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THE CENTURY PSYCHOLOGY SERIES

Richard M. Elliott Gardner Lindzey Kenneth MacCorquodale

editors

:. EMERGENT APPROACHESTO MENTAL HEALTH PROBLEMS

Emory L. Cowen, Ph.D. University of Rochester Elmer A. Gardner,MD. Templc University Melvin Zax, Ph.D. Universtty of Rochester

NewW York

All rights reserved. This book, or parts thereof, must notbe used or reproduced in any mannerwithout written permission. For ilaformation address thepublisher,Appleton-Century- Crofts, Division of MeredithPublishing Company, 440 Park Avenue South,New York, N. Y. 10016.

697-1

Library of Congress Card Number:67-26274

PRINTED IN THE UNITED STATES OF AMERICA E 21335 FOREWORD

This volume has drawn together thedescriptions of several emerging, innovative approaches to mentalhealth problems. It stems from an Instituteheld at the University of Rochester inJune, 1965, and reviles publication at a particularly advantageous time.With the passage of the staffing grant act (Public Law 89-105) the communitymental health center program is nearingfruition and, though stimulatingconsiderable expansion of mental health services, brings intofocus a number of problems requiring resolution. The development of mentalhealth centers throughout the nation emphasizes the need for increased manpower,better coordination of health and social services, a greater involvementof all the community caretakers in the promotion of mental health, moreflexibility and experimentation in the delivery of services and, wherever possible, ashift from therapeutic to preventive intervention. We need to reexamine the assumptionsand models that have guided our mental health programs, and tosearch for new methods in thedistribution of our manpower. In the pastthose who most required help toofrequently found it least available. The approachesdescribed in this book represent attempts to correct suchinadequacies and to reconceptualize existingmodels. Though still in an evolutionary stage, the programsdescribed here are important because they constituteclear-cut illustrations of emergent andchang- ing practice in the mental healthsphere and stand as operatingmodels. It is recognized that mental health problems cannotbe the exclusive responsibility of any single discipline. Conceptually, the volume emphasizes apreventive approach and the development of theory to underlinethe promotion of mental health. Ifthe community mental health centers are tobe truly innovative, they will need the background of knowledge andexperience presented in thisbook. The authors are eminently qualifiedby experience and training to discuss the emergentapproaches to mental health. The mentalhealth program in Rochester has long beenknown as a dynamic and innovative one,which has been not only home territory,but classroom and laboratory toDoctors Cowen, Gardner, and Zax. Liketheir colleagues elsewhere, I havefollowed with great interest the developmentsin Rochester and MonroeCounty. My visits there have added to myenthusiasm. This book which stems fromthe work there will fill a real need formental health workers. R. H. Felix, M.D., M.P.H. PREFACE

The mental health problems of modern society arecomplex and deeply rooted. Only relatively recently in thehistory of man has the significance of suchproblems been clearly recognized. Sincethen we have been engaged in a growing struggle to reduce thehuman inefficiency and to combat the human misery that derive fromemotional difficulties. This effort, necessarily, has been guided by pragmaticconsiderations and immediate, felt pressures for help. The presentvolume considers the effectiveness ofthe traditional and historically dominant approachesthat have evolved as part of the early, systematized efforts of society todeal with disordered function. On this basis, it seeks to delineatefundamental issues that must be engaged if we are to achieve a sounder mental healthorder in the future. An attempt is made to articulate alternativeconceptual models, including the typesof programs andresearch which stem logically from these. The largest single portion of the volume,however, consists of a series of concrete descriptionsof innovative and viable "programs-in-action"addressed to specific aspectsof our total mental health problem.Included among these are communitymental health programs, special mental programsfor the poor, programsfor training new, nonprofessional, mentalhealth manpower, and primary, as well as early secondary,preventive programs in the schools. The approach to the volume is nonparochial.The issues addressed are ones of general relevance to all members of thehelping professions. Contributing authors include educators, psychiatrists,psychologists, and sociologists. Considerable impetus for this volume camefrom a conference on "Emer- gent Approaches toMental Health Problems" (June 17-19, 1965)jointly sponsored by the Department of Psychologyand Psychiatry at the University of Rochester. The conference consistedof a series of half-day sessions, each of which dealt with a topic of centralrelevance to the larger area. The opening meeting on "NewApproaches in Mental Health Manpower" waschaired by Kenneth E. Clark, Ph.D., and itincluded an introduction overview talk by John Romano, M.D., invitedaddresses by Robert Reiff, Ph.D. and Rich- ard Sanders, Ph.D., anddiscussion by George W.. Albee, Ph.D.and Milton Greenblatt, M.D. The second session on"Primary Prevention in the Com- munity," chaired by Harole C.Miles, M.D., included formal talks by Fred Duhl, M.D. and Frank Riemman,Ph.D., discussed by John Cumming, M.D. and Sheldon R. Roen, Ph.D. A thirdsession dealing with "Early Secondary Prevention" was chaired by RobertHaggerty, M.D. and included invited presentations by Wilbert W. Lewis,Ed.D. and George T. Donahue, Ed.D., with discussion by Sidney Koret,Ph.D. and Eli M. Bower, Ed.D. Afourth session led by William Fullagar,Ed.D. was directed to the topic of"Pre- vii viii PREFACE ventive Approaches in the Schools" and included formal presentations by Ira Iscoe, Ph.D. and Margaret C.-L. Gildea, M.D. as discussed by Herbert Zimiles, Ph.D. and William C. Morse, Ph.D. A final plenary session consisted of free discussion, by all conference participants, with respect to the substance of the prior meetings and related materials. This session was chaired by S. D. Shirley Spragg, Ph.D. and moderated by Robert Berg, M.D. The conference described above was arranged by a coordinating committee including the three editors and Norman I. Harway, Ph.D., Head, Division of Psychology, Department of Psychiatry, University of Rochester School of Medicine. The editors wish to express their sincerest appreciation to Dr. Harway for his important contributions to this effort. Support for the conference came from several sources including the following: MH 5146-18, Training Program in Clinical Psychology; MH 8469-02, Graduate Training in Community Psychiatry; MH 1500-01, Early Detection and Prevention of Emotional Disorders--each of the foregoing from the National Institute of Mental Health. Additional support was provided from the General Funds of the Department of Psychiatry and from the Department of Psychology at the University of Rochester. We are most grateful to each of these sources for their help. It should also be noted that some of the thinking that goes into the volume, particularly the first and last chapters, may be traced back to the conference and, in that sense, the authors owe a debt of gratitude to all of the participants. The conduct of the conference itself was greatly facilitated by the generous participation of David Beach and James D. Laird, who assisted both with arrangements and recording, and by the important secretarial and clerical contributions of Miss Jane Ellickson, Mrs. Carol Hunt, and Mrs. Pattie Spencer. Preparation of the manuscript was effectively handled by Miss Jane Ellickson, Mrs. Thelma Levin, Mrs. Alice McKay, and by Mrs. Marcia R. Macklin, who typed the final draft. Mr. Julian Rappaport contributed meaningfully to the early editing of the individual chapters, as did Mr. G. Ramsay Liem and Mr. Richard J. Cowen during the latter phases of the editorial cycle. We are deeply indebted to the foregoing individuals and are most appreciative of their significant contributions to the final product. E. L. C. E. A. G. M. Z. CONTRIBUTORS

George W. Albee, Ph.D., Professorof Psychology andClinical Psychology Program Chairman, Departmentof Psychology, WesternReserve University, Cleveland, Ohio. Emory L. Cowen, Ph.D., Professorof Psychology, AssociateChairman and Director of Clinical Training,Department of Psychology,Uni- versity of Rochester, andAssociate in Psychiatry(Psychology), University of Rochester Schoolof Medicine, Rochester,New York. John Cumming, M.D., DeputyCommissioner for Mental Health,New York State Department of MentalHygiene, Albany, New York. Jewish Voca- George T. Donahue, Ed.D.,Director of Professional Services, tional Service, Milwaukee,Wisconsin; formerly AssistantSuper- intendent of Schools, NewRochelle, New York, andElmont, New York. S. Thomas Friedman, Ph.D.,Assistant Professor of EducationalPsychology, Department of EducationalPsychology, The University ofTexas; Research Director, PersonnelServices Research Center,The Uni- versity of Texas, Austin,Texas. Elmer A. Gardner, M.D.,Associate Professor of Psychiatry,Director, Com- munity Mental HealthCenter and Division of SocialPsychiatry, Department of Psychiatry,Temple University HealthSciences Center, Philadelphia, Pennsylvania. Margaret C.-L. Gildea, M.D.,Associate Clinical Professor ofPsychiatry, Washington University School ofMedicine, St. Louis, Missouri. John C. Glidewell, Ph.D.,Associate Professor of Educationand Sociology, Washington University, and Directorof Research and Develop- ment, St. LouisCounty Health Department, St.Louis, Missouri. Jules D. Holzberg, Ph.D.,Director of Research, ConnecticutValley Hos- pital; Professor of Psychology,Wesleyan University, Middletown, Conn,cticut. Ira Iscoe, Ph.D., Professor ofPsychology and Education,Department of Psychology, The University of Texas;Associate Director, Person- nel Services ResearchCenter; Director, GraduateTraining in Community Mental Health, TheUniversity of Texas, Austin, Texas. Mildred B. Kantor, Ph.D.,Assistant Professor of Sociologyand Associate Director of a Trail liik; Program inMental Health Research of the Social Science Instituteof Washington University, andDirec- tor of Vital Statisticsof the St. Louis County HealthDepartment, St. Louis, Missouri. ix x CONTRIBUTORS William L. Klein, Ph.D., Assistant Director for Training, Institute for Youth Studies, Howard University and Assistant Professor of Psychiatry, Howard University Medical School, Washington, D.C. (on leave); Lecturer, Department of Psychology, Hebrew University, Jerusalem, Israel, and Supervising Psychologist, National Institute for Counseling and Guidance, Israel. Robert H. Knapp, Ph.D., Professor of Psychology, Wesleyan University, Middletown, Connecticut. Wilbert W. Lewis, Ed.D., Associate Professor of Psychology, Director of Research and Training, Project Re-ED, and Director of Research Group on Children with Behavior Disorders, George Peabody College for Teachers, Nashville, Tennessee. Loyce D. McGehearty, Ph.D., Director of Guidance, The Universityof Corpus Christi, Corpus Christi, Texas; formerly Demonstration Center Coordinator, Personnel Services Research Center, The University of Texas, Austin, Texas. William C. Morse, Ph.D., Professor of Educational Psychology and Psychol- ogy; Chairman of the Combined Program in Education and Psychology, The University of Michigan, Ann Arbor, Michigan. John Pierce-jonest Ph.D., Professor of Educational Psychology,Department of Edicational Psychology, The University of Texas, and Direc- tor, Personnel Services Research Center and Director, Southwest Child Development Evaluation and Research Center, The Uni- versity of Texas, Austin, Texas. Robert Reiff, Ph.D., Associate Professor and Director, Division of Psychology, and the Center for the Study of Social Intervention, Aibert Ein- stein College of Medicine, New York, New York. Frank Riessman, Ph.D., Professor of Educational Sociology, NewYork Uni- versity, New York, New York; formerly Associate Professor, Department of Psychiatry, Albert Einstein College of Medicine and Director, Mental Health Aide Program of Lincoln Hospital Mental Health Services, New York, New York. Margaret J.Rioch, Ph.D., Clinical Psychologist; Member of Executive Council and Chairman of Group Relations Conference Commit- tee, Washington School of Psychiatry, Washington, D.C. Sheldon R. Roen, Ph.D., Associate Professor of Psychology and Education, Department of Psychology; Director, Psychological Consultation Center, Teachers College, Columbia University, New York, New York; formerly Director of Research, South Shore Mental Health Center, Quincy, Massachusetts. John Romano, M.D., Professor and Chairman, Department ofPsychiatry, University of Rochester School of Medicine and Dentistry; Psychiatrist-In-Chief, Strong Memorial Hospital, Rochester, New York. CONTRIBUTORS xi Richard Sanders, Ph.D., Director of Psychological Services, Philadelphia State Hospital, Philadelphia, Pennsylvania. Charles D. Spielberger, Ph.D., Professor of Psychology, Florida State Uni- versity, Tallahassee, Florida; formerly Professor of Psychology, Vanderbilt University, Nashville, Tennessee. John leB. Turner, Ph.D., Senior Research Psychologist, Connecticut Valley Hospital; Research Associate in Psychology, Wesleyan University, Middletown, Connecticut. R. Jay Turner, Ph.D., Senior Research Scientist, New York State Depart- ment of Mental Hygiene, Mental Health Research Unit, Syra- cuse, New York. Melvin Zax, Ph.D., Professor of Psychology and Associate Director of Clinical Training, Department of Psychology, University of Rochester, and Associate in Psychiatry (Psychology), University of Roches- ter School of Medicine, Rochester, New York. Herbert Zimiles, Ph.D., Chairman, Research Division, Bank Street College of Education, New York, New York. CONTENTS

Foreword v

Preface vii

Contributors ix

I. INTRODUCTION 1. The Mental Health Fields Today: Issuesand Problems Emory L. Cowen and Melvin Zax 3

II. CONCEPTUALIZATIONS

2.Psychiatry, the University, and the Community John Romano 33

3.Theoretical Malaise and Community Mental Health R. Jay Turner and John Cumming 40 4. The Relation of Conceptual Models to ManpowerNeeds George W. Albee 63

5.Mental Health Manpower and Institutional Change Robert Reiff 74

III. COMMUNITY PROGRAMS AND NEW SOURCES OF MANPOWER

6. College Students as Companions to the Mentally Ill Jules D. Holzberg, Robert H. Knapp, and John L. Turner 91

7.Pilot Projects in Training Mental Health Counselors Margaret J. Rioch 110 8. New Manpower for Mental Hospital Service Richard Sanders 128 9. The Training of Human Service Aides William L. Klein 144 10. A Neighborhood-Based Mental Health Approach Frank Riessman 162 11. Psychological Care for the Poor: The Need for New Service Patterns With a Proposal for Meeting This Need Elmer A. Gardner 185 _

xiv CONTENTS 12. A Mental Health Consultation Program in a Small Community With Limited Professional Mental Health Resources Charles D. Spielberger 214

IV. NEW APPROACHES IN THE SCHOOLS

13. Preventive Aspects of School Experience Herbert Zimiles 239 14. Primary Prevention in the Classroom Through a Teaching Program in the Behavioral Sciences Sheldon R. Roen 252 15. Enhancing the Classroom Teacher's Mental Health Function William C. Morse 271 16. The St. Louis School Mental Health Project: History and Evaluation Margaret C.-L. Gildea, John C. Glidewell, and Mildred B. Kantor 290 17. Some Strategies in Mental Health Consultation: A Brief De- scription of a Project and Some Preliminary Results Ira Iscoe, John Pierce-Jones, S. Thomas Friedman, kind Loyce McGehearty 307 18. Early Identification and Prevention of Emotional Disturbance in a Public School Melvin Zax and Emory L. Cowen 331

19.Project Re-ED: Educational Intervention in Discordant Child Rearing Systems W. W. Lewis 352 20. A School District Program for Schizophrenic, Organic, and Seriously Disturbed Children George T. Donahue 369

V. SUMMARY

21. Emergent Approaches to Mental Health Problems: An Over- view and Directions for Future Work Emory L. Cowen 389

Author Index 457

Subject Index 465 I INTRODUCTION 1 THE MENTAL HEALTH FIELDSTODAY: ISSUES AND PROBLEMS

Emory L. Cowen and Melvin Zax University of Rochester

This chapter begins witha review of the historical antecedents of current beliefs and practices in the mental health fields. Beyond that, itspur- poses are to phrase the questions to which the volume is addressed and to focus on some of the fundamental issues underlyingit. The aim is primarily that of exposing relevant problems rather than oftrying to speak to their resolution.

HISTORICAL PERSPECTIVES

The history of man's ideas about mental illness and mental health is a long and tortuous one. it has been marked bya series of conflicts, some of which seem rooted in man's needto feel secure and others of which are more strictly intellectual in nature. It seems man was initially drawn tocon- cern himself with behavior only because it went awry. Modernman, like the primitive, proceeds largely under the assumptions that he is in good command of his psychologicalprocesses and that he knows just why he behaves as he does. When unreasonable behavioroccurs, it demands explanation and attention either because it is troublesometo others or because it may suggest to those who seem outwardlysecure that they, too, are vulnerable. Man's first great struggle in attemptingto understand behavioral dysfunction was between the tendency to attribute itto supernatural causes, as was done with most natural phenomena, and the need to look at it closely in an attempt to deal with it rationally (Alexander & Selesnick, 1966). The invocation of spirits involved the assumption that justas some events occurred because man willed them and tooksteps to cause them, so, too, might such peculiar phenomena as mental illness arise becausesome powerful spirit, well-intentioned or otherwise, would have it thatway. Hippocrates' great contribution was his insistence that rational explanations couldbe found for mental aberration, and his contemporaries in the goldenage of Greece con-

3 4 INTRODUCTION tributed much concrete thought based on such an assumption. Down through the years, however, first the spiritistic, then the rational, idea prevailed; and a variety of factors seemed to determine which held sway. Certainly the state of' man's sense of security and safety was a crucially important, determining factor. As the Roman Empire began to break up and Europe was ravaged by plagues and marauding hordes of barbarians, life became so unsettled that man could not withstand threat while he sought rational solutions. He needed to do something which would bring quick relief and hope. His resolution was to turn to religion, which could bring some immediate order to his existence by prescribing much of his behavior. Even more, though, religion held out the hope of an afterlife in which surcease would be found. With this emphasis on the importance of the supernatural and an afterlife, interest in rational causes of behavior diminished. The rational approach was revived only after Western man began to undergo an intellectual reawakening. This revival, a struggle that continued over many years, began because the restrictions imposed by religious forces came to be more onerous than the insecurity associated with rebellion against the established order. It might be added that the conflict between faith and understanding was never won completely by either side. When man emerged from the Middle Ages and became more thoughtful about aspects of his own behavior, a new conflict emerged, one which was, in most respects, intellectual. The conflict involved the question of whether man's behavior was to be understood on the basis of his biology or his experiences. While many of those whose primary appeal was to biology took on overtones of spiritism, there has always been a group of such theorists who hewed to a strictly scientific line. In many ways a biological explanation of behavior, particularly behavior disorder, is an attractive one for man. This is probably so because, on this basis, the person who becomes ill can be regarded as the exception. He is the one with a vulnerable physiological structure. If experiential variables are the main causes of mental illness, then we are all vulnerable. We are all subject to noxious experiences, many of which we are at a loss to control. Thus, mental illness may befall us all. This is an idea that man has found extremely threatening down through the years. His preference has been to ignore it, despite occasional, perceptive reminders, usually from literary sources. Don Quixote, for example, may be seen as a characterization of the rational and irrational forces within all men. The vulnerability that man has always felt regarding control of his own behavior has, no doubt, been a determining factor in what he has regarded as mental illness, how he has thought about it, and what he had done about it. For most of the history of man, when mental illness was considered, the referent was to extreme or bizarre behavior (Zilboorg & Henry, 1941). Those manifesting such behavior were thought to be men apart, and indeed, 5 THE MENTAL HEALTHFIELDS TODAY conditions in early mental they were treated as such.The shameful history of substantiate this hospitals and the practiceswhich prevailed in them seems to for the idea thatattitudes view. Foucault(1965) makes a convincing case mentally ill, so that ex- formerly held towardlepers were transferred to the the problem. The clusion from societybecame the acceptable way to treat which all of society's early hospitals weresimply places of confinement to undesirablesthe beggar, 'hevagabond, the thief, thelunaticwere sent. They were The deranged, however,had a special place insuch institutions. under displayed to the public,much as animals in a zoo.They often lived conditions which can only becompared to those enduredby wild beasts, and animal-like protection against in fact, they werecommonly thought to possess Pinel marveled at the worst inclemencies.Even so great a humanitarian as insane of both sexes "the constancy and the easewith which certain of the 1965, p. 74). bear the most rigorous andprolonged cold" (Foucault, Man was slow to accept theidea that the behavior ofthe deranged was shifted on a continuumwith so-called normalbehavior, but as his attentions 1:fisturbed to the from the grossly peculiarmanifestations of the seriously symptoms of theless disturbed (e.g., theneurotic), man developed a new interest was in the mostdramatic awareness.Even in this instance, early essentially neurotic syndrome, hysteria,which was usually regarded as an physical condition. In his work onthis disorder, Freudformulated and crystal- Interest in such issues lized ideas about the causesof the behavior of all men. marked by a gen- wasbeginning to appear in thenineteenth century, an era question the merits erally greater feeling of securityfor man. Though we may there is no minimizing the of Freud's specificformulations about behavior, significance of his work tothe history of developmentof intellectual thought. biological and experi- He clearly viewed all men assubject to the same forces, mental, and thus pavedthe way for the readmissionof those with severe however, his work served to mental illness to thehuman race. Beyond that, refocus the attention ofthe helping professions, sothat their interest and seriously activities began to encompassnot only thepsychotic, but the less disturbed neurotic as well. This broadening of the scopeof the mental healthprofessions resulted recognition of determinants in a spate of new theoriesabout behavior and the that had not previously beenaccorded much significanceby professionals. The years following Freud'searly work witnessed afurther enlargement in mental health worker. the range of human behaviorwhich is of concern to the Interest in neurosis led to therecognition of the effectsof emotions on physi- medicine. Perhaps even more ology and to the developmentof psychosomatic important, a growing awarenessof the significance ofthe so-called ego struc- subtleties in behavior and its tures in mentalillness sensitized man to greater potential rooting in earlyexperience. Gradually manyof the "givens" of less certain now, for ex- human nature werecalled into question. We are ample, that IQ is entirelyrelated to innate qualities.We are less prone than 6 INTRODUCTION we used to be to regard certain groups of individualswhose behavior is, in some ways, "primitive" as inherently inferior. As a result,the mental health professions, especially in the United States, seem to be undergoing a new expansion of their horizons. This has not happened because the old problems have been solved; schizophrenia, for example, remains a vexing concern. It has probably come about because man is daring to look at himself more closely than he ever dared before and is willing to admit that there are subtle aspects of his behavior, to which large numbers of individuals are a party and, which concern him. It would be a mistake to attribute all of the changes in our thinking about mental functioning to the ideas of any single person. History is full of instances where advanced ideas were thrust aside in favor of primitive notions. Intellectual advance requires fertile soil and a proper climate in which to grow, and this seems especially true for man's ideas about his own behavior. Where there is a need for the security that superstitution and magical practices afford, the person who would apply his intellect to the problems of the day is a threat. His approach denies the validity of the supernatural and, whatever success a science achieves, it inevitably confronts man even more with his ignorance. Thus, it is the reasonably secure man who can tolerate rationality in thinking about how and why he acts. Lewis (1941) has gone so far as to assert "It is possible to say that the attitude of a peopletoward mental disorder is a fairly accurate indication of the stage of civilization attained by them" (p. 24). By such a standard modern man, especially in this country, is advanced indeed. The reasons for this are manifold, but in large measure, they can probably be reduced to the factthat he has achieved a degree of material security never before equaled. Western man no longer need fear for having enough to eat, a safe place to sleep, and protection against the elements. While the social turmoil attending the kind of rapid technological advances being achieved is stressful, the most elemental needs of man are better met today than at any other time in the history of civilization. The primary stresses of the time derive not from a lack either of technology or of understanding of the natural world, but rather from man's failure to have advanced as far in the social sciences as he has in the natural sciences. He is, therefore, for the first time in history, more at the mercy of his fellows than of the natural forces around him. Wherever man's problems with nature have been well resolved, it is reasonable to expect that his attention will turn to problems with his inner self and his fellow man (Schofield, 1964), and nowhere has this happened more obviously than in the United States. Though a product of Europe, Freud was the adopted son of the United States. Furthermore, the warm reception accorded Freud paralleled other movements within this country which contributed influentially to the manner in which the helping professions have evolved. The historical moment for such acceptance seems to have been ripe. The extensive efforts of Dorothea Dix over a century ago aided THE MENTAL HEALTH FIELDS TODAY 7 the establishment of our earliest state hospitals. Later, through the work of Isaac Ray and particularly as a result of the experiences and writings of Clif- ford Beers in the very early years of the twentieth century, the mental hygiene m ovement in this country wasfounded. With Beers as its guiding force, and with the backing of distinguished professionals of the time, including Adolph Meyer and William James, the mental hygiene movement emerged initially as a pressure group oriented to educatingthe public and stimulating action to solve the problem of mental illness. Beers' original concern waswith improving conditions in mental hospitals, but the primary aims of the movement soon shifted to two otherobjectivesestablishing a program of eugenics to deny parenthood tthose who were "manifestly unfit" and promoting the likelihood that children would be provided environments best-suited to their development. The National Committee for Mental Hygiene, established in 1908 as an offshoot of the mental hygiene movement, succeeded in the furtherance of some of the foregoing aims but failed in others.Its pioneering efforts to establish clinics for children, as one means of dealing early with problems of mental illness, bore fruit. Moreover, the Committee helped to institute the practice of keeping and reporting statistics on patients in mental hospitals and to create an inspection service for mental institutions. On the other hand, many of its proposals, such as aftercare programs for former mental patients and the launching of broad-gauge programs 2or prevention, failed almost completely to arouse enthusiasm. Despite the work of men like WilliamHealy, who around the turn of the century wrote extensively about the sociocultural roots of delinquent behavior, the time was not yet ripe for attacking a problem of such magnitude (Eisenberg, 1962b). One reason may well have been that the idea of being able to create a social system which could eliminate serious mental disorder was too remote or visionary. Another may have been that great hopes for curing mental illness were being aroused by the development of psychoanalysis and the successes that were being achieved with somatic approaches to disorders like paresis. Finally, psychiatrists themselves were just beginning to win respectability within the medical profession and were not ready to abandon work which scemed to be paying off in order to learn new disciplines and new techniques which might bring uncertain returns. Marked expansion of interest in the mental health fields in the United States seems to have gained major impetus from the growing acceptance of Freudian principles and practices following World War I. The work of men like Adolph Meyer very likely paved the way for an appreciation of Freudian concepts, particularly the need to view mental illness from the perspective of a lifetime of experiences which contribute to ultimate disorder. At any rate, psychoanalytic ideas flourished in this country and found their way not only into clinical practice but also into such diverse areas as literature, advertising, the arts, etc. (Duhl, 1965). This has been an important development in the popularization of the belief that all men are subject to similar dynamic forces I

8 INTRODUCTION and are equally vulnerable. One consequenceof greater acceptance ofthis notion has been the growingdemand for mental health services,particularly

, psychotherapynot entirely, however, on the partof those suffering the most serious illnesses. Indeed, by the 1950's, asHollingshead and Redlich (1958) were able to point out,intensive one-to-one psychotherapeuticapproaches had become most widely applied to the relativelywell-to-do and better functioning of the patient population.The less affluent and sometimes moreseriously disturbed patient, when treated, wasbeing treated far less intensively and often only with somatic methods. To back off a moment in time, it is also necessary tolook at the impact of another significant set of developments onthe evolving mental health scene. The presentcenturymarked by a resurgence ofman's hostility to man, with supportingtechnology to make such hostility many times more destructive than ever beforehas witnessed twomajor international conflagrations of disastrous proportions.These conflagrations had importantreverber- ations upon the mental health viewsof both professionals and thelaity. For one thing,specific interminglings of newcombinations of people from all walks of life, frequently underhighly stressful conditions, graphicallyexposed many, for thefirst time, to a systematic viewof the vagaries of emotional perturbation. Certain types of acutepsychological turmoil and mentalillness became much more widely known and,in many situations,became, very concretely, major problems in the livesof individuals and those inclose association with them (Bellak, 1964). As Sanford (1965) has pointed out, someadvances were made during World War I with respect to early diagnosisand treatment of emotionaldisturbance, and, particularly, in furthering acceptanceof the doctrine of psy- chogenic determination of disorder. Ourlevel of concern regarding such problems increased markedly at the timeof the outbreak of WorldWar II (Dunham, 1965). Psychiatric screeningof potential recruits becamemuch more intensive, and greatnumbers of individuals were rejectedfrom service as psychologicallyunfit. Moreover, closer attention waspaid to the problem of breakdown during service, and we werefurther shaken by the finding that nearly half a million servicemen weredischarged for reasons of emotional disability. Each of these discoveries served tohighlight the magnitude of our mental health needs and the consequencesof our past failures to respond to them. Sarason, Levine, Goldenberg, Cher lin, andBennett (1966) have noted that two of the major problems growing outof our experiences in World War II were those of the immediate and long-range careof hundreds of thousands of human beings who were psychologicalcasualties of the conflagration. We had neither the resources nor thepersonnel to discharge theseobligations effectively. Awareness of these lacksbecame a powerful determinant behind the federal government's appropriationof vast sums of money to the Veterans Administration at the end of World WarII. The principal objectives of these THE MENTAL HEALTH FIELDS TODAY 9 appropriations were twofold: to provide hospital and out-patientfacilities, with their attendant services, for the veteran; and tofoster the training of needed mental health professionals in these areas. As such, the VA program still in forcehas represented a powerful influence on the recentgrowth of the helping professions in this country. Largely in response to the events of World War but at an even broader and more basic level, Congress in 1946 passed the National Mental Health Act. This legislation, justifiably regarded by some(Romano, Ch. 2) as the single most importantdevelopment in the history or the mental health movement, provided a budget for widespread augmentalion of facilities and services, the training of professional personnel in all of thehelping fields, and comprehensive research in areas relevant to mental heali h. As anoutgrowth of this act, the National Institute of Mental Health wascreated several years later, and ithas served as the principal administiative agency for its implementation. In the years since the enactment of the originallegislation, the scope of activities encompassed by the NIMH programshas steadily widened, and iitotal budget now exceeds one quarter of a billion dollars per year. The contributionsof this act and its subsequent emendations to the mental health fields cannot be overestimated. Nearly a decade after the end of World War II, the need for a comprehensive and critical analysis of the mental health scene, independentof a precipitant so extreme as total conflagration, had crystallized.Accordingly, passage by Congress of theMental Health Study Act in 1955 established a Joint Commission on Mental Illness and Health with this objective inmind. The specific mandate of the Joint Commission was "...to survey the resources and to makerecommendations for combating mental illness in the United States" (Joint Commission Report, 1961, p. v). The compositionof the Commission, its objectives, the scope of its operations,and the substance of its recommendations have, by now, been detailed many timesmost completely, of course, in the constituent volumes and summary(Joint Commis- sion Report, 1961) that constitute itsfinal report. This report, as some observers (Sarason et al., 1966) have commented, served tounderscore forc- ibly the magnitude of our mental health problems, theshortages of qualified professional personnel, and some limitations deriving fromentrenched modes of mental health practice. One highly germane aspectof the report was the importance accorded to the community as apotential arena for the engagement of mental health problems. The significance of the issues addressed by the Joint CommissionReport is such that some controversy about itsrecommendations, almost inevitably, has been generated (Eisenberg, 1962c; Iscoe, 1962; Freedman,1963; Caplan, 1964; Sanford, 1965). In the main, however, the recommendations havebeen viewed as sound and forward-looking. As Glasscote, Sanders,Forstenzer, and Foley (1964) have said: "Their report was proclaimed a landmark inthe history of the mental health movement in this country" (p. 6).Whether it 10 INTRODUCTION will prove to be a landmark that future historiansmerely cite in their dis- passionate recording of past events,or one which they come to admire for its great functional significance, is a matter that only time will tell. Itis already soon enough to know, however, that the document has beenan extraordinarily influential one and that,at least for the next several decades, it is likely to constitute a blueprint in tile mental healthareas. The need perceived in the Joint Commission Reportto conduct our mental health business closerto the community reflects a series of factors which, collectively, support the logic andmerit of such a shift in orientatio.l. Among the most significant of these factorsare the changes in treatment approaches with seriously disturbed patients, leadingtoward the growing realization that confinement neednot be a lifetime matter and, thus, toward a more frequent establishment of "open-door" policies in mental hospitals (Eisenberg, 1926b; Williams, 1962; Greenblatt& Levinson, 1965). Perhaps the most dramatic of these changescame with the introduction of a series of chemotherapeutic agents, notably the psychotropic and antidepressantdrugs, which created new possibilities formany individuals, both for direct treatment and aftercare in community settings (Bellak, 1964). Another important strand in this developmentwas the increasing awareness of the antithera- peutic forces in total institutions, culminated by Goffman'ssearching essay (1961), and conversely, the utilityundercertain conditionsof the hospital as a therapeutic community (Jones, 1953; Fairweather, 1964; Jarvis & Nel- son, 1966). Each of these factors has directed attention toward thecommunity-at-large and itsresources as a potential force in combating emotional disorder. And, finally, there has beenan evident current of willingness, even outside of the helping professions,to widen our historically narrow conceptions of the factors which contributeto disorder and the form in which such disorder may be manifested. Thus, the potentiallinkings of lack of education, poverty, squalor, and the undermining of human dignity withscarring of the psyche have come,more and more, to be viewed as admissible (Clausen, 1966). This latterwave comes from recognizing the paradox of a society struggling to providemore and more opportunities for education, achievement, and the accumulation of material comfort and,at the same time, observing an ever-widening chasm between thosewho benefit from suchop- portunities and those who do not (Burgess, 1965). Theseriousness of this gulf has becomemore than a scientific or professional concern. It has prompt- ed the government of thiscountry to create, through massive appropriations of public funds,programs which are aimed at reducing the chasm (Office of Economic Opportunity, 1965) and making it possible for allpeople to live a more effective, fulfilling, and personally gratifying existence in what has come to be known as the "Great Society." The civil rightsmovement and a variety of programs sponsored by the Office of Economic Opportunity(e.g., Project Head Start) well exemplify this development. Theseprograms are 11 THE MENTAL HEALTH FIELDSTODAY anchored in the community, andthough they are targeted primarily tosocial problems, their relevance for the mentalhealth areas has not goneunnoticed (Reiff, Ch. 5). The foregoing factors havecontributed to the shift in orientationof mental health professionals towardthe community and its primaryinstitu- tionsa shift which isreflected to some extent in theJoint Commission Re- port. The fuller impactof this development wasdramatized in President Kennedy's February, 1963, address toCongress calling for a new typeof mental health facility. As Caplan (1964) comments:"The fact of the message itselfthe first official pronouncementby a head of government .. .aswell as its contentemphasize that henceforward theprevention, treatment, and rehabilitation of the mentally ill...are to beconsidered a community responsibility and not a private problem ..." (p. 3). The statement bythe President presaged enactment of theCommunity Mental Health Act of 1963, which is to be viewed as a majorpart-implementation of the JointCom- mission Report. This act establishedthe basis for a comprehensivenetwork of community mental health centersaround the country to engagemental health problems in a form and mannerwhich departed from long-standing practice in this area. The proposedactivities of such centers, bothmandatory and recommended, were setdown in a series of implementingregulations issued shortly after the enactment ofthe enabling legislation. Though much has been written about the communitymental health center, its implementation, and some of its potentialproblems (Albee, 1963; Albee, Ch. 4;Caplan, 1964; Glasscote et al., 1964; Smith& Hobbs, 1966), there is as yetlittle objective basis for its evaluation. Thepotential importance of the development is such, however,that critical thought and commentabout it, as well as intensive,logical analysis of its promise andpotential pitfalls, are sorely needed at this time (Felix, 1963; Brown& Cain, 1964):

CURRENT PERSPECTIVES

It is apparent from this brief historicalsketch that the past seventy- five years, and particularly the lasttwenty-five, have seen tremendouslyrapid and complex developments in themental health fields. Thesedevelopments grew out of theage-old concern for the severely illand came rapidly to encompass wide varietiesof behavior which had neverbefore been regarded as beingwithin the province of the mentalhealth worker. Yet, viewed in terms of the totalhistory of man, the mental health movementis still a young one. A great portionof our collective efforts has gone intothe establishment and legitimization of the movementinto animplantation of the notion that a mentalhealth orientation represents afundamental and necessary dimension in the evolution of anoptimal society. We have grown up inthe image of a particular model, themedical model, which had beendemonstrably effec- I

12 INTRODUCTION tive in other areas and had seeming relevance for the management of psychological dysfunction. But, in a panoramic social sense, the essential early struggle of the movement has been largely one of inside versus outside, of respectability versus nonrespectability, or of "pro"-mental health versus "anti"- mental health, rather than an internal struggle among alternative mental health stratagems and pathways. In other words, we have been so busy becoming respectable that we have had neither the time nor the security to look unto ourselves or to support truly critical evaluation of the substance of our efforts. It is only very recently that the foregoing situation has changed. The mental health movement has, by now, achieved a place of considerable respect and dignity in many quarters of modern society. We are no longer fighting for our professional existence as was Freud sixty years ago. On the contrary, the swing of the pendulum has been such that our current problem is more often that of being oversold and unable to deliver. The past decade has thus been characterized by restlessness, reexamination, and ferment concerning our mental health helping structures and practices (Caplan, 1964; Sarason, et al., 1966) and by a growing interest, on the part of social scientists and public health specialists, in both the theoretical and practical problems reflected in this area (Hobbs, 1964; Caplan, 1965). While acknowledging a substantial disagreement about the centrality of the various determinants, it is nevertheless possible to approximate a "bill of particulars" that comprises most of the variance of current discontent. In brief, our problems are these: (1) The need for mental health helping services far outstrips available resources; (2) Past practice has resulted in little progress in the treatment of entire classes ofdisorder; (3) It appears that both the effectiveness and impact of one of the backbone techniques in our helping armamentariumpsychotherapyhas been seriously overestimated; (4) Delivery of mental health helping services has been characterized by profound inequities, with particular reference to variables such as race, social class, education, and geography; and (5) Our modes for delivery of mental health services are, in the main, out of tune with the social reality and life- styles of vast numbers of potential recipients. These are some of the prime issues facing the mental health fields todayissues to which emergent approaches, such as those reported in the present volume, are addressed. In the sections that follow, more detailed consideration will be given to several of these problems.

DEMAND, NEED, AND RESOURCES Schofield (1964) uses the phrases "the countable thousands" versus "the hidden millions" to point up an important distinction between the demand and the need for mental health helping services. Though neither term lends itself to ready definition, it is clear that, of the two, demand is both a 13 THE MENTAL HEALTHFIELDS TODAY Estimates of de- more conservativeconcept andsomewhat easier to specify. such as the number mand for mental healthservices are based on statistics beds occupied, thenumber of people seekinghelp through of mental hospital practi- mental health clinicsand agencies, and thenumber seeing private in tioners. In otherwords, it is possible, atleast in part, to be "operational" speaking of existingdemand. However, suchfigures are subject to many For example, one biases, characteristically in thedirection of underestimation. Feld, 1960) of the reports in theJoint Commission series(Gurin, Veroff, & indicates that less than 20%of those who seethemselves as needing help problems take such problems tomental health special- with their emotional that the ists. Beyond that, it iswell known (Schofield,1964; Sanua, 1966) figures. That the num- availability of facilities is alimiting factor on demand of Columbia alone is ten ber of occupied mentalhospital beds in the District reflects geography andavail- times greater thanthe number in many states 1966). Recognizing the im- able facilities, notincidence or demand (Sanua, "The total number precision of any approximation,Nichols (1963) has said: ..(is)...at of people who demand some sortof psychological services . minimal estimate" least three million per year,and this is undoubtedly a (p. 3). Whatever the difficulties ofdefining demand forpsychological services, involved in defining they are minimal whencompared to the complexities need. Few, however, would arguewith the assertion thatneed is far greater be seen by him- than demand. To establishdemand requires that the person self or by others as having aproblem, that facilities forhelp be available, and that he, or responsibleothers, be able financiallyand motivationally to that the person in ques- request help.Faltering at any of these points means tion will not be reckoned as ademand "statistic." And,there is every reason falter at one to believe thatthere are many people,with great need, who do 50%-70% of or moreof them. Some of these maybe among "the recalcitrant later labelled 'neurotic' " the general practitioner'scase-load who are sooner or (Schofield, 1964, p. 5).Others, among the poor, arepeople who, though psychological or, if they beset with serious difficulties,do not define these as they will not seek do, find the potential sourcesof help so inimical that describes assistance. All belong tothe "hidden millions"that Schofield (1964) people who are unhappy,ineffective, and oftentimessuffering untold mental health problems in our misery, but who are notformally identified as statistical surveys. unrelated to some Assessment of need in themental health area is not fundamental questions, such as"What is a psychologicalproblem?" and very need vary as a "How do we determine itspresence?" Perceptions of existing On function of the stringencyof the answers weprovide to these questions. (Eisenberg, 1961; Joint the relatively conservativeside, several recent sources Commission Report, 1961;Nichols, 1963) have estimatedthat roughly 10% By contrast; of our present population is inneed of psychological assistance. 14 INTRODUCTION several epidemiological surveys (Leighton, 1956; Leighton, 1959; Leighton, Leighton & Armstrong, 1964; Srole, Langner, Michael, Op ler, & Rennie, 1962) and early detection studies with young children (Cowen, Izzo, Miles, Telschow, Trost, & Zax, 1963; Cowen, Zax, Izzo, & Trost, 1966) report up to one-third of the samples studied as evidencing either somedegree of psychiatric symptomatology or moderate to severe pathology. And, perhaps, most extreme of all, the two epidemiological surveys cited above indicate thatless than 15%-20% of the rural and urban samples studied (Stirling County, Nova Scotia, and midtown Manhattan) were free of indicants of emotional distress. These findings suggest that, insofar as mental health helping services are concerned, need may well exceeddemand by a factor of anywhere from six to twenty. For the moment, it will be sufficient to consider only the more conserva- tive demand statistics as a basis for evaluating existing resourcesparticularly available professional personnel. A searching examination of the problem was undertaken by Albee (1959) as part of the Joint Commission series. His key finding relevant to the principal helping professions of psychiatry, social work, and clinical psychology was that the then-existing shortages, using "adequate" rather than "ideal" standards of care as the criterion, ranged from 25% to 75%. Since there are far fewer professionals than needed in the corehelp- ing professions, it follows that many positions, whether due to type of setting, location, salary, or some combination of these factors, have remained permanently unfilled. Moreover, as Albee has emphasized, if we combine best estimates of population growth and professional training potential, it seems highly probable that we shall be unable to overcome these deficiencies in either the near or distant future. In fact, as has been suggested (Albee, 1963, Ch. 4), our manpower problem may get worse because of the increasing competition for professional services from agencies and organizations which are relative newcomers to the arena. In the fieldof psychology, for example, the need for teachers in colleges and universities is increasing so sharply that it is probable that all available psychologists could soon be absorbed in this function alone. As a very different case in point, the recommended staffing of our new community mental health centers calls for one psychiatrist, one social worker, and one clinical psychologist per 50,000 populationnot at all a luxurious ratio. For a nation of some200,000,000 people, this means an additional 12,000 fully trained helping professionals in a situation where we are already overtaxed by criticalshortages. The concept of mental health resources, of course, extends more broadly than just professional manpower. The monies available for mental heal th- relevant activities and programs, our mental hospitals and clinics, and a variety of caretaking agencies are further important elements in the total configuration of helping resources. Nichols (1963), following a review of the current availability of these types of resources, states "...it must be con- 15 THE MENTALHEALTH FIELDSTODAY of psychologicalservices eluded that there is a greatshortage in the supply personnel, inadequate the combinedresult of insufficient and that this is care-taking agencies. psychological facilitiesand too few funds, not enough people get no helpand The consequence isinescapable; at present many less than they need or getthe wrong kind"(p. 5). many more get of add up to acompelling sum.Merely in terms The foregoing facts which is inferred tobe health services(rather than need demand for mental criterion, greater), present resources,measured by almost any many times traditional course, it isprob- grossly insufficient.Moreover, steering the are critical over time.The chal- able that existingshortages will become more ignored. Indeed, itsfundamental clarity lenge of this situationcannot be failing of ourmental healthorder forces upon us an awarenessof a central foi exploring newapproaches and and a sense of urgencyabout the need help to reduce seriousexisting imbalances ways ofdoing things which may hand, and resources onthe other. At between need ordemand, on the one this end arelimited. We may logical level, thealternatives for achieving a and resources or toreduce need through strive either toincrease manpower framework or thedevelopment of improved technologywithin our present and approaches tomental healthproblems. newconceptualizations about involve dif- not mutuallyexclusive, they clearly Though these pathways are efforts may and emphases.Issues such as how our ferent tactics, stratagems, and what concep- in seeking toachieve such objectives best be apportioned this time are amongthe tualizations and approaches seemmost promising at approaches movementand a basic mostsignificant challengesof the emergent volume. focus of this should help to focus atten- Consideration of theforegoing broader issues utilization ofnonprofessional and tion on a seriesof questions pertaining to operation (Duhl,1965). Speak- professional manpower inthe mental health former: In what waysdoes utilization ofthe nonprofessional ing first of the in terms conceptualizations? Whatkinds of people, both relate to our guiding work? and personal attributes, maybe suited for such of group belongingness which the nonprofes- of mentalhealth-related roles for What is the range people? What is How do we goabout training such sional can be prepared? the one hand,and between selection andtraining factors, on the relationship contributions that the roles and functions onthe other? Arethere certain be made by theprofessional? nonprofessional may beable to make that cannot in helping activities, What is the effectof participationby the nonprofessional and on himself? both on the recipientof his services about the mentalhealth profes- Similar questions mustalso be raised What new rolesand functions mustbe acquired? sional, as for example: What sorts of changes about training forthese functions? How does one go time? What should will be needed inthe apportionmentof the professional's and the nonprofessional?What be the relationshipbetween the professional 16 INTRODUCTION are the sources of resistance that may be encountered, both from the professionals themselves and from influential training institutions, as we attempt to carve out new roles? It is certainly easier to associate to such problems than to resolve them. At the same time it is well to have them clearly in mind from the very beginning, since they are issues that will come up repeatedly in later sections of this volume.

PSYCHOTHERAPY: HOPES, DISAPPOINTMENTS, AND ALTERNATIVES

The development by Freud of psychoanalysis as a method forap- proaching the cure of emotional disorder marked the beginning ofa new era for the mental health professions. There was the exciting prospect of being able to deal with psychological problems largely through sophisticated application of techniques of verbal discoursea major breakthrough in the history of healing. In a relatively short period of time, therefore, psychoanalysis and its derivative approaches in psychotherapy became the primary tools in our helping armamentarium. Indeed, the history of the mental health movement in the twentieth century is dominated by the emergence and growth of psychotherapy, and it is not unfair to say thatwe have "placed our early bets" on this development. Psychotherapy has come to be valued above all other approaches by many mental health professionals, by professionals in training, and by major groups of potential recipients. Accordingly, other helping methods have frequently been viewed as unsophisticated, palliative,or half- hearted. A host of factors have contributed to the sometimes unreasoned and reverent adoration of psychotherapy and to its self-perpetuation (Eisenberg, 1961, 1962a; Goldston, 1965). Certainly among the more important of these is the fact that, for the professional, this function serves simultaneously to fulfill a powerful constellation of needs, including those for status andpres- tige, economic gain, and power and control. The foregoing considerations have contributed to a slowness in, and resistance to, rigorous evaluation. The decade of the 1950's was the period when the early flush of enthusiasm over psychoanalysis, its derivative psychotherapies, and the therapeutic role that it carved out for helping professionals in all fields began to yield to serious questions about the efficacy of the approach. Perhaps this development came about becausesome professionals had achieved a certain security with a definite role that was becoming widely honored. Perhaps it derived from a growing impatience with traditional techniquesor from the recognition that they failed to answer all mental health problems and that unless challenged, there would be little initiative for tryingnew approaches. In any case, a provocative and highly controversialpaper by Eysenck (1952) presented data suggesting not only that psychotherapy did not positively affect 17 THE MENTAL HEALTHFIELDS TODAY appeared to recovery fromneurotic disorder but alsothat intensive therapies been extended and up- be less efficacious thanbriefer ones. This position has Though Eysenck's dated in subsequent reports(Levitt, 1957; Eysenck, 1961). occasions (De Charms, logic and his data havebeen challenged on numerous Levy, & Wertheimer, 1954;Rosenzweig, 1954; Cartwright,1955,1956; Bindra, 1956), few, includinghis severest critic(Rosenzweig, 1954), argue of psychotherapy that convincing, positivedemonstrations of the effectiveness have been carried out.Schofield (1964) well reflectsthe current situation in 1 awaiting definitive researchwe the following statement:"... weare still still do not haveacceptable evidence thatpsychotherapy accomplishes significant reduction of neuroticsymptomatology, let alone evidencethat the several different forms ofpsychotherapy have differentlevels of efficacy" (p. 99). It is often not sufficientlyemphasized that evaluation ofthe clinical of the effectiveness of psychotherapy is evenfurther biased by the selectivity patient group that ittouches. Those who seek andobtain psychotherapeutic services are the relativelyaffluent, the better educated,and the less seriously disturbed in society. Failure tohave demonstrated theeffectiveness of psycho- have been based on therapy is therefore even moreserious, since evaluations `more favored"groups. Theoverall situation is aggravatedby the relative in- applicability of psychotherapy to manybasic emotional disorders, aswell as of the popula- by its social ineffectivenessand failure to reach major segments tion in need of help(Riessman, Cohen, & Pearl,1964). That psychotherapy remains as adominant approach todayreflects the motivational determinants citedabove, plus the fact that, as thestarting point of the modern mental health movement,it has been both our greathope and a powerfulimprinting force. In speaking tothis point, however, Eisenberg in which (1962a) warns: "The history of science ...is replete with instances institutionalized, became a bar- an initiallyliberating conceptualization, once Though we rier to progress" (p. 824).The matter is well put in such terms. are not yetready to abandon psychotherapy, arigid adherence to it as the major tool in coping withmental disorder, in the absenceof evidence of its clinical efficacy and positiveindications that it is sociallyineffective, would guarantee lack of progressin our mental healthefforts (Caplan, 1965). Here, Eisenberg's further comments(1962a) are most relevant:"The limitations of care-takers at a rate that present therapeuticmethods doom us to training ever lagsbehind the growing legionsof the ill, unless we strike out success- ..Society can fully in new directions in thesearch for cause and treatment. . learn one ill afford today's preciousoverspecialization in which trainees may method even superbly wellbut a method that ever lagsbehind the demands placed upon it, while they remainabysmally unaware of theproblems be- setting the bulk of thementally ill" (p. 825). The issueswhich grow out of several levels, seem clear- the foregoing analyses,though they may be posed at cut. How maythe effectiveness of existingapproaches to psychotherapy be 18 INTRODUCTION increased? What are the alternatives to psychotherapy?How may we begin to approach pressing and widespreadmental health problems whichhave been totally beyond the scope of psychotherapy?Our initial immersion in and enthusiasm for psychotherapy have lulled us into anunwarranted sense of security that has for too long blinded us toconsideration of these vital questions. Given the inadequacies of mental health resourcesand the evident limitations of psychotherapy and its kindredhealing procedures, one admissible and seemingly "face-valid" alternative isthat of prevention. This broad concept, borrowed originallyfrom public health medicine, encompasses a variety of meanings as applied to mental health problems(Eisenberg, 1926b; Bower, 1963, 1965; Caplan, 1964; Sanford, 1965). Primaryprevention is desgned to forestall the occurrence of disorder, or conversely, itseeks to promote mental health. As such, it has its roots in our basicsocial systems and influence processes, transcends theknowledge and expertise of the helpingprofessions, and implicates other key disciplines.Secondary prevention has as its aim shortening the duration, impact, and negativeafter-effects of disorder through heavy emphasis on early detection and treatment.This broad concept encompasses efforts toidentify and to deal with dysfunction either as early as possible in the individual's life history or in the courseof a given disorder whenever it occurs. These two components of secondaryprevention are quite different both philosophically and mechanically.Tertiary prevention is targeted to disorder which is largely irreversible, and itsgoal is primarily that of keeping impairment minimal. In this instance,the argument can be made that the term prevention is a misnomer. At the sametime, it is appropriate to note that aconsiderable portion of our past efforts in the mentalhealth fields have been in the service of tertiary prevention(Williams, 1962). Analysis of the problems confronting those concernedwith the mental health of modern society suggests a strong need forincreasing consideration of the potential of preventive approaches(Felix, 1956; Leighton, 1960; Eisen- berg, 1962c; Bower, 1963; Arsenian, 1965;Caplan, 1965; Sanford, 1965), particularly those of primary and early secondaryprevention. Our hopes for the future should reside as much, or more, in cuttingdown the flow of disorder as in developing more effective technologiesfor undoing damage. On the other hand, Bower's remark (1965) "Preventionis at present a high status word in the mentalhealth fields. ." (p. 8) reminds us that it is all too easy to espouse platitudes inthis area. It is one thing, then, to hail prevention as anoble cause; it is quite a different matter to implement this cause in the face ofobstacles, both within the community and within professional groups,which impede our efforts. Furthermore, even with the best of intentions, the creativetask of developing useful programs should not be minimized.Just how does one go about "preventing"? There are few questions that are more cogentin the mental health 19 THE MENTAL HEALTHFIELDS TODAY fields today, and while weshall certainly fall far short of acomprehensive and satisfactory answer to it, oneof the prime purposes of thisvolume is to approach this issue bothconcretely and abstractly.

INEQUITIES IN DELIVERYOF SERVICES There has been a sharply growing awarenessin recent years that social deprivation is related to ratesof occurrence of emotionaldisorder (Fried, 1964; Clausen, 1966)and that delivery of mentalhealth services is highly disproportionate for various segmentsbf society. Factorsincluding education, financial status, race,geography, and socioeconomic status are critical in this regard. Sanua(1966), in a comprehensive reviewof a number of surveys and studies pertaining topsychotherapy services, haspointed out the first that such variables determine, insignificant ways: seeking help in place, being accepted for treatment,the aature of the helpreceived, remain- the same can be ing in treatment, and prognosisfor positive outcome. Much said for all other types ofmental health services (Miller& Mishler, 1964). Where help is most needed, it istypically least available andleast effective. Several classic surveys havedemonstrated additional biasesrelated to this same cluster of variables.Some investigators(Hollingshead & Redlich, 1958; Pasamanick, Roberts,Lemkau, & Krueger, 1964)have demonstrated applied to that unfavorable diagnoses such asschizophrenia are more readily those from the lower economicclasses than to members ofthe middle and upper classes.McDermott, Harrison, Schrager,and Wilson (1965) have extended these findings by showingthat more pessimistic diagnoses areattached to children ofblue-collar workers than tochildren of white-collar workers. In the area of diagnosis, afascinating study by Haase(1964) contributes further to our understanding of theproblem. This investigator askedsophisti- cated clinical judges to evaluateRorschach records of patients.The same protocols were preceded in half the casesby identifying informationindicat- income and in theother ing a middle-classbackground, education, job, and rated half, by a typically lower socioeconomicclass picture. Judges uniformly patients sicker when theidentifying materials indicatedlower socioeconomic background. The related and importantquestion of themeaningfulness of typical psychological tests and assessmentsprocedures with the poor israised in a number ofchapters of the volume byRiessman, Cohen, and Pearl (1964). At another level, the MidtownManhattan Survey (Srole etal., 1962) uncovered a huge number ofpotential patients, particularly amongthe lower and who could never socioeconomic groups,who were not receiving treatment be accommodated bythe limited number ofavailable professional workers. For the poor, when dire moments come,a mentalhospital is the outlet of choice. Yet Goffman (1961)and others who havelooked into conditions in MEP

20 INTRODUCTION such hospitals found thatmany prevailing practices existed primarily to sim- plify the job of caring for and feeding large numbers ofincapacitated people, rather than because they hadany therapeutic value. In many cases such practices seemed detrimental to good patientcare, and much that passed for "therapy" in the hospitalwas a form of "window-dressing" for the benefit of outsiders. There is not only the question of imbalance in delivery of mental health services but perhaps theeven more fundamental one of translation of need to demand, which typifies large segments of the populace. Formany individuals the development ofa felt need for help is inhibited by the way in which they perceive their difficulties and by their basic style of lifetheonly style they know. The problem of howto introduce a force for adaptation and mental health into the lives of such people isa staggering one, even if we felt secure in knowing how they should be adapting. For this type of intervention there have been no good traditional models. Asa matter of fact, the model handed down within the medical profession emphasizing the needfor a patient with a distinct difficulty is simply not calibl ated to those who fail to recognize such a problem. The public health model within medicine has, perhaps, had something more to offer, buteven that usually starts with a clear goal in minda specific disease entity which needsto be dealt with by specific means. Often in such instances considerable publicsupport for professional efforts can be mustered from those wishingto avoid illness. How- ever, the mental health problem in this area is of another ilk, inhering often in the fact that people fail to finda psychologically impoverished way of life a problem, primarily because they know no other. The entire difficulty does not lie in the members of the community who would be the objects of mental health interventions. It lies in the professional specialists as well. They have been trained in the traditional scheme, and they, too, know no otherway of life (Miller, 1964; Riessman & Miller, 1964). Moreover, the traditi,mal role has allowed themto reap status and, with it, the security of seeming to know whatone is doing and why. Moving into work with the heretofore unreached means venturing forthamong a social class which is entirely unfamiliaramonga group of people who fail to respond in the fashion expected from patients. Theymay not be verbal in the manner of the middle class,nor at all impressed by psychodynamic formulations (Schneiderman, 1965). Theyare less concerned with self-actualization than they are with survival,even under minimally comfortable and gratifying circumstances. As Bredemeier (1964) pointsout, they are a class considered "inferior" by traditional mental health workers preciselybecause they do not share the values andconcerns of the classes that respond to actions based on psychodynamic formulations. The fact that the mentalhealth fields have contributed little to the resolution of the problems of thelower class is a blight on their record and a central challenge for the future. 21 THE MENTAL HEALTHFIELDS TODAY

SOME ISSUES REVISITED Commission Report The singularly influentialquality of the Joint be- (1961) has been noted in anearlier section of thischapter. Particularly mental health cause of thatfact, and now in the lightof our review of salient reexamine some of its corner- issues and problems, it isimportant that we and failings of ston?s in aneffort to appraise, morerealistically, the promise health appear fre- the report. The terms preventionand community mental focus some quently in the report,and one of its salutaryimpacts has been to would be a serious error attention on these movements.On the other hand, it emphases of therecommendations. A to assumethat these are the primary suffice to make this point direct quote from the summaryof the report should the core problem andunfinished business clear: "...major mental illness is of patients of the mental health movementand...the intensive treatment first call on fullytrained with prolonged mentalbreakdowns should have expanding members of the mentalhealth professions. Thereis a need for community treatment of theacutely ill mental patient inall directions via rapidly as psy- mental health clinics,general hospitals, andmental hospitals, as psychiatric social workers, chiatrists, clinical psychologists,psychiatric nurses, therapists becomeavailable and occupational, physicaland other nonmedical in the community"(p. xiv). the values that arereflected in this pivotal recom- It is well to underscore health mendation: (1) that psychosisis the centralproblem o." le mental of choice, (3) that our fields, (2) that intensive treatmentis the method and the supply of hopes lie in massive augmentationof hospitals, clinics, the extent helping professionals, and(4) that the communityis significant to of "mental breakdown." that it is instrumental inapproaching the problems in the course ofthe These values are hammeredhome time and time again considerable extent,eschewed: final report, and admiss...iealternatives are, to a `. [gives] a little discomfort to some ...who have .the bias of this report and programs aimed atthe promotion a strongcommitment toward practices .We have assumed that of positive mentalhealth in children andadults... from the core problem the mental hygiene movementhas diverted attention redirect attention to the possi- of major mentalillness. It is our purpose to the mentally ill" (p.242). Quite bilities of improvingthe mental health of with "...vari- explicitly, the report goes on to saythat its central concern is ..and continuing ous levelsof service, beginningwith secondary prevention . the acute and chronicallyill" through intensive andprotracted treatment of (p. 243). fundamental substance of the Serious question mustbe raised about the emphasis on secondaryand Joint Commissionrecommendations. Through its model that has not met with tertiary prevention, itreinforces utilization of a be well distinguished success inthe mental health areasand which may not thrust in suited for dealing withsuch problems. Itscall for a multiplicative INTRODUCTION 22 therefore, be based on facilities andrelevant personnel may, expansion of by the report tothe prob- The overridingsalience attributed shaky premises. a pointof applica- mental breakdown(i.e., psychosis) suggests lems of major which may bemuch too late. for our mentalhealth efforts, tion in time attributed to problemsof the psy- Moreover, largelybecause of the primacy vision" for manypathways that de- chotic, there is adisconcerting "tunnel comprehensive analysisof our mentalhealth mand consideration aspart of a the young, theunreached, and positive situation: preventionof disorder, building formental health. Report are reflected in theJoint Commission It is not thatthe values the report Certainly theproblems to which "bad" ones in theabsolute sense. the mental However, thecritical issue facing speaks are realand pressing. is that of therela- given the realityof limited resources, health fields today, be "good" inthe absolute of many values,each of which may tive ordering Caplan, 1964;Sanford, Joint CommissionReport (e.g., sense.Critics of the have made acompelling quick to seize onthis point and 1965) have been the occurrence of approacheswhich seek to prevent case forthe consideration that were we tobe guided bythe The presentauthors believe of disorder. recommendations, itwould leave spirit and forceof the JointCommission pathways towardresolution of mental unexplored some ofthe most promising therefore, question itssufficiency as ablueprint health problems.We must, health operations inthe comingdecades. for our mental "armchair philosophiz- argument hasmeaning beyond That the foregoing Mental HealthAct of the passage ofthe Community ing" is reflected in consequenceof the legislation is, perhaps,the major concrete 1963. This administrative regulations recommendations todate. The Joint Commission 1966) require (Glasscote et al., 1964;Smith & Hobbs, implementing the act out- provide five essential typesof service: inpatient care, that every center and consultationand partial hospitalization,emergency care, patient care; adequate activities:diag- education; and indicatefive additional,less urgent, training, andresearch and evalua- nosis, rehabilitation, precareand aftercare, that the currentAmerican mentalhealth tion. There canbe liti:e question "scrambling" to establishsuch communitymental scene ischaracterized by a scrutiny of theimplementing regulations health centers.However, careful in line withthe JointCommission indicates that theforce of the movement, with manifest"major mental emphasis, is in thedirection of trying to cope the great proportionof illness." As thelisting of essentialservices suggests, for perpetuation, on amore massive ourmental healthefforts is preempted with some(important) exceptions: basis, of what wehave done in the past, community andthe naturalhabitat of the keeping treatmentcloser to the disorder and tomodify it constructivelyearlier patient and attemptingto reach (Ozarin & than has beenheretofore possible in the processof its unfolding that this significantand potentially Brown, 1965). It is,however, regrettable sharply restrictedby its underlying assump- influential developmentmay be so THE MENTAL HEALTH FIELDS TODAY 23 tions and by the manner in which itsprescribed functions are "frozen." It is a legitimate question toask whether the gains to be derived from the community mental health center movement, asdefined, will exceed those that might accrue from other, more flexible utilizationsof comparable resources, placing greater emphasis on alternative assumptionsand goals, including those of prevention.

ABOUT THE VOLUME

The present volume was born of the convictionthat traditional approaches to the mental health problems of modern societyhave, at best, been inadequate. Reduction of the incidence of emotionaldisorder has failed to keep pace with expansion of the helping professions, greater"sophistication," and improved technology; and this has given rise to agrowing need to reexamine our assumptions and practices. It is not difficult to recognize that the mentalhealth problems confronting us are varied, complex, and deeplyrooted. For this reason it would be inappropriate to hope for simple resolutions.Different problems call for different types of attack, and both the need and present stateof our knowledge are such that a varietyof approaches is to be encouraged.There are no illu- sions about the comprehensiveness ofthis volume. As one written largely from the standpoint of the helping professions, it isclearly an oversimplification that fails to accord sufficient attention torelevant and significant determinants from otherdisciplines ranging from the political (Straetz & Padilla, 1966) to the biological. Certainly, this is a basicfailing, but it is one which should not be misconstrued as denial of the importanceof a broad-gauge assault on mental health problems. The principal aim of the introductory chapterhas been to identify a set of problems and issues facing the mentalhealth fields today and, in so doing, to define the scope of thevolume. Common denominators characterizing succeeding chapters are a deep sense of concernabout these issues, a challenging of historically dominant modes of mentalhealth practice, and a willingness to explore new pathwaysand potentially innovative solutions tolong-standing problems. To put the matter less in structural termsand more in substantive ones, the majorfoci of the volume include: criticalreexamination of the assumptions and models that haveguided our mental health operations, new ways of utilizingmental health manpower, alternativeapproaches to the delivery of mental health services, and issuesof timing (e.g., children versus adults) and locus (e.g., the communityand its primary institutions) of our mental health efforts. Specific chapters differ, however, with respect tothe aspect of the total configuration engaged, the modeladopted, and the resolutions offered. Al- though the volume includes severalchapters dealing almost exclusively with INTRODUCTION 24 ., matters, inthe main conceptual, theoretical, andperhaps, even philosophical latter by an emphasis on concrete programsin action. The it is characterized rather than exhaust areclearly not the only ones oftheir type; they illustrate guiding frame- 1 existing possibilities.In the aggregate,however, within the approaches. work of the volume,they represent a fairlybroad spectrum of which are largely con- Part II of this volumeincludes four chapters has drawn attention to ceptual in their orientation.In Chapter 2, Romano illness, how they current social movementsin the fields ofmental health and what their aims are. Inthe chapter thatfollows, Turner have come about, and of and Cumming (Ch. 3)undertake a comprehensiveand critical analysis health fields in an effort topoint the medical model asapplied to the mental assumptions and itsde- of its shortcomings.An alternative set of up some examina- then developed.Albee (Ch. 4), following an rivative practice are points up the tion of existingand projected mentalhealth manpower needs, and manpower problems, intimate relationshipbetween conceptual models of current approaches.The final with suggestionsfor drastic modification consists of a searchinganalysis of chapter in this section,by Reiff (Ch. 5), particular emphasis onideological the mental health needsof the poor, with institutional change components ofthe problem and theclose links between and the future of themental health movement. describing new The next group ofchapters (Part III) present programs delivering mental mental health manpowerand new ways for sources of Knapp, and health services in thecommunity. In the firstof these, Holzberg, undergraduate volunteers as Turner (Ch. 6)describe a project utilizing hospital. Considerable companions to chronicallyill mental patients in a state both the volunteers research data indicatingthe effects of the program on summary ofher work and the patients ispresented. Rioch (Ch. 7) presents a middle-aged housewives forroles, first, on twosignificant projects: training counselors in well-babyclinics and day- aspsychotherapists, and second, as for training collegegraduates care centers.Sanders (Ch. 8) reports a program with mental hospitalpatients. Next, to conductsocioenvironmental treatment teenagers Klein (Ch. 9) gives an accountof a training program to prepare with "drop-out" anddelin- from a hard-core area ofWashington, D.C., many services. In Chapter10, Riessman quent histories,for careers in the human Center, an approach tothe describes the innovativeNeighborhood Service the rendering of concrete serv- mental health problemsof the poor based on nonprofessional worker. ice, social action,and utilization ofthe indigenous of disorders Gardner (Ch. 1 1)provides data on theincidence and treatment study and then describes with the poor based on acounty-wide, case-register combined com- the nature andfunctions of the MentalHealth Team, a munity effort tocombat mental illness amonglower socioeconomic groups. (Ch. 12) describes a program, In the last chapter ofthis section, Spielberger deal with the mental featuring group consultationapproaches, designed to 25 THE MENTAL HEALTHFIELDS TODAY health problems of asouthern communitylargely devoid ofprofessional mental health personnel. children and, in par- Part IV of the volume isdirected to work with schools. Zimiles (Ch.13) ticular, emphasizes mentalhealth approaches in the psychological in- opens this sectionwith a report of aninvestigation of the experience, one formof much fluence of variations inschool atmosphere and program for needed social-systems analysis.In Chapter 14, Roen presents a psychology, at teaching the behavior sciences,with particular emphasis on Morse (Ch. 15) reports an ex- the fourth-grade level.In the next chapter, the schools, designed to tensive program ofmental health consultation to in the area andher increase both the sensitivityof the teacher to problems effectiveness in coping withthem. Gildea, Glidewell,and Kantor, in Chapter school, featuring discussion 16, describe several mentalhealth programs in the leaders. Research data onthe groups for parentsconducted by trained lay presented. effects of these programs on parentperceptions and attitudes are 17) report a program Iscoe, Pierce-Jones, Friedman,and McGehearty (Ch. by grad- in mental healthconsultation for teachersand principals manned Evaluation of this program isbeing undertaken throughutili- uate students. In Chapter zation of a comprehensive testbattery and follow-up interviews. for early detection and 18, Zax and Cowendescribe a school-based program featuring the use of house- early secondary preventionof emotional disorder, day-care, wives as mentalhealth aides and collegestudents in an after-school, activity program. in The last two programs ofthis section differfrom the preceding ones outside of the regular that they deal with moreseriously disturbed youngsters Re-ED, which seeks to test school setting. Lewis(Ch. 19) reports on Project facilities, staffed byspecially the feasibility ofutilizing small residential children. trained "teacher-counselors,"for work withemotionally disturbed In Chapter 20, Donahuedescribes a special programfor schizophrenic, or- who are often candi- ganic, and emotionallydisturbed childrenyoungsters housewives are used dates for institutionalization orhospitalizationin which child. Both the Lewis "teacher-moms" in a one-to-onerelationship with the as education is good and Donahue programs arebased on the view that proper stable, treatment, both areconducted in a manner thatallows for continuing, the child contact between thechild and his family,and both seek to return to the normalclassroom situation at theearliest possible time. r,in.gle overview chapter, The concluding section(Part V) consists of a of the volume, to the purposes of which are tosummarize the salient aspects implicas, and to offer crystallize alternativeconceptualizations and their suggestions for neededfuture work. Though many of the programsdescribed in this book arestill in an evolutionary state, they aceimportant because theyconstitute clear-cut illus- mental health sphere andstand trations of emergent,changing practice in the needed. If this as operatingmodels at a time whensuch models are sorely 26 INTRODUCTION volume helps to promote understanding of these new developments and why they have come about, and if it serves as a meaningful point of departure for future work of this type, then its aims will have been well fulfilled. And, in more optimistic moments, one may even dare to fantasy that certain of its guiding concepts and constituent programs may represent significant har- bingers of things to come in the mental health fields.

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Ment.Health J., 1966, 2, Washing- of disability inmental disorders. Williams, R. H.(Ed.) The prevention Public. No. 924, H.E.W., PublicHealth Serv. ton, D.C.:U.S. Dept. of 1962. medical psychiatry.New York: Nor- Zilboorg, G., &Henry, G. W.A history of ton, 1941. II CONCEPTUALIZATIONS 2 PSYCHIATRY, THEUNIVERSITY, AND THECOMMUNITY

John Romano University of Rochester MedicalSchool

One of the most dramatic ways toemphasize the intensity,magni- general field of mental tude, and acceleration of thesocial movement in the health might be to quotebriefly from a report receivedrecently from col- Professor leagues in Cali, ColombiaProfessorCarlos Leon and his associate, of Psychiatry of the Ernesto Zambrano. Thelatter served in the Department University of RochesterMedical Center for two years.They report the eight to nine changes which have occurred intheir university over the past years. An excerptpoints out, for example, conducted, ten years ago, .that the only place whereclinical teaching could be . of psychiatric was in anasylum, since no other failitiesexisted in Cali for the care in vacant lots surrounded patients. In previous yearsthe patiews had been gathered promiscuity. Diag- by barbed wire fenceswhere they idled naked and in utter defectives, as well as crip- nostically, they includedpsychotics, epileptics, mental historical span of progress ples and invalids of allkinds. At Asilo, San Isidro, the than that of Europe orthe in the care ofpsychiatric patients is much narrower the past eight to nine years. United States. San Isidrohas moved 200 years during unwanted mentally illand Eight years ago, it was ahuman garbage pail for the police literally dumped mentally defective humanbeings of el Valle. Here the compound of the hospital. these disabled people over thewall into the enclosed Acutely disturbed patients were Often bones were broken inthe fall to the ground. jackets and given cold chained to the floor of dirtycells, or placed in straight protecting the personnel showers with hoses. Theemphasis was directed toward custodial, enforced incarcera- rather than toward protectingthe patients. Care was minimal emphasis on therapeutic tion under the mostunsanitary conditions, with adage, "where there is no rehabilitation. The philosophyof care was based on the sense, there is nofeeling."1 and their associ- In the few years thathave passed, these two young men teaching of ates haveaccomplished a prodigioustask in the undergraduate

1 Personal communication. 33 i

34 CONCEPTUALIZATIONS medical students, in changes in patient care, in the graduateteaching program, and in thepreliminary investigative work of social problems such as predominant trends of behavior in Colombian adolescents, psychosocialfac- tors in prostitution, maritalstability in a sample of urban families, predominant attitudes of medicalstudents, and the adaptive pro.blems of a group of North American housewives in Latin America. This type of rapid development should be pointed outbecause there are those who say that unlike other disciplines in the medical field,within which there has been a progressive spiral of improvement, muc:1 activityin psychiatry is apt to be circular. We have had certain cycles ofhumanitarian reform, but fundamentally we have not made as much progress as have our colleagues in other disciplines. There were thchanges that occurred in ancient Greece, in the beginning of the Renaissance, in theperiod of Enlight- enment, and during the tremendous wave ofhumanism. A century ago there was the great socialrevolution in the mental hospitals of our own nation initiated by the intrepid, resolute figure of Dorothea Lynde Dix.Now we have our own period in which there is considerable excitement, interest,and vigor in bringing about changes in the whole nature ofthe problems relating to mental health and illness. It is to tir.,latter that the remainder of this presentation will be addressed. An attempt will be made toshare with you certain ideas which the writer believes have been significant incontributing toward the intensity, magnitude, and direction of the socialchange that is implicit in much of the current mental health movement. Perhaps a word about the sample of experiences to beincluded is desirable, since most of what will be discussed is based on personal experience.2 In the past thirty years the author's principal engagement hasbeen in teaching, patient care, and clinical investigation in a numberof university psychiatric clinics and hospitals. In two assignments, Cincinnatiand Rochester, there has been considerable opportunity to learn about communityagencies and hospitals, both public and private, their planning, and their practices. In addition, the author has had the privilege to study and visit in anumber i of clinics and hospitals in the United States, the United Kingdom, continental Europe, the Soviet Union, and the Middle East. He has alsohad the privilege to participate in the past fifteen years in governmental agenciesand private foundations in the allocation of funds for teaching,research, and patient care. A tremendous change has taken place in medical education in the past twenty years. This is reflected in the size, complexity,and responsibilities of departments of psychiatry in American medical schools. We have moved from departments of four or five full-time persons to departments of forty to sixty full-time persons, with comparable increases in the number of resident staff, part-time and volunteer staff, psychologists, social case workers,social scien- 2 Much of this material is derived from the Eighth Annual Albert D. Lasker Lec- ture given by the author (Romano, 1965). PSYCHIATRY, THE UNIVERSITY, AND THE COMMUNITY 35 tists, and bio!ogists. Furthermore, there is an extensiveresearch program in many departments. Second, a tremendous change has taken place inpsychiatric units in general hospitals. This has determined certain aspectsof our present movement. Prior to 1800, there were twogeneral hospitals in the United States which accepted psychiatric patients as part of their service tothe community. In .!Q00, there were 19. There were 32 in 1920and 170 in 1945. Currently, there are about five hundred psychiatric units ingeneral hospitals and an additional five hundred hospitals that admitpsychiatric patients without designated units. Eighty per cent of these unitsbegan to admit patients after 1947. The steepness of the curve is shownby the recent changes in the number and nature of general hospital units. In 1963fairly reliable data indicate that more psychiatric patients were treated inpsychiatric wards of general hospitals than were admitted to state and countymental hospitals. Ten per cent of these generalhospital patients were transferred to publicmental hospitals; one per cent to private mental hospitals.Only one out of three of the five hundred general hospitals extant hassignificant affiliations with a medical school (Glasscote & Kanno, 1965). Perhaps these points could be better understoodif they were projected into the larger ipattern of change inAmerican health services, research, and education. It is generally conceded that change hasbeen greater in the twenty years since WorldWar II than during any other period in thehistory of American health services, including the twodecades which followed the remarkable Flexner report in 1910. Psychiatry hasshared in this period of incredible change. Early in the century psychiatric education andresearch were conducted and pursued by individuals, most of them on apart-time basis at the universities, usually unaided by universityfunds or external grants. In the second part of the century, privateAmerican foundations, the Rockefeller Founda- tion particularly, contributed funds to supporteducation of the medical student and the furtherance of psychiatric research.It is the writer's belief that the single most significant factor in the growthof American psychiatry in the past twenty years was the actionof the 79th Congress in 1946 in passing the National Mental Health Law. Thismade possible the establishment of the National Institutes of MentalHealth and the extramural programs which support undergraduate and graduateeducation and allowed for additional research. The expansion and liberalizationof health insurance programs providedfor inpatient cost coverage of patients admitted topsychiatric units. Another political action ofsignificance was the Hill-Burton Hospital Law with provisions making possiblefederal matching funds for the building of psychiatric services in general hospitals. Yet, other factors are involved. Many peoplehave remarked how uniquely American is the intensity of our interest inthe study of psychology and the social sciences, points often made by Mr.Conant and others who have corn- f

CONCEPTUALIZATIONS 36 pared America with the modernEuropean scene. Some implythat this interest stems from our naïveté oroptimism, our continuingbelief in the modifiability deal in of man. We believe that man iseducable, and through his capacity to knowledge and natural cause and event sequences,he is able to accumulate experience and apply these tosolve his problems and toadvance his welfare. The mental health movementitself has drawn from thetraditional Hippo- humanism, and from cratic frame of reference,from the roots of Western modern science. Others speakof our relative freedom fromstarvation and the free- ravages ofcatastrophic disease, our highstandard of living, our greater dom from, or nakedness of,traditions, the speed and volumeof communication, the fact that for fourcenturies we have beenand are a nation of immi- grantsall have been suggested asdeterminants of our vigorousand sustained interest in the study of thesocial sciences, psychology,and mental health. It is also generally agreedthat psychoanalyticpsychology has had a education in the United greater impact onpsychiatry and on general medical States than in other nations.This provided not only a setof notions concern- correct illness ing the nature of mentalillness and the treatment procedures to but also opportunities tolearn more of normal behaviorand to accumulate data toward a general humanpsychology. Also, the experiences of WorldWar II, as they related toselection, performance, and rejection of militarypersonnel, and an increasing aware- and course ness of socialand psychological factors inthe onset, modification, of illness are thought to havebeen of consequence in theincreasing interest in psychiatric careers. Inthe past fifteen years, thetotal number of psychiatrists in practice hasincreased from about 7,500 toabout 15,000. Half of these are in private practice, and as wasnoted earlier, a significant andincreas- ing number hold full-timeuniversity positions indepartments of psychiatry at both seniorand junior levels. With thesechanges, it is neither strange nor unenpected that the psychiatric servicein the generalhospital plays an increasingly prominent part in the currentplanning for mental health services in the community. In general, some of theobjectives at the moment arethe following: reducing the size of public mentalhospital services; increasing generalhospital services; promoting greatercommunity participation inpreventive, recon- who structive, and rehabilitative measures.There are those, quite properly, have posted caveats on some ofthe uncritical, evangelical aspectsof movement toward community mental health centers,at times with verylittle regard to the fact that there is atthe moment very littleuseful knowledge that has helped us to reduce thechronic populations ofschizophrenic and cerebral arteriosclerotic patients. The caveatsposted by Dunham (1965),Zwerling (1963), and others shouldbe respected and identifiedfor what they are. They have a full view of what we are arehard-headed, realistic cautions to us to intelligently and with doing so that our communityplanning may be done empiric, informed data,rather than through evangelicalwish alone. 37 PSYCHIATRY, THE UNIVERSITY,AND THE COMMUNITY the In addition to the threeobjectives noted above, wealso should view preventive, or publichealth movement variablycalled community, social, (1963), more than anyone,has outlined clearlythe psychiatry. Zwerling stated operational criteria forcommunity mentalhealth programs. He has be differentiated from atradi- that "a communitymental health program can criteria: subjects forstudy tional program on thebasis of four operational individuals seen as membersof social groups arepopulations or groups of traditional genetic develop- zather than individuals seenin isolation. Next, factors in illness aresupple- mental, psychodynamicformulations of etiological of behavior. These are mented by data concerningthe social determinants national, social class, and data concerning families,small groups, community, preventive andrehabilitative cultural dynamics. Third,the approaches stress finding and early treatment,in addi- as well asdirect therapeutic efforts: case of full-blown cases ofillness; the widest useof com- tion to the treatment rather than the munity resources andnon-psychiatric agencies and agents, active treatment exclusive use of psychiatrists;small, open community-based custodial hospitals rather than large,security-oriented, geographically remote of psychotherapy. institutions; and brief,rather than long-term programs clarifying or interpretiveinterven- Treatment techniquesinclude supportive, well as in indi iidual intra- tion in family, group,and community processes as He mentions that instances at psychic processes"(Zwerling, 1963, p. 15). psychiatry are either extreme of thecontinuum fromindividual to community distinguished; on the otherhand, this is the casewith any readily enough arbitrary and, per- continuum, a rangeexists over whichthe differentiation is haps, without signifiance. number of other Zwerling, Dunham, and manyothers have pointed to a in psychiatry. factors which are playing a partin the current social movement communities, a numberof people With increasing sizeand complexity of believe that planning can nolonger be elective oridiosyncratic. Planning duplication of services inproviding becomes obligatory toavoid unnecessary distribution for economicand other purposes. for proper regional responsibility for the Second, there appears tobe a movement to return which it had beentaken care of thementally ill to localcommunities, from the exception of a century agoby state governments.In most states, with Wisconsin and a fewothers, county responsibilities orlocal responsibilities today is by state governmentsfor good reasons. The movement were assumed responsibility for the an attempt toreturn to thecommunities the direct This is aided and supported operation and fiscal supportof the mentally sick. the development of community by the promise ofadditional federal funds for Report health centers throughthe recommendationof the Joint Commission and recent legislation. Next, war and postwarexperiences have, outof necessity, produced modifications in the careof psychotic patients inEngland, Holland, and destruction of many other continental countriesfollowing the bombing and 38 CONCEPTUALIZATIONS hospitals. Much of the home care was developedbecause there were no available hospitals. Sivadon in Paris and theSoviet city plans have attempted to serve certain populations inurban areas. As mentioned earlier, the development of insurance programsand the increase in the number of psychiatric units ingeneral hospitals has also had an impact. The recentaction of the United Auto Workers will provideinsur- ance provisionsfor the care of ambulant psychiatric patients in manyof the outpatient clinics of our nation. The tremendousinfluences of the use of psychotropic drugs and the consistent usefulness ofelectroshock treatment in depressed patients are clearly evident. Next, we might consider the whole interest inparamedical groups. This has emerged from an imperative need to examine,empirically and operationally, the roles of certain professional people. Criseshave occurred in the identity of the nurse and of the social caseworker.This has touched the American social casework scene and has led us to examinewho is the social caseworker, and what are her responsibilities inthe modern scene. This examination is going on in schools, industries,hospitals, foster homes, and other areas where new types of health care persons areurgently needed. Do we need to examine moresystematically certain operations and from such operations to evolve the kinds of people whowill be needed? The increasing usefulness and awareness orshort-term therapeutic ventures, particularly at pointsof crisis, and the development throughoutthe nation of emergency walk-in and first aid serviceshas been considerable. Currently, in the Department of Psychiatry at theUniversity of Rochester Medical Center there is a twenty-four hours aday, seven days a week, fifty- two weeks a year emergency servicewhich admits patients, provides first aid, and gives care. Currently, there are fifteen toeighteen visits a day to this service. We need a critical examination ofthe actual usefulness of long-term versus short-termtherapeutic measures. There is also a general awarenessof the rediscovery of the human family and of thehuman community, with the increasing participation of social and behavioralscientists in the field of mental health and illness. The changes which have been described here areof concern to many. There are those who feel that we may losethe baby with the bath water if we depart too farfrom our traditional primary concern forthe sick person and his family and reach out toward larger social groupswith their economic and political repercussions. In the writer's view,however, clinical psychiatry will always be fundamentally concernedwith the clinician's capacity for human intimacy, as this is disciplined anddeveloped in his professional education. It is hoped that contributions to ourfield may come from many sources: from molecular biology at one extreme,from refined studies of social systems at the other. It ishoped that clinical psychiatry will maintain itsidentity and be nourished by contributions fromboth extremes. It must be the function of universities to distinguishbetween craft and profession. This means, 1

COMMUNITY 39 PSYCHIATRY, THEUNIVERSITY, AND THE imagination and courage toorganize then, that we mustconstantly try with add to our knowledge, and use intelligence in new waysin order that we may usefulness to society. to our skills,and hopefully to our

REFERENCES

Psychiat., 1965, 12, 303-313. Dunham, H. W. Communitypsychiatry. Arch. gen. psychiatric units. Washington, Glasscote, R. M., & Kanno,C. K. General hospital D.C.: Amer. Psychiat.Ass'n., 1965, Pp. 59. Eighth Annual AlLrt Romano, J. Psychiatry, theuniversity and the community. 1 13, 395-402. D. Lasker Lecture.Arch. gen. Psychiat., 1965, psychiatry. N.Y. StateDept. of Zwerling, I. Program ofcommunity and social Health, Health News, 1963,40, 14-19. THEORETICAL MALAISEAND COMMUNITY MENTAL HEALTH R. Jay Turner andJohn Cumming Mental Health Research Unit,Syracuse, New York

The term community mental health, in itscurrently popular usage, is by no means a unitary concept.Its referents are at least as varied asthe propositions and orientations thatcontribute to its present significance.To a considerable extent these contributingelements are parts of three general developments. The first is the advent of effectivepsychotropic drugs, making itpossible to consider treatmentof the mentally ill in the communitywith the hope that recovery will be facilitated if thepatient's usual environment isdisrupted as little aspossible. There is growing out of this, achange in philosophy of care and treatmentthat is tending to shift the locusof the mental health problem from the hospital to the community.As Freeman and Simmons observe that the major prob- (1963) have noted, "...it is no exaggeration to lem in the field of mentalillness is not the hospitalizedbut the formerly hospitalized patient" (p. 1). Second, there is now a politicaland social climate withinwhich the development of human potential istaken to be a reasonable goal.This orientation is influenced by therecognition that there are many"disordered" but untreated individuals in the community,and that among the ill,whether diagnosed or undiagnosed, treated oruntreated, the disadvantaged aredis- proportionately represented. It alsoderives from the more general recognition that there are vastnumbers among the poor who haveimportant and pressing needs, but who have neverbeen reached by mental health programs. Finally, among a number of mentalhealth professionals there is afeeling of strong dissatisfaction anddisappointment with currentpsychiatric practice. This feeling is generated bythe continued absence ofdemonstrated effectiveness of treatment, even amongthose regarded as treatable,and a recognition that psychiatry hasretreated before the challenge of severedis- order. Frustrated by failure, clinicianshave turned away from thehospitalized patient and the seriouslydisturbed ex-patient and focused mostof their attention upon the mildlyimpaired middle- and upper-classindividual. It is only 40 THEORETICAL MALAISE ANDCOMMUNITY MENTAL HEALTH 41 with this group, in searchof self-actualization, that thetherapist's technology may retain animage of utility. Although these elements are by no meansunrelated, their differential domain for salience accountsr much of theambiguity regarding the proper community mental health.Some view this movement as arevolution that promises to rehabilitate asick society, while others aresimply intent on improving methods andfacilities already available forindividuals who seek care; some areconcerned with preventing thedevelopment of mental disorder in entire populations,while others are concerned withrehabilitating already disordered patients; andfinally, some imagine mental healthpracti- tioners in a series ofradically different roles, while othersproject the traditional conception of thetherapist-patient relationship into theintended community settings. With such variability in views andexpectations, any theoreticaldiscus- sion is likely to appearsimilarly variable in its application orrelevance. This chapter makes no systematic attempt todiscuss all the various conceptionsand programs associatedwith community mental health.Our primary aim is to examine a pervading andinfluential preconception regardinghuman functioning that we believeprovides an important demarcationbetween programs that are basically innovative andexperimental and those likely to amount to little more than "old wine in newbottles." It is not uncommon to encounterserious questioning of theadequacy and appropriateness of the dominantmodes of conceptualizingpsychological functioning and disorder. A primeexample of such dissent may be seenin what Szasz (1961) and othershave called the medical modelof behavior disorders. While meanings attached tothe term medical model varysubstan- tially, many dissenters, includingseveral contributors to the presentvolume, share a genfral discomfort bornof the recognition that theirconceptualiza- tions, programs, techniques, andresults are not comprehensiblewithin the medical model, however understood. The focus of this chapter, then, isthe medical model and someunderly- ing assumptions that are morepervasive than the modelitself. We shall examine this model and its assumptionsand discuss what seems to havebeen their retarding effects upon boththeoretical and practical progress. Weshall attempt to lendsubstance to the notion that emergenteducational, problem- solving, or "action" programs formen'al health are, in certain respects, incompatible with the medical modeland to outline the beginnings of an alternative orientation more congenial tosuch efforts.

