologists, and social workers who are a process of mutual education is initiated thoroughly trained and grounded in basic out of which programs and practices evolve.