THE MEDICAL MODEL It may be well at the outset tospecify what we understand by the medical model as applied to mentalhealth problems. We take it to refer to that broad domain in whichattitudes, hypotheses, and expectations are 42 CONCEPTUALIZATIONS derived from the premise of ananalogy between psychological disorderand physical illness. It is the model thatearnestly subscribes to the aphorismthat mental illness is a sickness, just like anyother, and it seems to anticipate a discovery of the specific pathogenic agentsassociated with the various mental disease entities. In its most extreme application, themedical model is one that exhibits a special affinity for "real" medicalprocedures such as surgical intervention, insulin shock, electroshock, and a primaryreliance upon drugs. In its more common andless severe form, it takes a position thatmental health can be defined as the relative absence of pathology andthat ill health is any major deviation from this norm. The medical modelincludes as instances of mental disorder such deviations as learningdifficulties, stress reactions, sexual deviation, mental deficiencies, antisocialbehavior, and innumerable other problems listed in the Diagnostic andStatistical Manual of Mental Disorders.It is a model from which thefrequently-heard caution " ..,. %Idly followsthat one should notconfuse symptom and disease; behavicr i,,illi important for what it shows and not for what it is.Within this orientatio,it follows that the only efficacious long-range course is to uncoverand treat the pathogenic source of thedisorder, whether this source be physiological orexperiential. Finally, on a more fundamental level, themedical model reflects the belief that psychological functioning, likebiological functioning, can be ultimately comprehended as ordered systemsof closed,I:: hanical,reactive phenomena. A corollary to this frame of reference hasbeen a general maintenance of the classical, one-to-one, physician-patientrelationship. This is the relationship of an authoritative agent acting with a receptivepatient who, as with organic disease, takes the traditional sick role. Evidence suggests,however, that this role may be the most inappropriate or evendamaging of all possible roles for a personhaving psychological difficulties (Scheff,1963; Glass, 1953, 1955). That there are relationships between somespecifically physiological dys- functions and psychological dysfunction cannotbe denied. Certainly profound mental changes can be producedby injury, disease, aging, nutritional deficiencies, anoxia, and toxin, just as severesocial stress can alter body physiology, producing conditions such asulcers, thyroid dysfunction, or disturbances in brain metabolism. Also, there remainsthe possibility of variable genetic predispositions to breakdown in the face of emotional stress.While it is appropriate that the physical aspectsof disorder be viewed medicallyand treated physiologically, the core ofpsychological disorder is of a different nature. Psychological disorders representlevel-of-organization phenomena in the psychosocial domain that cannot beattributed reductionistically either to physiochemical pathogens or to a specificearly experience. There seem to be no etiological orepistemological manipulations that canprovide any other argument. Theexplicit attitude or mental habit of viewingbehavioral devia- THEORETICAL MALAISE AND COMMUNITYMENTAL HEALTH 43 tions as symptoms of some inner pathogenicelement, which must be identified through accurate diagnosis in order toknow how to treat it, reflects an assumption that organic disease andpsychological disorder are structurally and etiologically isomorphic. Such an assumptionis neither theoretically nor experimentally defensible. The above is the often-expressed view thatthe medical model simply does not describe psychologicaldisorderthat, inthis domain, itis not "truth." But the truth of a theory is not therelevant issue. Theories are never true or false; they areonly more or less useful. Based upon this pointof view, we will, in alater section, argue the general disutilityof the medical and similar models and sketch an alternative orientation. The present discussion might, thus far,be construed as another of the many attacks uponthe institutionalized priority ofmedical and psychiatric practitioners in the area of psychologicaldisorder. This is not, however, our objective. The comments that have been madeclearly transcend professional lines. They do not apply to all psychiatristsand are regarded as directly relevant to a majority ofpsychologists, social workers, and other mentalhealth professionals. While many nonpsychiatric mentalhealth specialists have rejected obvious tenets of the medical model,they have not discarded a prior and similar assumption that has beenwidely held with significant consequences since theEnlightenment. This assumption is reflected inWhite- head's (1925) thesis that modern science is notnearly so emancipated from medieval modes of thought as is generallysupposed. Having argued that a primary and necessary characteristic of thescientific mentality is an "instinc- tive faith" in the order of nature, he tracesthe rise of such a faith and concludes that the Middle Ages can be viewed as "... onelong training of the intellect of Western Europe in the sense of order."In elaborating the medieval contribution to the formation of the scientific movement,Whitehead points be corre- to "...the inexpugnable belief that every detailed occurrence can lated with its antecedents in a perfectly definite manner,exemplifying general principles." The transformation from the "ageof faith based on reason" to "the age of reason based on faith," an age not yetfully spent, left unaltered in its essentials man's fundamentalpresupposition concerning the functioning of the ,world and all its contains. There remained ascientific mentality which

holds "...that all things great and small areconceivable as exemplifications of general principles which reign throughoutthe natural order" (Whitehead, 1925, p. 13). The general conception toward which wehave been pointing may now be set forth: There has been a long seriesof attempts through which man sought to lend order to his world andthereby to attribute significance to himself. These, along with the impact of theinitial success of physical science (supplying as it did both a demonstration of thescrutability of nature and the model from which subsequent science wasdeveloped), left a residue that is still agglutinated to much of the social-scientificenterprise and that continues 44 CONCEPTUALIZATIONS to have some important and unfortunate consequences.There remains not just the necessary faith in an order of nature, in the sensethat events are not random and laws can be discovered, but a general, subtle,culturally inherited habit of thought that the world and each aspect of it aresomehow ordered systems and hence to be understood asquasi-closed, mechanical, reactive phe- nomenaphenomena in which the laws governing change are stableelements of the system itself. We view the medical model as one of several orientationsthat share the impact of the same prior assumption. This is seen inthe model's acceptance of the notion that personality can beunderstood as a relatively closed and mechanical system. The closed-system orientation is akin to nineteenth centurynaturalism, which generated a scientific imagery wholly dictatedby the necessities of classical mechanics. This was a period marked bythe tacit belief that whatever question yousought to answer, nature was the test. Whether thesubject was ideas, customs,institutions, or the character of man, the answer must obviously be in accord with those laws that nature reveals toall men. It was during this period that the conception of a whollymechanical world became widely accepted. The twin doctrines of evolution andthe dynamics of energy, togetherwith the successful mechanization of biology, physics, and chemistry, contributed to this conception. This was the time ofPasteur's important discoveries, with their implications for themechanization of medicine; the period usually given for the origin ofmodern behavior science; and the era during which, in Bruner's(1957)terms, there was a maximum readiness for mechanicalexplanation in the mental sphere. It was, moreover, the time out of which came the influential works ofSigmund Freud. It has become commonplace to criticize elements ofFreud's theory and to show how certain specificmisconceptions, as well as his metaphors and analogies, were natural products of the then existing climate of opinion.In his detailed biography, for example, Jones(1953)points out that although Freud was not consciouslyinfluenced by economic theory as he was by physical science, his choice of language, of metaphor,reflecting as it did both of these fields, grew out of the prevailing thought of his time.However, simply to note that Freud borrowed much ofhis technical language from physical science or to suggest, asHughes(1958)does, that the vocabulary and analogies so derived were"... aconvenient path to comprehension on the part of a public steeped in the cult of natural science" (p.135)overlooks a pertinent question. Were the vocabulary and analogies the onlyby-products of the intellectual climate of that period, or were there certainpresuppositions that may have influencedFreud's acceptance of such analogies as appropriate representations of personality functioning? It should be emphasized that theinfluence of Newtonian physics, in combination with other elements in the existingscientific and philosophical milieu, went far beyond provision of termsand metaphors. Such thinking MENTAL HEALTH 45 THEORETICAL MALAISEAND COMMUNITY henceforth set broadlimits on disposed Freud, andothers, to a model that the nature of theorizingin the mentalhealth area. is a quantitative The basic analogy inFreud's theory of personality distribution, based on theeconomics of scarcity.Freud analogy of economic quantity of constantly referred tothe economy ofpersonality, indicating a the libido-fund available for distribution.Basic to his thinking was energy this concept there is analogous to thewage-fund theory. According to concept It can be redis- of psychic energy(or money) available. a limited amount be removed, but it can- tributed, and obstacles toits proper distribution can remains todayunaltered not beenhanced or enriched.The libido-fund theory formulation among manytheorists in its essentials as anaccepted and utilized and practitioners. "libido-quantum," formula- Freud (1959) expressedhis libido-fund, or between ego libido andobject tion as: "We perceive ... acertain reciprocity the more impoverisheddoes the libido. The morethat is absorbed by the one, implicat;ons of this assumptionabout other become" (p.33). One of the is that objectcathexis (i.e., love of, ordevotion to, personality organization the extent that the ego other persons orone's work, duty,etc.) is possible to in jeopardy, energy mustbe retracted is not threatened,for when the self is producing libidinalcathexis. By from external mattersand directed internally, . that effective transactionwith extending these propositions,it can be seen functioning, depends uponthe the environment, i.e.,effective executive ego dynamic or syntheticwell-being of the ego. synthetic over executive ego This supposition of aninherent priority of the mental functioning clearly lies atthe heart of muchtheory and practice in implicitly accepted evenby health field. It is a suppositionthat appears to be propositions, and onethat is quite those highly criticalof psychoanalytic described. This important compatible with themedical model as previously subsequent section. issue will bediscussed in more detail in a psychic energy is the viewthat Intimately related to thetheory of limited devices. Born with personality develops bythe accumulationof compensating acted upon by internaland a certain setof instincts or drives,the individual is conflicts that impelhim to action external pressuresproducing tensions and thus a consistentlydynamic psy- in order to securerelease. Psychoanalysis is force, always chology. It begins withforce and ends withthe dissipation of tension-reducing followed by new forcesthat must bedischarged through is taken to behomeo- processes.Thus the pervadinggoal of human activity equilibrium and not anequilibrium stasis, i.e., the restorationof the previous at some otherlevel. various aspects of We have attempted to suggestthat the antecedents of enduring modern mental healththeory and practiceshare a powerful and Our contention is thatthe corol- presupposition aboutmental functioning. often unrecoi- laries of this historicallygenerated orientation amount to an 46 CONCEPTUALIZATIONS nized metapsychology that impinges uponand conditions current views and programs. Perhaps the meaning and impact of thisclosed-system supposition can be more closely specified by looking at theformulations of Gordon Allport. In evaluating the status of personalitytheories, Allport (1960) has suggested four criteria of open systems: (1)intake and output of both matterand energy, (2)the achievement and maintenance ofsteady (homeostatic) states, so that theintrusion of outer energy will notseriously disrupt internal form and order, (3) an increase oforder over time, owing to an increase inthe complexity and differentiation of parts,and (4) extensive transactional commerce with theenvironment. While there are probably nopersonality theories that can be regarded as trulyclosed systems, current theories differwidely in the amount of openness towhich they subscribe. In Allport's(1960) view, Cf. .they can be fairly well classifiedaccording to the varying emphasis they place upon each of these criteria andaccording to how many of the criteria they admit" (p. 303). Most current theories of personality,especially those subscribed to by mental health practitioners, take full accountof only the first two requirements of an open system.This is true certainly of psychoanalys'As asit is generally of clinical and abnormal psychology.Moreover, conceptualizations of adherents to the medical model,whether or not a psychoanalytic orienta- tation is disclaimed, are necessarilyof this order, as are most conceptsof social work theory. These theories arethus "biologistic" in the sense that they ascribe to personality only the two featuresof an open system that are clearly present in all livingorganismsthey emphasize system stability tothe exclusion of other considerations. Within these accounts of human functioning,behavior is portrayed as an effort to avoidrather than to approach, to compensatefor a deficit rather than to seek to realize an aim. In a strictlymechanistic theory of personality, attention to such factors as interest, purpose,curiosity, exploration, language, and the efficacy of instrumental competenceis either crowded out or tenu- ously ordered under an explanatory constructsuch as secondary reinforcement. Academic developmentalpsychology, for the most part, does not subscribe to this position. Members of thissubfield have for some time been attentive to such factors, regardingthem as probably intrinsically motivating elements. However, neither this position norassociated theory and research seem to have had anysizable impact upon the treatment or preventionof mental disorder. A considerable number of theorists haveexamined and rejected the supposition of a wholly negative, tension-releasing, compensatorymodel in favor of a more positive, tension-sustaining viewof the individual personality. Emphasis in these theories is upon "the tendency ... to gobeyond steady states and to strive for anenhancement and elaboration of internal order, even at the cost ofconsiderable disequilibrium" (Allport, 1960, p.305). THEORETICAL MALAISE AND COMMUNITYMENTAL HEALTH 47 In introducing his concept of "competence"and "effectance motivation," White (1959, p. 323, p. 329) has forcefullyargued the inadequacies of a strictly compensatory model. He takes the pc.iitionthat "...instrumental acts will be learned for the sole reward of engaging in[them]...Such activities in the ultimate service of competence must,therefore, be conceived to be motivated in their own right." Subsequently,White (1960,P.137) amplifies his contention that compensatorymodels are, in certain respects, inadequate and misleading, noting that they neglect animportant range of facts which cannot be slighted iffurther progress is to be made. Representing man as striving, seeking, desiring,and willing, Murray (1938, 1951) speaks for an active ratherthan a passive, until stimulated, view of personality. He stresses (Murray,1959, p. 18) the concept of progressive disequilibrium, seeing continuitythrough expansive, constructive change, as asupplement to that of homeostasis. Human beings, inMurray's view, are concerned with more than just the satisfaction ofspecific needs and a return to some previouslyestablished equilibrium. Implied is a sort of proactive directionality in human behavior. Some additionalexamples of this viewpoint are to befound in Hartmann's (1958) concept of a"conflict-free" portion of the ego, Erikson's (1950, 1959) "search foridentity," Anderson and Moore's (1959) "autotelic activities," Hendrick's (1942)"instinct for mastery," and Schilder's (1942) emphasis upon interest,action, and experimentation. Though these theories differ widely in both formand content, each implies acceptance of Allport's (1960)third criterion of open systems: "...the tendency of such systems to enhance their degree oforder and become something more than at present they are" (p. 305). The fourth criterion of open systems represents a ratherradical departure from conventional conceptions of personality. Historicalpreference has been to view personality status, andhence, mental health or illness as fundamentally within the individual and, therefore, identifiableindependent of the social situation in which he is enmeshed. Not surprisinglythen, theories that regard the milieu as an active participant in the personality systemhave been raatively uninfluential in the mental health field.' This view,however, is one which potentiallyhas considerable theoretical importa pointthat will be developed in a subsequent section. It appears to make a considerable differencewhether or not personality functioning is conceived in terms of psychic scarcity orwhether the system is viewed as open to the world and to newpossibility. Most dissenters from the traditional theory, including the presentauthors, do not question that the compensatory model accuratelyhandles many aspects of personalityfunction- ing and development. Our contention isthat there are aspects of functioning and development that the model excludesfrom open consideration. The issue is thus not a matter of a strictly compensatory versus astrictly noncompensa- 1 As examples of theorists accepting thefourth criterion, Allport (1960) lists Kurt Lewin, Gardner Murphy, and "role theorists."

ry 48 CONCEPTUALIZATIONS tory model or of a wholly mechanical versus awholly nonmechanical system orientation. What is important is that the nature of one'sunderlying suppositions determines the types of practices and programs that oneis willing to initiate and sets limits upon both theory and investigation.

THE MEDICAL MODEL IN PRACTICE

As suggested earlier, theories or models are neither true norfalse but only more or less useful. Let us look first at the probable utilityof the dominant, medical-type models in the domain of communitymental health from the standpoint of programs and practices that it generates. In spiteof the variable conceptions of the field, one basic starting pointof the community mental health emphasis is the recognition that there are a great many persons in the community,particularly among the poor, who exhibit real or potential psychological difficulties. A frequently expressedproblem in this connection is that we can never hope to have enoughprofessionals to provide psychotherapy for this vast number of potential clients.As a partial answer to this dilemma,Gordon (1965) has suggested the recruitment of nonprofessionals who could quickly be made available by restrictingtraining w limited and specifictechniques. Rioch's program for training mental health counselors, described elsewhere in this volume, is an implementationof this alternative and tends to suggest its feasibility at least on a limited scale.But whether such nonprofessional counselors and therapists can make asizable impact on the problem depends upon whether the techniquesthey learn and employ are effective, not simply on their availability. Are we not still waiting for the first convincing demonstrationthat uncovering-type therapies work? Is there any compelling reason tobelieve that, among the disordered, mental status is any more improved overthe same period of time intherapy as in the absence of therapy? It is difficult to imagine on what basis we should anticipate thatsubprofessionals will be more effective thanprofessionals have been. Although community programs will have to rely heavily upon nonprofessional workers, it i.. clear that, tobe effective, these workers will have to fill something other than psychotherapist- type roles. There are a number of instances inwhich the use of nonprofessionals in a number of roles other than "junior therapist"has been suggested or implemented. See, for example,Reiff and Riessman (1965), Reiff (Ch. 5), and Riessman (Ch. 10). It is of special importance to note thatthe techniques employed, the associated propositions, and the results observed insuch programs cannot be derived fromthe medical model. Their explanation, as the authors concerned point out, requires a different set of assumptions and hypotheses. Even if one maintains a faith in the efficacy of psychotherapy as it is currently practiced, communication problems between the therapistand a MENTAL HEALTH 49 THEORETICAL MALAISEAND COMMUNITY class patient maypreclude the successof treatment. lower socioeconomic that lead to the poor arecharacterized by qualities After all, many among 1954; Rosen- by psychotherapists(Schaffer & Myers, rejection as untreatable Allison, 1962; Brill & Storrow, 1960;Cole, Branch, & thal & Frank, 1958; Moreover, Hollingshead & Redlich,1958; Myers, Bean, &Pepper, 1965). selectivity, there isgood reason to even inthe absence ofsuch professional individuals will presentthemselves for therapy or re- question whether poor argued that mental begun. Reiff (Ch.5) has persuasively main in it once that they are un- health ideology is soalien to membersof the lower classes associated with it. likely to seek ortolerate programs at a minimum,satisfy the To be successful, acommunity program must, It must effectivelypromoteutilization of following threerequirements: (1) capable of producingappropriate modi- services; (2) It musthave techniques individuals; and (3)Ji. must providesufficient manpower fication of involved derived of such techniques orservices. Programs to achievefull employment model are not likely tomeet anyof these requirements. from the medical traditional mental the community programsfounded upon Thus, although custodial care, theyoffer little health views represent analternative to mere mental health. the pressingproblems of community promise of solving that assump- Returning now tc outmain argument, wehave contended model have constrainingconsequencesfor tions associatedwith La,. medical Some of the conceptualdifficulties, theory and research aswell as for practice. responsible, deserveattention. for which themodel Is partially effort to Commission onMental Health,after exhaustive The Joint agreement on health, finally stated"...there is no general define mental health means many mental health ormental illness; mental what constitutes 10). This state ofaffairs, of things to manypeople..." (Ewalt, 1960, p. the proliferationof both con- has long beenindirectly evidenced in course, illness (Scott, 1958)and is ceptual and operationaldefinitions of mental achieving consensus onjust what directly evidencedby difficulties in more Memorial Fund, 1953). constitutes apsychiatric case (Milbank illness the two mostfrequently Of the majorconceptualizations of mental (1) mental illness as exposureto psychiatrictreatment, used in research are first of these the presence ofsymptomatology. The and (2) mental illness as mental health move- dispensed with by notingthat if the community can be demise of the notionthat nothing else, itcertainly signals the ment signals good and poor is a reasonabledemarcation between "being in treatment" operational and con- Indeed, it was therecognition of the mental health. count all of this view thatstimulated some attempts to ceptual inadequacies whether or not treated.By psychological disorders inthe community, cases of people in the com- now, it iswidely agreed thatthere are perhaps more mentally ill thanthere are patients inmental munity whowould be labeled hospitals. with this revisedviewpoint is The criterion ofmental illness associated 50 CONCEPTUALIZATIONS that of symptomatologyor level of pathology, a conceptualization of mental illness that has dominated the thinking ofpsychiatry and psychology for perhaps the pastone hundred years. Indeed, diagnoses and pathology ratings based on the clinical detection ofsymptoms have always been the ultimate critena against which othermeans of identifying and estimating psychiatric disorder are validated. The validityof the psychiatric ratings themselves have most often been assumed to be implicit in the ratingprocess. After all, by definition the physician's opinion is diediagnosis, and by convention the only standard against whichto test itis another physician's opinion. In other words, the criterionmeasure for the validity of psychiatric judgment ispsy- chiatric judgment, and thereforeany reliability study is, perforce, also a validity study. Ifone accepts Campbell and Fiske's (1959) view that reliability is measurement by maximally similarmeans and validity is measurement by maximally differentmeans, it must be concluded that this is alla very peculiar set of concepts and procedures. Itis an instance in which standard social science tcchnology has been forsaken in favor ofclassic medical ortho- doxy. It seems unnecessary to document the difficultythat has been encountered in achieving reliability in psychiatric ratings (and therefore,of achieving adequate valklity) since that difficulty ;s, bynow, recognized to be notorious. There have been some instances in which psychiatricratings have been compared with outside criteria suchas performance, hospitalization, or peer ratings, thereby allowinga different sort of validity estimate. In such cases the amount of variance in performance,outcome, or present treatment status which has been accounted for by degree of pathologyhas been noteworthy only by its smallness.2 The inability of judged pathologyto account for differences in factors such as adequacy of performance and otherfactors that are integral parts of mental status posessome interesting and vital questions. Is it that psychopathology ratingsare insensitive or incomplete as a description of the intrapsychic status of the individual,orisit that social factors cause the unexplained variations? In spite of therecent vogue to select social variables for special study, it is proposed that both alternativesmay be true. It is not new to contend that degreeof manifest pathology is inadequate as a singular representative of mental statusor that positive factors such as skills, strengths, and successful patternedinstrumental response mechanisms are the ingredients that need to be added. Notmany would deny that, in a

2 One case in point is psychiatrists'gross inability during World War II to predict military performance as evidenced by the lackof relationship between strictness of screening procedures and subsequent rates of separationon psychiatric grounds (Ginz- berg, Anderson, Ginsburg, & Herma, 1959). A similarfinding is reported by Raines and Rohmer (1955). Inone of our studies in collaboration with the University of Rochester Department of Psychiatry (not yet reported) the pathologyratings of 214 randomly selected schizophrenics accounted for lessthan 10% of the variance in time spent in the hospital. THEORETICAL MALAISE ANDCOMMUNITY MENTAL HEALTH 51 practical as well as in a theoretical sense,mental health is personality somehow evaluated. And few would suggestthat any reasonable evaluationof tt personality" could consider only those mechanisms regarded aspathological. If these points are so generallyaccepted, why have we made solittle progress? Why does pathology, in practice,remain a focus that crowdsfrom attention the issue of positive elements?Our suggestion is that theexplanation lies in the pervading tendency toregard strengths and weaknesses asreciprocals. Such a view effectively dilutes anytension to achieve measuresof positive elements with the recognition thatthe inverse of any factor isautomatically and necessarily contained inthe measurement of that factor.Since measures or judgmentsof pathology seem easier toachieve and because many procedures and indices are alreadyavailable, pathology, in ourresearch, remains this a primaryand essentially exclusive focus.It may be time to challenge unsupported and long-standing habitof regarding strengths andweaknesses as highlyand negatively correlated and openthe question of their relationships and the contributions ofeach to what we intuitively meanwhen we speak of mental status or mentalhealth. mental The foregoing discussion suggeststhat the solutions to community health problems do not lie simply inthe tactic of increasing theavailability related problem of of current psychotherapeutictechniques. Similarly, the adequately defining our object of study is notlikely to be solved by thesimple be expedient of achieving consensus.Whichever major extant definition may selected, it is likely to fail, in important ways,to encompass allof what we view as mental illness or todistinguish groups whose status orperformance varies significantly. While continued empiricalresearch is needed and may verywell assist us in ourconceptualizing and defining problem, our argumentis that present orientations and definitions areprimarily expressions of theoreticalpredilec- tion. The problem, therefore, is more amatter of theorythan of empirical fact. AN ALTERNATIVE FRAME OFREFERENCE The formulation that follows beginswith a specific confrontationof one of the majorpresuppositions of medical-typemodels and provides suggestions as to the type of propositionsthat could follow from a revision.It will be contended that the dominanttendency to focus almost exclusively upon symptomatology derives primarily from a tacitassumption of the pervading priority of the synthetic functionsof the ego as discussed earlier.This assumption is challengeable on apurely conceptual basis as well as onthe grounds that it has led us away from anexplication of the ways in which anindividual, operating in a complexenvironment, becomes a healthy,successful person. Inaddition, the need to face theproblem of relating mental status to the individual'sability to resist disorganizationunder stress has, no doubt, been blurred by the force of thisquestionable assumption. 52 CONCEPTUALIZATIONS Earlier it was noted that the criticisms of Freud did not apply with equal force to all psychoanalysts. Those exceptions are pertinent here. The term ego psychology is used to designate what is now a fairlywidespread movement among contemporary psychoanalysts and psychiatrists to emphasize the role and importance of the ego, not only as a synthesizing agent but as a con- troller of a wider range of processes and behaviors. Ego psychology depicts the ego as rational and as responsible for intellectual and social achievements. The ego is not solely dependent upon the id, since it has its own source of energy, its own motives, and its own objectives. As an important theoretical force, ego psychology perhaps began with Hartmann's (1939) postulation of a conflict-free portion of the ego. Under- lying this idea was the hypothesis that there is intrinsic energy behind ego development and that, in this sphere, growth yields a pleasure all its own. Having observed the regularity of the development of children's speech and motility, Hartmann concluded that the instrumental ego functions must emerge, not through id-superego conflict but through maturationand the effects of the environment, in a process similar to overt learning. This formulation, later elaborated by other ego psychologists, revised Freud's libido-quantum theory and, along with it, the singular focus upon psychopathology. While workers such as Erikson (1950, 1959), White (1959, 1960), and Anderson and Moore (1959) have lent considerable support to the idea of a relatively independent executive domain, the implications of this view for theory and research have never been fully drawn out. If the bases of the executive and synthetic functions of the ego are indeed independent of each other, the customary notion that effective executive function is a consequence of the well being of the synthetic function may not be wholly accurate. There seems, in fact, no theoretical reason why the reverse may not be equally true, or why syntheticfunctioning, expressed in terms of adequacy of defense systems, is any more vital to a description of personality than is executive function, expressed in terms of skills or strengths. This view can be summarized into three premises:

1.That skills are to the executive portion of the ego what defense mechanisms are to the synthetic portion (Cumming, 1963; Cum- ming & Cumming, 1962). 2. That even though the two are doubtless intertwined in complex behavior, the synthetic and executive functions of the ego can be productively regarded as separate, and in some respects independent. 3. That to the extent that there is a degree of dependence between these domains, such dependence is bilateral rather than unilateral. Favorable considerations of the proposed shift in underlying suppositions carries with it two immediate implications:

1.That we accept, as a hypothesis, the notion that mental health can be modified by paying attention primarily to the executive domain MENTAL HEALTH 53 THEORETICAL MALAISEAND COMMUNITY assumption within aspects of ego functioning.This is implicit as an accept,:...d by s:weral con- of the "war on poverty"and is apparently Riessman, Ch. 10; tributors to the presentvolume (Reiff, Ch. 5; Klein, Ch. 9). the range of behaviors we arewilling to admit as 2. That we modify that relevant to mentalhealth. What must beadded are those data canprovide an index of executivefunctioning. (1963) In an article entitled"The InadequacySyndrome," Cumming .in the past restrictedthe types of has pointed out that"... wehave.. conceive behavior that we arewilling to call symptoms.It has been usual to evidence of disease, while of such symptoms asauditory hallucinations as hold a job as the resultsof thinking of phenomenasuch as the inability to realize "...that both illness" (p. 723). Hecontends that it is important to and can equally becalled symp- these behaviors areevidence of ego failure toms of mentalillness" (p. 723). Rudolph, 1963; Davis, Many investigators(McCaffrey, Cumming, & & Wilkins, 1966)have Freeman, & Simmons, 1957;Monck, 1963; Harrington inadequate reported a decidedlydisproportionate numberof occupationally relationship between people among those defined asmentally ill, suggesting a question of mental illness andwork failure. Suchfindings leave open the .. index whether work failure is aresult of illness or arelatively independent illness, severity of symptoms of illness. If inability tohold a job results from Among studies thathave and work performanceshould be highly correlated. impressive relationshiphas included some estimateof severity of illness, no long-term work per- been shown betweenlevel of pathology and current or Freeman & Simmons,1963), formance (Brown,Carstairs, & Topping, 1958; synthetic functions adding support tothe argument thatboth executive and considered in treatment aswell as in personalityevaluation. must be well, both in pre- There seems much to suggestthat we might do very social "symptoms" of egofailure and to vention and treatment,to recognize functioning, rather than tocontinue work directly onenhancing executive the pathogenic in the belief thatif we could justlearn to uncover and remove become a more effective,instru- sources of symptoms,the individual would be reasonable tohypothesize mentally competenthuman being. It may even functioning may affectsynthetic processes, that enhancementof executive symptomatology. producing a reduction in First, it Before moving ahead, twopoints warrantexplicit reemphasis. homeostatic principles areunim- is not our contentionthat mechanistic or insufficient. We do notwish to do away portant, butrather that eney are call is for more seriousattention with the concept oftension reduction; our beyond or fall out- to those factorsin developmentand functioning that go particularly radical and isbeing side such principles.Second, this view is not professionals concernedwith expressed by an increasinglylarge number of CONCEPTUALIZATIONS 54 produced little problems.. Such attention,unfortunely, has mental health rehabilitation. observable impact uponresearch or programsof prevention or model remains thedominant basis In practice, thequasi-closed personality awl the developmentof tech- uponwhich theories, trainingof professionals, therefore, an importantguiding and niques are based.Such models remain, constraining force.

IMPLICATIONS SOME ADDITIONALHYPOTHESES AND alternative supposi- We have, up to now,called attention to certain inquiry which aresomewhat tions that suggestdirections for theory and paths. The developmentof such a divergent fromtraditional and well-worn specification of processes ormechanisms revised frame ofreference requirc competence i.,produced and comes tobe differentially by which executive undertaken in distributed in thepopulation. While such atask cannot be hypotheses relevant to com- detail here, threeadditional and interrelated treated briefly. munity mentalhealth programs will be PRIMARY CRISIS OR PROBLEMRESOLUTION IS A FACTOR IN EGODEVELOPMENT ANDMODIFICATION 1959) has conceptualizedpersonality growth as Erik Erikson (1950, The the resolution of normative ordevelopmental crises. occurring through systematically inter- stages orphases differentiatedby Erikson are seen as those preceeding.3Only related, each depending uponthe provr solution of phases successfully resolved theproblems or crises of previous those who have subjective achieve a lasting solution tothe present stage, since are likely to building blocks for achievements derived fromprevious solutions are seen ,..s with the com- present andfuture solutions. Theposition is thus consistent monobservation that successbegets success. emphasizes theindividual's constant andactive Erikson's formulation Problems are intercourse with theenvironment ascrucial for development. resolved. The individual encountered and, with varyingdegrees of success, his reper- such engagements with newskills which are added to emerges from the probability toire of generalizable responsemechanisms, thereby increasing handled. Thisdevelopmental that future encounterswill be successfully addition to a synthesizingof new experiences process,therefore, involves, in the direct accumulationof an into a continuallyevolving self-perception, armamentarium forinstrumental response. phases of development.Though 3 Erikson discriminates atotal of eight stages or description of these stages,it should be noted he invests much inthe designation and through crucial to the basic conceptionof personality growth that their contents are not short, it is quite possible toaccept the crises resolutionwhich is to be discussed. In personality of crisis encountershave profound effects upon principle that solutions of the stages described. development withoutaccepting the substantive content MENTAL HEALTH 55 MALAISE ANDCOMMUNITY THEORETICAL theory is "egoiden- organizational constructin Erikson's The primary Turner (1963) as acollective has beeninterpreted by tity." This concept and evaluationsderived from oF thesignificant components representation one's repertoireof roles and such, it is seen asencompassing experience. As specific instrumentalresponse the skills,abilities, and segmental identitks, general responsetendencies related thereto, and the more by suc- mechanisms related therefore, isdirectly enhanced collective whole.Ego identity, the to the behavioral setsand adding to cessful crisisresolution, gaining proven abstract function- relatedness thatallows increasingly store ofsubject-object function- including thoseelements of executive ing. Identityis thus seen as have referred to asego competence. ing that we and normativecrises differfrom Erikson contendsthat developmental provides new energy crises in thatthe growth process imposed or traumatic frequently experi- however, non-normativecrises are for theirsolutions. Since, reasonable to proposethat: (1) with a varietyof outcomes, it seems enceu, resolved, also promoteegogrowth and hence such events,when successfully (2) crises remain unresolved aredetrimental, and mental health,and when far beyond theattainment ofadulthood. both problemsand opportunities Indeed, gen- proposal is notwithout someempirical support. The above suffered by anindividual when con- eralizations such asthe degree of stress of success situations depends uponthe amount fronted by newand difficult that competence and difficultsiteationsor experienced inprevious new documentation seems widely expressedthat little begets competenceareso (1) combat troopsand observed, forexample, that: necessary.It has been effective adapta- under repeated stressmake increasingly civilian populations future performance(Lecky, 1951), (2) pastperformance predicts tions (Janis, demonstrated ability to copewith crises islikely 1951), (3) a personwho has 1956), and (4)the ex- disaster (Perry,Silber, & Bloch, toperform well in handle extremesituations disaster helps equippopulations to perience of implication ofthese, as well as Lucas, 1960).The logical better (Beach & been expressedby Wilson and researchfindings has other, observations repeatedly thatdisaster research hasdemonstrated (1962). He statesthat ". .. social to eitherindividual health or necessarily and inall ways damaging .." is not curiously beneficialimplications . organizations and ...mayindeed have (p. 131). proposed a processof "thera- and hiscolleagues have Caplan (1961) this proposition.Klein and intervention" that isimplicitly related to peutic conclude, inreference to Lindemann (1961, p.286, p. 305),for example, of restoringthe equilibrium intervention, thatbeyond the goal therapeutic in some casesto foster a the crisis "...is the opportunity existing prior to individual and hisimmediate human desirable equilibriumbetween an for pro- more that hazardspl.ovide opportunities environment. ...Thus, it is clear measures." well as theoccasions forpreventive motion ofemotional growth as position thatthe Cumming (1962)have taken the Similarly,Cumming and CONCEPTUALIZATIONS opportunity to deal effectively with a series of crises of gradeddifficulty will produce ego growth and integration. Based upon this view, they haveformu- lated a therapeutic system of induced crisis and controlled environmentthat is presumed to be applicable to the whole array of mentalillnesses. The belief that attending primarily to the executive domainof ego functioning may be an avenue to personality inodification seemsof crucial importance for community mental healthpanning. Given this position, the burdensome task of routinely accomplishing diagnostic classification, inthe hope of somehow providing differential treatment, could kelinquished. Moreover, it would allow a consistent treatment approach withinthe relevant and mea:aingful context of assisting individlials in thesolution of their own problems (and program-generated problems) and in developing more successful actions and cOp;ng techniques. Before proceeding further, it should be made clear thatthe term crisis is being used here in a very broad sense to refer to any event,whether developmental or normative, imposed or traumatic, that places inquestion the individual's view of himself, of his environment, or both.We, therefore, understand crises to be personal experiences rather thanobjective social or physical occurrences. Whether a given event constitutes a crisisdepends upon its meaning to the individual in terms of his real orperceived ability to handle it emotionally and practically. As White (1963) points out,"Threat is not solely a quality of the stimulus; it lies rather in the relationshipbetween the stimulus and our ability to deal with it" (p. 138).

A VITAL COROLLARY TO THEEXPERIENCE OF CRISES IS A HEIGHTENED OPENNESSTO ENVIRONMENTAL INFLUENCE Erikson (1950, 1959) has contended that each newpsychosocial development carries with it its own specific vulnerabilityand it is through such vulnerability that the training agents of society are mosteffective. While Erikson specifically uses the term vulnerability to characterizethe individual's state during crisis, he seems tobe referring to a kind of openness to both harm and enhancement. This is evidenced in his view that ego growth occurs through the resolution of phase-specific crises and hence that thedisequilibria that characterize these crises offer potential for forwarddevelopmental leaps as well as for egodamage. Following Erikson, it is assumed that all crises are characterized by vulnerability or "openness." This assumption is of considerable theoretical importance and practical consequence. It is a major proposition inthe theory of Cumming and Cum- ming (1962) and is, implicitly, one basis for the"therapeutic intervention" scheme described by Klein and Lindemann (1961). Its tenability isfurther supported by many research studies, including those concerned with reaction to natural disasters. Illustratively,the generalization that "In the absence of THEORETICAL MALAISE AND COMMUNITY MENTAL HEALTH 57 reliable guidance from past experience for perceivingor acting, suggestibility is high," first suggested by Cantril (1941), has been applied by Kilpatrick (1957, p. 21) in relation to crisis situations. Kilpatrick observes that much experimental work has demonstrated its validity. Glass (1955) thinks "suggestibility"a form of opennessisa primary characteristic of soldiers who break down in the face ofacute combat stress. During World War II, theoccurrence of suggestibility among "combat exhaustion" casualties led to the formulation ofa new therapy system centered on the concept of "expectancy" (American Psychiatric Association, 1956). According to Glass (1955), "Military experience has demonstrated that situa- tionally induced...disorders worsen or improve, depending upon what is expected of the patients by persons responsible for theirtreatment and disposition" (p. 12). Nonverbal attitudes and actionswere found to be far more effective than words in communicating such expectations. The success of this expectancy-centered therapy as comparedto conventional psychotherapy led to the institutionalization of these procedures in treating victims of both combat exhaustion and large-scale disaster andargues forcefully for the proposition stated above. The principle that the disequilibria of crisescarry a heightened openness to environmental influence suggests, on the one hand, a mechanism for the conduct of programs for ego modificatior, and,on the other, the importance of timely intervention withpersons who are facing severe events. For programs that take seriously the need to provide assistance and treatment to the poor, this latter point may be particularly crucial. Dohrenwend and Dohrenwend (1965) have suggested that the observed high level of symptomatology in the lowest socioeconomicstratum may represent transient responses of individuals to objective, stress-producing events in the immediate environment (see also Dohrenwend, 1961; Tyhurst, 1957). Underlying this view are observations that normal individuals exposedto severe circumstances often respond with symptoms that would ordinarily be classified as psychopathological (Hastings, 1944; Janis, 1951; Lindemann, 1944; Fried, 1963) and evidence suggesting the relative pervasiveness of "stressors" in the lower-class environment. Thesestressors include such things as shorter life expectancy (Mayer & Hauser, 1950), unemployment and threat of unemployment (Hollingshead, 1947; Langner & Michael, 1963), problems of relocation (Fried, 1963), and the general degree of economic and social deprivation. If the expected frequency of cris's experiences is highamong low socioeconomic status individuals and if the two hypotheses stated aboveare legitimate, several conclusions regarding possible directions for community mental health programs follow. The first is that programs witha major commitment to providing knowledge, skills, and experience in crisis resolution offer a promising alternative to conventional treatment approaches. Suchprograms must be prepared to turn difficulty into advantage by utilizing ongoing prob- 58 CONCEPTUALIZATIONS lems as bases for growth-producing experiences for involvedindividuals and, where such raw material is insufficient, to provide relevantproblem situations. Since crises provide both hazards and opportunities, the program must be capable of minimizing hazards and maximizing opportunities.This requires sufficient problem screening, problem structuring,and guidance to insure some success in resolution. For it issuccessful problem solutions that are presumed toresult in ego growth and to contribute to the vital perception that one can, through his own efforts, have aneffect upon his environment. In addition, the program requires avoidance and evenrebuttal of sickness or mental problem labels for experienced difficulties.Given the corollary to crisis of heightened openness to environmentalsuggestion, such labels are likely to be deeply internalized and, as Glass(1955) has shown, to have important and enduring regressiveeffects. Based upon the foregoing consideration and because utilization by low socioeconomic groups maydepend upon it, the structure of such a program shouldpreclude the assumption that a person must be mentallyill in order to receive assistance. To takeadvantage ofIre openness inherent in natural or program-generateddisequilibria, a program musteffectively transmit an expectation that the individual can, or will be able to, cope with, adjust to, andeffectively approach, life problems.

PERSOMILITY FUNCTIONING IS SUBSTANTIALLY DEPENDENT UPON THE CHARACTER OFTHE RELEVANT SOCIAL MILIEU The hypothesis of heightened openness toinfluence as a characteristic of crisis experiences suggests one circumstancein which personality functioning may be closely dependent uponthe environment. It is proposed that such dependence, although variable acrossboth individuals and situations, is not restricted to severecircumstances, but is a general and continuous phenomenon. Indescribing his concept of ego identity, Erikson (1950, 1959) includes three elements: the definition of theself, the state of congruence between the self and the requirements ofthe environment, and the expectation that this congruence will continue.In this view the stability of the personality system depends upon environmentalfeedback. Experimental and clinical evidence that the sense of self and level offunctioning are dependent upon continued externalconfirmation supports this concept. Hebb (1955), for example, has interpreted sensory deprivationexperiments as demonstrations of the constant dependence of innerstability on the flow of environmental stimulation, and Heron (1961) has concluded thatsuch deprivation interferes with cognitive functions. The maintenance of one'sidentity is thus seen as Iequiring continuedreinforcement of the nature and appropriateness of its roles, skills, and abilities. All parts of the environment,the physical, the interpersonal, and the social-organizational, areinvolved in this process of ego reinforcement. If self-definition, including status,abilities, and roles, 59 THEORETICAL MALAISE ANDCOMMUNITY MENTAL HEALTH through which problems aresolved, is not maintained, theindividual may unable to make feel he no longer possesses suchcapacities and thus may be the adaptive responses ofwhich he is capable. The importance of themilieu cannot be overemphasized.In daily interaction with the environment,the individual not only learns new concepts and skills, but also receives newproofs of already achieved,cherished abilities and of continuing areas ofineptness. The environment,then, must be regarded as an inextricable partner inthe identity system. In addition, it provides the framework for carrying outactions, defines the paths openfor solution of problems, and determineswhether Or not group supportwill be forthcoming. Following Al lport (1960), wethus accept with cautionthe fourth criterion of open personalitysystemsthat of extensivetransactional commerce withthe environment. It follows from this propositionthat personality and social structure cannot ever beregarded as wholly independent. Wedo not deny that, for many purposes, personaladequacy and social factors canbe treated as though they were independentvariables. Our view is simply thatwhen dealing with such dependent variables as responses to stress,solution of problems, adjustment to hardship ordisability, or even ego disorganization,it is necessary to consider the intimate relationshipbetween personality functioning andthe social milieu. that are The hypotheses presentedabove are examples of propositions derivable from the suggestedrevision of basic assumptionsabout the nature of mental health. It is a separatequestion whether thesealternative directions will better serve communitymental health needs. Webelieve that this ques- There seems good reason tion can tentativelybe answered in the affirmative. to anticipate:(1) that programs andtechniques based on these conceptual revisions may be effective inprevention and in personalitymodification, (2) that these will better lendthemselves to the extensiveutilization of nonprofessional workers, and (3) thattheir "face validity" is likely to encourage rather than discourage participationby the poor.

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(Eds.), Man and societyin disaster. NewYork: Basic Books, 1962. 124-150. 4 MODELS THE RELATIONOFCONCEPTUAL TO MANPOWERNEEDS' George W. Albee Western ReserveUniversity

A day of reckoning iscoming! the next twenty yearsin the The manpowerdemands projected over people withemotional disorder fields concerned withprofessional care for people available as toconstitute a are sofar beyond theprobable supply of (Albee, 1965). major national crisis people with be- been a doublestandard of care for For years there has for disorders in this country, onefor the rich and one havioral and emotional been growing chasm between private careand public care has the poor. The widen. For years we the quality gaphas continued to steadily deeper, and training programs, have talked aboutthe need forexpanding our professional expanding much morerapidly than the outputof professional but demand is the need for training people from our trainingcenters. Wehave talked about of members ofthe mental subprofessional people tosupplement the efforts such people. We but we have notreally begun to train health professions, mental healthprofession have talked about usingqualified members of any and broad-rangingservice, but whenthe to provideadministrative leadership lobbies of and the regulations aredrafted, the powerful laws are written always there to invested-interest groupsespeciallythe medical groupsare illness model and onmedical control. sist on the bubble bursts! We The time is not faroff when the wholemental health people, to Congress, tothe state legis- have made irresponsiblepromises to the Unions chapter were presented as partof an all-day Workshop on 1 Sections of this Area Workers' MentalHealth Plan and and Mental Healthsponsored by the Chicago annual meeting of the Division of RooseveltUniversity at the the Labor Education Association in SanFrancisco in April,1966. Other sections American Orthopsychiatric form, were written in responseto a requestfrom of the chapter, insomewhat different Foundation for a paperfor distribu- the California MedicalEducational and Research Project in California. with their StateMental Health Planning tion in conjunction of the New YorkState Psychological Parts of the chapter werealso read at a meeting City in May, 1966. Meeting at the StalerHilton in New York Association's Annual planned which maycontain excerpts ofthis In each instance, aProceedings report is material for fairlylimited distribution. 63 64 CONCEPTUALIZATIONS latures, and to the labor unions. We will notbe able to deliver adequateand meaningful services. Our inability to provide servicewill derive largely from thedefects in the conceptual model that dictates thekinds of manpower required.Much useful and effective interventionwith emotionally disturbedchildren and adults could be done by peoplewith bachelor degrees (or with evenless education), who are in potentially largesupply. But exploration of these routes is blocked by our presentmodel. Let us look first at the kindsof demands that are developing,then at the professional resources available to meetthem, and finally at the needfor alternative models for intervention thatcould change the strategy of manpower utilization. We are told that currently morethan half of all first admissionsfor mental disorders are to psychiatricunits in general hospitals.But still the overwhelming majority of mentalhospital beds are in tax-supportedpublic mental hospitals. How is this magicfeat accomplished? It isaccomplished by admitting a growing number ofpeople to the small psychiatric unitsin general hospitals because theyhave hospitalization insurance to coverthe high cost of suchhospitalization. They receive intensive treatmentthere and then move out. Iftheir symptoms are still too severe to preventtheir being discharged after their hospitalizationinsurance runs out, they aretransferred for "continuing care" to thepublic mental hospital. They are notthen considered first admissions, but transfers,although this is purely a verbal game. In the past two decades morepeople, from the blue-collar group tothe upper class,have acquired hospital insurance coverage.This has resulted in strong demands for expansionof psychiatric facilities in generalhospitals. It has also drawn preciousprofessional mental health manpower intothese general hospitals, furtherdepleting the thin ranks available inpublic tax- supported mental hospitals. It has also cutinto time available for private office practice. But this is only the beginning! The anticipated demands of the newComprehensive Community Men- tal Health Centers themselvescould use up the available supplyof professional people. Added to these are currentand pending demands for augmented programs inmental retardation, in alcoholism, indrug addiction, in the emotional problems of children inschools, in the whole range of the poverty programs, injuvenile delinquency, etc. Alcoholism,for an example, now seems destined tobe labeled a disease (by thecourts) requiring treatment rather than punishment. Buthow will five million alcoholics betreated, and by whom? Any of these expanding programs may serve as anexample of th.: flavor of the unprecedented developingdemand. Much of the demand is for psychiatric care, so specified, andall of the programs accept without question the illness model ofmental disorder. One example isthe United Auto 65 TO MANPOWERNEEDS RELATION OFCONCEPTUAL MODELS for private outpatientpsychiatric Workers contract forthe insurance coverage, million people.Other members and families,totaling close to two care, of its have begun toestablish unions are movingin the samedirection; still others their members andfamilies. The exten- their own mentalhealth clinics for union membersand their sion of benefits to coveremotional disorders in labor press with aflurry and a fanfare. families has beenannounced by the who are going toprovide either theprivate But where arethe professionals the union cliniccare? outpatient care or requirement that first type of insurancecontract is a Written into the preferably a psychiatrist, services be providedby a physidian, the outpatient physician. While working under thedirect supervision of a or by someone rankles psycholo- backwards ininterprofessional tolerance this apparent step community, numer- workers providingpsychotherapy in the gists and social these services is so professional groupsavailable to provide ically the total of lealistically. How many small as to makerelatively little difference anyway, psychiatrists are theretoday in Flint, orPontiac, Michigan? can onlyhave the effect ofincreasing the This new outpatient coverage in any major time. But arethere any psychiatrists demands on professional have of free time intheir appointmentschedules? They city with blocks hours a weekthey are already reached thelimit in terms ofthe number of increased demand findincreased supply of able to work. Sowhere does the Union's best estimate)of those covered outpatient time?If 1 per cent (the have increaseddemand by by the union contractsseek care each year, we geographic areas wherethere are few 20,000 cases, fromthe UAW alone, in psychiatrist-psychotherapists. competent legislative act inthe whole Another example. The mostimportant single of Medicare oneof the care fieldis the Medicarebill. Under provisions of mental healthprofessional time largest single groupsof potential new users umbrellaed in forprepaid service. 1 has suddenly been provisions in theMedicare bill whichwill increase There are several psychiatry. mental healthprofessions, but especially on demands on all of the psychiatric care forthe the new assuranceof outpatient One of these is older persons, It seems reasonable toanticipate that over-sixty-five person. these outpatient monthly premiums(which entitle them to paying their of spokes- psychotherapeutic services on amatching basis),will have plenty complaints about theunavailability men inCongress ready toinvestigate their that the new coveragefor hospitalization of such services.It also seems sure will swamp availablepsychiatric beds in for mental disordersof older people general hospitals. Title 19. This component ofthe Medicare bill is But the most important sleeper of all time out to bethe biggest manpower section, which may turn and rehabilitative provides for a wide rangeof mental health in this field, indigent," and what is more,for services for all personsadjudged "medically language of the lawhere is sufficiently their children up to agenineteen. The 66 CONCEPTUALIZATIONS general as to include many services providedprimarily by members of the mental health professions. Not only ispsychotherapy included but also counseling, vocational guidance, and many formsof remedial training, including special education. When the manpower demands on psychiatry forsatisfying the requirements of Medicare areadded to those required for establishinglabor union consultation centers for the prepaid provisionof mental health care for blue-collar workers, plus the new insurance for outpatientpsychiatric care for union members (as typified by theAuto Workers plan), plus thedemands for people to staff the new ComprehensiveMental Health Centers, etc., we arrive in a Never-Never Land of promiseswithout personnel. So the day of reckoning is coming! All ofthe plans for augmented mental health carecare for the union member, forthe blue-collar worker, for the medically indigent, for the whole variety ofspecial groups in our society on whom the spotlight of public attention is nowfocusedall of these programs are foredoomed tofailure because of the unavailability of thekind of medical and paramedical professional resourcesdemanded by the illness model and the bankruptcy of our conceptual modelsgenerally in this field. The mental health professions are indesperately short supply. Most individual members of these professions areaddicted to a one-to-one, face-to face, psychotherapy model as the way todeal with the problems of all their clients. All, that is, except the poor, who getonly drugs or shock. All of the brave talk about communitymental health and about consultative roles represents just a doublehandful of people talking to each other. It is increasingly difficult to getprofessionals to work for salaries; most prefer private practice. Even if they arewilling to accept salaried positions, they are increasingly reluctant to work inlocal and state tax-supported agencies and clinics. It is going tobecome even more difficult to recruit professionals as the supply dwindles. There is little evidence of any significantproportional increase in available professional resources in the mentalhealth professions since the national manpower study eight years ago(Albee, 1959). Everyone agrees that the United States should be producing 11,000 newphysicians a year (U.S. Dept. of H.E.W., 1959) in order simply tohold our own against population increase and to provide replacements for thephysicians who retire or otherwise leave the field. But our medicalschools are not producing this number. In fact, they turn out at least 3,500 fewerthan this figure, year after year. So the only possible conclusion that canbe drawn is that physicians are in steadily decreasing supply in ratio to population. As psychiatry is a medical specialty, itdoes not seem logical to think that the supply of psychiatrists can increase, over anyappreciable number of years, whenthe supply of physicians is decreasing.Temporary gains are made by the cynical practice of importingforeign physicians as underpaid house officers, by whipping up special programsfor unhappy general practi- NEEDS 67 RELATION OF CONCEPTUALMODELS TO MANPOWER tioners, by hard-sellrecruitment programs,and by other emergency measures. off the end of thepipeline But because the basicsupply of physicians coming stay even, each year is at least 40 per centbelow the number required to the long run. the supply of psychiatrists cannothelp but decrease in social work. If Nor is the situation any morehopeful in psychology or will be in even shortersupply than psychiatristsin anything, psychologists mental the future. In addition tobeing in great demand forthe burgeoning academic discipline, must pro- health activities,psychology, traditionally an undergraduates. Practically every vide the teaching manpowerfor the nation's could be absorbed by Ph.D. in psychologyturned out in the next ten years demand for new collegeprofessors created by adou- the unbelievably high popularity of bling of the undergraduateenrollments and the increasing psychology as an undergraduatesubject. profession it was twenty In addition, psychologyis no longer the young The age distribution ofpsychology faculty isgradually approaching years ago. it faculty members ingeneral. This means that soon the age distribution of profes- will be necessary to step upthe rate of replacementof aging college increasing numbers sors ofpsychology, who willbe leaving the field in (Albee, 1963). it The shortage of socialworkers is so clear andwell documented that quoted statistic is thatthere need not be repeatedhere. The most frequently are twentyjobs for each MSWgraduate. So the day of reckoningis moving closer. the way of organized Up to the present timethere has been little in of outpatient services orabout protest from the poorabout the unavailability The poor, the lack of properprofessional care in ourtax-supported "hospitals." who have characteristically inarticulate anddisorganized, have been the ones and unions are not suffered in silence. But unionmembers are not poor, professional help is avail- inarticulate! If unions havebeen led to believe that announced to their mem- able and if they havenegotiated these benefits and going to be impatient bership that professional timewill be available, they are when they begin receiving when they discover that timeis not available and complaints to this effectfrom their members. Congress is also in the picture.The report of theJoint Commission partnership with the (1961) encouraged Congress tobelieve that, in federal and reduce theprevalence of states, somethingcould be done to improve care the funds for construc- mental illness. It acceptedthe assurance that, given "mentally ill." The day tion and staff salaries, a newday would dawn for the will be long adawning! Is there any hope for abreakthrough, for a newand imaginative solu- things are tion that will relievethis pessimistic situation?Perhaps, eventually; going to get so badthat new models willhave to emerge. For several years it hasbeen fashionable to saythat the best hope for shortages in mental healthwill solving the desperateprofessional manpower 68 CONCEPTUALIZATIONS be found when a research breakthrough is made in establishing the cause and cure of one or more of the more prevalentmental "diseases." This kind of statement is usually interpreted to mean the discoveryof some imbalance which will lead to a pill, drug, operation, or injection which will cure schizophrenia, or will remove symptoms of neurotic tension and anxiety, or will in some manner correct the structural, chemical, or other biological imbalance which is causing the mental disease.As a consequence of this breakthrough fewer professional people will be needed, bringing manpower demands more in line with supply. But it may be that our manpower problems will not be solved, and cannot be solved, until there has been a conceptual breakthroughwith regard to the causes and remedies of most forms of mentaldisorder. The whole professional field of concern with mental disorder, and of mental health manpower planning, is dominated bythe concept of mental disease, when in reality most mental disorders may be primarily learned patterns of socially deviant behavior which are inappropriately conceptualized in the disease model. Actually, the research breakthroughs may have been made already, but because of the limitations imposed by professional language, values, and cultures, we have failed to recognize their implications.Many psychopatholo- gists would agree with the argument that most neurotic and functionally psychotic mental conditions are more social than biological in causation. But little of the potential of this consensus has been felt in institutionalized care- delivery systems. Research has already demonstrated that psychopathology increases as the integrity of the family is damaged or destroyed and that, conversely, the amount of psychopathology is low in groups where thestability and strength of the family is high. Children from well-integrated families have very low lifelong rates of mental disorder, and children from emotionally disrupted families have high subsequent rates (see Sanua, 1961, for example). While all mental disorders conceivably can be included under the dictionary definition of disease, so also could many other prevalent human problems such as prejudice. The difficulty is that the consequences for action which derive from a decision to call either schizophrenia or prejudice diseases are inappropriate solutions toreducing the incidence of either condition. The identification of these conditions as disease leads, logically, to local, state, and federal planning for medical care, nursing care, hospitals, beds, and ultimately for investment of funds in biological research aimed at discovering their organic causation. So long as the disease model prevails for neurotic and functional psychotic mental disorders, our society will limp along with toofew medical and paramedical professional people attempting to treat sick human beings in hospitals and clinics with minimal effectiveness or appropriateness. When the sickness model ultimately is laid to rest, society can setabout training new RELATION OF CONCEPTUAL MODELS TO MANPOWERNEEDS 69 kinds of professionals, closer perhaps to school teachersthan to psychiatrists, to work with these disorderedpeople in new kinds of institutions, patterned on schools rather than onhospitals. In view of its inappropriateness, how is it possible to accountfor the persistence of the disease model in the field offunctional behavior disorder? First, it served as an excellent humanistic substitute to theolder explanations of uncontrolled behavior which ascribed causation tosinfulness, taint, or demonic infestation. These explanations had prevailed untilthe humanitarian movements of the late eighteenth andearly nineteenth centuries. The rise of science, the logical and programmatic successes of taxonomyand of disease classification, and the widespread replacement of superstitiousreligion with scientific rationalism combined to make the disease model, andefforts at nosology, seem proper and progressive when applied to the insane. Second, the disease model received wide acceptance due tothe phe- nomenal success of medicine and its basic sciences in uncoveringand reveal- ing the unseen world of microbiology and theelaboration and successful application of the germ theory of disease. In the field of biological research, too, onedisease after another yielded to the persistence ofscientific investigation. The elimination of typhoid fever, of smallpox, and of other plagues that had besetmankind from earliest recorded history and the further triumphs of physiologicalmedicine in controlling diseases such as diabetes combined to raise hopesthat the great mental scourges would be the next to yield. Indeed, the persistentinvestiga- tion of "General Paralysis of the Insane" over aperiod of two hundred years finally led to the discovery of the role of the spirochete in thedevelopment of paralytic-cum-mental symptoms, and then soon after to malaria treatment, and eventually to a sharp reduction in the incidence of general paresis.A similar success in uncovering the role of vitamin deficiency in theproduction of pellagral psychosis further added to the promise of the disease model (Zilboorg & Henry, 1941). It seemed just a matter of time untilbiological, biochemical, or neuro- logical discoveries would lead to the research breakthroughwhich would produce a compa.able reduction in the incidence ofschizophrenia or manic- depressive psychosis. The apparently growing evidence of a geneticfactor in these conditions was almost the clinching argument forthe structural-physiological disease model of behavior disorder. Third, the disease model has persisted because it supportsthe chronic social inclination to write off current victims of severe emotionaldisorder as Lost- Ones, who should be given at least minimallyadequate shelter and food but for whom there is little hope because of the irreversible natureof most of the disease processes with which they are afflicted.The victims themselves have cooperated by regressing and withdrawirg intn a worldof bizarre fantasy and behavior in theabsence of effective intervention. Public fear and CONCEPTUALIZATIONS 70 formed the zeitgeistwhich con- horrified fascination forthe insane asylum and irreversibility. tinued to nurture thecultural vision of hopelessness disease modelinvolves the A related, powerful sourceof support for the reduction in theincidence of appeal of the strategydemanded for seeking a indeed a disease,then funds canbe "mental disease." Ifmental disorder is research seeking theneurological, biological, spent ingood conscience for its best and society can convinceitself that it is doing and chemical causes mental disorder is eventu- to eliminatemental disease. If onthe other hand, cultural in origin, the consequences ally acknowledged tobe largely social and downright dangerous, tothe status quo. for action will be veryserious, if not prevention to themodification of It may be necessary todirect our efforts at which now enjoy strongsupport fromthose favoring the social institutions discrimination, with con- For example, if it isacknowledged that status quo. housing, is a unemployment, poverty,broken families, and poor sequent employment, emotional disorder, thensocial action to insure major cause of the remedy for equal social participationis indicated as decent housing, and Understandably, this solution mental disorder, not morebiological research. than a sicknessmodel which does not maybe more threatening tomany require socialremedies. is the veryunderstand- Another source of supportfor the disease model disordered people toacknowledge any able reluctance offamilies of mentally disorder. If a functionalmental dis- personal responsibilityfor the emotional "an illness just like anyother," then thefamilies are order can be regarded as of human absolved of guilt; ifthe causes of thedisorder are independent be judged responsible. interaction, then Fate can persistence of the Perhaps, however, the mostcompelling reason for the model. There disease model has beenthe absence of asatisfactory alternative somebody with nobody," rule in politics that"you can't beat is a well-known persist, despite and the same thing is truein science. Ascientific model will valid and heuristicalternative its incorrectness orabsurdity, until a more appears. out ofpsychodynamic theory, In recent yearsthere has begun to emerge and psychotherapythe ele- social work, experimentalpsychological research, theoretical model whichmight be termed theSocial-Learning ments of a that In very general termsthis approach suggests Theory of mental disorder. reinforced disorders are complex,learned behavioral patterns most emotional The origin of theanxiety to be by their effectiveness inanxiccy avoidance. conditioning during thefirst avoided is to be found inunfortunate emotional social interactionwith significanceadults, usually the few years of life in scientists and parents. It isthus held by a growingnumber of behavioral acquired defects insocial professionals that manyemotional disorders are continues to accumulatefrom interaction and socialparticipation. Evidence and from psychotherapyin general that the laboratory,from psychoanalysis, stability and strength ofthe social sociocultural conditionswhich influence the 71 RELATION OF CONCEPTUALMODELS TO MANPOWERNEEDS world of the infant and childhave profound effects on the rateand kind of subsequent emotional disorder. Another developing line of evidence suggeststhat alternative (and social) explanations may accountfor the very convincingfigures on the role of hereditary factors whichhave been reported for years.Not only has the genetic work been examinedand found to contain flawswhich make it less than convincing, but recentgerminal discussion of the data(Jackson, 1960) and even more recent researchin Finland (Tienari, 1963) suggestthat the genetic evidence is notsufficient to convict in the Courtof Occam. The real mental healthproblems have not yet beenfaced squarely. The real mental health problemof our nation is representedby a little girl being born today to a Negromother who has been abandonedby her husband and slum. This little girl's is living on inadequaterelief in the heart of the urban chances of being mentallyretarded are ten to fifteen times greaterthan those of her sister born today to awhite mother in suburbia.This little Negro girl will weigh 500 gramsless than the child born in the samehospital, on the private service, to a whitesuburban mother. Her low birthweight will be due in part to dietarydeficiencies during her mother's pregnancy. More than one-third of allmothers in cities with populationsof over one hundredthousand are "medically indigent."In our major cities as many as sixty per centof the mothers entering publictax-supported hospitals for delivery of babies have receivedlittle or no prenatal care. Due either to her poor start or tothe inability of her mother togive her enough love and consistent attention, ourlittle Negro girl is ten tofifteen the other times as likely to become aschizophrenic when she grows up as is in an little girl born upstairs. She starts outbehind the eight ball, growing up urban slum, without an adequatephysical or emotional diet, withoutadequate intellectual stimulation, withoutlearning the language used inthe polite outside culture. If she is unable todo well on verbal intelligence testsdevised she has had it. Of the by middle-class psychologistsand is adjudged retarded, today in the U.S., one and one-quartermillion retarded children of school age three-quarters of them do not have access to anykind of special education (U.S. Dept. of H.E.W., 1963).We are not training teachers towork with retarded children (nor withemotionally disturbed children), nor are we training professors to trainthe teachers to work withthem. As long as we think ofthis girl as mentallyillwhether as a mentally retarded child, as a juveniledelinquent, or as a youngschizophrenicwe will not have the manpower orthe concepts required tohelp her or to prevent future similar problems. Aslong as we try to "help" herby looking only for the chemicals responsiblefor her retardation, thebrain defects that make her the tranquilizers to blunt heradult an"incorrigible acting-out delinquent," or schizophrenia, there is nohope of sufficient manpower orviable kinds of treatment. But once itis finally recognizedand accepted that most functional disorders are learned patternsof deviant behavior, thenthe institutional CONCEPTUALIZATIONS 72 problems probablywill which societyevolves to dealwith these arrangement that properlyutilized It is alreadywidely recognized be educational in nature. desocialization which techniques preventthe serious behavioral modification college graduateswith hospitalization on theback wards. Using accompanies possible for society to reeducational techniques,it will be special training in rather easilyrecruited institutional formsthat require manpower develop new forms which suchinstitu- While it is difficult toanticipate the and trained. will be combinationsof present it is quitepossible that they tions may take, stateschools with aheavy day-care centers recastassmall tax-supported reeducation, andrehabilitation. emphasis onoccupational therapy, need not be therapy which maybe indicated Admittedly the social be trained intech- the professionalsof the future may psychotherapy, and rather than in one-to-one interaction andsocial conditioning niques of social will needindividual likely, however,that the field relationships. It seems insight into patternsof psychotherapists for along time as amajor source of of changingsocial structures. mental disorderwhich emerge as a consequence model the institutionswhich society has Under the rubricof the disease and mentallydisordered children evolved to care foremotionally disturbed bound to inappropriate, andthis situation is and adults areinadequaie and perhaps, to take severalgenerations, a century get worse.Because it will explanation of model with asocial-learning model as an replace the illness with a realistic the nation mustface the nextseveral decades mental disorder, picture is going to worsen understanding thatthe mental health manpower professionals to meetthe manpowerneeds the because it cannottrain enough disease modeldemands. realities. By persist- planning effort mustconfront these Any manpower enough professional illness model ofmental disorder not ing in using an need. This would not deal with thenation's growing people are available to the illnessmodel if it be sufficient reasonfor abandoning in itself, of course, valid, and so we aretrapped in a could be shown tobe valid. But it is not A conceptualbreakthrough isneeded blind and hopelessalley conceptually. institutional solutionswhich can that can lead to manpowersolutions and nowonly dimly beperceived.

REFERENCES

trends. New York:Basic Books, 1959. Albee, G. W.Mental health manpower 18, 90-95. psychology in the sixties.Amer. Psycho!, 1963, Albee, G. W. American and the role ofpsychology. Albee, G. W.Manpower needsfor mental health Cana& Psychol.,1965, 6a, 82-92. New York: BasicBooks, 1960. Jackson, D. D. Theetiology of schizophrenia. 73 RELATION OF CONCEPTUALMODELS TO MANPOWERNEEDS Joint Commission on MentalIllness and Health. Action formental health. New York: Basic Books, 1961. review of the Sanua, V. D. Socioculturalfactors in families of schizophrenics: a literature. Psychiatry, 1961, 24, 246-266. Tienari, P. Psychiatric illness inidentical twins. Acta PsychiatricaScandinavica, 1963, Supplementum, 171, Vol.39, Munskgaard, Copenhagen. U.S. Dept. of Health, Education,& Welfare. Physiciansfor a growing America. Washington, D.C.: GPO, 1959,Public Health Service PublicationNo. 709. U.S. Dept. of Health, Education,& Welfare. Mentalretardation. Washington, D.C.: GPO, 1963. Zilboorg, G., & Henry, G. W Ahistory of medical psychology. NewYork: Nor- ton, 1941. MENTAL HEALTH MANPOWER AND INSTITUTIONAL CHANGE'

Robert Reiff Department of Psychiatry, Albert Einstein College of Medicine

Mental health manpower problemsmay be approached from many different points of view. The most fruitful approach isto begin with the greatest social need and to examine what the manpower resources are and their potential for meeting it. In recent years there has been a growing and vitalconcern of the professional in human services and the more enlightened public-service-minded government agencies for reaching the lower socioeconomic groups, and particularly the poor. The increasing recognition that there is a vast multitude of people with unmet needs has resulted in two national programsthecom- munity mental health program and the antipoverty program. Both of these programs have as their aim attention to the problems of those in society whose needs are greatest. Both are concerned with developing programs in the community. It is to the credit of professional and political leaders that both these programs have come into existence as a result of their sense of social responsibility, their vision, and their initiative, but without the stimulus of a vocal and organized demand from the suffering people themselves. The absence of such a demand from below poses a question of crucial importance. What strategies can be developed to convert the very great existing need into effective demand for services? A great deal of productive thinking is going into this problem. Many new strategies relating to program, technology, and other aspects are being devised and demonstrated. The extent to which these will succeed depends ultimately on three factors: whether the services offered are appropriate, whether they are utilized, and whether there is sufficient manpower (Reiff & Scribner, 1963). These factors are closely interrelated, but before themanpower question can be tackled it is necessary to understand what accounts for

1 This chapter appeared as a paper inthe American Psychologist,1966, 21, 540- 548, and is reproduced with permission of the American Psychological Association.

74 1

MENTAL HEALTH MANPOWER ANDINSTITUTIONAL CHANGE 75 the lack of utilization of present services bythe poor, and if change is necessary, what mustbe changed to make them appropriate. The development of mental health services hasbeen one of increasing acceptance on the partof the middle and upper classes in this country.There has also been an ever-increasing expansionof its influence on child rearing practices, education, marriage, etc.In fact, there is hardly an area of social living over which the umbrella of the mental healthprofessional has not been extended. On the other hand, there has been along history of persistent alienation from mental health professionals of thelower socioeconomic groups in this country (Bockoven, 1963). This alienation represents acritical failure. It is not merely the failure of each individualmental health professional, although there is the element of the individual's socialresponsibility involved here. Neither is it primarily a matter of tools and skills,although, again, this element is also involved. Basically, the problem is anideological one. The roots of this alienationfrom the low-income populations lie primarily inthe middle-class ideology of contemporary mental health services andsecondarily in its technology. Ideology is probably mostoften used to refer to attitudes and values of people. This is not the sense in which it is usedhere. By ideology is meant the body of knowledge, the setof integrated assertions, theories, and aims, primarily psychoanalytical,which constitutes the individualistically oriented program for restoring to society thementally sick and socially deviant. There is a basic dichotomy between the popular point of viewabout mental illness and mental health, and the mental healthprofessionals' point of view. Studies by Star (1957), Reiff (1960), and others have shownthat the popular point of view starts with normal behavior as itsreference point. It seeks to explain normal behavior as the distinctive andessentially human qualities of rationality, and the ability to exercise self-control.Given this premise, normal behavior is viewed as a rational response tothe immediate circumstances in which the individual finds himself, which is atthe same time fully within the conscious control of the person. Mental illness isdefined as the extreme opposite of normality. It is behavior in whichrationality is so impaired that the individual has lost control and can no longer beresponsible for his acts. It is, therefore, quite logically, only the extremeform of psychosis which is considered mental illness by most workers. Itfollows from this that mental illness is a very threatening thing. It represents aloss of the distinctly human qualities, the ultimate catastrophe that can befall ahuman. Thus, in their view, mental health and mental illness are not related toeach other as on a continuum butthey are discontinuous phenomena. The professional point of view starts with abnormalbehavior as its reference point andextrapolates to the normal. It views mental health and mental illness as on a continuum, and it holds that personalitycharacteristics and behavior are universal, differing only in degree. It contendsthat there is really no such thing as a completely normal person,and that the same phe-

I 76 CONCEPTUALIZATIONS nomena seen inmental illness are present in all people. Infact, mental health professionals can hardly use the word "normal"without prefacing it with the walls "so-called" normal. Further, the professionals'point of view holds that characteristic emotional patterns are not entirelywithin the rational control of an individual. The modifications ofbehavior patterns do not depend entirely on rationality, self-help, willpower, reasoning, or evenpurely environmental manipulations. It assumes that a large partof our motivations are unconscious or unknown to us and that untilthey become conscious they are unmodifiable. Finally, the professionals' pointof view makes the implicit conclusion that mental illness is notnecessarily an overwhelming threat nor must it inevitably arousefear or alarm. But, whila it may be reassuring to a middle-class patient to hear that the emotionalmechanisms of sick people are not so different from anyoneelse's, it is anything hut acceptable to ahealthy worker that his emotional mechanisms are not sodifferent from the mentally ill, especially if he holds the point of viewthat mental illness is about as far from normal as you can get. It is notbeing suggested that the validity of a scientific concept depends upon its popular acceptance,but merely that a practical concept of normality is necessary tofind a basis of understanding with low-income groups essential to successful treatment aswell as primary and secondary prevention (Jahoda, 1958).The key to developing such a practical concept of normality is the recognitionthat, though personality characteristics and behavior may be universal,their meaning and significance for illness and health must be assessedwithin their social-cultural context. The failure to control violent acts of aggressionhas different implications for normality and illness in a civil rightsdemonstration, a quarrel in a working- class bar, a middle-class family quarrel, or ameeting of clinical psychologists. Furthermore, while the worker acknowledges thereis such a thing as mental illness which he equates with severelypsychotic behavior, from his point of view he has difficulty acceptingthe concept of a neurotic emotional disturbance as an illness. The term itself isconfusing to him. If he sees a raving psychotic screaming or apsychotic depressive crying and wailing, he can see how that canbe called emotionally upset. In that sense it issimply a synonym for excessiveemotional behavior out of control. However,if he is told that a man with a lame back or aparticularly passive person who lets everybody walk all over him is emotionally disturbed,this idea of sickness is incomprehensible to him. To him there is physicalillness and mental illness. In mental illness one sometimes sees severeemotional upsets. Sometimes people get upset over physical illness, death,stressful situations; but to him this is not mental illness. It is either a normalreaction to a stressful problem of living or a sign of physical or moralweakness. It follows then that the professional point of view, that failure to meetthe problems of living is an emotional disturbance, a milder form of mentalillness, to be treated by the same kind of doctor that treats the more seriouslymentally ill, only alienates him. To the worker, emotional disability or impairmentis either related to a physi- INSTITUTIONAL CHANGE 77 I MENTAL HEALTHMANPOWER AND doctor, or it is the resultof cal illness and shouldbe treated as such by the undue stresses or strains inthe environment; or it isrelated to a moral weak- priest or conquered byoneself or ness andshould be treated by a minister or what is considered to be a accepted and lived with.If one attempts to treat considers it a tremendous moral weakness, theworker, with his present view, reinforces his tendency invasion of his privacy.Also, the general practitioner physical illness, by making it so easy to identifyemotional disturbance with for him to find a physician to treatit as physical illness.Can present professional ideology make an impact onthe "moral weakness"problem? It can, of minority course, workthrough ministers and priests.That may help the small who seek help from them; butfor the most part, there islittle hope of getting of living workers or low-income groups to acceptfailure to meet the problems diagnosed as as anillness, and as long as problemsof living continue to be diseases and treated within aninstitutional framework forthe treatment of disease, the alienation will persist(Szasz, 1961). The present ideology andtechnology of mental healthprofessionals will continue to fail with low-incomepatients unless the focus isshifted. Riessman concerned (1964) points out that low-incomepeople are task oriented, concrete, primarily with the here and nowand focused on solvingimmediate problems. with them. If they have troubles they areinterested in finding a way to cope their need, as they see it,for If they are to behelped the response must be to shift the focus from how more successfulcoping techniques. It is necessary to they are reacting to howthey are acting, fromdefensive reactions to coping actions. styles, from changing their reactions toteaching them more successful This change of focus alsohas implications for theaims and goals of 4 treatment. Thefundamental justification and aimof most psychotherapy potential, and if he today is self-actualization. Everyoneshould realize his full is not able to do so, thenhe should be in therapy sothat he may fully actual- ize himself. This, of course, meets aresponsive chord in thefeelings of most their lives. They see middle- and upper-class personsabout themselves and themselves in many possible rolesand their hope is to selectthose roles which realize his full enable them to actualizethemselves. The view that one can potential presupposes a view of societyin which there are manypossibilities and opportunities and that oneneed only remove theinternal difficulties to make a rich, full life possible.For the most part,disturbed middle-class people, on patients see themselves as victimsof their own selves. Low-income of limited or no the other hand, are not futureoriented. They live in a world opportunities. There islittle or no role flexibility.They see themselves as conditions is meaning- victims of circumstances.Self-actualization under these less to them. Before they canbecome interested inself-actualization, they have to believe that they canplay a role in determiningwhat happens to realistic them. Thus, self-determinationrather than self-actualization is a more and more meaningful goalfor them. Another ideological problem isthe domination of the treatmentrelation- 78 CONCEPTUALIZATIONS ship by the values and mores of a "fee forservice" ethic. Even where the service is rendered by an agency this is true.Coffman (1961) eloquently describes this relationship which he says involves a setof interdependent assumptions that fit together to form amodel.

...When services are performed whose worth (o the client atthe time is very great, the server (that is, theprofessional mental health worker) is ideally supposed to restrict himself to a fee determined bytraditionpresumably what the server needs tokeep himself in decent circumstances while he devoteshis life to clients, the server his calling....When he performs major services for very poor may feel thatcharging no fee is more dignified (or perhaps safer)than a reduced fee. The server thus avoids dancing to theclient's tune, or even bargaining, and is able to show that he is motivated by adisinterested involvement in his work. The server's attachment to his conception ofhimself as a disinterested expert, and his readiness to relate to persons on the basisof it, is a kind of secular vow of chastity and is at the root of the wonderful use thatclients make of him. In him they find someone who does not have the usualpersonal, ideological, or contractual reasons for helpingthem; yet he is someone who will take anintense temporary interest hi them. ...It therefore pays the client to trust in thosefrom whom he does not have the usual guarantee of trust. This trustworthiness available on request wouldof itself provide a unique basis of relationship in our society. ...(pp. 327-328).

These implicit characteristics of the therapeuticrelationship are understandable and acceptable to most middle-classpeople who themselves are often engaged in trading their expertness toother individuals. But the worker finds it difficult to trust the personwho expects a fee for helping him with what he believes to be a moralproblem. Children, too, have difficulty understanding; and they are confused whenthey discover that the therapist is paid for "being his friend."Thus, the treatment relationship itself is con- fusing and untrustworthy in the eyes oflow-income people. The fact is that for any person in a low-income group,having a mental illness means being a medical indigent with all the unhealthy effectsthis situation has on a person's self-esteem. In addition to these there are the ideologicaldifferences in the more usual sense, values, goals,and styles of life between the low-income patientand the professional himself which effect communicationand the nature of the relationship between the two (Reiff & Riessman, 1965). It is clear that what will be required first arebold and even drastic changes in the mental health service, within theprofessional structure, and in the professional himself. The innovator of suchinstitutional change will need to break out of the moldof institutional thinking and to be constantly alert to all the forces within theprofessional ideology, within the technology, and within himself that are constantly straining to oppose orweaken innovation. Already the weakening of innovation can be seen inthe comprehensive community mental health program enacted intolegislation which promised INSTITUTIONAL CHANGE 79 MENTAL HEALTHMANPOWER AND and direction of treatmentfor mental illnessin to changethe whole nature idea that thementally ill can betreated in the community this country. The advances in drugtherapy and has becomepossible because of is relatively new do not cure mental during the last 10 or15 years. The newdrugs, although they patient sufficiently so asto make it illness, often changethe behavior of the with certain kindsof support from possible for him tolive in the community change in goals, inthe This has led to ashift in emphasis, a its resources. Once, custodial care wasthe only treatment and careof the mentally ill. Now, with anemphasis on alternative to the failure toqualify for treatment. habilitation have functioning rather than cure,rehabilitation and a return to and the alternativeof become the organizinggoals of the treatment process, institutionalization is less necessary. health development It has beenproclaimed that thecommunity mental Such a view is a gross exaggera- signals a revolution inmental health [care]. mental health hasthe potential forintroduc- tion. The conceptof community look will revealthat institutionalized ing revolutionaryinnovations, but a sober health under theFederal programstends to become an community mental and tech- professional ideology withmodified goals, tactics, extension of current It of society fromwhich it has beenhitherto alienated. niques, over that part consolidetion of consolidationrather than revolution, a is in fact a process perform the social motivated by therealization of thefailure to adequately Such a consolidation function of restorationof those whoseneeds are greatest. that it solves noneof the may be a stepforward. But it mustbe kept in mind them. It does more:It legitimates ideological problemsbut rather perpetuates countryself-actualiza- two-class system ofmental health treatmentin this a To hail this as arevolution will tion for the rich,rehabilitation for the poor. discouragement both amongthe poor only result in increasingcynicism and well. and the professional as and sufficient to Sometimes changes intactics or techniques arenecessary point out, however,that frequently solve a problem. Millerand Rein (1964) ideology they escapeinto technology. when professionalsface the issue of changes in techniqueswithout But when theproblem has ideological roots, result in nothing morethan old the necessary ideologicalinnovations often already happening in manyinstances to wine in new bottles.Witness what is clinic was a bold attemptto deal the walk-in clinic.The idea of the walk-in service. It was tobe the means of with the problemsof delay in providing lists, delayed referrals, etc.,and its doing away with theproblem of waiting It was to be the meansby which primary purpose wasimmediacy of service. routed without delay towhatever kind of the mentally illcould enter and be door to a full arrayof comprehen- service wasneeded. It was to be the open sive services. clinics have becomebrief psycho- But, for the most partthe new walk-in door to comprehensivemental health therapy clinics.The idea of an open been converted intothe old revolving services hasalready in many instances _

CONCEPTUALIZATIONS 80 door. They have become briefpsychotherapy clinics becausethat is what the professionals who man them knowhow to do. They have spent many years what they know. acquiring psychotherapyskills and they want to practice Here, out of this little illustration, emerges amajor mental health manpower problem. A really innovativecommunity mental health programrequires greater clinicalskill, knowledge about social processand social organization, and an ability to be versatile inshifting one's focus fromindividual, to group, to social systems. Community mental health programs arebecoming institutionalizedbefore the manpower with the appropriateskills necessary for its new operations can be trained. Out of necessity theywill be manned bytraditionally trained professionals who will practice what theyknow. Comprehensiveness, an important aspectof the new programs, isslipping away. In someinstances, the situation hasdeveloped where the kind of treatment patients getdepends on which door they walkinto. If they come to the walk-in clinics they get briefpsychotherapy, if they come tothe outpatient clinic they get long-termpsychotherapy, and if they come tothe emergency room they getdrugs, or are hospitalized. Rehabilitation, the major goal ofthe community mental health programs, hardly exists. First, becausetraditionally trained mental healthpersonnel know little or nothing aboutrehabilitation, and second, becauseof the ineffectiveness of present rehabilitation programs. These are some of the waysthat the manpower problemthreatens the community mental health programs.The manpower problem,however, is fundamentally inseparable from theproblem of institutional change.Chang- ing institutions of trainingis a slow and painful processand meets with great resistance from faculty andstudents alike, both of whom aremuch more interested in traditional psychotherapytraining. There is still a greatdemand for this kind of mental healthservice. When it comes toproviding psychotherapy to middle-class patientsthere is indeed a manpowershortage. By its very nature a manpowershortage sets in motion acompelling drive The to deal withthe problem from anempirical short-range point of view. feel that if only we need is urgent and immediateand there is a tendency to take this view- had more "bodies') our problemswould be solved. Those who point look to the industrialmodel for solving manpowershortages. The industrial model is tobreak up complex highlyskilled operations into a series of more simpletasks. The simplificationof the production proc- and thus makes increases inthe ess reducesthe amount of training necessary be simplified in the same manpower poolfeasible. Human services cannot practice have waywithout dehumanizing them.The last 20 years of medical amply demonstrated that. sudden In the past, industry's manpowershortages were created by a machines alone could not do and urgent need forincreased production when INSTITUTIONAL CHANGE 81 MENTAL HEALTHMANPOWER AND kind. Not man- that job. Today, industry's manpowercrisis is of a different shortage but manpower excessplagues it and it has nosolution. power and But today, in mentalhealth, we still look to theold industrial model subprofessional classifica- talk about breaking downthe professional role into by people with less than com- tions or subroles, eachof which may be filled specific to the roles.This plete professional trainingand whose training is model out of which grow model is proposed by JesseGordon (1965). It is the (1965) training of mentalhealth coun- programssuch as Margaret Rioch's receive betterpsychotherapy selors. Paradoxically,her counselors probably psychologists, and residents get. training than the majorityof social workers, They fill a real need inproviding manpower totraditional existing services. render some aspect of serv- But her counselors donothing new. They simply useful stop gap ice that mentalhealth professionals giveand as such are a of view of greatestsocial attack on the manpowerproblem. But from the point contributes little because itis based on theassumption need this solution tend to the that manpower shortageis the crucial factorin the failure to problems of those in societywhose needs are greatest. mental health profes- Nothing coui cl. be furtherfrom the truth. The product sionals' posture is notthat of a group ofpeople with a successful of desperate men harassed by a clamoringdemand, it is more like a group dike. struggling to hold back aflood and who cannotfind the hole in the shortage, for This kind of manpower crisisis totally differentfrom the usual hole is while it is true morebodies are needed to stemthe tide, unless the found and repaired orthe water redirected, it willbe a losing battle. the tide of mental There are some who suggestthat any attempt to halt that it would bebetter to illness by treatment alone isdoomed to failure and The idea has great promise.Duhl concentrateefforts on primary prevention. (1963, 1964) has pointed outthe compelling need todirect our energies and toward changing social systemsfor the benefit ofwhole communities The fact is that there is societies. But here toothere is a manpower problem. behavioral sciences who hardly anyone in the mentalhealth profession or the adequate theory on is trained in a body ofknowledge, a set of concepts, or an need and the most promis- which to base such training.But this is the greatest ing approach. What isneeded is a new professionof experts in changing social systems for the preventionof mental illness andfor the improvement society to deal withthe of the psychologicaleffectiveness of all individuals in problems of living. It is anexciting prospect but italso contains the same problems of manpower andinstitutional change.2 Caplan (1964) has pointed outthat primary preventionshould be an about the problem, Ithought that this new professional 2 In my early thinking clinical training and social would be a social systemsclinician, with a combination of develop social action programsand try to stimulate otherclinicians science. But as I help with its them, I am rapidly becomingconvinced that clinical training to think about psychodynamic or interper- emphasis on changing theindividual and its focus on the sonal is an impediment tothinking about changing social systems. CONCEPTUALIZATIONS 82 basic contra- integral part of communitymental health programs. He sees no is primarily consulta- diction in the requirementsof the clinicians' role which changing social systems.He tion and treatment,and the requirements of acknowledges that there maybe difficulties but feels they arebasically compatible. Actually, at presentthe prospect of any reallyeffective primary preventive programs incommunity mental healthatleast in the ones that are being planned nowisminimal; first, because with afew outstanding excep- taking this direction tions, institutionalizedcommunity mental health is not mental health, and, second, because fewclinicians, even those in community importantly, the social criticism, have die know-how.And finally, even more the concepts and reorganization, andinstitutional change needed require scientists and clini- technology of social scientists;and the functions of social cians are, at this stageof our knowledge, noteasily integrated. Reciprocity between the two is all that canbe achieved given the presentstate of knowl- different. edge. The social function of aclinician and of a social scientist are affecting and frequently It is necessary torecognize how society is professions. Miller (1963)calls limiting the developmentof the mental health though all they have todo attention to the factthat professionals often act as and that will solve thesocial is to decide whatprofessional skills are necessary other than those they problems. They act as thoughthere are no social forces set in motionoperating on the profession. which At the present timethere is no adequatetheory or set of concepts clini- integrates the social processand the individual.Until such a time the who is the engineer, per- cian, who is the repairman,and the social scientist, functions have different concepts, form different socialfunctions. These two different roles. Every social values, motivations, interests,and aims as well as and the function for whichthere is a need tends tobecome institutionalized, and restrict the role necessary process ofinstitutionalization tends to rigidify institutionalization process is to accomplishthe function. Theresult of this sanctions for those who to rigidlydefine the professionalrole and to proscribe role flexibility. In the may betempted to contaminatetheir function through work on professionalroles absence of an integrativetheory the social forces at and the clinician. Thebest will prevent the integrationof the social scientist relationship between the two that can be hoped for is areciprocal team-type until such time as a newprofessional emerges. What is needed is to start But it is not necessary towait for a theory. social and behavioral now todevelop a body ofknowledge and to encourage scientists, and mentalhealth professionals, tobecome participant-conceptual- functions where they izers in community action programsand public service social changes. will have the opportunity toinfluence decisions on which is outside of the This opportunity now existsin a social program the potential for playing community mental healthprogrambut which has mental health a moredecisive primary preventionrole than the community 83 MENTAL HEALTH MANPOWERAND INSTITUTIONALCHANGE Oppor- program. TheCommunity Action Program ofthe Office of Economic tunity is in much better position tosucceed where the mentalhealth professionals have failed because it is notbogged down by the difficultiesinherent in the ideology of mentalillness. The Community ActionProgram addresses itself to thenormal. The particularly the poor are notconsidered sick. The goal of the poverty program, Its Community Action Program, isself-determination not self-actualization. free from focus is on coping techniques, not onpsychodynamics. In brief, it is many of thecharacteristics of the mental healthprofessionals' ideology which make for alienation. Thus, it has abetter chance of reaching andmaintaining contact with the poor.It is an excellent opportunityfor mental health professionals to become involved insocial action, a prerequisitefor anyone who wishes to become engaged inprimary prevention. It is asignificant reaffirmation of all that is being saidhere, that, for the most part,the new community mental health programs arebeing developed independentof and isolated from the most significantdevelopment in urban communitiesin the United States in the last 20 years, i.e.,the Community ActionPrograms. There are one or two plaus,however, which have becomeexciting The experimental labs for communitymental health social action programs. Neighborhood Service Center ofthe Lincoln HospitalMental Health Pro- and gram is oneof these (Peck, Riessman, &Hallowitz, 1965). It has been continues to be a greatlearning experience. In it wasrevealed all of the tensions, conflicts, attitudinal,and ideological differencesthat have been mentioned here. Yet, the mentalhealth professionals haveremained excited, cohesive, and their spirit andworking relationships could notbe better. Out develop a social systems of such laboratories asthese we may learn how to mental health specialist. is the One of rile most exciting aspectsof community action programs ranks of the use theymake of nonprofessionalsrecruited directly from the poor in theneighborhoods they serve. There is no question that the useof these new nonprofessionals opens up health activities as well.But, un- a great reservoirof manpower for mental nothing more than less this manpower is usedeffectively they can become waiting for the wardens and nursemaids tendingthe mentally ill who are professional to serve them. They canalso become a garbageheap where the professional dumps the patientshe feels he can do nothingfor. And, finally, performs all the "dirty work" the nonprofessional canbecome the menial who rid of so that he could that the professional resentsand wishes he could get have more time to dothe same old things.Used this way, the nonprofessional will reinforce all thetendencies in institutionalizedmental health practice that mitigate againstchange. that the ability of the Reiff and Riessman(1965) have pointed out nonprofessionals to do the thingsthat the professionals cannotdo, such as, patient's life situation, establish a peer relationship,take an active part in the 84 CONCEPTUALIZATIONS empathize with his style of life, etc.,is bound to affect the natureof the mental health services, the role ofthe professional, and may evenhave an impact on the ideologyof the mental health professional.The training of the nonprofessional then, becomes itself a strategyfor affecting desirable change in the field of mentalhealth. The demand characteristicsof the effective use of the new nonprofessional inthis way will of necessity create a new pro- frssional. Through the nonprofessional the professionalhas a greater repertoire of preventive, remedial, treatment,and care modalities. But thenonprofessional cannot decide whatkind of service the patient needs.Rapid and appropriate assessment of eachindividual case will be required. Thus,the new professional will have to become skilled inmaking early assessments and referrals to the appropriatemodalities. This is in contradistinction to quickand rapid assessments that are made intoday's emergency rooms by first-yearresidents. Appropriate use of the nonprofessionalwill require the judgment of the most highly skilled clinicians who arethoroughly familiar with all the modalities of care, and who have developedcriteria for making such decisions.Further- more, the roleof the professional will change. Hewill need to be more of a consultant, supervisor, and administrator.And if he should venture into primary prevention orbecome involved in community action programs,he will probably also be required to play therole of organizer, politician, and educator. All of which willcompel him to face new conceptualproblems, such as when does community actionbecome political action, how shall hedifferenti- ate his citizenrole from his professional one, etc. Onething he will need to learn for certain is the harsh realityof power struggles. One cannot enter the field of institutionalchange without forthrightly facing power issues. The problemof creating institutional changes in mental health cannot be solved by the strategyof manpower alone. Bureaucratic and professional rigidities are not mattersof protecting practices alone but, in the final analysis, are power issues. There is atendency among professionals to ignore power issues and to act as thoughintelligence and rationality will con- quer all. But the powerissues are there, and more oftenthan not, determine the outcome of efforts at change and innovation.Within the field of mental health there are both intraprofessional andinterprofessional power issues which limit the efforts of those who arestruggling for institutional change. It often happens that intraprofessional power issues getcontaminated with interprofessional ones. For example, the recent attemptof neuropsychiatrists to take legal action against a therapy training instituteof psychologists. Interpro- fessional power issues, however, seldom becameintraprofessional ones because thc risk of losing an intraprofessional powerstruggle is greater than in an interprofessional one. The most significant power issue inchanging the field of mental health will inevitably bearound the question of the medical model. At the present time, it appearsthat this is primarily an interprofessional struggle. Let us analyze the situationand see what are the likely effects of this INSTITUTIONAL CHANGE 85 MENTAL HEALTHMANPOWER AND development of newand innovativemental health powerstruggle on the of new kinds of manpower. programsand the utilization responding to social pressures,developed its branch Clinical psychiatry, makes possible community psychiatry sothat now that legislation of social and psychiatry has a con- of community mentalhealth facilities, the development which can take responsi- ceptual and aprofessional organizationstructure It is significantthat no bility for the communitymental health centers. within the professionsof comparable organizationalstructure has grown and social work.For this reasonthe institutional com- clinical psychology be primarily health programs havebeen and will continue to munity mental psychiatry. They influenced by the forcesoperating withinthe institution of thinking of communityand social psy- will reflect notonly the innovative chiatry, but thepowerful forces ofmedicine as well. psychologist, on theother hand, is notrecognized particu- The clinical therapeutic skillsand mental healthprofessionals for his larly by the other this area, achieved recognizedindependent status in technology. He has never psychology has made a but he is respectedand recognizedwhere clinical impact on mentalhealth from workwhich is theoretical or technological has Modern psychoanalyticthinking, for example, indigenous to psychology. This is one incorporated a great dealof academicdevelopmental psychology. heavily on developmen- of psychology.Psychoanalysis draws of the heritages respected. In this area, the clinicalpsychologist's views are tal psychology. In modern psychi- psychological testing, again an areaindigenous to psychology, useful and acceptable as an atry findsthe contributions ofclinical psycholóiy But as far as treatmentis concerned,the clinical psy- independent function. psychologists continue to operate chologist is regarded asancillary. As long as this state of affairswill con- within the ideologicalframework of psychiatry if psychologists can overcometheir ownintraprofessional tinue. When and and primary pre- power issuesand move into thefield of community action basis of their ownbody of knowledgeabout normality, devel- vention on the only then will atruly opment, cognitive processes,and social psychology, possible. This point isforce- interdisciplinary relationshipwith psychiatry be who write fully made by Rosenbaumand Zwerling (1964) the familiar his (the socialpsychiatrist's) milieu is not The social scientist in sociologist, the psychiatric social worker orclinical psychologistbut rather the Whereas the traditionalsocial worker anthropologist, and thesocial psychologist. framework of psychoanalytictheory, the and psychologist operatefrom within the theory, and thepsychoanalyst in a unit social scientist operatesfrom social system more trulyinterdisciplinary team basis in social psychiatryis forced to work on a (p. 34). therefore, requir- Clinical psychologists are not seenasextradisciplinary and, relationships, but becauseclinical psychologists ing interdisciplinaryteam psychoanalytic theory,they are seen as an operate withinthe framework of CONCEPTUALIZATIONS 86 the relationship as- intradisciplinary substrate ofpsychiatry, and, therefore, asks sumes ahierarchical rather than teamform. Klein (1963) and require- Will [the training ofclinical psychologists] begeared to the nature psychiatry just as clinicalpsychology ments ofinstitutional social and community (p. 2). developed with the needsof clinical psychiatry as acritical determinant Will they be able todevelop a It is necessary to add tothis the question: assertions, theories,and aims body of systematicknowledge, a set of integrated socially oriented program based on psychologicaltradition, which constitute a of all individuals in oursociety for improving thepsychological effectiveness psychologists will to deal withthe problems of living?Unless this is done the of having to argue overrights to continue to putthemselves in the position psychiatric ideology. The employ the technologicalskills which are rooted in psychologists continue issue will always beposed as one of skill;and as long as their existence on thebasis of technologicalskills, they condemn to justify jurisdictional themselves to aninterminable power strugglein the form of a Power dispute with the othersections of the mentalhealth skilled trades. struggles and nothing else. struggles on the basis oftechnology result in power catalyst for A power struggle onthe basis of ideology canbe an important institutional change. mental health serviceswill The introduction ofthe nonprofessional into between nonprofessionals add a new dimension tothe power strugglethat exist. If thenonprofessional is to and professionals.Tensions will inevitably functions of doing whatthe professional cannotdo he must be serve the without being ab- integrated into the mentalhealth service establishment structure of his own. sorbed. He must bepermitted to develop a power political clout. Thepolitical In order to win a powerstruggle, one needs psychiatry lies in the FederalCommunity Mental Health clout of community much subject to other Program. But this is fraughtwith dangers and too work resides in political forces. Thepolitical clout ofpsychology and social their middle-class constitu- their respective professionalorganizations and in primarily in agencies. ency, of a One of the mosteffective forms of politicalclout is the development the power of the recipients constituency. Rein (1965)has called attention to workers of services. One of themajor reasons whypsychologists and social therapy is because theyhave an unorganized,informal constituency. can do fulfill 1 These are the people who areasking for their helpand for whom they redefined, clinical psy- a socialneed. But now that thesocial need is being constituency. Meanwhile chology and social workwill need to build a new psychologists. the pull of the old constituencywill make it difficult to attract psycho- While it is true thatthere will continue tobe a social need for direction of mental health therapists working withmiddle-class patients, the their social need. This service is shifting tolow-income groups and meeting that will have to befaced if existing paper tries toindicate some of the issues INSTITUTIONAL CHANGE 87 MENTAL HEALTHMANPOWER AND converted into effectivedemand. In terms ofthe power issues, need ito be of saying a constituency mustbe developed, a group that is another way of health people within thepopulation who aredemanding the new mental people to be services being offered.The nonprofessionalbeing closer to the this constituency.But served can be of inestimablevalue h helping to develop earlier, limits the pos- here again the medicalmodel, as has been pointed out professional and the poor, sibilities for changing therelationship between the as well asbetween the professionaland nonprofessional. health services today To summarize: The greatestsocial need for mental Meeting this need is not comes from thelow-income groups and the poor. ideology. The task is to primarily a problem of manpowerbut a problem of appropriate, effec- develop concepts, methods, programs,and services that are their needs, in tive, and related tothe life styles oflow-income people and to them. This will require a waywhich will create aneffective demand for problems do exist are significant institutionalchanges. Whatever manpower change. The solutions to man- inseparable from theproblem of institutional institutionalized mentalhealth [care] powerproblems can reinforce existing institutional change.Two or they canconstitute a strategyfor promoting professional things are certain. There isneed for a humanlink between the link. And there isneed for and the poor; the newnonprofessional can be that who is skilled inchanging social sys- a newmental health professional; a man effectiveness of all people insociety to deal tems to improvethe psychological achieving these is alsothe road to with the problems ofliving. The road to and professions ofthis changing significantlythe mental health services country.

REFERENCES

Springer, Bockoven, J. S. Moral treatmentin Americanpsychiatry. New York: 1963. 1964. Caplan, G. Principles ofpreventive psychiatry.New York: Basic Books, Duhl, L. J. The urbancondition. New York: BasicBooks, 1963. 1 Center of Ekistics,Athens, July, Duhl, L. J. Social planning.Paper read at Athens 1964. Coffman, E. Asylums. NewYork: Anchor Books,1961. and some impth. Gordon, J. Project cause:The Federal anti-poverty program Psychologist, 1965, 20, 334-343. tions of subprofessionaltraining. American health, Joint Commission onMen- Jahoda, M. Current conceptsof positive mental (No. 1) New York:Basic Books, 1958. tal illness and Health. psychology. Paper read at Klein, D. C. Communityneeds: A challenge for September, 1963. American PsychologicalAssociation, Philadelphia, competing modes ofexplanation. Syracuse Miller, S. M. Stupidityand power, two (Mimeo) University, YouthDevelopment Center, 1963. 88 CONCEPTUALIZATIONS Miller, S. M., & Rein, M. Change, ferment andideology in the social services. Toronto: Council of Social Work Education, 1964.(Mimeo) Peck, H. B., Riessman, F., & Hallowitz, E.Neighborhood service center program. New York: Lincoln Hospital Mental Health Services,1965. (Mimeo) Reiff, R. The mental health educationneeds of labor. (Working Paper No. 2) Washington, D.C.: National Institute of LaborEducation, 1960. Reiff, R., & Scribner, S. Issues in the newnational mental health program relating to labor and low income groups.(Report No. 1) Washington, D.C.: National Institute of Labor Education, 1963. Reiff, R., & Riessman, F. The indigenousnonprofessional. Community Mental Health Journal, 1965, Monograph No. 1. Rein, id. Strategies of planned change. Paper read atAmerican Orthopsychiatric Association, New York, March, 1965. Riessman, F. New approaches to mental health treatmentfor labor and low income groups. (Report No. 2)Washington, D.C.: National Institute ofLabor Education, 1964. Rioch, M. J., Elkes, C., & Flint, A. A. Pilot project intraining mental health counselors. (Publ. No. 1254) Washington, D.C.:United States Public Health Service, 1965. Rosenbaum, M., & Zwerling, I. Impact of socialpsychiatry on a psychoanalytically oriented department of psychiatry. Archivesof General Psychiatry, 1964, 3, 31-39. Star, Shirley. The place of psychiatry in popularthinking. Paper read at American Association for Public Opinion Research,Washington, D.C., May 1957. Szasz, T. The myth of mental illness. NewYork: Hoeber, 1961. III COMMUNITYPROGRAMSAND NEW SOURCESOF MANPOWER 6 COLLEGE STUDENTSAS COMPANIONS TO THE MENTALLY ILL'

Jules D. Holzberg,Robert H. Knapp, and John L. Turner Connecticut Valley Hospital andWesleyan University

EARLY HISTORY

The Companion Programoliginated as an adjunct to anunder- graduate course in abnormalpsychology. The senior authorhad been teaching this course at WesleyanUniversity since 1949. Oneof the requirements of the course had been the writingof a term paper, based onlibrary research. In 1957 the senior author was amember of an audiencewhen a group of Harvard students and Dr.Milton Greenblatt of theMassachusetts Mental Health Center visited theConnecticut Valley Hospital todiscuss a program hospital, a proof Harvard studentinvolvements in a Massachusetts state Dalsimer, gram thathas more recently beendescribed in print (Umbarger, consisted of two parts: Morrison, & Breggin, 1962).The Harvard Program aides groups ofstudents involved in wardrecreational programs and case As he reflected on (students) working withindividually assigned patients. and the mental health the exuberant descriptionby several of these students professional (Dr. Greenblatt), itoccurred to the senior authorthat the case aide part of the Harvard programcould be readily adapted tothe educational goals of the Wesleyan coursein abnormal psychology. In 1958 he offered studentsin this course the optionof engaging in lieu of the usual "field work" and writing a paperbased on this experience in weekly visit by term paper.Within this context, fieldwork was defined as a the student throughout the semester tothe same chronically illmental patient for a minimum of one hour.In addition, eachstudent was to meet immediately after his visit with a small groupof students (six to ten)who were also involved in this field work experience.The group meeting, ledby a psycholo- the students with any gist or a psychiatrist,provided an opportunity to assist problems occurring in theirrelationships with the patientsand to discuss States Public Health 1 The program to be describedhas been supported by a United Service project grant, MH-01499. 92 COMMUNITY PROGRAMS AND NEW SOURCES OF MANPOWER general issues of a practical or theoretical nature dealing with behavioral deviation and its treatment. Approximately three-fourths of the students in the course elected this option. These studentswere organized into five groups, each led by a mental health professional. A one-semester trial of the program indicated that this type of volunteer work could be significant for the education of the students and also could contribute to the hospital's treatmentprogram. It was therefore decided to continue and expand the program the following year. Its potential educational and therapeutic significance seemed so real that itwas decided that the program would not be anchored to the course in abnormal psychology but would be available to any studenton campus who wished to volunteer for this activity. Furthermore, itwas felt that the program would be most effective for both students and patients if itwere structured in terms of a full academic year rather than as a single-semester experience. A planningcommittee consisting of members of the hospital staff, an interested Wesleyan faculty member, and several students who had been involved in theprogram during the first year was set up to structure theprogram formally. It was at this time that the program was labeled "The Companion Program" (Holz- berg, Whiting, & Lowy, 1964). Out of the meetings of this committee, three major objectives of the program emerged: (1) To give patients the extent and kind of personal involvement that is recognizedas a vital factor in the comprehensive treatment of chronic mental illness. We saw the Companion Programas one facet of a total rehabilitationprogram designed to make social relationships less fearsome and more gratifying experiences; (2) To providea rewarding experience, both intellectually and emotionally, for the students,many of whom would become community leaders in later life. We agreed thatstu- dents in the program must not be regardedas a source of unpaid manpower. We wanted them to receive a personal, maturing experience that would equip them to deal with their own adjustments to life and conceivably lead some to seek careers in mental health professions (Holzberg, 1963); (3) To boost the morale of increasingly overburdened, often frustrated hospitalper- sonnel by bringing onto the wards young, intelligent scholars, full of the social idealism, hope, and vigor of youth. The program was conceived as one that would require theutmost cooperation between hospital and university. In practice, the hospital has accepted the role of the willing host for the students, welcoming themas real participants in its treatment and rehabilitation program. It accepts responsibility for the students' orientation and educational experiences and maintains professional responsibility for all patients involved in theprogram. This responsibility is carried through the chiefs of the units in which the students operate and through the professional group leaders who supervise the students. The university's responsibility is tO recruit and organize student partici- 93 COLLEGE STUDENTS ASCOMPANIONS body with pants, a functionthat the university hasdelegated to the student the first days a facultymember serving as adviser.Recruiting begins during literature on the Com- of fall semester with thedistribution of brochures and invited to attend a rally atthe panion Program.Interested students are university during the firstweek of school to hear adiscussion of the program Students who have par- mid its benefits for patients,students, and hospital. leader from the ticipated in the programpreviously, a professional group hospital, and the facultyadviser also speak to thestudents. Professional group leaders onthe hospital staff arecharged with main- problems. Therefore, taining a commonphilosophy and working out common with ward personnel to the group leaders meetperiodically. They also meet assess the responseof patients. the recruitment meet- The role and obligationsof a student are defined at first session at the hospital.His role ing at the universityand at the student's therapist, to a patieLt; andwithin is defined as thatof being a friend, not a of this context, the importanceto the patientof reliability and consistency Once committed to the program,the student is obligated to visits is stressed. hour in spend at least twohours a week (one hourwith the patient and one Christmas the group) at thehospital during theacademic year, except for and Spring vacations. The hospital attempts tobe as flexible as possiblein adapting itself to students find afternoon the time the students haveavailable. The bulk of the have had an evening group.The visits most convenient,but occasionally we the designation of precise actual assignment ofstudents to specific groups, transportation, etc. are hours to be spent at thehospital, arrangements for student in the group is left to the faculty adviser.Once a group is formed, a usually designated as thestudent leader, who arrangesfor transportation and other practical matters. without All interested students areallowed to sign up for the program frankly unknown. While prior screening. Criteriafor effective screening are predictors our research mayultimately yield predictorsof success, neither the for a full year nor thecriteria have as yet beendelineated. The commitment friendship screens out theobviously unmotivatedstudent. Emphasis upon students with the rather than therapeutic services servesto exclude some effectively; wrong motivation.The students screenthem-elves informally and they have made three they do not commit themselves tothe program until does, visits to the hospital.During this period astudent can, and occasionally withdraw gracefully fromthe program. As indicated earlier, amental health professionalis assigned to each leader has a three-foldfunction: group ofstudents. The professional group make certain that the rela- (1) Supervision. Hesupervises the students to tionship is one suitable to a"companion." He helpsstudents to understand and the relationship and tohandle problems that mayarise between student 94 COMMUNITY PROGRAMS AND NEW SOURCES OF MANPOWER patient. (2) Support. Typically, students require considerablesupport in dealing with their anxieties and frustrations. Their anxietiesare likely to occur during their first visits to the hospital due to false anticipations about patients and feelings of insufficient "training" for the work. Their frustrations occur when their ambitions for their patients stumble upon the reality of chronic mental illness (Holzberg, 1962). Thisoccurs when a patient does not make as much progress as anticipated, or when a patient has shown improvement and then relapsed. (3) Education. During thegroup meetings, there is usually considerable discussion of general issues pertainingto mental illness and hospitalization. *ibis is likely tooccur most intensively during the second half of the year, when the students' anxietiesare sufficiently reduced. An attempt is made to keep discussions general rather thanto concentrate on the problems, history, and dynamics of specific patients. Companions donot have access to their patients' psychiatric charts, butat the end of the year the group leader may discuss selected data from the patients' records. This is an event eagerly awaited by the Companions because it permits them to get another view about their patients. The group leader assumes considerable responsibility both for protecting the patient and for making the Companion's experiencea positive one. The essential qualifications for a group leader seem to be experience with patients, a dynamic approach to their problems, andsincere interest in working with students. Initially, we were under the impression that thesuccess of our program would depend, at least partially, on letting the students themselves choose patients with whom they thought they could become 'friends. Accordingly, the chiefi the unit involved, the nursing supervisor, and the professional group lea:.er selected a group of patients; and for three weeks following the initial orientation period at the hospital, the professional leader, the students, and the patients met ata weekly social hour held on a ward or in a special room of the patients' building. Students and patients mixed freely in the presence of the professional group leader. During these three weeks, the first hour was devoted to getting acquainted with patients in thegroup situation. Then, during the second hour, the professionalgroup leader guided a discussion on both general issues and the students' interests in specific patients. We believed that these sessions would allay the anxiety of the students, for many of whom this was their first experience in a mental hospital. At the end of this three-week period, each student selected the patient who would behis Companion for the entire year. We have since discovered that students often preferto have patients assigned to them, because frequently they feel guilty when theyselect one patient over another. Therefore,we may now assign a patient to each student with the understanding that the assignmentcan be changed at any time within the first three weeks. 93 COLLEGE STUDENTS ASCOMPANIONS student body with pants, afunction that the universityhas delegated to the Recruiting begins duringthe first days a facultymember serving as adviser. brochures and literature onthe Com- of fall semester withthe distribution of Interested students areinvited to attend arally at the panion Program. the program university during thefirst week of school tohear a discussion of patients, students, andhospital. Students whohave par- and itc benefits for leader from the ticipated in the programpreviously, a professional group hospital, and the facultyadviser also speak to thestudents. staff are chargedwith main- Professional groupleaders on the hospital problems. Therefore, taining a commonphilosophy and working out common with ward personnel to the group leaders meetperiodically. They also meet assess the responseof patients. defined at the recruitment meet- The role and obligationsof a student are and at the student'sfirst session at thehospital. His role ing at the university patient; and within is defined asthat of being afriend, not a therapist, to a of reliability andconsistency of this context, theimportance to the patient Once committed to the program,the student is obligated to visits is stressed. and one hour in spend at least twohours a week (onehour with the patient for Christmas the group) at thehospital during theacademic year, except and Spring vacations. possible in adaptingitself to The hospital attempts tobe as flexible as bulk of the studentsfind afternoon the time the studentshave available. The have had an evening group.The visits most convenient,but occasionally we the designation ofprecise actual assignment ofstudents to specific groups, for transportation, etc. are hours to be spent atthe hospital, arrangements formed, a student inthe group is left to the facultyadviser. Once a group is who arranges for transportationand usually designated asthe student leader, other practical matters. the program without All interested students areallowed to sign up for screening are franklyunknown. While prior screening.Criteria for effective ultimaHy yield predictorsof success, neitherthe predictors our research may for a full year nor the criteriahave as yet beendelineated. The commitment Emphasis uponfriendship screens outthe obviouslyunmotivated student. exclude some studentswith the rather than therapeuticservices serves to themselves informallyand effectively; wrong motivation.The students screen until they have madethree they do not committhemselves to the program student can, andoccasionally does, visits to the hospital.During this period a withdraw gracefully fromthe program. professional is assigned toeach As indicated earlier, amental health leader has a three-foldfunction: group ofstudents. The professional groq supervises thestudents to make certainthat the rela- (1) Supervision. He students to understand tionship is one suitable to a"companion." He helps arise between studentand the relationship and tohandle problems that may

1 COLLEGE STUDENTS AS COMPANIONS 95

STUDENT-PATIENT ACTIVITIES

While most student-patient activitiestake place at the hospital, we also allow Companions to take patientsinto town or on a visit tothe university if the chief of the unit approves.While visiting their patients,students may engage inwhatever activities seem appropriate tothe patients' interests, e.g., talking,walking, playing games, listening tomusic, reading, etc. The range of activities inwhich student and patient may engage are limited only by the interests of the patientand the good taste and judgment of the student. Occasionally an activity seemsto violate thelatter, as when a student was observed ridingwith his patient on a motorcycle.But even here it was later learned thatthe student had merelyresponded to the patient's comment that he had neverridden a motorcycle. Once the student has a Companionpatient, it is typical for thestudent to meet his patient inthe building in which the patientresides. This meeting may occur on the ward or inthe visitors' lounge. Thestudent and patient may havedecided during the previous visithow they would spend their time next week, orthis is decided on the day of the visit.A student may spend time alone with his patient, orseveral students and their patients maybecome a groupfor that visit. Exploration of the hospital grounds is a commonactivity in early visits. Sometimes it is the patient who takesthe initiative in orientingthe student to the hospital. He may escortthe student on visits to thechapel, occupational therapy, the movie house,the library, the greenhouse, etc. A frequent activity is justtalking. To most of our students,this is their most usual mode ofrelating to friends. This "talking" may occurin the context of taking walksthrough the hospital grounds,drinking coffee at the hospital canteen, listening to musicin the music department, etc.The content of such talks isvaried; they may cover areasof mutual interest, how each spends his usual day,their backgrounds, how thepatient feels about leaving the hospital, etc. Wherethe patient's interests indicate It,the student ,academic areas, as in the caseof the student who had a may discuss certain patient who shared his interestin mathematics. Sometimesthe student may bring something to the patient,such as drawing materials or abook that the patient has expressed interestin. However, talking is notalways a comfortable medium of interchangefor many of our patients.This may lead the student to engage in gamessuch as checkers, cards, tossing aball around outside, playing pool, etc.One student who had a patientwho was not a talker found that his patientand he could spend timethrowing pebbles ot skillful in this a treefrom varying distances. Thepatient was obviously activity; and presumablythis demonstration of skillmade the patient more relaxed with the student, forhe became more talkative onsubsequent visits. Where patients tend tospend much of their daytimehours on their 96 COMMUNITY PROGRAMS AND NEW SOURCES OF MANPOWER wards, students almost instinctively "pull" to get the patient toleave the ward for the visit. If the patient is too disturbed to leave the ward inthe opinion of the ward staff, the student may spend the entirehour with the patient on the ward. Occasionally a patient resists the student'sdesire to go outside, sometimes out of fear, sometimes out of negativism; but it is a rare Companion experience which is solely limited to visits on the wardthrough- out the year, even if the patient isresiding on a closed ward. The age and physical condition of the patient also determinethe kinds of activities in which patients and students engage. The younger, more vigorous patients can, of course, engage in more active pursuits,whereas the older, more debilitated patients are more likely to enjoy sedentary activities. Not infrequently students may take their patients to visitthe university (Wesleyan is only five minutes by car from the hospital). They mayexplore the university grounds together, have dinner at a fraternityhouse, attend a concert together, or meet and talk to a professor, asin the case of a patient who had expressed an interest in anthropology and whose studentarranged for the patient to visit with a professor in that department. Thus, considerable latitude is provided the students in terms of their activities with patients. Very little structure is provided by the professional staff, and it has been our experience that little structure is needed. The sensitivity of the students and their basically good judgment have been apparent throughout the history of the program.

PATIENT SELECTION

Considerable thought has been given to the question of the type of patient to be selected for this program. While the criteria have remained tentative, we are in general agreement that patients for this program should be chronically ill and have minimal involvement with ongoing hospital programs. They should present no symptoms orbehavior that would be especially disturbing to the students. They should not be so regressed that they would be more appropriate for a remotivation program,2 nor so socially developed and capable of tolerating an intense interpersonal relationship that they are ready for formal individual or group therapy with a professional. We believe the patient best suited to the Companion experience is one who has responded to remotivation and is now ready for a social relationship with a relatively benign individual. We are particularly interested in the "forgotten" patient who has minimum or no contact with other hospitalized patients or with members of his community, including his family. 2 Remotivation is a program designed for the most regressed and alienated patients to remotivate them to enter into the most minimal social interactionswith others. Ap- propriate patients for such programs are patients who do not communicate at all or who communicate incomprehensibly. Patients selected for the Companion Program are not usually at such a regressed state. COLLEGE STUDENTS AS COMPANIONS 97 No attempt has been made to match student and patient on anyvari- ables, including sex and age. It is entirely fortuitouswhether a group of patients selected for a group of students happens to consistof men, women, or both. The sameapplies to the ages of patients, although the bulkof patients selected are older than the studentsbecause of the criterion of chronicity. The largest number of patients areschizophrenic. The goals of the Companion Program for the patient areimprovement in his level of social communication, socialskill, and social responsibility that would help effect his social recovery and hopefullylead to his discharge. Patients for group therapy are often recruited fromthose who have been in the Companion Program. The problem of handling separation and termination is acontinuing one. The students are concerned about the effects ofthese on their patients, but at times more than isjustified by the nature of their relationships. Wehave thought about this problem but have collectivelyagreed that patients cannot and should not be protected from the realities ofliving, one of which is the movement of people into and outof their lives. The group leader's task is to help the students carrythrough separation and termination so that it is not traumatic, either forthe patients or for the students. Separations loom as a significantproblem twice a year, at the long Christmas vacationand at the end of the school year. We believe thatholding a party for patients and their Companions just prior to the Christmas vacationand a picnic just prior to the end of the year serves toallay separation anxiety for both. From its beginnings at one university, the programhas now expanded to students of seven collegesWesleyanUniversity, Yale University, Trinity College, Central Connecticut State CoPege, Universityof Hartford, Hart- ford College for Women, and St. Joseph's College ofWest Hartford, Con- necticut. Between 100 and 150 students participateeach year, including several who have been in the program for two and three years. This introduction to the program would be incompletewithout mention of concerns expressed by some of the hospital staff atthe program's beginning. Concerns were expressed that the student-patient encounterswould be damaging to patients, traumatic for students, anddisturbing to hospital routines. We are pleased to indicate that not oneof the hundreds of students was traumatized; onthe contrary, as we shall report later, manystudents apparently go through a quasi-therapeutic experience.Some students drop out of the program, but we are unaware evenin these instances of any genuine trauma to the students. As far as patients are concerned, we are reasonably certainthat their friendships with students are experienced as a positive encounterwith a deeply committed hum tn being. While a student mayoccasionally tend to get emotionally overly-iavolvedwith his patient, no student has ever been asked to resign from the program. While studentsoften take their patients off the wards, and some of these patients are fromclosed wards, there has

i 98 COMMUNITY PROGRAMS AND NEW SOURCES OF MANPOWER never been a single instance of a patient trying to escape fromthe hospital. It is inevitable that some disturbance of hospital routines would result from student involvements at the hospital. Students "unknowingly" impose demands for healthy behavior because they do not reinforce patient pathology. They view the patients in the most humanistic and equalitarian terms. They encourage patients to make demands on thehospital and its personnel. This should inevitably collide with the efficiency of hospital ward functioning. But it is a tribute to the nursing personnel of our hospital that they have been able and willing to adapt to the demands that must eventuate from such a program.

CHARACTERISTICS OF COLLEGE STUDENTS

It is a question of prime pedagogic interest to know if students volunteering for the program represent a self-selected and distinctive body in terms of psychological attributes, or whether they are a typical cross-section of the student population from which they are drawn. Fortunately, at Wesleyan University an extensive testing program involving all students has been in progress for many years. This testing occurs during the week of freshman orientation, and the results have been available to us for comparing students who have volunteered for the program with those who have not. One study (Knapp & Holzberg, 1964) compared such a group of Companion students and control subjects. The control group was a randomly selected sample of nonparticipating students. The two groups were compared on a variety of standard psychological tests. The analysis of the data offered strong refutation of any suspicion that the Companion Program has proven a refuge for the morbid and unstable personalities seeking a bizarre adventure. The evidence is particularly clear that such is not the case. On the other hand, it is clear that the Companion Program serves as an outlet for certain impulses of human generosity and altruism which has not normally been available to students in the college environment, at least until recently. The civil rights movement, poverty programs, etc. are more recent developments that provide such outlets. So far as our data indicate, the Com- panions are more idealistic in temper, more capable of generosity, less concerned with personal gain, and more responsive to religious values than their associates who have not elected to join this program. In particular, it proved possible to demonstrate that Companions differed from controls in the structure of their "moral life space." Thus, we were able to show that Companions were more sensitive to the dimensions ofgoodness and badness and less concerned with power versus weakness than were their corresponding controls. We think it has accordingly been demonstrated with reasonable confidence that the program does not attract significantly unstable or insecure personalities, but rather persons of more than usual moral sensitivity and compassion. I 99 COLLEGE STUDENTS ASCOMPANIONS and the A replication of thisstudy was undertakenwith a larger sample, As part of this results are essentially asreported in the first investigation. (personal, larger study, however, wealso explored 13additional variables distinguish Companionsfrom familial, and academic)which might further controls. None of thepersonal and familialvariables proved differentiating. variables did prove significant.There was asignificantly Certain academic consistent lower incidence ofdisciplinary action directedagainst Companions, by a higher sense of with the proposition thatCompanions are distinguished Beyond this, Companions moreoften belong to fraterni- moral responsibility. The first of these ties and mostfrequently major inpsychology and biology. seek others; the latter findings suggests thatCompanions more often tend to of the CompanionPro- finding is understandablebecause of the pertinence gram topsychological and medicalscience. observing Further light may beshed on the characterof Companions by administered at their declaration of motives asrevealed on a questionnaire sorted under the beginning of the year.Responses to this questionnaire were motives were: toacquire knowledge sevenheadings. The most prominent be of service to a person concerning mental illnessand abnormal behavior; to More in misfortune and toaid his recovery; andfinally, to obtain self-insight. friends with unusual persons,to rarely mentioned werethe desile to make help prepare for anintended vocation, and toobtain personal therapeutic is advantage. It may beobserved in passing thatthis hierarchy of motives there generally sustained inrewards reported at theend of the year, though be said that the hope are anumber of significantchanges. Briefly, it may significance, while the contribute to the recoveryof the patient dropped in to appeared to be an unex- reward of knowing anunusual and different friend pected gain from theexperience. the We have been keepingcareful records ofstudent dropouts from 10%-15% each year)and are currently program(these number between examining data aboutthese people which willhelp us to understand more complete it. fully the student who startsthe program but does not

EFFECTS ON PATIENTS

Initial attempts to evaluatethe program in terms of itsimpact on students, observations of the patients have rested onquestionnaire ratings by study professional leaders, and variousanecdotal information. A questionnaire carried out on the first year'sCompanions offered somebasis for considering the experience a significant onefor the patients. Clearly,these data are not objective, being based on thestudents' own perceptionsof their experiences. consider. Of the stu- However, they may neverthelessbe of some interest to dents who responded to thequestionnaire at the end ofthe year, 84% reported relationship and sought to main- that their patients desiredthe companionship 100 COMMUNITY PROGRAMS AND NEW SOURCES OF MANPOWER tain it. A typical student comment was, "She seems to appreciate my visits and attention." Seventy-one per cent reported that students and patients con- versed more freely. Sixty-five per cent reported that their patients showed positive changes in self-confidence. Sixty-four per cent reported greater interest on the part of the patient in his surroundings. A comment of oneof the students in this regard was, "She's more interested in the activity of the hospital. She began helping with aged patients in the Infirmary. She is generally more aware of herself and hersurroundings. She began corresponding again with friends outside the hospital." Another student reported, "It has brought him out from his withdrawn state. He is first starting to show significant improvement." Positive changes in the patients' personal appearance were reported by 55% of the students, and 48% reported that the patients' social behavior had improved during the year. The students also reported changes in certain symptomatic expressions of their patients. Forty-two per cent of the students reported that their patients showed improvement in realistic thinking, and 46% of the students reported that their patients showed improvement in their mood, reflected in reduction of depressive indications. Overall, the students considered that 71% of the patients had shown improve,fient in the Companionship year. Twenty- nine per cent were unchanged. If these findings could be corroborated with controlled investigation, the result would be quite startling, considering the fact that all of the patients were chronically ill and had been in the hospital for a substantial number of years, some for more than twenty years. Greenblatt (1962) reported that a similar program at Harvard resulted in the release of many patients who were "...elderly, chronic, institutionalized people." Kantoi (1962), in describing this same study, indicated that 11 of 5'.) chronic patients who had been in the hospital for at least five consecu- tive years were able to leave the hospital. The absence of controlled data on a population not associatedwith college students limits this type of information, but both authors express confidence that the results are attributable to the college student involvements. However, one must note that the onset of college volunteer program!' coincides with many changes in institutional policies, such as the Open Door, and with the use of the ataractic drugs, so that it is difficult to evaluate discharge rates without control groups. More recently we have collected psychological test data in order to compare Companion patients with a group of control patientswho were not in the program. A number of psychological assessment procedures have been used, including the Minnesota Multiphasic Personality Inventory, Bender Gestalt Designs, and Draw-a-Person. Of the patients to whom the MMPI was administered, only 14 Companion patientsand 30 control patients completed full MMPIs before and after the program. While we cannot be certain that these MMPI performances are representative of the total Companion and control patient populations, we nevertheless believe that it is of interest to report that one clinical scale (Depression) changed significantlyfrom the 101 COLLEGE STUDENTS ASCOMPANIONS significant decline on pretest to the posttest.Companion patients showed a direction on the Paranoid this scale. A comparabledifference in the same Bender and Draw-a-Person scale barely missedsignificance. The data on the have are currentlybeing analyzed to determineif any significant changes occurred in our Companionpatients on these instruments. Beyond this, in order to assessthe saliency of theCompanion experience after the termina- for the patient, Companionpatients have been interviewed they attached to tion of the Companion yearwith regard to the importance the student, what theybe- their Companions, howmuch they knew about why they would lieve the students' motives werefor coming, whether and the patient from seeing like a Companion thefollowing year, the values to the experience was, aCompanion, what theyexpected and how satisfactory These data are presently and their suggestionsfor improving the program. being examined. In addition,professional group leaders haveprovided ratings students. These on theoverall degree of change inthe patients seen by their data are also currentlybeing analyzed. We are now in themidst of collecting data onboth Companion and control patients withregard to their ward behavior.Ratings on a hospital adjustment scale were made atthe beginning and end of the yearby nursing personnel. This scaleprovides information on three aspectsof hospital adjust- of self and social ment: communicationand interpersonal relations; care responsibility; and work, activities,and recreation. In addition, we areexamin- ing the extent towhich the Companion experienceproduces changes in the patients' interest in, awarenessof, and adaptation to,their immediate environment. Companion patientsand control patients wereadministered a hospital information test atthe beginning and end of theCompanion year. of a patient's The test is designed to yield a measureof the extent and nature related to a knowledge of the hospital environment.This test has been and variety of variables,including patient styles ofadaptation to the hospital discharge rates.

EFFECTS ON STUDENTS

KNOWLEDGE ANDATTITUDES ABOUT MENTAL ILLNESS Indifference, or something worsethan indifference, hascharacterized society's attitude towards thementally ill throughouthistory. While encourag- is still ing changes hsvc:recently been taking placein official attitudes, it outright rejection disconcerting to observe thecontinued indifference, if not of the mentally ill,by substantial segments ofthe public. Extensive programs impact on the puNie of community education seemsomehow to have had less problems. Pity may than comparable programsconcerned with other health 102 COMMUNITY PROGRAMS AND NEW SOURCESOF MANPOWER have been aroused, but this has not substantiallydiminished ,...ie public's ostracism or isolation of the mentally ill. The paucity of results achieved in altering thepublic's attitudes has recently been examined by the Joint Commission onMental Illness and Health (1961). This report has detailed anumber of ways in which the abnormal personality plays a significant role indetermining the public's attitudes of indifference and rejection. The mentallyill are often unpredictable people, and thus they threaten theordered stability of the community. Furthermore, by their apparent refusal to get alongwith other people, they create the impression of being unwilling tobe fully responsible members of thesocial community. Finally, the mentally ill patientis frequently unwilling to accept sympathy and assistance because he does not seehimself as "ill." He thus turns away from aidand sympathy that may initially havebeen generously offered. This refusal is experienced bythe community as rejection, which leads into a vicious circle of mutualrejection. Considerations such as these help in understanding the strong resistance tochange in the public's attitudes in spite of massive educational programs onmental illness. The need for improved publicunderstanding of mental illness is clear when one considers the cost of theprevalent indifference and rejection to afflicted individuals and their relatives and tosociety at large. Persons who might live profitably, or at leastharmlessly, in a more acceptant community are unnecessarilyplaced in mental hospitals ("put away," inthe popular phrase) or are kept there to little or notherapeutic purpose only because they have 1;owhere to go where they canbe accepted. Employers, fearful of the stigma attached to the label"mental patient," may refuse to hire well-qualified former patients, to the detriment ofboth their own businesses and the ex- patients' self-respect. At the same time, personsin serious need of psychiatric care may fail toseek it, or to accept it if offered, or to profitfrom it if forced on them,because of unwillingness to be placed in aclass which they themselves fear or despise. Still another consequenceof the public's negative attitudes is the difficulty experienced bymental hospitals in recruiting sufficient professional and semiprofessionalpersonnel. These concerns have led us to examinethe question of the impact of the Companionship experience onthe attitudes toward mental illness and the mentally ill of those participating in it. In one study (Holzberg & Gewirtz, 1963), a groupof Companion students were compared to a control group ofstudents who had volunteered for other forms of social service activities inthe local community, e.g.,the Y.M.C.A., Big Brothers, etc. The selectionof control students in social service activities was an attempt to makethe groups as comparable as possible in terms of social interest. Both groups wereadministered a questionnaire dealing with mental illness.While to a great extent the questionnaire probed for specific information, it was feltthat it would nevertheless reveal certain attitudes toward the mentallyill. The questionnaire was administered 103 COLLEGE STUDENTS ASCOMPANIONS of stu- at the beginningand at the end of theacademic year to both groups dents. The results of thestudy were rather clear-cut.The two groups, which signifi- were notsignificantly different from eachother at the outset, were cantly different at the posttest.The companion groupdemonstrated that its members had gained inknowledge and positive attitudesfrom their experi- highly ence. Whilethe subjects of the studyconstitute a sampling of a selected and limited partof the general population, wefeel that its impor- occupying tance lies inthe fact that this segmentof the population will be positions of leadership inthe future. Consequently, theknowledge gained should lead to more and the attitudes affectedby the Companion experience constructive approaches inthe field of mental illness. More recently, we have done afurther study on possibleshifts in attitudes toward the mentally ill.We have used an extensivelyvalidated instrument, Opinionsabout Mental Illness (OMI),which was administered to student Companions and controls atthe beginning and end ofthe Compan- ionship year. A factor analysis ofthe pretest data yielded sixfactors: authori- tarianism, benevolence, mentalhealth ideology, social restrictiveness,interpersonal etiology, and alienation.While we found overalldifferences in the differences in levels of the factors betweenCompanions and controls and the two student groups combinedfrom pretesting to posttesting,the analyses function of the Com- do not indicate significantchanges in these factors as a panionship experience. However, separateanalyses of every item in theOMI indicate that Companions dochange more than controls intheir agreements and disagreements with items,suggesting that the Companionsshow more "stirring up" of attitudes eventhough the items on whichthey change do not clusteraccording to the factorial structurefound in the analysis of the pretest data.There was reason to believe thatdifferent Companions were changing in different ways,that they were in fact beingaffected by the experience. CHANGES IN MORALJUDGMENT AND SELF-ACCEPTANCE From the very first year of the program,there were indications that the students were undergoing certainimportant personality changesthat conceivably could be attributed tothe nature of their experience.From discussions with students duringtheir hospital visits and fromcertain written reports prepared by someof the students, we sensed veryearly that the impact of this socialexperience transcended mereintellectual enlightenment pedagogically, it ap- and involved basic personalitygrowth. Thus, viewed peared to us that the program wasserving in many cases a moretranscendant educational aim than that commonlysubsumed under the designation"academic." Involved here, itappeared to us, was a growthof social awareness, empathic range, andself-realization which might bedescribed by the phrase "nonintellective education." 104 COMMUNITY PROGRAMS AND NEW SOURCES OFMANPOWER Although numerous personality dimensions seem conceptuallyrelevant to this process, further examinationof the students' subjective reports of the kinds of changes they perceived in themselves suggested twofoci of research interestmoral judgment and self-acceptance. We designed a study to measure, during the courseof a year, changes in these two areas of personality in the group of Companion students and a comparable group ofcontrol students (Holzberg, Gewirtz, & Ebner, 1964). The first instrument administered to the subjects consistedof a scale of moral judgments of our own design. Changes on this scalerevealed that the Companions became more tolerant of their judgmental evaluations of sexual and aggressive behaviors. It is of interest that theCompanions began the year presenting a picture of greatermoral severity than the control group, that they were more disapproving of thebehaviors relating to sexuality and aggression. This may reflect the findings ofanother study showing that religious values occupy a more central role in the philosophiesof the Com- panion students as compared to non-Companioncontrols. The fact that the Companions shifted toward greater to!-rance of sexual andaggressive behaviors suggests that the Companion experience mayfacilitate the relaxation of initial moral rigidities. Although, on variousgrounds, one might expect similar kinds of changes in college students from thematurational and presumably broadening effects of the college experience, it isnoteworthy that the control group revealed no sudi change. On the self-acceptance measure,while it was found that the two groups did not differ significantly at the beginningof the yecr, the Companions shifted conspicuously toward greaterself-acceptance, while the non-Com- panions showed a slight trend towardless self-acceptance at the end of the year. Thislatter trend is difficult to interpret in view ofthe diverse factors which might influence such a broad variable inthe normal course of the year's activity. This change might be areflection of heightened tension and anxiety concerning the approach of thefinal examination period, which coin- cided with the time of the retesting. However,regardless of the cause of this trend in our control group, it is noteworthy thatthe Companions, exposed to the same general campusenvironment, exhibited a significant opposite change.

CHANGES IN INTROSPECTIVENESS Companion students and controls were evaluated on a preprogram- postprogram design forchanges in their level of anxiety and the extent to which they utilized repression as measuredby scales of the Minnesota Multi- phasic 13::sonality Inventory. While there were nosignificant differences between the groups in terms of changes on therepression scale, there was a significant tendency for the Companionstudents to manifest increased scores on the anxietyscale. Because of the nature of the items used to assessanxiety, 105 COLLEGE STUDENTS ASCOMPANIONS change in greater introspec- this latter result hasbeen interpreted by us as a tiveness on the partof the Companionstudents.

STUDENT EVALUATIONOF THE PROGRAM At the end of the first yearof the program a questionnaire wasad- indicated they ministered to the participatingstudents. All of the students had grown in theirknowledge of mental hospitalsand the consequences of hospitalization. Ninety-one per centstated that they hadbecome less anxious Ninety per cent felt working with patientsduring the course of the year. mental illness, its causes,and treat- they had grown intheir understanding of bad changed: ment. Eighty-one percent said thattheir feelings about patients the ability to see patients assick people who wereworthy they had acquired of the of support and aidrather than derision.Implicit was the recognition prejudices that they hadbrought into their encounterwith patients. Eighty- mental hospital personnel tour per cent reportedthat their feelings about problems had changed, and thatthey understood betterthe nature of the understanding of the experienced by these people.Many also reported better various mental healthprofessions. alluding to the multi- A number of thestudents volunteered statements good and effective ple values of the experiencefor them: "This Program is a by mental hospitals today. method of letting othersknow the problems faced generation." "I feel that I sincerely hope that it reaps areward in the future terrific the companionship I hadthis year was more orless one-sided. I gained and its problems." "I insights into the mentalhospital complex, its patients psychology, and maybe even feel quite strongly that allgraduate students in Program. It is a veryvaluable all majors in psychology,should take part in the objective view of experience." "The Programhas caused me to take a more the Program. For me,and I think my ownemotional problems." "Keep up been most rewarding."Ninety-seven for most everyone,the experience has had contlibuted to their per centof the students feltthat their experience student who has expressed personal growth. Therehas been the occasional the opinion that being aCompanion has been his"most valuable college experience." During one of the recent yearsof the CompanionProgram, students at the endof the year designed to wereadministered another questionnaire determine how theyassessed their Companionexperience retrospectively. factors were tentativelyidenti- The responses werefactor analyzed and five characterized different groups fied, designating differentstyles of outcome that by of studi2nts. The firstfactor defined a styleof outcome characterized program.Here the growth in knowledgeabout the hospital and its treatment intellectual. The sec- knowledge was impersonaland the prime reward was changes in ond factor defined astyle of outcomecharacterized by desirable life outlook and rewardingpersonal gains associatedwith a feeling on the NEW SOURCES OFMANPOWER 106 COMMUNITY PROGRAMS AND with part of thestudent that he had developed arelationship of friendship which was also the patient. The thirdfactor described a style of outcome this case it was characterized by genuine friendshipwith the patient, but in accompanied by emotional stirringsof a deep nature. Thefourth factor de- and indignant concern fined a style of outcomecharacterized by an intense life with the patient'smisfortunes, leading to asomewhat more pessimistic of outlook but with thestudent feeling that therehad been gratification altruistic motives. The fifthfactor defined a style of outcomecharacterized patients and how it mustfeel by the acquisition ofpersonal knowledge about to be a patient,combined here also with thefeeling that altruistic motives had been gratified. occurred in We are currently studyingsystematically changes that have the basic life values ofCompanions.

FOLLOW-UP STUDY participated in the A questionnaire wasmailed to all graduates who Companion Program. Anunusually high return wasachieved. The questionnaire sought data onhow the alumni assessedtheir Companion experience retrospectively. While there wereconsiderable individualdifferences in the the overall re- way inwhich they describedtheir Companion experience, who responded sponses ofthe alumni could besummarized as follows. Those indicated that they hadhad feelings of solicitudetoward their patients, a desire to help them, andcuriosity and interest inthe patient's case. They having been repulsed denied having beentempted to laugh at the patient or manifesta- by the patient's illness.They also denied anyfear of viewing the general anxiety on their tions of mentalillness. While admitting to some self- initial contacts with theirpatients, they deniedhaving had any fear of revelation or any anxietyabout their own mentalhealth or the possibility the waste of humanpotential of mental illness.They expressed anguish over responsible for his condition in the patientsand denied that the patient was described their relation- orresponsible for causingsuffering to others. They experience for them (the ships with their patients ashaving been a unique alumni). A substantialnumber indicated thattheir Companion experience related to mental health had confirmed theirvocational interest in careers rarely in the ministry notably in psychology,psychiatry, and social work; more number expressed dismay and legal profession.A small though important and indignation at the stateof psychotherapy and the treatmentof mental disease. While these general findingscontain few surprises,they do generally confirm the high value whichCompanions tend to attach tothe Companion however, is contained experience in retrospect.A more penetrating analysis, styles as contained in this ques- in the identification ofcertain modal reaction tionnaire. From thisanalysis, four definable reaction3tyles emerged. 107 COLLEGE STUDENTS ASCOMPANIONS First, there is the "friend,"namely, the Companion whoshows little anxiety upon entering the program,is dominated by amiableintentions, has little hope of vocational gain,and, in the main, describeshis experience as be described as the "soul- easy andfriendly. The second reaction type may searcher." This type of personconfesses to his own problemsand anxieties, optimism in admits his hope for gainingpersonal insight, and avoids an easy reaction type might his estimate of the gravityof mental illness. The third ; be described as the"vocation-seeker," or better,"vocation-finder." In any the importance cf the pro- event, this persontends retrospectively to indicate interests gram inconfirming or directing himtoward his present vocational be relatively objective in his concerns or pursuits.This individual appears to devoid of the quickamiability of the first and practical in his orientation, 1 type and the anxiouspreoccupation of the second.Finally, our fourth factor yields a hypothetical typethat might be designated asthe "altruist." The prime motive of this type, asmight well be surmised, isthe ambition to alleviate suffering and contribute tothe healing of the patient.Such persons show a combination ofempathic involvement combinedwith moral indignation unparalleled inthe other three types. This mode of analysis is asalutary correction to the co:iception that general trends in our datareveal the whole story. Indeed, itwould appear different that the Companion Programoffers a wide variety of meaning to that persons,depending upon their qualities atthe outset, the circumstances impel them to enter the program,the type of patient towhom they are assigned, and the type ofdirection and supervision theyreceive during the course of theCompanion year. The manner inwhich the reported experience dimensions is the subject of of the Companion isrelated to these and other that we can already demon- current inquiry,but it may be observed in passing strate that the ageand sex of the patient aremeaningfully related to the study. Thus, for example, four styles of experiencereported in this follow-up individuals assigned to youngermale patient morefrequently report the soul-searching attitude, while thosewith older women asCompanion patients experience. In brief,the rarely show vocational trendsin their Companion recognition of pluralism inreaction styles as afunction of motives for enter- obtained, and its retrospective ing the program, thequality of the experience evaluation is important to afull comprehension ofthis enterprise.

CONCLUSION is viewed The Companion Program,after eight years in operation, whose as asignificant contribution to the treatmentof a patient population remaining outside the main- inertia and alienationtend to result in their stream of hospital treatmentprograms. It isjudged to provide a "therapeutic" human relationship ,4 intimacyand consistency for aselect group of patients 108 COMMUNITY PROGRAMS AND NEW SOURCES OF MANPOWER who, if left to their own devices, would assiduously avoid it. Whilewe are currently theorizing about the basis for the therapeutic value of this experience for the patient, we have recognized one important therapeutic "attitude" the student brings: blind to the patient's psychopathology, he relates to the patient as another human being and not as a phenomenon of mental illness. It has been suggested that the studentmay be the only person with such an attitude who encounters the patient,a patient who has withdrawn and insulated himself from human relationships which he feels will beas hurtful as those he has endured in the past. The program is also viewed as a significant contributionto the nonintellective education of college students. Students participatingin the program undergo changes in personality not unlike those that have been observed and reported as occurring in psychotherapy. They showa reshuffling of attitudes about mental illness with a modal shift towardmore sympathetic and realistic understanding of this problemarea; they demonstrate a modal shift toward greater self-acceptance, greater tolerance for heterosexual and aggressive Lhaviors, and a heightening of introspectiveness. It seems to us that the Companion Program has brought togethertwo individuals who normally would havea rare or transient encounterthe patient, often lost in despair and retired from life; the student,a younger person at the height of social idealism, courage, and optimism. What has emerged thus far in our work is that the relationship between thesetwo has had many beneficial consequences for both. The patientseems to borrow some of the optimism and courage of his Companion and the Companion gains wisdom and charity that is personally enlarging. Above and beyond this, it has opened another channel of communication between the hospital and its patients and the outside community.

REFERENCES

Greenblatt, M. A role for the voluntary organizations in the work of mental health institutions. In College student companionprogram: Contribution to the social rehabilitation of the mentally ill. Hartford, Conn.: Conn. State Dept. of Mental Health, 1962, Pp. 10-18. Holzberg, J. D. The significance of the companionship experience for the college student. In College student companion program: Contributionto the social rehabilitation of the mentally ill. Hartford, Conn.: Conn. State Dept. of Mental Health, 1962, Pp. 39-48. Holzberg, J. D. The companion program: Implementing themanpower recommendations of the Joint Commissionon Mental Illness and Health. Amer. Psychol., 1963, 18, 224-226. Holzberg, J. D., & Gewirtz, H. A method of altering attitudes toward mental illness. Psychiat. Quart. Supplem., 1963, 37, 56-61. 109 COLLEGE STUDENTSAS COMPANIONS Changes in moraljudgment and self- Holzberg, J. D., Gewirtz,H., & Ebner, E. function of companionshipwith hospital- acceptance incollege students as a J. consult. Psychol.,1964, 28, 299-303. ized mental patients. patients and acollege Holzberg, J. D.,Whiting, H. S., &Lowy, D. G. Chronic 15, 152-158. companion program.Mental Hospitals, 1964, Health. Action formental health. New Joint Commission onMental Illness and York: Basic Books,1961. patients, and onthe of college students onchronic mental Kantor, D. Impact program: mental hospital. InCollege student companion organization of the Hartford, Conn.: Contribution to thesocial rehabilitationof the mentally ill. Conn. State Dept.of Mental Health,1962, Pp. 28-38. Characteristics of collegestudents volunteering Knapp, R. H., &Holzberg, J. D. Psychol., 1964, 28,82-85. for service to mentalpatients. J. consult. A. P., & Breggin,P. R. College stu- Urnbarger, C. C.,Dalsimer, J. S., Morrison, Grune & Stratton,1962. dents in a mentalhospital. New York: 7 PILOT PROJECTS IN TRAINING MENTAL HEALTH COUNSELORS

Margaret J. Rioch The Washington School of Psychiatry

In 1958 when the projects described in this chapter were first envisioned, community psychiatry had not yet become a popular concept. But a trend in the mental health field towardthinking in terms larger than individual problems had long been operating in people's minds, even when it was not fully conscious. In line with this trend, the Pilot Projects inTraining Mental Health Counselors attempted to demonstrate that two large-scale community problems brought together could help to solve each other. When we think in community terms, we are awarethat no problem is isolated and that the solution of one problem may bring about even greater difficulties in some other area. In one sense this is unavoidable and apparently inherent in human society, which seems to have within itself some built-in obstacles to attaining Utopia. But in a less fundamental sense, it is avoidable. Weneed not and should not concentrate on the solution of one problem inisolatioi, without regard to the consequences in other areas. For example, it is conceivable that we might solve the shortage of mental health professionals by making this field so attractive that all the people who would ordinarily go into general medicine, nursing, teaching, etc. would become psychiatrists, psychologists, and socialworkers. Obviously this would not be a boon to society. Even the legitimate recruitmentof college students to go into psychology and of medical students to go intopsychiatry could be looked upe-1 as increasing the shortage of teachers and general practitioners, arid thus not helpful in the solution of the community's total problem.If we could find a reservoir of manpower which is not at present exploited, then we should be paying Paulwithout robbing Peter. Women in general, and mature women in particular, represent one ofthe chief underused groups in the labor market of the United States. Although large numbers of women are employed, they occupythe lower-level jobs in the labor force. This may be appropriate for some, and in accordance with their education and skills, but it is a gross waste of the talents of others. In recent years the idea of "second careers" for wotien has become in-

110 PROJECTS IN TRAINING MENTAL HEALTH COUNSELORS 111 creasingly popular. While keeping in mind that all students should notbe forced into the same mold, those responsible for the education of women are aware that the majority ofgirls want first and foremost to marry and have children; and this is usually their first career. But also, and especially if they are of above; ^,nrageintelligence, they want something else. They want it particularly after the children no longer provide them with a full-time job and a reason for existence. At this time in their lives they are ready psychologically for a second career. But more likely than not, their way to itis strewn with obstacles. They have not beenadequately prepared for this phase of their lives. Most young girls tend to overlook the fact that they will probably live beyond the age of thirty and that they will probably outlive their husbands by about seven years. Thus they are often taken off balance by the psychological "change of life" which occurs when the center of interest which has been occupied for fifteen years or so by small children is left unoccupied. They are ill prepared for the kind of mild depression and sense of worthless- ness which settles in when they arefaced with a good chance of forty more years of life and not enough work todo to fill each day. To be sure, there are ways of curing or obscuring thisdepression. There are trips, clubs, hob- bies, volunteer activities, and grandchildren. These are fine if they work. Women who are particularly vulnerable to this kind of depression are not necessarily the neurotic type. They may be intelligent, competent, healthy, and energetic. When their abilities are not being used to the full, they suffer as anyone suffers who does not find an appropriate outletfor his talents. typical woman of this kind married early, before she got any specialized training or work experience in a field that might represent a long-term interest. Or perhaps she did have training, for example, in biology. After fifteen years out of the field, she feels rusty and unable to compete with young people fresh from school. Or perhaps, and this is a frequent phenomenon, her interests have shifted in the fifteen years of preoccupation with family affairs from biology to interpersonal relationships. -What is she to do then? If women like this could be mobilized to use their full energies and capacities in the mental health field without having to spend an inordinate and discouraging length of time in preparation, we should have a significant addition to the manpower pool and at the same time a marked increase in the health and welfare of the women themselves. There might even be a few men who in their forties found that they were in the wrongjobs. If they could afford to do it financially, they might be happier to switch over to the mental health field. There would probably be only a small number of men who would have the inclination, the talent, and the financial security to do this. But there is a very large number of mature women who have all three. In addition they have the advantage of their life experience in the field of human relations. If they have had their eyes open at all, they have had the equivalent of several courses in child development, to say nothing of family dynamics and the problems of adolescence. This does not mean that their 112 COMMUNITY PROGRAMS AND NEW SOURCES OFMANPOWER knowledge is optimally usable without training. But itdoes mean that they start with atremendous advantage on the experience side of theledger over the young student who has to gain hisknowledge by less intimate, less constant, and less participantobservation. The question is sometimes asked why shouldspecial programs be set up for suchwomen? It may be agreed that they represent anexcellent reservoir of manpower, but why not encouragethem to go into one of the traditional professions, in particular social work, sincethat is the one which requires the least number of postgraduate years tocomplete? The answer to this question is twofold. First, traditionalprofessional training programs, until very recently, havepreferred the young student just out of college to the mature woman who has notheld a job or taken a course for the pastfifteen years. Traditional traininghas been difficult for the mature woman to obtain, even whenshe sought it vigorously, and itis still not always open to her. Second, she has often been reluctant to seek it e--.-.ven when she wasready and eager to do something with her talents. '1.!e ,,o1,3 for this arecomplex. One very practical reason is the requirement :most traditional professional training programs of at least one year offull-time work. The women with whom we are concerned do continue to havedomestic responsibilities of varying degrees. Their children are often still living athome, even though they spend most of their days in school. If the mther tries tohandle a full- time course of study with littledomestic help, she ..vay find that her energies are too depleted tofill the decreasing but still present emotional and practical needs of her children, to say nothing of those ofher husband. This is something which varies enormously with individual women andthe individual situation. Some are so efficient or so blessed with cooperativehusbands and able domestic help that it is no hardship to study orwork full time. They should by all means do so. But many, many others whocould give a generous half time find the requirement of full time more thanthey can carry. Another reason has to do with the educational prerequisites ofthe traditional training programs. These include a bachelor'sdegree and sometimes particular undergraduate courses. There are many mature womenwho either did not attend or did not finish college who are today asalert and as well educated in a general sense as are their contemporaries who did.They are often children of the depression. If there was any money left forcollege tuition, it was for the boys of the family. With early marriages we arebuilding up again, fordifferent reasons, a large number of women who did not graduate from college but who, at around age thirty-five, will be lookingfor interesting work but without the formal prerequisitesfor entering traditional graduate training. Faced with the prospect of four years or moreof study, much of which she finds dull and irrelevant to her purposes,the mature woman often decides thatlife is too short to spend such a large proportion of it in preparation for a new career. A third reason for reluctance on the part of the mature woman to enter PROJECTS IN TRAINING MENTALHEALTH COUNSELORS 113 traditional training is her recognition that she is outof practice in ordinary academic work and that she will be competingwith bright youngsters who are very much inthe groove and know about the latest theories orthe latest experiments. It is not uncommon that womenwith excellent grades in college and excellent capacities for mature graduatework do badly on the graduate record examination. It is still less uncommon thatthey fear they will do badly. There are two seemingly opposite, but closelyrelated, attitudes which women express about goingback to school after a fifteen-year pause. One is an attitude of fearful timidity and apprehension about notbeing able to keep up. The other is an attitude of superiority to the ritualisticrequirements that are not strictly relevant to whatis necessary for the tasks they want tounder- take. Young students gripe about rigid requirementswhich seem to have as their purpose nothing but being part of anobstacle race on the way to high grades and diplomas, but they are used to themand grumblingly they plough through them. Mature women who have enjoyed aplace of importance and authority in the family and of prestige in the community,through either their husbands' positions or their own volunteer activities, arereluctant to put themselves in the position of having to do whatever teacher says,especially when they consider it stupid. Thus, many women continuein tasks which use only a quarterof themselves rather than risk the humiliationof failure or of subservience.It is easy to object that such women are cowardly orlazy or both and that theywould be no great addition to the mental healthfield. In the extreme case this is true. But there are many, manypeople in whom these factors operate just sufficiently to keep them awayfrom the competitive professional schools but not to such a degree that theireffectiveness would be impaired. In fact, a touch of timidity andself-doubt, a touch of refusal to follow rules for the sakeof rules, are qualities which may be quite desirable in a counselor or therapist. For all these reasons, then, itis important to establish nontraditional programs which will train mature women(and perhaps others as well) in a minimum of time to do the jobs which need tobe done in the mental health field. The two nontraditional pilot projects to be described heretrained a total of sixteen women to be "Mental Health Counselors."This .designation did not fill any of those responsiblefor the ptojects with enthusiasm, but no one could think of anything better. The term seemed to have theadvantage that it could be an umbrella, applicable to manyspecial kinds of counselors and to varying degrees of competence. In 1960 the first Pilot Project in Training MentalHealth Counselors was begun at theNational Institute of Mental Health (Rioch, Elkes, & Flint, 1965). The two principal investigators were Dr.Charmian Elkes and the present author. Dr. Arden A. Flint wasalso a major participant in the program. The project was anexperiment to determine whether and to what extent mature, intelligent womenwith no previous special preparation could NEW SOURCES OF MANPOWER 114 COMMUNITY PROGRAMS AND be expected to do therapeuticinterviewing after two yearsof part-time training. There would havebeen no need to demonstratethat they could be kindly into hospital visitors. The question was,what would they do if they were sent members, a mentalhealth agency to work, likethe other professional staff inability to with people who complain of anxiety,depression, compulsions, or words, could they study, hold a job, marry, or getalong with anyone? In other take responsibility for workingtherapeutically with patients whohad already found the advice and comfortof friends and family tobe insufficient and who needed more professionalhelp? The project staff did not sufferunder the illusion that in lessthan two years of trainingthey could turn out full-fledgedall round psychotherapists equipped to deal with any andall psychiatric problems.The idea was that we could train maturepeople in a short time to dealwith a selected population. While giving a broadbasis of understanding ofpsychodynamic principles, we would limit ourselves inpractice to one kind of patient,for example, determining factors in the to one age group.If there had been no special situation in which we foundourselves as a staff, we might havethought of training for work withchildren, or with physicallyhandicapped people, or with young parents, or with anynumber of other groups ofpeople characterized by a particular age or,ituation or kind of problem.As a matter of fact, we were limited first, by our ownexperience and interestsand second, by the external situation.Our first thought was to train forcounseling with college students. This seemed like arelatively easy task, appropriate to afirst experiment. If we had been in auniversity setting, this mightindeed have been the best way to begin. Butgeographical and transportationfactors made it difficult for many collegestudents to visit the NIMHOutpatient Clinic. We persisted in our intention to concentrate onadolescents, however, and broadened our intake requirements toinclude high school students.Since in the case of these youngerpatients, the parents usuallyeither had to be seen or wanted tobe seen, we soon had a caseload of middle-aged people along with the younger ones.Other adults also made use ofthe service. Thus, without actually intending it, webroadened the scope of our experiment to include a very wide age rangefrom fourteen to sixty. We also had in mind in thebeginning to limit the patients tothose with minor emotional disorders. Butthis, too, turned out to beunrealistic and impossible. Patients with minordisorders are hard to find. Those whosought out our services atthe NIMH Outpatient Clinicpresented by and large quite serious problems. Wedid attempt to screen out those who wereovertly psychotic, or suicidal, and those whoacted out in grossly antisocial ways.But in the agencies in which thestudents were placed for part of theirtraining, we had no real control over theselection of patients, and even very extreme cases wereoccasionally encountered. Thediagnoses of the patients seen under our ownsupervision ranged from"adjustment reaction of adolescence" to "borderline schizophrenia" and"psychosis in remission." PROJECTS IN TRAINING MENTAL HEALTH COUNSELORS 115 A third kind of specialization which we had thought to impose upon our students was that we did not intend them tobe diagnosticians or to do intake interviews. At NIMH one of the staff consistently saw all patients initially. But, again, in some of the community placements, initial interviewing was part of the students' job; and we therefore gave someconsideration to this in the course work of the second year. The experiment was designed, then, to show whether and to what extent mature women could be trained within two years,less than full time, to function as psychotherapists in certain limited situations. The limitations which we envisioned in the beginning were widened considerably beforethe program was over. At the end of the trainingperiod, the question was wl- they could work adequately under supervision as therapists in mentalheaah agencies such as community clinics with adolescent and adult outpatients. There was one limitation in the experience and training of ourstudents which was not mentioned in any of our published reports on the project.This was the fact that most of the patients seenby our trainees during their training period were middle-class people from suburban Maryland orfrom the almost suburban areas of the District of Columbia. This was notconsistently the case. Some of the students worked for a time in agencies dealing primarily with the underprivileged, such as the Juvenile Court and theFederal Probation Service in the District of Columbia. A few peopleof minimal educational and occupational level found their way to the clinicswhere the students worked. But these were the exception rather than therule. In our reporting of the numbers of patients, their ages, diagnoses, etc.,nothing was included about class orientation. This is an interesting omission.It did not occur to any of us onthe staff to make particular note of this factor or to consider its significance in the monograph which we wrote together.Today, only three years after the project was written up, it wouldbe impossible to overlook this. In retrospect it seems that in this oversight wefailed to mention one of the factorswhich contributed to the success of the program. We of the staff were a middle-class group working with middle-classstudents who were working by and large with middle-class patients. Theprincipal instructors in the program had had most of their own experience withmiddle-class patients. We were teaching a very homogeneous group of students to work in a very familiar world, the world which we ourselves knew best. To what extent this limitation can be overcome is a matter for further experimentation. It was explored to some extent in the second pilot project in training mature women. The second pilot project, begun in February, 1964, and completed in February, 1966, used similar students but in a different task. The question here was whether mature, intelligent women could be trained in two years to counsel effectively with mothersof young children. The task was envisioned as a preventive one. If emotional problems could be nipped in the bud in infancy or early childhood, there should be less trouble for allconcerned later on. Whereas the middle-class mother has the pediatrician, the child. 116 COMMUNITY PROGRAMS AND NEW SOURCES OF MANPOWER psychiatrist, the nursery school teacher, and other experts all within her ken and within her reach, the lower-class mother is often without resources for information and counsel. The idea of using the experience and talents of women like those in our first project,augmented by training, to produce counselors with a specialty in Child Development who would work primarily with underprivileged mothers originated with Dr. Reginald Lourie, Chief of Psychiatry in the D.C. Children's Hospital. Under an NIMH grant, the D.C. Children's Hospital Research Foundation and the Bureau of Maternal and Child Health of the D.C. Department of Health sponsored a second two-year training program with Dr. Lourie as Director and the present author as Project Administrator.' ExecutiveTraining Director was Mrs. Margaret Stolzenbach, one of the graduates of the first pilot project. Recruitment and selection procedures in both projects followed similar patterns. Community leaders, women's associations, PTAs,church groups, college clubs, and other organizations were informed that the programs were about to take place. Potential applicants were warned that these were experimental programs with no assurance of future employment, even if the training were successfully completed.In spite of this, there were approximately fifty serious applicants for the first pr-ject and one hundred for the second. Recruitment was by far the easiest aspect of both projects and demonstrated that programs of this nature fill a real need on the part of a large number of women. Selection was a more difficult task. In both projects eight students were to be selected. This number proved to be a good one for forming a groupand did not make excessive demands on staff supervisory time. In both projects the people chiefly responsible for selection were also instructors in the program. We found this to be desirable in that the students thus selected were likely to be congenial with their instructors. Furthermore, the instructors felt a special responsibility for those whom they had themselves selected. In both programs the instructors were well satisfied with the students. There is no way of knowing, however, whether the chosen candidates were actually the best of the applicants. In both programs each applicant was required to write an autobiography of about 1,500 words, in which she was to tell not only the major facts of her life but also how she saw her own development. She was then required to participate in some group procedures. This meant that groups of eight to ten applicants assembled to spend four or five hours with two or three staff members, who observed the applicants as they discussed several topics and asked whatever questions they liked about the program. One task required of each

I Dr. Samuel Schwartz, Chief of the Bureau of Maternal and Child Health of the D.C. Heahh Department was Co-Director of the project. Duting most of the first semester the project administrator was Mrs. Minerva Boomer, who withdrew from the program for personal reasons. The other major instructors were Dr.Hillary Millar and Dr. Allen Marans. 117 PROJECTS IN TRAININGMENTAL HEALTHCOUNSELORS and come up with a consensus. group was todiscuss a particular question which all had just lis- Another was to discuss atape-recorded interview to the suggestion of one tened. In the second project atask was introduced at be both enlightening tothe of the graduates ofthe first which proved to discuss how they would observers and helpful tothe applicants. This was to rejected. They all knew think and feel and whatthey would do if they were and the task that the great majorityof applicants wasbound to be rejected, feelings about this. It also provided them w:th anopportunity to air their kind and degree of provided the observers with anopportunity to see the defensiveness which eachapplicant showe0. sessions it was possible On the basis of theautobiography and the group The others were seen inindividual to eliminate overhalf of the applicants. occasions. In the interviews, usually by twodifferent interviewers on separate These were omitted in first project we alsoadministered psychological tests. add sufficiently to theother the second projectbecause they did not seem to required for their admin- techniques to warrant thelarge investment in time istration and adequateinterpretation. individual interviews not The group meetingsheld in advance of any subsequent only saved time ineliminating many applicantsbut also made the the individ- individual interviews moremeaningful. The candidates came to already had some ual interviews not as strangers,but as people who :tad important to contact withthe interviewer.Furthermore, it was particularly because during know how these potentialstudents would function in a group deal and because theirbehavior the training theywould be together a great being able with co-workers incommunity settingswould be crucial in their to functioneffectively. kind of person. We In both programs we werelooking for the same school and whose wanted a woman whose youngestchild was already in potentially family was willing tohave her become involvedin what would necessarily imply full-time become a new career, eventhough it would not schedule flexibly work. We asked specificallythat applicants be able to We twenty hours aweek outside theirhomes during the training years. stable so that the training needed women whosefamilies were geographically We wanted would be completed and some1"....Alow-up could be carried out. people of good generalintelligence who werewell-informed, conscientious, well with others. We looked reliable, reasonably stable,and able to get along with a sense especially for those who wereundefensive and unpretentious, concerned with where or how for psychological subleties.We were very little they had obtained theirformal schooling. the In both programs the average ageof the successful candidates2 at first project were JaneDonner, Anita Gamson, Leslie Hoge- 2 The students in the Showalter, Margaret Stolzen- boom, Mabel Mango, MargaretReid, Alison Sharpe, Lois second project were CarolineBirnberg, Elizabeth Harper, bach. The students in the Schulman, Shirley Seeman, Margaret Howard, HelenLarson, Ann Salzman, Joanne Minna West. 118 COMMUNITY PROGRAMS AND NEW SOURCES OF MANPOWER time of selection was between forty and forty-four. One was widowed; all the others were living with their husbands. All had children; the average number was between two and three. Their husbands were all either professionals, executives, or in upper management. Four of the candidates in the first group and three in the second had had more than two years of psychoanalysis or psychotherapy. Six in the first group and all eight in the second had had previous paid employment. The students in both programs were from quite similar middle-class backgrounds, but there was one difference in formai educational level. In the first project all the students were college graduates; three had advanced degrees. In the second, three of the eight had begun but had not finished college; one had an advanced degree. In the first project it had not been our considered policy to reject noncollege graduates. It had simply happened that the applicants whom we thought to be the best ones for our purposes all had bachelor's degrees. It did turn out to be an advantage in seeking placements and employment for them to be able to say that they were all college graduates, since this not only filled certain bureaucratic requirements but also carried with it the implication of a certain level of intelligence and sophistication. In the second project we again had no fixed policy, but we did welcome the opportunity to test our hypothesis that a bachelor's degree is not a necessary requirement for excellent performance in this field. The three students who had not finished college had more than made up for their lack of formal education by wide reading and inquiring attitudes, so that they were not distinguishable from the others in degree of intelligence, sophistication, or general information. During the training period the differences in number of years of schooling were quite irrelevant; in relation to employment it became another matter. The two projects will be discussed separately with regard to training and subsequent employment, since the pattern and purpose were different for each. In the first project the training program consisted of practical work and supervision at the National Institute of Mental Health; practical work and supervision in community agencies such as mental health clinirs; observation of individual, family, and group therapy; lectures and seminars. These last included courses on personality development, adolescence, family dynamics, and psychopathology, as well as practical case-seminars. The training was narrow but intensive. It was sharply focused on psychotherapy, and all other instruction was subsidiary and related to this focus. This differentiates it from training for social work, psychology, and psychiatry. Members of all these three professions engage in psychotherapy, but their education includes many other things. Our training was focused on this one goal. We did not try to make any sharp, or evendull, distinction between psychotherapy and counseling, but we tried to help our students to respond authentically and therapeutically without reference to any particular system 119 PROJECTS IN TRAINING MENTALHEALTH COUNSELORS and to go as far as they could go inunderstanding the patient and thedynam- ics of the therapeuticrelationship. The students were taughtexplicitly that there is no one right way to dotherapy since it is an integral functionof each one's personality. They were alsotaught explicitly and allowed to seewith their own eyes and hear with their own earsthat their instructors were quite fallible and that they conducted interviewswhich were far from perfect.They could learn this by watching usthrough one-way screens and bylistening to tape-recorded interviews. One of theirinstructors, early in the program, gave them something of the flavor of acontinuing case-seminar byplaying for them and discussing with themrecorded interviews he washaving with an adolescent boy. This was a case which was notgoing well, and he purposely let them in on his puzzles andstruggles with a difficult patient.Participating in the program werepsychoanalysts, psychiatrists,psychologists, and social workers, all of whom thought indynamic terms anti held quitebroad, undog- matic points of view. No one was anevangelical disciple for a particular school of thought. Eleven peoplealtogether had some part in the instruction. This sounds like a huge staff but wasactually roughly the equivalent of two full-time people. Since we expected our students tobe primarily practitioners, itseemed to us obvious thatthe trairing should be firstand foremost practical. The actual work of interviewing , ganfor them within three weeksof the start of the program, before there wa3 anyformalized teaching of theory.We wanted them to build up their concepts onthe basis of concrete experienceand not to try to fit theirexperience into predigested concepts.We thought that an initial theoretical indoctrinationmight result in "psychologyzing" or auto- listen to each patient af, matic responses,whereas we wanted our students to a uniqueindividual rather than as a memberof a diagnostic classification. We wanted them especially tobe aware of their ownemotional reactions to the patients. Therefore, we putlittle stress on theory andpostponed any systematic teaching of it untilthe second year. It was part of our philosophy thatthe teaching was to benonteaching or unteaching. We were going toplunge the students into the watersof confrontation with another person andlet them find out for themselveshow to keep afloat. Swimming strokescould be perfected later andeach student was to have her choice as towhich stroke she would prefer.But there were going of to be plentyof observers around to rescueboth patient and student in case need. As a matter of fact, it neverhappened that a patient had to berescued from a student. The practical work of interviewingpatients, which was doneboth in the NIMH Outpatient Clinic and in variouscommunity agencies and institutions, was usually on aonce-a-week basis. All the interviews atNIMH and many in thecommunity placements weretape-recorded. This permitted the supervisors to know exactlywhat was going on; and in thebeginning, a part, at least, ofeach interview was listened to by oneof the instructors. Later on, 120 COMMUNITY PROGRAMS AND NEW SOURCES OF MANPOWER as the number of interviews by each student increased, thiswas obviously impossible; but throughout theprogram, the two principal instructors took home tapes and listened to themover weekends. Discussion of the tapes took place in both individual andgroup sessions. Taping occurred fvom the very beginning and was takenso much for granted that it almost seemed as if an interview was incomplete if itwere not taped and shared with fellow students or an :nstructor. The total program and the students in itwere evaluated in a number of different ways, of which onlytwo will be mentioned here. At the end of the first year two series of the students' tape-recordedinterviews were sent to be assessed by four raters from outside theWashington area who, without knowing anything about theprogram or the background of the trainees, agreed to do blind ratingson a five-point scale of the tape-recorded interviews and of the trainees' autocriticisms of the interviews.3The ratings averaged in the middle range of the scale, which representedsatisfactory performance. At the end of the secondyear a panel of three outside examiners was invited to come to the NIMH for three daysto evaluate the program. They were Dr. Lotte Bernstein, Director of the Child Guidance Clinic in Louis- ville, Kentucky, anda former member of the Berlin Psychoanalytic Group; Dr. Robert Gibson, Medical Director, Sheppardand Enoch Pratt Hospital, Towson, Maryland; and Dr. Julius Seeman, Professor ofPsychology, George Peabody College for Teachers in NashAlle, Tennessee.The examiners listened to a raped interview by each trainee, reada case report, and examined each one for aboutan hour. Each examination included role playing of a patient by Dr. Seeman, while the traineewas the therapist. The ratings of the trainees by the examinerswere gratifyingly high, as was also the degree of agreement among them. They stressed particularlyfive points. First, they were impressed by the degree ofcommitment to the work, which they felt to be greater in thisgroup than in the average professional group. Second, they found in thesewomen a striking lack of defensiveness which they attributed to the training. (We of the staffthought that this resulted in part from the early and consistentexposure of themselves to us and to each other through the discussion of thetape recordings and in part from our own exposure of ourselvesto them.) Third, they sussed what they feltto be a strong point in the training, namely that "it kickedover the traditional traces of giving a long string of academic work ahead of time and then buildingup to a little bit of practice." This program gave a great deal of practice first and latera little theory so that the trainees builtup their abstractions on the basis of concrete experience. Fourth, they thought that thewomen had a strong sense of group iden-

3 We are indebted to Drs. Roy R. Grinker, Jr., LeroyP. Levitt, and Melvin N. Seglin from the Michael Reese Hospital, Chicago, andto Miss Nea Norton, Assistant Professor of Psychiatry, Yale University, for their helpin this part of the evaluation. PROJECTS IN TRAINING MENTAL HEALTH COUNSELORS 121 tity which had served them so far and might continue todo so in place of a conventional professional "union card." Fifth, they were struck by a fact which the womenthemselves stressed, namely, that they did not have to rely on this program and ontheir success in it for their major sources of security eithereconomically or psychologically. They had their families and their places in the community quite apartfrom the success or failure of the project. This seemed to everyone tobe an advantage. Immediately upon graduation every one of the students wasoffered at least one job. Most of them were in agencies or institutions inwhich they had had placements during the training period. Duringthe first year, four were employed in mentalhealth clinics; two in hospitals; one in a school; one in a college. All wereengaged in therapeutic interviewing of patients. Since then, five have changed to other jobs which were moredesirable in terms of money, location, orkind of work. In March, 1966, almost four years after theirgraduation, all eight of the original students are still employed in the greaterWashington area. All are working at least half time; six are working full time. Five areemployed in a mental health clinic or center; one on an NIMHexperimental ward; one in a universitycounseling center; one in a college. Most of them, encouraged and often urged by thc agencies where they areemployed, have broadened their spheres of activity. To their original training inindividual therapy with adolescents and adults, they have added group therapy and childtherapy, intake work, administration, teaching, and consultation.Most of them have participated in workshops and institutes or taken courses to increase their knowledge and skills. Their salaries are considerably higher than when they began at a full-time rate of $5,000 a year. They are valued members of the professional staffs in the agencies in which they work. A three-year follow-up study carried out by Drs. ThomasMagoon, Stuart Golann, and their co-workers from the University of Maryland gave a generally very favorable picture of the counselors as they were seenby employers, supervisors, and co-workers in their places of employment(Golann, Breiter, & Magoon, 1966; Magoon & Golann, 1966).4 The second project, as envisioned bv Dr. Lourie, had a different taskand a different area of specialization. The groupof people with whom the trainees were to counsel were to be mothers, and sometimesfathers, of young children,

4 This study will be reported in detail in a monograph which is in the processof publication. Partial reports were made at the Annual Meetings of the American Psycho- logical Association and are abstracted in the following issues of the American Psycho lo- gist: Vol. 18, 1963, p. 404 (a): "Non-traditionally TrainedCounselorsPsychotherapists Their Training, Employment Progress and Perceived Employability"; Vol. 19, 1964, p. 567 (a): "Evaluation of MentalHealth Counselors after Two Years of Employment and Implications for Counseling Psychology"; Vol. 20, 1965, p. 525(a); "Employment Progress of Non-traditionally Trained Psychotherapists: Three Years ofFollow-up Eval- uations." 122 COMMUNITY PROGRAMS AND NEW SOURCES OFMANPOWER especially preschool children. They were to be primarily from theunder- privileged parts of the community. The goal of the work was to be prevention. The settings in which the work was to take place were tobe first and foremost the child health clinics of theDistrict of Columbia to which mothers bring their children for routine immunization and generalcheckups. Other situations in which mothers of young children gather werealso to be used, such as nursery schools or day-care centers. These settings are notmental health clinics where people come asking for help with theiremotional problems. The job of the counselor in such settings is a different onefrom that of the therapist in the mental health clinic. The area ofspecialized knowledge of the counselors in the new project was to be that of childdevelopment, and during their training they were called Child Development Counselors. The major difficulty in this program was thedefinition of just what the counselors were to do. Definition is a difficult matter altogether inthe mental health field. In the first project we avoided it as much aspossible. But it was possible to demonstrate to the students by example what they wereexpected to do. They had ample opportunity tofind out by observing through one-way screens and by listening to tapeswhat experienced therapists did. While they learned in this way that no therapist is perfect, they also found somelive models which served a useful purpose for as long as they wereneeded. In the child health clinics of the District ofColumbia no one was doing the kind of counseling we were asking ourstudents to do. Occasionally they were able toobserve at Children's Hospital a competent andexperienced pediatrician examine a baby, interview the mother, and talk withher about the baby's developmental difficulties. They found this helpful to adegree but, as they were quick to point out,they were not in the position of the pediatrician, who started with an examination of theinfant and went on to intersperse medical advice with questions regarding thetotal family situation. In the child health clinics the pediatriciansand nurses were too busy with their large caseloads and their own specific roles tohave time to do the kind of counseling we wanted our trainees tolearn. This was in fact the reason why the project had been started. There was a needfor someone to listen to and offer counsel to the mothers in these clinics, butthe traditional personnel had neither the time nor the training to do this. The trainees inthe second project not only had to learn a skill which was new tothem but had to forge a place for themselvesand create a role which was new in the settings in which they worked. At the same time they had to learn the language of peoplewho came from a background quite different from their own. They werefaced with problems which were not the ones with which they were familiar intheir own families and in those of their neighbors, namely, the problems of dire poverty anu familydisruption. Good advice about techniques of feeding, weaning, toilet training, etc. often seemed meaningless when the family wasabout to 123 PROJECTS IN TRAININGMENTAL HEALTHCOUNSELORS children in one family, be evicted or when noneof the various fathers of six all under eight yearsold, was to be found to payfor the groceries. the lack of Another source of frustrationwhich the students met was understanding of what they werethere for which theyencountered initially While this was on the partof both patients and someof the clinic personnel. in spite far from true in all cases, it wasin some, especiallyin the beginning, of efforts on the part of thestaff to smooth the wayfor the students. discouraged and that thetask of It was little wonder thatthe trainees felt than in the first training and learning was adifficult one, more difficult the course to thesatisfaction project. Neverthelessall eight women completed they did not knowwhat of their instructors. Havingcomplained bitterly that creating a valuedrole for they were doing, theynevertheless succeeded in themselves in the settings inwhich they were placed. middle-class people attempt- The fact that they andtheir instructors were and cultural ing to work chieflywith patients from adifferent socioeconomic overcome.But in the background presenteddifficulties which were not easy to be much more their two years' experiencethe students did come to course of with patients. In comfortable and much more competentin their contacts which the students inthe first other words, theylearned to do something however, have the practiceand acquire program did notlearn. They did not, that the students in thefirst the skills and experience inlong-term counseling project did. work in the first The two programs went indifferent directions. The explanation for the fact afforded greater immediatesatisfactions. This is one hours in practical workthan that the students on thefirst project put in more required of them, so that weconsidered the program tobe the equivalent was the of a year and a half ofgraduate work. On thesecond project we limited demonstrate that in total scheduled time to twentyhours a week in order to equivalent of one year ofgraduate work, two yearshalf-time, that is, in the specialty. This we couldtrain Mental HealthCounselors in a particular was, wethink, demonstrated. The training, as in the firstproject, was first andforemost practical. In the child health clinics, the second week the studentsbegan as observers in and in the fourth weekthey were interviewingand taking histories on new referred by the clinic mothers. Later on they sawmothers who were either initial contact in the waiting staff or who were invitedby them after some offices. The interviewsfocused room to continuethe discussion in their private factors, on a widevariety of topics. In over onehalf of them socioeconomic education, played a major such as lack of housing,clothing, employment, or Problems part. Marital orother family discord was afrequent complaint. centering on childrenincluded physical complaintssuch as malnutrition; school perform- psychological difficulties,including mental retardation or poor overdependency, ance inolder children; emotionaland social problems such as of "badness." The overaggressiveness, fearfulness,and a frequent complaint 124 COMMUNITY PROGRAMS AND NEWSOURCES OF MANPOWER trainees found that one of theirchief functions was that of referral to appropriate agencies for further help.These included psychiatric clinics; but more often they were welfare agencies orclinics for special disabilities, such as speech or hearing. While keeping inmind that their goal was preventionof future mentaJ and emotional disorders inthe young preschool children, the trainees found themselves facedwith such urgent social andemotional problems in the parents and older childrenthat these often had to be dealtwith before either the mother or the counselorcould be free to think of the much less pressing problems of the infant ortwo-year-old, which the mothers often did not even perceive to be present.Some of their instructors emphasized the need for concentration on the areaof child development. Others encouraged them to handle whatever problems arose tothe extent that they could. Most of the mothers interviewed in theclinics were seen by the trainees only once. As time went on those studentswho had been fortunate enough to be assigned for two years tq ttj :. sameclinic began to build up a "caseload" of people who came back to themeither in connection with thechild's next routine visit or, on special occasions,without the child for the purpose of continuing the counseling interviews.It is clear that from these casesthe trainees derived their greatestgratification. And it is from these cases, too, that we have some idea of how much impactthe counselors had. In addition co the practical work in thechild health clinics which constituted the backbone of the program,the trainees had other field placementsin the second, third, and fourth semesters.These included two semesters for each trainee in a nursery schoolobserving children, counseling withmothers who requested it, and consulting withteachers. Other placements in the fourth semester included maternityclinics, family and child service agencies, and neighborhood centers. In addition to the practical work, thetraining included case-seminars and individual supervision. Didactic courses,spread over the two years, covered quite thoroughly the areas of normalchild development, physical and psychosocial, with special stress on the early years;general personality development reaching intoadulthood and including deviations fromthe normal; community resource and backgroundstudies of the District of Columbia. Briefer courses touched lightly upon manyspecial topics; for example, mental retardation, family dynamics, techniquesof school consultation, psychological testing, prenatal care, and frequentlyencountered medical problems of young children. It is clear that the students :n this program weresubjected to many pulls and tugs from both patients and staff.They often protested vigorously. At the end of the two-year trainingperiod they demonstrated a remarkably flexible, practical approach to the problemswhich they encountered. They were not much concernedabout what may be considered to be the propertech- niques of interviewing. They were veryalert to see what works and what does not and to learn fromexperience. Since they knew thatthey would be limited I COUNSELORS 125 PROJECTS IN TRAININGMENTAL HEALTH they acquired a greatdeal to not morethan a few sessionswith each patient, single interview.They learned not of skill in makingmeaningful contacts in a interventions which went tothe heart of thepatients' to wastetime, to risk worries, and to concentrateon onesignificant area. the training period toevaluate the No attempt wasmade at the end of first of all thepractical students as it wasdone in the firstproject. There was recordings in theclinics so that this reasonthat we wereunable to get tape Even more important wasthe awareness on avenue ofevaluation was closed. that there is nomodel by which tojudge these students' the part of the staff they have had performance. There is no wayto assessadequately the effects indeed be asking toomuch even of anexperi- upontheir patients. It would brand new situationworking only enced professional toproduce results in a left the formalevaluation week in each setting.We have, therefore, one day a employed.5 We can when the studentwill actually be for the next years clinics in whichthe that the physicians incharge of the report, however, unanimous in theirapprecia- trainees workedduring their last semester were rendered. All ofthem wished thatthe tion of the servicesthe trainees had They be assigned to them asfullledged counselors. trainees could continue to of individual their understandingof the variety werealso discriminating in the nursery which the eight traineesdemonstrated. Further, styles and gifts earlier in the program school teachers towhom the studentshad been assigned competently and usefullyin observ- agreed that the traineeshad all performed ing children andcounseling with mothers. in March,1966, as Mental Seven of the graduatesstarted work part time the Washington,D.C. Health Counselors inthe Bureau ofMental Health of child health clinicsand other centers Health Department.They will work in continue to findfor themselvesthe where they will counselwith mothers and One of the sevenaccepted a second best ways in whichthey can function. Two otherscontinued train- part-time job as acounselor in a day-care center. useful as employees.The agencies which maylater find them ing part time in Baby Clinic Mental HealthCounselor in the Well eighth was employed as a few years of Hospital. It seems to uslikely that after a of the Children's teaching, consulting, clink:al experience these womenwill find themselves well as counseling. and administering, as the matter of their In arranging forthe employmentof these trainees became an acuteproblem. They were formal education priorto the project service system,which has its owncategories. to beemployed in the civil counselors in child staff thought thatcompetence as Although the project positively nor nega- development in this groupof eight wascorrelated neither the requirements ofthe system made tively with yearsof formal schooling, much simpler thanof those without. hiring of those withbachelor's degrees could be hired atall came the Along with the questionof whether they stuart Golann, Ph.D.,of the University of ri This evaluationwill be carried on by Maryland and hisco-workers. AND NEW SOURCESOF MANPOWER 126 COMMUNITY PROGRAMS emotional question of whetherthey could be hired atthe same grade. The be imagined but is notin itself stress which thiscaused in the group can that they could all important. They allsurvived the strain. The decision was full time) and the same have the same salary(approximately $5,000 per year grade (5), but those withdegrees would be classifiedin the professional ll expected to do the series; those without,would not. They are,however, large same kindof job. It is no doubtimpossible to create any system on a scale, like the civil service,which will be just to allindividuals. The experiment demonstratedthat a college degree is not a necessary had prerequisite for training as aMental Health Counselor.The trainees who those only one or two y ears ofcollege were as active andfull participants as with some graduate work.From the point of viewof function, graduation of fitting into the from college is an irrelevantfact; from the point of view existing system, thediscrepancies in formalschooling created considerable difficulty. trainees as profes- The official classificationof at least five of the eight satisfaction to the staff sionals in the civil service systemhas been a source of that their students were of both projects, whohave consistently maintained being trained not astechnicians or subprofessionals,but as professionals. By students were exposed to a variety this we meant that inboth programs the them ultimately to find of theories and practiceswith the purpose of helping according to a their own way. They were notexpected to follow directions high standards of ethics andof inde- set method.They were to adhere to pendence of thought.There need be no fear thatthese trainees will uncriti- untried practices. Typical cally and gullibly go alongwith unsound theories or of all of them is the commentof one who, havingattended a large profes- claims for various thera- sional meeting, notedthat mutually contradictory dogmatism, one just down the peutic techniques werebeing made with equal field for so many hall from the other. Shewondered Inw people could be in a years withoutrealizing the unsoundness ofsuch oversimplified statements. training of The program just describedhave often been referred to as nonprofessionals. If lay persons, or ofvolunteers, or of subprofessionals or they have contributed to aninterest in the greater useand development of their authors. But people in these categories, itis a source of satisfaction to this task. They have the programs themselveshave not been devoted to While we experi- addressed themselves to theshortages at and near the top. tech- ment with the useof the indigenous worker,the teacher's aide, and the nicians of various kinds, weshould not forget thatthere is an equally great need to add to our supply oftrained "first-rate heartsand minds to guide our 284). We have learned atlast ever morecomplex society" (Michael, 1965, p. when there is little or no by turning our attention tothe underprivileged that opportunity, there will belittle or no ambition, thatwhen there is no outlet The same is true for the for the use of skills, the skillswill not be developed. capacity for intellectual and emo- mature womanwith her largely unused 127 MENTAL HEALTHCOUNSELORS PROJECTS INTRAINING the work onboth pro- deeply gratifyingaspect of tional growth.The really the students. (I significantdevelopment in grams wasthe facilitation jobs at aprofessional have demonstratedthat important The projects formal trainingthan is usually filled by superiorpeople with less level can be modifications of someaspectsof pres- have alsosuggested that required. They Mature womenrepresent a great professional training maybe desirable. ent for high level,nontraditional training. unexploited resourcethat is available guardians of our operating againsttheir use. Many But there arealso factors of peoplewho lack fear that shorter,nontraditional training present system require long,traditional prerequisites todo jobs which now the usual formal the destructionof will be an openingwedge leading to professional training fought. This is anunderstandable for whichthey have the high standards which claim, as ourshave claimed, to fear. Nontraditionaltraining programs their worth professionals at a highlevel must prove preparepeople to work as is done,and it safeguards againstmisuse. If this and must providetheir own short- offer a way toalleviate the manpower done, then such programs of can be field whileproviding an avenue age nearthe :op in themental health womenseeking second careers. growth anddevelopment to mature

REFERENCES the evalua- T. M. A filmedinterview applied to Colann, S., Breiter,D., & Magoon, 3, 21-24. health counselors.Psychotherapy, 1966, tion of mental Nontraditionally trained womenasmental health Magoon, T. M., &Golan, S. E. 44, 788-793. Personnel andGuidance J., 1966, counselors/psychotherapists. Inst. Planners, the rationalizedsociety, J. Amer. Michael, D.Urban policy in 1965, 31, 283-288. of mentalhealth pilot Elkes, C., &Flint, A. A.National institute Rioch, M. J., counselors. Washington,D.C.: U.S. Dept. project in trainingmental health Sew. Public.No. 1254, 1965. of H.E.W.,Public Health NEW MANPOWER FORMENTAL HOSPITAL SERVICE'

Richard Sanders Philadelphia State Hospital

INTRODUCTION

There is a continuing and growingshortage of professional manpower for mentalhealth services. Public acceptance of mentalhealth services has increased to the pointwhere a larger proportion of the population is now seeking help. The ManhattanStudy (Srole, Langner, Michael, Op ler, & Rennie, 1962) indicates that an even greaterproportion is in need of help. The shortage of professional mentalhealth personnel becomes critical when considered in terms of the rapid rate ofpopulation growth and the anticipated population explosion. Indeed, even nowthe manpower shortage is so great as to result in grossdeficiencies in mental health services. George Albee (1959) in his study ofMental Health Manpower Trends relates the shortage in mental health manpower tothe shortages in professional manpower in general. He contendsthat our system of secondaryand higher education fails to stimulate sufficientnumbers of bright young people to seek professional careers.He attributes this to anti-intellectual,anti-educational, and antiprofessional social andcultural values. Our society rewards private initiative and individualenterprise. The makers and sellersof goods reap greaterfinancial rewards than those who offer aprofessional service. Not only are the rewards greater for the entrepreneurbut his investment of time in education is considerablyless, and he reaches high-level earningsmuch sooner. What then are the inducements to enterthe professions? When one considers that it takes twelve years ofpost-high school training to become a psychiatrist, ten or more years to become apsychologist, and seven years to become a social worker, it is understandablethat so few are sufficiently motivated to enter these mental healthprofessions. Furthermore, in view ofthe increasing competition between privateand public organizations for the 1 The author is indebted to BernardWeinman, Ph.D., for his critical review of the contents of this chapterand his help in preparation of the manuscript. 128 SERVICE 129 NEW MANPOWER FORMENTAL HOSPITAL that there will already short supplyof mental healthpersonnel, it seems never beenough manpower forpublic service. health field, cannot help The state hospital, the"stepchild" of the mental personnel. Low salariesand but be affected bythe scarcity of professional hospitals to compete forprofessional poor publicimage hardly help the state ethos in the mental personnel. So long ascustodialism was the prevailing Tradition- hospital, the need forprofessional personnel couldbe minimized. functions ally in state hospitals,professional penonnelfulfilled "gatekeeper" transfers, and discharges,while the nonprofessionals,the such as admissions, World attendants, carried out thebulk of the custodialfunctions. Following therapies War II, with the adventof the somatic, chemical,and psychological mentally ill, a demand and recognition of a morefavorable prognosis for the therapeutic regimens for patients.The was createdfor more humanistic and personnel, state hospital, inthe face of an alreadyshort supply of professional rehabilita- was illprepared to share in this newZeitgeist of more humanistic, tive services. In an effort to meet thepublic clamor for morehumanistic treatment, the therapeutic potential of itsleast costly state hospitalattempted to mobilize the attendant, however, is already and most availableemployeethe attendant. The that he has limited timeavailable so heavilyburdened wih custodial functions psychiatric aide work for therapeutic services.Furthermore, the rewards for are usually so poorthat those choosing this typeof employment have been This type of reported to be only marginallyemployable and poorly educated. background limits the degree to whichthese people can assimilateand apply invested in upgrad- specialized training. Althoughconsiderable effort is being therapeutic impact on the ing the training of theattendant to effect a greater fulfilling the patient, this caliber personneloffers limited hope of adequately therapeutic needs of the statemental hospital. population is to be Quite obviously, if thelarge institutionalized patient adequately treated, manpower mustbe drawn from sources otherthan existing function hospital personnel. These newpersonnel should not be expected to existing mental health pro- in the established,highly specialized roles of the fessions, but rather in newroles that will maximize thetherapeutic potential function and of the hospital. Theseroles, then, must cmcompass a treatment untreated must bedesigned to serve the largenumbers of patients currently and languishing in hospitalwards.

SOCIOENVIRONMENTAL THERAPY

A treatment approachwhich has been found tobe both promising and appropriate for thelarge state hospital populationis socioenvironmental stabilize patients in therapy. Unlike traditionalhospital care, which tends to designed to activate social custodial routines,socioenvironmental therapy is

! 130 COMMUNITY PROGRAMS AND NEW SOURCES OF MANPOWER behavior through democratic, humanistictreatment and interpersonal activities. Socioenvironmental therapy has its antecedents in the "total push"treatment introduced by Myerson (1939), the "therapeutic social club" and "situational therapy" of Bierer (1942, 1951, 1959), the "therapeutic community"as conceived by Jones (1953), the principles ofgroup treatment advanced by Bion (1961), and the application of these principlesto comprehensive hospital programs for psychotics by Greenblatt, York,and Brown (1955). Meyer- son stressed activation through forced participation in activities. Bierer attempted to restore the patient to social responsibility andcompetence through self-governing social groups and involvement in controlled social situations. Jones, working with sociopaths, extended the concept of the therapeutic social club to total community life. He emphasized democratic living, self- government, and confrontation with reality. Bion utilized group interaction and group forces as the therapeutic agents to effect productive behavior. Greenblatt demonstrated the therapeutic value of reorganizing the mental hospital and its wards in accord with social treatment principles. Socioen- vironmental therapy, today, consists of an extension of composites of these ideas applied to ward programs, day hospitals, open hospitals, and aftercare centers. In general, the reports on the effectiveness of such newly developed programs have been favorable.

SOCIOENVIRONMENTAL TREATMENT OF CHRONIC MENTAL PATIENTS For the past seven years the Psychology Department of the Philadel- phia State Hospital has been concerned with the development of socioenvironmental programs for chronic patients and with the evaluation of the therapeutic effectiveness of different forms of this treatment. In view of the characteristic isolation and withdrawal of chronic psychotics, social interaction was considered the major treatment variable. The social treatment programs designed to induce, augment, and manipulate appropriate social behavior included three major components, namely, a social milieu, rehabilitation skills and content, and a corrective experience. The social milieu, or therapeutic community, was established by modifying the physical environment of the state hospital to approximate that of the extramural community, changing staff attitudes to attaina more optimistic view of the chronic patients' potential for recovery, encouraging freecom- munication among patients and between patients and staff, introducingpa- tient social organizations to permit the emergence of spontaneous social behavior, and establishing patient government to permit patientsto be more instrumental in determining and managing their daily lives. The physical environment of the state hospitalwas changed to approximate more closely the extramural community. Patients were moved from large dormitory-type buildings to smaller buildings with privaterooms. Males were 131 HOSPITAL SERVICE NEW MANPOWERFOR MENTAL twenty-four private each cottagecontaining housed in threesmall cottages, den or game room.A large, private roomsserved as a rooms.One of these furnished with atelevision set in each cottage was comfortable living room issued a key tohis roomand had materials. Everypatient was housed in and reading of his room.Females were responsibility forthe daily care devoted to office complete ground floor ofwhich was larger, three-storybuilding, the and third floors a sleeping rooms onthe second for projectpersonnel. The slept two space had private rooms,while others varied in size sothat some patients thirty-six. There was alounge on bed capacity was to a room.The maximum shared by all another on theground floor.Both were the secondfloor, and were building. In mostrespectsthe accommodations patients residingin the "family style" in All patients wereserved meals similar to thosefor the males. maintained partiallyby the patients. dining halloperated and of both a hospital wasthe promulgation modification of the state therapeutic A second to theestablishment of a staff and patientattitudes conducive with the nursingpersonnel meetings wereheld regularly foster community. Staff These meetings weredesigned to immediately involvedin patient care. through social mental patientscould berehabilitated the attitudethat chronic oriented to assistpatients staff members were interaction. Atthese meetings, Among patients,the responsibility fortheir socialcommunity. in assuming community wasgenerated through responsibility fortheir social staff feeling of meetingsconducted by conferences andregularly held group individual prerequisite of atherapeuticcommunity ii members. In this manner,a major and staffwas patients andbetween patients free communicationamong attained. social livingsitua- development ofthe therapeutic A third factorin the The purposeof of a varietyof socialorganizations. tion wasthe initiation within which provide nondidacticsocial groups these organizationswas to attendance wasvol- could emerge.Accordingly, spontaneoussocial behavior regularly held meet- informal. Monthlyparties and untaryand participation Personal Grooming Model RailroadClub and a ings of socialclubs, such as a organization, theAlumni available to allpatients. Anadditional Club, were preparing toleave thehospital and both to patientswho were Club, was open This cluboffered afamiliar and those whohad alreadybeen discharged. of adjustment tothe during theirinitial period supportive groupfor patients almost ready encouragementfor patients extramural communityand afforded to leavethe hospital. wasthe developing thetherapeutic community A fourthinnovation in process to augmentthe resocialization patient government and by establishment of for cottagemanagement, the patientsthe responsibility Patients by granting for meetingthis responsibility. establishing themodes of interaction officers conducted officers and acouncil. Theexecutive elected executive discussion andaction. could bring upproblems for meetings, atwhich patients routine aspectsof the conductof the more Patients tookresponsibility for SOURCES OF MANPOWER 132 COMMUNITY PROGRAMS AND NEW cottage management such asthe organization of housekeepingdetails, scheduling of wake-up teams, andregulation and scheduling of the useof cottage facilities such as showers and television.Elections were held at sufficiently frequent intervals so that almost allpatients were able to becomeinvolved in leadership functions. Rehabilitation skills and content were provided in astructured group activity program, consisting of grouptasks varying from simple recreational pursuits to complex, community-centeredactivities. Training in the repertoireof social behaviors necessary for everydayliving was available in a special setof group activities.Through discussions, practice, and trips tothe community, patients were instructed in personalgrooming, preparation of meals, repairof clothing, budgeting, use of transportationand communication facilities, and other community resources. In addition,these activities also provided training in the basic requirernents ofinterpersonal relations, the essentialsof etiquette, meeting and interacting withpeople in new situations, and meansof dealing with interpersonal stress. A corrective experience was providedthroughout the program in individual counseling sessions, group activities,and daily life experiences.The emphasis was on providing pressure towardincreased interaction, reinforcing socially adaptive behavior, discouragingand modifying maladaptive behavior, and helping patients to develop moreappropriate ways of coming to grips with the problems of everyday living.To accomplish these goals, techniques which focus on the behavior of theindividual and/or the group processes were utilized. The results of the study of thetherapeutic efficacy of these programs (Sanders, Weinman, Smith, Smith,Kenny, & Fitzgerald, 1962; Sanders, Smith, & Weinman, 1967) indicatethat socioenvironmental treatmentdoes, indeed, improve the social functioningof most chronic patients and has particular utility for the older, morechronic patients who show morefavorable psychiatric adjustment and heightenedrelease rates as a consequence ofthis treatment

NEW PERSONNEL The question arises as to which typeof personnel should be trained to utilize the techniquesof social interaction therapy. Inthe Philadelphia State Hospital Project,2 personnel fromall hospital disciplines were trained to conduct social interaction therapy. Five yearsof experience in the training and evaluation of these personnel hasmade it clear that none of the existing disciplines is fully equipped to practice socialinteraction treatment without additional training. It is also apparent that afairly broad educational back- 2The programs to be described havebeen supported by two NIMH grants: OM- 126 Rehabilitation of the ChronicNP Patient: A Pilot Study (1958-1965);MH-8210 Training New Workers for SocialInteraction Therapy (1963-1968). 133 NEW MANPOWER FORMENTAL HOSPITALSERVICE and application ofthe ground is one prerequisitefor successful learning concepts ofsocial interaction therapy. understanding Social interactiontherapy has several requirements: an proficiency in the use of activityskills and group tasks of abnormal behavior, to interaction, knowledgeof the educational content necessary to stimulate familiarity reorient theinstitutionalized patienttoward extramural living, finally, the ability toutil- with the therapeutic aspectsof a social milieu, and behavior and ize group andindividual techniques tomodify maladaptive provide more adaptive waysof dealing withinterpersonal situations. good social therapists Per3onnel having thebackground for becoming disciplines of psychiatry,psychol- might be drawnfrom the already depleted and nursing, but theirrecruitment for ogy, socialwork, occupational therapy, would serve to deprive supplementary training insocial interaction therapy professional services. The most numerous patients of sorelyneeded 3pecialized aides. Although some personnel available are theattendants and the activity therapists, the majority is notof of these are uniquelysuited to become social a caliberappropriate for such trainingand service. In view of the apparentnecessity for a fairlybroad educational back- the col- ground as a prerequisite fortraining insocioenvironmental therapy, candidate for this training. lege graduate seems tobe the most suitable provide the Hopefully, he can betrained in a relativelyshort time period to socioenvironmental therapy. generalized therapeutic serviceswhich constitute long felt the need for new The Commonwealthof Pennsylvania has services. The use of therapeutic services and newpersonnel to provide such institutions was first college graduates as mentalhealth workers in state March, 1962. In June, explored in a TechnicalAssistance Conference in Department of Public Wel- 1962, the Director, Bureauof Mental Hospitals, State Hospital plan forrecruiting fare, approved theproposed Philadelphia treatment. InJuly, and training collegegraduates for socioenvironmental Psychology 1963, the NationalInstitute of MentalHealth awarded the approxi- Departmert of thePhiladelphia State Hospital agrant to train treatment tech- mately thirt, mental healthworkers in socioenvironmental 1964, after a train- niques. The training program wasunder way in January, had been determined,and the ing staff had beenselected, the course content six most qualifiedapplicants had beenappointed.

PROGRAM THE TRAINING I to orientcollege The following are thegoals of the training program: mental graduates, novices inthe mental healthfield, to mental illness and mental illness; to hospitals; to instill in themhumanitarian attitudes toward therapy; and train them in thespecial skills necessary forsocial interaction

i AND NEW SOURCESOF MANPOWER 134 COMMUNITY PROGRAMS with other mentalhealth disciplines finally, to preparethem to deal effectively of social interaction treatmentonhospital wards. in establishing programs attainment of thesegoals The training programdesigned to facilitate the Psychopathology, andTreat- includes five courses:Personality Theory, now Skills; and SocialInter- ment; GroupDynamics; SocialInstitutions; Activity action Therapy. Treatment is Personality Theory,Psychopathology, and The course in developmental se- phrases. The firstphase reviews the divided into three each focuses on the typeof object relationsprevalent during quence and The sec- critical period, as well as onthe dynamics ofinterpersonal behavior. psychopathology and reviewsrecent researchfindings ond part focuses on psychological, and social regarding the biological,biochemical, physiological, phase, current treatment pro- bases for personalitymalfunction. In the third and socioenvironmental cedures including somatic,chemical, psychological, arediscussed and evaluated. participation in an The course in GroupDynamics consists of two parts: in the theoryand concep- ongoing self-evaluation group,and a didactic course of being part of a groupthat tions of group life.The first-hand experience participant's sensitivity tohis own studies itself aids thedevelopment of the members of the group.The study feelings and to thefeelings of the other deals with anxiety- utilizes the group situation as ateaching device and group student's own life. The historicalantecedents of the arousing areas of group the defenses are not investigated.The student focuses on adjustments and contribution to the group group's defenses againstanxiety and on his own the technique3 through In this manner thestudent gains insight into process. by group processes.The which individual and groupbehavior are modified is then utilized toprovide a didactic course whichfollows the study group experience and abroader range of theoretical framework forthe study group approaches to the use of groupsin the modificationof behavior. give the traineefirst- The course in SocialInstitutions is designed to of the hospital.This includes hand experience withthe therapeutic programs each of the hospitalservice disciplinesand experience one an orientation to the various during the first six monthsof training in assisting day per week Following this their specializedtherapeutic services. disciplines in conducting concerning the the student is presenteddidactic material practical experience such as the family,the impact on themental patient ofsocial institutions community, the ward,and the hospital. teach the traineesthe general The Activity Skills courseis designed to projects. The con- patients developand execute group skills necessary to help cooking, and includes arts and crafts,rc-seation, sewing, tent of this course worker with a general budgeting. The course presentsthe mental health vehicles for stimu- background of activityskills which can thenbe utilized as groupbehavior. Trainees lating group interactionand effecting appropriate occupational, recreational,and also learn how the morespecialized skills of NEW MANPOWER FOR MENTAL HOSPITAL SERVICE 135 music therapy can be used to enrich the hospital therapeutic program. Instead of providing only didactic training in the arts and crafts, the classes are conducted using group techniques similar to those which the mental health worker will utilize in conducting patient activity groups. This teaching procedure gives immediate application to the skills learned. The course on Social Interaction Therapy is fundamental in preparing trainees to conduct social treatment with groups of chronic patients. This course provides practice in using group process to improve interpersonal behavior and to correct maladaptive responses, in teaching mental patients how to live in the extramural community, and in structuring a ward environment into a social milieu. As a first step in this course, trainees under supervision conduct activities in an established program at the Rehabilitation Center. As group leaders for these activities, theyare guided by the level of social behavior manifested by patients and provide the patients the support, encouragement, and assistance needed to progress from rudimentary interpersonal responses to the social complexities of group participation. Through group leadership, trainees learn to utilize the group for setting goals, for making decisions, and for helping to solve interpersonal problems between group members, and thereby correct maladaptive behavior and enhance social adjustment of group members. Following supervised experience in the conduct of activities in theongo- ing program, trainees move to a back ward where few if any programs are available. Here the task consists of selecting an appropriate sample of patients, structuring a therapeutic milieu, establishing a program of activities especially suited for the population selected, implementing and conducting the program activities, and integrating the members of other hospital services into this program. To date, this type of experience has led to the establishment of two levels of programs on the back wards: a patient government program for higher level patients, andan activity program for more regressed patients. The patient government program utilizes both discussion and performance activities to stimulate interaction and prepare the patients for extramural living. Here the group leader's task is to get the patients to assume leadership roles in the activities and to moderate thepressure which the group exerts on individual members to participate in the group processes. The regressed- patient program relies more on performance-type activities to activate patients and involve them in social relations. This program requires that the group leader assume a more directive and controlling role in order to initiate even rudimentary group interaction and prepare the patient for higher order social relations. The patient government programs as well as the programs for regressed patients have involved, in therapeutic activities, many patients formerly neglected because of staff shortages. Supervision in the conduct of social interaction treatment is the key teaching method utilized to develop group leader skills. These skills are incul- cated primarily through a supervisor's critical appraisal of actual performance 1

136 COMMUNITY PROGRAMS AND NEW SOURCES OF MANPOWER and the trainee's continued practice to perfect the application of approved techniques. Supervision focuses on offering the trainee the opportunity to integrate the content presented in the various courses and to apply it in accordance with his understanding of the needs of the group and its individual members. The supervisory process is directed toward a depth examination of the trainee's involvement, his awareness of group processes, the appropriateness of his leadership behavior, as well as an exploration of alternative approaches to group problems. The goal of supervision is the emotional and intellectual involvement of the trainee in the learning process. Supervision is based upon actual observation of the trainee's behavior as a group leader. Extensive use is made of the two-way mirror room for direct observation and taped recordings for review of experiences. Supervision is provided on both an individual and group basis. Each trainee is assigned a staff supervisor who observes one trainee-conducted group session per week. In addition, trainees observe each other conducting groups on alternate weeks. Supervisory sessions follow these observation sessions. The training program is a one-year program; six trainees are accepted every six months. Approximately one-third of the time is spent in didactic course work and two-thirds in supervised practice in conducting socia', interaction therapy groups. A major problem in establishing such a training program is the recruitment of a competent training faculty. A core of experienced staff who had been involved in the original socioenvironmental programs was available to serve as model group leaders and participate in the didactic and supervisory aspects of the program. Finding additional staff trained and experienced in group work with chronic mental patients was a difficult task. However, the services of a psychiatric social worker, a doctoral candidate who had had considerable experience in working with groups of chronic mental patients, were obtained. Also secured, on a part-time basis, were the services of several psychologists with considerable group psychotherapy experience with mental patients. Thus, the training faculty is multi-disciplinary, composed of psychologists, group social workers, and occupational therapists. Staff psychiatrists are also utilized for special lectures on diagnostic classification,psychopathology, and psychotherapy. The recruitment of college graduates for training as mental health workers has been surprisingly successful. The $3600 annual NIMH stipend offered from grant funds and the opportunity for training for employment in the mental health field at an annual salary of $6090-$7775 seem to be sufficient inducements to attract a large number of applicants. A group screening procedure had to be developed to make the selection process efficient and economically feasible. The screening teams, composed of a psychologist and a group worker from the training faculty, developed a number of situations which would elicit sufficient applicant participation to enable staff to rate the applicants on a variety of personality traits. For exam- NEW MANPOWER FOR MENTAL HOSPITALSERVICE 137 ple, in one screening situation, applicants arepaired and given five minutes in which to learn about their partners prior tointroducing them to the larger group. Another screeningprocedure requires the candidate, after hearing a case study of anindividual under stress, to devise a plan of action whichhe feels will be helpful to the disturbed individual.A third screening task requires the candidate to present aself-analysis. These tasks generally produce an array ofbehavior useful for rating such traits as altruism, personalwarmth, independence, drive level, emotional expression,flexibility, and interpersonal skills. Candidates with the best ratings areselected for admission to the training program.

EVALUATION OF THE PROGRAM

A number of major research issues must beresolved before the success of the training program canbe determined and a broader applicationof the services of this new worker can be made.The first question is whether or not the college graduatemental health trainee is able to masterthe skills of social interaction therapy. To answer this question, two typesof evaluations are made. Thefirst is a subjective appraisal by the trainingstaff of the trainee's performance in the program: howwell he learns and applies the course content;how he gets along with patients, staff, andfellow trainees; how dependable and reliable he is; howmuch initiative and perseverance he shows. Since every trainee is assigned quarterly to adifferent staff member for supervision, the supervisor's ratings serve assystematic measures of the trainee's progress. 1 A more objective assessment derivesfrom direct behavioral observations of the trainee's group leadershipperformance by trained raters who use the Group Leader Evaluation Inventory(GLEI)a locally constructed instru- mentto record theirobservations. This instrument, basically, is achecklist composed of items judged by the trainingstaff to be representative of sound group leadership or tobe representative of behavior whichobstructs or defeats the aims of social interactiontherapy. Items such as "maintained group process whenfaced with disruptive behavior" or "relatedseemingly irrelevant or meaninglessremarks to the main topic of discussion" areviewed as positive leadership behavior. Items such as"belittled contribution of individual patients" or "ignored, suppressed, or otherwisedisowned pathological behavior" are examples of negativeleadership behavior. Weights are assigned toeach item in accord with empiricallydetermined frequencies of occurrence in group situationsand the mean ratings given to each itemby personnel experienced in the conduct of social interaction treatment.A total of sixty-two positive and negative items are includedin the checklist. Also included in the GLEI are three rating scales which aredesigned to measure: (1) how often the group leader tries to get patients tointeract, (2) the level of therapeutic interaction displayed, and (3) thenumber of patients who actively partici-

1 138 COMMUNITY PROGRAMS AND NEW SOURCES OF MANPOWER pate in the group process. At regular intervals, trained staff observe thegroup leadership behavior manifested by the trainess and complete the GLEI. The inter-rater reliability on the GLEI has been foundto be quite satisfactory. An additional criterionmeasure of success derives from the sociometric rankings of trainees by supervisors andpeers. At completion of training, trainees are ranked in regard to cooperativeness, relationship withpeers, relationship with authorities, efficiencyas group leader, etc. The individuals performing the sociometricsare asked to rank three fictitious trainees: Mr. Above Average, Mr. Average, and Mr. Below Average. These fictitiousper- sons serve as "rating anchors," allowing comparison of trainees across groups. A second research task is the identification of the characteristics ofa successful mental health worker. Success in thisarea would be of considerable help in the selection of candidates for training. During the first week of the training program, trainees are given a number of personalitytests (California Psychological Inventory, Interpersonal Check List), interest inventories (All- port Vernon Study of Values, Vocational Preference Inventory), attitude scales (Opinions about Mental Illness), and locally standardizedgroup tasks. Scores on these measures will be examined after all trainees have completed the training program in an effort to discover those personality factorswhich predict the performance criteria. Some of thesemeasures are repeated at the end of the training program,so that changes in attitudes and/or awareness of self and others, whichoccur as a result of exposure to the training program, can also be identified and related to the performance criteria. The prediction problem is a complex feature of this research. This problemis further complicated by the fact that onlya small number of mental health workers are being trained and that thegroup selected for training is markedly homogeneous. Both factors reduce the chances of finding significant correlationsbetween personality measures and performance criteria. From a hospital service point of view, the trainingprogram is already paying dividends. Fifteen out of the first twenty-four traineesare now employed at the hospital to provide therapeutic serviceson wards heretofore exclusively directed toward custodialcare. Of the nine remaining trainees, four are employed at a neighboringstate hospital, one is employed by a private agency providing services to chronic mental patients in thecommunity, and two returned to graduate school following completion ofour program. Only two trainees dropped out for personal reasons before completion of training.

CAREER OPPORTUNITIESFOR THE NEW PERSONNEL

The issue of what career opportunities the Commonwealthwill make available to the graduates of the Mental Health Workers TrainingProgram is still being resolved. At first, the establishment ofa new and separate profes- SERVICE 139 NEW MANPOWERFOR MENTAL HOSPITAL Health Worker, wasconsidered. The problemsof establish- sion, the Mental The 'Jig such a newprofession are numerousand seem insurmountable. professionals would have tobe resistance of theestablished mental health scale of duties andresponsibilities would overcome,and a new and graduated within the state system topermit the mentalhealth have to be established remuneration. Also, in worker's professionaladvancement and commensurate university wouldprobably have order to traditionalizethis new profession, a give academic recognitionand to to take over partof the training program to lead to an appropriate programwith additional courses to augment the current would professional degree. If a newprofession wereestablished, its members principles more broadly, notonly in be expected to applysocial treatment also in schools for theretarded, child mental hospitals forchronic patients but Obviously, the statehospital development centers, andmental health centers. the breadth of trainingrequired to by itself cannot beexpected to provide in mental healthfacili- prepareworkers for generalsocial treatment services comprehensive training programwould have to bedeveloped ties. A more health facilities, through the cooperationof the universityand other mental for its own serviceneeds. each facility offeringtraining specialized for mental health A second avenue forestablishing career opportunities hospital disciplinesand hierar- workers is to incorporatethem into existing workers in the ActivityThera- chies. For example,employing mental health considerable resistance was pies Department wasconsidered at first. Here, too, "Sure we'd like tohave these encountered. The resistancetook the form of members of our sta ff,but in order to makethem com- trained 1-)ersonne1 as person- staff, wouldn't youfirst have to give our current parable with existing mental health of training?" Thefear was that the new nel the same kind them. workers might dominatethe activity workersand gradually subjugate accepted the mentalhealth Actually, had the ActivityTherapies Department namely, the activitytherapists workers, the oppositemight have occurred, mental health workersand used might have assimilatedand subjugated the rather than for small group them for hospital-wide massactivity programs, treatment programs onsegments ofhospital wards. offers the greatest promiseof A third course of action,and the one which for these new workers immediate success, is toestablish career opportunities subprofessi-nal group inthe psychologyhierarchy. Since psychology as a therapy undertook the task ofdeveloping the techniquesof social interaction college graduates toutilize and established thetraining program to prepare psychologists to this new groupof work- these techniques, theresistance from ladder for psycholo- be minimized.Furthermore, a professional ers tends to making available gists already exists.The Commonwealthof Pennsylvania is the employment andtraining of Government CareerTrainee positions for positions can be used totrain college graduates.These government career Eventually, Commonwealthfunds college graduates forpsychological service. currently support themental health will replace theNIMH stipends which 140 COMMUNITY PROGRAMS AND NEW SOURCES OF MANPOWER worker trainees during the one-year training program. Upon completion of the training program, the new workers will be eligible for appointment as Psychological Service Associate l's, the entrance position in the Psychology Series in the Commonwealth of Pennsylvania. The graduates of the Mental Health Worker Training Program, therefore, will have ready access to a career in psychology. By obtaining a master's degree in oneof the specialties of psychology these workers will be able to move up the professional ladder to higher levels of responsibility and commensurately higher salaries. In order to traditionalize the Mental Health Worker Training Program and establish this group as a subprofession of psychology, discussions are currently under way with two of the neighboring universities regarding the possibility of accreditation for the training program. A training syllabus has been prepared for evaluation by the curriculum committees of these universities. Since the content of the didactic courses offered in the training program is comparable to the content of established university courses, equivalent graduate credits might be offered for the courses in our training program. Trainees would therefore be working toward their graduate degrees while engaged in training at the hospital. Those who wish to advance in the psychology hierarchy could complete their master's degrees at the university. An added inducement which makes such graduate training even more attractive is the Commonwealth's Tuition Reimbursement Program, which would pay the tuition costs of such further academic training.

PROBLEMS IN TRAINING NEW MENTAL HEALTH PERSONNEL

The training of new workers for subprofessional sefvice in the mental health field should not be undertaken without an awareness of the problems posed by such an endeavor. A major disadvantage of training for specific job functions is the limited job flexibility and the danger of rapid job obsolescence. The professional psychologist, by virtue of having experienced a broad, theoretically-based training program, is prepared to offer a fairly wide range of services. Also, the conceptual foundation of his training prepares him to integrate and apply the newdevelopments which emerge in his field. The one-year Mental Health Worker Training Program is necessarily oriented to specific aspects of treatment. Accordingly, this training program restricts the presentation of concepts tothose necessary for the learning and application of social interaction treatment techniques. The mental health worker is prepared almost exclusively for this delimited job function, and he is not fully prepared to integrate or apply new and emergent techniques on his own. It therefore behooves the trainers and supervisors of such personnel to establish continuous in-service opportunities designed to upgrade HOSPITAL SERVICE 141 NEW MANPOWERFOR MENTAL help them keepabreast of new their training, maintaintheir interest, and upgrade personneland facili- developments. Industryutilizes this practice to 1 health shifts when jobfunctions becomeobsolete. The mental tate manpower example of industry inestab- field must be prepared tofollow and surpass the lishing such in-service programs. which looks so promis- Quite conceivably,socioenvironmental treatment, successful techniquesin the near future. ing today, willbe replaced by more the top 15%-30%of the The research atthis hospital isbased on work with showing at leastrudimentary social chronic population,namely those patients Favorable results andthe urgent needfor such specialized responsiveness. effort before more the initiation ofthe current training services impelled available. This is of the utility ofthe techniques was broadly based evidence tech- practice prevalentin the mentalhealth field. New similar to the general that they result in a more niques are applied as soon asthere is evidence do traditionaltechniques. favorable outcome than mental health is the resistanceof the established A second problem area discipline tends to disciplines to newworkers and newtechniques. Each and look withsuspicion at the guard jealously itsrights and prerogatives developing social interaction Since the mentalhealth worker, in newcomer. problem areas which arein the activities, deals with someof the content and tend to view him as purview of thetraditional disciplines,these disciplines worker thus canbecome a focal duplicating their services.The mental health frequently greetedwith the point for muchdefensive hostility.His efforts are There is littledoubt that the protest,"We've been doingthis all along." times. Slavson onceindicated mental health workerinvites such resistance at of group therapyby the medical that the only wayhe could obtain acceptance this system oftherapy. However, profession was toemphasize the limits of unable to effect suchmodesty. Too some of ourmental health workers are the posture of aPinel loosening thechains of the patients. often, they adopt of whom are This attitude isbound to arouse the ireof personnel, many youth and enthusiasmof the dedicated to patient service.To be sure, the natural attributes forthe learningand successful mental health workers are be manifested application of newtechniques. However,their enthusiasm can aside the contributionof others and thuspotentiate with such zeal as to sweep they must work inclose the resistance of the verypersonnel with whom collaboration. anticipated in the trainingof A third problem areawhich needs to be health service is thepossibility that these more newpersonnel for mental will present themselves tothe public as limited, specificallytrained personnel This danger is at apeak when the supplyof exist- fully trained professionals. Two limited and the demandfor their services is great. ing professionals is built into the train- safeguards can be employed.The first needs to be types of trainees are exposed to acode of ing programitself. In the current program, 142 COMMUNITY PROGRAMS AND NEW SOURCES OFMANPOWER ethical practices and indoctrinated with the attitude thatthey are prepared to work collaboratively with otherprofessionals, but not independently from more broadly trainedindividuals. A second safeguard, external to the training program, is derivedfrom the current effort to establish standards and certify or license thosepractitioners qualified to offer services to the public.The mental health workers clearly are not qualified for suchindependent service. The dangers inherent in the training ofsubprofessional workers do not outweigh the advantages derived from the services whichthey can provide. The established mental health professions arepresently looking within their areas of functionsand services for generalized and routinized dutieswhich can be fulfilledby relatively untrained personnel. Each of theprofessions is already using or recruiting and training its ownsubprofessional workers. Psychiatry is using the medical student for somegeneral medical services in the mental hospital. Social work is recruitingbachelor's level personnel untrained in social work practices for on-the-job trainingfor general casework services. Psychology is training master's andbachelor's level personnel for psychometric services in the mental hospital. However, eachof these disciplines still must do its own research and development work to uncover new types of specialized services which wouldmaximally utilize new personnel to improve the overall hospital treatment program. The uncovering of such new hospital services to augmentand improve existing hospital treatment programs can best beundertaken by hospital-based personnel, since they are most aware of the hospital'sneeds. Needless to say, most state hospitals do not havethe caliber personnel to undertake such a research and development task. However, each state systemhas within it personnel with sufficient intelligence, dedication, andsheer naïveté to enable them to tackle this task. The institutes which various stateshave established to serve as centers for trainingand research have failed to fulfill this research and development task. These institutes have become thedomain of the neighboring medical schools and are used for the training of psychiatricresidents. The research problems undertaken at theseinstitutes are either of a traditional nature, in accord with the traditional training atthese institutes, or of a basic nature, in accord with the academic interestsof the faculty. Program research, so necessary for the development of newtechniques for the treatment of large numbers of patientslanguishing on state hospital wards, is rarely undertaken by these institutes. This task hasfallen to the staff of the service institutions, namely people like Jones inEngland, Sivadon in France, Fairweather, the Philadelphia State Hospital group, andothers in this country. The service institutions,having taken the initiative for developing new treatment procedures, will alsohave to pioneer in the training of new personnel to implement these procedures on a broadscale and thus help fill the vast demand for therapeutic services. 143 1 HOSPITAL SERVICE NEW MANPOWERFOR MENTAL

REFERENCES

trends. New York:Basic Books, 1959. Albee, G. W. Mentalhealth manpower Med. J., 1942, 1,214-217. Bierer, J. Grouppsychotherapy. Brit. social psychiatryand synthoanalytic Bierer, J. The dayhospital, an experiment in Lewis, 1951. psychotherapy. London: 1959, 2, 901-902. Bierer, J. The theoryand practice of theday hospital. Lancet, York: Basic Books,1961. Bion, W. R.Experiences in groups. New From custodial totherapeutic patient Greenblatt, M., York, R.H., & Brown, E. L. Foundation, 1955. mental hospitals. NewYork: Russell Sage care in Books, 1953. Jones, M. Thetherapeutic community.New York: Basic total push in the treatmentof chronic Myerson, A. Theoryand principles of Psychiat., 1939, 95,1197-1204. schizophrenia. Amer. J. an ex- R., & Weinman, B.Chronic psychoses and recovery: Sanders, R., Smith, Jossey-Bass, 1967. socio-environmental therapy.San Francisco: periment in B. B., Smith, R.,Smith, A., Kenny,J., & Fitzgerald, Sanders, R., Weinman, mental patient. J. nerv.ment. Dis., Social treatment ofthe male chronic 1962, 134, 244-255. T., Op ler, M. K., &Rennie, T. A. C. Srole, L., Langner,T. S., Michael, S. study. Vol. 1. Mental health inthe metropolis: Themidtown Manhattan New York:McGraw-Hill, 1962.

t 9 THE TRAINING OF HUMANSERVICE AIDES'

William L. Klein Howard University

In the spring of 1964, ten young people, allbetween the ages of seventeen and twenty-one,began a three-month training program2 to prepare them for jobs as aides and assistants inchild care centers, neighborhood recreation programs, and social research projects.The seven boys and three girls who had been selected were all high schooldropouts. Four of the boys had delinquent records, while two of the girls had givenbirth to children out of wedlock some time before the program began.All were Negro youth from the poor "central city" area of Washington, D.C.,chosen from a pool of individuals referred to the program by several youth-servingagencies in the city. No attempt was made to pick out the best ofthe applicants. Instead, on the basis of demographic data and individual interviews, each personwho applied was assigned a"risk category" ratingessentially, a predictionderived from previous empilyment and delinquent history,school achievement, and personal and social behavior as to how likely it wasthat the individual would complete the training and function effectively on thejob. Applicants were paired on the foregoing variables, as well as onthose of age and sex. One member of each pair was then randomly chosen for the training group;those not selected constituted acontrol group. In this way, the training of theaides, to be described in thischapter, began. Six months later, after the training was completed andthe aides were all working in city recreation programs, child care centers, andsocial research 1 This chapter is derived from various publicationsand reports of the Institute for Youth Studies, Howard University, particularly: Fishman, J.R., Klein, W. L., MacLen- nan, B. W., Mitchell,L., Pearl, A., and Walker, W. (1965). All of the authorslisted have played a major role in the further development and expansionof the program. 2 This program was supported in part by contract #3TI-MH-8318-0381 with the Community Services Branch, National Institute of MentalHealth, and in part by Train- ing Center Grant #63215 from the Office ofJuvenile Delinquency and Youth Develop- ment, U.S. Department ofHealth, Education, and Welfare, in cooperation withthe President's Committee on Juvenile Delinquency and YouthCrime. Further development of the project was made possible through contract withthe Office of Manpower, Automa- tion and Training, U.S. Departmentof Labor, and the Office of Education, U.S. Department of Health, Education, andWelfare. 144 THE TRAINING OF HUMANSERVICE AIDES 145 projects, none had dropped outof the program; and there were noclear-cut differences in job performancebetween those originally described as poor risks and those considered goodrisks. With one exception (an arrestfor dis- orderly conduct) they had nofurther involvement with law enforcement agencies. In most cases their supervisorsfound them valuable additions to programstaffeager to learn, quick to catch on,and often innovative and resourceful in carrying out their assignments.One of the aides, working in a quickly local demonstration programaimed at army enlistment rejectees, was to fill a slot vacatedby the dropping of a graduatestudent who had been found wanting.Two others played a majorrole in organizing neighborhood youngsters into activity groupsthat were to form the basisof an experimentalcommunity mental health program. The striking outcome of this initial programled the staff of the Institute for Youth Studies at Howard University toexpand the project andexplcre a variety of jobsinvolving work with people forwhich deprived, delinquent, and drop-out youths could be trainedand hired. To date, over onehundred such youths have graduated from the program.A large number areworking as classroomaides in elementary schools; others areinvolved in a detached worker program of the city recreationdepartment. A group of nine is employed as youth leaders in acommunity-based mental health centerfor children and adolescents. Both young womenand young men havebeen successfully trained to serve as aides in anumber of the city's preschooland early childhood day-care centers,generally those geared specificallyfor the children of the disadvantaged. Another groupis employed as counselingaides in wellare department institutionsfor dependent and delinquentchildren. Ironically, in several instances theseinstitutions are the same ones orsimilar to those in whichthe aides had once beenconfined as inmates. Others are working in a geriatrics institution, in consumereducation and youth organization projects of the localcommunity action program,and in the research division of the local poverty program agency. Many of the findings of the original projecthave been supported inthese ensuing programs. Thedrop-out rate from training and, atleast over the short run, fromemployMent, has been minimal. Therehave been few instances of delinquent or criminal involvement,and none directly connectedwith the actual work setting. Theeffect of the program on the traineeshas generally been one of raising personal andeducational aspirations. A numberof aides have gone on to prepare for and receivehigh school equivalencycertificates; in some cases, they haveenrolled in advanced courses in areacolleges and other training institutions.Supervisors have been highlyenthusiastic about the contributions of the aides totheir particular agencies, with someof the aides already being raised to more seniorpositions in places with opportunities for advancement.Moreover, as in the initial progam, mostof the aides were chosenfor training, almost randomly,from a pool of applicants. The attempt was to include aswide a variety of individuals aspossible, rather than 146 COMMUNITY PROGRAMS AND NEW SOURCESOF MANPOWER to exclude any particularsubgroup on the basis of preconceptionsabout who, from this population, could or could not functionsuccessfully. Almost all attempts at predicting individual success orfailure on the basis of intake intemiews, test scores, school record, or otherindicators have not worked out. Many youths who do not meet commonly held criteriafor human service work often, and strikingly, "blossom" into highlyeffective aides when given the chance to show what they are capableof. We have written elsewhere (Fishman, et al., 1965, pp. 46-47) that:"...school performance, a delinquency record, and an erraticjob history may, in the main, reflectdifficulties in coping with problems in a particular kind of context,and thus may have littk predictive value for behavior in a radically changed situation(one that is in many ways discontinuous with past experienceand expectations)." Who are these aides and why choose them for thisparticular kind of work? Some of them come with the more obvious"characteristics of the street": a reputation for leadership and/or delinquent prowess, a$70 sweater or a $30 pair ofshoes (highly prized elements in one's "identitykit" when there is very little else to bolster status or self-esteem), avaried history of encounters with the law, and an erratichome and family history. Although there are often unique differences and almost as muchvariability in this population as in any other, a brief portrait of one of theaides should convey sharply the important features:

Aide X finished the tenth grade at a Washington, D.C. highschool before quitting school altogether. He is somewhat small in statureand, when first seen, his tendency to wear clothes one or two sizes too large onlyaccentuated this fact. He gave the impression of being an extremely waryand guarded individual who hardly ever looked at or spoke directly to whomever he wasaddressing. In the early days of the program, he was quite critical of it,and openly questioned the possibility of its having any effect on the behaviorof the group members. At the same time, he was quick to point out positivedirections for action and to assume leadership. He is oneof live children, and has lived for 17 years at the same add:ess (a public housing project). His mother is ahousewife, and his stepfather, a post office employee. In recent years,Aide X has tried to become more self- sufficient, at least in part because of a conflict with hisstepfather. He has alter- nated between living at his parents' home, an aunt's apartment,and an apartment of his own. His employment record includes a seriesof low-paying, unskilled, temporary jobs, the most recent ofwhich was as a one-dollar-an-hour kitchen helper. Aide X's delinquency arrest record includes chargesof robbery and truancy. For both of these, he was confined to a correctionalinstitution (Fishman et al., 1965, p. 14).

There are other, perhaps less Dbvious, things thatthe aides bring with them. Often central to their outlook on life is afeeling of, "That's the way it is, man." This brief sentencesuccinctly conveys their perception of a world that has very little to offer which they can attainand over which they are powerless to exert influence or control. They are suspiciousof hope and possi- THE TRAINING OF HUMANSERVICE AIDES 147 bility since they are all too familiarwith how quickly such things can vapor- ize. Fate and luck are often prominent partsof their belief systems, at least in part because they see norational way of interacting with thewider society and its widely advertised benefits.All of these things and more; a poor self- image, lack of future orientation,marked potential for antisocial behavior and impulsive acting out, and concreteconceptual ability have been ascribed to, and found in,these young people by many socialscientists searching for clues as to what makes these youngstersdifferent from their more aspiring, achieving, and stable middle-class peers.These observations have often led to the hypothesisthat if, somehow, one could "getinside" and change these intrapsychic variables, self-concept, styleof life, and behavior might also change. Thus, those who are not "in the sameboat" as these individuals are called upon to provide the therapeutic,welfare, and rehabilitative services to help change those who are seen as notbeing able to help themselves. What is often overlooked, however, is thelarge, sometimes overwhelming, reality component of theoutlook and behavior described. To motivate someone to want towork and to hold down a steady job is arather pointless effort if there are no jobs to be had, as isoften the case. To convince someone of the importance of staying in schoolwhen there is little hope of going on to higher education andwhen one can see peers with high schooldiplomas standing on the same street corners as oneself is notthe easiest undertaking. For these and other reasons, many of theattitudes and actions described above can be seen in amuch more practical and heuristically valuable way."Much of their 'aberrant' or 'delinquent' behavior ... maybe seen as a central feature of being increasinglyrelegated to the sidelines as spectators of society a role thatcontributes very little to any kind of positiveself-concept or identification. This dilemma molds a significant part oftheir social, psychological, economic and educational life" (Fishman et al.,1965, p. 2). Posed in this fashion, the problembecomes one of finding real channels for moving these young people fromtheir "outsider" and "spectator" roles (often elaborated with particular stylesof life, norms, and valties) into meaningful "participant" roles in society.What is also suggested is that the kinds of participation need not be limited tothe hackneyed range a semi- skilled and unskilled vocational education typejobs that are usually offered, based on the assumption that people whodemonstrate certain kinds of characteristics are best suited for suchwork. Pigeonholing of this type occurs because many of the young people we aretalking about are generally un- familiar with other kinds of work. If, as webelieve to be the case, a major component of theirbehaviors and perceptions is a result ofhaving continuously to find effective ways of coping with aparticular set of social conditions, then there may be potential for theirfunctioning meaningfully in areas which are different fromthose they are used to, areas whichchallenge and support them in new kinds of endeavors. Thiswould be particularly true if the new NEW SOURCES OF MANPOWER 148 COMMUNITY PROGRAMS AND roles, in themselves, contained avenues toheightened status andincreased self-esteem by their very performance. One obvious area in whichsuch roles are to be found iswhat Pearl (1965) has called the areaof "unmet needs of society," mostnotably the directly related to human services. Relativelyunaffected by automation and population growth, these services,including education, welfare,recreation, of all kinds, child care, public health,mental health, and counseling services be are alreadyfacing manpowet shortages ofcriticl dimensions. It should noted that, as a group,they comprise many of thecaretaker agencies and important in the services which Duhl(1963) has pointed to as singularly undertaking of a comprehensivemental health program. It is oniy alogical juxtaposition to the step, once havingidentified these needs, to place them in need of huge army of the alienated andunemployed who are desperately in meaningful, horizon-opening worksuch as can very easily comefrom giving service to a fellow humanbeing. It is out of such considerationsthat the concept of the humanservice aide has grown. He is a nonprofessionalwho, with some initial training,does those things which, in any helping service,do not require extensiveeduca- tion and background. Byrelieving the professional of more routinetasks, he helps the professional to do more ofwhat the latter is uniquely trained todo. Thus, he may become the basis of a newapproach to service that was formerly impossible because of a shortage of time orspecially suited personnel. Of course, the emergenceof the concept cannot hide the factthat contained within it are a wide array ofcomplex and problematic issues, such ascreating and defining jobs, providing forupward mobility and career lines,certifica- tion, orientation of professionals,and ongoing education. Each ofthe foregoing issues is dealt with moreextensively elsewhere (Duhl, 1963;Fishman et al., 1965;MacLennan, Klein, Pearl, &Fishman, 1966; Pearl, 1965; Pearl & Riessman, 1965;Institute for Youth Studies of HowardUniversity, 1966). Here, we will be largelyconcerned with the training of thehuman service aide: how it has been done,and what its significant features are.With some modifications and changes, the trainingmodel used in the first project has been implemented in all the ensuing programs.

THE TRAINING PROGRAM

The young people who areaccepted for the project bringwith them a wide varietyof behaviors and interpersonalskills. Many of the latter are clearly designed to protect themfrom feeling responsible forthemselves and for others, from the threat ofbeing blamed for failure, and fromthe risk of making long-term, independentdecisions about themselves and theirfutures. They are often quite expert at"proving," through goading authorities or professional staff, that their perceptionof "the way it is" is accurate andthat 149 SERVICE AIDES THE TRAININGOF HUMAN theme morevariation on anexploitative, uncaring the program is just one particular points all familiar. This maytake the form, at with which they are back to the street to"rob and training, ofthreatening to go of crisis in the could be moreeffec- implied threats ofviolence, nothing steal." Along with professional staff.The tive in raising agreat dealof consternation among example, wouldsometimes findhimself groupleader of theinitial project, for before these attacks,vacillating between unable to adopt aconsistent stand wondering if and "well liked,"and angrily trying to besupportive, helpful, approach were necessary.Another gambit a moredemanding and punitive these youths were be called "the streetargument." When is what came to might have to give upsomeof their faced with thepossibility that they in order tofulfill the more"square" de- deviant andirresponsible behaviors defended themselvesby loudly protesting mands of their newaide roles, they be for them.Using a kind ofnaïve environ- just howdifficult this would prove tothe professionalstaff that mentalist approach,they would attempt to there." Traineeafter traineemight pick "you don't knowwhat it's like out and of the street,each one reinforcing up on someparticularly lurid account in pitch other, with thewhole tone ofthe meeting rising embellishing the what Raush andSweet effect rapidlybecomes similar to and tempo. The net professional contagion" phenomenon,with the (1961) oncelabeled a 'verbal the stories he ishearing, orsympathetic alternately fascinatedand seduced by and unable tothink of a goodcounterargument.

THE COREGROUP decided that acentral Because of these typesof behavior, it was be somemechanism for training programfor the aides had to feature of the Part of theimpetus for working toward achange of valuesand attitudes. the actual workin humanservices, offering such changewould come from and derived from doingmeaningful work as itdoes a sense of competence useful such by supervisors, afeeling of making a having it recognized as relevance oftheir work the opportunityof seeing the contribution through responsibility to peoplewith, and for people, and a wayof exercising and to other however, oftranslating feelings whom, one works.The problem remains, and using this tolay knowledge andgeneralizable concepts experience in to and valuesadapted for the developmentof norms, sanctions, the groundwork other peopleand performingsatis- to thedemon ds of workingtogether with factorily in thehuman services. change in chosen in aneffort to bringabout relevant The mechanism "Core Group"(MacLennan & attitude and values cameto beknown as the Klein, 1965),defined as: society, small groups, which its memberswould learn how . a traininggromp in Within . felt, functioned,and developed. people in general,and they themselves particularly job-related analyze personal,social and this groupaides learn how to 150 COMMUNITY PROGRAMS AND NEW SOURCES OF MANPOWER problems, make their own decisions, try on various roles and attitudes for size, and learn to cope more effectively with people and the world around them. Starting from their own experience, the members of the core group are encouraged to examine the processes of their immediate lives and the problems of living in a poor area of the city. As the group Progresses, it draws upon experts to examine with it areas of knowledge of common concern to all.These include: problems of human development, i.e., family life, childhood, adolescence, nor- malcy and deviance; community institutions and resources; the special problemsof the socially deprived; health care; labor and employment; the law andlegal aid; credit unions, insurance and medical care; and general problems of working with people.

...The business of the group is focused by a number of questions underlying all issues which the leader continually throws back to the members to grapple withquestions such as: How does one observe accurately and assess situations? How does one sort out alternatives and think through the consequences of actions? How does one judge what information is important and relevant? And how can one use others to help in this activity? Issues actually dealt with in the group cover a wide range, including: who is best suited for what job and why; problems of minority group discrimination; how to deal with annoying supervisors; rules and regulationsabout tardiness and pay; why someone is not able to feel a part of the project; and why the leader can be trusted more than group members. As far as possible, and within the limits of ground rules clearly set up at the beginning of the program, realistic decisions necessitated by these issues are left to the group. If the leader has to make a decision by default, then this itself becomes an issue for the group to take up (Fishman et al., 1965, pp. 18-19).

The core group, then, is a multipurpose instrument. In it, the trainee learns more about himself, the community, and the world he lives in. In addition it gives him a better chance to relate the specifics of what he is doing on the job to broader considerations. He also acquires basic training in those skills and aspects of knowledge that would potentially make him a useful addition to any one of a variety of human service positions. This includes observational and recording skills, use of supervision, pattern and function of community services, and interpersonal relations. Above all, his attention is lleing constantly focused on the "here-and-now" of his job performance, the problems and issues itraises, and their connection to his personal life, aspirations, and relationships with other trainees. As Empey (1966) has pointed out, it is this focus on the "here-and-now" that allows for the group members to interact with one another in terms of current ways of behaving or relating to people, rather than in terms of self-made definitions of what they once were like. In this way, stereotyped behaviors and expectations about the job, authority, personal future, and dealings with others can be reality-tested and broken down and a basis formed for a new kind of personal and group identity. As put into practice in the training program, the young people who are 151 THE TRAINING OFHUMAN SERVICE AIDES ranging from one tothree hours, selected meet dailyfor core group sessions the first half ofthe three- depending on the topicunder discussion. During during the last halfthey meet month program they meetfive days a week; available time for on- twice a week.This is done to increasethe amount of other half day, inanticipation of the-job experience,which takes place the completing trainingand going to workfull time. through the settingsfor The first week of the programis spent rotating kind of aide position isbeing the various jobpossibilities (if more than one of job is available,the trained for). In those programswhere only one type setting, the rolesof profession- time is spent orientingthe trainee to the work of work they wouldbe doing. This als, dimensions ofservice, and the kind information because manyof aspect oftraining is provided forthe trainees' either the range or contentof jobs these youth havelittle appreciation of confines of what theyusually look for(e.g., as maids, outside the narrow etc.). They need this cooks, busboys, constructionworkers, garbage men, field, get oriented toadministrative time to becomefamiliarized with the Also during thisperiod, routines of the program,and establish the core group. thzoughout the program,outside officials andrepresentatives and extending their work, and institutions areinvited to talk about of community agencies be doing particularly about how itrelates to the kinds ofthings the aides will of horizons" alsoinvolves taking and experiencing.This initial "widening educational, social, andcultural institutions the group on anumber of visits to period, a regularschedule goes into in the area.Following the orientation usually in the settingwhere the effect of half-day,on-the-job experience, half-day in the core groupand instruc- aides will eventuallybe employed, and tional sessions. always an easy task.It Getting the group tofunction effectively is not and there is no reasonfor them to come is not, after all,the aides' own idea, of commitment. Atfirst, they may to the programwith a ready-made sense feel that, in order to gettheir pay (they receive asmall training seem to do as they are toldand allowance during thisthree-month period), they must frustration, and boredom. sit it out, even if it meanslong stretches of silence, demand that they changetheir attitudes, thenthey If the program appears to often prepared to tell and to givethe staff whatthey want. They may are also "problem-solving" on the program as indicate that they aredoing as much the program is trying todo on them. found that to sit withthese young In the initial project,the group leader become a problem initself. Days people every day forhours at a time can importance to talkabout and sometimes go bywithout anything of apparent around which to make adecision. As if to find some com- without some issue "marginal" person in the fortable and familiar way tospend the time, some of the others. The group mayoften be singled outfor the verbal attack ferret out the reasonsfor this may bemisinterpreted as leader's attempts to of the task of sanction for anonslaught. Yet all theseactions become part 152 COMMUNITY PROGRAMS AND NEW SOURCES OF MANPOWER getting the aides to adjust to their new jobs and to make meaningful decisions related to it, themselves, and the group. On several occasions, for example, administrative errors and mix-ups caused the delay of trainee pay checks. The aides were furious, openly expressing their anger and cynical disappointment in the program and threatening to quit. The first time this happened, the leader anxiously responded to the group's reaction by calling in the Director of the Institute for Youth Studies. He offered to establish an emergency fund from which the aides could borrow money until they were paid. Five of the group accepted the offer, repaying the loan when their checks came through. In further discussion of this matter in the group, however, the other aides proudly said that they would never be in the position of having to ask the boss for money. Many of the group members told of how they had felt cheated of a chance to express their righteous indignation at the wrong that had been committed. The group as a whole, with the help of the leader, then began exploring ways of banding together so that none of them would again be caught in the position in which some of then, now found themselves. When salary checks were delayed again a short time later, once more the threats of quitting, of going out to commit crimes, and the accusations of betrayal and lack of concern were heard. This time the leader did not jump; the groupresponded quickly by coming up with alternative plans of action, including the possibility of calling in a newspaper reporter and getting him to apply public pressure. The choice finally agreed upon was for the group to write a petition stating they would abandon their jobs in a body if they did not get firm assurance that they would be paid as soon as possible. Effective action was taken almost immediately, and the group had a firm instance of its own power and influence, as well as of its ability to act together for its mutual benefit. One of the most significant instances of the youths' ability to make constructive use of the group situation, particularly when given the opportunity to make meaningful decisions, revolved around one of the girls in the group. Early in the program, she had been assigned to Research Aide training, given a tape recorder, and asked to interview some of the other aides. She had been given a "hard time" by one of the interviewees, leaving an undertone of resentment that carried over into the group sessions. Taking the tape recorder home with her, the girl did not return for three days. In discussing the issue, it became clear that the girl had always emphasized her higher socioeconomic background and remained aloof from the others. The boys in particular re- sented her attitude and had been looking for a way to "bring her down front" (demoralize her). Three alternatives emerged from the discussion and were presented as follows: (1) the police could be called and the girl charged with theft; (2) the leader could visit her and at least get the tape recorder back; and (3) the group itself could assume responsibility for the situation. The last alternative was decided upon, and it was left to the group to work out a solution. 153 SERVICE AIDES THE TRAININGOF HUMAN returned. The otheraides had setthem- Soon afterwards,the absent girl where- the girl's homeuntil she returned, selves up in teamsand waited at of the program.This same type they had convincedher to return to upon of the ensuingaide programs. has now takenplace in at least two occurrence members couldmobilize illustrated howall the group Again, the incidents encountering, evenwhen the difficulties oneof them was themselves around all responsibility. might haverelieved them of there werealternatives which for the usual expectationof a lack of concern This is strikingly incontrast to these young peo- difficulties in choosing amongalternatives with others and incident, none ofthe members fashion, duringthe pay ple. In a similar frustration or todelay for future showed any markedinability to tolerate and their jobs wereconcerned (as might gratification insofar asthe program purposely doingpoorly on the actually leavingthe program, be signified by the setting,the oppor- in delinquentbehavior). Given job, or reengaging their angerwithin accept- the aides wereable to express tunity, and support, constructively, and to actin a unifiedand able limits, toexplore alternatives be is best illus- Just how permanentthese behaviors can responsible manner. after the training programhad trated by thefollowing anecdote.Some weeks the Institutestaff experienced some ended, a professionalsocial worker on and was angrilyand loudlydenouncing delay in receivingher own salary One of theaides, while threatening someform of reprisal. the administration and patted hergently on theback, who happened tohear her, walked over before. It's just there. I've beenthrough this reassuring herwith, "There, to." something you have toget used the also be a meansof exploringand "imprinting" The core group can the im- responsibilities, aswell as of examining dimensions of newroles and training behavior in relation tothem. In another plications of individual 1966), the moodof the trainees (Klein, Walker,Levine, & MacLennan, group moved into itssecond month.A kind of began to change asthe program Trainees were cominglate, using thetele- general apathyseemed to set in. sleeping in class, periods of time, notcompleting assignments, phone for long they wereuninvolved manifesting behaviorssuggesting that and generally with the trainees,heavy pres- with the program.In discussingthis behavior staff to be moreauthoritative, to set sure arosefrom them forthe training regulations so everyonewould know what to limits and morerules and more description of whatwould be involvedshould do. They weregiven a detailed take over and tomake all thedecisions, par- the trainingstaff be obliged to things. The the trainees'ability to do these ticularly as thiswould reflect on preferable, if more self-discipline andresponsibility as a groupbegan to see actively involved inthis alternative. All thetrainees were difficult to attain, They expressedpleasure, and wanted more meetingsof this type. session and and involvement wasof serious con- not a littlesurprise, thattheir behavior cern tothe trainingstaff. history of alcoholicinvolvement engaged At a later date, atrainee with a NEW SOURCES OF MANPOWER 154 COMMUNITY PROGRAMS AND hours. The nature in some unbecomingbehavior in the streets after working of the offense, some prior warnings,and other factors led tohis dismissal from the program. When thisdecision was brought back to theother trainees, their reactions ranged from passive acceptanceto open anger.Most of the discussion focused around thetrainees' ambivalence aboutinforming on another member and their coveringthis over by accusations ofbetrayal and irre- sponsibility on the part of thetraining staff. The latter refused tobe pushed into an apologetic cornerand insisted that a hard lookbe taken at the requirements of the programand the trainees' responsibilityfor their own ramifications of behavior. The discussiongradually shifted to the nature and "covering up" and whether itaided or impeded the process ofindividual and groupresponsibility. It turned out thatseveral of the trainees had been "covering" for the one who hadbeen dismissed when hehad slept or been drinking on the job.Individuals in the group hadlong been aware of his behavior and had even tried tospeak to him about it at varioustimes. Their actions had, in an important way,affected the range of choices open tothe administration of the program, as well asthe image of the group inthe eyes of the community. These and similar discussions make upthe life of the core group,with much of the content derived fromthe ongoing and parallelinvolvements of the trainees with on-the-job experience, oneanother, and the wider society. Parenthetically, it should beobvious that the role of leaderfor these groups is both complex and not a veryfavored one for hiding or duckingissues. He is not there as a grouptherapist, a role which is a greattemptation for the contemporary professional.Instead, his role involves a greatdeal of personal risk and willingness to offerhis own actions, values, andabilities as models to be emulated.This includes the possibilitythat many of these may be found wanting and will have tobe replaced by others, both for theleader and the trainees. Moreover, theleader must be able to tolerate thefoundering, indecision, and lack of closeness thatoften characterize the group,indicating intervention by his demands for competentperformance and lack of anxious that in this group decisions canbe made, problems can besolved, and individuals are going to "make it."He is less concerned aboutwhat he can do to, or for, the youththan he is about how to workwith them toward their becoming active participants in a processof mutual regulation,problem-solving, and growth. Significantly, it is notonly the highly trainedprofessionals who can serve as thiskind of leader but also youngadults, often with the same backgrounds as those of the trainees,who have been trained tofunction in this capacity (Klein et al.,1966). While the core group constitutes onepart of the training process, a second significant element isspecialized skill instruction inthe particular field for which the aide is beingtrained. Usually, four to six hours perweek are set aside forinstruction by specialists in the variousskill areas. The primary AIDES 155 THE TRAININGOF HUMAN SERVICE provide the aide with some goals of this instruction arethe following: to the job so that hedoes not have skills that he can beginusing immediately on observer; to lay thegroundwork for to remain toolong in the role of passive advancement by inspiringhim to im- the aide's educationaland professional for advancement; himself and by providingthe prerequisites necessary prove The crucial aide a more valuableworker to his particular agency. to make the Questions feature of this instructionis its link withon-the-job experience. situation are broughtback to the class- and problems thatarise in the work determine the range of contentmaterial to be room,where they help to classroom can be almostimmedi- covered. Conversely,what is taught in the performance. ately tried out in thejob setting andreinforced through actual training during theinitial project, forexample, the In Research Aide interview assigned to this specialty werefirst given instruction in two aides inter- techniques and in the useof tape recorders.They then conducted an critically reviewed view as part oftheir work assignment.The interview was suggestions were madefor improving in thv presenceof the instructor and the same treatment.In like technique. Each successiveinterview was given of the basic techniquesof controlled manner,the aides were taught some do this. Again, theseobserva- observation and thenimmediately assigned to After some proficiencyhad been tions were broughtback for critical review. of coding and analyzingobser- gained, the aides weretaught systematic ways analyses. In order vation data throughthe use of Bales'model and sociometric these data, theythen learned somesimple statistical computa- to deal with element of of the calculator. As canbe seen, almost every tions and the use with each unit their instruction wastied to an actualand meaningful task, and the demands ofthe work built on what hadpreviously been learned situation.

ON-THE-JOB EXPERIENCE classes generally have aclear idea The instructors ofthese specialty cover, butthey are con- of the range of contentmaterial that they want to situations that arise inthe course tinually alert to thepossibilities of using or skills.In training aides of work experiencefor introducing new concepts there are a numberof areas that for work in child caresettings, for example, growth and development,techniques need to be covered:principles of human of emotional problems,the mean- for managing problemchildren, recognition skills and techniques, gamesand ing and functionof play, observational of complexity, preschool activities, and parent contacts.When, at what level dictated by a combinationof what and in what fashionthese are taught is be most useful, actualproblems supervisors feel theaides need to know to encountering on thejob, and how muchprior experience that the aides are The notes of the the aides have hadwith the conceptsand issues involved. child care instructorgive some graphicillustrations: 156 COMMUNITY PROGRAMS AND NEW SOURCESOF MANPOWER I explained what a case conference was, what youneeded to know, how you would have to be able to present material, etc. (theaides had been invited, a few weeks after beginning their on-the-job training, toparticipate in professional staff conferences at the child care center). They were veryinterested in this, and eager to go on and presentthe observations they made in response to myassign- ment to them (including thechild who was to be presented at theconference). Some had written them, most had not, but all hadcertainly done the observation. I pointed out the need to be able to write them down inthe future...but I felt we ought to bring out someof their difficulties in doing so. Aide Y saidhow confused she got when she was trying to watch one child andanother began playing with him, how she couldn't write as fast as she couldthink, etc. We practiced a trouble with writing few of these...I said I also knew some of them had had and spelling and stuff like that in school, andwondered if perhaps they were afraid of making mistakes, reassuring them thatmistakes wouldn't bother me. I asked if they wanted me to point out spelling errors andthey all said they did, Y adding that this was a way not to keep onmaking the same mistake (this eventually developed into a series of remedial English classesfor the aides)...

...The coffee fixed and served, we went into Aide X's report onS (a child in the child care center). He had answered each of myquestions with a sentence, had had the wit to add that S seemed to want to play with onelittle girl exclusively, had done a fairly good job of observation, but theEnglish was execrable. We talked about how the mother is with S. Aide X hadnoticed that she didn't let the child take her own outer clothes off and the kidwanted to do it herself; also, that the child controlled the mother. We went intowhat might make the mother this way, and I found myself needing to get acrossthe concept of the unconscious, so I waded inusing as example (notexactly accurate but I got the point across) the fact that sometimes when one meets a person, onefeels instant like or dislike, and tied this up with past experiences withbrothers, fathers, etc. They got the point right away, Aide W commenting that sometimes onefeels as if one had met the person before. I stressed the influence ofone's childhood and the people in it on future behavior, and then went into awoman's possible unconscious need to keep a child a baby, and why, using anexample of how I felt when my only kid went away to school. They were veryinterested in this, and added comments of their ownX commenting at one pointthat he would like to hit the child S sometimes when she was so mean tothe other kids. I brought in the fact that S was an angry child, and we tried to get at someof the reasons and results of this. X was extremely interested. ...We got down to the business of playing with blocks. Ishowed them how they should be stored ...how they were modules of one another and howthe kids learned shapes and relationships and even rudiments offractions by playing with them, but even more how much fun they had playingwith them. They went to work to buildAide W with alacrityand his usual creativity, making a nice castle; Aide X more slowly and having to overcome some shyness;Aide Z not at all for a while. ...I said, "This is the kid who won't enter into the blockbuild- ing; how do we get her into it?" I took Z's hand andasked if she wanted me to help her get started, just as if she were a kid ...I showed them what kids do to each other's buildings, how to handle situationswhere they kick down each other's buildings, etc. (Fishman et al., 1965, pp. 31-32).

, 157 OF HUMANSERVICE AIDES THE TRAINING that the indication of thevaried armamentarium These notes give some lecture, bring to bear onthe contentmaterial: straight specialty instructor can role playing, of personaland work experience, groupdiscussion, exploration has repeatedly workshops, films, etc.Experience in this program participant and enthusiasm tolearn can be demonstrated that a greatdeal of interest "anti-intellectual"disadvantaged youths generated in these"unmotivated" and increased of what they arelearning to their when they can seethe relevance job, and whenthey have animmediately efficiency and competenceon the what problems and raisingquestions about available forumfor bringing up they are doing. fallacy in workingwith, training, This leads towhat is often a common assumption ofhow much, orhow these youths.An erroneous and employing and intellectualis based on little, they can graspof thetechnically complex people (concrete,down-to-earth, action- the presentingstyles of these young and relevanceof problem lies much morein the presentation oriented). The presented of whatthey can learn, well as theexpectation the material, as aides. In one groupbeing intrinsic to thecapabilities of the than in anything the trainees very counseling aides inwelfare institutions, trained for work as the effects of caught up inquestions ofinstitutional roles, quickly became for highrecidivism rates.This institutionalization, staffmorale, and reasons experiencing in animmediate, oftenpainful, way wassomething they were job and forget and no amountof "just do your in theiron-the-job training, for their alleviate their concern.The instructor it" advice wasgoing to consideration of sequenceshifted to a Human Growthand Development and effects asde- about institutionsand their structures someof the ideas Schwartz, Goffman,Henry, investigators asStanton and veloped by such and illustrationsin as t others, stressingthe major concepts Bettelheim, and readings wererequired, nontechnical a manner aspossible. No direct and exists at areading level thatwould little of thiskind of material since very "translating" portionsof one of the trainees (anexperiment at be useful for highly successful).With simplified English,however, was the authors into able to see therelevance of the traineesquickly were verylittle guidance, problems they werefacing. Soon these ideas tothe kinds ofdilemmas and they they applied someof the principles afterward, in aclassroom exercise, of the institutionsat analyzing the structuresand programs had learned to this exercise the more positiveoutcomes of which they weretraining. One of "staying alive inthe began to derivestrategies for wasthat the trainees modification of toward theimprovement and system" whilehelping to work the program. often turns upin decidingwhat of fallacynoted above The same kind has been aprinciple of the do in their jobassignments. It the aides should jointly with thestaff of the agency Institute's training programstaff, working ascomplete a jobdescrip- the aides arebeing trained, to prepare for which should be able todo as is possible. tion of whatthe aides willbe doing and

1 158 COMMUNITY PROGRAMS AND NEW SOURCES OF MANPOWER This description outlines tasks whichcan be performed with a minimum of training and which the aidecan start doing almost immediately after the beginning of the training period. It alsocontains tasks that may require lengthy training or may dependon abilities and qualities of the individual that become visible during his work experience. The word meaningful has often been used in this chapterto describe our concept of the work for which human service aidescan be trained. To restrict their duties to only routine, menial, and housekeeping tasksis to confirm their worst expectations of what thisnew job really is. Such an orientation would provide little opportunity for the kinds ofexperiences that can be capitalized on for additional learning andtraining. Moreover, it denies the agency in questiona chance to see what the aides are capable of and to use them in ways that may be more directly beneficial to the service being offered. The job description, then, at best should providea series of tasks graded in terms of demonstrated responsibility,competence, and knowledge or ability prerequisites. It need not bea fixed document, but can be modified as experience and practice dictate. This is all themore important when we realize that the use of such aides isnew and relatively untried. Each project in which aides are utilized will, forsome time to come, be in the nature of a demonstration. We hope through such projectsto be able to answer questions such as "who can do the job?" and "what kinds of thingscan be done by a particular group ina given setting?" The accumulation of such data becomes one of the more important tasks for the future.

SUMMARY AND CONCLUSIONS

The three major components of the trainingprocess have now been identified as: (1) thecore group, including basic training in what can be described as generic human service skills, (2) specializedskill instruction, and (3) immediate on-the-job experience. It should beclear from the foregoing presentation that each one of thesecomponents is designed to comple- ment the others. Each derives its significance and impetus from the othertwo. Some of the problems and issues that arise fromtrying to achieve an integration of program elements have already been suggested. Perhapsthe simplest guiding principle for successful integrationis contained in the notion of flexible and sdfcritical programming. There isa need to be flexible in the sense that because this isa new kind of approach, there are very few available guidelines or experts. The trainingprogram must be responsive to changing needs, and it must be organized in sucha way that those internal changes that are requiredmay be made rapidly. Our use of the tenn self- critical is intended to underscore the necessity that theprogram be set up and kept open to receive continually informational feedbackabout what is going on in its various components. Thus problemscan be confronted im- 159 SERVICE AIDES THE TRAININGOF HUMAN fester. In this way,the program does mediately, rather thanbeing allowed to planned to be, oftenwith not end upbeing something otherthan what it was consternation of bothprofessionals and trainees.This the resentment and and potentially and unpredictedneeds to be recognized also allows for new example, grew out dealt with. The issueof remediation forthe trainees, for reading and writingabilities and of their own recognitionof shortcomings in well as to theexploration of new led to the creationof remedial classes, as with academics. TheInstitute for Youth ways ofcombining aide training local high schoolin an ex- Studies is, for example, nowcooperating with a into an aidetraining pro- perimental venture forturning their school year high school seniors. gram forthirty disadvantaged be seen as that has beendescribed above should The initial training been defined in just thata first stepdesigned to take youthswho have often pathological terms and totrain them tohelp render many negative or even clearly has re- often prescribed forthem. Although it of the same services aim of the programis to habilitative and therapeuticfeatures, the primary of manpower forthe effectively a huge,generally overlooked source tap however, if we were content human services. Wewould make a serious error, kind of attendant orday laborer to stop withthisto create, as it were, a new where he is as is theditchdigger or who would just asirremediably be fixed choose to remain at afairly low level the janitor. Someof the youths will however, must be giventhe chance to of a particularoccupation. Others, without having to"give it all up" advance educationallyand professionally, order to accomplishthis, changes, in order to reachprofessional status. In conceptualization, willhave to many ofwhich are still in theearly stages of education, and humanservice. To refine be made in patternsof employment, also need the kindof new professional and implementthese ideas further, we only for programplanning that Reiff describeselsewhere in this book, not for training, supervising,and most and institutionalmodification but also manpowerrepresented effectively utilizing the newcadre of human service by the aides andother nonprofessionals. for the future, if we are tosustain All of this is part ofthe critical task these observations of a seventeen- the momentum andenthusiasm reflected in for almost two yearsin a child year-old, tenth-gradedropout, now working meaning is clear: care center.The grammar is notthe best, but the handling kids. I alsohave learned In Day Care, I havelearned many ways of problems, shy, the onesthat don't talk very how to cope withkids with home the group, how toplay or what to much, the ones that getalong with the rest of small kids you shouldknow their back- play with on a rainyday. In working with from, where didtheir parents comefrom, what do grounds, like where they come they staying they living with theirmother and father, or are their parents do, are they were born inthe alone, or with theirfather alone, whether with their mother do they live in now? District or elsewhere,what kind of environment child, and what to say tothem, how to You have to learnhow to talk to a 160 COMMUNITY PROGRAMS AND NEW SOURCES OFMANPOWER say it. You should learn how tofirm grip a child and you will have to learn how to give a child a lot of attention andfind out whether he or she really needs it, or whether they just trying to getit whenever they feel like it; you can't giveall of your attention to one child; it is alright to play with thekids but you must let them know that you are the teacher, and they must stay intheir class and you in yours. ... Some of the reasons why I like Day Care, being with smallkids and on the other hand working, it gave me some kind of feeling;watching and playing with them makes me think of my past, of some of the things orchances that I did not have when I was coming up. Sometimes while you areplaying with the kids you let yourself get carried away, you think of some of the things that youmissed when you were coming up.And then you get hold of yourself, and remember that you have a job to do, for I say to those that do not work in DayCare or don't like to work in it they don't know what they are missing. I think that itwould be better if more men were teaching in Day Care Centers. ...

...I know that some of us grew up the hard way or some came up easy way, but it seems like mine was the hardest, if Itold you the way that I came up you won't believe it, but ever since I got this job I havelearned and enjoyed every day of it. (Fishman et al., pp. 59-60). Put as concisely as possible, the human service aide program represents one aspect of amajor attempt at intervention into ongoing problems of manpower, patterning of services,and therapeutic effectiveness. Programs such as the one described in this chapter can provide areadily trained reservoir of personnel for the fields of human service. Moreover, theyoffer a combination of training, rehabilitation, and realistic employment that isstrikingly effective for a population that has long appeared resistant totraditional approaches. It must be emphasized, however, that dealing withimmediate manpower shortages, no matter how exciting the project is itself, can be an easy way of short-circuiting serious exploration of new concepts andapproaches. An appearance of change and movement canbe approximated, while it is only vacant job slots and service needs that arebeing filled. The significance of the aide program will be lost if we allowthe important fact of who the aides are toobscure the wider issues. The creation of human service aide positions is only one aspect of efforts to reorganizeexisting program structuresand institutions in line with new perspectives on community mental health, organization, and involvement.Seen in this light, the human service aide has the potential for becoming either one of anumber of gimmicks that are bound to appear in a period of reorientation or an occasion for serious planning, conceptualization, andresearch. Under the impetus of various new possibilitiesof federal funding and programs, the kind of training and manpower development described in this chapter isalready being experimented with in a number of communities across the country. Hopefully, these projects will not be content merely to demonstrate the efficacy of training the aides but will also come to see such programs as a major tool for investigating some of the more pressing issues of our time. 161 THE TRAINING OFHUMAN SERVICE AIDES

REFERENCES

Duhl, L. J. (Ed.) Theurban condition. NewYork: Basic Books, 1963. small groups withsocially Empey, L. T. A social systemsapproach for working in Psychotherapy Association, deprived youth. Paperread at American Group 1966. Philadelphia, Pa., January, Pearl, A., & L., MacLennan, B.W., Mitchell, L., Fishman, J. R., Klein, W. Com- Walker, W. Training for new careers.Washington, D.C.: President's mittee on JuvenileDelinquency and Youth Crime,1965. Studies of HowardUniversity. Trainingnon-professional Institute for Youth and process. Washing- workers for human services:A manual of organization ton, D. C., 1966. Levine, M., & MacLennan,B. W. Leadership inthe Klein, W. L., Walker, W., C.: Institute for Youth training of human serviceaides. Washington, D. ,. Studies of HowardUniversity, 1966. , of groups in job training.Int. J. MacLennan, B. W., &Klein, W. L. Utilization Psychother., 1965, 15,424-433. group Training for new MacLennan, B. W.,Klein, W. L., Pearl,A., & Fishman, J. R. 2, 135-141. careers. Comm.Ment. Health J., 1966, Fishman, B. W. MacLennan,& A. Pearl, A. New careersanoverview. In J. R. Ways out of povertyfor disadvantagedyouth. Pearl (Eds.), New careers: 1965, Washington, D. C.: Institutefor Youth Studiesof Howard University, Pp. 10-23. the poor. New York:Free Press, 1965. Pearl, A., & Riessman,F. New careers for Some observationsof normal Raush, H. L., & Sweet,B. The preadolescent ego: children. Psychiatry, 1961,24, 122-132. 10 A NEIGHBORHOOD-BASEDMENTAL HEALTH APPROACH

Frank Riessman Formerly, Director, Lincoln Hospital Mental HealthAide Program'

INTRODUCTION

The under-utilization of mental health resourcesby low-income populations has been attested to in a variety ofstudies beginning with Hol- lingshead and Redlich's classic Social Class andMental Illness (1958). A number of factors have been suggested ascontributing causes: high cost of services, lack of availability of services,failure of low-income populations to define distress in psychologically relevant terms,attitudes of low-income people toward mental illness, fear ofinstitutionalization on the part of the poor, andfinally, the middle-class character of the mentalhealth movement and the associated inappropriate nature ofthe services offered to low-income people. Stated another way, the present dayorganization of mental health resources isprimarily congenial to middle-class style and expectations.It has been noted that low-income individualsoften believe their problems to be externally produced or physiologically caused.They expect mental health clinics to provide drugs and clear-cut directiveadvice. Their focus is more on present, crisis-relatedproblems. They prefer that help be given in a more informal fashion. The setting of theoffice, the futuristic orientation, the stress on self-actualizationfound in the mental health movement is not congenial to them. With these factors inmind, most of the recommendations that have been directed toward working withlow-income populations have been mainly concerned with matching services totheir style and meeting their expectations, while less emphasis hasbeen placed upon content and program. The style match approach is oriented toward"reach" and communication. It is an effort to meet the low-income person onhis own "turf" and to utilize this person's style (and strengths) as abasis for working with him. Other than style match, there has been somedeveloping concern with

I Currently Professor of Educational Sociology, NewYork University.

162 A NEIGHBORHOOD-BASED MENTAL HEALTH APPROACH 163 what might be called style and skill expansion; thus a number of programs, particularly in the counseling area, have recognized the need for expanding coping techniques, know-how, verbalization, and other related factors among the poor. The use of role playing for stimulating verbal development is illustrative. But until now most of the emphasis has been on style matchand meeting the expectations of the low-income person, with little emphasis on content or goals. This has, in most cases, been justifiedbecause of the danger of imposing middle-class goals on the low-income population. It may be entirely possible to develop goals and programs that are consistent with the development of low-income life without necessarily "middle-classizing" the people involved.

THE NEIGHBORHOOD SERVICE CENTER

The Neighborhood Service Center (NSC) program to be outlined below attempts through structure, personnel, and program to integrate the many different proposed approaches to low-incomepopulation; but it endeavors to go considerably beyond 3tyle match and even style expansion. The NSC escapes the office atmosphere, shortens intake procedures and makes them less formal, has no waiting list, accepts any problem in any form, does not require continued visits, catches people at the nointof crisis, uses treatment agents recruited from the population itself1..1c, can be informal, personal, and friendly. It helps people with concrete, present-oriented problems and provides directive advice and assistance (i.e., it does not demand that the individual do it himself). Its staff is willing to make home visits at any time and participates in all types of activities including funerals, outings, helping people to move, ttrextinguishing fires in apartments. Recording of information and contact, is kept to a minimum. Talk and concrete help are combined. The NSC attempts to expand the know-how and coping ability of its clients. The NSC emphasizes group approaches yet has available hospital-based mental health clinics, with doctors and drugs as a backup resource. It stresses social activities and, finally, is concerned with developing a well-organized action program, one that is not only therapeutic but fundamentally concerned with problems ofthe neighborhooddrugs, violence,jobs,institutional changes in the service-providing agencies. This last provides a unique aspect which goes beyond most previous approaches. In essence, the basic strategy of the program represents an attempted integration of community action and preventive approaches to mental health problems. The NSC program is a structural outgrowth of the Lincoln Hospital Mental Health Services. The community served is a highly disadvantaged one located in the southeast section of theBronx, a borough of New York City. Not only is the population economically deprived but there is a marked dearth of services available to it. Compared to the Bronx as a whole, most of 164 COMMUNITY PROGRAMS AND NEW SOURCES OF MANPOWER the Lincoln area falls into the lowest quartile of median family income ($3700-$5400) and educational attainment (7.6-8.8 years) and the highest rate of male unemployment. The rate ofunemployment in this area is approximately twice that of the Bronx average. Similarly, the amount of over- crowded housing and school facilities is about twice that of the Bronx as a whole. In addition, compared to the Bronx as a whole:

1.Rates for juvenile delinquency offenses are 25% higher. 2. Rates of venereal disease among youth under twenty-one arethree times greater in some neighborhoods of the Lincoln area and one and one-fourth times as high in other areas. 3. The rate of public assistance cases is approximately twice ashigh. 4. Admission rates to state mental hospitals are 40% higher from this area. 5. Although reliable figures are not available, estimates of the percentage of deliveries of the LincolnHospital Obstetrical Service in which there is no legal father run as high as 70%. Comparable figures for the Bronx as a whole are not available. The NSC is a storefront, functioning at street level. Each center is staffed by five or six indigenous nonprofessionals from the neighborhood and one professional mentalhealth specialist or NSC director. The center is intended to serve a radius of five blocks (approximately 50,000 people). Be- cause of its storefrontcharacter, the center is easily available to area residents; in addition, staffing of the center by nonprofessional mental health aides makes for easy access by neighborhood people from the disadvantaged area. The NSC is seen as a basic new unit in a community mental health program devoted to preventiveintervention. It is conceived as a structural innovation in community mental health programs. Within this context, the NSC has the possibility of serving many different mental health roles at numerous levels. It can even function primarily as aclinical adjunct directed mainly toward secondary and tertiary prevention. In this sense, it might be more accuratelyemribed as a neighborhood-based mental health clinic. The preventive community approach of the NSC program is primarily related to its two sources of support: the Lincoln Hospital Mental Health Services, funded by the Department of Hospitals of New York City, and the Community Action Program of the Office of Economic Opportunity. The mandates provided by these two sources of support have been considered in defining both the goals and programming of the NSC. One emphasis, for example, which suggests itselfthe development of autonomy,independence, self-determination, and coping skills among neighborhoodresidentswould seem to combine elementsthat are clearly related to both sources of support. From the positive mental health viewpoint, autonomy is a primaryobjective, in the sense that Jahoda (1958) uses this concept inher survey of mental health principles. Likewise, the anti-poverty program is committed to com- 165 A NEIGHBORHOOD-BASEDMENTAL HEALTH APPROACH self- munity action projectswhich are oriented towardthe development of determination and autonomy onthe part of the individualsand groups in the community. It is important to attempt tospecify more clearly the mentalhealth focus of the NSC program inorder to understand the selectionof activities and specific programs. We havealready said that the larger mentalhealth goal of increasing autonomy is central tothe NSC design and, thus,programming the must develop inconsideration of this objective.It is in this context that significance of group services isstressed. It is hypothesized that grouplife directed toward certainmeaningful, achievable goalsinstrinsically contains significant mental health components.The experience of workingtogether, sharing, cooperating, andobjectifying problems is vital torehabilitation, increasing feelings of strength,and reducing helplessnessand alienation. How make a great dif- groups areformed, developed, and utilized, of course, can ference in the achievement of autonomyand in the decrease ofhelplessness. The use of the helper principle maybe of special importance.Here people aid other people but for are consciouslyplaced in a helper role not only to the development of thehelper himself: increasing hisleadership, coping ability, self-image, etc. (Riessman,1965a).

THREE GOALS OF THENEIGHBORHOOD SERVICE CENTER The three goals of the NSC program are,in actuality, means toward larger mental health goals; and inthis sense, they might moreaccurately be considered subgoals. The larger mentalhealth goals relate to increasing positive mental health andreducing negative mental healthby limiting, containing, and controllingpathology and its development. The three goals to be discussed are notpresented in any order of priority, but rather in the time sequencein which they arelikely to be developed. Thus, goal number one may overlapwith the later goals, but it willbe emphasized primarily in the early stagesof the program. Goal number twowill be developed at a later pointand is based upon some measureof success with regard to the earlier goal. The three goals are as follows: relevant to mental health.This 1.Expediting and providing services includes bringing new clientsinto the system of services,making service systems more responsive toclients, and providing additional new services. An effort is 2. Increasing socialcohesion within the concentration area. made to produce community impact,particularly with regard to the development of various types of groupsleading to the development of community action. Thus,the effort is to provide asociotherapeutic

i 166 COMMUNITY PROGRAMS AND NEW SOURCES OF MANPOWER approach oriented toward reducing powerlessness, building community ties, and group involvement. 3.Initiating various types of institutional change, particularly with regard to better coordination of services for the people in the community. An effort is made to change agency policies and practices with regard to service delivery and the development of comprehensive mental health services. This is a long-range goal and it is more connected, than are the first two goals, with other programs in the Lincoln Hospital Mental Health Services complex.

In the sections that follow these three fundamental goals and their concrete mode of implementation will be discussed in considerably greater detail.

Service and Preventive Intervention It is possible to conceive of a preventive mental health model that did not begin with individual services but proceeded directly to the development of groups or other efforts at building community action. In the present NSC design, however, individual services provide the entering wedge. It is through individual services that the target population enters the system. The target population is that segment of the poor who have been least active, are in greatest need of service, and are not responsive to militant social action appeals. We believe that through a service-oriented program beginning with service to the individuals, many of these individuals can be encouraged first to participate in informal social groups, later in more formal service groups and task-oriented groups, and finally, in various types of community action and intergroup activity. This sequence will be described more fully below. It should be underscored here, however, that we believe that it is necessary to begin with the service needs of the population in question. While service can be viewed as an instrument to the other ends of the NSCinstitutional change and community actionit isalso necessary to clarify the importance of service as an end in itself (or as a major means for improving mental health). Well-delivered service may provide increased comfort, reduce strain, and perhaps most significantly, prevent the development of cumulative stress. Langner and Michael (1963) hold the view that psychiatric disturbance is related to the number of stresses operative upon the individual. Thus, a service program designed to reduce stresses should have implications for mental health, both in the reduction of pathology and in the increase of positive mental health. Within this framework, the NSC is conceived of and presented to the community as a place where people can bring any type of problem. This is extremely important. It allows people the possibility of receiving immediate help and comfort without having to define the problem in a way apropriate for the caretaker or care-giver in the help-giving system. By so doing, it allows the individual some immediate assistance before A NEIGHBORHOOD-BASED MENTALHEALTH APPROACH 167 the problem becomes aggravated and perhapsdevelops into less reversible pathology. It allows for catching a problem in its early stageof development. Further, it enables the mental health system todeal with problems before they become symptoms, and it does not impose uponthe client the need to develop symptomatology in order to receivemental health assistance. More- over, it does not requirethat the client label his difficulties assickness or mental problems. Low-income clients, inparticular, have not been responsive to so labelingthemselves. Aside from the negative overtones involved inhav- ing a mental health problem,being defined as sick, as such, has regressive implications for the client; and to the extent thathe can be assisted with his problem without it being defined as sickness,the ego-weakening properties related to being defined as ill are reduced. It is our contention that the very nature ofthe NSC will enable the individual to define his problems in a more everydayfashion and to be less apt to conceive of himself assick. This, of course, requires not only the existence of the NSC but such an orientationby its personnel. It is clear, then, that a service-orientedapproach of the NSC is basically related to primary prevention. The orientation toservice includes:

I.Direct provision of service to clientsescortingof clients, giving information, filling out forms, writing a letter. 2. Expediting service from other agencies. 3.Integration and coordination of services (sincethe NSC can deal with multiple problems either directly or by expeditingservice from other agencies). 4. Referral and follow-up. The service orientation, to be mosteffective, has to be integrated with other dimensions of the program, such as thecommunity action aspect. These approaches should not be separated from eachother as they were, for example, at Mobilization for Youth (Riessman,1965b). Such bifurcation limits both the role of service and the role of communityaction. Many people receiving service have excellent potential forforming groups, perhaps service- oriented groups at first and later, task-oriented groupsmoving toward larger community action. Service groups are composed of peoplewith a shared service need, e.g., a group ofwelfare clients who experience inability in managing on alimited budget might form a group that discussedpurchasing, where and how to shop, etc. Task-oriented groups ar ..:. focusedtoward community issues of a broader kind, not simply immediate serviceneeds of the participants. For example, a committee c ,rganized to establishafter-school centers or to convert a vacant lot into aplayground is a task-oriented group. The service emphasis of the groups willprovide an input of specific community demand into the community actionapproach. Thus, it is unlikely that the community action prcgramwill develop goals, such as those that 168 COMMUNITY PROGRAMS AND NEW SOURCES OF MANPOWER developed at Mobilization for Youth, whichare not related to the immediate, voiced needs of the population receiving service. Mobilization for Youth developed rent strikes and school boycotts which, while, theymay have quite well reflected the long-range needs of the people in thearea, were not related to the immediate service requests of the population thatwas being served. The latter is clearly the focus of the NSC. Thus far, the services that have been discussedare what might be termed nonspecific mental health-related services. In addition, howeVer, the NSC program provides more specific "psychosocial first aid" and counseling of a simple type. In the early phases, this counseling consists largely ofpro- viding a listening ear andsome emotional support. The skills involved are based on enlarging the friendliness and warmth believedto be characteristic of the neighborhood worker's style. The nonprofessional's basicpattern of relationship is not "trained out,"so to speak, but is expanded by training appropriate for the rather primitive counseling to be providedat this stage. Later, this counseling skill can be expanded so that mental health aidesmay be able to assist clients in problem definition, in the consideration of alternatives, and in giving advice and guidance. In addition, the mental health aide is made aware of the fact that, in providing all types ofconcrete service, it is important to enable the client to talk fully and freely about his problems; that is, to provide an opportunity for catharsis andto furnish the personal emotional support that is so valuable. Thus,a psychological service is built in as a concomitant of most other services. It is unlikely tha the provision of counseling and psychologicalassistance will ever become separate from other services in the NSC framework.Multi- needs are typical of the population, and multiservicesare offered. This is quite different from the more traditional mental hygiene clinic wherepsy- chological service is often isolated from othertypes of concrete help. In the NSC the ruk is the combination of services, and it israre for psychosocial first aid or counseling to be furnished independent of other services. We believe this is a particularly appropriatepattern for a low-income population and that counseling and mental health servicesare much more acceptable in thiscontext,particularlyas provided by nonprofessional neighborhood "friends." An important dimension in furnishing service at the NSC isto have the nonprofessional mental health aide providean appropriate model to the client or customer. The program encourages the client to become involved in a mutual and reciprocal relationship with other people who are also in need of help. People are encouraged to help each other andnot simply to receive help. The aide has to be trained to present this model and toencourage this form of interaction and development. He has to be constantlyon the alert to transform helpees into helpers, and basic communitynorms must be built that emphasize co.nmunality, mutuality, and reciprocity. In this connection, 169 A NEIGHBORHOOD-BASEDMENTAL HEALTH APPROACH Weissman's2 approach todeveloping service-giving powerand technology in consider. Weiss- the people who comefor service is extremely important to the client man envisionsthe provision of service asthe first step in teaching client the ability to how a service system operates.His aim is to give the administer services (e.g.,filling out housing forms) and toexpedite services. power to Weissman is concerned withproviding elements of service-giving service is rarely to the members of the community,and thus he argues that of service and even be given without alsoteaching the client the machinery this does not how to teach the service operation toother people. Obviously, possible, it may be a related apply to all people coming forservice; but where service orien- goal of considerable significanceand may greatly strengthen a tation.

Past Failures It is important to note that mostindividual service programsdevel- oped by social agencies appear tohave been relativelyunsuccessful with that there are probably anumber of . low-income populations. We suspect reasons forthis: (e.g., community 1.Service was not articulatedwith other approaches typi- action). The debilitating stigmaattached to receiving help was cally not counteracted by acommunity action self-helporientation, focused on the developing of powerby the low-incomeindividuals receiving help. 2. The service approachdid not focus on specific targets,neighborhoods, and problems. It did not concentratesufficiently on a circumscribed area, but ratherattempted to provide servicesfor the community as limited a whole;hence, impact was minimal.By "keying" on a more five-block radius, it may be possible tomaximize service effectiveness. forms of service 3.Service was defined toonarrowly; the need for new and group service approaches wasoverlooked. servicesthe 4.Little attempt was made tointegrate and coordinate special importance of theexpediter role was ignored. 5. The services were toomiddle-class oriented and notwithin the reach intended for, and of the low-incomepopulations. They were not were notpresented in, a style appropriatefor these populations.

By way of overview, theservice approach in itsfullest sense may not only reduce stress and containpathology but should alsoproduce additional strengths in the communityand increase positivemental health in various service oriented will prob- ways. However, anNSC program which is simply ably be limited. It is onlytogether with other forms ofintervention that the

2 Personal communication. 170 COMMUNITY PROGRAMS AND NEW SOURCES OF MANPOWER maximal potentialities of the service approach can be harnessed. We begin with a service approach because people who are most in need of service and least responsive to other types of appeals are our main target among the disadvantaged population; however, our aim is to go far beyond this entry point. A more concrete picture of the service function of the NSC program can be obtained by a brief look at some of the statistics gathered in the first six weeks in which the first center was operative. Of those people seen, approximately 70% were women, 69% were Puerto Rican, 18% Negro, 13% non- Puerto Rican white. Fifty-one per cent were walk-ins, 16% were referred by other agencies, 19% were referred by families or friends, and 4% were referred by Lincoln Hospital. The main areas in which service was requested were housing 25%, welfare 22%, employment 23%, and family problems 8%. With regard to disposition, 39% of the cases were concerned with information and referral, while 49% involved direct expediting. Looking at our statistics over a somewhat longer bloc of time, we can report the following. From February 22, 1965, when the first center opened, to December 31, 1965, 7,119 differer: people were served by two of the centers. During the six-month period (July-December) when both centers were in full operation, 6,620 new cases came for servicean average of 1,037 cases per month. Projecting these figures for a full year's operation gives a total of 6,220 individuals per year per center. The size of the average family coming to the center is 3.9 persons. Thus, it is not unreasonable to state that, indirectly, each center touches the lives of some 25,000 people; and this does not include the many hundreds more who have become involved with the center through the various community education and action campaigns. Based on these statistics, it appears that the NSC is an excellent device for reaching a large proportion of the residents in the area it is designated to serve. Though experience with the centers is limited, findings to date are most encouraging. It seems fairly clear that nonprofessionals can provide and expedite service for large numbers of disadvantaged families. Moreover, it is evident that nonprofessionals can interveneincriticalsituations,engage comparatively pathological people in meaningful relationships, stimulate them to take action in their own behalf, mobilize community resources, and serve as a bridge between the client in need and the professional service. The nonprofessional is able to perform some tasks that are usually carried out by professionals but really do not require professional training and experience. In this manner, the outreach of the professional service is expanded, and considerably more people can be affected than would be possible by using professional personnel alone. In sum, then, it may be said that the service approach emphasizes, in the main, the "supply" aspect of the problem. It attempts to provide a more efficient, better integrated caretaker supply of resources for the client. It endeavors to connect the person with the service more efficiently via its expediter APPROACH 171 A NEIGHBORHOOD-BASEDMENTAL HEALTH of consumer demand dimension. It is not concernedwith the development objective that the secondmajor goal and community action.It is to this latter of NSC is directed.

Community Action and social action A point of historical contrastbetween mental health within formal and exist- models is that the formerhave functioned primarily whereas the latter are morelikely to deal with ing institutional structures, of inE7mal elements of thecommunity at large, toactivate large numbers individuals, and to energizeself-helping orientationsand self-improvement. militant or otherwise, from The social action approachactivates pressure, outside (Peck, Kaplan, &Roman,1966). whose preventive psychiatry It is interesting to notethat Caplan(1964), base for the presentchapter, framework has provided muchof the conceptual defines social action in termsof affecting administrativepolicy: policies and Social action is the namegiven to efforts tomodify political and social education, welfare,correctional, legislative and regulatoryactions in the health, community-wide scale theprovision of and religious fields so as toimprove on a and the organizationof basic physical, psychosocial,and sociocultural supplies with crises. Themental health specialistoffers con- services to help people cope with other citizens in sultation to legislators andadministrators and collaborates laws and regulations(p. 56). influencing governmentalagencies to change community action from Caplan's system has notdeveloped the role of influencing mental healthand a below as a major positiveinstrument for disorder. Indeed, relativelyfew strategic element inprevention of emotional the role of com- mental health professionalshave given much attention to nonprofessionals, as munity action. TheNSC, as a structure,and the use of personnel, allow for themuch fuller developmentof community action. concerned with The mental health movementcharacteristically has been from above; hence thecritique of the integration andorganization of supplies providing continuity andinte- the fragmentation ofservices and the stress on above quotation gration. Caplan isprimarily concernedwith supplies as the with the developmentof indicates. By contrast, Reiff(1964)is concerned section of theEconomic "effective demand," andthe community action Opportunity Act is orientedtoward the developmentof community demand movement islargely con- from below. It isnoteworthy that the anti-poverty therapeutic aspects ofthis communitydevelopmentwith cerned with the of -nm- self-help and the likeandis less concernedwith the development the direction ofinstitutional change. Thisreflects the munity action in goal is anti-poverty focus onchanging people ratherthan institutions. The institutional change. While the direction ofsociotherapy rather than more in believe that in order f6r we recognizethe potential valueof sociotherapy, we i 172 COMMUNITY PROGRAMS AND NEW SOURCES OF MANPOWER action to be fully effective at a therapeutic level it must have adirection. The particular direction that we shall suggest later is institutional changeof a certain type. Caplan (1964) has noted that preventive psychiatry is fundamentally concerned with affecting rates of disorder. In this sense it is sociological in the Durkheimian tradition, not directed toward the individual.Durkheim (1952), and his followers, long ago noted that rates of pathologyand other social facts could be varied as a reflection of other social phenomena.In particular, Durkheim observed that one type of pathology, namelysuicide, varied inversely with the social cohesion of the group; thus, suicide rates were greater among urban groups,divorced individuals, people whose economic status had changed rapidly, and so on.More recently, Leighton (1965) has noted that more integrated communities appear to be lesssubject to mental stress and mental illness. Socialcohesion, of course, is only one community relevant variable that might be treated, and it does not affect all typesof disorder equally. In fact, there are certain types of disorder which may notbe significantly affected at all by varying the cohesion of a community.It is of interest to note that suicide rates are relatively low in theHarlem community, while other forms of social pathology, e.g., drug addiction, arehigh. Increas- ing cohesion, however, should not only limit pathologybut should also provide increased positive mental health, greater autonomy,independence, and the like. Another community-relevant variable which might be effectivelymanipu- lated in a similar fashion is the *nvolvement of the community inlocal issues. These can vary from clean-up campaigns to the reductionof violence or anti-drug approaches to social and political issues. PrestonWilcox in East Harlem has developed a self-help approach oriented toward someof these issues largely in a nonpolitical and nonconflict format(Sexton, 1965). On the other hand, as Riessman (1965c) has observed, Saul Alinsky hasemphasized the stimulation of conflict which is to be directed toward somelocal enemy. Alinsky's followers have claimed marked sociotherapeuticresults as well as the reduction of crime and delinquency in areas he hasorganizedin particular, the Wood lawn Organization (TWO) in Chicago.One of the mechanisms that may be operative here is the eliminationof the little "rumbles" by making one great big "rumble"; that is, turning attention andhostility toward a common enemyoutside the community. Both Haggstrom (1964) and Sil- berman (1964), in discussing the Alinsky approach, haveemphasized the importance of social action in developing the dignityof the poor, reducing apathy, and the like. There are a number of dangers in the sociotherapeutic approachwhich should be mentioned before going further. Most of itsadvocates generally suggest social and politicalgoals of a liberal or progressive character, e.g., civil rights, rent strikes, campaigns against consumerfraud, and so on. It should be noted, however, that it might be possible to have highly reactionary APPROACH 173 A NEIGHBORHOOD-BASEDMENTAL HEALTH argued that it ispossible which are alsosociotherapeutic. Reiff3 has programs effects for many in Germanyhad sociotherapeutic that the Nazi movement that involved in it. Anotherissue which mustbe considered is of the people depends which is mounted, thesociotherapeutic effectiveness in any program meaning and atleast careful planning to assurethat the program has upon spread, or limited success. It is importantthat such programsbe sustained and Otherwise the gainswiil multiply in the community,and not be short-lived. disappointment will set in. be short-lived, andcynicism and something to learnfrom certain We believe that anNSC program has but his focus has anumber of sociotherapeutic aspects ofAlinsky's approach, viewpoint. For the mostpart, Alinskyhas focused on and limits from our of the poor who are more helped to organize thepotentially militant sections he advocates. In anyneighborhood of the prone to acceptthe conflict position forward when grievances arestressed, and it is not poor,people will come the But we suspectthat these people represent difficult to stir their anger. in the community. By contrast,there are large segments potential "actives" of unmoved by mili- the communities ofthe poor who areleft untouched and tant appeals. is a Organizing the inactive poor,sometimes calledthe apathetic poor, militant or activist task than organizingthe potentially much more difficult appealed to initially on poor. It is ourcontention that theformer can be best service rather thanmilitant group action.After provid- the basis of individual drawn into small groups for them, theseindividuals can be ing some service buildings of initially these groups meetin the houses or of an informal type; highly informal andprimarily the people beingserved. Their meetings are the nature of theinteraction. Later on,these groups meet social in terms of staffed by people from which is characterizedby informality and in the NSC, meetings that are The indigenousnonprofessionals lead the neighborhood. improved character. These groupswork toward obtaining highly social in influencing institutional service for themembers of thecommunity and This is the long-rungoal; the imme- change in theservice-providing agencies. development of various typesof small groups, diate objectivewould be the social groups, service groups,task-oriented groups. of cohesion,involvement, The sociotherapeuticgoal is the development of isolation,apathy, and powerlessness. and independenceand the reduction this goal is theutilization of individual The means forthe achievement of meetings and thedevelopment of service, group service,and community various types ofleadership. NSC and itsnonprofessional staffing It is believed thatthe nature of the of this type ofsociotherapeutic areespecially appropriatefor the development community actionmodel represents programming. Thefollowing outline of a in relation to sixphases of development, an attempt toformulate the program

3 Personal communication. 174 COMMUNITY PROGRAMS AND NEW SOURCES OFMANPOWER 1 the first phase involving the recruitment and trainingof the nonprofessionals who are primarily responsible for theimplementation of the later phases.

A New Community Action Model This new approach to community action is proposedin order to involve segments of the poor hitherto unreached byeither service programs or protestsocial action groups. The objective is to engage thispopulation in a graduated series of tasks of increasing complexity,beginning with individual service and moving through five phasestoward involvement in large-scale community action. The target population is composed of segments of the poorwho are most in need of services, have been least active intheir own behalf, are least responsive to militant, conflict-centered appeals,and have limited experience with meetings, organized activity, and formal leadership. Our assumption is that previous social actionapproaches have failed because they have not started where the poor are. The programs werenot begun in relation to the service needs of the populationconcerned. On the other hand, service-oriented approachns have alsotypically failed with this population because of a lack of direction anddevelopment; that is,the approaches wdre largely oriented toward providingindividual nrvices for the people involved but were not aimed at moving themtoward group activity, stages of community action, andleadership development. In other words, there has been a bifurcation of service and social actionapproaches. This is most evident in the programmingof Mobilization for Youth, where the Com- munity Organization and the NeighborhoodService Center approaches were, in the main, separated from each other.We believe that the form of service- based social action to be outlined is most appropriatefor government-supported projects, since it is likely to produce theleast political backlash of any type of social action. The proposed program is based on an attemptedintegration of projects and concepts such as Mobilization for Youth'sParent Education Program developed by Dowery as distinguished from its other moremilitant community organization programs (Riessman,1964), the self-help concepts formulated in particular by Preston Wilcox (Sexton,1965), applications of small group theory and technology to social change, asenunciated by Peck, Kaplan, and Roman (1965), and the utilization ofthe style and know-how of indigenous -oersonnel (Brager, 1965). The approachis in sharp contrast with the community mobilization, protest social actionapproaches of Alinsky and Mobilization for Youth. The model isoutlined in a six-phase plan as listed below for an NSC program functioning in amental health context.

Phase One: Recruitment and Training ofNonprofessional Mental Health Aides.The nonprofessional mental health aides are such afundamental part 175 MENTAL HEALTHAPPROACH ANEIGHBOR400D-BASED that it may be useful tosurvey of the functioningof the NSC program selection, and trainingof the group. briefly some aspectsof the recruitment, done largely throughthe formal andinformal The initial recruiting was meetings, the agencies of thecommunity, localradio stations, community JOIN, and so on.We indicated that we were stateemployment services, who lived in theneighborhood and wouldlike to work looking for people school educa- that we did not requirecompletion of a high with people and ulti- people applied forthe positions, and sixof these were tion. Forty-five The selection procedure was mately selected forthe initial training program. asfollows: held at which wedescribed 1. A large meetingof all the applicants was salary, and so on,and answered the job, indicatedpersonnel practices, cpiestions. the total phase consisted of groupinterviews in which 2. The next individuals. group wasbroken down into groupsof ten or eleven had a one-way screen These interviews wereheld in a room which social worker, a psy- behind which satfour judges: a psychologist, a conducted by two chiatrist, and a nurse.The group interview was candidates' attitudes people and was directedtoward ascertaining the they rejected thepeople toward theneighborhoodwhether or not toward people onwelfare; who lived in theneighborhood; attitudes disturbed people, and feelings aboutdiscrimination, minority groups, and rated the applicants so on.The judges observedthe group process empathy, attitudetoward with regard to thefollowing characteristics: ideas and feel- authority, comfort in a group,ability to communicate for self-awareness,reaction ings, trainabilityand flexibility, capacity work and life experience. to stress,pathology, and relevant concerned that the people weselected be "bridge" We were particularly the professionals, people; that is, beable to communicatewith ourselves, with and with the people inthe neighborhood. selected for 3. From the fouroriginal groups, afurther group was another group session. whom there 4. An individualinterview was heldfor candidates about was stilldoubt. The training program wasdivided into threephrases: based at of three weeks inwhich the training was 1. A pre-job period The emphasis was on the Lincoln HospitalMental Health Clinic. operational tasks such ascommunity surveys,door-to-door interviews the hospital,visits to with families, assistingthe intake team at such as theDepartment of Welfare,the Police various agencies playing Department, the schoolsand so on. Jobstimulation and role OF MANPOWER PROGRAMS ANDNEW SOURCES 176 COMMUNITY in thisphase, andthere was central featuresof the training the were The training wasconducted by verylittle didacticpresentation. workers. All psychologists andthree social including two had NSC staff, training, andthree of them had considerableexperience in ofnonprofessionals. specific experiencein the training the aides were intensive trainingprogram, 2. Followingthe three-week their time was period of twoweeks; half of placed at theNSC for a and the otherIn lf service toresidents of the area devoted to specific on-the-job experi- training based nowon the was spentin further of the day,and the Thus, the center wasopenfor one-half ences. in thisperiod of time. aides actuallyfunctioned fully which is now place continuouslyat the center 3. Ongoingtraining takes one-fifth of theweek is operation.Approximately openand in full development of newskills, further spent onsystematictrainingthe Once a week of mentallyill people. understanding ofand identifying meeting withthe trainingcoordinator the aidesparticipate in a group general prin- problems and tohelp develop to discusstheir on-the-job techniques.On-the-job supervision ciples and learnadditional helper of the NSC.In addition toregularly is suppliedby the director to usethe aides havethe opportunity scheduledconferences, the supervisor on anas-needed basis. non- In this phase,the indigenous Basic IndividualServices. of the com- Phase Two: focus discoveringthe needs have as their Major professional workers the presenceof the NSC. informing thecommunity of munity and of serviceand to theprovision itself relate tothe expediting tasks of the center letters, escortingpeople, filling outforms, writing of simpleservices such as is providedby discussion of theexpediting function translating, etc.A fuller Riessman (1965). of information Reiff and phase relate tothe acquisition The trainingneeds in this how to cutthrough about knowingchannels and about communityresouices, interviewingskills clients to followthrough. Basic red tape,about stimulating neighbor has tobe enlarged role modelof friendly have to belearned. The and emotionalsupport provide thelistening ear upon toenable theworkers to first aid. necessaryfor psychosocial this phase is onthe Groups. Theemphasis in Phase Three:Small Informal preparation for activity, initiallyhome-based, in development ofsmall group service at involving all thepeople whohave received the communitymeeting visited the centerfor service all the peoplewho have the NSC.Each month, the mental meeting atthe centerconducted by areinvited to acommunity discovering theneeds of the is orientedtoward health aides.The meeting deal with theseproblems, organizing groups orcommittees to neighborhood, and developingleadership. 177 A NEIGHBORHOOD-BASEDMENTAL HEALTH APPROACH The training needs at this stagerelate to the developmentof groups, home visits and follow-up, the spottingof leaders, the deepeningof counseling approaches, and furtherpsychological understanding.

Phase Four: The CommunityMeeting and Task-OrientedGroups. The emphasis in this phase isdirected toward the development ofvarious types of more organized group activity.The functions of the nonprofessionalinvolve organizing the communitymeetinginformal, social dimensions andtask- oriented aspects; starting service groupsand task-oriented groups;developing campaigns, particularly inrelation to under-utilized health services,the use of surplus foods, and registrationof children in preschool programs. The training needs at this stagerelate to providing skills fordeveloping committees, preparing people toparticipate in other organizations, e.g.,PTA meetings, and planning campaigns.

relating Phase Five: Intergroup Programs.The emphasis in this phase is on and forces the committees and groupsdeveloped at the NSC to other groups extremely important phase of in the community.Leadership development, an agencies, planning the program, is facilitatedthrough combining with other councils, and community groups on alarger community actionbasis; planning community action in relation toservices which are notunder-utilized and where there may be somepolitical backlash (e.g., welfare,schools, etc.); for- techniques, mal leadership trainingdevelopment, knowledge of service-giving participation on advisorycommittees, special counseling,and clinical assistance where necessary. Training needs here relate to communityaction skills, the development of "meeting" tactics at ahigher level, leadership trainingtechniques, and methods of "teaching" low-incomepeople.

Phase Six: Institutional Change.This final phase, to beelaborated on more fully in the next major sectionof the chapter, is concernedwith coordinating community action programsthroughout the city and country.The "open conspiracy openly arrivedat" calls for bringing togetherrepresentatives of community action projects fromdiverse places who have problems in common, the solution of which requiresthe development of programs inrelation to employment, welfare, and housing on anational scale. This is a long-run objective.

Institutional Change In order for the sociotherapeuticeffects of community action to be other than temporary, the program musthave achievable objectives; and some of these objectives must, infact, be achieved in a reasonableperiod of time. School boycotts that do notproduce changes in the schools canhave socio- 178 COMMUNITY PROGRAMS AND NEW SOURCES OF MANPOWER therapeutic effects of only short duration. Moreover, the disillusion thatsets in from repeated failure may haveconsequences that far outweigh the short- lived sociotherapeutic effects. It is not difficult to establish and achieve certain short-runaims: under- utilized services such as prenatalcare can be better utilized through organized group-oriented campaigns; self-help projects directed towardclean-up campaigns, renovating vacant lots, etc.are eminently achievable. There is no question that "the system" has considerable "give" in it, andit is the responsibility of community actionprograms to assess this "give" and maximize it. But there comes a point where in order for thecommunity action program to have continued momentum, larger, more fundamental changesare necessary. The question arises as to which of these changes falls within the province of a mental health orientedagency supported by public funds. We believe that it is appropriate foran NSC program to seek institutional changes in public and private agencies that will enable themto provide improved, integrated service. A widely held mental health aim todayis directed toward more continuotr, coordinated, comprehensive service. Hence, changes in policies, practices, and structure in relationto the service-providing agencies would seem to be an appropriate aim. This objectiveis consistent with the overall mental health orientation of the Lincoln Hospital MentalHealth Services and seemsnecessary if the war against poverty is to have any large meaning. However, the goal of institutional change is less intrinsically relatedto the structure and character of the NSCprogram than is the direct service goal or the development of communityaction. The center is, by its very nature, related to the development of demand by the peopk in theirown locale. It is less immediately relatedto the formal agencies of the community. Of course, it isnecessary to relate to these agencies in order to expedite service, but this requires a reachingout by the NSC. Its more natural function relates to the people in thearea, not to the institutions. Even when it reaches out to the institutions, this is by way of expediting service rather than institutional change. Providing service and developingcommunity action are, thus, seen as objectives that are more intrinsic to the NSC, while institutional change is somewhatmore extrinsic and, to some extent, appended. Neverthe- less, for the reasons cited above,we feel that it is a necessary aim if we are to develop service to new levels and provide a meaningful long-run objective for the community actionprogram. To be fully effective, the NSC orientation toward institutional change should probably be placed in thecontext of the larger parent group, in thiscase the Lincoln Hospital Mental Health Services and its network of influence. The strategy and technology of theparent group is more definitely directed toward institutional change (Pecket al., 1965). There are, however, a number of dimensions of the NSC itself which bring it into the arena of institutional change,at least indirectly. First, its very existence upsets the equilibrium of the agency system. By its very nature A NEIGHBORHOOD-BASED MENTAL HEALTH APPROACH 179 it makes new demands with regard to the distribution and organization of services by the other agencies in the community. Its mandate from the Office of Economic Opportunity provides a legitimacy for its service demand and role in the community. Moreover, it does not simply treat its "customers" as consumers of service, but organizes them as group members, citizens, demand- ers of service. Its community action dimension provides a powerful lever for institutional change. It cannot be emphasized enough that the present anti-poverty climate provides further implicit power for the NSC. The center's mandate seems to require the improvement of services, and it has certain sources of power for implementing the betterment of these services. For example, it has fairly easy access to publicity and thus can play a type of watchdog role, making knowii its complaints about the inadequacy of service to the poor. Moreover, the stance of the NSC program represents something of a third force, suggesting that it is an intercessor or mediator between the people and the agency decision makers. The NSC does, in fact, stand midway between these two forces, much nearer to the neighborhood people than any other agency, and nearer to the agencies than any other community organized group. While it has special power deriving from this position, there are attendant limitations. A protest social action group, which lies further away from the agencies, has force that the NSC does not possess. On the other hand, the social action group does not have the mediation potential of the NSC. The NSC can also affect institutions in the community via an imitation or contagion effect. We have observed that a variety of group-serving agencies in the area have requestLi guidance in establishing smaller NSC programs. There are many paths by which institutional change can be introduced into the community by means of the NSC program. The power of the NSC to provide assistance to other agencies in the community, via the service and expediting it provides, can serve to influence, reciprocally, the responses and rules of these agencies. Thus, the Welfare Department might be persuaded to provide for consolidated caseloads with a welfare worker based in one NSC and serving the center's area. A similar development could be achieved with other agencies, such as housing. JOINJobs in the Neighborhoodestab- lished such a relationship with the first NSC. To the extent that the NSC program utilizes a legal approach, such as that developed at Mobilization for Youth, it has the possibility of fostering institutional change through the use of the law. Mobilization for Youth is attempting to make significant changes in Department of Welfare practices by taking specific oces to court. It should be noted that the legal approach does not require an NSC. It is neither a natural outgrowth nor a necessary development of the NSC program. Nevertheless, it may be extremely useful as an added feature. Insofar as the NSC, in its community action role, develops leaders in the community, it indirectly produces a force related to institutional change. 180 COMMUNITY PROGRAMS AND NEW SOURCES OF MANPOWER Finally, it should be noted that the NSC itself might become a permanent new institution in the community. It can and should perpetuate itself as a new force in the service development of the community. By so doing, all the practices and policies that it develops become part of the institutional fabric of the area. Any program such as we have described must plan for the continued development and motion of people. Plans must be developed not only for the high periods of excitement and intense activity but also for the low periods in which there is an ebb in motivation and concrete action. New activities must be planned for different stagesin the early phases, the small groups and social types of activity which are more informal in character; later, the service groups, the task-oriented groups, the community meetings, the campaigns, etc. It is only through this type of planning that the involvement of the poor can be developed and maintained. These plans must also include the recognition that many people will not move along through all the various phases and that these people must not be lost. The community's development is uneven, and we cannot demand that everyone become involved in intense campaigns. People must have the possibility of maintaining their involvement and attachment to the groups that are formed, and various roles must be developed that they can fulfill other than through their becoming leaders. The impact of institutional change on mental health is somewhat more indirect than the sociotherapeutic effects of community action or the stress- reducing effects of added or improved service. Intervention at the "top" takes time to develop; and its effects on mental health, while perhaps more pervasive, are more delayed than is direct functioning in groups aimed toward greater cohesion. The latter probably has more immediate mental health-producing properties.rtis important, however, that community action not simply endeavor to be a therapeutic process in and of itself, but actually achieve some changes in the system that have long-run mental health consequences.

OTHER NSC GOALS: SECONDARY AND TERTIARY PREVENTION There are various possible models for the mental health-oriented NSC. One way of viewing the possibilities relates to whether the center is to be concerned mainly with primary prevention, secondary prevention, or tertiary prevention. The model described above is principally concerned with primary prevention. The tasks of the aides are related to this goal, as is their recruitment, selection, and training. The NSC oriented toward secondary prevention and tertiary prevention would develop very different programs and correlatively would have different recruitment, selection, arid trainingpro- cedures. Secondary prevention-focused centers, since they would be concerned

1 A NEIGHBORHOOD-BASED MENTAL HEALTHAPPROACH 181 with early case finding and rapid referral, wouldhave to train the mental health aides much more fully to detect the signs ofpathology, to persuade clients to utilize clinical facilities, and to serve inholding actions or other interventions where these facilities were notavailable. Twenty-four hour emergency service at such anNSC might be indispensable inorder to catch people at the poi:t of crisis and provide immediate assistance,both of the first-aid type as well as the clinical referral thatwould be expedited and followed up by the aides. There is the possibilitythat the referral sources in the community may be limited, andtherefore a secondary prevention-oriented program might uncover more casesthan could be adequately treated by the existing clinical facilities. Under thesecircumstances, a secondary prevention program mightconsider adding to the treatment technology orintervention skills of the mental health aides themselves. Herethe aides would not merely provide psychosocial first aid but would expandtheir skills and move toward various types of counseling, groupapproaches, etc. The aides might be trained in how to coordinate with mentalhealth specialists, who would appear at the NSC weekly toconduct specialized diagnostic work,prescribe drugs, and so on. In addition, the aides mightbe trained as group therapy assistants, thereby expanding the efficiency of professionalpersonnel. In this model, the NSC begins to approach a neighborhoodmental health clinic. While it is possible to develop anNSC orientation which focuses on finding the ill members of the communityand institutes some intervention as rapidly aspossible, there are some special issues thathave to be confronted in doing this. First, if the NSCbecomes known as a clinic for emotional problems, there is the possibility that theneighborhood will focus more on these problems; people to some extent maydevelop the appropriate symptomatology in order to receive service, andthe community action orientation may be reduced.Community people and social agenciesalike may find and refer far more people with emotionalproblems. It is interesting to note that as the first NSCbecomes known for its mental healthaides and mental health back-up orientation, social agencies inthis community increasingly refer more and more people withpsychological problems. As yet, this form of referral has not taken place from amongthe population of the area itself. In other words it is the externalcaretakers, not the internal ones, who are referring clinical cases so far. It is noteworthy that in the earlydays of the operation of the Benjamin Rush Clinic in Los Angeles, hundredsof low-income people waited in long lines to receive crisis-oriented, short-termtherapy after the newspapers had announced that such treatment wasavailable at low cost. The question remains whether it is useful to a community toselect this emphasis and appeal. It might be argued that largenumbers of people in the low-income community have ego defects andtherefore have need for therapeutic intervention. In this formulation,secondary preventionis carried considerably beyond the public health modelespoused by Caplan (1964). Caplan is 182 COMMUNITY PROGRAMS AND NEW SOURCES OF MANPOWER mainly concerned with case finding, rapid referral, and treatment of actual disorders; he wishes to reduce the prevalence of mental illness, not underlying pathology, and he aims to do this by reducing the length and intensity of the disorder by means of early detection. There is no necessary reason, of course, why clinically oriented treatment as well as other forms of intervention (environmental manipulation, involvement in social groups, etc.) cannot be made available for people with emotional disturbance at the same time that other problemshealth, housing, and the likeare dealt with and perhaps even emphasized at the NSC. The question remains whether the treatment technology to be provided through an NSC program for the psychologically disturbed should consist of counseling, group therapy, and the like, or whether the emphasis should be more on social forms of interventioninvolvement of people in various types of groups, etc. If the latter is the case, the training of the aides and the program of the center would be of a different character. In this model, although the aim would be the reduction of pathology, the methodology would not be clinical. It is clear, of course, that for different :nde. ,1 fathology, different intervention patterns would be necessary. We are not.=,gesting that sociotherapeutic methods can be equally effective with all types of illness. What is less clear, however, is whether the NSC is an appropriate place for the extended utilization of technologies other than sociotherapeutic ones. A related issue that arises is whether it is possible to train mental health aides in a wide range of skillswhether they can, in fact, be generalists. Is it likely that the same nonprofessional can develop community action skills and clinical skills, or is it more appropriate to think of different aides developing different repertoires depending on their personalities, previous backgrounds, and the training that is introduced to develop these latent abilities? Moreover, the approach to nonprofessionals which emphasizes the development of their style, neighborhood "know-how," basic approach to peopletheir "subjectiv- ity"and peership would seem to be less relevant in terms of development of specific therapeutic skills. From the viewpoint of counteracting the mental health manpower shortage, it may be useful to develop nonprofessionals as group therapy assistants and the like, but it does not particularly take advantage of the nonprofessional's neighborhood base, history, and background. In the tertiary prevention model, the NSC could serve as a rehabilitation base for aftercare groups, keep-in-touch clubs, etc. Social groups of various kinds could meet at the center with the aides playing an important role in working with these groups, always supervised and perhaps assisted by judicious, periodic use of professional personnelpersonnel that need not necessarily be stationed at the centei. The aides might serve a strategic role helping the returning patient to relate to his family and the community. Home visits could be made to the patients' families to help them prepare for the returnees. The mental health aides could also work with the patient upon his return and assist him in becoming involved in the community. We believe that it would 183 MENTAL HEALTHAPPROACH ANEIGHBORHOOD-BASED to devoteitself entirely totertiary be uneconomicalfor an NSC program although it can serve asignificant ancillaryfunction. prevention, approaches whereby some There is morelikely to be amelding of NSC of the community, aswell as the of the internalcaretakers or care-givers for the rehabilitationof people returning be utilized in anaftercare program which mental institutions.Thus, a sewing group to thecommunity from living in the areamight specific value for anumber of people might have is planned inrelation to for returnees.Here, the program also be suited adjunctive fashion as arehabilitation primary preventionand serves in an resource. the involvement secondary and tertiaryprevention models, In both the well as the caretakers or care-giversof the community, as of the internal important feature.Alco- self-help groups,might be an various therapeutic in the com- and other similar groupscould be developed holics Anonymous the center couldbe used as a munity, conceivablybased at the center; or In this sense, treatmentand prevention major meetingplace for these groups. areclosely allied.

CONCLUSION (NSC) is an innovativestruc- The NeighborhoodService Center effective approach tolow-income ture directedtoward providing a more The present programis a productof the cross-fertiliza- disadvantaged people. mental health distinct orientations: apreventive approach to tion of two include staffing by action. Its threeunique features problems and community orientation, and its underlyingmental health indigenous nonprofessionals, phased sequence. and community actionin a carefully the uniting of service and to integrate serv- The program hasthree primegoals: to expedite directed towardincreased social ices; to develop acommunity action program the five-block areaserved by the cohesion within aspecific areain this case of a limited typein relation center; and toeffect certaininstitutional changes of the community. to theservice-providing agencies The total salariesof feature of the programis its low cost. An important Center are in oneNeighborhood Service the fivenonprofessionals working The operating the salary of onefull-time psychiatrist. equal to or less ,:han including theprofessional of one NeighborhoodService Center, expenses the neighborhood),the five director, the secretary(who is indigenous to all other expenses,total less mental health aides,the rent forthe store, and than $50,000 per year. focused on primary While the NSCmodel presentedhere is mainly been given toalternative NSC prevention efforts, someconsideration has and tertiary prevention.The recruitment, models whichemphasize secondary 184 COMMUNITY PROGRAMS AND NEW SOURCES OF MANPOWER training, and functions of center workers would vary considerably under the latter two orientations. The NSC approach is viewed as a viable and necessary approach to the mental health problems of the poor.

REFERENCES

Brager, C. The indigenous worker: A new approach for the social work tech- nician. Social Work, 1965, 10, 33-40. Caplan, C. Principles of preventive psychiatry. New York: Basic Books, 1964. Durkheim, E. Suicide. New York: Free Press, 1952. Haggstrom, W. The power of the poor. In F. Riessman, J. Cohen, tic A. Pearl (Eds.), Mental health of the poor. New York: Free Press, 1964. Pp. 205- 226. Hollingshead, A. B., & Redlich, F. C. Social class and mental illness. New York: Wiley, 1958. Jahoda, M. Current concepts of positive mental health. New York: Basic Books, 1958. Langner, T. S., & Michael, S. T. Life stress and mental health. New York: Free Press, 1963. Leighton, A. H. Poverty and social change. Sci. Amer., 1965, 212, 21-27. Peck, H. B., Kaplan, S. R., & Roman, M. An approach to the study of the small group in a psychiatric day hospital. Int. J. group Psychother., 1965, 15, 207-219. Peck, H. B., Kaplan, S. R., & Roman, M. Prevention treatment and social action: A strategy of intervention in a disadvantaged urban area. Amer. J. Orthopsy- chiat., 1966, 36, 57-69. Reiff, R. Social psychological act;, n research for change. New York: Low Income Center, Albert Einstein College of Medicine, 1964. Reiff, R., & Riessman, F. The indigenous nonprofessional. Comm. Ment. Health J., 1965, Monograph No. 1. Riessman, F. The revolution in social work: The new nonprofessional. Trans- action, 1964, 2, 12-17. Riessman, F. The "helper" therapy principle. Social Work, 1965, 10, 27-32. (a) Riessman, F. Mobilizing the poor. Commonweal., 1965, 82, 285-289. (b) Riessman, F. Self-help among the poor. Transaction, 1965, 2, 32-36. (c) Sexton, P. Spanish Harlem. New York: Harper & Row, 1965. Silberman, C. Up from apathy: The Wood lawn experiment. Commentary, 1964, 37, 51-58. 11 PSYCHOLOGICAL CARE FORTHE POOR: THE NEED FOR NEWSERVICE PATTERNS WITH APROPOSAL FOR MEETING THISNEED'

Elmer A. Gardner Temple University2

INTRODUCTION

The age of poverty is borne out inthe history of man. Yet we have suddenly entered an ageof growing concern about the poor(Harring- ton, 1962; May, 1964;Schorr, 1963). Poverty, togetherwith all of its socioeconomic implications, hasbecome the concern of science aswell as of government, aswitnessed in the rapid development ofthe behavioral sciences. Social scientists in general, andpsychiatrists in particular, arebecoming increasingly alarmed by the magnitudeand complexity of the mentalhealth problems which this group poses,particularly in the heart of oururban Hollingshead & Redlich, 1958; centers. Severalstudies (Auld & Myers, 1954; Hunt, 1960; Imber, Nash, &Stone, 1955; Myers & Schaffer,1954; Winder & Hersko, 1955) have served to point outdiscrepancies in psychiatric service ineffectiveness of classical to different segmentsof the population and the models and methods to copeadequately with certainproblems. Most strikingly inadequate is the psychiatric careprovided to the poor.McMahon (1964) summarizes the problem verywell in his statement,"The lower one finds himself on the socialclass ladder, the moreunavailable does effective psychiatric care become" (p.284). found a decrease of In their classical study,Faris and Dunham (1939) psychiatric hospital admission ratesfor schizophrenia andpersonality disorders drafting and editing 1 I wish to thank Mary Lynchfor her valuable assistance in this chapter. Elise Remmeli, computerprogrammer, andCarol Huff, statistical clerk, compiled the data and preparedthe graphs for this paper. Professor and Director, Divisionof Preventive Psychiatry, 2 Formerly, Associate and Dentistry, Department of Psychiatry, Universityof Rochester School of Medicine Rochester, New York. 185

i AND NEW SOURCESOF MANPOWER 186 COMMUNITY PROGRAMS Because of methodo- proceeded from the centerof the city outward. as one mental logical difficulties it is notpossible to relatecommunity-wide surveys of Studies such as the Mid- disorder directly to thestudies of psychiatric service. indicate, town project(Srole, Langner, Michael,Op ler, & Rennie, 1962) higher in the lower-income however, that theprevalence of mental disorder is does not indicate merely groupsand thac the distributionof admission rates Hollingshead and Redlich increased utilization ofservices by this group. that both prevalence (1958), in their well-knownstudy, further demonstrated received are directly of treated mental illnessand the type of psychiatric care noted that there arethose who related to social classvariables. It should be disorder in the lowersocial dispute the findings ofhigher rates of mental mental classes and contend thatthese rates are biasedby our definition of 1938; disorder and by themiddle-class orientation ofthe investigators (Davis, economic Gursslin, Hunt, & Roach,1964). Studies alsohave noted that the lower classes; factors are not solelyresponsible for ineffective care to failed in their ventures clinics, mainly designed to carefor these groups, have (Brill & Storrow, 1960;Schaffer & Myers, 1954). behavior have become Many people working inthe fields of human but of our hesitation aware notonly of our lack ofknowledge in many areas already possess or inability to putto efficient usethat knowledge which we Myers & Schaffer, (Brill & Storrow, 1960;Hollingshead & Redlich, 1958; register 1954). The followingpresentation of datafrom the psychiatric case longitudinal view of thepsychi- of Monroe County,New York, describes a and lower socioeconomic areas atric services provided topatients from upper comparison of rates ofdiagnosed of the county, withparticular reference to a attempt tobridge mental disorder in thoseareas.3 We will then present an in a descriptionof a the gap between suchknowledge and its application guided services topopulation seg- project organized toprovide psychiatrically need, but often do not nowreceive, adequatepsychosocial help. ments which when work- In addition, we willdiscuss some of thedifficulties encountered organization. Finally, we ing within theframework of present community approach to this problem. will discuss our ownviews of a holistic

THE REGISTERSTUDY provided to the residents A case register of thepsychiatric services in January, 1960.A compre- of Monroe County,New York, was initiated of the register hasbeen hensive description ofthe goals and the operation Romano, 1963; Gardner, presented elsewhere(Gardner, Miles, Bahn, & demographic, diagnostic, and treat- Miles, Iker, & Romano,1963). Essential 3 Figures 1, 2, 3, 4, 5 arefrom the comparative studyof psychiatric services for County, New York. low-, middle-, andhigh-income areas in Monroe PSYCHOLOGICAL CARE FOR THEPOOR: NEW SERVICE 187 by ment informationis reported to this centralfile upon initiation of service almost complete range of any of thefollowing facilities, which comprise an traditional psychiatric service: a statehospital and its outpatient services;the inpatient, clinic, and emergencydepartment services of a universityhospital; Administration hospital and clinic; a an acuteobservation unit; a Veterans alcoholism clinic; two child guid- children's residential treatmentcenter; an portions of ance clinics;and about fifty-fivepsychiatrists who spend varying but an estimated 3% their time in private practice.Since January, 1960, all been reported to the of the county residents seenfor psychiatric care have register. In utilizing the case register tostudy the usual service patternfor resi- without a history dents of the inner city, wefirst selected all patients with or of psychiatric care prior toJanuary, 1960, who werereported between January shall be 1, 1960, and December31, 1962. In oursubsequent discussion we referring to cVtagnosedmental disorder and notall mental disorder within have more than one episode anyparticular population. Because a person may than one diagnostic of psychiatric service'and because he may receive more impression for eachepisode, we utilized a priority systemin assigning an priority was given individual to one of threebroad diagnostic categories. First brain syndrome, to thediagnosis of schizophrenia,second priority to chronic and last priority to anyother category. We haveincluded the diagnoses of affective psychoses within thebroad category of "others"due to the insignifi- the cant rates ofthese diagnoses for the inner citytracts, particularly among Negro population. The address for eachindividual is assigned to a census tract,and priority was given to the innercity tracts in instancesof multiple addresses selected the census tracts during a succession ofpsychiatric contacts. We first which comprised four out offive settlement house districtswithin the city of Rochester, New York. Thefifth district, which differedconsiderably from the others, was includedwith the remainder ofthe city. It soon became ap- contained a socially hetero- parent, however,that these four settlement areas and demographic character- geneouspopulation; using selected socioeconomic settlement areas were selected istics, five census tractsfrom within these four population. These five tracts in an attempt toprovide a more homogeneous other will be referred to asthe study area. For comparativepurposes, two II. The areas wereselected and designated ascontrol area I and control area of census tracts location of the settlement districtsand the smaller groupings selected for study are shown inFigure 1, while Figures 2and 3 depict some of the selected areas. pertinent socioeconomicand demographic characteristics synonymously throughout 4 The terms episode of serviceand contact will be used the paper. They refer to any onecomplete continuous period ofpsychiatric service in These terms may a hospitalunit, a clinic, or with onepsychiatrist in private office care. refer, therefore, to one or moreoutpatient visits. CONTROL AREA ll (HIGH-INCOME)

CONTROL AREA I (MIDDLE-INCOME)

/41

STUDY AREA

(LOW-INCOME) 1

CENSUS TRACTS OF SETTLEMENT AREAS IN THIS STUDY

Baden Street Settlement 11,12,13,14, half of 15 Genesee Street Settlement 43,53,55,56, half of 15 Lewis Street Center 44,45,09 Montgomery Neighborhood 3, 4, 26, 27, 64, 65, 66, 67 Center

Figure 1.Geographic Location of Study and Control Areas in the City of Rochester, New York, and Vicinity.

188 SERVICE 189 PSYCHOLO.31CAL CARE FORTHE POOR: NEW , 10,000

R 8000

A 6000 z..

g o0 _0 4000 D A BC ..; MC Median School YearCompleted _ R

80 2000

60 0 MC A BCD R Median Income of Families and UnrelatedIndividuals

KEY TO STUDY AREAS

A Selected Study Area

B Settlement Areas

20 C Control Area I D --Control Area II MC Monroe County

R Rochester

A B C D Per Cent of PopulationLiving in Same Household1955 to 1960 Character- Selected Socioeconomicand Demographic Figure 2. County, New istics from 1960Census for StudyAreas, Monroe York.

distribution by areaand race based on1960 Table 1 presentsthe population socioeconomic anddemographic censusdata. As notedfrom the selected Figures 2 and 3, thestudy area represented alow-income characteristics in population; control areaI and deteriorated area with atwo-thirds nonwhite and high-incomelevels, respec- control area II arecharacterized by average 190 COMMUNITY PROGRAMS AND NEW SOURCES OF MANPOWER

60_ 30

4-, C CU C-)40_ 20 4-, CU C a. CU C 7 %- CU R CI. MC 20 10ar :.

A. R ...... =0 MC A BCD A BCD Per Cent of Nonwhites Per Cent of Foreign Born

40 4-,= KEY TO STUDY AREAS CU C., 1- CD Selected Study Area 1.1. A B Settlement Ai eas 20 C Control Area I OM WO MO : R ,Mle MC D Control Area II MC Monroe County

R Rochester A B CD Per Cent Deteriorated and Dilapidated Housing

Figure 3.Selected Socioeconomic and Demographic Character- istics from 1960 Census for Study Areas, Monroe County, New York.

tively. Thus, the settlement districts and the three selected areas rangefrom the low to high points along socioeconomic anddemographic parameters. The 1960 census data and our own direct observations ofthe areas have shown that the study area and the two control areas, respectively,each provided a fairly homogeneous population sample. NEW SERVICE 191 PSYCHOLOGICAL CAREFOR THE POOR: for Low-, Table 1.Comparative Study ofPsychiatric Services Monroe County,New York Middle-, andHigh-Income Areas in I Per Cent DistributionBy Race % NON- WHITE % WHITE AREAS OF STUDY POPULATION 4.3 95.7 MONROE COUNTY,TOTAL 586,387 318,611 7.6 92.4 Rochester 0.3 99.7 Balance of County 267,776 32.2 67.8 Settlement Areas 64,252 69.0 31.0 Select,:td "Study Area" 13,751 (Low-Income) 0.01 99.99 Control Area I 15,019 (Middle-Income) 0.1 99.9 Control Area II 14,005 (High-Income)

0 PSYCHIATRIC SERVICE:CROSS-SECTIONAL PATTERNS diagnostic groupingsfor Figures 4 and 5 comparethe rates by broad 1960-1962. As psychiatric serviceduring the years all persons admitted to mental disorder are greatest studies, the rates5of diagnosed noted in other toward the and become progressivelylower as we proceed for the inner city selects differential becomes even morestriking when one outlying areas. This them with the tracts withinthe inner city and compares the most homogeneous between the study areaand of peripheral tracts.The contrast two groups schizophrenics andalco- is most markedin the rates for the two control areas both inpatientand out- holics. Thus, in ourstudy of totalpsychiatric service, that noted by Farisand Dunham patient, we find adistribution comparable to study of hospitaladmissions. (1939) in their (or 2.3% of the county During the three-yearperiod, 14,067 persons register. Of these,2,406 individuals population) werereported to the case Although the lattercomprise only8.9% of camefrom the settlemerit areas. 17% of all countyresidents receiving the county population,they account for diagnosed asschizophrenic. If psychiatric serviceand 21% of those persons the rates forpsychiatric care exclude the populationunder age ten, where we find that slightly morethan 6% areextremely low inMonroe County, we population had apsychiatric contactduring this of the adultsettlement area three-year period. in the figures ortables are age adjusted 5 These rates andall other rates presented to the 1960United States population. 192 COMMUNITY PROGRAMS AND NEWSOURCES OF MANPOWER

8 8

1111111

/==a, MN IMIMMI : I.IMI=

: 11111.10 0 C U E A BCDE Schizophrenia Chronic Brain Syndrome

KEY TO STUDY AREAS

A Settlement Areas B Rochester, Excluding Settlement Areas C Monroe County, Excluding Rochester D Selected Study Area E Control Area I F Control Area ll

Figure 4.Comparison of Rates of Schizophrenicand Chronic Brain Syndrome for Persons fromAreas of Study, Admitted to Psychiatric Service, 1960-1962.

Within the settlement areas, andparticularly for the study area, the rates of psychiatric service arehigher for whites than for nonwhites(18.4 versus 13.2 per 1000of the study area population). The samedifferential is noted within each diagnostic category.However, a contrast obtains for the remainder of the city, excluding thesettlement areas, where the rates of diagnosed mental disorder are higher fornonwhites than for whites (12.8 per 1000 versus 8.9 per 1000). This, too,is similar to the findings ofFaris and Dunham (1939).

PSYCHIATRIC SERVICE: LONGITUDINAL PATTERNS To study further the pattern ofpsychiatric care, we selected two subgroups of patients, onefrom the study area, and another from the twocontrol areas combined.From each area we selected persons reported tothe register between January 1, 1960, and June 30,1962, eliminating those with a diag- PSYCHOLOGICAL CARE FOR THE POOR:NEW SERVICE 193

8 8

. 0 0

.i, -

111111

A BC D EF A BCD E Diagnostic Category "Other" Diagnostic Category "Other" Without Alcoholism With Alcoholism

KEY TO STUDY AREAS

A Settlement Areas B Rochester, Excluding Settlement Areas C Monroe County, Excluding Rochester D Selected Study Area E Control AreaI F Control Area II Figure 5.Comparison of Rates of DiagnosticCategory "Other" With and Without Alcoholism forPersons from Areas ofStudy, Admitted to Psychiatric Service,1960-1962.

nosis of chronic brain syndrome oraffective psychosis and anyonewith a history of psychiatric contact prior toJanuary 1, 1960. The relativelyhigh mortality rate in the chronic brain syndrome groupdistorts any longitudinal survey of theirpsychiatric care. Both groups werefollowed through the register for an eighteen-monthperiod for subsequent psychiatric care. During the one and one-half yearperiod, 251 patients from the,study area and 358 patientsfrom the control areas met the criteria,with 67 Oa 52 persons, respectively,receiving a diagnosis of schizophrenia.The remainder were diagnosed asnonpsychotic. Table 2 presents the pattern of service thesepatients received after their first report to the register. In examiningthe distribution of service for the schizophrenics, we note that there are nostriking differences in the type of psychiatric care received by the twosubgroups. In both groups, a high percentage was hospitalized at somepoint during the follow-upperiod (98% from the study area versus 85%from the control area). A greater proportion

, Table 2. Comparison of Psychiatric Service for Persons from the Study Area and Control Area, 1960-1962, by Major Diagnostic Category, No Prior Psychiatric Contact SCHIZOPHRENIA 18 Months Follow-Up Period NONPSYCHOSIS OUTPATIENTDiagnostic Outpatient CARE No. 10 Study Area 14.9% No.Control Area 3 %5.8 No.101 Study Area 54.9% No.107 Control Area 35.0% 4:..1") ContactContactTreatment Only Only Outpatient 5 7.5 5 9.6 30 16.3 163 53.3 HospitalizationContactDiagnosticHOSPITAL Prior Outpatient CARE or Following 10 14.9 10 19.2 15 8.2 13 4.2 Pre-HospitalAftercare OnlyNo Treatment 27 3 40.3 4.5 1118 21.134.6 12 1 0.56.5 98 2.92.6 TOTALOnlyNoWith Outpatient Hospitalizationor Without Contact-- Aftercare 6712 100.0 17.9 52 5 99.9 9.6 184 25 100.0 13.6 306 6 100.0 2.0 195 PSYCHOLOGICAL CARE FORTHE POOR: NEWSERVICE mental hospital (69% of the study area group washospitalized in a public patients versus 49%) in contrastto the gleaterproportion of control area 41%). experiencing an inpatientepisode in a generalhospital (66% versus from each group Although slightly less than halfof those hospitalized patients experienced a greater werereadmitted once or more, thestudy area subgroup proportion of inpatient timethan the controls; theformer group spent 23% of their follow-up time in ahospital in contrast to thecontrol area patients, who spent 17% of theirfollow-up period in a hospital. The pattern of outpatient caredoes not reflect anystriking differences for the control area group in treatment, althoughthere was a greater tendency outpatient treatment prior tohospital- to receiveonly outpatient treatment, or ization. This is in contrast tothe study area group, whoexperienced largely those hospitalized diagnostic outpatient contacts.Approximately one-half of all considered one or more visits from each group receivedaftercare. Because we subsequent to hospitalization asconstituting aftercare,these figures present patients, particularly a betterpicture than thatwhich exists in fact. Many hospital dis- from the study area group, were seenonly once subsequent to charge. The pattern of service forthe two groups contrastssharply when we compare the patientswho received a diagnosisother than psychosis (Table 2). Twenty-nine per centof the study area groupand 12% of the control public area group werehospitalized. Again, move ofthe former experienced a mental hospital admission, and a greaterpercentage of thelatter group were 30% of at some timehospitalized in a general hospitalunit. Approximately readmitted once or more,but the patients hospitalizedfrom each area were the study area group spent moredays in the hospital (8%of their follow-up nonpsychotic population, we time versus 5% forthe control areas). For the received by these two note a strikingdifference in the type of outpatient care had only a diagnostic out- groups. Morethan 50% of the study area group received any kind patient contact. Only22% of the entire study area group hospitalization. In contrast, 59%of of outpatient treatment,with or without the control area subgroupreceived outpatient treatmentand approximately 39% of the groupexperienced only a diagnostic contact. psychotic and It appears, therefore, thatwhen a person is recognized as is in need of acute care,he will be hospitalizedregardless of his area of residence. Although psychotic patientsfrom the higher-income areas are more apt to experience aperiod of outpatient treatmentprior to hospitalization, their overall outpatient care is notstrikingly different from thatof patients psychiatric service, par- of the lower-income areas.However, the pattern of ticularly outpatient care, differsmarkedly for an individualwho is not psy- elsewhere that there chotic or not recognized aspsychotic. (We have noted Gardner, Miles, & Ro- is a teudency tounderdiagnose psychosis [Babigian, mano, 1965].)It is more likely that a personfrom the higher-income area from the lower- will receive outpatient treatmentonly, and the individual 196 COMMUNITY PROGRAMS AND NEWSOURCES OF MANPOWER income area usually will be seen onlydiagnostically on one or more occasions. Although this can be partially explained bythe ability of a higher-income group to payfor private psychiatric care, the discrepancyin the pattern of care remains evenwhen investigation is confined to clinic services: among those persons seen in clinics, the proportionof patients who receive treatment is greater for the control arca groupthan for patients who reside in thestudy area. One can argue whether the different kindsof psychiatric care for the two groups is afunction of the patient's resistance, his suitabilityfor outpatient treatment, or a bias on the partof the psychiatrist. Nevertheless, the fact remains that the individual fromthe lower-income area oftenreceived inpatient care and, when seen on anoutpatient basis, received onlybrief diagnostic service. As noted above, the psychiatric careprovided to the residents of Monroe County encompasses the full range oftraditional psychiatric services. The quantity and quality ofpsychiatric care available and the sophisticationof the population in the use of allhealth and social services, as well asthe pattern of service forthe acutely ill psychotic individual, maybe atypical for most metropolitan andnonmetropolitan areas.

A NEW APPROACH: THEMENTAL HEALTH TEAM, ITS ORIGIN AND OPERATION

With the move of psychiatry into the community,psychiatrists have become more aware of the reservoir ofmental illness which goes largely untreated and remains beyond the scope ofpsychiatric services. In Monroe County, New York, our own experience in a courtclinic and in a follow-up study of schizophrenics (Hetznecker,Gardner, Odoroff, & Turner, 1966) supports the beliefthat there are significant numbers ofmentally ill people who are generally managed throughnonpsychiatric care. While these peisons may or may not comeunder the purview of a psychiatrist,they usually do not receive continuing psychiatric care.A recent survey, part of theColumbia Washington Heights CommunityMental Health Project, estimated that approximately 70% of the social agencycaseloads demonstrate serious psychiatric impairment (Bemmels, 1964).This finding is consistent with the experience of others working withsocial agencies. The nature of social agency care wasinvestigated by Buell (1952) in St.Paul. The study revealed that 6% of the city population (largely fromthe inner city) utilized 55% to 68% of the "help services." Thisdemonstrates the marked extent ofmultiple agencyinvolvement. When mental illness is not identified or isminimized in these clients, it continues to interferewith the agencies' attempts to help. Theworkers are left discouraged, frustrated, andoften angry at the failure of their clients to NEW SERVICE 197 PSYCHOLOGICAL CAREFOR THE POOR: there is usually noready source respond. When mentaldisorder is identified, enough to requirehospitalization. of help, unless theillness is severe service to thesefamilies have However, the majorfailures in providing helping services and adiscontinuity been a lack ofcoordination among the the latter may beexplained partially bythe characterological in care. While the la ck of interagency com- patterns inthis group, it isfostered greatly by orientation that focuses onlimited aspects of thetotal munication and a crisis hampered by large case- disability. In addition, agencyworkers have been loads and otherlimitations of time. socioeconomic populationdoes Although, as indicatedabove, the lower psychiatric services, ithas be- adequate care fromthe traditional not receive psychiatry that the increasingly apparent toall who work inthe field of come going to be solvedby simply inadequacies of our presentservices are never after panacea-in-a-pill seems more ofthe same. Likewise,the long sought than ever. Further,psychiatric care is only part moreelusive and mythical needs of these people,and it is difficult to of the broaderhealth and welfare psychopathology plays iiisocial pathology,and vice measurethe part which versa(Schorr, 1964). namely, a focus appropriate to'test a new approach; Thus, it appeared pathology within this correlates of psychiatricdisorder and social on the discussion with various com- group. InJanuary, 1964, afterseveral months of Team was initiatedby the Divisionof munity agencies,the Mental Health Department ofPsychiatry, Universityof Rochester Preventive Psychiatry, January to December, School of Medicineand Dentistry.The year from which data andimpressions were 1964, was used as apilot phase, during the following isdrawn from gathered prior to initiatingevaluation. Much of this experience. NEW SERVICE THE PROBLEM:DEVELOPMENT OF A APPROACH WITHINCURRENT COMMUNITY ORGANIZATIONALSTRUCTURE this approach mustbe, "Is a co- A first questionwhich is raised by necessity?" or perhaps,"What is ordinated communityapproach :eally a different agenciesorganized to wrongwith the care beingdistributed among problems?" One responseis supplied bythe evidence from deal with specific clearly defined multi-agency involvement:families do not have separate, isolation from eachother. This is strik- problems which canbe dealt with in involved with an averageof families, which inthe past have been ing in our fifteen different agencies. agencies and, onoccasion, with as many as seven these agencies hasbeen The lack ofcommunication andcoordination among of an activeCentral Index for marked despite the presencein the community experience to have agencyrepresenta: social agencies. Ithas been a common of our project expressconsiderable surprise tives attendingintake conferences 198 COMMUNITY PROGRAMS AND NEW SOURCES OF MANPOWER in learning about the number of agencies involved with a givenfamily. Moreover, this involvement is more than superficial: some of our families have received as many as twenty-five home visits from five or more agencies in one month. The financial waste and the inefficient use of worker time, as a sufficient argument forchange, is only magnified when one considers the duplication of paper work and supervisory time which is also involved. More insidious is the effect on the clients. Consider the case of a woman living alone in the inner city with her five preschool and school age children. Her housing is substandard and her housekeeping standards are poor. Be- cause of "junk" accumulated in thehouse, she is threatened with eviction by the Bureau of Buildings and the Fire Department. At the same time, there is pressure from the Welfare Department to manage on a budget limited to less than the bare necessities of modern life. How, in this situation, can she be expected to respond to the public health nurse's pressure to give more adequate care to her children? Involvement by the Society for the Prevention of Cruelty to Children, with the concomitant threat of removing thechildren, becomes simply an additional pressure. What can be expected of this woman, who has demonstratedthat she cannot bear even the normal pressures of life? Which pressure,which agency, should she consider most significant? In which direction should she move? The result is often paralysis rather than action. And if the housing is substandard, what can be done? The welfare rent payments can be stopped and the woman ultimately forced to move. But there is no oneresponsible to help her secure new housing, and there are no means of inspecting her new housing until she has already moved. To whom does she turn for help? Who is responsible for the client? One mother described the six or seven workers regularly visiting herhome as "vague figures" who wander in and out, asking many of the same questions but usually referring her requests to "the other" worker who also visits.If one of these vaguefigures becomes aware of the possibility of mental disorder in this woman, the psychiatric care available is short, crisis-oriented,and more likely to consist of hospitalization than outpatient care. The latter contacts are usually brief andprimarily diagnostic. The woman in the above situation might be seen one or two times and receive a diagnosis of inadequate personality, borderline psychosis, or depression, depending upon her presentation of complaints and the diagnostic inclination of the examining physician. With her multiple social problems and her lack of verbal facility, she would be considered a poor case for therapy. She might be considered the proper responsibility of a social casework agency, or she might be sent back into the community to continue the cycle. If there were communication with any agency, it often would not be of any practicalhelp other than the occasional recommendation for hospitalization. If there is a recognized problem of fragmentation of care, why has it 199 PSYCHOLOGICAL CARE FORTHE POOR: NEW SERVICE reorganized?' In addition to developed, and why have theservices not been origins of many otherinfluences, we believe muchof the answer lies in the organization, for example, is adescendant our presentservices. The welfare of the alms house; and manyof our welfare lawsstill embody some aspects have been considered"sin- of the Elizabethan PoorLaws of 1601. The poor the stigma of a ners," "lacking will,"and "lazy"; and they continue to carry disgraceful and loathsome group setapart from society.The view has per- who remair poor do sisted from the Elizabethanperiod forward that those unemployment. not want towork, that the comfortsof welfare relief enhance shared by mil- These attitudes persistdespite the fact that poverty was stimulated some of the lions during the greatdepression and that this period that the poor of the depres- current welfare structure.The ideology remains the same po- sion era and their contemporaryurban-slum counterpart share comparison ignores tential to climb up thesocioeconomic ladder. But such a the historical andcultural dissimilarities; itforgets the frequent disruption (produced by a multiplicity of family life in ourpresent-day inner city life with its con- of factors); and it glosses overthe state of chronic depression which this current styleof comittant apathy,hopelessness, and helplessness living tends to breed(Schorr, 1963; Wilensky &Lebeaus, 1958; Wiltse, 1963). during The welfare programs wereexpanded as an emergency measure belief that the depres- the depression of theearly 1930's with the optimistic persists to this day. We sion would be resolvedshortly. This crisis orientation in the Welfare have discussed fragmentationof service between agencies; evidenced by Aid Department there is fragmentationwithin the structure, as Aid to the Blind, etc. Many are to DependentChildren, Old Age Assistance, result: it is often easier to familiar with thestriking paradoxes that may home or for childrenborn out receive assistancewithout a husband in the available if the husband isde- of wedlock.7 Frequentlyaid is more readily clared permanently disabled on apsychiatric basis (Aid tothe Disabled), Only recently has rather than encouraged toview his disability as temporary. there been any source of incentiveaid for the intact family. The shock wave ofenlightenment during thelate eighteenth century, become enmeshed in thecomplexly B A detailed discussionof this problem would culture. This involves theethics of individualism, the interwoven fabric of American of bureaucracy. In addi- problems of industrialization, andindeed, the whole problem social prestige, and otherfactors encourage specialization,the tion, increased efficiency, particularly in medicine. Such a impact of which is beingfelt keenly in many areas, book, indeed it already has(Wilensky & Lebeaus,1958). discussion could easily fill a children made 7 Although the ADC program wasoriginally conceived in terms of 1952,among families on dependent by the death ordisability of parents, by theend of the father was dead in only one casein five. Parental disability was pres- ADC rolls, the families on ADC, divorce,desertion, ent in only one casein four, and in over half child dependency (AmericanAssociation of or unmarriedmotherhood was the cause of in one 1954).A more recent surveyshows that 70% of ADC families Social Workers, 1960). county included one or moreillegitimate children (GreenleighAssociates, 200 COMMUNITY PROGRAMS AND NEWSOURCES OF MANPOWER which was produced by the humane movementboth here and in England, saw thedevelopment of the Society for the Preventionof Cruelty to Children. Ironically, attention was given first toanimals with the historic formationof the Royal SPCA by Richard Martin in1822 and of the American SPCAby Henry Berch in 1866. Only with thefamous "Case of Mary Ellen" was concern finallyfocused on children. The first SPCC wasorganized by Com- modore Elbridge Gerry in New YorkCity in 1874 and was the impetusfor most of the child protectionlaws which followed (Coleman, 1924;American Humane Society, 1962). The grossabuses and maltreatment ofchildren, which generated the creation of theSPCC, no longer exist for the most part; and many of the contemporaryproblems are more subtle thantheir counterparts of the previous century.The SPCC still serves primarily as aprotective agency, oftenworking with the courts. Essentiallyit polices families, thus attempting to assure reasonable treatmentof children; but the agencysuffers from weak and poorly defined lawswhich frequently restrict itseffectiveness (except in extreme cases) and reduceits efforts to threats and temporary action. Any attempts todeal with underlying causes of deviantfamily behavior are hampered by usuallyshort (even if recurrent) contacts,overworked personnel, and the fact that it is notprimarily this agency's responsibility. Additional broad responsibilitiesthrust upon the Society servefurther to obscure its focal function. The Health Department comesclosest to providing generalized carefor the poor. Traditionally, this carehas been oriented primarilytoward infec- tious diseases and generalchild care. Perhaps the greatestproblem of the public health nurse isovergeneralization of her function. She isresponsible for school health, rehabilitationservices, and child care counseling.In addition, the care is not directed in aconcentrated way to those in mostneed. Despite the fact that the publichealth nurse may be responsible forthe most general care of families, theHealth Department has no control overthe financial status of these families.Indeed, the medical care of theindigent is regulated by the Welfare Department. We have dealt with three ofthe public agencies and have notspecifically discussed the voluntary social agencies.Almost all of these agencies face many problems similar to those describedabove and contribute further to thelack of communication 'imong the serviceorganizations. What of the role of medicine?Historically, physicians have been morally obligated to treat all the sick, andphysicians regularly donate time tothe care of theindigent. Clinics have beenestablished for both service to the indigent and the education ofphysicians. Yet, under the pressureof large caselcads, concern for efficiency may preemptconcern forindividual patient care. Inobstetric clinics, where therelationship of the patient to her physician is recognized asbeing of crucial psychologicalimportance, patients may indeed, for delivery be assigned to differentphysicians on different visits, and and follow-up care. 1 PSYCHOLOGICAL CARE FOR THE POOR: NEWSERVICE 201 While psychiatry had been concerned primarilywith the care of the hospitalized patient, the steady growth of outpatientpsychiatry, which we have witnessed in more recent years, is due to anumbr:r of factors: the enlightenment of the psychoanalytic movement,the impact of psychiatric services developed during World WarH, the recognition of institutionalization and its effects, and the increasing recognitionof psychiatric disorders that do not require hospitalization.The source of the enlightenment,however, explains much of the present problem. Analytictheory, upon which most psychiatric care is based, originated in amiddle-class setting; and such requirements as verbal facility, persistence,and an introspective orientation, not to mention intact family structure andfinancial means, are much more typical of the middle class than of the poor (Davis,1938; Freud, 1962). The development of psychiatricclinics has not generally lessened the demand forthe other requirements. As we attempt to apply a mentalhealth model, developed in a specific cultural climate, to abroader range of cultures, we face the difficulty of differentiating cultural values frommental illness. These problems were recognized byKingsley Davis in the earlier development of themental health movement and by others morerecently (Davis, 1938; Gursslin, Hunt, & Roach, 1959; 1964; AmericanAssociation of Social Workers, 1954). The frustration of applying inappropriatetherapeutic techniques because of inappropriate expectations usually leadsthe patient or therapist to terminate. OPERATION AND EV ALUATION The approach of the Mental HealthTeam centers on the multiproblem family as a prototype of the family presentingthe previously defined correlates. Frequently, such families have had somepsychiatric contact, and it is our impression that one or moremembers of a large percentage of these families is psychotic or marginally compensated.In 39 of the 55 families (71%) referred to the Team during the year's pilotstudy, at least one member had experienced a psychiatric contact in the pastfive years. Although it may be argued that our criteria for referral biasthis sample, we would point out that roughly one in every 15 persons in this innercity population has had a reported psychiatric contact in a three-year period.Our statistics are even less surprising if computed on the basis of familiesrather than individuals. The Mental Health Team, which isbased within a settlement house, though its operations are totally distinct fromthat agency, functions as a training base for both the psychiatristsand agency workers. The Team consists of seven workers on half-timeloan from the following agencies: Depart- ment of SocialWelfare (one); Baden Street Settlement house,Volunteer Case Aide Division (one); Health Department(two); Psychiatric Court Clinic (one); Society for the Prevention ofCruelty to Children (one); Family Service Center (one). At present there arefour psychiatrists (residents and staff from the Division of PreventivePsychiatry of the University of Rochester Medical Center) who are active withthe Team. :

202 COMMUNITY PROGRAMS AND NEW SOURCES OF MANPOWER Referrals to the Mental Health Team are accepted from any social agency, school, court, psychiatric service, the Department ofHealth, and the social service department in any of the hospitals in the community. The criteria for referral are somewhat narrow: they have emerged, in part, because of the lack of any generally accepted referral criteria in the field, and in part because of the limitations imposed by the research evaluation. Were a Team approach to become an established service, these criteria could be expanded. At present the referral criteria are as follows:

1.All referred families must live within one of the 36 census tracts that comprise the inner city, encompassing the settlement areas. 2. A family is defined as consisting of at least one parent and two children, with at least one child in elementary grades 1-5. 3."Multiproblem" is defined as contact with at least two or more agencies, currently or during the previous six months. At least one of these agencies must be the Department of Welfare, the Society for the Prevention of Cruelty to Children, or the Department of Health. 4. At least one parent is considered to have significant mental illness in the judgment of the referring worker. Diagnosis by a psychiatrist is not required. 5.All agencies active with the referred family at the time of referral must be willing to terminate their relationship. All referrals meeting the foregoing criteria are scheduled for our intake conference, which is attended by the referring agency and all community agencies actively engaged, or having had recent contact with the family, and by a Team worker and a psychiatrist who are paired in rotation to each case. Subsequently, the Team worker makes four or more home visits to the family, during which time she collects detailed historical data and information on present problems and records observations on the psychological status of the family. Then the Team worker introduces the family to the psychiatrist, who visits one or more times and conducts a diagnostic evaluation. A reevaluation conference is then scheduled, with the whole Team and the involved agencies participating. During the evaluation period these agencies maintain their usual involvement with the family, and the Mental Health Team is presented as consultants to the agencies. A family which is found to meet all the criteria is then assigned on a random basis to the Team or to a control group. With assignment to the control group, agencies continue their previous patterns of service; and the Team terminates contact. If the case is assigned to the Team, all agencies terminate their relationship with the family, as outlined in criterion 5 above, and the Team assumes full responsibility for further care. Thus, we initially coordinate the agency activities through the intake process, and for active PSYCHOLOGICAL CARE FOR THEPOOR: NEW SERVICE 203 cases, continuethe coordination operationallyby assigning to the Team worker total responsibility foreach family. The approach is an active onein which we bring care tothe family through home visits, either withthe family as a unit or withthe individual members separately, andoccasionally actively pursue reluctantpatients. We the actions utilize social manipulation,which frequently involves mediating of various government agencies uponthe clients, as well as variousmodalities of psychotherapy; and we areprepared to follow members ofthese families through a hospital admission.Therapy is at times uncovering andinsight- directed, but most often it issupportive in nature. Inaddition, medication is used under thepsychiatrist's direction. The psychiatristfunctions as a supervisor on the case, meetingregularly with the worker and revisitingthe family periodically to reassesstheir needs. A detailed description of one case(the E family) may serve toillustrate quite concretely the operationof the Team. This couple and their fourchildren were referred by theDepartment of Welfare shortly after the birth of theirfourth child. The E's hadreceived well public assistance intermittentlyduring the past several years and were known by the caseworker responsiblefor their district, part ofthe more deterior3ted slum area in thecentral city. The worker couldrecognize Mrs. E's severe depression and was awarethat Mr. E was drinkingheavily and contributing little or no financial support tothe family. Mr. E had injured his arm approximately one yearpreviously; he wds awaiting a decisionregard- ing compensation and nowused this as the reason for hisdrinking. Mrs. E appeared to be anineffectual bedraggled woman,looking considerably older than her stated age,incapable of dealing with herhusband, children, or household duties,and seemingly oblivious to itall. Two genera- tions of het family wereknown to the Department ofWelfare; and Mrs. E viewed berlf as another inthe line of public dependents,doomed to a life of unhapp;ness and fortunate tohave any husband, despitehis abusiveness and alcoholism. Some neighbors had reportedthe E family to the SPCC,but the latter agency did notbelieve there was sufficientabuse or neglect to warrant any action. The oldest daughterpresented a problem at school inthat she usually times complained of nothaving wasunkempt, occasionally filthy, and at sufficient food. Nevertheless,she presented no markedbehavioral problem and obtained passing grades orbetter. At the time of referral tothe Team, a public health nursehad visited the home several times to guideMrs. E in the care of thebaby. Although the nurse spent most of her timediscussing the baby's formula andthe problems of feeding, she hadbeen particularly impressedby the baby's unre- sponsiveness and listlessness.He was gaining weightsatisfactorily and showed the proper motoric developmentbut, even at age five months,he could be characterized as withdrawn. The nursehad wanted the baby seen at apedi- ;

SOURCES OF MANPOWER 204 COMMUNITY PROGRAMS AND NEW atric clinic but had been unable to arrangethis, due partially to Mrs.E's apathy and, perhaps, reluctance. Though a number of agencies wereinvolved with the E family, no one worker visited them regularly; nor was any one personfamiliar with the full pattern of theirproblems. The Department ofWelfare caseworker had known the family for the longestlength of time but saw theminfrequently since they were not continuously receivingpublic assistance. Mrs. E viewedeach of worker as someone who wouldhelp with a specific problem or category problems but saw no one as aconfidante with whom she mightdiscuss major concerns, such asher husband's alcoholism. Mr.E viewed all "caretakers" with suspicion. He saw them aspeople who were there largely tocheck on him. To him, all such visitors wereauthority figures to be deceivedand manipulated to get "what was coming tohim." When the E family was referred to theMental Health Team, theintake conference was attended by the referringcaseworker and her supervisorfrom the Department of Welfare, thepublic health nurse and hersupervisor, a worker from SPCC, the schoolsocial worker, a policewomanwho had helped with the family disputes in the past,and a volunteer from achurch-sponsored program forlow-income families. A fairly completehistory and picture of the family emerged at the conference,though no single person seemed tobe well acquainted with the family. Becauseof the apparent lack ofaffect described in Mrs. E and heroccasionally confused, perhaps "peculiar"behavior, there schizophrenic. Although no was somediscussion as to whether she might be final diagnostic judgment was made atthe conference, the possibilityof hospital admission for Mrs. E wasconsidered. One of the public health nursesfrom the Mental HealthTeam was assigned to the E family andintroduced as a replacement for the nursewho had been visiting. After three visitsby the Team nurse, bothshe and a psychiatrist saw the entire Efamily twice and subsequentlypresented their evaluation at the diagnosticconference. They were both struckby the apathy and almost total lack of self-caremanifested by all members ofthe family. The apartment in which theylived obviously had not beencared for by the landlord or the E family. Thewalls were discolored, spotted,cracked, and had large sections of plaster missing orready to fall. The windowscould not be opened, contributing to theoverwhelming stench thatgreeted anyone upon first enteringthe apartment. The floors werewarped, covered with debris. There was little closet orcabinet space, and it appearedthat most of the family's belongings hadbeen randomly scattered aboutthe furniture and floors. The scarce furniture present wasold, dusty, marred, and torn.But most striking ofall was the general filth thatcovered the members of the E family. Mrs. E appeared, on thebasis of the initial contact period, tobe severely depressed but not psychotic. Thisseemed to be related to her pregnancyand the postpartum period;however, the duration of thedepression was difficult 205 PSYCHOLOGICAL CARE FORTHE POOR: NEW SERVICE about the baby, she to delimit. Thoughshe expressed the usual concerns virtually ignored him duringthe course of each interview.Both the nurse and psychiatrist had the impressionthat no one in the familysaid more than a few words tothe baby throughout theday. the Although Mr. E had a superficialfriendliness, he obviously disliked visits by the nurse and wasparticularly threatened by thepsychiatrist. He usually would be out at thetime of the Teammember's visit, occasionally drinking with his cronies.When the Team memberswaited for him to re- terminate turn, he wouldbe annoyed by this andwould search for reasons to the visit quickly. Hefluctuated between momentsof gruffness with threats inability to work, toward Mrs. E and periods ofbemoaning his arm injury, his and his fate in general. When the E family wasassigned to the MentalHealth Team for con- withdraw or to tinuing care, the other agencyworkers willingly agreed to willingness and their maintain minimum contact.Despite this ostensibk. complaints about the E family, it wasinteresting to note that someworkers from them. later showed resentment about"their case" being taken The Team worker (nurse)began visiting the Efamily weekly, occasionally twice a week. Sheleft both her work andhome phone numbers for jointly with the Mrs. E to call whenever necessary.The psychiatrist visited, worker, approximately once amonth and, occasionally,received calls from Mrs. E when the worker could notbe contacted. Althoughthe nurse tried to family, it was doubt- explain the operation of theMental Health Team to the ful that this was fullyunderstood. She probably wasviewed as a public health nurse, withthe psychiatrist seen as some typeof consultant or supervisor. During the first several visits theworker spent most of the timelistening to both Mr. andMrs. E relate theirproblems and, when specifically ques- tried to sort tioned, discuss their backgrounds.Both she and the psychiatrist problems presented by the out the most pressingneeds from the maze of family and to choose the bestinitial approach. It wasthought Mr. E needed help in quickly getting his compensation caseresolved and then in obtaining full-time employment. An effort wasmade to give him a more activerole in the family, in the disciplineof the children, repairof the apartment, etc. With Mrs. E the worker acted more as asympathetic listener, givingadvice, when asked, in regard to thechildren, the budget, andpurchase of food and discussing Mrs. E's negativeself-image with her. Whenthe E's complained about the deteriorated stateof their apartment, theworker contacted the landlord and tried to have repairsmade. When he resisted, theDepartment of Welfare was notified towithhold rent payments and tolook for another apartment. The most rapid andnoticeable effect of the Teamworker's efforts was the change in Mrs. E.Within two months she wasrelating quite dependently to the workerand obviously looking forward toher visits. She brightened con- depression. She became siderably, emphasizing thedegree of her previous AND NEW SOURCES OFMANPOWER 206 COMMUNITY PROGRAMS and moresociable, showed much moreinterest in her own appearance, Both the started to take much better careof the children and the apartment. she worker and the psychiatrist weresurprised by Mrs. E's attractiveness as gave moreattention to her personal care. In contrast to Mrs. E'simprovement, Mr. E seemed todeteriorate further. abusive toward his wife, He began to drinkcontinuously, became physically and began to accuse herof going out with other men.Mr. E's lawyer, when contacted by the worker,viewed our efforts to settle thecompensation case rapidly as an infringement onMr. E's right to gain thebest possible settlement. Heindicated, however, that contrary toMr. E's statements, there was no reason notto seek full-timeemployment while awaiting settlement. by one incident. Mr. E's ineffectuality wasperhaps best demonstrated fire started in the next While the worker andpsychiatrist were visiting, a the Fire apartment. Althoughthe fire was broughtunder control quickly by Department, the E familyand the Team membershad to evacuate furniture and clothing from two rooms toprotect themfrom water damage. In contrast panic, Mr. E becameparalyzed. to Mrs. E andthe older children, who did not his He stood in thekitchen, crying openly,trembling and complaining of from the apartment. fear of rein juring his arm.He finally had to be led Subsequent to this incident,the E family had to bemoved into tem- located. During this periodthe porary quarterswhile a new apartment was 'Team worker kept in close contactwith the Department ofWelfare caseworker and with the Bureauof Buildings. The Efamily was encouraged to made to care for the look for quarters themselves,and arrangements were children. When a new apartment waslocated, the family appeared tobe stimulated by this and seemed toenjoy painting, cleaning, etc.Soon, however, and began to have his Mr. E resumed his drinking,again became abusive, three days at a time. drinking companions boardwith the family for two or Efforts to involve him intherapy on an outpatientbasis or to have him admitted to the hospital drewonly further complaintsabout his arm. Appoint- ments with aphysician were not kept. It was apparent thatthe tenuous maritalbalance could be maintained considerable support for only with Mrs. E in aninferior, passive role or with presented by the Mr. E's easily threatenedmasculinity. The complications in obtainingsuitable pending compensation, thesomewhat realistic difficulties all precluded much unskilled employment, andhis long standing alcoholism support for Mr.E. Thus, further efforts toresolve the marital stress were discontinued and attentiondirected toward Mrs. E'stalk of separation. Al- of being alone and the though she had spoken ofthis for some time, her fear deterred any move image of herself as anineffective, disorganized individual keeping the children. toward separation. She alsofeared Mr. E's threats about and With support from theTeam worker and herincreasing confidence for the separa- assertiveness, Mrs. E wasdirected to Family Court to prepare PSYCHOLOGICAL CARE FOR THEPOOR: NEW SERVICE 207 tion. Another apartmenthad to be located and plansmade to divert welfare funds from Mr. E to Mrs. E andthe children. It was apparent that Mr. E wasusing most of the welfare moneyfor his drinking. Though threatenedwith loss of welfare support,Mr. E refused to move fromthe apartment, continued hisdrinking, and became more assaul- tive. After considerablediscussion and several meetingsof everyone concerned, an order of protection wasobtained. Mrs. E and the children were moved to another apartment;public assistance payments weretransferred to her; and temporary quarters wereobtained for Mr. E at the CountyHome. He was soon arrested forpublic intoxication, however,and arrangements were made viapsychiatric consultation to theCity Court for admission to the County Infirmary. Although Mrs. E made all the necessarycontacts herself,through the entire period she depended onthe Team worker for guidanceand support. She particularly had todiscuss her ambivalence towardMr. E, her guilt about leaving him, and herfeeling that she was bound to sufferand might as well notresist it. The worker frequentlyhad to maintain coordination between the agencies and interprettheir activities for Mrs. E. At times,the authority of the Team'spsychiatrist was required to facilitate certainaction. Subsequent to the separation and move,the change in Mrs. E andthe children was remarkable. Althoughshe first called the Teamworker frequently for reassurance, this subsidedand Mrs. E began to callonly in emergencies. She became much moreoutgoing, independent, andcheerful. She claimed that she had never feltbetter. Her new apartment wasdecorated tastefully, as she took obvious pride inits appearance. The childrenappeared brighter, more sociable, and moretalkative, both in school and during visits with the Team worker. Mr. E resumed his drinkingwhen discharged from the hospitaland again entered the CountyHome. His lawyer was moreagreeable to a quick of resolution of the compensation case,but this now awaited an improvement Mr. E's condition. A year after the first contacts withthe Team, the worker was visiting Mrs. E every two to three weeksand receiving calls from her onlyrarely. The Department of Welfare caseworker sawMrs. E. every few months andthen briefly conferred with the Team worker.Other than this, no other agency or worker had any contact with the Efamily.

EV ALU ATION The pilot study period in 1964 wasused to accumulate experience and to plan for an evaluationprocedure to study the impact of theMental Health Team intervention. From the oneyear's experience, it became apparent that there were twomajor areas to be evaluated:(1) The reduction of mental disorder in the children ofMental Health Team families.Through

1 208 COMMUNITY PROGRAMS AND NEW SOURCES OF MANPOWER our intervention with these families we hoped to bring aboutstabilizing influences in the environment of the children, especially through changes in the attitudes and behavior of the parents. Thus, one major component of the entire evaluation procedure was the measure of longitudinal behavioral changes in the children at school and at home. (2) Reduction in the psychopathology and disability manifested by the adult members of the Mental Health Team families. Although our primary goal was the reduction of mental disorder in the children, we did wish to correlate these latter changes with any concomitant behavioral alteration in the adults. The evaluation period began in September, 1965, and at that time, all families referred to the Team, who met the criteria outlined above, were randomly assigned to the experimental group or control group, each of which consists of 35 families. The families of the experimental group were assigned to a Mental Health Team worker and psychiatrist for the usualfollow-up care. The control group families were seenby independent evaluators, who obtained the necessary historical data and administered the various questionnaires; they were then referred back to the referring agencies for further care, but were to be followed at six-month intervals by the evaluators. Much of the data for evaluating any changes in the children of the Mental Health Team families will be gathered in the school setting. We have attempted to avoid bias on the part of teachers or others evaluating these children by testing all, or part, of each class containing any children from the Mental Health Team families. This third group of children, a control group, will also allow us to evaluate the impact of the testing situation upon all of the children. Furthermore, it will provide us with data about the kinds of behavior that may be expected from this population and, therefore, give us a much better basis for refining further our various instruments. The evaluation of change in the children will derive from the data obtained in three settings: (1) school, (2) home, and (3) community. We will use information already available such as school grades, attendance reports, delinquency records, etc., in addition to the data collected using various rating scales and objective tests. The latter include a teachers' behavior rating cheek list (Cowen, Izzo, Miles, Telschow, Trost, & Zax, 1963) and the Children's Manifest Anxiety ScaleCMAS (Castaneda, McCandless, & Palermo, 1956). Evaluation of adults will focus on behavioral changes both in the community and within the home and family setting. Again, we will make use of the data already available in addition to the information obtained from our interviews. Several more objective assessment procedures, including a behavioral and mental status check list (Hetznecker, etal.,1966) and a maternal attitude to child-rearing scale (Glidewell, 1961), will be utilized in this context. PSYCHOLOGICAL CARE FOR THEPOOR: NEW SERVICE 209

A PROPOSAL FORREORGANIZATION The response from many inpsychiatry, when confronted withthe problems presented by the poor,has been, "It's not our problem.It's a problem for society" (Berlin, 1964, p.801). We have stated thatpsychiatric care is only a part of thebroader health and welfare needsof the lower class. In addition to any service approach, morefar-reaching changes, legislativeand cultural, may be required to providethe ultimate solution totheir needs. Despite this, we believe thatmuch can be accomplishedthrough direct service, given our present stateof knowledge in the behavioralsciences. A psychiatric approach, however,whether it be communitymental health centers, home visiting teams, orrehabilitative services, if isolatedfrom the other helping services, will continue tofail in its service to the poor.There is much inherent in the presentorganization of services which preventsgood care. Wehave attempted to outline thecharacteristics of the organization and some of its origins. Whatthen do we propose? Thiscould, in part, be indicated in the demonstration projectdescribed; we might suggestthat a mental health team or a comparable structurebe added to the present organization of community agencies.But this would be a partialand temporary of a response.Indeed, our present Team,although it exists only as part demonstration project whose stated purposeis temporary, has feltthe pres- need for service. sure toward permanencedue to the community's unsatisfied The rapid assimilation of a new groupsuch as the Mental HealthTeam as a viable structure reflects the factthat existing agencies concernedwith the problems of the poor are typifiedby considerable organizationalconfusion.8 Some of the present agencies may,in fact, have arisen asdemonstration projects, only to berapidly assimilated into theoverall community organizational scheme as permanent structureswith their own territorialrights and responsibilities. Despite the general acceptanceof the Team and the desire to cooperate, often to the point of stretchinglegal limits, a basic conflict of interestsand operating principles often existsbetween the Team and other agencies.Such divergent approaches have, onoccasion, defeated the attempt atcoordination does represent an and continuity of care.The Mental Health Team, in part, addition to the present organizationof services, and to thatdegree, poses similar problems. An alternative proposalmight call for centralization atadministrative (Chope & Black- levels, and such has beenaccomplished partially in one area

8 These problems and theneed for coordination werenoted by Warner, Queen, and Harper (1930) at the turnof the century. They state,"Thus we find on every hand the principle of coordinationbut considerable difference evidence of the acceptance of the methods of putting it into in opinion as to howfar it should be carried and as to effect." 210 COMMUNITY PROGRAMS AND NEW SOURCES OF MANPOWER ford, 1963). Although this can reduce duplication in record keeping and increase communication among workers in various roles, it does not resolve the primary problem. Families are still shunted between the various services. Each service assumes temporary responsibility for coordinating allefforts. Although continuity and improved communications are necessary at the administrative level, they are of crucial importance at the operational level. We would propose, therefore, a drastic reorganization of the helping services and would envision a central agency with broad responsibilities for the health, education, and welfare of the community. At the operational level, service would be provided via teams, distributed geographically throughout the city, with total responsibility for the care of the population within their designated areas. While the make-up of such teams might vary, they should have supervisory and consultative personnel of a broad and varied nature, including psychiatric, welfare, legal, and medical services, as required. In some situations, several teams could share supervisorypersonnel. Most importantly, the team workers would be responsible for the total social-medical care of the assigned families. These services could be interwoven into a more complete system of day-night services, outpatient clinics, and hospital wards such as have been proposed elsewhere (Babayan, 1965; Joint Commission on Mental Illness and Health, 1961). It should be noted that under the reorganization we propose, the particular knowledge and skills gained in specialized areas, as developed by the community structure, would not be wasted; on the contrary, they would be put to more efficient use. Effective worker time would be likely to increase despite the increased time initially required for each case. In addition, other sources of personnel from relatively untapped sources maybecome more accessible and more useful. Our own use of volunteer case aides is one example. What we propose may appear, at best, idealistic and utopian. We also are well aware of the vested interests which have developed inentrenched organizational structures and the usual resistance to change. But we are convinced that without a radical reorganization of services at all levels, future programs are bound to fail, despite the astronomical sums of money and personnel time which are channeled into such programs. Stated in another way, it is an issue not only of personnel but of organization.

SUMMARY

Using the psychiatric case register, rates of diagnosed mental illness for patients from lower socioeconomic areas were compared with those for patients from higher socioeconomic areas of Monroe County, New York. Regardless of the area of residence, patients diagnosed as psychotic and in need of acute psychiatric care (schizophrenics) usually are hospitalized. Our 211 PSYCHOLOGICAL CARE FORTHE POOR: NEWSERVICE elsewhere, indicate thatdespite data, generally consistentwith those reported and despite comparable rates of hospitalizationfor all socioeconomic groups, illnesses, the overrepresentation ofthe lower class in allreported psychiatric lower-class individuals isabout the rate of outpatienttherapy received by contacted one-third the rate of the restof the population.Further, those who received a strikingly outpatient services and were notdiagnosed as psychotic experi- different pattern of care;the group from thelower socioeconomic area the higher socioeco- enced mainly diagnostic contact,while the group from nomic area frequentlyreceived therapeutic service. and the lack ofcoordina- We have focused onthe fragmentation of care project currently activein tion of helping agencies.We then described a attempt tocoordinate Monroe County, NewYork, which demonstrates an services and give total care tomultiproblem families. The discussion raised somequestions as to whythe present organization needs of the lowerclass. We at- of psychosocial servicesfails to meet the the pattern of care,and we tempted to answer thisquestion by describing explored the origin of our presentpatterns ofpsychosocial care historically. longer applicable to our current It has been notedthat various services are no of improving the services to situation. We exploredseveral possible methods radical reorganization ofthe the poor and arguedthat what is needed is a make more efficient patterns ofpsychosocial care. Suchreorganization would needs of the popula- use ofpersonnel and money; itwould be guided by the of an antiquated organizationof tion served ratherthan by the demands services.

REFERENCES

Social work year book.New York: Au- American Associationof Social Workers. thor, 1954. humane review. Golden anniversary American HumaneSociety. The national issue. 1962, 50, 4-98. theory for selectingpsychotherapy Auld, F. Jr., & Myers,J. K. Contributions to a patients, J. din.Psychol., 1954, 10, 56-60. services in the U.S.S.R.Internat. Babayan, E. E. Theorganization of psychiatric J. Psychiat., 1965, 1,31-35. Romano, J. Diagnostic con- Babigian, H. M., Gardner,E. A., Miles, H. C., & patients. Amer. J.Psychiat., sistency and change in afollow-up study of 1215 1965, 121, 895-901. caseloads. Beinmels, V. G. Surveyof mental healthproblems in social agency Amer. J. Psychiat., 1964,121, 136.147. Editorial in Amer. J.Orthopsy- Berlin, I. N. New directionsin A0Aone view. chiat., 1964, 34, 801. 212 COMMUNITY PROGRAMS AND NEW SOURCES OF MANPOWER Brill, N. Q., & Storrow, H. A. Social class and psychiatric treatment. Arch. gen. Psychiat., 1960, 3, 340-344. Buell, B. et al. Community planning for human services. New York: Columbia, 1952. Castaneda, A., McCandless, B.R., & Palermo, D. S. The children's form of the manifest anxiety scale. Child Developm., 1956, 27, 317-326. Chope, H. D., & Blackford, L. The chronic problem family: San Mateo County's experience. Amer. J. Orthopsychiat., 1963, 33, 462-469. Coleman, S. H. The humane society leaders in America. Albany, N. Y. The American Humane Association, 1924. Cowen, E. L., Izzo, L. D., Miles, H. C., Telschow, E. F., Trost, M. A., & Zax, M. A preventive mental health program in the school setting: Description and evaluation. J. Psychol., 1963, 56, 307-356. Davis, K. Mental hygiene and the class structure. Psychiatry, 1938, 1, 55-65. Faris, R. E. L., & Dunham, H. W. Mental disorders in urban areas. New York: Hafner, 1939. Freud, S. Collected papers. Vol. 1. On psychotherapy. London: Hogarth Press, 1962. Pp. 249-263. Gardner, E. A., Miles, H. C., Bahn, A. K., & Romano, J. All psychiatric experience in a community. Arch. gen. Psychiat., 1963, 9, 369-378. Gardner, E. A., Miles, H. C., Iker, H., & Romano, J. A cumulative register of psychiatric services in a community. Amer. J. publ. Health, 1963, 53, 1269- 1277. Glidewell, J. C. Parental attitudes and child behavior. Proceedings of second annual conference on community mental health research. Springfield, Ill.: Charles C Thomas, 1961. Greenleigh Associates, Inc. Facts, fallacies and future: A study of the aid to dependent children program of Cook County, Illinois. New York: Author, 1960. Gursslin, 0. R., Hunt, R. G., & Roach, J. L. Social class, mental hygiene and psychiatric practice. The Social Service Rev., 1959, 33, 237-244. Gursslin, 0. R., Hunt, R. G., & Roach, J. L. Social class and the mental health movement. In F. Ricssman, J. Cohen, & A. Pearl (Eds.), Mentalhealth of the poor. New York: Free Press, 1964. Pp. 57-67. Harrington, M. The other America. Baltimore, Md.: Penguin, 1962. Hetznecker, W., Gardner, E. A., Odoroff, C. L., & Turner, R. J. Field survey methods in psychiatry: A symptom check list, mental status and clinical status scales for evaluation of psychiatricimpairment. Arch. gen. Psychiat., 1966, 15, 427-438. Hollingshead, A. B., & Redlich, F. C. Social class and mental illness. NewYork: Wiley, 1958. Hunt, R. G. Social class and mental illness: Some implications for clinical theory and practice. Amer. J. Psychiat., 1960, 116, 1065-1069. Imber, S. D., Nash, E. H., & Stone, A. R. Social class and duration of psychotherapy. J. din. Psyck ol., 1955, 11, 281-284. Joint Commission on Ment 11 Illness and Health. Action for mental health. New York: Basic Books, 1 90. NEW SERVICE 213 PSYCHOLOGICAL CAREFOR THE POOR: view. In F. working class psychiatricpatient: A clinical McMahon, J. T. The the poor. New Reissman, J. Cohen, &A. Pearl (Eds.),Mental health of York: Free Press, 1964.Pp. 283-302. York: Harper & Row,1964. May, E. Thewasted Americans. New stratification and psychiatricpractice: A study Myers, J. K., &Schaffer, L. Social clinic. Amer. soc. Rev.,1954, 19, 307-310. of an outpatient Psychiatry, Schaffer, L., & Myers,J. K. Psychotherapyand social stratification. 1954, 17, 83-93. Washington, D.C.: U.S.Dept. of Schorr, A. L. Slumsand social insecurity. Research Statistics,1963. H.E.W., Social SecurityAdministration, Division of 1964, 34, 907-912. Schorr, A. L.Non-culture of poverty.Amer. J. Orthopsychiat., ler, M. K., & Rennie,T. A. C. Men- Srole, L., Langner, T.S., Michael, S. T., Op Manhattan study. Vol. 1.New York: tal health in themetropolis: Midtown McGraw-Hill, 1962. American charities andsocial work. New Warner, A., Queen,S., & Harper, E. York: Crowell, 1930(first edition, 1894),Chap. 31. society and socialwelfare. New Wilensky, H. Z., &Lebeaus, C. W. Industrial York: Russell SageFoundation, 1958. for socially deprived groups.Amer. J. Wiltse, K. T.Orthopsychiatric programs 806-813. Orthopsychiat., 1963, 33, length and type of Hersko, M. The effectof social class on the Winder, A. E., & hygiene clinic. J.din. psychotherapy in a VeteransAdministration mental Psychol., 1955, 11, 77-79. 12 A MENTAL HEALTH CONSULTATION PROGRAM IN A SMALL COMMUNITY WITH LIMITED PROFESSIONAL MENTAL HEALTH RESOURCES'

Charles D. Spielberger Florida State University

It is estimated that over 19 million people in the United States, or about 1 in 10, have emotional problems that require professional attention. The magnitude of the mental health problem in this country is further demonstrated by the fact that approximately 1 out of every 2 hospital beds is occupied by a mental patient. These statistics, which by now are quite familiar to all of us, do not include the nearly 5 million mentally retarded children and adults who also require special professional services and, in many cases, institutional care. Yet, in contrast to the number of persons who are in need of assistance, the professional manpower resources available for helping individuals with mental and emotional problemsare extremely limited. On the basis of nationwide studies of mental health manpower needs, it appears likely that we will continue to be faced with serious personnel shortages in all of the professionsnow counted upon to provide mental health services (Albee, 1959). Acute shortages in trained mental health manpower are perhaps nowhere more evident than in areas located at some distance from large metropolitan centers and training institutions (Libo & Griffith, 1966). Several years ago, the writer was asked to assist a small urban community with limited professional mental health resources in developing a mental health program. The program described in this chapter was evolved in the course of working in this community with key professional groups such as public health nurses, ministers, teachers, and community leaders over a four- year period.

1 Some of the ideas expressed here were first presented in a report to the New Hanover County Association for Mental Health in Wilmington, North Carolina, 1959, and in a symposium at the American Orthopsychiatric Association Meetings in New York City, 1961. I am most grateful to John Altrocchi and Warren C. Lamson for their helpful comments and suggestions on early drafts of this chapter.

214 215 A MENTAL HEALTHCONSULTATION PROGRAM

THE COMMUNITYSETTING IN WHICH THE CONSULTATION PROGRAM WASDEVELOPED

In the fall of 1958, atwhich time the writer was amember of the Carolina, he was Psychology Faculty of DukeUniversity in Durham, North invited to become a consultant tothe Association for MentalHealth and the County, Consolidated Health Department ofWilmington and New Hanover North Carolina. Wilmington, theprincipal seaport ofNorth Carolina, is At the located on the Cape Fear River in thesoutheastern corner of the state. time the consultationrelationship was established,New Hanover County concentrated largely in had a year-round population ofabout 75,000 people, the city of Wilmington and itssuburbs; the county's population wasconsid- erably greater in the summerswith an influx of vacationers tothe popular resort areas atWrightsville Beach and CarolinaBeach. consisting of a single A child guidance clinicwith a professional staff part-time psychiatrist hadbeen established in Wilmingtonin 1947. Unfor- tunately, it had been necessary todiscontinue the operations ofthis clinic in possible to secure other 1949 when the psychiatristdeparted and it was not qualified staff. From 1949until 1957, there hadbeen no active community organization or agencythat invested its major energiesand resources in coping be handled by with mental health problems;those problems that could not individuals or agencies inthe community had beenreferred to distant diagnos- comprehensive mental healthfacili- tic and treatmentfacilities. The nearest both ties were located atthe university centers inChapel Hill and Durham, approximately 150 miles fromWilmington. formed The New Hanover CountyAssociation for Mental Health was readily in 1957. This grouphad strong backing fromthe community and obtained financial supportfrom the United Fund.In collaboration with the develop a mental staff of the Health Department,the Association set about to created for a health program. To implementthis program, a position was Department. This full-time clinical psychologist onthe staff of the Health position was filled on apart-time basis in the summerof 1958, but remained pressures to filled for only six months.During this time, there were constant provide clinical services. of the part-time psy- In November, 1958,shortly before the departure chologist from the HealthDepartment staff, the writermade his first consultation visit to Wilmington.Almost immediately the HealthDepartment inquiries con- received requests for diagnosticpsychological examinations and This was not surpris- cerning the possibilityof referring patients for treatment. ing since there wasonly one mental healthprofessional residing in the Hanover County but also community, a psychiatristwho served not only New the surrounding areas inNorth and South Carolinawith an aggregate popu- psychiatrist's practice was, of lation of over aquarter-million people. The MANPOWER 2:6 COMMUNITY PROGRAMS ANDNEW SOURCES OF necessity, limited primarily tothe treatment of the moreserious manifestations of mental disorder. Initially, it was determined thatthe consultant wouldspend one day increased to each month in the community,but after four months this was two days permonth. It was also agreed at the outset(with representatives of the Mental Health Associationand the HealthDepartment) that the consultant's limited time would be usedsparingly for providingdirect services to individual patients. Instead, theemphasis of the program was tobe on the promotion of mental healthand the prevention of mentalillness through consultation with key professionalworkers. In addition, wehoped to stimu- involvement of late, to the maximum possible extent,the active concern and all facets of the communityin mental healthproblems. Elements of the discussed in detail, mental health consultation programthat evolved will be but first we should considerthe general principlesof mental health consultation that guided the programand describe the methodof group consultation that was developed as the primarymechanism for its implementation.

PRINCIPLES OF MENTALHEALTH CONSULTATION

Growing interest in the preventionof psychological disordersand the promotion of mental health inthe past decade haveled mental health specialists to engage in a wide varietyof consultation activities.Gerald Caplan mental health consulta- and his associates havepioneered the development of tion practice and theformulation of consultation theory(e.g., Bindman, 1959; Caplan, 1964). Caplan'sapproach focuses uponproviding consultation for generally called upon key professional workers indisciplines other than those in the to cope withproblems of mental healthand mental illness. Included worked are professional groups with whomCaplan and his colleagues have pediatricians, teachers, clergymen,social workers, and nurses.In principle, any person ormember of a profession thatperforms important "caretaking" services in a community is a propertarget for mentalhealth consultation. an Mental health consultation hasbeen defined as "a helping process, educational process, and a growth processachieved through interpersonal relationships" (Rieman, 1963, p.85). Through mentalhealth consultation, workers of a the mental health specialist mayassist the key professional community in becoming moresensitive to the needsof their clients and associates and more comfortable.in their relationshipswith them. Ministers, physicians, lawyers, public health nurses,and members of numerousother professional groups are often called uponby the individuals withwhom they work in times of personal andinterpersonal crises. Mental healthconsultation professional to theory holds that crises provide opportunetimes for a sensitive (Caplan, 1964). By be of significant assistance tothose who seek his services promoting the mentalhealth of their clients andby helping to restore emo- 217 A MENTAL HEALTHCONSULTATION PROGRAM of key professional groups tional equilibrium indisturbed clients, members develop serious mental can reducethe number of personswho are likely to disorders. mechanism whereby In essence, mentalhealth consultation provides a caretaking agents of a community the mental healthspecialist may assist the professional roles, can so thatthe latter, within theframework of their usual the major goal ofmental health better utilize mentalhealth principles. While with greater effective- consultation is to assist otherprofessionals in handling, subgoals are to ness, certainemotional problems oftheir clients, important the symptoms of mental help persons in keyprofessions better to recognize referrals to mental health illness and to assistthem in making appropriate noted, however, that themental specialists when this isrequired. It should be health consultant does not attemptto teachspecialized mental health tech- members of the key profes- niques (e.g.,psychodiagnosis, psychotherapy) to sional groups with whomhe works. consultation have been con- The theory and practiceof mental health single consultee cerned primarily with interactionsbetween a consultant and a relationship is established in (Bindman, 1959; Caplan,1964). Typically, a may call upon which the consultee, amember of a key professional group, stimulated by one aconsultant for assistance with aproblem that has been often a well-trained specialist of the consultee's clients.The consultant, most consultation in on thestaff of a nearby mentalhealth facility, then arranges a relationship may be dis- which the client's problemsand the consultee-client the consultant's cussed. In Wilmington, restrictionsimposed by the fact that month rendered "on- activities in the community werelimited to two days per Furthermore, the call" response to individualconsultee crises impractical. number of key profes- active interest in mentalhealth problems of a large for assistance, sionals in the community, asreflected in numerous requests suggested that it would nothave been possible torespond to these requests mental health on anindividual basis. Therefore, acase-seminar method of consultation with groups wasdeveloped as our principalconsultation procedure.

CASE-SEMINAR METHODOF MENTALHEALTH CONSULTATION WITHGROUPS consultation2 consists of The case-seminar methodof mental health mental health specialist regularly scheduled groupmeetings in which a Group members generally consults with members of akey professional group. mental health consulta- 2 Many of the ideas on thecase-seminar method of group developed in collaboration withJohn tion that arediscussed in this chapter were whom the writer is deeplygrateful. Fori moredetailed Altrocchi and Carl Eisdorfer, to the reackr is referred to theoretical treatment of mentalhealth consultation with groups, Spielberger, and Eisdorfer(1965). The writer is further in- the paper by Altrocchi, Community Mental HealthJournal debted to Drs. Altrocchiand Eisdorfer, and to the for granting permission to quotefrom this paper. AND NEW SOURCESOF MANPOWER 218 COMMUNITY PROGRAMS for the same community have similar professionaltraining and/or work aproblem each meeting, a memberof the consultee group reports I agency. At Consultees are asked to case onwhich he (or she) iscurrently working. that are likely to be ofgeneral interest to other groupmembers. present cases believed to be They are further encouraged toselect cases in which there is be facilitated through suc- good potential for clientimprovement which may volunteer to present cessful professional engagement.However, those who final selc-tion of the case.In working cases are givencomplete freedom in the observed that the cases with the same groups over aperiod of time, we have by the agency 1 presented generally represent agood cross-section of those seen professional group. or discuss the case Prior to the group meeting,the consultant arranges to which might not be appro- with the reportingprofessional. Aspects of the case considered at this priately brought up fordiscussion in the case-seminar are with time. Wheneverpracticable, the consultantobtains first-hand contact with the client, either byinterviewing the client orobserving him interact being the consultee. We havefound that clients aregenerally receptive to consultee's arranging the inter- interviewed by the consultantand regard the view as an indicationof his interest in them.The consultant's interaction surprisingly therapeutic in its with the client is typicallysupportive and often possible for the consultant impact. Actual contactwith the client makes it evaluating the case to bring tobear the full range of hisprofessional skills in safeguard against for teaching purposes andalso serves as a precautionary homicidal tendencies) missing crucial diagnosticinformation (e.g., suicidal or conferring with the which may not be evident tothe consultee. In addition, demonstrate inter- client in the consultee's presencepermits :he consultant to consultee in working with viewing techniques that maybe employed by the other clients. dynamics of the client'sprob- In case-seminar meetings,the etiology and The responsibility of lems are discussed inrelatively nontechnical terms. all matters consid- groupmembers for maintainingthe confidentiality of between the client ered in these meetings isstrongly emphasized. Relations other persons involved in and the consultee, andbetween each of them and workers), are consid- the case (e.g., tile client'sfamily and other professional consultant who ered in detail. The complexroles and functions of the group by Altrocchi, Spiel- utilizes the case-seminarmethod have been described berger, & Eisdorfer (1965) asfollows: case-seminar approach must The mental healthconsultant who uses the clinician function simultaneously inseveral different roles:teacher, group leader, community groups. As ateacher, the and facilitator ofcommunication between specialized technical knowl- consultant does notnecessarily attempt to transmit knowledge about thosetechniques edge; but he does conveygeneral principles and professional which can be usedwithin the range of theconsultee's particular function as a seminar leader, a background. In this capacity,the consultant may 219 A MENTAL HEALTHCONSULTATION PROGRAM naturally depend upon resource person,and a lecturer; thespecific techniques will background as well as thequalifications, experiences,and his own professional lecturing on personality needs of the consultee group.In early sessions formal well as suggestions oninterviewing tech- development and psychopathology, as to function as a nique, are often appropriate.In later sessions he is more apt the leader sessions it isparticularly impor- resource personand seminar leader. In consultant be careful toclarify the limits of hisability to resolve tant that the omnipotence questions raised bythe consultees and todispel any omniscience or primary goal is to helpthe which may be imputed tohim. Since the consultant's meaningful solu- group andthe individual consultees tolearn to be able to derive should gratify demandsfor him to tions for workproblems on their own, he consultation sessions frombecoming provide solutions onlyenough to keep the unduly frustrating to theconsultees. stimulate members of As a group leader theconsultant acts as a catalyst to together the problemsof their the group to share experiencesand to explore and conceptualizesolu- clients, and helps to clarifyproblems, focus discussion, leader and teacher, wehave tions suggested byconsultees. In the roles of group discussion to our ownclinical experi- also found it useful torelate the case under the group our ownlimitations and continuingefforts to ence and to expose to typically broaden our understandingof human problems.Such personal reflection emphasizes his humannessand lack fosters identification withthe consultant and omnipotence (Berlin,1962).... of omniscience and often merges with his The mental health consultant'srole as group leader during the discussion of thefeelings of a consultee role as a clinician, especially be required in deciding toward a client. Considerableclinical sensitivity may affective expression by a when to slow down or,instead, to deal directly with consultee. However, we do not concurwith Caplan (1964)that the consultant consultee's feelings and should consistently avoid anydirect discussion of the spontaneously in a consultation should interrupt suchdiscussions if they arise patients and therefore Members of professional groups arenot as fragile as group. of the do not require the samedegree of protection, giventhe existing protection work-group setting. We dodraw the line when aspectsof the historical develop- the discussion. On rareoccasions, ment of theconsultee's personal feelings enter be deemed appropriate a briefexcursion into aconsultee's personal problems may of the particularprofessional because of the centralityof the problem to the role invasions of the consultee'sprivate life shouldonly be pursued if the group. Such the consultee has the requisitestrength to deal withhis problems, commands for discussing his personalprob- respect of the group,and provides the initiative lems as "a case at point." be prepared to use hisclinical As a clinician, theconsultant must always and procedures in casesof client skills and his knowledgeof referral resources ability as a clinician is aparticular emergencies. Theconsultant's experience and "practical approaches" and notmerely asset whenconsultees are interested in theoretical approaches totheir problems. becomes clear in his Finally, an additional importantrole of the consultant reveal the interaction with differentcommunity agencies.Case presentations often personnel from other agencies. frustrations of consulteeswho must work with of other professionals to Complaints range fromindividual ineptitude on the part 220 COMMUNITY PROGRAMS AND NEWSOURCES OF MANPOWER red tape, gross obstructionism, andglory seeking. On more than one occasion, workers from two agencies competingfor the management of a client presented the same case in their respective seminar groups.This presents the mental health consultant with an ideal opportunity forfacilitating inter-agency communication by helping members of different professional groups toappreciate the role of other professionals. Thus the mental health consulta, twho works with groups on a community-wide basis has the role of a facilitatorof communication between various community caretakers andthe professional groups they represent(pp. 131-132). During a productive group mentalhealth consultation session, four phases may generally be observed: anintroductory phase, a warming-up phase, a probiem-focused phase, and anending phase (Kevin, 1963).3 In the introductory phase, the reportingprofessional presents backgrounddata and current information about the case,and the consultant describeshis interview with the client. Feedbackand follow-up information on casesprevi- ously discussed may also be brought up atthe beginning of the session. The warming-up phase generally consistsof the elaboration and clarificationof information presented in the introductoryphase in response to questions from members of the consultee group. In theproblem-focused phase, the etiology and dynamics of the client'sproblems are formulated, taking special noteof the client's strengths and resources aswell as of his shortcomings and limitations. Alternative approaches tothe case are then proposed by groupmembers in the context of arealistic appraisal of community resources.In the ending phase, the collective experience of the group isbrought to bear on the merits of these alternatives, and one or morespecific courses of action is suggested by the group to the reporting professionalfor exploration. A brief discussion A arrangements for the next case-seminarmeeting usually concludes the session. Striking differences may be observed in mentalhealth consultation with different professional groups, and from session to sessionwith the same group. Differences in group process and in therapidity with which the group proceeds from one phase of consultation to the next appear tobe related to the professional training and experience of groupmembers, group morale and cohesiveness, and specific factors associated with the casethat is being discussed. Groups with strong cohesiveness and highmorale may move rapidly into the problem-focused phase, wherethey work creatively in formulating solutions .0 vexing questions raised by the caseunder consideration. In contrast, the consultation process may never movebeyond the introductory or warm-up phases in groupsthat are simply collections ofprofessionals with similar jobs.

3 Kazanjian, Stein, and Weinberg (1962)have used similar terms to conceptualize phases they have observed in individual consultation.They describe individual consultation as consisting of the following: preparatoryphase, beginning phase, problem-solving phase, and termination. 221 A MENTALHEALTHCONSULTATION PROGRAM consultees over aperiod of time,the In working withthe same group of consultation is clearlyreflected in cumulative impact of groupmental health i and in the mannerin which each the cases that areselected for presentation "impossible" cases aceoften presented inthe case ispresented. Bizarre or consultation (Rieman,1963). For such cases, one early stages of group consultees to understand of the consultant'srole is helping important facet likely to benefit fact that, in workingwith clients who are not 1 and accept the time is unwar- the investment ofinordinate amounts of from their services, members of consultee later stages ofconsultation, experienced ranted. In the representative of tend to select casesfor presentationthat are more groups useful for generating those seen by the group as awhole and thus more mental healthproblems and a more 1 fruitful discussions.Greater sensitivity to also generallyreflected in sophisticated understandingof these problems are these cases. the presentation of will depend, in The productivity of amental healthconsultation group successful in fostering the degree to whichthe consultant is large measure, on and nonjudgmen- of a group atmospherethat is supportive the development experiences andprofessional tal, that stimulates groupmembers to share work basis for meaningfulcommunica- problems. Sharingexperiences establishes a members to bring tobear the full rangeof their tion which permits group being solving the specificproblems raised by the case collective experience in for group prob- considered. The sharingof problems isparticularly important reduce the consultee'sfeelings of isolation, lem solving inthat this tends to Consultees who initiallyvolunteer to professional inadequacy,and anxiety. ready to share theirpersonal reactions to present cases arealso usually more comments on casespresented by their own clientsand to offer constructive of these groupmembers are most their colleagues.While the contributions problem-focused phase,the consultant helpful in movingthe group into the ahead with themuntil he perceivesthat must resistthe temptation to move of the group isready to do so. a majority effectiveness ofmental little objectiveevidence of the There is, as yet, aspects ofthe with groups. However,in regard to many health consultation those who is considerableagreement among groupconsultation process there observations (e.g.,Altrocchi, et al.,1965; have compiled andrecorded their 1963). It 1963; Maddux,1953; Parker,1958; Rieman, Berlin, 1962; Kevin, members of consultee consistently that thesensitivity of has been observed enhanced, as interpersonal relationsis greatly groups tothe dynamics of their clients. relationships betweenconsultees and reflected in improved cohesiveness consultation alsogenerally improves group Group mental health among group mem- and tends tofacilitate communication and group morale consultee who gains community agencies.In addition, the bers and between is understanding of thereactions common tohis professional group a better conflicts and personalitydynam- helped to achieve greaterinsight into his own his work (Parker,1962). ics and howthese may influence MANPOWER 222 COMMUNITY PROGRAMS ANDNEW SOURCES OF While agreement among those whohave engaged in groupmental health consultation is impressive, there isneed for a more objectiveconfirmation of these observations and impressions.Research is required todetermine the impact of group consultation onthe skills and attitudes ofmembers of various key professional groups aswell as on the effectivenessof these professionals about such things in working with theirclients. We need to know much more of the as tl,eoptimal length and frequency of groupsessions, the dynamics and technical skills that group consultation process,and the personal qualities contribute to making mentalhealth professionals effective as group consultants.

THE MENTAL HEALTHCONSULTATION PROGRAM IN WILMINGTON

The mental healthconsultation program in Wilmingtonevolved within the context of the programsof the Association for MentalHealth and the Health Departmentand was greatly influenced bythe public health traditions and communityeducation orientation of the sponsoringorganizations. Mental health consultation wasinitiated with public health nurses,ministers, and caseworkers on the staff ofthe Department of PublicWelfare. The significant contributions of theseprofessional groups as communitycaretakers was self-evident;frequent requests fromindividual group members for assistance with cases involvingthe mental and emotionalproblems of their clients attested to their interest inreceiving consultation andtheir potential for contributing to communitymental health. In conferenceswith agency officials and with officers of theministerial association, approval wasgiven for scheduling continuingcase-seminars with each ofthese groups on a monthly basis. An office for the mentalhealth consultation program wasestablished within the Health Department, and astaff public health nurse wasappointed as thecoordinator of the program. Thenurse-coordinator organized the consultant's schedule and arrangedfor him to meet with professionalswho were presenting cases, and withtheir clients. She also scheduledconferences and interviews with communityleaders and professionals requestingconsultation, handled all requests for mental healthservices, and maintained the program records and files. On the recommendation of theconsultant, a planning committee was established to serve as a policy-makingboard for the consultation program. This committee, called theMental Health Program PlanningCommittee, was appointed by the sponsoring organizationsand consisted of representatives of the Association for MentalHealth, the Health Department, andother community agencies andprofessional groups. When theconsultant's time in the community was increased to twodays per month, a monthly meetingwith the 223 A MENTAL HEALTHCONSULTATION PROGRAM of the consultation Planning Committee wasscheduled as a regular part program. represented an excellent cross- The members of thePlanning Committee leadership of the communityand provided section of the layand professional realistic perceptionsof the com- the consultation programwith sensitive and Planning Committee notonly provided munity's mentalhealth needs. The important functionof inter- guidance and advicebut also served the very the community.The col- mental healthconsultation program to preting !le actions of thePlanning lective wisdom, communityinsight, and constructive factor, contributed tothe growthand Committee, morethan any other mental healthconsultation program.4 development of the Committee was to One of the firsttasks to be tackledby the Planning time in thecommunity mightbest determine how theconsultant's additional the long-termmental health interests be utilized. It wasgenerally agreed that by concentrating onproblems involv- of the communitycould be best served institution throughwhich childrenwith ing children,and that the single reached mosteffectively was thepublic mental healthproblems could be with decided that conferenceswould be held school system.Therefore, it was feasibility of extendingthe mentalhealth school officials todetermine the the schools. Onthe basis of theseconferences, consultation program into school elementary schoolteachers and high case-seminars wereinitiated with Arrangements were alsomade for individualconsultation guidance counselors. officials, principals,and on atime-available basis withschool administrative teachers. services in requests forconsultation and clinical There were many more number of groups in could be honored.There were also a Wilmington than who did not request whom we wished tooffer consultation the community to and of affairs led tointensive discussionsof program priorities it. This state ethical choice. Thisimplies articulation of a conceptthat we have called to the development on thebasis of method of working outpriorities for program a of communitymental health (1) value judgmentsconcerning significant areas of the "readiness"of specificprofessional need, and (2)realistic appraisals in benefit fromconsultation at a given point groups orcommunity agencies to limitations of theconsultant must, of course, time. Theprofessional skills and equation fordetermining programpriorities. also figureprominently in the health consultation programinto the Thus, the decision toextend the mental New Hanover County indebted to many citizensof Wilmington and 4 The writer is Consultation Program,and particularly to the Mental Health West of for their contributions to Wading, Miss A. LouDavis, and Mrs. Betty Dr. C. B. Davis,Miss Elizabeth Lounsbury, Miss Kathryn Mrs. HerbertBleutenthal, Mrs. Bea the Health Department; Francis Walker ofthe Mental HealthAssociation; Noyes, Mrs. AliceSisson, and Mrs. the New HanoverCounty Mrs. Ethel Booth, andMr. Fred Capps of Mr. T. 0. Page, Johnson of theMinisterial Association;Mrs. Schools; Rev. John Irwinand Rev. Richard Welfare; Mrs. Emma New Hanover CountyDepartment of Public Helen Sneeden, M. Hall, Jr.,Chairman, Board ofCounty Howell, Family ServiceSociety; and Mr. J. Commissioners. 224 COMMUNITY PROGRAMS AND NEW SOURCESOF MANPOWER schools was based upon the Planning Committee'sjudgment that promoting the mental health of school children was a high prioritycommunity goal, the expressed readiness of school officials to permit and facilitatethe establishment of appropriate consultation groups, and the consultant'sdiscernment that he could work effectively with these groups. The concept of ethical choice was also useful as a guide inselecting the particular groups or units within an institution to whomconsultation would be first offered. For example, it was necessary on one occasion todecide with which of two schools a consulting relationship would beestablished. There was only timeenough to work with one of these schools. From allavailable data, School A, located in a deteriorating lower-class neighborhood,appeared to have a larger proportionof children with severe mental health problems than School B, which was located in an attractivemiddle-class suburb. The area served bySchool A had a higher incidence of crime, mental hospital admissions, delinquency, and broken homes than the area servedby School B. While it was generally agreed that mental health consultation was more urgently needed in School A than in School B, the principalof School A did not feel that consultation wouldhelp him solve his school's problems. Rather, he wanted to refer disturbed children for treatment. In contrast,the principal of School B had repeatedly requested consultation and was quite receptive to exploring various ways in which the consultant's limitedtimeabout two hours per monthcould be used most effectively. On the basis ofperceived differences in readiness in these two schools, the establishment of aconsultation relationship with School B seemed to make thebest use of the consultant's time. As things turned out, it was also eventuallypossible to establish a consulting relationship with School A; and this was facilitatedby having demonstrated the value of consultation under more optimal circumstances in School B. During the more than four years in which consultation visits weremade to Wilmington on a regular basis, there were requestsfor assistance from a variety of sources. At first, these came primarily from professionals atthe grass roots level, including individualmembers of consultee groups, and physicians, lawyers, probation officers, directors of religious education, nursery school teachers, Family Service workers, and many others who worked directly with people. After the consultant had worked in the community for several years, there were more frequent opportunities toconfer with community leaders on a variety of topics with important mental health implications,and particularly with members of the boards that established policiesfor the professional groups with whom the case-seminars were conducted.There were also more opportunities toconsult with top agency executives such as the Superintendent of Schools, the Directors of the Health and Welfare departments, and elected officials of the cityand county government. In the summers, when schools were not in session andthe case-seminar with the ministerial group was not held, a series of conferences were held with 225 A MENTAL HEALTHCONSULTATION PROGRAM administrative employees of thePublic Housing Authority.The consultant activities within local also explored the possibilityof developing mental health industrial settings in conferenceswith personnel directors,production man- of these agers, andindustrial health workers.Among the concrete results exploratory activities were(1) the participation ofseveral industrial nurses of a in the case-seminarwith public health nurses,and (2) the convening conference with the Board ofthe Public HousingAuthority. In the latter the the acceptance of mental health implicationsof prevailing policies governing relating to gen- applicants for low-rent housing werediscussed, and questions Housing Au- eral management policies wereconsidered. The meeting with number of important thority Board membersalso served to point up a employees should have, in personal qualifications thatHousing Authority effectively with tenants. addition to their technicalskills, if they are to work in Wil- A schematic diagram of themental health consultation program organized during its third yearis presented inFigure 1. mington as it was of the Limitations in the consultant'stime preventedfurther development added program untilthe fourth year, in which afull-time psychologist was establish to the staff ofthe Health Department.This made it possible to schools and to expand consultation relationships withadditional groups in the professional and com- the time available forconsultation with individual munity leaders. As soon asarrangements couldbe made to obtain the part- limited time services of aqualified psychiatrist, it wasalso possible to offer direct services to individualswho were referred to theHealth Department. While the mental healthconsultation programcontinued to place special education, it was emphasis on prevention ofmental illness and community establishment of not longbefore funds were appropriatedthat permitted the a fullystaffed mental health center.

CASE-SEMINARS WITHSPECIFIC PROFESSIONAL GROUPS welfare case- The case-seminars withpublic health nurses, ministers, period of workers, and public schoolpersonnel met continuously over a several years. Generalcharacteristics of the mentalhealth consultation process observed to be common tothese groups have alreadybeen described. Some aspects of the caseconsultation process which seemed tobe more specific to individual professional groupswill now be discussed.

Case-Seminar with PublicHealth Nurses

The case-seminar withpublic health nurses wasconducted during the working day as a partof the in-service training programof this group. them to care for all of the The responsibilities ofpublic health nurses require health needs of their patients,and they have neither the time northe training 4 SOURCES OF MANPOWER 226 COMMUNITY PROGRAMS AND NEW

MUNICIPAL GOVERNMENT ,

_l____ _L. I_ BOARD PUBLIC 1BOARD HOUSING OF WELFARE OF AUTHORITY BOARD HEALTH EDUCATION

MME111=r I INDIVIDUAL MEMBERS OF MENTAL LOCAL HEALTH HEALTH PROFESSIONAL ASSOCIATION DEPARTMENT GROUPS

PUBLIC PUBLIC WELFARE IPUBLIC HEALTH HOUSING MINISTERS WORKERS SCHOOLS NURSES OFFICE -T- -F- -1- GENERAL PUBLIC I

Figure 1.The administrative organization ofthe community mental health consultation programin Wilmington and New Hanover County, North Carolina, as itfunctioned during its third year as an integral partof the progxams of the HealthDepartment and the Mental Health Association.A staff public health nurse was assigned as program coordinator,and representatives of theAsso- ciation for Mental Health, theHealth Department, and other community agencies served as thepolicy-making board. The mental health specialist spent twodays each month in thecommunity providing group consultation forpublic health nurses, ministers, Department of Public Welfarecaseworkers, elementary school teachers, and school guidancecounselcrs. The consultant also worked with Public Housingofficials and with the executivesand boards that set policies for theagencies with whom group consultation was conducted. In addition,individual consultation was provided, on a time availablebasis, for members of theconsultee groups andother professional workers.

for full-scale mental healthrehabilitation work. But public health nurses can be more effective in theirjobs if they have a morebasic and broader understanding of the whole patient.Furthermore, given the high regard inwhich she is held by her patientsand the trust that characterizesthe attitudes of 227 A MENTAL HEALTHCONSULTATION PROGRAM unique position todo patients toward her, thepublic health nurse is in a preventive mental healthwork. oriented The content of the case-seminarwith public health nurses was in toward the many ways inwhich the nurse couldintervene appropriately their families. In a order to promote the mentalhealth of her patients and such as the number of cases this involvedmaking referrals to other agencies helping the patients Family Service Society and theWelfare Department and In others, the nurseassisted to establishrelationships with these agencies. to state men- seriously disturbed patients inarranging voluntary commitment occurred. Through their tal hospitals before acomplete mental breakdown conducted at the Health work in maternity clinicsand well-baby clinics, Department and in publichousing developments, nurseshad many opportuni- stemmed from emotional ties to work with patientswhose major problems these cases focused rather than physical causes.Case-seminar discussions of child-rearing patterns and onatti- upon thepotential impact of the nurse on tudinal problems that had tobe overcome in order toassist the patient in obtaining available healthservices for themselvesand their children. morepublic Most of the nurses wereassigned as school nurse to one or concentrate onproblems schools. Therefore, inkeeping with our decision to in the schools involving children, the activitiesof the public health nurse this group. Accordingly, were thefocal point of theconsultant's work with concerned with the the didactic content of anumber of case-seminars was with the use of intellectual and personalitydevelopment of children and conferred symptoms tosatisfy emotional needs.Most cases on which nurses of the child's physi- with teachers about schoolchildren involved some aspect referred to the cal health. However, in asubstantial proportion of the cases school nurse, the mentalhealth problems of thechildren were paramount; possible, and such cases wereoften presented in thecase-seminar. Whenever invited to attend the seminar the child's teacher andthe school principal were and to contributeinformation based on theirpersonal observations. helpful for the On several occasions, it wasdecided that it might be than the nurse to visitthe child's parents. She wasoften in a better position toward nurses are generally teacher to do this becausethe attitudes of parents children's teachers areoften positive, whereas theirattitudes toward their role of the nurse in ambivalent. The nurse-teacherrelationship and the liaison teachers and parents repre- helping to work out abetter relationship between role which seemed sented a meaningful extensionof the nurses' professional to have importantmental health implications.

Case-Seminar with Ministers parishioners and their The cases discussedwith this group included variety of reasons, families who sought assistancefrom their ministers for a child-rearing problems, alco- e.g.,vocational adjustment,marital difficulties, 228 COMMUNITY PROGRAMS AND NEW SOURCES OF MANPOWER holism, and not infrequently, psychotic conditions. The ministers as a group were particularly interested in gaining a betterunderstanding of the personality problems and emotional needs of their parishioners, and in how the minister could assist parishioners in dealing with life situations complicated by emotional conflicts. They were also highly sensitive to their limitations in working with severely disturbed parishioners and very much concerned with ascertaining procedures for making referrals of such parishioners for psychiatric treatment. A number of sessions with this group were devoted to considering techniques that could be employed by ministers in pastoral counseling with parishioners who came to them with specific kinds of problems. For example, in four successive cases, presented by different ministers and considered over a six-month period, weconcentrated on problems related to alcoholism. Some of the substantive issues that were discussed included: (1) alcoholism as a symptom of emotional disturbance, (2) the effects of alcoholism upon family relationships, (3) the minister's personal attitudes toward the use of alcohol and how these attitudes complicated his working with parishioners with drinking problems. It became apparent that, in general, the minister's role in pastoral counseling is considerably more complex than that of a mental health specialist in psychotherapy, especially if the parishioner is an active member of his congregation. In addition to counseling with parishioners, the minister must address them from the pulpitand make numerous other demands on them within the context of the total church program. Perhaps the most difficult problem that confronts the minister in his pastmal counseling role is keeping his other roles from intruding upon it, and this was frequently the subject of lively discussion in the case-seminar sessions. In working with clergymen, the consultant was initially concerned with how to approach conflicts that might arise between theological and psychological principles. However, these concerns proved groundless. Differences between the theological views of ministers from different religious denomina- tions were vastly greater than any that arose between the convictions of individual ministers and the psychological principles of the consultant. On those occasions when apparent conflicts between theology and psychology were brought out, after further discussion, the difficulties were easily resolved. For example, in a discussion of the development of conscience, one minister took strong exception to the consultant's psychoanalytically oriented descriptionof the effects of early experience on the formation of the superego components the conscience and the ego-ideal. The minister insisted instead on the theological principle that "conscience was God-given." After pondering the apparent conflict between these theological and psychological views of conscience, the group came to the conclusion that while the potential for conscience might be God-given, helping people to develop this potential was a proper task for clergyman and psychologist alike! 229 PROGRAM A MENTALHEALTHCONSULTATION Case-Seminar withWelfare Caseworkers with Departmentof PublicWelfare (DPW) The cases discussed in- foster homeplacement, situations caseworkers includedproblems such as who werepermanently andtotally volving dependentchildren, and clients clients, by legalrequirement,belonged to disabled. Almost allof the DPW Since a siz- classes; and poverty was aubiquitous problem. the lower social with DPW clients wereNegroes, discussion able proportionof the DPW experienced by centered arounddifficulties that are caseworkers frequently lower- professionals in workingwith predominantly Caucasian middle-class In some cases,the commentsof the class clientsfrom other racial groups. helping particularly meaningful totheir colleagues in Negro caseworkers were minority group status;but the problemsassociated with them to understand required to helpthe here, class bias wasapparent.Much discussion was even feelings of angerand disgust which caseworkers understandand handle their called upon tohelp clientswhose morals and often eruptedwhen they were different from their own. behavior were so by that a substantialpercentage ofthe clients served There is little doubt had they been would have receivedpsychiatric diagnoses DPW caseworkers of the caseworkers mental health clinic(Maddux, 1950). Yet most seen at a with seriousemotional had little or notraining in workingwith individuals time in case-seminarmeetings wasthere- problems. A considerableamount of information aboutpersonality andpsycho- fore given toproviding didactic relationships in of the significanceof parent-child pathology. Discussions of hostility and personality patterns,especially the patterns determining adult helped caseworkers to dependency that sooften characterizedDPW clients, of hostility fromclients understand why they werefrequently the targets also helped them todevelop whom they tried sohard to help.Such discussions independence in theirclients. relationships thatfostered greater clients with dignityin order tohelp them The significanceof treating all emphasized withDPW caseworkers, develop and maintainself-respect was client to helphimself." It wasevident, as wasthe philosophyof "helping the carried by membersof this groupmade it however, that thelarge caseloads single case to have for them todevote enough time to any almost impossible goals of thecase-seminar impact. Therefore, oneof the major much beneficial clients according totheir help the caseworkerdifferentiate among was to time could be spentwith those rehabilitation potential sothat relatively more and acceptanceof the who might benefitmost. Thisrequired recognition there was littlethat anyone coulddo unfortunate realitythat, in many cases, to help theclient. Consultation in thePublic Schools within the schools wasinitially limited The mentalhealth program health nurses intheir roles as school to theconsultant's workwith public 230 COMMUNITY PROGRAMS AND NEW SOURCES OF MANPOWER nurses. Whenever a nurseselected a case involving a school child for presentation to the case-seminar, prior permission was obtained from thechild's parents, his teacher, and the school principal; the teacher andprincipal were also invited to attend the case-conference. This procedure brought the consultant into direct contact with school personnel and provided an opportunity for discussing mental health problems with them. Subsequently, when additional consultation time in the community became available, there was considerable enthusiasm for setting up more formally structured consultation activities within the public schools. The first seminars to be established were with elementary school teachers and high school guidance counselors.5 The case-seminar with elementary school teachers was coordinated by the supervisor of elementary education. This group met in the evenings, and the teachers who attended did so on a voluntary basis. Teachers were encouraged to bring up "mental health" problems from their own classroom experiences, with mental health defined in very broad terms. For example, it wassuggested that students with superior ability who did not live up to their academic potential might have significant mental health problems even though they did not exhibit overt symptoms of behavorial disturbance. Topics brought up by teachers included: (1) difficulties in dealing with children who use attention-getting mechanisms in the classroom, (2) techniques and procedures that teachers can use in the classroom for assisting children withemotional problems, (3) the teacher as a person with emotional needs of her own,(4) underachievement as an indication of mental health problems, (5) questions concerning the IQ grading system which served as the major basis for the assignmentof children to particular class sections. A regular case-seminar with high school guidance counselors developed out of the consultant's evaluation of astudent who was referred to him by the director of the Family Service Society. This case involved Robert, an eleventh-grade pupil who planned to withdraw from school prior to his senior year to take a job. Robert had performed extremely poorly in the past, was failing most of his presentsubjects, and was drifting toward delinquency in his behavior at school Pnd in the community. Most of Robert's teachersfelt that he had very limited ability; and this opinion was supported (or perhaps largely determined) by his IQ test scores, which ranged from 60 to 74 on three different administrations of the Otis Group Intelligence Test. However, one teacher was convincedthat Robert had the ability to do better work than was indicated by his pastperformance, and this teacher requested help from Family Service in arranging to have Robert tested. The consultant agreed to evaluate Robert provided that a meeting could be arranged with his teachers to review the test findings with them. In addition to Robert's teachers, the high school guidance counselors, including 5 For an excellent discussion of the roles and functions of the mental health specialist as a consultant in the schools, see Berlin (1956, 1962). 231 A MENTAL HEALTHCONSULTATION PROGRAM invited to this meeting. teachers who served as part-timecounselors, were also had high-average to The psychological examinationrevealed that Robert reflected in his school per- bright-normal intellectualpotential that was not obviously formance because of a severereading defect. Thisreading disability intelligence tests which detracted from Robert'sperformance on the group Personality tests fur- wereheavily weighted withverbal and reading skills. extremely limited, reflecting ther indicated thatRobert perceived himself as teachersand no doubt ofhis peers as wellthathe was the opinion of his that he If mentally retarded." This self-perceptiondisposed Robert to believe caused him to give upquickly on lacked the ability todo school work and effort. His low self-esteem any taskthat required morethan minimal mental him to seek acceptancefrom peers by in school-relatedactivities also led engaging in antisocial gangbehavior. On the basis of thediscussion of Robert'sproblems in the conference made for him to receive with teachers andcounselors, arrangements were and a program was special remedial readinginstruction during the summer; reading deficiency. With outlined for his senior yearthat took account of his with his parents, withwhom Robert's permission, aconference was also held that Robert be allowed to information was shared.It was recommended our agreed attend school in thefall, at least until theChristmas recess; his parents his senior year, and to this.Robert continued withremedial reading during difficulty. With specialhelp and his teachers werealerted to his reading high school; andachievement tests encouragement,Robert graduated from senior year. In a follow-up indicated he had madeoutstanding progress in his that Robert had married, was of this case three yearslater, it was learned responsible job, and wasregarded continuing to makeexce;lent progress in a good citizen. by his employer andothers in the community as a with high schoolguidance An important featureof the case-conference students to be seen bythe counselors was the selectionand scheduling of they felt might consultant. Members of the groupproposed students whom The profit from talking withthe consultant abouttheir school difficulties. and a decision problems of these students werethen discussed by the group, which students wouldbe invited to meetwith the consultant. was made as to students, the teacher- In an effort to avoidplacing undue pressure upon of the interview was to counselor carefully explainedthat: (1) the purpose help the student; (2) thesubjects discussed wouldbe kept confidential; The fact that over (3) the student's participation wascompletely voluntary. consultant declined a thirdof the students who wereinvited to meet with the at leastmoderately success- to do so suggeststhat the teacher-counselors were ful in structuring thesituation as "voluntary." students who indicated Significant changes inbehavior were observed in and these generally oc- that they were willing totalk with the consultant, that a sympathetic curred before the interview evertook place. It appeared confrontation of the studentwith his problembehavior by a teacher-counselor IMP

AND NEW SOURCESOF MANPOWER 232 COMMUNITY PROGRAMS the student's behavior.Such changes who offered helphad a salutary effect on of more constructiveattitudes probably facilitatedby the development were of personal interes;in in theteacher-counselor and byher direct expression important lesson tobe learned helping the student tosolve his problem. An often result in beneficialbehavioral here is that minimalintervention can deeply ingrained. change in personswhose problems are not yet

TRAINING ASPECTSOF THECONSULTATION PROGRAM consultation program inWilmington contributed The mental health Public of public health nursesand Department of to thein-service training minis- and it served an importanttraining function for Welfare caseworkers, who received personnel, and membersof other professional groups ters, school Department of Psychology consultation. This program wasalso utilized by the for graduate students in at DukeUniversity as a partof its training program who accompaniedthe consultant on clinical psychology.Initially, students irregular and informalbasis. Later, his visits to thecommunity did so on an Advanced ClinicalSeminar regu- students who wereenrolled in the writer's him on consultation visits tothe community. larly accompanied participant ob- The students sat in on groupconsultation sessions as public health nurses,ministers, and welfare case- serversand accompanied requirement, students were workers on visits totheir clients. As a course detailed reports oftheir observations.In addition, each required to write relat- student wrote a term paper onsome aspectof the consultation program, general literature on groupdynamics, clinical ing theirobservations to the students' reactions inthis limited psychology, socialpsychology, etc. The consultation were mostenthusiastic, and their exposure tomental health served to provideneeded per- observations and experiencesin the community the consultant's pointof view, the spective for theirclinical work. From the program of thestudents who observations, reactions,and enthusiasm for accompanied him wereinvaluable.

CONSULTATION AS ANAPPROACH TO COMMUNITY MENTALHEALTH PROBLEMS Conference on Over a decade ago,in an address tothe Stanford Felix, then Directorof the Na- Psychology and MentalHealth, Robert H. Mental Health,took cognizance ofprevailing manpower tional Institute of (1957) noted that itwould mental healthdisciplines. Felix shortages in the therapists to handle be unlikely that ournation could everproduce enough treatmentbasis. Conse- all the psyciwiogicalproblems of all people on a specialists becomeconcerned with quently, he suggestedthat mental health A MENTAL HEALTH CONSULTATIONPROGRAM 233 facilitating the contributions of otherprofessions and community agencies in the promotion of mentalhealth and the prevention of mentalillness. At the same meeting, in a similar vein,Carter (1957) posed the following question: "Shall we commit ourlimited and expensive professional resources to the treatment of only a few ofthe many seriously disturbed individuals in the community or shall we give moreemphasis to preventive services and to serving large numbers ofpeople?" (p. 25). Our current answer to Carter's question isreflected in the results of a survey of 595mental health clinics by Norman,Rosen, and Bahn (1961). Their findings indicated that in 1958 onlyabout 6% of the professional man- hours in these clinics was used for communityservices. For the median clinic, the percentage of professional timeinvested in community services was 4.2 withthree-fourths of the clinics reporting thateither no time or less than 10% of their scheduled professionalman-hours were used for indirect services or direct preventive functions.In a follow-up report to the Surgeon General's Ad Hoc Committee on MentalHealth Activities (1962), Bahn indicated that little change had beennoted in the amount of time that clinic professional personnel were devoting to communityservices. Thus, despite serious shortages in trained mentalhealth personnel and growing awareness that the mental health contributionsof other professions and community agencies could be enhanced ifthey were given more assistanceby mental health specialists, the major time commitmentof mental health professionals continues to be in direct services topatients. With the publication several years agoof Action for Mental Healthby the Joint Commission on MentalIllness and Health (1961), therehas been notable and significant reexamination of presentefforts to meet the mental health needs of the nation. However, inthe recommendations of the Joint Commission a sc:rious admitted bias in favorof direct services to the mentally illis revealed;Ad this may account, in part,for the reluctance of mental health specialists to engage in community services.The report states:

We shall emphasize various dimensions of service totroubled persons and to mental patients. We must not repeat themistake, made in the 1909 foundingof the National Committee for MentalHygiene, of diverting attention to the more appealing and stimulating but as yet visionary prospectof true, or primary preven- hygiene tion of mental illness (p. 241). ...We have assumed that the mental movement has diverted attentionfrom the core problem of majormental illness. It is our purpose to redirect attention tothe possibilities of improving themental health of the mentally ill (p. 242).

Does the Joint Commission's emphasis ondirect services to mental health patients provide a realistic approach tomeeting community mental health needs? In commenting on this aspectof the report, Stubbs (1963) points out that helping the"sick" to recover is only half the joband that it may be even more important tohelp the total population achieve anoptimal l:.vel 234 COMMUNITY PROGRAMS AND NEW SOURCES OF MANPOWER of "emotional well-being." Stubbs recommends that wedeploy our limited mental health manpower resources in balanced programsthat focus on psychological growth and the development of creative potential aswell as on psychopathology. The Surgeon General's Ad Hoc Committee onMental Health Activities (1962) has also recommended that communitymental health programs place greater emphasis on indirect services such asconsulta- tion and in-service training to other agencypersonnel. If we are to begin to meet community mental healthneeds, the mental health specialist must spend as much time in working with people who deal with people ashe does in working directly with disturbed persons.

INDIVIDUAL AND GROUP CONSULTATION As an approach to community mental health problems,consultation with key professional groups and community leaders represents an important and essential component of a balanced mental health program.Consultation with members of professional groups helps them assist their clients tofunction more effectively and productively in solvingproblems and resolving emotional conflicts before they reach a degree of severity that requiresthe attention of a mental health specialist. It also greatlyenhances the quality and the timing of referrals from the community caretaker to themental health specialist. Group consultation is more efficient than consultation with individuals in that it allows the mental health specialist toreach a larger number of professionals during a given period of time and permits the individual group member to absorb information and raise questions that arerelevant to his particular level of professional development. Groupconsultation also facili- tates exchange of informationand sharing of experiences, often stimulating considerable spontaneous interaction among group members on cases other than those discussed in group meetings. Consultation withindividual professionals is more adaptable than group consultation for responding toconsultee- client crises and more appropriate for working with insecure consultees who may be unwillirg toshare work problems with their peers. Individual consultation also permits more candid discussion of sensitive case materials and makes it easier for the consukee to bring up personal matters that may have important bearing on the case. The case-seminar method hasprovided a meaningful combination of group and individual consultationfor the professional groups with whom we have worked. In group sessions,consultees become familiar with the professional competence of theconsultant and learn to trust him. Subsequently, anindividual consultee may seek help on a problem that he might feel reluctant to discuss in the group.As a result of this individual consultation, the consultee generally becomes morecomfortable in sharing his work-related problems with the group. The mental health consultant who works with anumber of professional 235 4 MENTAL HEALTHCONSULTATION PROGRAM facilitate interagency groups andcommunity agencies cando a great deal to professional workerfrom understanding and cooperation.By arranging for a consultation session withanother agency, one agency toparticipate in a group comprehensive understanding the consultant canhelp to bring about a more involvement. The visitingprofes- of cases on whichthere is multiple agency helps to clarify the nature sional, in describing hisinvolvement on the case, offered by his agency andhow these services areperformed. of the services permits a more The resultingclarification of professionalroles and functions optimal utilization ofcommunity resources.

CONSULTATION WITHCOMMUNITY LEADERS critical determinants Since economic, social,and cultural factors are leaders and well-being,consultation with community of emotional disturbance Effective balanced and comprehensivemental health program. is essential in a involvement and community actionfor mental healthrequires community for the troubledindividual community control aswell as continuity of concern mental health servicesfrom other (Smith & Hobbs, 1966).The separation of effective programmingwhich community institutionsis a major barrier to surmounted only ifresponsible representativesof the community are can be community leaders actively involved in programdevelopment. Citizens and with mental healthspecialists in the plan- must thereforeshare responsibility ning of community programs. leaders in program The early andcontinued participationof community health needs of thepeople, and planning is essential tomeeting the mental health services these needs canbe optimally servedby integrating mental active involvement with other community programs(Lamson, 1955). The such as the Na- of citizens inmental health programsthrough organizations "visionary" nor a diversionof tional Association forMental Health is neither Such involvement ismanda- attention as suggestedby the Joint Commission. develop a mental health tory, for itprovides the perspectivethat is required to and resources of thecommunity. programbefitting the needs, customs,

REFERENCES Books, 1959. health manpower trends.New York: Basic Albee, G. W. Mental consultation with Altrocchi, J., Spielberger,C. D., & Eisdorfer,C. Mental health groups. Comm.Ment. Health J., 1965,1, 127-134. psychiatric consultant inthe schools. Berlin, I. N. Somelearning experiences as Ment. Hygiene, 1956,40, 215-236. schools as a meansof communicating Berlin, I. N. Mentalhealth consultation in Child Psychiat., 1962, 1671-679. mental health principles.J. Amer. Acad. 236 COMMUNITY PROGRAMS AND NEW SOURCES OF MANPOWER Bindman, A. J. Mental health consultation: Theory and practice. J. consult. Psychol., 1959, 23, 473-482. Caplan, G. Principles of preventive psychiatry. New York: Basic Books, 1964. Carter, J. W. The training needs of psychologists in community mental health programs at state and local levels. In C. R. Strother (Ed.),Psychology and mental health. Washington, D.C.: Amer. Psychol. Ass'n., 1957. Pp. 21-40. Felix, R. H. The role of psychology in the mental health effort. In C. R. Strother (Ed.), Psychology and mental health. Washington, D.C.: Amer. Psychol. Ass'n., 1957, Pp. 4-20. Joint Commission on Mental Illness and Health. Action for mental health. New York: Basic Books, 1961. Kazanjian, V., Stein, S., & Weinberg, W. L. An introduction to mental health consultation. Public Health Monograph No. 69, Washington, D.C.: GPO, 1962. Kevin, D. Use of the group method in consultation. In L. Rapoport (Ed.), Con- sultation in social work practice. New York: Nat'l. Ass'n. of Social Workers, 1963, Pp. 69-84. Lamson, W. C. Integrating mental health services into the community health and welfare program. J. Psychiat. Soc. Work, 1955, 24, 243-249. Libo, L. M., & Griffith, C. R. Developing mental health programs in areas lacking professional facilities: The community consultant approach in New Mexico. Comm. Ment. Health J., 1966, 2, 163-169. Maddux, J. F. Psychiatric consultation in a public welfare agency. Amer. J. Orthopsychiat., 1950, 20, 754-764. Maddux, J. F. Psychiatric consultation in a rural setting. Amer. J. Orthopsychiat., 1953, 23, 775-784. Norman, V. B., Rosen, B. M., & Bahn, A. K. Community oriented services of psychiatric clinics, 1958. Public Health Reports, 1961, 76, 231-237. Parker, B. Psychiatric consultation for nonpsychiatric professional workers. Public Health Monograph No. 53. Washington, D.C.: U.S. Dept. of H.E.W., 1958. Parker, B. Some observations on psychiatric consultation with nursery school teachers. Ment. Hygiene, 1962, 46, 559-566. Report of the Surgeon General's Ad Hoc Committee. Mental health activities and the development of comprehensive health programs in the community. Wash- ington, D.C.: GPO, 1962. Rieman, D. W. Group mental health consultation with Public Health Nurses. In L. Rapoport (Ed.), Consultation in social work practice. New York: Nat'l. Ass'n. of Social Workers, 1963. Pp. 85-98. Smith, M. B., & Hobbs, N. The community and the community mental health center. Amer. Psychol., 1966, 21, 499-509. Stubbs, T. H. The risk of false promise in achieving public emotional well-being. Alabama Mental Health, 1963, 15, 3-6. IV NEW APPROACHESIN THE SCHOOLS 13 PREVENTIVEASPECTS OFSCHOOL EXPERIENCE'

Herbert Zimiles Bank Street College ofEducation

THE SCHOOL AS APSYCHOLOGICAL INFLUENCE mental health phenomena A result of currentinterest in preventive has become a focus forboth primary andsecondary preven- is that the school not compli- The reasons for thisemphasis on the school are tion programs. should begin early inthe life cated. It is axiomaticthat efforts at prevention helping the school-agechild of the individual, sinceintervention geared to effective than that concernedwith the adult,who is less is likely to be more advantage of the Moreover, working inthe school has the receptive to change. in the com- of the mostinfluential institutional agents fact that it is one part, preven- munity, unique in its accessto all strataof society. For the most focused on the earlyidentification of tion programs inthe school have referral, and occasionally, emotional disturbance, oil promptand appropriate selected as the setting on a treatmentregimen itself.Usually, the school is available and because itprovides the for such workbecause it has children facilities and institutionalleverage. necessary rather than as a The concept of aschool as a placewhere children live sophisticated place where they arekept or trained is noteasily learned. Even mental health issues appearto social scientistsconcerned with preventive principally as a repositoryfor the childrenwhose future view the school health dedicated to protect.Although school mental mental health they are that often differ from otherforms of publichealth involvement in programs operationunlike the alien they are not totallydivorced from theeducational of children, amental health pro- dental clinic standingamid the classrooms teachers to helpidentify the mostdisturbed and gramwill often recruit with them vulnerable children onthe basis of theirclassroom experience usually seen asmarking a departurefrom the participationof the teacher is health worker sees aconnection between her customary role.If the mental those of the teacher,it is that thechild's extra-learning his own concerns and and impairs his behavior prevents hisintegration intothe classroom routine Wallace for theirthoughtful re- 1 Thanks are due toJacqueline Rosen and Doris view of this manuscript. 239 NEW APPROACHESIN THE SCHOOLS 240 classroom proper, with all itschildren, is seldomtaken ability to learn. The though it province of a mentalhealth prevention program, even to be the his formative constitutes an environmentin which thechild will live during shape his ultimate years and inwhich he will undergoexperiences that will psychological structure. modern educationaltheory, A contrasting viewpoint,growing out of mental health. assigns to the school amuch more active rolein preventive intervention; it serves Schooling is seen as a primaryform of psychological mediating cognitive- for promotingpsychological growth, for as an agent personal fulfill- affective integrations which supporteffective functioning and does not imply that theschool has ment. Todescribe the school as an agent psychological impact. an activechoice to make as towhether it will have have profound andwide- From a dynamic viewpoint,schools must inevitably influence of schools varies spread psychologicalinfluence. The psychological according to characteristicsabout according to theirexpressed goals, but also They produce bothintended which they may haveonly limited awareness. classroom and the school are and unintended outcomes.Only when the of all transactions occur- regarded as psychologicalfields, and the implications evaluation of an educa- ring within thesefields are made explicit, can proper made. While mostmodern educators areinterested in tional program be and objectives, it is one broadening and reformulLcingeducational programs influence of existingschool proof their main contentionsthat the scope of recognized, that life inschool grams isalready much greaterthan is generally impinges on virtuallyall other facets of thechild's existence. from the less inclusive, The overall psychologicalimpact, as distinguished experience, is oftenviewed as purely academic-intellectualimpact of school educators, like most of us,prefer to formu- anunintended side effect because This is one reason late the goals of their enterprisesin very concrete terms. been used to assesseduca- why acquisition ofknowledge has traditionally conventional tional growth. Morecomplex effects thanthose assessed by amorphous status ofunpredict- achievement tests areusually relegated to the these "side effects" is able and intangible consequences.The complexity of children. Neverthe- compounded by their being verydifferent for different of school less, it is maintainedthat these morenebulous, interactive aspects The way in whichschool experience are moresignificant in the long run. other reinforces or alterspsychological growth, the wayit combines with has greater implicationsfor influence processes tochange their path of action, discrete skills the future developmentof the child thanthe acquisition of solely attributable to theschool. Another factor whichdiscourages interest in thepsychological influence tradition of limited emotional in- of school experience isthe long-standing often define their role asnarrowly as vestment inschool affairs. Teachers of knowledge according possible, restrictingthemselves to the dissemination bulletins. The children, in turn,respond to thespecifications of curriculum PREVENTIVE ASPECTS OF SCHOOL EXPERIENCE 241 by developing a stylized reaction to school characterized by overt compliance but limited emotional commitment. Just as men are capable of isolating several years of their lives in the armed forces in order to disconnect the experience from the basic directionsand purpose of their lives, so, too, can children learn to "tune out" experiences in the school, thus minimizing their impact. However, because the child is not fully integrated in his psychological functioning during these formative years, the effectiveness of hispsychological withdrawal from the classroom is reduced. Such withdrawal is not without psychological significance; the idea that the child thereby creates a psychological vacuum is, of course, an illusion. If the primary mood of theschool is disinterest or uninvolvement, this, too, becomes a potentpsychological influence. An analysis of the psychological implications of classroom events and the formulation of a set of coordinate educational objectives has been a major contribution of the work of Barbara Biber (1955, 1961). Among the potential consequences of school experience, cited byher, is the opportunity it can offer for extending the child's feeling of acceptance to an orbit beyond his immediate family. The primitive, early childhood relationships with the family forge a concept of self and outer world which becomes solidifiedby the regularity of the family-dominated Pnviron m en t of early childhood. Upon entering school, the world of the child is expanded, elaborated,and reordered. What he experiences in school can serve to confirm and validate what he has already learned at home, or it can offer a set of alternatives which permit him to view his already established relationships and perceptions from a new, substantial perspective. The impact of a school program, however, does not have an invariant effect on all those exposed to it, since the effects of the child's new experiences in school are governed by the character of his psychic organization, by hisability to assimilate novelty and modify previous perceptions and cognitive orientation on the basis of new experience. No realistic appraisal of the influence of school experience would ascribe to it those psychological forces which have been set in motionand sustained by the home. What is customarily regarded as the characterological core of the child's psychological make-up owes its formation to the nuclear relationships within the family. Nevertheless, the child begins to attend school early enough for some of these more basic psychological structures to be affected. From one standpoint at least, one might speculate that the school's psychological impact will be stronger than that of the home. Early experiences and relationships have so decisive an effect on the development of perception and values that the home environment may form the background against which extrafamilial figures in the contemporaneous world are sorted and responded to by the child. In contrast to the fixed perceptions derived from family life, the variation in school life provided by transitions from year to year in teacher and class compositionintroduces enough novelty to permit the* SCHOOLS 242 NEW APPROACHES IN THE school to maintain a compellingquality as figure against the groundof the home. be In sum, these argumentschallenge the idea that school impact can the restricted to academic or specificpsychological dimensions according to will of the teacher. What transpiresin the classroom canbe examined through different lenses. Theaffective and the intellectual aredifferent modes of classifying aspects of thepsychological processes which inhere inall classroom behavior.Whatever the style of teaching andquality of classroom life, they can be studied in relation totheir implications for thepsychological influence on the participatingchildren, according to whichevervariables interest the observer.The emphasis here is on thetotality of factors and their interrelations which operate in theclassroom, on an educational program based upon a sociopsychologicalanalysis of the classroom situation. It should be noted that the pointof view summarized in thepreceding paragraphs does not imply anunqualified endorsement of recentsecondary approaches to mental health in theschools. While such preventive programs tend to increase the psychological awarenessof school personnel, they exert a conservativeinfluence upon education byhelping emotionally disturbed and other groups of children torespond effectively to alreadyestablished patterns of teaching.A psychological viewpoint shouldpervade the total planning of the school program,and not be confined to copingwith isolated problems such as the identificationof pathology. Special serviceswithin a school should emanate from a masterplan based upon an analysis ofthe needs of children from the standpointof developmental theory (Biber &Franklin, 1967). These same reservations apply tocrash programs now directed atdis- advantaged children. Preventive mentalhealth in the school is too universal and too complex a task to bestudied by ad hoc groups expectingshort-term breakthroughs. It would appear thatthese efforts would be better spentif they were directed toward achieving a morepervasive and enduring influence. Furthermore, children who are manifestlyineffective in school may constitute the most serious problem; butthey are outnumbered by the massesof children who go through school unnoticed yetwho have not truly learned or experienced gratification from learning,who have been exposed to aschool environment that reinforcestheir acceptance of anonymityand marginal effectiveness.

A STUDY OF SCHOOLEFFECTS AT BANK STREETCOLLEGE2

At Bank Street College, wherethere has been a long-standing commitment to modern educationaltheory based on years of practice andobservation in the schools, it wasdecided to put some of theseempirically-based 2 This research project, "ThePsychological Impact of School Experience," was supported by a grant from the NationalInstitute of Mental Health (M 1075).The com- 243 PREVENTIVE ASPECTS OFSCHOOL EXPERIENCE determine convictions to a more systematicand rigorous test.We wanted to the ways we had come whether children really areaffected by schooling in school influence.Con- to believeand to explore otherpossible dimensions of intensive study ofchildren sequently the ResearchDivision undertook an Countless facets of theschool en- who attended differentkinds of schools. variables in theanalysis vironment merit systematicstudy as independent Among these, we chose a of the psychologicaleffects of school experience. of school ideologyand prac- molar variable, themodern-traditional continuum approach to educationwhich em- tice. By traditionalideology we meant an achievement alongpredetermined lines anddemands 4 phasizes intellectual value to modern ideology wasdefined as assigning greater rapid socialization; learning than to the individuality and totheprocessesof thinking and quality of a school mastery ofspecified content.The modern-traditional salient influencing factors.The environment wasjudged to embody its most provided a frameworkfor describing howdiverse modern-traditional concept achieve a variety educational considerations wereorganized and integrated to educational goals. Weconcluded that schools,explicitly or of interrelated the basis of aconstellation of implicitly, organizedtheir programming on modern-traditional continuum. ideas which occupieddifferent points on the became our indcpendentvariable. The continuum by modern and tradi- This stance required us todefine what we meant and to devise criteriafor judging tional educationalideology and practice child-rearing pracikesalong this dimension.It was surprising schools and compromised some staff mem- how difficult this was toaccomplish and how used were estab- ultimate definitionsand criteria to be bers felt when the questions regarding lished. Multiple criteria wereestablished, thereby raising interaction. If criterionA is present their hierarchy andthe nature of their criterion B, is A ofthe same qualitywhen it is accom- in a school but not criteria, we could panied by B? It wasalso recognizedthat in using multiple of antecedents were never be surewhich componentsof the configuration less responsible forthe effects weobserved. more or of essen- The basic strategy ofthe study was tofind groups of children background who attendedschools which i tially equivalentsocioeconomic and then to subjectthese varied along themodern-traditional continuum, study along a setof selected children to intensiveindividual psychological meaningful variables,rather dimensions in order toexplore psychologically Practical considerationsdictated than mere indices ofacademic achievement. (which was to extend oversix that the intensive assessmentof the children covering a total ofeight different individual interviewand testing sessions, investi- will be reported in aforthcoming book by the senicr plete results of this study Edna Shapiro, and HerbertZimiles, to be gators, PatriciaMinuchin, Barbara Biber, Inc. in 1968. Theselected findings reported inthis article published by Basic Books, members of the ResearchDivision result of the collectiveefforts of a great many are the but responsibility forthe interpretation ofthe at Bank StreetCollege of Education, findings presented here restssolely with the author. SCHOOLS 244 NEW APPROACHES IN THE or nine hours)be restricted to a relatively smallnumber of subjects. In all, 105 fourth graders constitutedthe subject group. Four different schools, each representingdifferent points on the modern- traditional continuum, were chosen.Although it would have been less complicated to include only public schools inthe study, our wish to have the most modern endof the continuum represented requiredthe inclusion of an independent private school. The four schoolsfrom which fourth-grade children were selected for intensive study,therefore, consisted of three public schools, two of which were considered quitetraditional and the other modern, and a very modern, independent privateschool. The series of comprehensive and rather complex criteria established tocharacterize whether a school was modern or traditional, which guided theselection of schools, included judgments of: the role of theschool in educating for competence; therelation of the school as an institution to itssocial and professional milieu; thequality of personal interaction amongchildren and school staff and withinthe hierarchical structure; the school's view ofindividuality; and the manner in which it deals with issues ofmotivation, autonomy, andself-realization. An obvious methodological barrier tothe study of the effects of variations in school experience isthe problem of controllingfor sources of influence other than the schoolmostprominently the influence of thehome. Two methods of control over the influenceof the home, both approximate, were employed. The groups were equatedwith regard to certain homevariables the children were selected sothat the four groups were essentiallyequivalent as to thesocioeducational-economic character of thehome, so that variation among the groupsin the dependent variablescould not be attributed to variation in these characteristics.In addition, each of themothers of the study children was interviewed andcompleted a questionnaire regardingchild- rearing ideology. Thedegree of correlation between the measuresof child- rearing practices andideology and attributes of the children'spsychological functioning was recorded toestablish the relation between homecharacter- istics and the dependentvariables. In this manner differences independent variable measures found amongschool groups could be examined inthe light of information regardingthe relative contribution of homeinfluence. This mode of control wasneither complete nor precise butoffered an estimate of the relative impact of the mostcompetitive source of psychologicalinflu- encethe home. In planning the assessmentprocedures, it became apparent that our expectations regarding the school'sinfluence on the child did notnecessarily involve variables for whichpsychologists had developed methods of measurement. Theantecedent conditions we studied were notof the type routinely manipulated by experimenters;they constituted a large segment of thechild's environment, the effects ofwhich had not been studied previously.In addition, our mental healthframework forced us to break out of thecircle of conventional research variables, so that some newconceptualizations and methods were created.For example, we were interested insuch variables as the quality 245 EXPERIENCE PREVENTIVE ASPECTSOF SCHOOL degree of articulationof present inthese childrenthe of self-differentiation also interested intheir of themselves aspeople. We were their awareness adulthood, in the natureof relative commitment tochildhood as opposed to involved they were inanticipating and their investment inchildhood, in how rehearsing adultroles and values. studying the effectsof variation in Along similarlines, our interest in development reminded usthat cognition school experience uponcognitive by psychologists in termsof existing experi- had been verynarrowly defined relating to this procedures. Bothmethods and concepts mental measurement disappointingly limited. psychological process, sobasic to education, were investigation of thissphere of functioning Consequently, theresults of our well as a Marked variation amongthe groups, as wereextremely uneven. group, werefound in an areaof cog- unique patterningof abilities within a washighly refined,whereas dif- nitive functioningfor which measurement failed to appear inthose sphereswhich ferences betweenthe groups often were not sowell developedmethodologically. all of the brief chapter, it is notpossible to summarize In this relatively w'Ach were assessedranged of the children.The variables results of the study style, patterns ofself- toward school to aspectsof cognitive from attitudes and relatedness.The perception andfeeling, andinterpersonal perception restricted to a singledimension cited previ- presentation offindings will be orientation towardchildhood. ouslythe child's facet of thechild's childhood wasconsidered to be one How he views regarded as pivotal relatedness to theself, and the issueof self-perception was It can beargued that the issues in assessingthe effects ofschool experience. lie at the core ofthe philosophical con- of individualityand self-enhancement They appear in a traditional theoriesof education. flict betweenmodern and character impinging onquestions ofimpulse control, variety of contexts, depth. One of thehall- in whichlearning occurs in building, and the way with the develop- education is itsfundamental concern marks of traditional child. The school is "self-control" in the yetundisciplined school-age ment of thoughts, feelings,and im- helping the child tosubjugate his inner seen as development and clearthe path for pulses in order tofacilitate his moral knowledge. other hand, markspersonal experience as The moderneducator, on the of focuses more onthe hypothetical process the starting pointof learning. He of mastery andcompetence.Conse- ego-enhancement andthe achievement mediator of thelearning process. quently the selfconstitutes the prime dramatization as amedium for learning as The utilization ofplay and with the acceptingatmosphere of the well as for emotionalexpression, along to usethe child's ownchildlike modern school andthe deliberate attempt for directing thepath of learning, are experiences andinterests as a resource school's central concernwith socialization, in contrastwith the traditional growth towardadulthood, oftenaccompanied with facilitatingand hastening and childhood.This wouid tend to sug- by the stigmatizationof childishness 246 NEW APPROACHES IN THE SCHOOLS gest that the child's perspective with regard to child-adult statuswould be differentially affected by school experience. A number of measures bearing upon this issue were obtained, both direct and indirect, most of which tend to substantiate this expectation. In the course of the interview and testing sessions, the child was asked what age he believed to be best, what he thought was the best job in the world, and what he would do with a million dollars if it were given him to spend in one day. responses to these questions, and the storieshe made up to a set of pictures, were ratedaccording to their adult-child quality according to whether the jobs chosen and the modes of spending the million dollars adhered to adult patterns and images of work and wealth or typified the child's orientation to money and jobs and were concerned with fulfilling more child-like impulses. There were reliable differences among the school groups in their responses to the question about the best age tobe. The modern private school group consistently favored earlierlife stages, showing a greater affinity for childhood and their current age level. The rank order of the mean preferred age corresponded exactly to the rankorder of the degree of traditionalism in the four schools.3 The remaining findings of this cluster present a more consistent pattern. The responses given to the Chi ldfen's Picture Story Test, a variant of the TAT, were rated according to the degree to which they involved themes relating to older social sex roles such as dating, marriage, and having children. Here, once again, the rank order of mean ratings paralleled the rank order of traditionalism. The magnitude of the differences among schools did not achieve statistically significant levels. In a similar vein, the traditional school groups more oftendescribed adult-oriented jobs as those they considered best. These included engineer, lawyer, doctor, housewife, teacher. Their conception of the desirablejob was clearly modeled upon adult standards. By age nine their ideas aboutwhat constituted desirable work were hardly distinguishable from thoseoffered by adults. In contrast, the modern school group's responsesforexample, fire- man,detective, bariet dancerwere reliably more fantasy-derived and more closely associated with the facets of life in which they were mostdeeply interested. Their choices were clearly more child-centered. Responses to the million dollars dilemma followed the same pattern. The traditional school group more often gave adultlike responses. They thought of buying property, of making huge investments and acquiring companies. They were much more concerned with the accoutrements of wealth as aduhs tend to see them. The modern private school again was much more preoccu-

3 It should be noted, however, that in this instance, data obtained from a self-rating procedure concerned with a very similar issue failed to reliably differentiate the four school groups. The difference in results between the two sets of data is probably attributable to the wording of each of the procedures. 247 PREVENTIVE ASPECTS OF SCHOOLEXPERIENCE with buying toys, pied with securing pleasuresassociated with childhood, they longed finding opportunities to visitplaces, and obtaining entertainment their way of disposingof for. They were less systematicand businesslike in order of money; their responses were morechildlike. The rank so large a sum rank order of of group means correspondedperfectly with the traditionalism reliable, as was the groups. The overalldifference among school means was school mean and that ofeach of the difference betweenthe modern private the two traditional school means. In these instances, then, arelatively consistent patternof differentiation that the modern among theschool groups was obtained.It is important to note with childhood, was not private school group,found to be more identified associated simply more childlike.The usual constellationof characteristics with immaturity were not presentin these children.There was no evidence human beings. In this re- that they felt morehelpless or less responsible as references to adult figures; gard, their fantasyproductions contained fewer figures in the events they apparently there was lessneed to include parent they portrayed in fantasy. Inaddition, when parentfigures were included, children from the traditional portrayed them with lessveneration than did the home were just as strong schools. Other evidenceindicated that the ties to difference between the two groupslay in in thesenine-year-old children; the prominence of parentfigures and their the content oftheir fantasy, in the supportive quality. about crime Additional data of interest camefrom a series of questions what they and punishment inwhich the children wereasked to indicate unanimity; almost all thought was the worst crime.Here there was virtual equally heinous act.But when the children respondedwith murder or some thing that a child intheir they were asked toindicate what was the worst public school groupsusually class could do, mostof the children from the substantial number fromthe mentioned some formof childish prank. A with murder. modern private school group,however, responded once again When ex- This difference in response canbe interpreted in various ways. cited results, it appears to express amined in conjunctionwith th2 previously and influence. The the children's differingperception of their own power childhood state as a formof pre- public school childrenlearned to view their privileges and adulthood or apprenticeship, astate ofbeing with limited hereas those from themodern private school sawchildhood as power, w potential power and having a status of its ownand children as possessing destruction not unlikeadults. of the level of analysis em- These findings arepresented as illustrative study. ployed and the modesof differentiationobtained in our comprehensive studied with regard toschool As one dependentvariable after another was findings to emerge wasthe effects, one of the mostprominent patterns of of school. For example,strik- difference between boysand girls, irrespective of identification with ing sex differences werefound among the measures 248 NEW APPROACHES IN THE SCHOOLS childhood cited above. In response to the question about thebest age, the girls reliably more often favored older stagesadolescenceand adulthood whereas the boys preferred their present age or slightly younger.The differences among the school groups intheir tendency to include themes relating to older social sex roles on theChildren's Picture Story Test were primarily accounted for by the higher mean scores found among thetraditional school girls. Sinificant sex differences in each of the twotraditional schools, as well as in the total sample, werefound. Statistically significant differences between the sexes werefound among many of the other variableswh:ch were studiedimaginativeness, the degree and quality of self-differentiation, the tendency tointroduce parent figures into fantasy productions, the mode inwhich aggressive feelings were expressed in fantasy, and the manner in which the self wasprojected in figure drawings. There were differences, too, in how popular and competentthe boys and the girls believed themselves to be in relation tothe rest of their class and in how convinced they were that it wasbetter to be a member of their own sex. The rediscovery of sex differences is a majortheme among the findings of current research in developmental psychology. The sexdifference results of greatest interest in our study were those whichinteracted with school differences (Minuchin, 1965). Such patterns occurredwith sufficient reliability and regularity to conclude that some of the schoolswhich were studied reinforced the psychological divergence among the sexes morethan others, and that questions regarding the responsiveness to school environments needed to be studied separately for each sex.

CONCLUSIONS AND IMPLICATIONS FOR FUTURE RESEARCH

Although the findings reported here pertain to only a fragment of the variables which were studied, it is apparent that a great deal ofadditional work is needed to clarify the issues raised by our work. More dimensionsof personality and cognitive functioning need to be investigated and thesample broadened to include children from more diverse socioeconomicbackgrounds. Perhaps most important, the effects of school experience shouldbe studied at several points in development, spanning theperiod from the beginning to the end of school. Clearly the impact of schoolingevolves over time; it is a developmental process. The residue of each component of school experience interacts with future school experiences anddevelopmental changes. School programming, when planned with deliberation andforesight, takes the current developmental needsof the child into account and utilizes these trends in shaping a programa that will maximallyfoster growth according to ultimate goals. If we think of the child's school career as ajourney, comparisons of school effects at any single point in time are usefuland illuminating but 249 PREVENTIVE ASPECTSOF SCHOOLEXPERIENCE Variation among theschools in pacinghowmuch reveal only landmarks. planning the entire trip, time is takeninitially for primingthe participants or of the more difficultterrain whether they havechosen to traverse some ultimate outcome onthe basis earlier or latermakes itdifficult to forecast the relative position at someintermediate point. of the school group's that contrasting edu- One fault of theabove analogy is that it suggests single destination.The differ- cational ideologies offeralternative paths to a with respect between the modern andtraditional school children t.nces found in later stagesof investment in childhoodand their involvement to their developmental processes were development strongly suggestthat different different patterns ofchild involved, that theseschools weie cultivating The differing growth in order toachieve oralappingbut different objectives. issue which warrants objectives of contrastingeducational programs is an receives. We oftenoversimplify con- more intensivethought than it usually ideology by stating thatthey are concernedwith different troversies over values inherent in the means toachieve a common end.Yet the hierarchy of the repertoire ofbehaviors modern and traditionalideologies is clearly distinct; adult are far fromidentical. Over- they value most highlyin the functioning distinct hierarchical structures areasdifferent lapping value systems with When the time from one another as a patronof the arts is from an artist. implement their goalswith great pre- comes thateducators can specify and between the educationalpractitioner cision, the problemof conflicting values and client will have tobe confronted. led to the customary Where our findings havebeen negative, they have prob- reevaluation of theory andmethod. But thecomplexity of our research enigmatic quality.For lem is such that even ourpositive findings have an attitude toward example, striking differences werefound in the children's indicated something many school, which confirmed ourexpectations. The data made attractive and even educators have longknownthat school can be who were studied, lovable. And it is accurate to saythat many of the children particularly those from themodern schools, reallyloved school. It satisfied along per- their thirst for inquiryand supporteddevelopment of competence desirability sonally selected andmeaningful lines. However,the self-evident which of these outcomes should not causeus tolose sight of the purposes attitudes of hostility towardschool may have served.The very more customary about its durability of traditionaleducation would suggestthat something approach serves form renders it dynamicallyfunctional, that its particular congeniality of the rela- adaptive ends. Consideredfrom this standpoint, the the modern school raises ques- tionship between childand school effected in animosity tions we have nothad an opportunity tostudy. Does the customary child's psychic economy?For toward school have somespecial function in the the object of displacedhostil- example, to what extentdoes the school serve as relation- ity toward the parents, as akind of safety valve inthe parent-child disadvantages, ship? Are there someadvantages, as well asthe self-evident 250 NEW APPROACHES IN THE SCHOOLS associated with a limited commitment to school? How does investment in school affect other primary relationships? These questions remind us that the child's relatedness to school is part of a dynamic network; they introduce still other perspectives to the study of school influence. In a number of instances, this study has contributed new formulations of dimensions of personality and cognition. The child's investment in childhood and his degree of involvement in later stages of development have been shown to be significantly affected by school experience. Other findings, not presented in this chapter, have pointed to the significance of the dimension of group functioning, at a cognitive as well as social level. Our work also confirmed that relatively fine distinctions in personality functioning, such as degrees of self-differentiation, can be assessed and, further, can be shown to be related to particular forms of school experience. Among the most unexpectedand interesting findings were those relating differential school experience to the sex of the children. It would appear that someeducational theorists have been so concerned with overcoming arbitrary and restrictiveattitudes which differentiate the activities and interest patterns of boys and girls that they have lost sight of important developmental and psychological differences between the sexes which affect the meaning and influence of school. It scarcely needs to be noted that our findings have not demonstrated that thoughtful planning and execution of school programs can prevent mental illness. Disabling pathology usually involves factors outside the realm influenced by school experience. However, when the psychological organization of the child is more plastic, when it is not rigidified by pathology, the findings indicate that significant dimensions of psychological functioning can be influelit ;d by the character of school environment. Since, obviously, the modern-traditional quality is not the school's only dimension of variation, and since the study itself should properly be regarded as only a pilot version of the evaluation of this modern-traditional continuum, it may be suggested that the influences of school experience are far more extensive and complex than our study has revealed. The relevance of thi$ work to the preventive mental ht..alth movement lies as much in its form as in its substantive findings. It is rare for behavioral scientists to have tl'e opportunity to study the effects of so profnund a difference in stable, enduring conditions oflifeenvironmental factors which are at the same time completely malleable, which can be shaped by man'swill. If preventive work is to advance beyond the point of exclusive concern with the early identification and treatment of pathology, if it is to contribute to social planning by gauging and manipulating psychosocial environments, then it must embark upon a similar course of study. It must first identify the dominant influence systems in the environment and then systematically assess the effects of variation along its most salient continua. Such work is destined to proceed slowly because it requires far morerefined analytic procedures for dealing with simultaneous multiple influence factors and their interaction 251 PREVENTIVE ASPECTSOF SCHOOLEXPERIENCE such work is essentialif the than now exist. In thefinal analysis, however, instruments for inquiryand the social sciences are tobecome more potent goal of effective prevention. mental health movementis to approach its

REFERENCES

healthy personality. In R.Kotin- Biber, B. Schooling as aninfluence in developing for mental health.Cam- sky & H. L. Witmer(Eds.), Community programs bridge, Mass. :Harvard, 1955. Pp. 158-221. mental health principles inthe school setting. In G.Cap- Biber, B. Integration of children. New York: Basic lan (Ed.), Prenntionof mental disorders in Books, 1961. Pp. 323-351. M. The relevanceof developmental andpsychodynamic Biber, B., & Franklin, 1967, concepts to theeducation of the pre-schoolchild. J. child Psychiat., 6, 5-24. childhood as a function of Minuchin, P. Sex-role conceptsand sex typing in 1033-1048. school and home environments.Child Develpm., 1965, 36, 14 PPIMARY PREVENTION IN THE CLASSROOM THROUGH A TEACHING PROGRAM IN THE BEHAVIORAL SCIENCES'

Sheldon R. Roen Teachers College, Columbia University

Schools present a most compelling avenue for preventive programs since they are institutionalized settings in which all children can be found. Programs of mental hygiene in classrooms have been advocated for many years (Group for the Advancement of Psychiatry, 1951). The bulk ofthese programs, however, have not met with adequate success. Among the reasons for this are the following: some programs required special training of scarce personnel; others asked for the enthusiastic cooperation of overtaxed, disinterested, and professionally reluctant teachers and administrators; and still others were so lacking in appeal or validity as to appear solely an exercise in moralizing.

PRIMARY PREVENTION IN THE CLASSROOM

Primary prevention aims at reducing the incidence of disturbance. It is not always necessary to know the exact cause of a disturbance in order to make some gains in preventing it from occurring. Improvement programs based on educated guesses of the relationship between variables have often realized positive results. For example, even before the existence of germs was known, the observation that cleanliness, sanitation, and pleasant living conditions relate to the maintenance of physical health was sufficient to carry forth effective public health programs. In the economic realm, where determination of etiology is also frustrated by complexities, the recent bold stroke of reducing taxes so as to increase consumer spending seems to havemaintained the period of prosperity. Currently, the approach to general problems of social well-being in the United States suggests that concerted action on plausible notions is the order of the day. Although behavior has long been regarded as a function of a person and 1 The teaching program represents a project carried out at the South Shore Mental Health Center, Quincy, Massachusetts, where the author was Director of Research.

252 253 PRIMARY PREVENTIONIN THE CLASSROOM machinations of deeplyembedded an environment,fascination with internal dynamics has led toconcentrated attention onpsychotherapeutic treatment. psychoanalytic theory,because of its individualapproach, The influence of The new interest of delayed seriousconsideration of preventive programs. of people with theirenviron- mental health professionalsin the interaction restimulated thoughtsabout prevention. ments has the risk group in such a In essence, primaryprevention either fortifies environment so manner as toenable it to ward offaffliction or rearranges an the earlier this can be accom- expel the harmfulfeatures. It follows that as to lowering incidence of plished in a life cycle, the greaterthe opportunity for tend to focus on disturbance. Thus, many programsof primary prevention parents and onschools. children cope moreeffec- In considering what canbe done to help school be directed to boththe tively with life stresses, anoptimal approach would however, it is helpful child and his school environment.At a practical level, .1,! school to focus on one orthe other of thesealternatives. With regard t- the environment, the assumptionis made that theconditions surrou, !silo, educational process have the power tomold. The teacher'sattitude, ingredients of this environ- and relationships withher pupils are each prime the school and theclassroom, and ment. Additionally,the social structure of business, are important the very manner in whicheducation goes about its fortified, components. If, onthe other hand, the childhimself is to be directly consideration should be given tothe more formal learninginputs. ?ttention the specific learnings would then be focused oncurriculum content, and on and values inherent in aparticular curriculum.

TWO SUSTAINEDAPPROACHES There have been several attemptsto come to gripswith issues of efforts includes a large- mental health and theclassroom. The history of past schools (Loftus, 1940, 1943), scale activity program inthe New York City schools (Bullis, 1941),develop- human relations classesin the junior high understanding (Taba, ment ofmaterials and approaches toimprove intergroup 1949), and the trainingof selected teachersand school administrators to (Seeley, enable them to guidediscussions of humanrelations in the classroom necessarily germane to the 1954). Critical elaborationof these projects is not sustained for over twenty- purposes ofthis chapter. However, two programs prevention strategy, five years, each reflecting adifferent prong of primary stand out as guideposts.

The Total SchoolAtmosphere Emphasis the work of The first sustained program tobe discussed stems from Their method, which Barbara Biber and theBank Street College group. interaction, advocates evolved from Dewey's conceptsof learning and social 254 NEW APPROACHES IN THE SCHOOLS "infusing mental health principles inevery school process" (Biber, 1961, p. 348). Based on a multiple criterion approach, which integrates the goals of education and the goals of mental health, theirprogram emphasizes the positive relations of children with teachers and administrators, cooperative relations among the staff, flexibility of curriculum and evaluation, and the cordiality of the teaching process. They see an inescapable circularity in the intricate interdependence of cognicive and affective growth (Cartwright & Biber, 1965). Although mastery and achievement are recognized as essential toego strength, they feel that th t! experiences and relationships through which cognitive learning functions are also prime factors. Their teacher education methods (Biber, Gilkerson, & Winsor, 1959) are based on general propositions whichserve the purposes of mental health; they are useful in understanding psychological constancies in the educational process. The following interlocking goals (Biber, 1961) have been formulated: (1) positive feeling toward self, (2) realistic perception of self and others, (3) relatedness to people, (4) relatedness to environment, (5) independence, (6) curiosity and creativity, and (7)recovery and coping strength. There is obvious difficulty in conducting reseahon the formulation developed by the Bank Street Collegegroup, but a critical study of the assumption that the quality of school experience significantly effects the total psychological growth of children has been undertaken by them (Biber, 1961). The research design calls for the examination of 106 fourth graders, matched for IQ, in four different schools. The schools were selected in terms of significant differences along the modern-traditional continuum. Some general results of this study are presented by Zimiles in Chapter 13.

The Improved Curriculum Emphasis Since 1941, Ojemann (1961) and his colleagues at the University of Iowa have conducted a conscientious research and developmentprogram on teaching children a causal orientation to the social environment. This causal orientation was defined by Ojemann asan understanding and appreciation of the dynamic, compkx, and interacting nature of the forces thatoper- ate in human behavior; it involves an attitude of flexibility, of seeing things from the viewpoint of others, and anawareness of the probabilistic nature of knowledge. Their approach assumes that a person who isaware of the dynamics and causal nature of human activities is better able to solve his own problems and to deal with social situations. The Iowa project involves no specific intent to introducenew subject matter, as such, into the school curriculum. Rather, the intent is to restructure the existing curriculum (social studies, English, geography, etc.)so that it attends to issues of human behavior. Intensive teacher trainingprograms PRIMARY PREVENTION IN THE CLASSROOM 255 were developed (Stiles, 1950) to foster a causal orientation amongteachers so that their pupils would benefit from early and sytematic exposure to this mode of thinking. For Ojemann (1959) "the essential problem is to devise a curriculum that is causally oriented throughout and that is taught by a causally oriented teacher beginning in the early years" (p. 21). Various studies from the Iowa Child Welfare Research Station have shown their work to be effective. Muuss (1960) matched three groups of 25 sixth graders on IQ and sex. One group participated in the program for one year, another group for two years, and thethird group did not participate at all. Criterion measures included the Problem Situation Test (a measure of the tendency to use immediate punitiveness), the Children's Anti-democratic Scale (CADS), and certainty scores of a test for intolerance of ambiguity. The group exposed to the program for two years showed a significantly positive gain over the one-year group on these measures. Levitt (1955) showed in a previous study that experimental subjects,exposed to the causal teaching program, had become significantly lessauthoritarian and more willing to assume responsibility. Stiles (1950) investigatedchanges in the method used by fourth-, fifth-, and sixth-grade children to handle daily behavior situations brought up for consideration in the "Room Council." He found that the causal learning program produced significant changes in the direction of decreased punitiveness; the children werc more concerned with understanding before deciding. Ojemann, Levitt, Lyle, and Whiteside (1955) trained teachers to use special curriculum methods emphasizing multideterminism. The teachers were trained for one month in the summer, and group conferences were held every three weeks during the year.Experimental teachers were matched with controlteachers, who made use of materials if they so desired but were not trained to use them. The results showed that classes belonging to the experimental teachers showed a marked positive change in punitiveness and causal orientation. In a more recent study (Ojemann & Snider, 1964), a causally oriented behavior observation form was used by trained observers. Results showed significant gains in causally oriented behavior by the experimental groups. A somewhat different curriculum approach has been conducted by Lip- pitt, Lippitt, and Fox (1964) at the Institute of Social Research at the University of Michigan. They formulated a pilot project to explore the possibilities, of early social science education and developed and taught six social science laboratory units, including learning from grownups,feedback in interpersonal relations, and rules and standards in group life.These units were planned to fit flexibly into currentsocial studies programs.

Discussion The Bank Street College approach involves, by its very nature, an 256 NEW APPROACHES IN THE SCHOOLS espousal of a value system. It is allied to the "social-political liberalism of the century, or more generally, the values of the humanist point of view" (Biber, 1961, p. 325). Personality is to be engineered, so to speak, on the basis of a congruence between mental health values and the goals of modern education through the medium of interacting factors in school life. The assumption is that an emotionally "healthy" experience with the process of learning will aid in developing a child's ego strength. While there is a compelling logic to this point of view, the values underlying the program are not held by all. Some believe such specifications about personality are not in the realm of the educational mandate and interfere with the child's or Family's spontaneous finding of their own most comfortable level of contribution, unencumbered by homogeneity of perceived values. Society, itis agreed, is better for having the fragile, exquisitely sensitive person as well as the brash promoter. Although elements of the Bank Street College program have had an influence on school procedures in general, acceptance has not been widespread; its greatest influence has been in selected private school settings. The improved curriculum approach as represented by Ojemann and his co-workers has had even less impact on school procedures. In part this may be due to the fact that the program requires that the teachers be motivated to seek training. Good teachers do, in fact, often supplement the prescribed curriculum with current events or interests stemming from their own background and experiences, but such supplements do not generally require extended knowledge about the materials being considered. The "causal orientation" would seem to be not only an attitude of mind but also a serious subject .cor study and mastery by the teacher. Since specific allotments of time are not set aside for this aspect of the curriculum, but rather the orientation is interlaced through units already being taught, it requires considerable organizational ingenuity in order to incorporate it effectively into a teaching program. The Ojemann program is also hampered by the way teacher education institutions organize their training programs. Courses are usually taken along subject matter lines, and things psychological are taught peripherally as foundation subjects. If this model were to change so as to articulate better the purposes of a truly integrated curriculum, greater success with the causally oriented curriculum might be realized. However, the trend appears to be in the opposite direction; the times advocate an even higher degree of specialization and a commitment to specific skills and subject matter. Educators may be more likely to accept the teaching of an entirely new discipline, replete with its own curriculum materials, methods, and trained teachers, than to rework old, established ways of doing things. The "new" mathematics and science curricula were brought into forward-looking school systems in toto, rather than as piecemeal revisions of existing approaches. 257 PRIMARY PREVENTION INTHE CLASSROOM

THE BEHAVIORALSCIENCES CURRICULUM IN THEELEMENTARY GRADES

Since 1963 an experimental programof teaching the behavioralsciences as aformal, academic, curriculumsubject has been conducted in just outside of selected elementary schoolslocated in the South Shore area Boston. Sponsored by theSouth Shore Mental HealthCenter, this program school mental health consultation was initiallybegun as an extension to the program thathas been in effect for over adecade. The teaching program has In the gone throughseveral stages of development sinceit was first instituted. subsequent sections of this chapter an attemptwill be made to describethe program's rationale, its history, itsapplication to fourth-gradeclasses, and its subsequent extension into residential treatment.Furthermore, a controlled development of a evaluation of the effectiveness ofthe program, and the seminar for teachers, which has grown outof it, will be described.

HISTORY OF THE PROJECT The impact of Sputnik onAmerican education resulted in a movement toward revisionof elementary schoolcurricula in the areas of natural science and mathematics. Atthe time, this type ofcurriculum revision seemed an appropriatereaction. However, with theadvent of the frightening prospect of holocaust due to aninability to settle the questionof atomic testing, it became increasingly clear to some thathumanity was less in need ofscientific preeminence than of solutions toits behavioral problems.Competition for technical superiority seemed almostbeside the point whenconsideration was reflected in disordered given the unsolvedproblems of human behavior as international relationships. At about this time, also,there appeared a resurgenceof interest in preventive mental health programsstimulated by the publicationof the final report of the JointCommission on Mental Illnessand Health (1961). Draw- ing on the author's previous attempt tofoster mental health in theclassroom children in New York by teaching "behavioral science"units to public school City's Harlem (Rosenthal, 1952),and contemplating the meager progress achieved by advocates of mentalhealth programs in theschools, it seemed timely to think about a broadconceptualization of the school'srole in both framework needed to mental health and behavioralstudies. Such a conceptual encompass the currentphilosophy of education,incorporate the salient concerns of contemporarylife, and serve the purposesof primary prevention in the field of mental health. Theconceptualization that emerged wasthe teaching of the behavioral sciences as aformal, academic subject in theelementary schools. Bruner's (1961) influential essayThe Process of Educationseemed to IN THE SCHOOLS 258 NEW APPROACHES subject can be taught lend support to this approao. Inthe assertion that "any of effectively in some intellectuallyhonest form to anychild at any age development" (Bruner, 1961, p. 33), onefinds a basis for npgradingthe tradi- algebra, science, eco- tional elementary schoolcurriculum in subjects such as of nomics, and foreignlanguages (Gross, 1964), aswell as for the creation Bruner (1965) curricula in the heretoforeunexplored behavioral science areas. himself has developed ananthropological course ofstudy for grade school children in which the content is man.Currently designed Esfifth graders, three questions: What is his curriculum is organizedaround approaches to ..and, How human about human beings? ...How did they get that way? . is congruent can theybe made more so? Thismode of curriculum revision with, and can well serve as a partof, a broader curriculum inthe behavioral through the remainder sciences extending fromfirst grade, if not kindergarten, of public school education.

RATIONALE Supporting arguments forintroducing the behavioral sciences as a school subject in the primarygrades can be advanced fromvarious perspectives. A detaileddiscussion of such a program'srationale fi mu an educational point of view hasbeen presented elsewhere (Roen,i966, 1967b). The main educational argument holdsthat psychology, sociology,and anthropology have become have come of age as scientific andprofessional disciplines; they exposed so much a partof contemporary culture thatthose who have not been to their subject matter areconsidered lacking. Thesedisciplines, together with might elements of psychiatry, economics,political science, and demography, also serve as a structure tobridge the estrangementbetween the humanities behavioral sciences, al- and the sciences so welldescribed by C. P. Snow. The thoagh they, too, are plaguedby camps who hold differentvalue systems, are rooted in both objective andsubjective approaches, reflectingthe very nature of the subject matter itself. The concern of this chapter isthe program's potential forthe prevention of emotional disorder. Thisrationale takes three forms:(1) fortification of of ego, (2) greatercomfort at school, and (3)recruitment and the spread effect.

Fortification of Ego A person's ability to copewith life can be buttressed inseveral ways, Those not the leastsignificant of which is theaccumulation of knowledge. be those who most successful inhandling the problems of living appear to educational are bestequipped with the skills andinformation required. Our philosophy is predicated on the faiththat knowledge will find its ownrewards. Elementary grade children are stillfairly close to the developmentaldecisions which will mold theirpersonality; they are, for the most part,still free of 259 PREVENTION INTHE CLASSROOM PRIMARY the Teaching them in alogical sequence inhibited thoughtand behavior. influences ofin- knowledge aboutthe behavioral substance ofaccumulated learning, emotions,the social systems,intelligence, heritance, environment, effects ofalcohol and the conceptof self, the order of biqh,mental illness, them in aretrospectiveand substances, etc.;reviewing with have other addictive issues theyhave facedand will the developmental the anticipatory manner them to experienceand/or discover and allowing pivotal to face inthe future; ought to bebeneficialif not inquiry intothese matters, techniques of with the worldof humanproblems. sensein theirencounter the in a personal and howeverintricate the processof adaptation, However subtle learning, themechanismsinvolved affect andcognitive knowl- relationship between confrontation withbasic behavioral enhanced by adirect the processof would be objective manner.If skill in taught in an confi- edge methodically the same time,further strength or behavioral inquiry canbe fostered at the symbolswith addition, learning alanguage or dence mightresult. In discomforts couldlead to subjectively feltteusions and which to express referred to byBower (1964) behavioral freedom" increasing the"degrees of prevention. in hisdiscussion ofprimary

Greater Comfortin School hypothesize that astudy of thebehavioral It seemsappropriate to of children in the generallearning tasks sciences couldmake for greater ease appreciate theeducational better tounderstand and and and couldhelp them in thebehavioral sciences, Learning is afundamental concept pupils. process. which could provebeneficial to taught inrelation to it much can be influences onthe learning process absorbed aboutthe variety of Knowledge Comparative lessons onthe school as a should find somepersonal reference. of the classroom,and therole-relationships social system,the social structure for the student. well haveimmediate application of teachersand pupils may might serve as avehicle behavioral sciencesclassroom )eriod Also, the is not to saysthat the program perceived problems.T?, for freediscussion of classroom or encouragesthe public therapeuticmethods in the advocates group Rather, in thespirit offree behavioral , airing ofsensitivepersonal issues. discussions, pupils and tell" or incurrent events inquiry, asfound in "show issues which canbe examined might feel free tobring to thefore behavioral in aneducationallyproductive manner. of Effect Recruitment andthe Spread this type of potential spreadof effect of ,o, Not to beoverlooked is the public of view of careerchoice and the greater teaching, bothfrom the point listings of honorhigh school the behavioralsciences. Recent knowledge of indicated that not asingle one ofthem graduates in theBoston newspapers 260 NEW APPROACHES IN THE SCHOOLS was planning to go on to major in anyof the behavioral sciences in college. Although there could be many explanations for this, a rather plausible one is that they knew little of the behavioral sciences since they had notbeen exposed to them in their schooling. A careful longitudinal study on careel development of scientists (Cooley, 1963) suggested that the juniorhigh schools were of great importance as a point in career choice. Since there is no significant formal exposure to the behavioral sciences in grade school, career choices in these fields would seem to be handicapped. Recruitment problems in the field of mental health are already acute, and attracting competent young scholars to the study of behavior in graduate schools has been aproblem for a long time. Teaching children about the behavioral sciences should spread its effect to parents and the community at largealmost immediately. This could help restructure the general milieu in more supportive waysfor those who have not succeeded in handling theirbehavioral inconsistencies. Thus, we may obtain greater community support for professionals working withrecalcitrant cases of self-defeatingbehavior as well as greater public interest in scientific behavioral inquiry.

THE INITIAL PROGRAM During the 1963-1964 academic year, as part of a school consultation program, the author contracted withthe Hingham, Massachusetts school system to teach the behavial sciences to a fourth-grade class on the basis of a forty-minute period once aweek over both semesters (oen, 1965a, 1967a, 1967b). This experience was gratifying in several respects. Thechildren were enthusiastic and receptive, and it was not difficult in most instances to formulate the concepts and content on their level of understanding. Thereremained sufficient subject matter, not covered in the time period available, sothat the class could have been extended over a considerably longerperiod of time. Despite the newness of the program and its intrusion ofseldom-touched topics, there was no criticism from parents or others in the school community.In fact, newspaper publicity brought forth requests frompersonnel associated with other school systems in Massachusets for informationand consultation directed toward instituting similar programs in their settings. At the end of the course, the children were given atypical classroom achievement-type test covering che content in order to supplement thesubjec- tive impressions of the instructor. The same examination wasalso given to 25 graduate students taking an advanced psychology courseand to 51 undergraduates enrolled in an introductory psychology course. The scoresfor the three groups were as follows: graduate students' mean =61, standard deviation = 12; undergraduates' mean = 84,standard deviation = 13; fourth graders' mean = 76, standard deviation = 14. In a very gross waythese data suggest that the fourthgraders were, indeed, able to master the content quite 261 PREVENTION INTHE CLASSROOM PRIMARY (Roen, 1965b), finding, reported morefully elsewhere satisfactorily. This impressions aboutthe program, the highlypositive subjective together with concerning thisinitial venture. provided somebasis for encouragement be best for this initialprogram may The course ofstudy developed outline, which wasused forplanning understood in termsof the following purposes: I. What isbehavioral science? Psychology, Sociology,Anthropology, Psych'atry. What do youalready knowabout behavior? function of a personand an environment. Behavior is a another just givein if child have a tempertantrum and Why will one program? Howwould refuse to let themwatch a TV their parents to thisquestion? you goabout trying tofind out the answer 3. The person. rock. List all the ways you aredifferent from a children. List all the ways you arethe same as other environment, influencesthe kind of person 4. What,besides your general you willbe? Heredity. Development ormaturation. Learning. 5.Heredity. Instincts. what kind ofbehaviors babies Formal interview ofmother: to find out are bornwith. 6. Development. Which characteristicsdevelop first? unable to do. One cannot dowhat one is people in different stagesof development? At what pointsin life are of development. 7. Erickson'spsychosocial stages what do you suppose How do youknow the infantis around and from them thefunction of mouth he might bethinking? (Extract the developmentof a sense oftrust.) and its relation to around and whatdo know the two orthree year old is How do you the function of he is thinking?(Extract from them you suppose development of a senseof au- muscles and theirielation to the tonomy.) differences and the senseof initiative. Similarly: boy-girl and the senseof duty andaccomplishment. Their current stage maturity, and old age. Also: adolescence,marriage, being parents, the idea of "I,""me," or "self"develop? 8. How does when you sayme? What body partdo you point to bicycle, beliefs, etc. Self extension:hair, house, Self-esteem and idealself. 9. Learning. do we learn? By what different ways of a card. Condition them toraise theirhand at the sight 262 NEW APPROACHES IN THE SCHOOLS Pavlov's dogs and how animals who are conditioned could be used to serve man. Stimulus, reinforcement, extinction, generalization, etc. How could you use conditioning to help people with bad habits? 10.Classroom experiment with pupils as subjects on retroactive inhibition. An example of how psychologists discover facts about learning. 11. Rote learning. Best ways to memorize: intent to learn, meaningfulness, distributed practice, active performance, organization and rhythm. Demonstration of memorizing a grocery list through association. 12. Trial and error learning. Construct a maze and through discussion encourage learning experiments with animals. How do rewards and punishments influence learning? 13.Insight and thinking. Examples of solving certain puzzles by changing set. Daydreaming as a form of thinking. Creative thinking. Reasoning. 14.Doing, knowing, and feeling: their relation to muscles, head, and organs. Feelings and bodily changeslie detector test. The emergency functions of emotions. 15. The psychosomatic concept. What may happen to the body when strong emotions last for long periods of time? 16.Emotions. Attaching names to feelings: anger, fear, anxiety, pleasure, love, etc. 17. Anxiety and psychological pain. Their examples of how anxiety is different from fear. Anxiety as an opportunity for growth. Neurotic anxiety and the temptation to escape. The handling of anxiety. 18. Doing, and the motives of man. Physiological motives and the planning of an experiment with animals to discover the relative strength of drives. Personal motives. Unconscious motivation and hypnosis. 19. Knowing and intelligence. Their definitions of what intelligence is. The IQ. Social and cultural influences on the IQ. 20. Environment. Library assignment on the experiences of children in other cultures. Race and religion. 21. Demography and social structure. Urban, rural, and social class. 22.Institutions. What "institutions" influence their daily lives: political, legal, educational, religious, family, art, science, and medicine. 263 PRIMARY PREVENTION IN THECLASSROOM

23.Sociological analysis of theclassroom. Comparison of their classroom structureand roles played with a neighboring class. 24. Personality and environment. The effect of birth order onrivalry between children andrelationship to parents. 25. Biographical integration. person Write an autobiographythat emphasizes your uniqueness as a and explains the influencesthat have made you differentfrom others.

The course of study outlinedabove borrowed heavily fromgeneral psychology since this was theauthor's unavoidable bias.However, collaboration curriculum so as of an interdis:iplinary committeecould alter this tentative units to reflect thebehavioral sciences as anintegrated whole. Some of the could have outlined above extended beyond oneperiod, and many of them been elaborated to cover longerperiods of time. There wouldbe little diffi- end, to cover a culty in enriching the currentoutline, especially toward the two-year period. It isfelt that with some effort acurriculum of fruitful teaching could be designed to coverthe six years of elementaryschooling. The teaching method attempted tomotivate the children toconduct their own inquiries intobehavioral phenomena. Wheneverapplicable, research studies were devised andcarried through by thechildren. The classroom itself proved to be a fairlyadequate laboratory for manyof the lessons. The regular classroom teacher sat in onthe lessons and tried to integratethe subject into the rest of hercurriculum, i.e., included the newwords in her word review lessons and stacks. Interspersed throughthe outline presented were classroom tests. The childrenkept a special notebook onthe behavioral sci- A more detailed account of ences whichthey referred to for review purposes. 1967c). some of theclass sessions has beenpresented elsewhere (Roen, 1967a,

EXTENSION OF THEPROGRAM INTO A RESIDENTIAL SETTING A. J. Burnes (1966), aresearch fellow at the SouthShore Mental Health Center, as part of hisconsultation activity at theHampshire Country School, a residential treatmentschool in New Hampshire,has extended the behavioral sciences teaching program toinclude a behavioral sciencelabora- tory. In the contextof discovery, he hastaught his pupils to build apparatus for the solution of specifiedquestions on behavior.Among the homemade equipment to be found inhis laboratory areteaching machines; operant conditioning devices for rats,monkeys, pigeons, and perch; ananalogue computer; ananesthesiometer for skinsensitivity; and apparatus for mirror trac- ing, depth perception,and color constancy. Of prime importance inhis laboratory is the simplicityof the instru- devices have little meaning ments. Arguingthat sophisticated experimental 264 NEW APPROACHES IN THE SCHOOLS for those who cannot appreciateor understand the inner working of the apparatus, Burnes has built his laboratory of simple articles which typically have other purposes in everyday life. For example, a long cardboard cylinder mounted on wood serves as a spontaneous method for studying level of aspira- tion when he, without prediscussion, puts the cylinder on the floor, stands upright, and tries to drop pennies into it. The childrensoon become engrossed in this task and play the game too. A few questions, strategically asked, serve to motivate experimental inquiry into the dynamics of wanting to improve scores. In similar fashion, an inquiry into whether the skin reacts to emotion is Endertaken through the use of a 1.5 volt battery, paper clips, rubber bands, a homemade armature, nails, a nylon watchstrap, bell wire, a ballpoint pen refill, polished quarters, and a music box drive and roller. The measurement of skin resistance as a variable in strong emotion is in this way grasped by the student. In evaluating this experience Burnes states, "It ismore important for children to learn how to inquire than for them to know facts;we are not so much interested in developing retrieval skills for getting back information about behavioral science which is presumed to be true, butare far more concerned with how a student can self-initiate investigations ofa particular issue" (Burnes, 1966, p. 22).

EVALUATING THE EFFECTIVENESS OF THE BEHAVIORAL SCIENCES TEACHING PROGRAM During the academic year following the initial demonstration, Bartolo Spano (1965) did a doctoral dissertation for the University of Floridaon the behavioral sciences teaching program. The Quincy, Massachusetts, school system had been interested in instituting a similar program and made classes available to him on an experimental basis. Spano designed his study primarily to find out what effecta behavioral science teaching program had on pupils. He hypothesized changes in such variables as causal thinking ability, personality traits, democratic behavior, critical thinking, mental health assets and liabilities, and self-peer perception as a function of exposure to a behavioral sciences teaching program. A secondary purpose of his researchwas to test for possible differential impact of such a program on children from differing socioeconomic backgrounds. For research purposes, he selected an experimental class in each oftwo schools from divergent socioeconomic neighborhoods; for controls he matched each class with another class in the same schoolon the basis of IQ, grade achievement, and chronological age. The four classeswere all on a fourth- grade level. A socioeconomic index showed the children from the school in the lower socioeconomic neighborhood to be significantly different from the school children in the middle-class neighborhood. Both experimental and control pupils were tested one week prior to the initiation of the behavioral sciences 265 PRIMARY PREVENTIONIN THE CLASSROOM wasconducted the end of the finalclass. The teaching program course and at five-month period. basis of one fifty-minuteperiod per week over a on the teacher taught by the experimenter,with the classroom Twenty lessons were included: (1) intro- attending and taking notes.The planned class content differences, (2) thecomplexiA, of causes duction to the conceptof individual methods of obtaininginforma- underlying humanbehavior and the varying (3) introduction tothe sources of individualdifferences tion regarding causes, of various heredity, maturation,and learning, and(4) detailed discussions stages ofdevelopment. instruments. He measurements,Spano used various Fez before and after (Huang, 1943), fashioned a revision ofthe original CausalTest by Ojemann each followed by aseries of true- consisting of eightdescriptions of behavior, choices in the interpretationof the previouslydescribed false items offering reliability study of the behavior. Spanoconducted a one-month test-retest ch.:MI-en and obtained areliabil- revised version of the test on56 fourth-grade Record (Wood, 1953) of .78. He used theBehavior Prefovpr.ce ity coefficient The test consists of for measuringdemocratic behaviorand critical thinking. followed by three tofive possible coursesof a seriesof problem situations the student selects one.For measures of mentalhealth action, from which (Thorpe, Clark, & liabilities he used theMental Health Analysis assets and the pupils he Tiegs, 1959). To measurethe personal andsocial adjustment of Clark, & Tiegs, 1953).His used the California Testof Personality (Thorpe, and school records. other measures wereobtained from teacher ratings significant changes in After exposure to thebehavioral sciences classes, democratic behavior werefound the positive direction forcausal thinking and predictive of thesechanges in the experimental group.Factors which were and IQ. (The changes were appeared to be the initiallevel of causal thinking, levels.) Althoughcritical not, however,differential across socioeconomic in the experimental thinking did not showoverall significant improvement showed signifi- groups, theexperimental class defined aslower socioeconomic compared to the highersocio- cantly greater growth onthis variable when have been due toinitially economic experimentalclass. This finding may this variable or to thefact that lower scores of the lowsocioeconomic group on thinking and therefore these children are usuallyunderexposed to critical catch up quickly when giventhe opportunity. measured The lack of significantpositive changes inthe other variables that a behavioral sciencesteaching program has no does not necessarily mean there were some effect on them. Spano quiteappropriately cautions that accurately measur- serious limitations tohis study, includingthe difficulty of the instruments for assessingchange, ing these variables,the low sensitivity of the program. Furtherresearch and the very short exposureof the children to if not longer. More"inshould include ateaching exposure of a year or two, procedures would alsobe in order. depth" assessment After One secondary findingof the Spano study isof particular interest. THE SCHOOLS 266 NEW APPROACHES IN partialling out the effects of IQ, asignificant initial relationship wasfound between causal thinl.ing and social adjustment.In addition, althoughmiddle- class children were significantly morecausally oriented thanlower-class youngsters to begin with,when IQ and social adjustment werepartialled out, socioeconomic status was found not tobe related to the initial levelof causal thinking. This latter datum lends support tothe notion that bettercausal thinking is genuinely, rather thanartifactually, related to bettersocial adjus- ment. This isparticularly true in light of theadditional finding that the causal thinker is seers throughthe eyes of his teacher as onewith a creative interest in many facets ofhis life, including his presentschool experience.

SEMINAR FOR TEACHERS If interest in the teaching ofthe behavioral sciences in theelementary grades is to spread, itshould obtain university auspices.Behavioral scientists can demonstrate thereasonableness of the program, but theteaching profession must mold it into theeducational process. Toward this end,Lesley College, Cambridge, Massachusetts,has offered graduate schoolcredit for teachers in a seminar, "Teaching theBehavioral Sciences to Children." A more elaborate report of the seminar,which was offered in the Fall semester of 1965,has been detailed elsewhere (Roen,1966, 1967b). Besides regular grade school teachers, the courseenrolled teachers of specialclasses and kindergarten teachers.Assignments included creatinglessons based on Berelson and Steiner (1964), HumanBehavior: An Inventory ofScientific Findings, which was used as a text. Theparticipants taught theirlessons to their classes, paying attention tospecial methods and materials,and reported back to the seminar. A first-grade teacher fashioned alesson on the transfer of trainingby having children memorize three setsof words and analyzing withthem afterward why it was easier to remember someof the words than others. Asecond- grade teacher focused on "whychildren tattled" and worked up adictionary lesson in which the words tattling,telling, gossip, idle, etc. weresemantically differentiated. A third-grade teacherdevised a lesson on "habitformation" in which she conditioned the classguinea pig to climb a boxfor food when a bell was rung. A fifth-gradeteacher focused on "the blackoutof November, 1965," and formulated a seriesof lessons that studied thedifferential reactions of children and adults.She focused on questions such aswhether fear is acquired, how morale canbe maintained in crisis situations,and how events are reported inthe media of mass communication.A remedial reading teacher took the bull by thehorns and taught her group"visual perception and organization as applied toreading." A teacher of a specialclass of slow learners taught a lesson on "beingafraid" by eliciting from the classthe fact that most of them were fearfulof lightning and thendemonstrating to them, using a balloon and a staticelectric charge caused by rubbingthe balloon, PRIMARY PREVENTION IN THE CLASSROOM 267 that a spark will fly in a darkened closet. The childrendiscussed the generalization that one is less afraid of what one understands.A kindergarten teacher focused on "fear" by reading to the classthe story of "Little Red I Riding Hood," analyzing it with them in relation tohow the pupils overcame some of their own fearswhen they were little. The seminar drew sufficient interest and attentionthat the Hingham, Massachusetts, school system asked to have oneexclusively for its teachers the following semester, and Lesley College has instituted the seminar as aregular I graduate school offering.

FURTHER IMPLEMENTATION

This chapter has described a classroom approach to the primary prevention of emotional disorder through the substantially cognitive strategyof teaching the contents, methods, and way of thiaking of the behavioral sciences. Representation of thebehavioral sciences in the elementary school curriculum may serve to focus the needs for education and remediation in the field of mental health. When and if schools begin toimplement a program related to what isoutlined in this chapter, local variations may well be able to encompass exercises even more relevant to mentalhealth. Such a development seems especially possible in light of the extensionof consultation programs emanating fromcommunity mental health centers to the schools. There are several ways in which further implementationof the behavioral sciences teaching program can proceed. Mentalhealth professionals working in the community and with schools can continue tostimulate interest by entering the classroomthemselves to teach. Aside from the direct effect on the childrentaught, this type of program influences other teachers in the system, the community at large, andthe thinking of school administrators. Better opportunities for consultation frequently emergebecause the professional himself is experiencing the teachiri; process firsthand, and his roJe within the social system of the school makes him lessthreatening. Another path toward implementation might be supplementingthe general training of teachers. Special seminars, similar tothe one described, can stimulate teachers to make room for the behavioral sciences intheir classroom program. In the initial project,the classroom teacher borrowed time from either the science program or the social studies area, and sometimes alittle from both. If teachers in training can be helped to formulatelessons and to think causally themselves, and if they have access toauthoritative curriculum material, they may well feel comfortable enough toembark on this type of program. A third method of implementation, not at all in conflict withthe other two, is most compelling of all.This approach would be to interest behavioral scientists to organize an elementary schoolcurriculum, based on a study of 268 NEW APPROACHES IN THE SCHOOLS the "simple structure" of their sciences, much in the manner of what has been done for mathematics and physical science. Special committees could evolve curriculum materials:, appropriate methods of teaching, texts, and simple apparatus. Creators of teacher education programs might then be motivated to develop special programs for "behavioral science teachers." These teachers could serve in the increasingly popular team-teaching programs or as teacher specialists like those in music, art, and, more recently, science. The "behavioral science teacher" might also be provided with some guided exposure to clinical issues so that subject matter could be taught with sensitivity and special awareness. Recruitment of potential teachers to this new specialty ought not to be a problem. Many students major inpsychology and the other behavioral sciences in their undergraduate years; because they have no desire to go on to graduate study, they become public school teachers in areas which are not their first love.

REFERENCES

Berelson, B., & Steiner, G. A. Human behavior: An inventory of scientific findings. New York: Harcourt, Brace & World, 1964. Biber, B. Integratioa of mental health principles in the school setting. In G. Cap- lan (Ed.), Prevention of mental disorders in children. New York: Basic Books, 1961. Pp. 323-352. Biber, B., Gilkerson, E., & Winsor, C. Basic approaches to mental health: Teacher education at Bank Street College. New York: Bank Street College, Publica- tion No. 62, 1959. Bower, E. M. Primary prevention of mental and emotional disorders: A frame of reference. In N. M. Lambert (Ed.), The protection and promotion of mental health in schools. Bethesda, Md.: U.S. Dept. of H.E.W., 1964. Pp. 1-9. Bruner, J. S. The process of education. Cambridge, Mass.: Harvard, 1961. Bruner, J. S. The growth of mind. Amer. Psychol., 1965, 20, 1007-1017. Bullis, H. E. How the human relations class works. Understanding the Child, 1941, 10, 5-10. Burnes, A. J. Laboratory instruction in the behavioral sciences in the grammar school. In B. Gertz (Ed.), Behavioral sciences in the elementary grades. Cambridge, Mass.: Lesley Col:ege, Second Annual Graduate Symposium, 1966. Pp. 14-25. Cartwright, R., & Biber, 13. The teacher's role in a comprehensive program for mental health. Paper presented to the Fifth Institute on Preventive Psychi- atry, Univer. of Iowa, Iowa City, May 14, 1965. Cooley, W. W. Career development cf scientists: An overlapping longitudinal study. Cambridge, Mass.: Harvard Graduate School of Education, 1963. Gross, R. Two-year-olds are very smart. The Now York Times Magazine, Septem- ber 6, 1964, p. 10. Group for the Advancement of Psychiatry, Committee on Preventive Psychiatry. PRIMARY PREVENTION IN THECLASSROOM 269 Promotion of mental health inthe primary and secondary schools.Topeka, Kan.: Author, 1951. Report No.18. Huang, I. Children's conception ofphysical causality: A critical summary.J. Genet. Psychol., 1943, 63, 71-121. Joint Commission on Mental Illnessand Health. Action for mentalhealth. New York: Basic Books, 1961. Levitt, E. E. Effects of a "causal" teacher training program onauthoritarianism and responsibility in grade school children.Psycho!. Rep., 1955, 1, 449-459. Lippitt, R., Lippitt, P., & Fox, R. Behavioralscience education for the young:A laboratory approach to social science education.Ann Arbor, Mich.: Author, mimeographed, 1964. Loftus, J. J. New York City's large-scaleexperimentation with an activity program. ProgressiveEducation, 1940, 17, 116-124. Loftus, J. J. The activity program in N.Y.C.schools. J. aluc. Sociology, 1943, 17, 65-124. Muuss, R. E,. The effects of a one- and two-yearcausal learning program. J. Pers., 1960, 28, 479-491. Ojemann, R. H. Developing a program foreducation in human behavior. Iowa City: State University of Iowa, 1959. Ojemann, R. H. Investigations on the effectsof teaching an understanding and appreciation of behavior dynamics. In G.Caplan (Ed.), Prevention of mental disorders in children. NewYork: Basic Books, 1961. Pp. 378-396. Ojemann, R. H., Levitt, E. E., Lyle,W. H., & Whiteside, M. F.Effects of a "causal" teacher training program and certaincurriculum changes on grade school children. J. exp. Educ., 1955 24,95-114. Ojemaim, R. H., & Snider, B.Effects of a teacher training program inbehavioral s-ience on changes in causalbehavior scores. J. Edw. Research,1964, 57, 255-260. Roen, S. R. The behavioral sciences inthe primary grades. Amer.Psychol., 1965, 20, 430-432. (a) Roen, S. R. The behavioral sciences inthe primary grades: Can childrenleala the subject matter? Teachingof Psychology Newsletter,August, 1965, P. 4. (b) Roen, S. R. The study of behavior bychildren. In B. Gertz (Ed.),Behavioral sciences in the elementary grades.Cambridge, Mass.: Lesley College,Second Annual Graduate Symposium, 1966.Pp. 3-13. Roen, S. R. Teaching the behavioralsciences to children. Bull.Instit. Child Study, 1967, 29, 21-31. (a) Roen, S. R. Behavioral studies as acurriculum subject. Teachers College Record, 1967, 69, 541-550. (b) Roen, S. R. Teaching the behavioral sciencesin the elementary grades. J.School Psychol., 1967, 5, 205-216. (c) Rosenthal, S. A fifth grade classroomexperiment in fostering mentalhealth. J. Child. Psychiat., 1952, 2, 302-329. Seeley, J. R. The Forest HillVillage project. Understanding theChild, 1954, 23, 104-110. Spano, B. J. Causal thinking,adjustment and social perception as afunction of 270 NEW APPROACHES IN THE SCHOOLS behavioral science concepts in elementary school children.Doctoral dissertation, Univer. of Florida, December, 1965. Stiles, F. S. Developing an understanding of human behavior at theelementary school level. J. Educ. Research, 1950, 43, 516-521. Taba, H. Reading ladders for human relations. Washington, D.C.:American Council on Education, 1949. Thorpe, L. P., Clark, W. W., & Tiegs, E. W. California test ofpersonality manual. Monterey, Calif.: California Test Bureau, 1953 revision. Thorpe, L. P., Clark, W. W., & Tiegs, E. W. Mentalhealth analysismanual. Los Angeles, Calif.: California Test Bureau, 1959 revision. Wood, H. Behavior preference recordmanual. LosAngeles, Calif.: California Test Bureau, 1953. 15 ENHANCING THE CLASSROOMTEACHER'S MENTAL HEALTH FUNCTION

William C. Morse University of Michigan

OVERVIEW The fact that there has been no clear andbroadly accepted concept of school mental health programming attests tothe complexity of the task. For example, Allinsmith and Goethals inThe Role of Schools in Mental Health (1962) are more explicit in identifyingand describing problems and basic conflicts in this area than in establishingtheir resolutions. Over the years the Michigan Society forMental Health has encouraged a seriesof efforts conducted by various specialistswith the intent of stimulating school mental health programs.The pilot programs have included attempts at universalsensitization of total staff (evencafeteria cooks and custodians) to problems and needs inthis field, using techniques ranging from mental health films anddiscussions to psychiatric consultationand didactic lectures. Other groupshave indoctrinated school personnelwith rational therapy as the finalsalvation. Several state conferences were con- vened to explore common groundand reasonable program designs;these produced no unified theory or direction forthe mental health role of thepublic school system. In fact, even the perimetersof responsibility were nevermade clear. By now it has become obviousthat the vastly increased complexityof the teacher's task constitutes thebasic dilemma in school mentalhealth. Schools have proliferated the "helping"specialists of various sorts, butthe collective efforts of specialists have notbeen sufficient to mitigate the strain that the teacher feels as a resultof her many responsibilities and apolyglot classroom population. Indeed, in someinstances, specialists, by emphasizing teacher "shoulds" while failing toprovide reasonable "hows," havemade teacher anxiety higher. For example,mental health as a goal and a responsibility is often presumed by the helpingprofession to include some appreciation of unconscious motivation.To some there is the furtherimplication that all behavior has to behandled in a manner which reflectsunderlying psychodynamics. 271 NEW APPROACHES.IN THE SCHOOLS 272 immobilize them When this stance is suggestedfor teachers, it tends to When just such aclassroom in the face ofday-by-day classroom difficulties. interviews and question- situation was examined(Morse, 1961), through trying to help asbest they naires, it became clearthat master teachers were doing a creative knew how with concreteday-to-day problems; and most were job under pressure. There was an opennessand willingness on their part to mental health accept anyreasonable assistance. At the sametime, the typical discipline and in professional in the schools was moreinterested in his own helping the teacher withclass- one-to-onerelationships with pupils than in uncertainty about limitsof responsi- room problems.There was actually great bility. Some teachers askedwhether they werehired to conduct detention homes, mental hospital programs, orpublic school classrooms. post- Factors influencing learning,particularly under the then current through the new cur- Sputnik goal of academicachievement for everybody A naïve rationale ricula, were generally left outby mental hygiene experts. about learning due to his con- that a happy child willbe more enthusiastic tentment is still commonin mental healthefforts. Mental health programs motivation rather than ashaving the were beingsold as the key to automatic its own right. Major goal of improved pupiladjustmenta valuable end in specialists were most specialist time was invested indiagnosis, with which in specific planning familiar and comfortable, notin establishing prognoses or which, though perhaps morecogent, theyknew less well. Consultation was producing inscrutable flavored with expertstalking down to the teacher or exceptions, but thehelping reports. Of coursethere were, and are, notable schools and neglect to professions often bringtheir role-baggage into the recognize the systemswithin the total educationalmilieu.

THE EVOLUTION OFCORE CONCEPTS IN A SCHOOL MENTALHEALTH PROGRAM

The following material openswith a brief account ofthe develop- chapter and a ment of theMichigan program tobe reviewed in the present Next, an overview of description of some of theearly efforts of that program. description of the present pro- the problem-centeredapproach is presented. A gram andrelated research effortsconcludes the chapter. responsibility for the It is significant that thethree persons with major development of this approach were,at once,involved in both the most tradi- hygiene practice. tional and most experimentalmethods of fostering mental college courses in childdynam- On the one hand, allparticipated in teaching the team members were ics and mental hygiene toteachers. At the same time, also participating in agraduate laboratory trainingsetting which involved disturbed children in a summer group direct confrontationwith emotionally planning for seri- therapy camp. The staff wasresponsible for therapeutic ENHANCING THE TEACHER'S MENTAL HEALTH FUNCTION 273 ously disturbed boys. Direct confrontation taxes theory and practicealike, as well as boththe "student" and the "teacher." It is hard to imagine two more different approaches than thetypical college classroom and an action laboratory. A gradual disenchantment with the potential of the college classroom developed in spite of the factthat various simulation exercises were used to create an artificialreality. Every effort was made to encourage teachers to work directly with theirpupils and to write reports andmaterials on their own classroom situations. Yet it was obvious that this was much less than a second-best approach tohelping teachers change their behavior through systematic growth. The particular program to be described is not offered as unique. It is the product of gradual evolution, and the present formulation is a consequenceof cross-fertilization from educational, school, and clinical psychology. Itreflects a gradual movementfrom the traditional to an open, experimental methodology. Research andevaluative schemes have served as monitors. While this mental health program borrows from many sources, it is hardlyeclectic since it has come to constitute a particular point of view. Through joint efforts with the Michigan Society for Mental Health' several programs were tried to bridge the gap between the reality wehad experienced at camp and the happenings in a college classroom. TheSociety supported experimental work through a special grant.2 To vitalize the teaching of mental health meant to move from the academic to morepractical experience related to the teacher's day-by-day activities.The program developed in an effort to meet these objectives spanned several yearsand included projects in over a dozen school systems, but their principalelements can be covered quite simply. Schools were asked about possible in-service mental healthwork. Each system was studied for potential promise by anon-the-spot worker who interviewed teachers, administrators, and local citizens to achieve abetter understanding of the actual dynamics of the system. Frequentlyadministrative interest is a poor index of the actual staff interest. Programs maybe needed but not wanted. The concept of a "hospitality index"evolved. For example, if teachers requested released time or special dispensation for meetings,it seemed probable that the actual interest in the program waslower than where teachers indicated an interest in participating on their own time.When motivation was marginal, an unbelievable amount of haggling over arrangements took place. Another hospitality item was the willingness of the system to provide incentives; still another was the willingness of teachers tocontribute actual data on both themselves and their pupils. Locations withwide differences in motivation wereselected to begin work. The basic premise was that

1 Mr. James Kipfer was director of the School Mental HealthProject for the Society for Mental Health. Annual reports are available. 2This work was made possible by a grant from the McGregor Fund ofMichigan to the Michigan Society for MentalHealth, August, 1959.

I NEW APPROACHESIN THE SCHOOLS 274 situation and startwherever the the mental healthworker would enter the participating group com- particular group was ready tobegin. Sometimes the subgroups were interested. prised the total schoolfacult7. Other times, only which, In the end the programproved to be arelatively comprehensive one with approximately over athree-year period, involved some20 school districts 1000 participatingteachers (Kipfer, 1959). starting where thefaculty If one takes seriouslythe stipulation of place will, to a large extent,be idiosyncratic.Actual wishes to start, what takes health to activities ranged fromgeneral meetings onthe nature of mental counseling program. In afew very specificprojects such as how to set up a For example, after case instances, a modified grouptherapy program evolved. individuals wished to remainfor conference meetings in theafternoon, certain began with discussions of group discussion.While such meetings an evening school about pupils, they oftenmoved to discussionsof roadblocks in the provided and system andpersonal problems.Individual consultation was referral sources located forhelp with nonschooldifficulties. The consultants assumed avariety of roles.There were ordinary content mental health, hygienic meetings using lecturesand films on such topics as conferences on problem discipline, evaluation, andpersonality theory. Case consultations with individual pupils were popular.Much time was devoted to discuss matters with teachers about their classes.Meetings were arranged to and planning. certain parents. Children were seenfor diagnostic interviews projects on marking,teacher feelings aboutpupils, and Small group study deal of approaches to curriculum wereorganized. There was a great new problems of vari- consultation with administrativepersonnel regarding school became neces- When proposals requiredboard action, it sometimes ous sorts. provided a sary to meetwith school boardmembers. Forum-type meetings and covert, in theschool liaison for variouscontending factions, both overt psychological help wherever milieu. The commondenominator was to offer omnipotence, the consumer saw aneed. It may be judgedthat this smacks of the knowledge that but this was not the case.The fundamental element was understanding in a variety of areas. psychology as a toolcould bring further insight was minimal, Admittedly, there were timeswhen the amount of new the applica- notwithstanding aproblem-analysis and"solving" format. While difficult, the belief thatpsychology has an essentialcontribu- tion was most and continues to be,the tion to make in allfacets of school practice was, work with people ratherthan underlying assumption.The consultants had to than try to change them. on them;they had to respecttheir integrity rather Changes are a by-productof working together onproblems. The eventual impact of ameaningful school mentalhealth program the school lies in the hands ofthe classroom teacher.Any major change in the mental health establishment involves in situcapability. The elements of portion of the schoolactivity. This program arefacilitators to the classroom adjustment and learningfacets of the viewpoint impliesintrinsically that the HEALTH FUNCTION 275 ENHANCING THETEACHER'S MENTAL Consultation on mental and should notbe separated. child's life cannot learning conditions are health takes place in a vacuumunless academic classrooms are group treated as mattersof equal importance.In addition, planning, teachers willfind the operations. If this is notkept in mind while heavy emphasis on matters ideas of little value.Thus there must be a new and the group settingfor relating to groups, groupdiscipline and control, academic learning. ineffective was rooted out atthe start Any assumptionthat teachers are best they can, giventheir current by open discussion.Teachers do the very find more serviceable conceptsto re- circumstances. Onlywhen they test and working conditions canbe allevi- place old ones, andonly when unfavorable right to expectchange. ated, have we a independently, each For two years theseveral consultantsworked quite the unique aspectsof his local with his own styleand each responding to be pooled and afresh start made sub- school situation.Could the experiences section reports theresearch done on ject to systematicassessment? The next project that was the outcomeof this ex- one specificschool mental health ploration.

THE CLINICALMANAGEMENT OFEDUCATION that evolved wasreflected in The overall philosophyof the program (McNeil, Cutler, &Morse, Clinical Managementof Education its title, The of adding the 1963). The problem was todiscover more effective means knowledge to theteachers' repertoires sothat they depth of psychological insight. What was might handle groupsand individualchildren with more approach (a populardichotomy needed was not a "soft"approach or a "hard" based upon differential school personnel),but a realistic approach among pathology viewed inthe context of diagnosis andunderstanding of child dynamics were prominet.Since the normal childdevelopment. Group to be nohesitation in recog- teacher is always arelationship agent, there was role as well as thesignificance of the nizing the importanceof the teacher's teacher. The natureof the class- personality configurationof the individual produced by teacherpersonality, interactive process,which is in part room involving consultant was no moretaboo than werethe interactive processes The sacred cows in mostschool mental healthwork personality and teacher. with rather than continue to bethese very factors,which must be dealt normal imperfections inteachers (as ignored. Does thetypical specialist view implies? Does this meanthat discus- in all of us) as"sickness," with all that It may as well meanthat con- sion of school mattersconstitutes "treatment"? when the "client" hasfreedom to sultants mistrust theircapacities in this area the leaders inpsychological reject the help. Inactuality, the teachers were pussyfooting, which, in essence, wasa honesty and weredispleased with show of mistrust. SCHOOLS 276 NEW APPROACHES IN THE The next issue was the content of theservice aspect of this projectwhich was to besubject to research. The activities werethose the school personnel indicated as desired. Seminars meeting everyother week were organized by the administrative personnel. Themethod was free discussion, withthe psychologist serving as commentatorand problem clarifier. Theeffort was to encourage franktalk focused on a psychologicalexamination of the issue. Considerable time was spent on analysisand handling of day-by-dayissues with teachers and specific pupils. Timestudies were kept of teacheractivities. In a large school system theinterlocking roles of the administrativehierarchy was a matterof almost constant attention. Theprincipals felt pressures from the superintendent's office andfrom the classroom teachersthey were supposed to lead. Styles of leadership,"discipline" versus mental health,feelings about imposing one's ideas on others,and the mAture of the jobwhich had to be done were at issue. Whateverthe point of departure, mostphilosophical and practical matters regarding education came upfor discussion during these meetings. Seminars were heldwith the school specialists,the psychologists, counselors, nurses, speech correctionists,and school social workers.Assistance programs werearranged for the classroom teachers inbi-weekly meetings. But the chief emphasis was ondirect work with volunteer groupsof elementary and junior high schoolclassroom teachers. Of the 30teachers starting in the program, abouttwo-thirds remained active forthe year. Meet- ings and individual consultationabout problems took place on requestof the teachers. General content presentations wereused only to get under way. There was no implication that thisprocedure or later consultationwould actually solve the problems of child management.Subgroups formed interested in attacking particular problems,and a great deal of time was spent on methods for working with individualchildren. Some teachers were seen individually every week, whileothers resolved their immediateproblem quickly. The junior high group was mostconcerned with aggressive and underachieving pupils. Several specificsubgroups formed to deal with particular problems, and a special program wasdeveloped to assist pupils low in skills and talent. An attempt to work onproblems of delinquency and aggressive behavior with the highschool faculty failed to generate sustaininginter- est. An activesmall group of elementaryteachers took up the problem of transition to junior high andworked out a gradual transition programwhich they felt was suitable for theearly junior high age. Special meetings were developed for parents.Since parent cooperation was necessary forresearch, considerable attention was given tothe nature of research plans and possiblecontributions from parents. As thesituation evolved, certain parent groups becamethe most interesting aspect of thewhole program, and an intensive parentstudy group with leadership training was organized.3 This group wished toprovide leadership for morefundamental 3 Dr. Alan Menlo, School ofEducation, University of Michigan, wasresponsible for this part of the work. 277 ENHANCING THE TEACHER'SMENTAL HEALTHFUNCTION study of resourcematerial PTA meetings andengaged in sensitivity training, higher degree of parentinvolvement. on child care,and methods of getting a changing culture, parent re- Again, profound issuesabout child raising, the brought sponsibility, and how tobring home and schoolcloser together were up fordiscussion. described by Cutlerand The complete effort atevaluation has been information McNeil (no date). Inbrief, the teacherssupplied biographical and type of help and professional histories.They also indicated the nature satisfaction. The knowledgeof they expected and, at theclose, their degree of before and after the program wasalso assessed. An mental health concepts and the adjective checklist was used to assessaself-perception of participants A sentence completion test was type of resource personthey viewed as ideal. teacher-pupil relationships, used to assess attitudesabout teaching children, There was also a knowledge and various self-concepts,both ideal and real. health concepts. These measureswere usedwith 163 teachers test of mental and again at the and were given twice: once atthe beginning of the program variables, including end. Parent information wasobtained relevant to 56 attitudes attitudes toward teachersand school effectiveness,the PARI parent Pupils filled out questionnaires on scale, and ideal andreal self-descriptions. Questions dealt withthe style of the way they perceivedtheir classrooms. mental health matters,and classroom teaching, schoolanxiety, motivation, relationships. In all there were19 such variablesextracted from the group tested in the fourth, children's data. Experimentaland control groups were grades. sixth, and ninth moved The results show thatteachers who participatedin the program themselves as having toward seeing themselves morepositively. They viewed well as being more more egostrength, being lesscomplaining and timid, as This is, of course, achange in self-per- generous intheir judgment of situations. from ignoring, excluding, or ception. On a sentencecompletion test, they moved seeking positive control over punishing troublesomechildren toward methods with; while theyoriented the child. These wereable, friendly teachers to start along, the main result themselves more to personsthan content as time went difficulties they faced in self-perceivedability to manage the was an increase of the i.e., a growth intheir sense of competence.A general strengthening and self-confidence oc- teacher's classroom position,directness, assertiveness, their mental curred. It is also interesting tonote thatthere was no increase in knowledge level showed no hygiene content information atthe close. Actual substantive experiences inthe program. In gains althoughthere were many intense the participationin the regard to the degree ofparticipation, the more experienced elementary program,the greater the change.The younger, less susceptible to change. teachers were most paralleled by the This ego strengthdevelopment in the teachers was definitive in change in the experimental groupof parents. They became more pal and more of anauthority. their relationshipswith their childrenless a 278 NEW APPROACHES IN THE SCHOOLS They became less uncertain and lessuneasy, which is not to say punitive or harsh. There was a decrease in both "parent-deification" andattempts at "will- breaking" and more willingnessto allow children to live their own lives. Parent and child roles were separatedmore clearly. More involvement in the school program also took place. The analysis of pupil changes bringsus to what eventually is the central point of departurethe diversenature of classrooms, each representing an idiosyncratic complex equalto that of an individual personality, but perhaps more complicated. Since, of course, the teachers were not alike to start with, changes could not be identical. Further, theimpact of such individual changes on a highly variant series of classes imposeda most difficult task of analysis. Some of the classes taught by teachersin the program became more work-oriented but alsomore anxious; others became more comfortable and less work-directed. Themore ideal goal of reasonable structure, high acceptance, and high motivation is the one stated by Cutler and McNeilas the most likely direction of change found in their analysis ofindividual classes. Over- all, the teachers in theprogram at the close were seen by pupils as less nag- ging and punitive, but setting strong limits and givingsupport that reduced anxiety. Since general classroom morale tendsto decline as the school year progresses, the effect of the present mental health programwas to arrest or reverse this trend. Further analysis of individual classrooms has led to far more sophisticated appreciation of the difficulty in surmising reasons for pupil changes (Ketcham & Morse, 1965). Thus, the research, tentative though it is considering the complicated problem and the inadequate instrumentationin this area, does indicate that the mental health program helped the adults, bothparents and teachers, to develop a more defined and secure role in their work with children. Perhaps ,

they were helped toovercome uncertainty and indecision. As a result of , exposure to this program, they came to their new patterns not reflexively but having faced the deeper problems ofour time. They thought through their beliefs and found procedures thatwere suited to their relationships with the children. The pupils' classroom adjustment isa many-faceted affair. Changing one aspect may influence another in a direction not intended. Contentment without effort is not enough, and the interrelationship of the various classroom conditions is more complicated than changes inan individual personality. facile single measures may bemore misleading than helpful in this area.

INGREDIENTS OF A VIABLE SCHOOL MENTAL HEALTH PROGRAM

The genesis of the Michigan approachto school men tal health programming has been reviewed, and the research findings relatedto a specific program have been presented. Since the content of any individualprogram ENHANCING THE TEACHER'SMENTAL HEALTH FUNCTION 279 follows the perceived needs of a givenschool clientele, there is no setroutine which has become an acceptedformat. The point of accessand activities depend upon the locale; on theother hand, one may oftenfind shared goals and a common starting pointin different schools.Finally, there are action time in a program aspects which,though not inevitable, often appear at some because of the generalized presenceof particular problems andpotential 1ines for their resolution in theschool milieu. McNeil, Cutler, and Morse(1963) indicated four primarygoals 6.- a (1) to increase the teacher'ssensitivity t school mental health program: t individual and group psychologicalproblems, (2) to presentdiagnostic procedures which will direct the teacher'sefforts along more sophisticatedand complete dimensions, (3) tostudy the management of thelearning process according to the principles ofgood mental health, (4) totranslate the theoretical knowledge of psychology intopractical action. To this end there are certain processeswhich become a basis for program operation. The first is definingthe relationship of themental health consultant as co-equal, rather than assuperior. He has particularknowledge to contribute in a joint enterprise concerningthe solution of classroomproblems. Second, the teacher can best beginby a rough rank-ordering ofthe problems as he seesthemwhatever they may beinorder to find an optimal starting point. Sometimes the chosenstarting point represents anunrealistic problem teach- or requires moretime than is availablefrom the consultant. However, realistic concerns about which some- ers soonbecome more adept in listing formulate a func- thing can be done. Indeed,the very process of learning to tional problem is a most importantskill. These problems usuallyinvolve children who are difficult to managebecause of acting out. Butalmost as common areproblems concerning youngsterswho are difficult to teach because they seem not tolearn by the procedures adequatefor most pupils. The next step is a search forrelevant psychologicalprinciples to apply both to diagnostic planning and to aproposed program of action.There must be some actual activity forthe teacher to try out, not justabstract theorizing. A rehearsal is often attempted inthe consultation or seminar.The teacher then goes about trying to follow amutually worked out sequenceof actions. Generally speaking, teachers arefar more effective than"experts" in devising the specific useful classroomstrategies. Hence, with aclearly formulated understanding of the problem situation,the teacher himself may be inthe best position to develop a concreteplan of action. The subsequent step is anevaluation of the action. That is,the teacher reports back onwhat transpired at the nextsession of the seminar or consultation. Usually the consequenceis a reevaluation of theproblem and a proposal of new action. Often a morecomplete understanding of the events indicates the need for helpfrom school specialists to workwith the parents, or referral to aclinic. Findings might suggest newdesigns for classroom experiences. Perhaps theanalysis suggested on-the-spotstudy of particular issues through collectingorganized responses from thepupils or making 280 NEW APPROACHES IN THE SCHOOLS observations in the classroom. Teachers might see the need for learning new techniques in interviewing. It becomes obvious that for the most part one works with the teacher's perceptions of the classroom events. The assumption is that these perceptions constitute a critical world which is just as "true" a world as would be a therapist's perception of his client's life events. If the teacher and consultant can work together to move from "what actually happened" to what the happening signifies, psychologically speaking, we have the nuclear material for school mental health work. The stance is one of problem solving, with facts and feelings both considered. That this is not as simply done as stated will become evident shortly. Each consultant must work in his own particular way. Though their goals are common, no two work settings are the same. The unique nature of each psychologist and his capacity to establish meaningful relationships and solve problemsnot a set of cliches about the consultee-consultant relationship determine the course of action to be followed. As consultation programs were established, it became clear that school personnel believed that some push or assistance from the outside was necessary if the consultation program were to be successful, despite the fact that there were able people in the system itself. This may mean that specialists totally within the milieu become too constricted to act in sensitive areas with the necessary freedom. This is a matter of great concern which needs much more careful study. The following enumeration defines the school mental hygiene program content, i.e., what actually goes on in sessions with teachers. At the present time, certain combinations may find a place in didactic courses, in seminars, and in consultation in field settings. Consultants must be ready to Wance open-endedness with structure, since too much of either may create uneasiness. By and large, teachers have been promised more than has been delivered so consistently that there is almost always a testing-out period with regard to what is to be done and how it will be handled. Accordingly, skill in explaining possible ingredients for an action effort is basic to consultation. But the assurance that there are program elements which have evolved from joint work with teachers is important. The consultant first explains the general methods of operation of the program and makes tentative suggestions to get a discussion undc.iway. From this comes the following action steps.

RELIEVING STRAIN Consultation should relieve the strain about the demands of teaching which most classroom teachers feel. This requires a school-relevant psychological point of view rather than the traditional clinical psychological practice divorced from the school context and school problems. Such an orientation emphasizes things to do rather than abstract principles. An approach that has been found to be both psychologically valid and meaningful to teachers is HEALTH FUNCTION 281 ENHANCING THETEACHER'S MENTAL with the life space orcontemporaneous one thatcombines depth psychology (Morse, 1965). A basicemphasis here is the contrast emphasis of Kurt Lewin life space or between the usual lifehistory approach and thecontemporary indoctrinated with theclinical or milieu approach. Mostteachers have been to explainand to under- life history approach,and there is a tendency to try behavior primarily in termsof the past. Thedaily problems of stand human of his life history, the pupil aredepicted, almostexclusively, as the result much of which liesburied in his unconscious. conditions to bringthese matters Thus change effortsrequire the proper understanding and, throughindividual therapy, to create new to the surface orientation may, of course,be and rectified behavior.While the foregoing recognize the importanceof important and sometimesessential, we must also emphasisi.e., on teachingchildren to cope withthe present a contemporary that there difficulties on the basisof learning principles.It is thus proposed psychodynamic depthapproach are otherviable methodsalternativesto the should also command respect.It is well to mentalhealth problemswhich and to work to thefullest possible within the provinceof teachers to study child. The exclusivelife his- extent withthe contemporarylife space of the refer, which is seldomlikely to tory approachleaves them helpless excepz io take place. of one's life The life spacetheory, as we use it,holds that the distillates dynamics are incorporated, history constitute the presentself concept. Thus, field. The working but the emphasis is in termsof their impact on the current and total school milieuwill also influencethe class- forces of the community material is not elimi- through impact on pupilself concept. Historical room it is jelled inthe the circumstantial orthe sociological, but nated in favor of forces of the present self conceptand self-esteem ofthe pupil. The external of the teacher, areemphasized. here anet now, beingwithin the jurisdiction with these issueshave been devel- As will be indicated,instruments to deal oped to aid theteacher. differently The life space theoryfurther implies thatchildren behave is, in part,demonstrated by radically soin varioussituations. This point Sutton-Smith, 1955).This work research done at atherapy camp (Gump & role and the child'sbehavior underscores how completelydifferent the adult's be a policeman in onesetting arc invarious settings.The same adult may forces can stimulatecooperativeness and a helper inanother. Environmental roles for the samechild. All or hostility amongpeers. Gamescreate varying self ar;d the contemporaryenvironment of this meant; thatthe contemporary behavior. In awell-plartned children'spsychiatric hospi- interact to produce normal than not, the disturbedchildren may look more tal, for example, planning (Redl, most of thetime, as a consequenceof astute environmental 1959a). Teachers examine the types This leads to an issueof major importance. forces. What changes canbe made to sup- of behaviorinduced by classroom 282 NEW APPROACHES IN THE SCHOOLS port the child's capacity to learn andadapt? Obviously the nature of adult- child relationships represents one area for possible change; another isthat of the demands of the taskshow they are presented andevaluated. A third matter is the peer or grouprelationships produced in the classroom. These latter elements certainly operate in the classroom, but they arefiltered through the particular self concepts of the individual pupils. This is theunique part and means that the same input will have very differentbehavioral consequences for different children.This is a dynaniic approach to the teacher's number one problemindividual differenceswhich, hopefully, is more useful than static age, achievement, or intelligence data since itincludes motivation, ideology, and needs. The total implication of the life space system is to study moreand plan more for the conditions about whichthe teacher can do something. But again, the consultant must point out the power and limitations of thisemphasis, lest an oversimplified "either-or" polarization be created. Whilethere are many classroom interventionsthat can produce a richer and more effective school experience for the child, there is also a limit to this approach.Many times the consultant must help the teacher appreciate thelimitations of schools in restoring a long-damaged self concept. At such times, the prime concern becomes that of how to work mosteffectively with supporting referral services. Of central importance is the need to get away from apseudoclinical approach to the educational province. In the final analysis, answers to major mental health problems are likely to be found to lie in the classroomitself, and in those things which can be done by the teacher with thechildren in that environment. Unless we can find better methods of working withinthe classroom, school mental health programs will falter.

SITUATIONAL ANALYSIS One of the major skills which teachers can develop is the ability to make a comprehensive analysis of particular children or of a total classroom situation. This embodies essentially a phenomenological approach to the here and now, internal and external life space. What are the forces active in the child's mind? What is the attitudinal system in this class? The important thing is to have tools for looking at these situations from a teacher's point of view rather than to misapply measures that are primarily those of other disciplines. To aid in this process we have developed scales and devices which enable a teacher to study certain aspects of individual pupils, as well as the overall classroom. There are nineteen major dimensions to this classroom analysis which provide data to chart an individual or group profile on standardized norms. Pupil and the class distributions can be plotted on such dimensions as the following: motivation for school work; perception of the teacher as ahelping agent; school anxiety; social acceptance;satisfaction-dissatisfaction with the 283 ENHANCING THE TEACHER'SMENTAL HEALTH FUNCTION need complex (achieve- class structure; perceptionof the climate for learning; In addition, the ordinary measures ment, affiliation,power); and self concept. ability are included. Trainingin of educationalachievement and intellectual limitations of scales the use of these devicesfocuses attention on the severe with such material as a way and the use of directobservation in combination problems. Teachers arequick to point out to collectinformation for analyzing The major purpose of defensive reporting ofchildren they may know well. since no device can go these procedures is tosharpen our intellectual wits, farther than theteacher's insight. Thus, the teacher can look atthe response pattern ofparticular children of distribution on anyof these in school-relateddomains and see the type girls, at any grade. dimensions for the totalclass, as adjusted for boys or Sometimes it is easier to come togrips with an issuethrough objective infor- classes increases. Two junior mation. Sensitivity toindividual children and to generated an interest high school staffs, using justthe self concept measures, in working on ways tohelp many of the childrenwho had been known to have problems but werepreviously ignored by the school.

SELF ANALYSIS A vital aspect of themental health potentialof a classroom is obvi- fostered by the teacher ously the character of theinterpersonal relationship another, see as a personand as a professional. Manyteachers, at one time or teaching role. But value in an analysis of their ownbehavior relative to the client for the consult- this is not best accomplishedby making a teacher the ant's therapy. Several devices, including avariety of ratingscales, are available to enable a teacher to gain inself-awareness, beyond theinherent by-products scales and some are of planned discussions.Norms are available on these self-scoring, so that a teacherneed not identify himselfunless he so chooses. relative to learning, men- On one scale dimensionsinclude value investment Another scale cate- tal health, individualdifferences, or group processes. operation relative to gorizes the general stanceof the teacher's classroom also be discipline, counseling, referral, etc.Deeper motivational patterns can affiliate or to assessed. For example, a teacher maybe motivated by a need to achieve. Essential ego strengthand self-image of theteacher are very impor- dimensions are reflected in tant since theyunderlie so much else, and these still other scales. The teacher can now examine aclassroom profile, includingpupil needs and his own needs. Do theymatch or are they inconflict? Again the limitations of the devices mustbe emphasized, and theteacher is urged to check against other types ofevidence. No one holds that areally disturbed teacher will be helped by such egolevel approaches; it ismaintained that normal their output, people can monitor and mitigateparticular peaks or valleys in i 284 NEW APPROACHES IN THE SCHOOLS if they appreciate what their style happens to be.In the negative sense, this is certainly no intent to create a single,"ideal," homogenized teacher profile. Rather, the goal is to help teachers to develop their ownstyle in a way that best suits their positive attributes and to strive tohold less fortunate elements under control when trying to help particularchildren for whom they are responsible. None of these devices are handed outcold. They are used as part of a program involvingprior discussion, and any teacher may reserve his own personal data for himself. It is also clear that the teacher does notnecessarily stand pat with the classroom profile which represents the pupils at any point intime. The availability of such profiles provides concrete evidenceof the possibilities of specifically planned interventions. If motivation forschool work is very low, if pupil self-concepts are marginal, if social acceptanceis nil, these become the starting point for planning. Plans mustbe made with the same care one utilizes in working with an individual, but it isstimulating to see how productive teachers are in thinking of appropriate classroomstrategies once the problem is delineated. The purpose of the instruments is to movefrom global principles to specific and concrete elements for moreeffective classroom work. Too much mental health effort is still generaland is characterized by the rather unspecific platitude "be good to thechildren."

LEARNING SPECIAL SKILLS Beyond the analysis of situations andgeneral strategic planning, a teacher may wish to learn new skills forworking with children. These comprise the school interventionswhich teachers practice, but oftenwithout adequate sophistication. It has alreadybeen indicated that alteration of the tasks, evaluative procedures, teacher behavior,and working through group situations will be part of the action. Butthis is often not enough. Hence there is a continuing orientation to theacquisition of special skills, includingthe following.

Skill in Life Space Interviewing A major necessity for effective workwith children in any action setting is a technique formeaningful and profitable verbal discourse with youngsters (Redl, 1959b).This is particularly true in handling acting-out or difficu't-to-managechildren, but itis also true with unmotivated and passive children. Teachersalready spend a great amount of time in interpersonal interaction with the obvious intentof changing the pupil's behavior directly or finding which environmentalconditions should be altered. Skill in this area can be upgraded onlythrough supervised practice. However, there are steps forthe teacher to follow, and seminars areused to work out the exact things onemight try with a child under givenconditions. Recordings of interviews, with specificdiscussions of the content and meaning, become ENHANCING THE TEACHER'S MENTAL HEALTHFUNCTION 285 the focus. The way the teacher expresses his empathic concernfor the child is to understand him. The way one understands thechild is to accept him as he is, as far as his verbal statements go, to listen tohim, and to think with him about the way his experiences seem to him. Considerable time is spent helping the teacher learn tolisten. First, the teacher listens to the child and learns his point of view.Other steps follow, such as exploring the depth of the issue, inquiring as tothe generality of a particular problem in other situations, and going on todiscuss what might be done in such a situation. The teacherexplores the child's recognitionof the need for change and particular copingmechanisms that might be taught to him. There is always an attempt to close aninterview with some minoraltera- tion S9 that behavior can be moreacceptable in the future. The approachis certainly not an easy one, but at least theconversation between the childand teacher should be turned to the mostproductive use possible. Seminarsand field consultation have been devoted toteaching life space interviewingfor use withindividuals or groups.

The Use of Curriculum Contentfor Mental Hygiene Most teachers find classroom content tobe the most natural medium for interacting with children. Ojemann(1959) has demonstrated that understanding of behavior can be approachedthrough specific types of conceptual material used with pupils. In addition tothe stories and materials whichhe presents, any storywhich has dynamic implications or valueimplications can be used as the basis for meaningfulclassroom discussion. It seems particularly important that adolescents havethe opportunity to discuss concernswhich may or may notnaturally come up in the course of the semester.Themes, projects, and books can deal withmental health matters. Teachers in areas other than social studies or Englishhave found that anxieties abouttheir subject matter area, grades, or teachingmethods represent appropriate areas for scrutiny. For example, for oneof the teachers in our program,fear of failure in science and mathematicsbecame the point of departure fordiscussion. He now routinely uses abrief anxiety assessment questionnaire as an introduction to every math class. In addition to such curriculumchanges, teachers frequentlyfeel it is desirable to set up specific programsfor "high risk" youth. Some haveutilized group counseling,while others have primarily emphasizedremedial work. These activities can be led by theteacher if he has had prior relevant training and if adequate consultation isavailable to him.

WORK ON INSTITUTIONALROADBLOCKS It is obvious that there may be manybuilt-in chronic roadblocks to optimal mental health in theeducational setting. Mental health as primary prevention presumes work to removethese constricting elements. There are 286 NEW APPROACHES IN THE SCHOOLS some fifteen to twenty prevalent roadblockswhich have come up in teacher- discussion groups. These include such things as the limitations of a constant teaching method when populations vary, problems engendered by constant- rate expectations for children at different grade levels,rigid subject matter content in some schools, the fractionation of helping roles (e.g., theprincipal versus guidance worker, etc.), unsatisfactoryevaluation procedures which are prevalent in most schools (here concrete suggestions are made for alterations and more reasonable feedback procedures), the need for greater attention to nonvisible reward systems in schools (Coleman, 1961), the potentially unfortunate consequence inherent in maintenance of classrooms of relatively comparable size even though some pupils need much more teacher help than others, the tendency toward inflexible use of special personal capacities of teachers, and the use of curricula far removed from the lives of children. Quite probably, such roadblocks as these have more unfortunate mental health consequences in the school than any particular program can hope to eliminate. When teachers are provided an opportunity to consider the potential consequences of change, they become more aware of the need for a total attack on the inanities of certain present educational practices. Flexibility itself reduces many of the problems which now cause serious difficulty. With the increasing emphasis on education, teachers are at a critical stress point. It is also true, as Berlin (1964) has indicated, that serious changes in the psychological motivation of pupils today may be taking place. Teaching cannot remain static in a fast changing socialclimate. Changes in the school system or in any other entrenched social institution are never easy toeffect but accomplishment in any of these areas is fundamental rather remedial, and growth in these directions may be most appealing to the master career teacher.

CONCEPTUAL MATERIAL There is an obvious place for a fuller understanding of material on childhood dynamics, once a teacher comes to grasp its value. Phenomenolog- ical and self concept theory has already been described as "practical" theory which may lie at the core of this approach to the child. There is the further crucial matter of understanding differential diagnosis so that proper handling which, in the last analysis, depends upon the nature of the self being handled, can be accomplished. Basicinformation on the particular dilemma of a child offers the opportunity for bringing in related conceptual information. The problem has not been lack of need for conceptual information; rather it has been the fact that the particular type of conceptual information offered often pays very low, if any,dividends. When concepts help a teacher work more effectively, there is no resistance. For example, the screening devices that are necessary to objectify one's impression of a child's adjustment are very useful to teachers, and teachers ENHANCING THE TEACHER'SMENTAL HEALTH FUNCTION 287 show a good deal of interest inthem. Such simple things as a "bugme" index, which one teacher kept of thedaily irritations, or the study of countertrans- ference phenomena help the teacher to operate moreeffectively. We find no reluctance at all on the part ofteachers to study such matters as interpersonal communication, differentialdiagnosis, the nature of empathic response,vaii- ous typesof pathology, and the like. The mental health consultantsshould be aware that a major problemof many teachersinvolves children with learningdifficulties, perceptual and otherwise, so that these aspects areincluded in the overall consultative program.

USING REFERRAL PROCESSES It is important to emphasize that manychildren require referral. Even the most skilled teacher cannothope to cope satisfactorily with allproblems of all children. While the percentageof those who cannot be handledeffec- tively in the classroom may notbe large, the guilt, irritation, anddifficulty generated by them make the fewexceptions an imposing problemfor the teacher. The difficulty of gettingreferrals and the nature of the waitinglists, even whenthere are good resources, is well known.When no help is available, individualized course plans, ashorter day, orin extreme caseseven school exclusion may be needed inorder to underscore the magnitudeof the problem and, perhaps, to put pressure on parentsunwilling to acknowledge the severity of the child's problem.This is done not through a precipitous decision, but only after attempts at lessdrastic procedures by the school have failed. Parents are consulted, and allother possibilities are eliminated. If nothing is found to alleviatethe situation, it becomes obvious thatthe school is incapable of helping thatparticular child. If his particularproblem is one which does not causeschool disturbance, it may be difficult to getaddi- tional help, especially so if the parents areunwilling to cooperate. However, if the child is impeding the learningof other children, the school has a responsibility to exclude him, at least forthat part of the time when he functions disruptively. Such extremeaction is necessary in order to protectthe mental health of others in the schooland, in the long run, of theparticular child as well. Public school masochism,foisted on the teacher as it sooften is, has no place in schoolmental health. The teachers in some schoolshave worked with a different referral source namely a crisis teacher who canpick up the overflow of schoolproblems outside the scope of the groupclassroom situation. The conceptof crisis teacher and its way of functioning aredescribed more fully elsewhere (Morse, 1962). In addition, teachers havebecome active in working for special classes, mental health clinics, day-care programs,and inpatient care for the community. In a recent study ofMichigan's mental health problems itbecame clear that a major problem waslack of adequate services to handlethe few 288 NEW APPROACHES IN THE SCHOOLS extremely disturbed children. Thismeant that each service was backedup 1 with cases beyond thescope of its helping potential. All parties concerned, including the classroom teachers,were attempting to solve the problems of children far too disturbedto be handled with theresources available in the given situation, particularly in theaverage classroom. It is important to be 1 realistic about these difficulties rather thanto imply indirectly that teachers I should be able to handle all difficultiesof all children who walk (orare forced) through the doors of publicschools.

CONCLUSION

This has beena hurried journey through a very complex andextensive series of activities. Membersof the training staff of consultantsin the Michiganprogram. have moved from didactic lecturesto direct work through the school milieu. It becomesincreasingly clear that the schoolprogram is merely a link in a long series of services andthat a defect atany point in this sequence burdens others andmakes their work less effective. When it comes to positive action, theanticipation is that each classroom and each school communityis unique and requiresa particular selection of program elements tuned to the needs of thatinstitution, with itsresources, its insights, and its readiness. Anexternal resourceperson can bring illustrations and the like, but his majorcontribution is to help analyzethe problem and to think, with the peopleinvolved, aboutresources which are available in their situation. Thas, thecore of this mental hygiene approach in school is not a Oven set of thingsto do, but rather a point of view. Inpractice, this may lead to setting up a group therapyprogram, a big brother movement,a program L tilizing mental health materials directlyin the curriculum,or even a course. The prime function of the outsideconsultant is to facilitatea problem-solvingprocess by bringing to the attention of the classroomteacher, or others, aspects of the problem andpossible ways of seekinga solution. A basic respect for the local school personnelpresumes that the consultant come.s in to work through and with themon the problems as they see them,or come to see them. On the other hand, ifone studies the school as a social system, the role of the teacher, and the demandsof mental health work, thereare certain general aspects in childmanagement which tend to recur in most schools, although the form and shapemay differ in suburbia and central city. A school mental health consultant is effectiveonly if he has considerablearmament at his disposal and at the same timecomes to a particular school with humility, knowing he will learnmore than he teaches. The only preknownaspect is that the program will require a great deal of brain work to do the kind of 1 diagnostic assessment in total planningwhich school mental health demands. HEALTH FUNCTION 289 ENHAUCING THETEACHER'S MENTAL

REFERENCES

The role of schoolsin mentalhealth. New Allinsmith, W., &Goethals, G. W. York: Basic Books,1962. education. Sat. Rev.,1964, 47, 56-58. Berlin, I. N. Unrealitiesin teacher No. 4. schools. CooperativeRes. Monogr. Coleman, J. S. Socialclimates in high H.E.W., Office ofEducation, OE 33016, Washington, D.C.:U.S. Dept. of 1961. consultation inschools. Dept. of Cutler, R. L., &McNeil, E. B.Mental health Psychol., Univet. ofMichigan (no date). and social intervention.Amer. J. Gump, P., &Sutton-Smith, B.Activity setting Orthopsychiat., 1955, 25,755-760. children's social andpsycholog- Ketcham, W. A., &Morse, W. G.Dimensions of achievement. CooperativeResearch Proj- icd developmentrelated to school USUE, Univer. ofMichigan, 1965. ect 1286, Michigan Society forMental Health, Kipfer, J. F. Schoolmental health. Detroit: 1959. W. C. The schoolmental health program. McNeil, E. B., Cutler,11. L., & Morse, (Eds.), Professionalschool psychol- In M. G. Gottsegen& G. B. Gottsegen Grune & Stratton,1963. Pp. 102-123. ogy. Vol.2. New York: approach to mentalhealth. Morse, W. C. Aresearch evaluationof an action 1961, 31, 324-331. Amer. J. Orthopsychiat., for the disturbedpupil. Morse, W. C.The crisis teacherpublic school provision 101-104. Sch. of Educ.Bull., 1962, 37, School J., viewpoint on schooldiscipline. High Morse, W. C. Themental hygiene 1965, 47, 396-401. for education inhuman behavior.Iowa Ojemann, R. H.Developing a program City: State Universityof Iowa, 1959. 29, milieu. Amer. J.Orthopsychiat., 1959, Redl, F. The conceptof therapeutic 721-727. (a) J. Orthopsy- the life spaceinterview. Amer. Redl, F. Strategyand techniques of chiat., 1959, 29,1-18. (b) 16 THE ST. LOUIS SCHOOL MENTAL HEALTH PROJECT: HISTORY AND EVALUATION Margaret C...L. Gildea, John C. Gliaewell, and Mildred B. Kantor St. Louis County Mental Health Department

HISTORY OF SERVICE

The school mental health services with which this paper is concerned (Gildea, 1959) began in the city of St. Louis in 1947 and were started in St. Louis County under the auspices of the St. Louis County Health Depart- ment in 1951. The research project for evaluation, reported in the second section of this chapter, was conducted in the St. Louis County Health De- partment, financed by the National Institute of Mental Health.' In the city of St. Louis, in 1947, there was an active organization of educators and lay people called The St. Louis Council for Parent Education. This group had originally come together for the purpose of developing programs to help parents understand the problems in raising and educatingchil- dren. The social disruption following the war and concern about delinquency and behavior problems generally bad given impetus to the movement. Initially this group had set up lectures and institutes in which experts told the audi- ence what was wrong and how to correct it.Gradually it became apparent that those listening were already familiar with the material and that, in fact, the same middle- and upper-class groups gathered together, talking mainly to each other. Therefore the group began looking for a new project in an attempt to reach out to parents who were so far uninvolved. The leader in developing the new activity was a school principal with a long personal and family background in the St. Louis German liberal education tradition. She particularly wanted help for the school parents in the lower middle-class and lower-class areas where she and some of her colleagues wereworking. These particular schools, in which the pilot project was introduced, were segregated white schools in well-settled old parts of the city. The principals were enthusiastic

' Research Grant M-592 from the National Institute of Mental Heaith of the National Institutes of Health, United States Public Health Service.

290 THE ST. LOUIS SCHOOL MENTALHEALTH PROJECT 291 about a proposed school mentalhealth project, and the superintendentand board were accepting, so long asfinancing was arranged fromoutside and budgetary problems not brought up. Meanwhile a renewed interest in grouptherapy among psychiatrists and the allied professions wasdeveloping. The AmericanOrthopsychiatric Asso- ciation had spearheadedthis interest in using groupmethods for treating children with problems andtheir parents (Amster, 1944;Slavson, 1943). Using this technique the consultingprofessional staff of the councildeveloped problems in a projectof group therapy for parentsof children with behavior public schools. Tne program was set up toemploy a psychiatric social workerhalf-time to work in twoschools, or about one-fourth time ineach school of five to six hundred children. This was aconcentration of social work timethat had and doubtless some of the never beenequaled in public schools of this area, social worker's success wasdue to this fact alone. Manyother favorable factors entered into his considerable success,such as warm relations betweenhim and the principals, his ownfriendly unpressured personality, andhis expertise. Viewed along many dimensions,this pilot project was anunqualified success. Cooperation during its course wasexcellent, and there was anoteworthy absence of complaints by participants.The services provided receivedenthusi- astic acceptance by schoolpersonnel and parents, and requests werereceived for expansion of the programs into newschools. A fuller account of the reactions to this project hasbeen presented elsewhere(Gildea, 1959). It is sufficient here to note that thisinitial success led to a strongdrive to develop and expand the program. This new work was directedprimarily to the parents. Teachersselected children with behavior problems oremotional maladjustment fromeach grade, and their parents were invited to meetthe social worker. He theninvited the parents whom hethought suitable to weekly groupmeetings. These were group therapysessionsinformal, sociable, andaccompanied by coffee and cake. The children themselves were not seenby the worker, and the teachers were seenonly in referral interviews orinformally. In reporting the development of subject matterin the groups the worker observed that the parents invariablybegan their participation by expressing resentment against theschool, its personnel, or society.They disclaimed responsibility for the child's problems andlaid the blame elsewhere.Gradually, through discussion, each mother came to seewhat she could do to improve matters and began to be able to acceptresponsibility for the climate in her home. This change in attitude wasusually associated with an improvement in the child's behavior asjudged by the teacher. Thus theimportance of maternal attitudes emerged, especiallythe attitude relating to responsibility for the child's behavior. Thisinfluenced much of the subsequentwork. The success of this program led into awider development in the next several years in the city of St. Louis,and several other schools wereinvolved, SCHOOLS 292 NEW APPROACHES IN THE using a variety of workers.Another white social worker attempted toorganize mothers' groups in a segregated Negroschool. This effort met withfailure and rejection. The schoolpersonnel, all Negro, were not accepting .or responsive; and the mothers, in their own courteousway, rejectedthe service. This same worker was successful inanother white school. Awell-trained Negro social worker also tried to getNegro school mothers' groupstogether, but also failed. She was moresuccessful than the white worker,however, in her individual casework contacts withthe Negro mothers. Other experiences in different settingsshowed that a variety of workers could be successful. In one case theworker was a woman psychologist atthe master's degree level. In another, theworker was a nonprofessional woman who had grown children and whoseeducation included a B.A., but noformal graduate training. She did very well inthe school, consultation and group therapy work. This experience led tothe wider use of volunteers,nonprofessionals, or lay people, in thelay-education program. During the development ofthe group therapy program itbecame apparent to the peopleinvolved that the success of the servicein each school setting hinged on severalfactors; but most prominent amongthem was the general level of understandingand acceptance of mentalhealth concepts within the community comprisingthe school area, both parents andteachers. The failure of the program inthe Negro schools brought home tothe board members and the workers, withparticular force, the necessity of ageneral mental health education program. At about this time the St. LouisCouncil for Parent Education merged with the Mental Hygiene Society.The resulting group, the St. LouisMental Health Association, becameparticularly interested in mental healtheducation. An active group of voluuteers cametogether and developed a programof group discussions,led by each other, centering aroundideas presented in the new mentalhealth films. Previous experience of exhibitingthese films at board meetings had demonstrated that they created considerableanxiety when they wereshown alone. In most cases spontaneous discussionfollowing the film quickly reduced this anxiety to manageable proportions, inaddition to emphasizing and under- scoring the points that had beenmade. In fact, discussion oftenseemed to lead to enthusiastic acceptance ofthe ideas presented. Thus a program of discussion groups ledby lay leaders was developed. These leaders were trained in a seriesof workshops conducted by professionals, a psychiatrist and a psychiatricsocial worker, and held in theAssocia- tion offices. At first the participants werechiefly board members and their friends, largely self-selected. Later an effort wasmade to screen the applicants, but it was generally held that anyonewho wanted to could lead adiscussion. The process of self-selection went onduring the training period, and later, too. For instance, aworkshop might start with thirty peopleand wind up with twenty who wanted to go aheadwith it. The rest would have eliminated 293 THE ST. LOUIS SCHOOLMENTAL HEALTHPROJECT feeling that themselves. Some woulddrop out after leading afew discussions, three sessions they did not like it or were notsuited to it. The woi kshops were The basic teaching wasthat discussion should arisefrom of two hours each. and the group, that therole of the leaders was tokeep discussion going that they were tension withinmanageable limits. Theleaders were reminded difficult or theoretical questions. not expertsand should not attempt to answer considered to have positive The very fact thatthey were not experts was relations there are nopositive II value in promotingthe idea that in human answers. The groupseeks to find a useful pointof view together. Leaders were usually sent out tomeetings in pairs, with a moreexperi- The groups were most enced leader accompaniedby a less experienced one. clubs, but some were alsoheld in often held in schools,PTAs, and mothers' they were requested.The churches, before serviceclubs, and wherever else their panel, andfrequently Association had some 40 or50 volunteer leaders on during a year. Oftenthe leaders 20,000 people wereinvolved in the groups regularly arranged intwo-hour requested follow-upworkshops. These were sessions with variousprofessionals leadingthem. offered in the city ofSt. There were, thus, twomental health services and the educational Louis: the school-centered grouptherapy for parents, private financing discussion groups. As the grouptherapy program expanded, Education had a divisionwhich became more difficult.The St. Louis Board of services werediscontinued gave services toparents, andthe privately financed in 1951. became in- At this time theHealth Commissionerof St. Louis County the project of grouptherapy terested in school mentalhealth, and especially in long tradition in the county for parents in the cityschools. There had been a with the county HealthDepart- in which variousschool districts contracted service became part ofthis health services. Theschool mental health ment for offered a school mental Initially the countyHealth Department structure. which they paid 750 percapita health service to threeschool districts, for under which thesedistricts yearly. This was the samekind of arrangement contracted for nursingand dentistry. and the service was The financing arrangementchanged after two years, worker in the school.This has now paid for on the basis of$5 an hour for the Department pays the restof the been increased to $7.50.The county Health has now expanded into sevendistricts and has expense.The service program each district to meetspecific con- assumed a somewhatdifferent character in ditions and specific requests. the program The expectation atthe beginning ofthe services was that in the countywould be similar to of group therapyfor parents established This, however, was true toonly that which had beendeveloped in the city. between the two programs canbe explained by a smalldegree. Differences well as by central administra- different characteristicsof the areas involved, as Department and the localschool districts. tive features ofthe county Health 294 NEW APPROACHES IN THE SCHOOLS The situation in the county contrasts with that in the city inmany ways. In the city there is one superintendent of schools, who is firmly established, and the schools themselves are in well-settled neighborhoods. Traditionally the city schools are concerned with their neighborhoodparents, who can easily walk to school and thusare familiar with the schools and their personnel. These parents are readily accessible to the school, and therewas no problem getting them to come in. The county,on the other hand, is undergo:ng rapid growth and population expansion. Many of the school districts are made up largely of new subdivisions with very little social cohesion, or even inter- or intra-community transportation. In many districts, especially the newer ones, the school boards and their superintendentswere uneasy about the parents, whoare their electorate. This uneasiness seeped down to the principals and made all the school officials guarded and defensive about allowing workers to have direct contact with parents. Some of them felt that this kind of new program, coming from the outside (i.e., the Health Depart- ment), represented a potential threatto the school image in the eyes of the electorate; and it was particularly difficult insome of the districts to have free access to the parents. In several districts,even though the superintendents had voluntarily contracted for their services, the workers found it hardto give any because of lack of referrals. In some districts the guidance counselors blocked referrals. In at least one schoola worker was given no place to interview except a boiler room or a broom closet. Other factors which made access to theparents difficult were transportation, shortage of workers' time, and type ofcase referred. As mentioned above, there was little public transportation, especially in the evenings whenmeet- ings of parentc were usually scheduled. However, parental participationwas also difficult to obtain in schools serving upper-classor upper middle-class areas where transportation was no problem. The shortage of the workers' time made it impossible to make home visits for intakeor follow-up. Further, in the early period at least, very difficult cases whichwere intrinsically untreatable in the school settingwere referred. These cases usually required referral to a clinic or other facility; this absorbed all the availabletime. Because seven different independent districtswere involved in the county and because there was a considerableturnover in school mental health personnel, the programs developed in the various districtswere not uniform. Workers were quite free to follow their individual interests if theyhad sympathetic school administrators. Thus,some of them conducted workshops and case-conferences for teachers. Ina few schools, groups of classroom mothers, all invited, come in for discussiongroups. Some of the workers used group therapy with groups of adolescents, and therewere one or two ongoing groups of referred parents. However, theprogram in the schools has gradually developed into a casework service, andgroup therapy has played a minor role. For similar reasons the lay discussiongroups did not take hold in the particular schools in which the school mental healthprogram was operating. 295 THE ST. LOUIS SCHOOLMENTAL HEALTH PROJECT and county, but it The program was going onactively elsewhere in the city schools. Although a numberof was notaccepted well in the experimental well attended, as they discussions were scheduledand held, they were not usually were in the placesthat had actively requestedthem.

SUMMARY OF RESEARCHFINDINGS2

From the beginning, in 1947,evaluation of the group therapy program for parentsof public school childrenwho exhibited behavior symptoms of the was muchtalked about. It seemed atfirst that a follow-up interview teachers by the schoolworker himself would give a pictureof the success or that failure of the parent therapy groups.However, it soon became apparent the teacher's report of thechild's current condition wasinfluenced to a marked degree by her transferencefeelings for the worker and byher general orientation toward the programand her principal whointroduced it. These follow-up interviews showed that inthe early school work 80%of the children whose improved in adjust- parents participated inthe group therapy were seen as ment by the teachers,while about the same per centof those whose parents did net participate were seen asunimproved (Gildea, 1959). It appeared that objectiveresults could not be expectedfrom a worker's widely accepted as one might ownfollow-up, although this precept is not as think. Many well-knownfollow-up studies of treatmentmethods are done by the people involved in the treatment, orby others close to them.This factor accounts in part forthe glowing results obtained in somedrug studies, as well as in other treatmentmethod follow-ups. Recognizing this sourceof error, the group thoughtthat counting the relevant police dis- referrals of pupils from thestudied school districts to the tricts before and afterthe program would be a measureof its effectiveness in variables averting gross disturbance.But again, it was apparent too many advice from were involved inthis simple countingprocedure. Therefore, with the NIMH3 a research program wasdeveloped in cooperationwith social scientists. In order to study theeffectiveness of the two programsdescribed in Section I, it was first necessary todevelop methods of measuringthe adjustment of children.Second, because it was felt thatmaternal attitudes strongly influence children's behavior andthat improving theseattitudes was one of the chief aims of these programs,it was necessary toconceive of ways of below is an out- studying and quantifying thesematernal attitudes. Reported following col- 2 The authors acknowledge withgratitude the contributions of the laborators: Ivan N. Mensh, Ph.D.,Herbert R. Domke, M.D., M.P. H. and A. D. Buchmueller, M.S.W. Eberhard, Ph.D., and 3 We acknowledge with gratitudethe personal interest John later Ronald Lippitt, Ph.D., took inthis proposal. SCHOOLS 296 NEW APPROACHES IN THE line of parts of the researchconceptualization. Inferences andconclusions selected for inclusion here arebased on parts of the data collected.Much of the detail of data analyses hasbeen already published in the citedreferences. Some is still in preparation for futurepublication.

ASSESSMENT OF LEVELS OFEMOTIONAL ADJUSTMENT OF CHILDREN Determining ways of classifying themental health of children was the first undertaking. A decision wasreached to consider the child's general state of emotionalwell-being from the points of viewof his teacher, his mother, and his classmates (Glidewell,Mensh, Domke, Gildea, & Buch- mueller, 1957; Gildea, Glidewell, &Kantor, 1960). Teachers were asked to grade the children on a4-point rating scale, from normal to very disturbed, needingclinical help. In the small or pilotsample described below the children werealso graded by professionals, the staffof the child guidance clinic. It wasfound that the teachers' ratingscorrelated highly with the opinions of professionalworkers. Indeed, in 80% of the cases there was exact numerical agreementbetween the ratings of the teachers and the ratings of the professionals. The mothers' opinions of theirchildren's emotional state were covered and in a detailed questionnairedesigned to collect data about family structure social characteristics, as well asinformation about how the mother experienced and perceived her child. Oneof the ways this information wasobtained was through a symptomchecklist (Glidewell, Mensh, & Gildea,1957; Glide- well, Gildea, Domke, & Kantor, 1959;Mensh, Kantor, Domke, Gildea, & Glidewell, 1959) accompanied by suitableprobe questions for each symptom the mother reported in herchild. This questioning collected data onthe frequency, duration, and severity ofthe symptom and on the mother's attitudes toward the cause of thedifficulty and how she thought it wouldprobably come out. In order to assess the classmates'views of each other, several instruments were used.The most valuable, in that itcorrelated with the mothers' and the teachers' opinions, was thesociometric questionnaire(Mensh & Glide- well, 1958). A semiprojective storycompletion instrument called "Secret Stories," and an adaptation of Rogers' useof a "Wishes" test were used.In addition, a most ingenious methodof classroom observation called "TheBean Game," devised by Ronald Lippitt, wasused. Data from the lastthree tests are stillunder analysis.

The Samples Two groups of children andmothers were used in this research. The first, called the pilot study, orthe small sample, was composedof 91 white public school children inthe third grade of threedifferent schools in St. 297 THE ST. LOUIS SCHOOLMENTAL HEALTH PROJECT Louis County. These were schoolscontracting with the countyHealth Depart- few ment for mentalhealth services. This group of"normal" children had so disturbed ones in it (only 6)that 35 children drawn fromreferrals to the St. Louis County ChildGuidance Clinic were added inorder to produce a broader spectrum for the pilotwork. The large study was composedof 30 third-grade classrooms in15 con- tracting schools. These weredivided into experimental andcontrol classrooms. change. The last The study was repeatedannually, three times, to determine repetition occurred 21/2 yearsafter the first. There were 830families in the first year, but a marked degreeof attrition occurred; by theend of the study, 21/2 years Jater, only abouthalf the children were left.About 25'A had moved out of theclassrooms, and thus out of theresearch, each year.

Findings Related to Mothers'Reports of Symptoms One section of the questionnaire wasdevoted to asking mothers if their children had any of a listof 21 symptoms (see Table 1).

Table 1.The Twenty-one Areas ofDifficulty Screened by a Symptom Inventory

1.Eating 11. Overactivity 2. Sleeping 12. Crying 3. Digestion 13. Sex 4. Getting along with children,withdrawn 14. Daydreaming 5. Getting along withchildren, acting out 15. Temper tantrums 6. Getting along with grownups,withdrawn16. Lying 7. Getting along with grownups,acting out17. Stealing 8. Unusual fears 18. Destructiveness 9. Nervousness 19. Rejection of School 10. Thumbsucking 20. Wetting 21. Speech

Sample Inventory Question "Does Johnny have any trouble gettingalong with other children?" A. "How often does he have thistrouble?" B. "How long has he had thistrouble?" C. "How serious is it?"

If a mother agreed that the childexhibited a particular symptom, she was askedabout its duration, severity, andfrequency. A number of interesting findings developed outof this symptom inquiry. The first wasthe question of the reliability ofthe mother's reporting. To determinethis, a subsample of 18,i mothers, who hadhad no contact with mental health resources during the intervening year, wasdrawn from the large sample that had re- I

NEW APPROACHES IN THESCHOOLS 298 sponded to the questionnairetwice in successive years.It was found that 30% the second interview of the symptoms reportedthe first year were denied in as having everoccurred. The mother's reportsabout her child's symptoms this special subsample(i.e., wereabout 70% reliable from year to year on approximately 70% of the symptomsreported in a given year are again reported the following year). On the large school sampleof 830 white third-gradechildren, most mothers reported some symptoms.There was a regularrelationship between of adjustment the number of symptomsreported by the mother and the rating given by the teacher. Thechildren rated best adjustedaveraged 1.7 symptoms, and those rated as needingclinical help were reportedby their mothers as having three or more symptoms.There was no difference innumbers of difference symptoms reportedfor boys or girls, andthere was no social class in symptom reportingby mothers. In the large sample, containing veryfew seriously disturbedchildren, there was no increased differentiatingeffect found by using data reporting frequency, severity, andduration of the symptoms. Inthe small sample (in frequency, severity, which about one-third weredisturbed clinic children) the and duration did increasethe sensitivity. The mothersof these disturbed clinic children reported an averageof six symptoms. In the small pilot study itappeared that the symptomscorrelating best "trouble getting along with with disturbance forboys were "sleeping trouble," while for girls other children," "nervousness,""unusual fears," and "stealing," going to school" seemed "sleeping trouble," "lying,"and "making a fuss about school sample these findingsdis- to differentiatebest. However, in the large appeared, and the symptomthat was most significantfor both boys and girls well with the was"trouble getting alongwith other children." This agrees schoolmates' ability to selectdis- sociometric findingsthat demonstrated the turbed children with a highdegree of reliability. be used with As a screening tool, themothers' reports of symptoms can medical screening device about 70% efficiency, whichis about as good as any (Glidewell, Domke, & Kantor,1963). The extent of the agreementbetween adjustment of the chil- mothers' reports of symptomsand teachers' ratings of dren tends to increase as one goes upthe social scale from lowerclass to upper class. It is well known thatteachers' reports of the levelof adjustment of differences in children shows a social classbias. There were no significant the several numbers or types of symptomsrepord by mothers representing socioeconomic strata. Theteachers, nowever, in theirratings of levels of childrens' adjustment saw asignificantly greater prevalenceof disturbance in middle-class children. It was the upper- and lower-classchildren than in the with the teachers found that upper-classmothers show a tendency to agree actual fact, in the about the emotional adjustmentof their children. As an school, and therefore St. Louis area upper-classchildren tend to be in private 299 THE ST. LOUIS SCHOOLMENTAL HEALTH PROJECT the ones that appear withtheir mothers in this sample frompublic schools are probably nottypical. Lower-class mothers lessoften agree with teachers about disturbance in theirchildren. Middle-class children in ourmiddle-class society probably showsimilar behavior at home and atschool, and mothers and teachers tend tohave similar attitudes toward theirbehavior. Therefore these mothers andteachers tend to agree aboutthe children. Lower-class mothersreported more than the well- averagenumber of symptoms for thetotal group of children rated adjusted by the teacher, andfewer symptoms for children rated asdisturbed. Therefore in the lower classesthere was least correlation betweenthe num- adjustment. This is ber of symptoms reportedand the teachers' ratings of just another item in theenlarging body of evidence indicatingthe difficulty is not to be of really understandinglower-class phenomena. Communication taken for granted, and it isparticularly difficult to know justwhere and when it has failed.

Findings Related to Sociometrics The children were given asheet with all the names of thepupils on it, in their correct seatingposition. They were asked tomake six sets of judgments about theirclassmates. These were to identifywhich child they liked best, and which child theyliked most to play with. Thenthey were asked which child they did not like,and which child they did notlike to play with. Further they were asked whichchild asks them most often todo things they ask them to do do not want to do, andcorrespondingly, which child does not things they do not want to do.The last two questions were toelicit demand- ingness or bossiness.Analyses of these data showedthe children's choices of each other remarkably in agreementwith their parents' and theirteachers' with opinions (Mensh & Glidewell,1958).The results correlated positively findings in the mothers' symptom reportsand the teachers' ratings. Inthe professional staff of the pilot study, where thechildren were rated by the child guidance clinic aswell as by mothers andteachers, the children's related to these choices of each other werefound to be also significantly confirmed these workers' opinions. Sociometricanalyses of the large sample ratings of children's ad- findings. The averagecorrelation between teachers' justments in the largesample and sociometrics was.35.

Findings Related to MaternalAttitudes In the study of maternalattitudes, two approaches weredeveloped questionnaire (Gildea et al., 1960; Glidewell,1961).The first was a 17-item mothers, 80 stimulated by Shoben's(1949)work. In the pilot study of 126 items were submitted,but only 13 of them showed asignificant relationship determined by professional to emotionaldisturbance in these children as SCHOOLS 300 NEW APPROACHES IN THE personnel (social workers, psychiatrists,and psychologists). Three moreof the items showed a positive trend, and one(whether mothers thought they had more fun than children) wasadded. Thus, 17 items were compiledfor the final test form. These arepresented in Table 2.

Table 2.Maternal Attitudes Scales

TEST ITEMS CONTENT AREA

1.Problems in children come out of trouble inside the family. Responsibility 2. Children have more fun than grownups do. Unclassified 3.It is hard to know when to make a ruleand stick by it. Discipline 4. Jealousy is just a sign of selfishness inchildren. Rejection 5.School is a hard place for children to get along in. Unclassified 6.Parents who are strict with their childrenknow ahead of time what their children will do andwhat they won't do. Discipline 7.It is hard to know what healthy sex ideas are. Uncertainty 8. When neighbors or teachers complainabout the behavior of a child, this shows that the parentshaven't done a good job. Responsibility 9.It is hard to know what to do when achild is afraid of something that won't hurt him. Unclassified 10.It is hard to know what healthy sexplay is. Uncertainty 11. Children don't try to understandtheir parents. Rejection 12. No matter what parents try todo, there are children who don't change at all in the way theybehave. Responsibility 13. The most important thing childrenshould learn is obedience to their parents. Discipline 14.It is hard to know when to let boysand girls play together where they can't be seen. Uncertainty 15. When they can't have their own way,children try to get around the parents someother way. Rejection 16.It is hard to know when I am forcing mychild to be different from other children. Discipline 17. Children should not bother their parentswith petty problems. Rejection

Contrary to the findings in the mothers' reportingof symptoms (in which there was 30% unreliability in their reporting),there was found here a high degree of stability of responses in the totalsample. Answers repeated three times in 21/2 years were highly consistent.The stability of these responses wassocial-class related; the higher thesocial class of the respondent, the more consistent wereher responses. THE ST. LOUIS SCHOOL MENTAL HEALTH PROJECT 301 It was found that most of the 17 items were significantly related tosocial class. Generally, the higher social class mother tended to disagree with any statement. This might be interpreted as personalrejection of the interviewers, most of whom were youngishmiddle-class women. This possible reason for the finding was not tested, but the finding itself indicates thatupper-class mothers are probably not as accepting of mental health programs asmiddle- class ones are. The higher the social class of the mother, the greater is her tendency to believe that grownups have more fun than children do. Conversely, the lower the social class, the more strongly the mother feels that the childrenhave more fun. There were six items grouped as "hard to know" (3, 7, 9, 10, 14, 16). These items stated that it is "hard to know" how to deal with sex anddis- cipline and other problems of raising children. Significant social class differences appeared in four of these (3, 7, 10, 14). The higher the socialclass of the mother, the more likely she is to believe that it is nothard to know what to do about child behavior. None of the 17-attitude items correlated significantly with theteachers' ratings of the children's adjustment. When social class effects wereremoved, there were also no significant findings. Some of the attitude items were more likely thanothers to relate significantly to disturbance as measured by the mother's reportsof her child's symptoms. All four of the discipline items(3, 6, 13, 16) and two of the sex items (7, 10) were significant in this respect.Only one of four "rejection" items (15) and one of four "responsibility" items(1) were significant. In five of the six "hard to know" items (3, 7, 9, 10, 16)there were significant relationships found also. In general it was found that favorable adjustment of the child was related to the mother's having a certain flexibility with regard todiscipline, being sure how she was going to act in various situations, and accepting the child. The mothers who reported a high number of symptoms in the children did not see themselves as involved in the child's problems. They were anxious and uncertain about how they should act in regard to the various issues in bringing up children, and they rejected the chili. Of the three factors emerging from the factor analysis of the 17-item attitude scale, only the first was clearly identifiable. This was the one containing all six of the "hard to know" questions, and it appeared quite definitely to represent an "uncertainty" factor. None of the three factors correlated with emotional adjustment of the children, as measured by either teachers' ratings or mothers' reports of symptoms. The professional staff agreed that the mothers' sense of responsibility for the children's welfare and adjustment was a most important element in the child's development. The clinical staff, especially, felt that a strong sense of responsibility for the child on the part of the mother correlated with good 302 NEW APPROACHES IN THE SCHOOLS adjustment in the child. The work in the city schools seemed to have demonstrated this. In the pilot study it appeared that the mother's recognition that one or more clear causes of the problem wasrelated to her concept of her responsibility, and her feeling that she was capable of doing something about itthat is, her potency in this regard. Therefore an open-ended questionnaire was developed investigating the mother's opinions aboutthe cause of the symptom, whether or not she felt herself to be involved, what if anything she expected to do about it, and whether or not she expected to be successful. In collecting these data the mother was asked, "What worries you most about your child?" "How do you think it is going to come out?" "What caused it?" "Are you planning to do anything about it?" and "Do you expect to be successful in dealing with the problem?" It was found that the lowest disturbance rate (as reported by teachers) occurred in the group of mothers who said they had no worries about their children. Teachers' ratings agreed that these mothers actually had nothing to worry about, in four out of five cases. Forthose mothers who admitted some worry, the lowest disturbance rate (19%) was found in thechildren of mothers who thought the problem had several different causes, who felt that they were responsible in part at least, and who were able to do something about it. The sickest children were those of mothers who thought there were several reasons for the problem, but who thought they were not responsible for it and were unable to do anything about it. Fifty-four and five tenths per cent of these mothers' children were disturbed. In summary, the 17-item questionnaire related more to social class than to adjustment of children, but the open-ended questionnairerelated more to adjustment than to social class, although there were social class findings here too: the lower-class mothers felt lessresponsible and more helpless, and they projected blame more. They tended to be more paranoid. When upper-class mothers had disturbed children, they tended to feel responsible but impotent, that is, depressed.

Experimental Design The problem of setting up an experimental design that would produce data on the effects of the two mental health programs together and separately, using suitable controls in order to eliminate extraneous influences, has been reported in detail (Glidewell et al., 1957). The basic problem was to compare the effects of three levels of operationof the school-centered mental health programs in St. Louis County: 1. A combined operation, school-centered mental health services offered by the professional worker of the health department plus the educational program offered by volunteers of the St. Louis Mental Health Association. 2. The volunteer education program alone, and 3. The controls, involving no mental health services. 303 THE ST. LOUIS SCHOOLMENTAL HEALTH PROJECT to In order to deal with thethree levels of programs it was necessary experimental units in organize the sample into groupsof three homogeneous the same school. An attempt todo this failed even for schoolsin the same geographical areas, since nonehad more than two third grades.Therefore, classrooms were selected asthe most workable experiment units.For purposes of this research pupils in asingle school were assigned atrandom to each desired homogeneity for of two third-gradeclassrooms. This resulted in the third-grade class- the two classrooms. Becausethere were generally only two create a design per- rooms in eachschool, however, it became necessary to only two at a time. An mitting the assignment ofthree levels of the program, incomplete block design was selected inorder to separate theeffects of the programs fromthe effects of extraneousvariables.

Change Data The 17-item attitude questionnaire wasadministered to the uothers also once a year,making a total of three administrationsin all. Teachers were asked to rate the children annuallythree times. Each year adifferent teacher rated each child, as thechildren moved through third,fourth, and fifth grades, while the mothers forthe most part remained the same. There was no evidence thatthere was any difference ineffect of the volunteer education programalone or in combination with theprofessional school-centered program; but asdescribed in Section I, both p_ograms were less intense than originallyplanned or predicted. Over the three-year period theteachers' ratings indicated thatthey thought the children got worse, inboth experimental and controlclassrooms, but more markedly in theexperimental ones. Looked atfrom one point of view, this can be considered arather favorable finding. Itwould seem to indicate that all the teachers werebecoming more sensitive to theemotional adjustment of their children and so werereporting more evidence ofdis- turbance. The ones who had some exposure tothe school mental health program, however,moved farther in the directionof recognizing emotional ill health than the controls. The mothers, on the other hand,thought all the children gotbetter; and there was no important differencebetween the experimental andcontrol the schools. During the first andsecond years, in each interview response, in mothers reported a reduction of symptomsin their children. This was true the second interval between tests, aswell as in the first. This is someevidence that the symptom reduction is not aninterview error caused by themother's recognizing that the interviewwould be shorter if she denied symptoms. There was a social class findinghere, too. Although childrenof all classes showed some diminution insymptomatology, middle-class childrenseemed children. These findings are to lose more symptomsfaster than lower-class statistically significant. Thisloss of symptoms probably representssuccessful socialization of most childrenduring the early school years, theprepubertal 304 NEW APPROACHES IN THE SCHOOLS period. It is to be expected that middle-class children would be the most successful in this regard. So far as changes in attitudes were concerned, taken overall, using the final or basic sample, there was no difference between the experimental and control groups in either measure of attitudes. The responses to the 17 items remained substantially unchanged. The attitudes measured by the open- ended questions, however, showed movement in the direction of the mothers' generally accepting more responsibility for their children's behavior and acquiring a greater sense of potency in coping with it; in other words, the mothers here showed a general improvement in attitude, in both experimental and control groups. This may reflect tne generally beneficial effect of the questionnaire itself, administered three times by sympathetic women, or a general trend toward the acceptance of mental health educadon brought about by communication media in these years. Although there was still no difference over the 21/2-year period in the experimental and control groups, there was a small positive correlation between change in the mothers' reports of symptoms and change in their attitudes; that is, the mothers thought the children got better, and the examiners thought the mothers' attitudes improved.

COMMENT

1. The success or failure of community mental health services seems to hinge on a number of factors that have been vaguely apprehended, but not too clearly defined. There is a positive element that has to do with enthusiasm, both for the giving of services and the receiving of them. For instance, skilled workers who fr.... anenthusiastic supporting board raising money for them can go into positively accepting schools and do an inspiring job with the problems of children and their parents. If there is any faltering of positive support, or especially any resistance or resentment in the recipient group, the job becomes infinitely more difficult. 2. There is an increasing body of direct and indirect evidence that mental health services have great difficulty surmounting the barriers set up by class distinctions. 3. The amount of time the worker has available to spend in the school is an important factor determining success or failure. In this study the most successful workers in group therapy spent one-fourth time in schools of 500 children; this was the maximum saturation available. 4. Continued strong leadership and close supervision are very important. For the best results, clinical and ancillary services should be available for easy referral. Thus the backlog of very difficult cases can be readily dealt with and more preventive and educational activities pursued. 5. In this kind of large-scale evaluative research project it is difficult to 305 HEALTH PROJECT THE ST. LOUISSCHOOL MENT4L period identicalwith those ineffect maintain servicesthroughout the study much more timeand money the project wasdeveloped. It takes at the time and it is difficult tokeep to do thiskind of study than isgenerally predicted, together as theanalyses and reporting the same service orresearch teams drag out. screening devices are necessaryto select70% of the 6. No elaborate Teachers can do italone. A emotionally disturbedchildren for special care. teachers can select 90%. clinic team plus mothers who down the socialscale, one increasingly sees 7. As one goes and somewhat para- tend to feel impotent, toproject more, tofeel uncertain workers and clientsbecome noid. Language andcommunication between moredifficult. with questionnaire 8. In the upperclasses, motherstend to disagree feel responsibleand impotent, i.e., items. If they haveproblem children they depressed. and projection ofblame are the 9. A feeling ofhelplessness, impotence, unfavorable to theiryoungsters' mental attitudes in motherswhich are most health. reported by themother, 10. The mostimportant individual symptom, is "trouble gettingalong for distinguishing anemotionally disturbed youngster with other children,"social maladjustment. losing symptoms asthey become better 11. Mothers seetheir children as socially adapted at ageseight, nine, and ten. mental health programtend to see 12. Teacherswho are exposed to a during the sameperiod. moredisturbance in the youngsters behavior improvedslightly over the 13. Maternalattitudes toward child specific mental health program. 21/2-year period,but not in relation to any

REFERENCES

of emotionallydisturbed children. Amster, F., Collectivepsychotherapy of mothers 1944, 14, 44-52. Amer. J. Orthopsychiat., Ill.: Charles C Thomas, Gildea, M. C.-L.,Community mentalhealth. Springfield, 1959. Kantor, M. B. Twoapproaches to the study Gildea, M. C.-L.,Glidewell, J. C., & Psychiat. Res. Rep., 1960,13, 182-206. of maternal attitudes. behavior. Springfield,Ill.: Glidewell, J. C.(Ed.), Parentalattitudes and child Charles C Thomas,1961. Kantor, M. B.Screening in schoolsfor Glidewell, J. C.,Domke, H. R., & of symptoms. J.Educ. Research, behavior disorders:Use of mothers' reports 1963, 56, 508-515. Domke, H. R., &Kantor, M. B. Behavior Glidewell, J. C.,Gildea, M. C.-L., 306 NEW APPROACHES IN THE SCHOOLS symptoms in children andadjustment in public school. Hum. Org.,1959, 18, 123-130. Glidewell, J. C., Mensh, I. N., Domke, H. R., Gildea,M. C.-L., & Buchmueller, A. D. Methods for community mental healthresearch. Amer. J. Orthopsy- chiat., 1957, 27, 38-54. Glidewell, J. C., Mensh, I. N., & Gildea, M. C.-L.,Behavior symptoms in children and degree of sickness. Amer. J.Psychiat., 1957, 114, 47-53. Mensh, I. N., & Glidewell, J. C. Children's perceptionsof relationships among their family and friends. J. exp. Educ., 1958, 27,65-71. Mensh, I. N., Kantor, M. B., Domke, H. R.,Gildea, M. C.-L., & Glidewell, J. C. Children's behavior symptoms and theirrelationships to school adjustment, sex and socialclass. J. soc. Issues, 1959, 15, 8-15. Shoben, E. J., Jr. The assessment ofparental attitudes in relation to child adjustment. Genet. Psycho!.Monogr., 1949, 39, 101-148. Slavson, S. R. An introduction to grouptherapy. New York: Commonwealth Fund, 1943. 17 SOME STRATEGIESIN MENTAL HEALTH CONSULTATION: A BRIEFDESCRIPTION OF A PROJECTAND SOME PRELIMINARY RESULTS' lra lscoe, JohnPierce-Jones, S. ThomasFriedman, and Loyce McGehearty The University of Texas

INTRODUCTION

As the title of this book implies, emergentapproaches to mental health are related to emergent problemsof mental health. There was a time, not too far in the past,when early case finding anddiagnosis were looked upon as thebest approach to preventive mentalhealth. Although this concept still has value, we are facedwith the realities of mentalhealth manpower shortages and the urgent need to experimentin the developmentof innovative techniques at all levelsof prevention. Primary preventionimplies creating conditions whereby moreeffective coping with the stresses ofproblems of living will presumably result inbetter mental health. It is aprobabilistic approach rather than an absolute one.It recognizes, or at leastshould recognize, that there will alwaysbe problems of mental healthand that the fostering of "constructive coping"will allow children, their parents,and their teach- " The project described in thischapter is supported by theInterprofessional Re- search Commission on Pupil PersonnelServices (IRCOPPS) from a grantfrom the National Institute of Mental Health(MH1428). The University of TexasPersonnel Services Research Center, John Pierce-Jones,Director, Ira Iscoe, AssociateDirector, Coordinator of S. Thomas Friedman, ResearchCoordinator, and Loyce McGehearty, Consultants, was set up as one of four centersfunded by IRCOPPS in 1963. Theaim of the Commission is "to promote moreeffective pupil personnel servicesby providing through research a body of knowledgethat will increase the effectivenessof all those collaborating to provide the total schoollearning experience; demonstratingdifferent best for various kinds of pupil services programs inorder to determine those that are research on preventive sizes and types of communities;and conducting and stimulating mental hygiene in an effort to fosterdesirable pupil growth." The University of Texas project isfunded to October 31, 1967, being afour-year project. Besides the project described inthis chapter, the PersonnelServices Research Center is conducting research inother areas concerned withstudents and school personnel. i 307 308 NEW APPROACHES IN THE SCHOOLS ers to deal more effectively with "problems of living" as these arise in everyday life. The complexity of human behavior and the multicausal nature of mental illness would seem to mitigate against total prevention of emotional disturbance; nor, perhaps, would it be desirable to have within our grasp the means to produce such serenity or even apathy. The decreased incidence of tuberculosis was primarily due to the general improvement of living and working conditions rather than to the development of new methods of treatment of the disease itself. The necessary condition for tuberculosis, a specific bacterium, is endemic in the population. The sufficient condition for tuberculosis is a weakening of the body's ability to cope. Raising the general health of the populace has resulted in better resistance and a consequent reduction of tuberculosis. In a similar vein, anxiety and stress will always be with us. How these are handled is more important than their presence or absence. During the school years a wide spectrum of behavior is displayed by children. This behavior is frequently classified according to the value system of the teacher. Some of it is labeled "bad," some of it "good," and a healthy residue is variously interpreted or ignored. There has been much written on how the school can serve to "screen out" children who need "help." But not much has been written on what would really happen if teachers were truly as sensitive to the indications of developing emotional problems as psychologists would wish them to be. How would these identified cases be treated? By conventional methods? Already child guidance centers, the supposed bastions of secondary prevention, are handicapped by long waiting lists which, although testifying to the existing need, also point to a technological lag in the rendering of effective services. In fact, the general record of success of our traditional approaches in child guidance clinics is only fair. Clearly, then, some new strategies are called for, especially if we are to make progress in true preventive approaches. This does not mean that the child as a child or an adult will not experience anxiety,frustration, and the like. It does imply that within the school system the child will have a heightened probability of being dealt with by persons who can place his problems in perspective and can deal with them in more effective ways than at present. Referral for treatment does not result in the child's being "dumped." He still remains a pupil in a class or a school and is dealt with by increasingly sophisticated teachers.

INFLUENCE OF TECHNOLOGICAL CHANGE

It has been said that more knowledge has been created in the last fifty years than since the dawn of recorded history and that we are just at the threshold of this geometric increase. Technological advances have resulted in a higher standard of living for most of our population. However, our CONSULTATION 309 SOME STRATEGIESIN MENTAL HEALTH that, while on increasing awarenessof the culturallydeprived underscores are stillconfronted with the whole Americahas grown more prosperous, we cumulative deficits in some areasof our educationalsystem. the dilemma of programs In order to rectifythis lamentable stateof affairs some innovative faced with theproblem of have already beenlaunched. Our society is now health and ofdeveloping an edu- laying the foundationsfor positive mental in a technological cational system that equipschildren both for participation potential as humanbeings. How the world and for fullerutilization of their will affect children technology and the new conceptsof space and time new will the child of only be imagined.How, for example, of the future can What changes in a world that willdouble in population? tomorrow function What living habits, and invalue orientationswill take place? in sex mores, in for certain, but it isclear will be the psychologicalstresses? No one can say between the educationalsystem that there may be anincreased cultural lag fully able to comprehendthe rapidly and the child, unlessthe system is more and methods ofcoping. changing world of thechild, his needs, stresses,

THE SCHOOL AS ACOMPETENT INSTITUTION primary orientation Schools have changedrapidly from their former that learning has an emo- tofundamentals. There is anincreasing awareness recognition thatclassrooms, tional component; andthere is at least a tacit their ability to meet theemotional schools, and evenschool systems differ in With the advent ofautomated devices of various sorts needs of children. and more in those areas the teacher will becalled upon to perform more machine. One of thesewould appear to bethe where she is superior to a implication here is that a human relationshipsand sensitivity. The area of able to cope effec- competent schoolbuilds up a repertoireof resources better that arise in theclassroom, on theplayground, or in tively with the problems of of the faculty. Itfurther implies theincreased secularization a meeting be a tremendous mental health. Ateacher, with a littlehelp, can or should She does not have to act as apsychothera- resource to achild with a problem. competent teacher. pist or a psychologist.She merely acts as a more health and with theavowed With the increasingsecularization of mental what contributions tothe and serious mentalhealth manpower shortage, health specialists? Tradi- school or the classroom maybe made by mental of children withproblems and tional approachesinvolve the identification enough" to warrantpsychi- some sortof a decision as towhether "it is serious help. In this approachthe psychologisttraditionally has atric or psychological the principal been the seer who,by virtue of his tests,tells the teacher or demean this process,and something about thechild. Without wishing to we mustadmit that giving readily acknowledgingits necessity in many cases, relieve the teacher's anxietyand the child a test manytimes serves largely to NEW APPROACHESIN THE SCHOOLS 310 something for the child.It is stands as objective proofthat the teacher did behavior or school failure also a call for help and a wayof bringing disruptive Other traditionalapproaches to the attentionof the school administration. geared to let the teacher,the principal, and,indeed, the school are equally relationship is one in system "offthe hook." If the mentalhealth consultation of a case andacknowledges which a psychiatrist orpsychologist takes charge school or the teacher except the need for the referral,little is learned by the the only way to dealwith that referral to a mentalhealth specialist is perhaps disruptive behavior oremotional problems ingeneral. of learning, would seem Advances in tducation,especially in the process the notion that learning is notentirely an intellectual process. to support believe it is, then There is a large emotional component.If this is so, and we teach- there may come a time (orperhaps the time hasalready arrived) when and processes that be more concerned withemotional preconditions ers will than with crises of interfere with full learningand human development in the classroom. human adjustment which maysuddenly become manifest gradual turning awayfrom Not that the two are clearlyseparated but, in the of the teacher pathology to areas of positivemental health, the ability areas of in addi- and the school system to encouragelearning, inquiry, and creativity stressed. The tion to the acquisitionof factual knowledgewill be increasingly strategy that this suggestsis to considermental health consultation as an the skills of the teacher aspect of in-serviceeducation designed to improve her use of the resources in relevant areas.More subtly, it seeks to encourage within the school and to supportthe development ofneeded resources should need not be of thetraditional they be insufficient orabsent. These resources psychologist to per- variety. Indeed, theaddition of another psychiatrist or of the creative form traditional functions mayimpede optimal utilization potential of the teacher orof the entire school systemin dealing effectively with the everyday problems with mental healthproblems (or, more broadly, of living as they aremanifested in a classroom or onthe playground). teachers can, with a little The implication isthat care-givers such as to help, deal with an increased spectrumof problems. There is no attempt social workers. Like- phase out the services ofpsychiatrists, psychologists, and already functioning, is wise the contributionof pupil personnel services, about respected and, indeed,welcomed. The issue issimply one of bringing that are already thereand of a moreeffective utilization of the resources health workers and increasing communicationbetween professional mental deployment of scarce resourcessuch as psychiatrists the schools. The strategic teacher and as a dictates a change in role. Theteacher is respected as a that human being. When sheasks for help, there isthe implicit recognition worked or that some underly- her usual approaches tothe problem have not effectively ing factor or factors areoperative whichhandicap her in dealing "free her up" the mental with the presentingproblem. In attempting to health consultant, in theapproach we have adopted,in essence "lives the 311 SOME STRATEGIES INMENTAL HEALTH CONSULTATION problem" along with the teacher.He explores alternatives, he attemptsclari- fication, and all the while,he asks himself what is preventingthe teacher from taking a certain courseof action or why has the teachertaken a particular approach to theproblem. The reader will recognizethat this orientation is essentiallythe one advocated by Caplan (1956,1959, 1963, 1964). With somemodifications this has governed the approach toschool personnel in the projectreported here. We turn now to adescription of that research. The intentionis to give the reader a broad view of its purposesrather than a detailed description.An orientation to the schedule maybe of assistance.

October, 1963-August, 1964Staffproject, construct instruments,train consultants, make arrangementsfor test batteries to beadministered, general planning. September-October, 1964Test batteries toall personnel in twenty-eight schools. October, 1964Begin consultation service. April, 1965Readminister someselected scales, evaluate some aspects of program. Fall, 1966Readminister selectedinstruments, pick up fallbattery on new personnel. Spring, 1966Administer instruments,evaluate consultation service via interviews. Fall, 1966November, 1968Analyzedata, write up project.

THE PROJECT

COOPERATION OF THESCHOOLS

Working with one or twoschools in a system is the usualprocedure in mental health consultationresearch or demonstration projects.Difficulties in this way of proceeding arecompounded when the researchinvolves a prolonged association (two years)with two school systems(Northeast Inde- pendent School System, SanAntonio, and Austin IndependentSchool Dis- trict) and where the type ofservice is noveland, therefore, potentially threatening. Sixteen schools in theNortheast District (eightexperimental and six and eight control) and twelveschools in Austin (six experimental control) are involved. A further complication isthat school superintendentsrealistically ask what their systems are going to get outof participation in the project.Even chosen. In if they are satisfied, school principalsoften ask why they have been addition, there is the understandabledifficulty of asking the entirepersonnel rather lengthy batteries in fourteen controlschools to submit themselves to SCHOOLS 312 NEW APPROACHES IN THE of tests. Finally, even if the superintendentsand principals are agreed,how about the teachers? Without going into all the details,suffice it to say that acceptance of the project by the superintendents ofthe school systems was the first step. ,4 Extensive meetings were held with theprincipals of the schools concerned (both experimental and control).Sometime later a meeting was heldwith all the teachers in those schools,during which the Director, theAssociate Director, the Director of Research, and the projectCoordinator gave individual presentations. These were held inApril, 1964. The purpose ofthe research was explained, the various organizationssupporting IRCOPPS were mentioned, and the role of the various staffmembers was described. It was emphasized that the purpose of the study was toevaluate the effectiveness of a particular kind of pupil serviceworker called a Child BehaviorCon- sultant (CBC). The reactions of the teachers tothese services were to provide the project with data for determining theusefulness of this type of consulting function. The purpose of the consultation service was toenable the teacher to utilize her ability as ateacher to the fullest degree. The belief was expressed that often a little work early in achild's schooling could help him to cope and to learn moreeffectively than could much more work later on. The means for selecting elementary schools werestressed. No pretense was made of having all the answers, but the belief was putforth that effective consultation could resolve some of the problemsof children. The whole- hearted involvement and cooperation of theteachers was solicited. They, in turn, were assured that allinformation would be handled confidentially,that neither the school administration nor theconsultants would have access to the data gathered from them. Thus, thedata would remain anonymous as far as the teachers as individuals wereconcerned. The reason for the control schools was explained: only in this way couldthe impact of consultation be assessed. The control schools were vital tothe project even if they did not get any direct servicesfrom the consultants. Some further description of the schools involved inthe study would be helpful. The Northeast Independent SchoolDistrict is separate from the San Antonio school system, although located inthe same city. Northeast is a relatively prosperousdistrict with at least two schoolshaving Mexican American populations and a lesser percentage ofNegroes. The San Antonio area itself possesses aconcentration of MexicanAmericanswell in excess of the 12%-15% found in the Texas population as awhole. One experimental and one control school, both with aboutequal MexicanAmerican student populations, were included in our study. Theother schools in the study ranged from lower middle-class to uppermiddle-class status, and each of these was matched by acontrol school of comparable status. In the Austin Independent SchoolDistrict a more heterogenous distribution of schools was available. TwoNegro schools were included in the be characterized as being mainly corn- study. One of these schools could best ,

_ SOME STRATEGIES IN MENTAL HEALTHCONSULTATION 313 , posed of children whose families weremembers of the "rising" middleclass. The other Negro school was less affluentand more in the commonly perceived mold of Negro schools both inthe South and in the North.For example, the orientation of the "rising"middle class school (and its control) was moretoward achievement and middle-classvalues. In contrast, the principal of the less affluent Negro school spent moreof his time on matters of subsistence, such as money forlunch and clothing, and dealing withthe social pathology found in schoolswhere there is a high degree offamily breakup, working mothers, and low incomes.For this latter school a control was easilylocated. A MexicanAmerican school wasincluded (plus its control). Primarily staffed byAnglo teachers, the reading level of mostof the students is retarded, and attendance atPTA meetings is poor. The predominantly MexicanAmerican studentpopulation is handicapped by having to learn English as a second language,by the low income of their parents,and by an unfortunately high degreeof alienation of both the children andtheir parents from the school.A lower-class school and its control werein a mixed area composedof roughly 50% MexicanAmericansand 50% Anglos with a small sprinkling of Negroes. The twoother schools, bringing the total to six, were selected asrepresenting a typical middle-class,somewhat suburban school, and a lower-class, largelywhite Anglo student population. 1 Despite the need for repeatedadministration of some of the test instruments, the generallevel of cooperation was excellent.We were especially fortunate in having been able tocapitalize on previous good relationships with the two school systemsinvolved. The Northeast School Districtand the Austin School Districtboth cooperated at a level and extentthat was exemplary.2 It would be an act ofdenial to report that "bursts of static" did not arise during the courseof the program. These were mostprevalent when retesting times came around(Spring, 1965; Fall, 1965; Spring,1966). These bursts were not widespread; theyusually originated from one or twoschools, experimental or control. What sparked thereactions is not entirely clear. With regard to the experimentalschools one clear factor emergedthebetter the relationship between consultantand principal, the less the staticand the more promptthe completion of the test instruments.We also found that the control schools could not be ignored.The principals and teachers had tobe contacted carefully before eachreadministration and their cooperation solicited.3

2 Our appreciation is extended to Dr.Virgil Blossom, Superintendent of theNorth- east School District, and toDr. Irby Carruth, Superintendentof the Austin School District, in this regard. 3 The untimely death of Dr.Blossom was indeed a loss to progressiveand fore- sighted education throughout the country.His successor, Mr. Joseph Woods,has continued to provide the Northeast SchoolDistrict with leadership of the highestquality. His cooperation with the program hasinsured its success. Dr. Carruth of the Austin Independent School District is entirely supportiveand has aided materially in the smoothness of data gathering in his school system. THE SCHOOLS 314 NEW APPROACHES IN

TRAINING THE CHILD BEHAVIORCONSULTANTS The provision of mental healthconsultation to public schools isin itself no novelty. There is a reasonablylong history of socialworkers, psychiatrists, and psychologists working more orless collaboratively withpublic schools. Their roles and functionshave varied, depending onthe situation. In some cases the equivalent ofchild guidance clinics havebeen set up within school systems. In others,psychiatric or psychologicalconsultation about individual children orproblems has been available toteachers. The type of consultation has varied from"Expert Advice, Casefinding," to anapproach somewhat similar to what we haveemployed. In setting up the presentproject there was understandable concernabout who was to do the mentalhealth consultation and where we wereto find sufficiently trained personnel. Inthe conceptual scheme,consultation was viewed as the "input" designed toeffect changes that would bereasonable. The adequacy of the "input" wastherefore of vital concern. The answers encompassed by the project were soonforthcoming. In the geographical area (indeed in the whole Southwest)there were few if any personstrained in what is essentially a Caplanianorientation to mental healthconsultation. The what few persons who had this orientation were,of course, not available for amounted to token payment for oneafternoon a week's work, including completion of lengthy forms at theend of each consultationday. Of necessity, then, graduate students inEducational Psychology andPsychology were selected to be trained as consultants.Most of these were enrolledin the School Psychology Training Programin the Department ofEducational Psy- Consultant" chology. All were Ph.D. candidates.The term "Child Behavior 1 Consultant." There were several was chosen inpreference to "Mental Health reasons for this,including some negative connotationsin regard to mental health on the part of someschools and communities andthe thoroughly legitimate claim that the consultantwould be dealing with childbehavior. (Generally this turned out to be true,although the consultant-trainees,when they eventually started work, wezequite amazed at thenumber of adult behavior problems with whichthey had to deal.) How does a project goabout training sufficient personnel toservice fourteen schools on ahalf-a-day-a-week basis? In the Springof 1964, a seminar week on MentalHealth Consultation was set up on a two-to three-hour per basis. Reference works inconsultation were assignedreading, and the first author assumed major responsibilityfor the seminar. Most of thestudents had, by this time in their training,received some theoretical backgroundand practical experience in counseling orpsychotherapy. A fundamental reorientation had to be effected in thestudents' view of being helpful.Their previous training, and indeed, thetraining of most psychologists, was morein line the with the medical model involving one-to-onework with the client. In 315 SOME STRATEGIES INMENTAL HEALTHCONSULTATION interposed orientation employed intheir new type of training someonewas between the child and theconsultant, namely theconsultee, be it school teacher or principal or someother person in contactwith the child. of the trainee In all types of trainingthere is some faith on the part "works." This was not that what he is being taughthas value, that it really Consultant trainees. It was notthat easy toaccomplish with Child Behavior experience for they were particularly resistant,but rather that this was a new techniques of crisis inter- them. Heavy emphasis onthe theory of crisis and students were required to vention helped makethe conversion easier. All read in the area of the crisis concept,using sources such asCaplan (1955, 1961), Miller and Iscoe(1963), Gildea (1959),and Bindman, Helpern, Isaksen, Klein, Rosenblum,and Wolf (1964).There was considerable and understandable debate aboutwhether crisis intervention wasreally anything the view- more thansuperficial treatment. Graduallythe students acquired with point that if a personcould be helped in a crisisand could learn to cope in his quiver. it more effectively,he would at least have one more arrow what There was considerable speculation onthe part of the trainees as to of con- teachers would want to consultabout. Numerous verbatim reports sultation sessions were presented,all with the orientationthat the consultee, facing some sort in asking for theconsultation at this particular time, was ask for a consulta- of crisis. For example, whyshould an experienced teacher the tion on the status of achild's intelligence? Theproblem was not whether teacher could accurately assessthe child's potential(there were, after all, achievement tests and psychometricservices available), but morefundamen- the PTA tally, how could this particularteacher tell the mother, who was president, that the child wasretarded, and not simply aslow learner? Why should a new teacher ask forthe consultant's help indisciplining a third discipline, or was the grader? Was it because shedidn't know how to impose worried about problem, more fundamentally,that as a new teacher, she was being backed up by her principalin a situation where,with justification, she constantly set firmlimits for the child? Whyshould an experienced teachcr consultant? mention "His mother wasin a mental hospital"in speaking to a Did she see signs ofmental illness in thechild's descriptivecfassroom behavior, or was there someother underlying factor? students was how Another area that causedconsiderable concern to the would to impart to theteachers the fact that theChild Behavior Consultant of the not see thechild and would only"see" behavior through the eyes teacher. This role reflects aradical departure fromwhat is learned in traditional training. The questions mostfrequently asked by the trainees were "How can I tell the teacheranything about the childif I don't see him?" and "How can the teacher have aw;confidence in what I say ifshe keeps insisting that I should see the childfor myself?" These wereviewed as entirely reasonable questions, but also asquestions that wereindicative of the mounting pointed out that implicit anxiety of the traineesabout their new role. It was 316 NEW APPROACHES IN THE SCHOOLS in the comultant-consultee relationship is thefaith of the consultant that what the teacher is telling him is the teacher's perception ofthe situation, and that all that he, the trainee, need be concerned with is this perception. When the trainees finally started work in the Fall of1964, the great majority of them reported attempts on the part of theteachers to get them to see a particular child. To their surprisethe great majority of teachers never refused to usethe consultant's service because "he did not see thechild himself." To come to accept this view was part of the in-serviceeducation of the teachers. It carried within it :he implicit assumption that theteacher would take primary responsibility t'or dealing with the child,with the consultant taking on a resource function. There is, oftentimes, a large and unbridged gap betweentheory and practice. Despite a semester's intensive training and afew "dry runs," the trainees approached their initial assignments to thefourteen experimental schools with much trepidation. Added to this was the further stressof having student status, having to prepare for qualifying exams, to writedissertation proposals, and to meet other academic demands. Moreover, there wasthe necessity of each consultant filling out his ConsultantReport Form. This form had to go through several revisions and encountered the usual resistance inherent in a "research plus service" function. In order to reduce anxiety, the trainees were permitted virtually twenty- four hours access to their supervisor, and most of them utilized thisprivilege rather heavily during the first two or three afternoons that they worked.The first full group discussion session after the first week of consultation was not a happy one for mostof the trainees. Some were resentful that they had not been received with open arms. Others were astounded that, in spiteof extensive preparation on the part of the project directors with theteachers and principals, some principals and many teachers asked them "What are youhere for?" or otherwise incorrectly interpreted their functions.One or two were left cooling their heels in the teachers' lounge or in theprincipal's office. All of them had been warned that each school wouldmanipulate them according to its needs.4 Despite these warnings, manipulation wasinterpreted as rejection. One trainee, a female, felt so rejected that she vented profusehostility on the principal and one ofthe teachers. It was difficult to convince trainees that it might be important "to be manipulated" andthat, at the appropriate time, the trainee could control this manipulation.Another trainee consultant, fortunately a mature one, found himself attending a rather stormy meeting in the principal's office, facing two irate parents with theprincipal introducing him as a psychologist who "we have called in in order tohelp us with Jimmy." Students gradually learned that manipulation by principals orteach- ers is an integral aspectof the consultation process and, indeed, is something 4 Gratitude is expressed to Gerald Caplan and Miss CharlotteOwens for pointing out the dynamics of being manipulated. 317 SOME STRATEGIES INMENTAL HEALTHCONSULTATION It was not easy to which could, ultimately,have beneficial consequences. he who ismanipulated have the students accept thedictum that, eventually, control over the becomes vital to themanipulator and thus acquiresmore situation. student acquires rein- In the process of learningabout psychotherapy a along the line. An interpretationis made, thepatient forcement somewhere reinforcement did has some insight, andthe therapist isdelighted. Positive Special pains not take placeimmediately for the ChildBehavior Consultants. about what wouldhappen in the were thereforetaken to make predictions hopes that this mightincrease various cases presentedfor group discussion, in For example, in one casewhere feedback and gratificationfor the trainees. consultant in order to conveyher the teacher was quiteobviously using the that in the next session displeasure with the principal, aprediction was made of the child. Thisprediction the teacher would actuallyfocus on the problem consultant had put intothe interview, was made onthe basis of what the difficult for well-moti- especially his remark that"sometimes it must be very deserve." Another vated teachers not toreceive the supportthey feel they would be left to coolhis heels prediction was made thatthe consultant-trainee and several after that,until some in that particularschool for the next session, prediction, after someprolonged real crisis arose in theschool. True to the enhanced his positionby heel-cooling sessionsduring which the consultant teachers and talking tothem informally in thelounge, the having lunch with for principal greeted him atthe door and said,"We have all been waiting maniac; you have got you. Wehave a serious problemof a child who is a sex from a principalwho had to dosomething." This changeof attitude came there were no problems inhis school. earlier announced that created The locus of occurrenceand time allocatedfor consultations On the basis of prior considerable shock for thefledgling consultant-trainees. isolated one-to-one situations, clinical experience,they were accustomed to duration. Here they had tolearn to talk to teachersin the usually of an hour Thinking on hall or in a lounge, aswell as in the privacyof a separate room. The trainees at firstcomplained one's feet is not taughtin graduate schools. class with a teacher about having to conduct aconsultation while walking to and were unani- standing in the hall. They soonbecame more proficient or and quick thinking mous indeciding that consultationrequired more alertness than did psychotherapy. teachers, most of the After the first half-dozenmeetings with various particular consultants were able tostrengthen theirrelationships with the about doing this inhis schools in which theyworked. Each consultant went supervisors. Some hadlunch with teachers own way,aided by discussion with begin their consultationday by in the cafeteria;others made it a point to established allies amongthe teachers. visiting with theprincipal. Still others ools. The weeklysupervi- Acceptance increasedrather rapidly in mostsch by individual sessionsinvolving sion meeting wasstill being supplemented SCHOOLS 318 NEW APPROACHES IN THE trainees and supervisors. At this pointit became obvious thatthere were important, and sometimeshandicapping, blind spots in someof the trainees. Intensive effort was therefore exerted toloosen them up. For example, one trainee definitely disliked theschool secretary, and their relationshipreached the point where she was doing herbest to sabotage his work.Another, a female, was unconsciously "dumping" mostreferrals by indicating to the teacher that "nothing much could bedone about the case." Despitethese pitfalls and despite some obvious errors onthe part of some of the trainees (and their supervisor), by the Spring of 1965trainees began to reach their full stride as consultants. Eachworked according to his own style of operation. It also became apparent thateach school had its own personality,exemplified most clearly by thebehavior of the principal. The Fall of 1965 marked thesecond year of providing childbehavior consultation to the experimental schools.During the Sprin3 of 1965 some new trainees weretaken on (again from the samesources) in order to replace four of the consultants scheduled forgraduation. Training of the new people was easierbecause of the experience gained withthe first group and, more importantly, because of the supportand informal instruction thatexperienced trainees could provide.Therefore, we approached the Fall of1965 with a more seasoned groupof consultants and with bettertrained novices. ;For one thing it was possible to presenteach trainee with a Handbook forChild Behavior Consultants. This contained someof the materials used in the training sessions 1964-1965, as well as some newmaterials. Further, we had begun to know our schools and couldoffer more direct guidance for avoiding pitfalls. Also; we had survived the year;the school system was used to us, and sufficient positive feeling hadbeen generated in most of the recipientsof consultation so that the consultants' entrée waseasier. In addition to the research reportforms filled out by each consultant, they were, in the final year,required to write a fairly detaileddescription of the school with which theyconsulted. This involved such matters as:How does this school go about solvingcertain problems? How doesthe principal relate to the teachers? How doesthe school relate to the centraladministra- tion? How much do parentscontrol the decisions made bythe school? Infor- mation derived from consultant responsesto these andother questions are presently being analyzed.

INSTRUMENTS A detailed description of the construction,rationale, validation, and factor analytic composition of all theinstruments must of necessity awaitthe final write-up of the project. TheMarch, 1965, and 1966 reports tothe Inter- professional Research Commission go intofurther detail (Pierce-Jones, Fried- man, & Iscoe,1964; Pierce-Jones, 1965; PierceJones, Iscoc, & Friedman, 319 SOME STRATEGIES IN MENTALHEALTH CONSULTATION description of the 1966). In this chapter, wewill limit ourselves to a brief main instrumentsemployed. 1. Dimensions ofTeachers Opinions (DOTO) Form12c. Designed to devised measureteachers' orientation to childbehavior, this 110-item scale was by comparing the responses of alarge sample of elementaryschool teachers to those of 150Fellows of the APA Division ofClinical, Counseling, School and Developmental Psychology.Factor analytic studies have been encouraging and have provided goodevidence that the scale measuresfactors such as Concern for Need to Understand Behavior andEncourage Competence, and five point the Child's Emotional Well-Being.Examples of specific items (on a agree-disagree continuum) follow. a. Hostilitytoward classmates may be a symptomof the child's hostility toward the teacher. b. The slow learner achieves morewhen assigned only taskswhich he can easilyperform. 2. Autobiographical Data(Form 20a). This device coversthe full range of the teachers' life history and presentsituation. It is objectivelyscoreable for all of its 77 items. So far somepromising factors haveemerged that would seem ofrelevance to the use, misuse, or nonuseof the consultation service. For example, FactorVIICommittment to teachingandFactor XAuton- omy withinfamily. 3. Need for AssistanceScale (Form 19a). This contains50 items and is designed to identify the classesof problems which schoolpersonnel need help in managing, plus thestrength of such needs. Therespondent is asked to indicate on a five-point scalethe extent to which he orshe would seek assistance for the behaviordescribed. The range extendsfrom "would seek assistance every time" to"would never seek assistance."Examples of items follow. a. Athird-grade boy has come to classextremely upset several times, and you have heard that hishome life is extremely disruptive. b. The whole class left the roomwhen the bell rang, but before you dismissed them. c. A littlegirl uses some swear words outloud in front of the class. 92-item scale 4. Behavior ClassificationChecklist (Form 11B1). This the classroom and how much it is designed todetermine what a child does in irritates the teacher. Examplesof some of the itemsfollow. a. Cheats on tests. b. Spells poorly. c. Says"Everybody picks on me." d. Asks to do assignmentdifferently than given. Besides eventually providing some sortof hierarchy of problemsfor which teachers need assistance,there is the possibility ofbOng able to sort 320 NEW APPROACHES IN THE SCHOOLS clusters of behavior and to relate these to the problems teachers bring up in consultation as well as to variables obtained from the other instruments. 5. Consultant Report Form (CRF). In the planning phase of the project (October, 1963-September, 1964) much attention was paid to how each consultant would report his contact with his consultee. The possibility of using narrative reports was considered. The decision to construct and utilize an objective reporting device was not an easy one to make, and certainly the form itself was not easy to construct. No doubt some of the poignant aspects of the consultant-consultee interactions were lost to us by deciding to use an objective rather than a narrative approach. However, the benefits, in our opinion, outweighed the liabilities. The need for a standardized method of data-gathering was dictated by the realization of the large number of interviews that would be scheduled and fed into a computer. Additionally, the reliability of raters had to be ascertained. The construction and availability of an objective reporting form allowed the investigators to determine how much agreement there was between two or more consultants judging the same interview with the consultee. During the course of the two-year project arrangements were made for a floating consultant to accompany a regular consultant on his visits and to compare ratings. To be sure, the Consultant Reporting Form forced focusing on selected aspects of the consultation process with the possible loss of other aspects that would have been picked up by other means. All considered, however, the objectivity and susceptibility to quantification supports the use of a report form such as we have employed. Subsequent practice and actual use have brought about even better agreement. Since the CRF was the main instrument linking child-consultee and consultant, its full completion by the consultant was vital and necessitated the consultant's making sure that the child's name was spelled correctly, that the teacher and school were correctly identified, and that other pertinent data were recorded on the form. In subsequent consultations about the same case it was not necessary to gather all the data again. Only the child's and teacher's names were necessary. The form could therefore be completed more rapidly for second and succeeding interviews. The seven-page CRF may be broken down into a number of sections: a. Coordinates: Here are listed the client code (supplied by research section), the status of the consulteei.e., teacher, principal, nurse, etc.and other pertinent variables. b. Client Demography: The usual demographic information including treatment status, Li addition to the specific question: Is this child a problem to teachers as well? (1) No. (2) One other teacher. (3) Several others. (4) Problem to all.It is obvious that we were concerned here with the breadth of impact of a child's problerr on the school. c. Characteristics of the Interview: Here we included location of inter- SOME STRATEGIES IN MENTAL HEALTH CONSULTATION 321 view, such as hall, office, lounge; length of interview; typeof consultation (composition); etc. d. CBCConsultee Interaction: (1) Attitude toward CBCDefensiveness Low 1 23 4 5 6 789High (2) Emotional state of consultee Unemotional 1 23 4 5 6789Emotional (3) Introduces personal material Minimum 1 234 5 678 9 Maximum e. Origins andApproach to Case: Here we included source referral, as well as reason forreferral at the present time. F. Consultee-Client Relationship: Here the consultantcompleted 12 items intended to characterize this relationship. Forexample, Consultee attitude toward client Rejecting 1 234 5 6 789Receptive g. CBC Consultee Assessment:In many ways this section is the most important in the entire form. It calls for the judgment of the consultantabout what is the real problem facing the teacher and for judgments regardingthe appropriateness of the concern expressed by the teacher and the realityof the degree of responsibility which she is assuming for this particular situation. Finally, out of some 100 themes, the consultant had to select mainand secondary ones most likely to characterize the difficulty accurately. Anexample would be: Teacher asking for support of consultant to carry out adecision already arrived at. Role threat to consultee by other teachers,principal, janitor, etc. Teacher is saying "I'm not sure whatthis behavior meansplease help me understand and resolve my own uncertainties." h. Way of Handling Case: How the consultant handledthe problem. What did he say? Here, too, some 100 messages designed todeal with the theme were possible. The consultant did not use a message verbatim,but was required to list the one that best approximated his action. Healso had to state his degree of confidence that an appointmentwould be kept by the consultee, if one were made. To do so accurately presumed that an assessment of the established relationship had been made.

In addition to the five instruments described above, anumber of other instruments were utilized regularly. They were What is anIdeal Pupil (Torrance, 1964); The Child Attitude Survey administered at thebeginning of the study and at the end of the academic year; Assessmentof Consultation Service given to personnel at end of each year; and School andCommunity Survey administered at beginning and end of academic year.The Torrance Scale was included in order to compare the responses ofthe teachers in the present investigation to responses byteachers in other geographical areas and 322 NEW APPROACHES IN THE SCHOOLS to determine whether there is anyrelationship between this test instrument and The Dimension of Teacher Opinions Scale and TheNeed for Assistance Scale. The Child Attitude Survey was used to surveyattitudes of teachers in regard to aspects of child behavior and to determinewhether these attitudes were in any wayrelated to educational and background factors onthe part of teachers and the use of consultation service. TheAssessment of the Con- sultation Service was a questionnaire given to teachers inboth experimental and control schools in order to determine how muchthey knew about the consultation service and how much they thought it hadbeen used. In addition, it was used to determine how using or not usingthe consultation service affected the use of other special services provided bythe schools such as visiting teachers, elementary school counselors,curriculum supervisors, and the like. The School and Community Survey wasincluded in order to determine the teacher's perception of tin interactionbetween her school and the community.

SOME QUESTIONS ASKED The provision of mental health consultation for a two-yearperiod is, in part, designed to produce certain changes in thebehavior of the recipients. Moreover, it provides an opportunityfor gathering data relevant to the consultation process itself. In broad scope there is a belief thatthe changes as measured by the various instruments will reflect movement of therespondents in the direction of increased competence and sophisticationin the handling and understanding of the myriad of problems presented byelementary school children. Even if no significant changes in the predicted direction were to occur on the project evaluationinstruments, significant information could be obtained about various aspects and variables of consultation. Ifconsultation is to be a viable mental health technique,then extensive study is called for. The following will give the reader some feel for the types of questionswhich are susceptible to research inquirywithin the framework of the program that has been described. 1. What kind of children (i.e., sex, age, grade, family size,and type of problem) are the subject of consultation? What kinds of relationships exist among these variables? 2. Are there differences between the schools innumber, type, and severity of problems and in use of consultation services? 3. Do different schools evaluate the consultation servicedifferently? 4. Do experienced teachers utilize the service more orless frequently than inexperienced ones? 5. Do schools with predominantly Negro orMexicanAmerican students make differential use of the service? Do teachers in theseschools bring up different problems than those in predominantly white schools? 323 SOME STRATEGIES INMENTAL HEALTHCONSULTATION the most? How arethese 6. What kinds ofproblems concern teachers background, training, and problems related to variousfactors in the teacher's p test responses? increased coping on the 7. Does frequencyof use of the consultant mean problems over a periodof part of theteacher? Does shebring up different time? Does she persistwith the same ones? consultation services versus 8. What are thecharacteristics of users of schools where when such services areavailable? In comparable nonusers chil- consultation services are notavailable teachers whohave problems with provided by the school system. dren make differential useof other resources in this respect? How do the nonusers ofavailable consultation service compare make use of anyresources? Do they make use ofother services, or do they not personnel, 9. How is childbehavior consultationperceived by school relative to other services? provided fail to meetthe needs 10. Where doesconsultation of the type of the school? Whatsuggestions are there forimprovement? k)btP!'t 1 These are only some ofthe questions possible.Answers can b.. the beginning of theproject by examination ofthe data system set up at progressed. added to as the research task is The richness of thedata plus the magnitudeof the statistical experimental schools (asof amply reflected in thefact that in the fourteen available. 1964) there were 380certified personnel towhom consultation was schools who In addition to this,there were 389 personnel inthe comparison but whose responses tovarious did not actually havethe service available scales and interviews areincluded in the data.

SOME PRELIMINARYFINDINGS still In a project which isboth prolonged andinvolved and which findings has a year to go there is anunderstandable reluctance to state any speculative, and without the usual precautionsabout their being tentative, the annual progress report subject to change. Someresults have been given in Personnel Services to theInterprofessional ResearchCommission on Pupil following pages, some (Pierce-Jones, 1965; Pierce-Jones etal., 1966). In the time are summarized. salient preliminary findingsknown to us at the present

Equivalence of Personnelin Demonstrationand Comparison Schools Results indicate that eitherthrough careful matchingof schools, luck, when random distribution ofteachers, there were nosignificant differences or demonstration versus control the program beganbetween teachers in the Scale (DOTO), nor onthe schools on the Dimensionof Teacher Opinion in that it makespossible Behavior ClassificationChecklist. This is comforting 324 NEW APPROACHES INTHE SCHOOLS a relatively clean test of the effectsof the consultationprogram on the various factors constitutingthesemeasures of teachers.

Extent of Use of CBCs Up to February, 1965, some 600 consultations had beenconducted. Of the 377persons in the demonstration schools who were potentialcon- sultees, some 41% had actually used the CBCone or more times. Therewas some differential use by the school districts. Northeast SchoolDistrict in San Antonio showed 45% of potential consulteesusing the service compared 36.6% in Austin. Whether to this difference willcontinue remains It may reflect to be seen. our somewhat reinforced belief thatcertain minority schools do not group use CBCs the sameway as other schools, both in frequency type of consultation. Although or the schools withpredominantly Mexican American populations in our study haveAngloAmerican principals and teachers. The all-Negro school,by virtue ofyears of segregation, may have built up more resistance to accepting and using outside help than haveschools with predominantly white Angloor MexicanAmerican populations.While it is understandably too early to be definitive, the impressiongained from theconsultants assignedto these schools suggestsmore reserve on thr part of the teachers and principal and more difficulty in gainingacceptance. This, of course, is a two-way street. It may well be that the consultantswere not as comfortable in these schools.Furthermore, it takesa certain amount of rity on the part of secu- a school to refer problemsto a consultant, and therefore only certain types of problems may be brought to the attention ofthe consultant. This limitation couldwell contributeto reductions in the frequency of of the consultants. use In the final analysis ofdata it will be possibleto check carefully on some of these suggested variables andalso to determine whether such factors as male versus female consultant affectedfrequency ofuse and type of referral.

Characteristics of ChildrenConsulted About Sex

Not surprising is the findingthat roughly 70% of thechildren consulted aboutwere boys. Fifty-four per cent of these boys had been subjectsfor consultation fouror more times, while about 44% ofthe girls had this frequency.

Age and Grade

Approximately 56% of thechildren includedin the total have been about nine program years old or younger. While about55% of the children 325 SOME STRATEGIES INMENTAL HEALTHCONSULTATION through three, only 47%of in the overall programhave been in grades one those consulted about have beenin these primary grades.

Degree of Pathology About 34% of the children forwhom there has beenconsultation handicaps. A scale have been judged by theCBCs to have moderate to severe utilized as the developed by Bower (1959)contained in the CRF has been basis for this judgment. TheBower Scale asks that childrenbe rated on a psychotic children to 7-point continuum rangingfrom markedly disturbed two-thirds of the those with normal problemsof everyday living. Roughly children consulted about havehad only minor handicaps(1-3 on Bower Scale as we have used it). Thisfinding may reflect a strong needfor primary preventive work. t,

What Problems Are Presented? I I A rough categorization ofproblems presented to theconsultants indicates that 14% had todo with parent-child relationsand other aspects of the home situation. Forty-five per cent canbe classified as centeredaround con- learn. cern aboutthe child's emotional state,school motivation, or ability to Fifteen per cent focus on theteacher's own professional uncertainty,while and anxieties. About 7% some 14%deal with the consultee's personal concern have to do with variouskinds of role conflicts andinterpersonal relationships. indications of a If personal concern andanxieties plus role conflicts are roughly one in five of our less than smoothlyfunctioning consultee, then consultees was asking for someform of help in the interpersonal areas.This may have someimplication for understandingmental health problems of teachers as these may affectchildren. The addition of the 15%who expressed professional uncertainty producesroughly a third of theconsultees who needed assistance in areas thatcould be closely related totheir own adjustment. This figure,of course, may be inflatedand will be compared to later data, including some breakdown intoexperienced versus relativelyinexperi- enced consultants and theirjudgments. I

Autobiographical Differences An analysis of data on 119teacher-consultees who used theCBCs them at least oncecompared to those not usingthe CBCs' services available to suggests thatcomparatively younger, lessprofessionally experienced teachers from somewhat larger familiestend to use consultation serviceswith significantly greater frequency thantheir contrasting counterparts.They also tend to report poorerpersonal academic records thando nonconsultee teachers. There is, therefore, the suspicion,which must await further data for con-

i 326 NEW APPROACHES IN THE SCHOOLS firmation, that those teachers who use consulting services may be differentiated by a network of factors which make utilization of such service more attractive to them than to nonusers. It will be interesting to compare length of stay in the profession of the users of consultation as compared to nonusers. There are a variety of other findings which are encouraging and which seem to indicate that the CBC service has an impact on the school and, indeed, the system. Several of the principals took it upon themselves to write and express their appreciation for the help provided by the consultants. As an example of the wide range of involvement of consultants, one of these letters was written by a new principal who had the unenviable task of stepping into a school in midyear after the regular principal had been incapacitated. The consultant spent many hours with the new principal, calming his anxieties and acting as a valuable mental health resource. This was a prime example of the application of crisis principles. Although the consultant knew nothing about administrative procedures of the school, his support of the principal, in terms of helping him to recognize that the apparent resentment of the teachers and secretary might actually be a feeling of loyalty to the departed principal, eventually allowed for an effective transition. The principal was not hesitant in expressing his gratitude, claiming that "the consultant had made an extremely important contribution to the entire school." Rather significantly, during the month of crisis the graduate student-consultant was not fully aware of the immensity of the impact he was having. In a similar vein, many consultants have been startled by the expressions of gratitude on the part of teachers and principals. Not all of these expressions clearly define what the consultant did; they are rather confined to such statements as "he helped me so much," or "he told me just what to do and it worked out so well." With direct advice virtually taboo, it seems only reasonable that a subtle type of communication was working (as had been planned) which allowed the teacher to exercise her best judgment after the consultant had helped in clarifying the ,:aiation.

SOME IMPLICATIONS FOR THE FUTURE The provision of mental health consultation services may be viewed as a type of "input." In the present project such services have some uniqueness in that they were provided, in the main, by graduate students on half-a-day basis per week, per school. They were one type among a variety of pupil personnel services provided by the schools. It is our belief that they did not conflict with, but rather complemented, ether existing services. How well the purposes of the program have been accomplished remains to be seen in the final evaluation of our research data, which should be available in the foreseeable future. There is promise of some significant changes as measured by the various instruments we have described. Nonethelei,s, the practical minded CONSULTATION 327 SOME STRATEGIESIN MENTAL HEALTH proof of the psychologist and administrator maylegitimately ask for further value of the service. highly significant level. Suppose that ourhoped-for changes occur at a indeed makes teachers moretoler- Assume that childbehavior consultation better able to deal effec- ant, moresupportive, betterable to use resources, previously were unable tohandle. tively with types ofbehavior which they interesting and cogentrelationships are foundbetween Suppose, further, that data will be and the productilie useof consultants. These certain variables "styles" will be valuable per se; moreoverit is higi4probable that certain teachers. found in the use ofconsultants by schoolsand by individual institution, how well From the point of viewof developing a competent be and how much ofcontinued use of childbehavior consultation will the schools were receiving encouraged by the schools?Recall, if you will, that in both the experimental this service without theexpenditure of funds. True, personnel and requiredthem to and control schoolsthey contributed their However, schools arealways fill out rather lengthyquestionnaires and forms. than money. In terms ofthe in a better position tocontribute seivices rather the salaries of ChildBe- future, how willing wouldthe schools be to pay full or palt-time basis?If the havior Consultants (orvariants thereof) on a how willing would efficacy of child behaviorconsultation is demonstrated, pupil school systems be to assistin the reorientationof some of the present personnel to theconsultant's role? For example,could high school counselors counselors? Could retrained be trained to function asconsultants as well as special services maintain counselors and other personneldirectly involved in work on role clarity to the extentof encouragingteachers and the school to experts? Main- problems rather than movingin and taking overin the role of demands for direct service taining the consultantrole in the face of increasing if this particular form to children isunderstandably difficult, yet necessary, familiar with the internal of consultation is toachieve its goal. To those struggles that exist organizations of school systemsand the inevitable power in schools, as inother institutions, thesequestions are certainly germane. reappraisal of most pupil per- They point, in the lorig run, tothe need for a that findings emanating sonnel services and a possiblereorientation. It is not rather confident from our project are likely tobe revolutionary; but we are obtained via child behavior that they will indicate thatthe type of results attitude and behavior consultation does bring aboutsignificant change in the of teachers and otherpersonnel. raised. There are, There are no clear answers tothe questions we have superintendent of one of theschool however, some encouragingsigns. The who will replace theconsultants systems involved hasraised the question of The elemen- and has inquired about some sortof arrangements for next year. the Child Behavior tary schoolcounselors who have comein contact with assistance they have re- Consultants have generallybeen pleased with the this new role. This hasbeen ceived and have profitedfrom being oriented to 328 NEW APPROACHES IN THE SCHOOLS especially true for the recently appointed elementary school counselors sup ported by federal funds in schools catering to lower socioeconomic groups. Since our research project is now completed, we do not haveplans at present for the continuation of consultation services.There will, however, be systematic follow-up of teachers and pupils. This, alone, will notbe sufficient to answer the main question,which, in its barest terms, boils down to the following: Assuming demonstration of the efficacy of this type of activity on a research basis, can itbe translated into continuous support by the school system and the community? The matter is even morecomplicated by the fact that even if one or both of the school systems involvedshould be able to move towardbudgetary support of a child behavior consultation program, it would probably not be possible at the present time to find theneeded consultants. Other questions, of course, arise. Would consultants be as well accepted and function as effectively if they were part of the central office of a given school district rather than outsiders who came in one afternoon a week? One advantage of using outsiders is that they are not enmeshed in the power structure of the administration. A teacher or aprincipal may, oftentimes, feel easier talking to an outsider than to someone linked to the ach; inistration. However, if a school system took the outsider route, what agenciesin the community would be available to service the consultation needs ofthe school system? These are logistical questions which have implications for community mental health. Analysis of the problems noted seems to point to theneed, in urban areas, for closer relationships between child guidance centers, social agencies, and schools. It would imply that new patterns in thedelivery of mental health services have to emerge, and it also carries with it an implication of the need for training a mental health consultant who may notbe a Ph.D. Such a possibility is exciting in the sense ofhaving within it the potential for providing an effective mental health resource via a mature housewife or a retired businessman. Properly trained, these personsmight be able to perform effectively in a mental health-relevant situation. Inthis context it should be emphasized that oneof the central aspects of the mental health consultation carried out in our program was that ourconsultants (and this was repeatedly underscored in their training) were not afraid toadmit that they were puzzled by the problem or that they "didn't know,"always adding that they would try to be of help anyway. Since many of our Child Behavior Consultants are continuing their training in the area of School Psychology, it is our hope that, based on their experience, they will not be caught in the traditional activities ofschool psychologists. With mental health consultation in their armamentarium of skills, they should be able to devote an appreciable portion of their time to consultation with teachers. They should also be in a particularly favored posi- 329 HEALTHCONSULTATION SOME STRATEGIESIN MENTAL school counselors, programswith elementary tion to conductin-service training 1 like. special skillsteachers, and the and limited research project wasdeliberately focused on, Although our with highschool the implicationsfor working to, theelementary schools, role of thehigh counselors, have notescaped us. The personnel, particularly and varies fromsystem to least in Texas,is ambiguous school counselor, at of the highschool coun- It would seem to usthat a reorientation system. training and inin-service work,should selor's role, bothduring his academic health consultant as counselor who is acapable mental eventually produce a of a coun- the other dutiespresently required well as capableof performing selor. health much emergentproblems of mental In a bookconcerned with the dictates the exerciseof patienceand an excitement isgenerated; yet reason are noteasily changed.It is our understanding of thefact that social systems of the positiveimpact ofchild behavior hope that amodest demonstration the growingbelief that pupil per- consultation serviceswill add strength to 1 secondary preventiveeffects foster significantprimary and sonnel services can indeed, be made moreeffective and that care-giverssuch as teachers can, first-echelon mentalhealth resources.

REFERENCES Rosenblum, G., & Isaksen, H. L.,Klein, H., Bindman, A. J.,Helpern, J. M., health, J. Educ.,Boston and functions inschool mental Wolf, D. Roles Whole No. 3. Univer. School ofEduc., 1964, 146, handicapped child inthe school.Sacramento, Bower, E. M.The emotionally 1959. Calif.: Calif. StateDept. of Educ., of a com- in schools. InThe elements Caplan, G. Mentalhealth consultation Fund, 1956. New York:Milbank Memorial munity mentalhealth program. Pp. 77-85. Chil- and consultation.Washington: U.S. Caplan, G. Conceptsof mental health dren's Bureau,1959. 1963, consultation. Amer.J. Orthopsychiat., Caplan, G. Typesof mental health 33, 470-481. Books, 1964. psychiatry. NewYork: Basic Caplan, G.Principles of preventive Thomas, health. Springfield,Ill.: Charles C Gildea, M. C.-L.Community mental 1959. mental health of crisis: currentstatus and Miller, K., & Iscoe,I. The concept Org. 1963, 22,196-201. implications. Hum. consultation research atthe Orientation to schoolmental health Pierce-Jones, J. Research Commission University of Texas.A report tothe Interprofessional Austin, Texas(mimeo), 1965. on PupilPersonnel Services.

: 330 NEW APPROACHES IN THE SCHOOLS Pierce-Jones, J., Friedman, S. T., & Iscoe, I. Annualreport 63-64 to Interprofes- sional Research Commissionon Pupil Personnel Services. Univer. of Texas (mimeo), 1964. Pierce-Jones, J., Iscoe, I., & Friedman, S. T. Preliminaryfindings from child behavior consultation research at the University of Texas.Report prepared for presentation to the Interprofessional Research Commissionon Pupil Person- nel Services. Austin, Texas (mimeo), 1966. Torrance, E. P. What is an ideal pupil. Minneapolis:Bureau of Educational Re- search, Univer. of Minnesota, 1964. EARLYIDENTI71CATION ANDPREVENTION OF EMOTIONALDISTURBANCE IN A PUBLICSCHOOL Melvin Zax andEmory L. Cowen University of Rochester

INTRODUCTION

The program to bedescribed has its roots in anearlier project, (Cowen, Izzo, Miles, reported in some detail inseveral recent publications 1966a). In those Telschow, Trost, & Zax, 1963;Cowen, Zax, Izzo, & Trost, prob- reports some space wastaken to justify a searchfor new approaches to that emo- lems of mental health inthe light of society'sgrowing awareness tional problems develop at a ratewhich far outstrips ourcapacity to train professionals to cope withthem by traditionalmethods. The school was because so much of the selected as an excellent focusfor preventive efforts because impor- young child'slearning and socializationtake place there and Certainly the same and moremight tant identificationmodels are found there. considerations, such as geo- be said for the home; butfor many practical the likelihood graphical concentration, theavailability of captive audiences, procedures, of securing cooperation inexperimental programs and assessment engendered by ongoing and the readiness for researchthat may have been grades were contacts with mentalhealth workers, children inthe early school selected as the target group for ourefforts. New York, This earlier program conducted atSchool #33 in Rochester, under the auspices of a research grantfrom the Division ofCommunity Serv- deal ices of the New YorkState Department of MentalHygiene attempted to with parents and teachers aswell as children. The aspectof the original project directed toward thechildren involved bothcomprehensive evaluation of youngsters based onpsychological testing, socialwork interviews with below for parents, andobservation of behavior, notunlike that to be described the current project, andafter-school activity groups.It was hoped that any would be at least of beneficial effects of programsfor parents and teachers indirect benefit to the children. 331 NEW APPROACHES IN THESCHOOLS 332 It The program for teachers hadboth a formal and a semiformal aspect. teachers, the included a series of five seminar-typemeetings for primary-grade These were organ- topics of which wereselected by the teachers themselves. ized and conducted by aschool psychologist and a schoolsocial worker with full-time assignment to theschool as a Mental HealthClinical Services (MHCS) team. In addition, sixother meetings, led eitherby the MHCS entire faculty of team members or communityspecialists, were held for the the school. These meetingsdealt with the following topics:the socioeconomic structure of their ownschool district, problems resultingfrom differing standards in the school and the community,the classroom applicationof mental hygiene principles, the effectsof emotional deprivation,and mental health /For teachers. In a less formal aspectof the program primary-gradeteachers met aperiodicallywith MHCS team members aswell as with a consulting psychiatrist to discuss individualproblems and to exchangehelpful information. Such meetings, infact, took place quite frequently;and it was estimated that by the end of the school year,about one-third of the first-gradechildren had been brought up forconsideration and discussion. Parents of the primary-gradechildren in this experimentalschool were invited to a series of six eveningmeetings at the school. Eachmeeting was led by both a consultant of theDepartment of Parent Educationof the Rochester Board of Education andthe MHCS team members.Brief presentations on topics such asdiscipline, the changing roles offathers and mothers, sex education, etc. werefollowed by a "buzz session" anddiscussion format. These coffee hours, as they werelabeled, lasted approximately twoand one- half hours each and werefairly well attended (i.e., from aminimum of 24 parents on a snowymidwinter night to a high of 70 parentsfrom a grade totaling 110 youngsters). The evaluations of the effectsof the program (Cowen etal.,1963; Cowen et al., 1966a) revealed ratherconvincingly that childrencould be designated at the first-grade level aslikely to experience later emotionalproblems and that, in fact, by the timethey had reached third grade,these children were doing significantly less well ascompared to others not so designated on a varietyof indices measuring achievement,classroom adjustment, anxiety, and peer relationships. In addition,the total group in the experimentalschool was found tohave less anxiety, as measuredby the Children's Manifest Anxiety Scale (CMAS), superiorachievement scores on report cardsand standardized tests, and higherteacher and peer ratings thanthose in control schools. The most notable changesin parents and teachers alike werefound in their attitudes towardmental health workers, who were seenin a more positive light after the programthan before (Cowen et aL,1963; Cowen et al., 1966a). In retrospect, it was felt thatthe results of the School #33 program were sufficiently encouraging to promptexpansion of our original activities.Par- ticularly, it appeared that whilethe program which has beendescribed had 333 EARLY IDENTIFICATIONAND PREVENTION of early identi- effects, it was largelyoriented to the problem some salutary pre- functioning or emotionaldisorder rather than to 1 fication of ineffective would have to vention. We recognizedthat efforts in thelatter direction with children to aconsiderably greater extent,both emphasize direct contact and measureswith early identifiedproblem children in terms of interventive wished, then, to generalized impact onthe total classroomsituation. We and early secondary move moreactively in the directionof comprehensive being the case, further supportwassought and obtained prevention. That Institute Services and ResearchBranch of the National from the Community preventive for a new five-year programemphasizing global of Mental Health interventions of asecondary efforts, early detectionof pathology, and concrete which will be describedin the follow- preventive nature.It is this program ing pages.'

THE PRESENTPROGRAM

The basic design of the presentprogram issimilar in many ways to psychologist and aschool social that developed inSchool #33. A school primary grades of apublic ele- worker2 have beenassigned full time w the themselves, not withthe traditional mentary school,where they concern role aimed towardthe early duties of such workers,but with developing a of conceptual detection and preventionof emotionaldisturbance. This type orientation is basic to our programand guides its"battle-line" implementa- attached to the projectin the tion. Thus themental health professionals high-level resource peoplefor the schools serve, perhapsfirst and foremost, as teachers, the parents,and anyone else whomight come school principal, the the volunteer interpersonal contact withthe children (such as into close mental health clinical groups tobe described below).The efforts of the augmented by those of apsychiatrist3 who consultswith services team are detailed account of the them on a biweeklybasis. Before presenting a more the mental healthclinical services team(the preventive specific functions of discussion of staff) in the schoolsetting it would bewell to provide a brief the choice of a sitefor the program.

THE SELECTION OF ASCHOOL considerable invest- Since the program is anexperimental one with a felt that care should betaken to ment of time, energy,and money, it was unfavorable to its optimal exe- select a school wherecircumstances were not described was supported byNIMH grant MH-01500. 1 The project to be Trost, M.S., social worker. 2 Louis D. Izzo, M.A.,psychologist and Mary Ann 3 Angelo Madonia,M.D. SCHOOLS 334 NEW APPROACHES IN THE cution. The factors which seemedparticularly crucial at the outset werefew in number. First, a schoolwhich had relatively little pupil turnover was preferred, and this required focusing on arelatively stable residentialneighborhood. This seemed important since the program was tobe tested on children who would be exposed to it for alengthy period of time and, equallyimpor- tant, follow-upstudies of program effects were planned atvarious intervals after children had been exposed.Second, it seemed desirable to avoid,for the time being, the setting upof a program in a school which wasreceiving large numbers of children from remoteneighborhoods in connection with an operational community plan for racialintegration in the schools.This seemed advisable since the "open enrollees"would not be in a position to take partin after-school phases of program and their parentswould be limited in their availability for participation. Finally, aschool which had an administration that was not unreceptive to anexperimental program such as ours wassought. It was felt that until the mentalhealth roles that were being developed were well delineated and their worthdemonstrated, many school administrators might well look upon such a project as aburdensome nuisance. To the extent that this were the case, suchattitudes could defeat its purpose early. Parenthetically, it was also hoped thatthe experimental schoolwould have little teacher turnover and highteacher receptivity to the project,but it was recognized that this wasnearly impossible to predictbeforehand. Some mild concern was also harbored overthe possibility that the idealschool might have few children with evident orincipient emotional difficulties.This fear was quickly dispelled byexperienced school mental healthworkers who had found no dearth of such problems in anyof the schools of the Rochester system. The elementary school that wasultimately selected as the site of the program was arelatively small, fifty-three year-oldschool in a predominantly white, largely older residentialneighborhood that ranges widely inquality from middle class through upperand lower-lower class. It had a totalof approximately 70 first graders, 55 secondgraders, and 60 third graders. The principal of this school appeared tobe receptive to the establishment of an early detection and prevention programand seemed to display anappreciable understanding of its potential benefits.

DUTIES OF THE MENTAL HEALTHCLINICAL SERVICES TEAM

EARLY DETECTION The earliest task to which the schoolsocial worker and school psychologist devote themselves is the detection, amongfirst graders, of children who are either already displayingemotional problems or seem to have con- EARLY IDENTIFICATION ANDPREVENTION 335 siderable potential for this. This detectionprocedure involves two phases: one conductcd by the school psychologistand the other by the school social worker. These are described below.

Psychological Evaluation Under ordinary circumstances, formal testing ofchildren in the Rochester City School District does not startbefore third grille. In the interest of furthering earlyidentification of manifest or incipient emotional problems, a diagnostic battery wasdeveloped for administration to first-grade youngsters, shortly after the startof the school year. This evaluation, conducted by the project psychologist with thehelp of the classroom teacher, is given to the children in small groupsof 10-15. l:t includes the California Test of Mental Maturity and the Goodenough Draw-A-Mao test.To these formal results, the psychologist adds his actual behavioralobseiv^*hons and the teacher provides an ability estimate, based on a six-pointscale, the composite consti- tuting a preliminary estimate of the child'sintellectual potential and emotional status. The social worker isapprised of these findings prior to her interview with first-grade mothers, and wherever relevant,the information is transmitted to other school personnel.

Parent Interviews The school social worker (SSW) holdsapproximately one-hour interviews with the mothers of all firstgraders at the earliest possible time. These are directed toward the gathering ofinformation regarding the youngster's ability, personality, and behavior as well asthe mother's interests and attitudes. Before the interview takes place, the SSW hasfamiliarized herself with all available data relevant to the childhisschool history, his test results, and reports based on actual behavioral observations.Wherever specific follow-up based on any of these data issuggested, she is prepared to carry it out. The interview isstructured as part of a routine procedure for getting better acquainted and as a reflection of the continuinginterest of the school and the project team in the child and hisfamily. Its purposes are to elicit pertinent background information about thechild and his family situation, to help develop an imageof the school as an interested institution, tohelp provide a clearer picture of the educational roleof the school and the functions of the project staff, and finally, toformulate some casework impressions. More specifically the SSW inquires into mostof the following substantive areas: developmental andhealth history; adaptation to childhood training experiences and family practices inthese matters; child's adjustment to play- mates and to hisimmediate community; parents' evaluationof the child's functioning at home, school, and in theneighborhood; data relevant to the 336 NEW APPROACHES IN THESCHOOLS parents' own education and employment history; parentattitudes in key areas such as sex, sex education, parental roles, goals,and aspirations, religious orientation, etc. The SSW's impressions are summarized in thechild's confidential project folder, as arespecific notations of unusual or poor prognosticindicators. Based upon these data as well as on the priorcumulated record, when emotional difficulties are already manifest or incipientdifficulties are judged to be probable, the child's folder is clippedwith a Red Tag, so indicating. To this point this judgment has been a largelyclinical one rendered jointly by the project psychologist and socialworker. Attempts at more specific quantification of the elements contributing to the categorization arecurrently well underway.

PREVENTIVE FEATURES

The preventive aspects of the school program aredirected toward school personnel, pupils, and parents. Again, the primaryresponsibility for coordinating these efforts falls to the mental health clinicalservices team, but outside resources in the form of a consultingpsychiatrist, two clinical psychologists, two different types of volunteer groups,and other professionals are utilized incarrying out the program. The program itself may best be described byfocusing on those aspects of it which are directed toward the children. In the courseof so doing, it will, hopefully, become clearer how the teachers aredrawn into the program as well.

THE TEACHER AIDE (TA) PROGRAM A unique feature of the present program is the attemptthat has been made to reach the child at school by recruiting and training a groupof housewives as mental health aides and placingthem in the school for part of each day. Several operating models, including location ofthe aide inside and outside the class, have been explored over a two-yearperiod. In either instance the rationale for this type of developmentresides in the oft-noted fact that certain children seem to need more of ateacher's attention than she can give them without seriously depriving the rest of herclass. It was felt that many such children could be helped to adapt to therequirements of group participation and, indeed, to specific academicdemands if there were a warm, interested human being available with the time,inclination, and experiential background to minister to their emotional needs as they arose. Furthermore, it was felt that a great potential source of manpower(actually womanpower) for fulfilling such afunction was to be found in the community in the form of women who havesuccessfully reared their own

I 337 EARLY IDENTIFICATIONAND PREVENTION and a desire to apply children to a point wherethey have much free time developed themselves to some usefulpursuit. (This argumentis more fully Accordingly, a "HelpWanted" in Rioch's chapter inthe present volume.) professional groups and to notice was distributed tomembers of a few local clergymen inviting them todescribe the prospectiveschool program a few and snitable to friends oracquaintances who theyfelt might be interested in volunteers who possessed for such work. This noticestressed that we wanted children, in connectionwith which the a "personalwarmth and liking for experience of havingsuccessfully reared childrenof their own would seem emphasized that the important prerequisite."In addition, it was to be an genuine type of person wewould be intere ;ted inshould possess "flexibility, a which would permit her commitment to thework described, a life situation in the school to devotethe necessary time tothe project, and an interest volunteer should be free situation." Finally, it wasindicated that the ideal would of major emotionalproblems and that theattributes described above be valued above formaleducation. This procedure afforded a typeof screening whichlightened the task of selecting those bestsuited to be aides. Mostof the women who were suitable attracted to the projectfrom this source werethought to be quite psychologist, each of whom inter- by the project directorsand by the project variety of characteristics. viewed each applicantseparately and rated her on a expressed interest in par- Even from these limited sources manymore women ticipating than could beaccommodated, suggesting thatsuch a program might be feasible on a muchwider scale than was possiblewithin the framework of the present project. to fifty-eight, Six teacher aide trainees,ranging in age from twenty-six and one had not com- wereselected. None of thesehad a college degree, moderately in their educational pleted high school so thatthey ranged at least attainment. All were seen as atleast reasonably adequatemothers and were they judged to be capable ofrelating well to children.At the same time, excessively critical of the appeared to have no greatneed f5 usurp or to be teacher's role as an imparterof knowledge. Aides A five-week training program wasdeveloped for these Teacher (TAs) which was notintended to provide themwith a body of information tossed into the arena but rather to assuage thefeeling that they were being with absolutely no tools forcoping with what theywould encounter. While, heavily on the volun- in point of fact, theexperimenters were counting very they felt the volunteers teers' personal qualities astheir most potent resources, might pro- needed the intellectual andemotional support a training program catalyze a point of vide. Moreover, such trainingcould serve to activate and the emotional needs and view, process, or wayof thinking with respect to problems of children.Accordingly, their trainingincluded academic-type personality develop- materials on mental hygieneand concepts of prevention, would con- ment, andadjustment problems inchildren which, it was hoped, 338 NEW APPROACHES IN THE SCHOOLS vey an appreciationof such fundamental notions as psychic determinism and the importance of interpersonal experiences in thelives of children. This material was presented in a relatively simplified,discussion-oriented, issue- cenlitred context directed primarily toward activating aparticular way of thinking. Another brief section of the training program was devoted toenlighten- ing the TAs about the structure of the school systemand the role-relationships therein, and to a brief, introductory survey of teachingmethods. This material was presented by the school principal, theschool psychologist, and the social worker. It was hoped that such content would helpTAs better understand the teacher's role and provide a better understandingof the usual classroom routines. A third componentof the training program may be termed ((case material." This varied in nature from films such as "Unconscious Moti- vation" and "The Quiet One" followed by discussions, toclassroom observations followed by discussions. The early weeks of training were heavily loaded withdidactic materials, while the later weeks placed a much heavier emphasis on casematerial. The later phases of f,nining involved several sessionswhere TAs observed in several different classrooms and then discussed what theyhad seen with the school psychologist, the social worker, and the consultingchild psychiatrist. These sessions allowed the TAs to become acclimated to theclassroom and to begin to sense what useful purposes they might serve oncethey were actually incorporated into the class structure. Ultimately, TAs met informally with the six teachers ofthe primary grades and were assigned to a classroom. Someefforts were made to match aides with teachers on the basis of the personalitiesof each, but these attempts were quiteinformal and more a product of the project personnel'scompulsive natures than an act of great moment.The fact is that the project personnel had very little idea as to what criteria to apply informing optimal pairings. With training completed and assignmentsmade for the initial year, TAs set up their ownschedules; each arranged to spend one half of eachschool day in her assigned classroom, the choice of whichhalf being left to her. One TA was assigned to each of the sixprimary-grade (first, second, third) level classes. Once the program got under way, arrangements weremade for the TAs to meet as a group with the schoolpsychologist and the social worker, their direct supervisors, on a weekly basis. Inaddition, the consulting psychiatrist attended about half of these meetings. The meetings weredesigned to allow the TAs to discusstheir evolving relationships with both teachers and children and to air any problems that mightbe arising. No attempt was made to prescribe a set ofroles or functions for the TAs. The program was based on the assumptionthat each TA was a person with considerable assets and resources acquiredby virtue of personality makeup and many yearsof "battle-line" experience. Hence, she should be allowed to operate in a mannerconsistent with her own spontaneous inclinations. EARLY IDENTIFICATION AND PREVENTION 339 Quite frankly it was our view that the relationship betweenTA and child oi children was more basicthan the specific activity through which therelation happened to be expressed at any given time.Equally clear was the fact that the TA's role would have to be determined, in good measure,by her own personality, thatof the teacher, and the interaction between the two. In actual practice a variety of activities wereundertaken by TAs, with different patterns becoming dominant in differentclassroom situations. Talk- ing informally with individual children or small groupsof children occurzed very frequently, particularly so attimes when the teacher was engaged in group activities with a segmentof the class. Children came to talk freely and easily with the TAs who, from their point of view,blended readily into the classroom setting. Frequently, TAs would read, tell stories, orplay games with the youngsters. On occasion, when a child seemedparticularly incapable of profiting from the classroom activities, perhaps being disruptive toothers, the TA would take him out of the classroom situationfor a walk or to an unoccupied room in the building. Quite often TAs engageddirectly in specific subject matter remedial work with youngsters requiringspecial help or attention. Here again, st,-1 work was done in the contextof a warm and understanding relationship and with an eye toward thechild's emotional as well as educationalneeds. In principle, by her intensive work with theemotionally needy child, the TA not only contributed toward secondary preventivework with that child but also made some small contribution in a primarypreventive direction by making the classroom situation an easierand more productive one for the teacher and the child's peers. Aperiodic meetings were held with teachers before theactual inception of the TA program. Actually, each teacher volunteered tohave a TA assigned to her class. In later teacher meetings,after the program started, it was hoped that they would express feelings engendered bythe aide program, either positive or negative. The frequency of these meetingsincreased as teachers' experience with the aide program accumulated.At this time they began to voice many negative feelings, particularlyabout the nature of the roles which were evolving foraides and how this affected their ownrelationships with their classes. Specifically, they had begun to feelthat TAs were becoming identified as "good mothers" in the sense thatthey neither defined nor set limits for the children. Thus, the latter rolefell to the teacher, who at times felt she was being looked upon as an ogre.As a result of this problem as well as ofothers which indicated inadequate communicationbetween TA and teacher, we believed that supervisory relationsneeded restructuring. The original setup, which has just been described,seemed to create two groups, TAs and teachers, who did not alwaysfeel they were working toward the same ends. It alsoseemed to have the effect of cementing allegiances toone's own group andthus prevented the coming together of TA andteacher In the way which was altogether necessaryif they were to function as an effec- 340 NEW APPROACHES IN THE SCHOOLS tive team. We emerged from this experience with thefeeling that a supervisory format which brings each teacher and her TA intoregular contact with the school psychologist and the social worker shouldbe created. In a second year of work on this project the supervisoryformat and the way in which the TA functioned werealtered. The TA was removed from the classroom, except for specific periods of time when, oninvitation of the teacher, she entered to observe one or more children.During most of her time at the school, she was "stationed" in a room whichserved as the locus for a variety of interactions between her and the primary-gradechildren ruerred by teachers. The teachers, who strongly supported this revisionin the program, used the TAs as resources to whom they could turnwhen a child presented any one of a variety of problems. These ranged frombe- havior which disrupted classroom routine through failure to benefit from the curriculum to withdrawal which seemed potentially damaging to a child's emotional adjustment. The referral process brought teacher and TA together withmembers of the mental health team around the problem posed by a specific child.On the basis of the teacher's observations and other information possessed by the team, a concrete plan was worked out for the youngsters.The TA might then spend an hour a day, two or three times a week working with the child. Usually, the interaction focused on school work, but in many cases the major emphasis was on providing a relationship whichsupported the child emotionally and fostered better school adjustment. At times, and for a variety of reasons, theTAs worked with children in small groups. This group technique seemed quite promisingwith youngsters whose withdrawal, timidity, and undersocialization had made relating to their peers verydif- ficult. Thus, in addition to receiving extra help with academic work, these youngsters were being given an opportunity to formrelationships in a less complex and competitive setting than the classroom with peers who, in sharing a problem with them, were no doubt seen as less threatening thanthe average child. All of this took placeunder the close supervision and with the guiding encouragement of a warm and interested adult. TAs in this role were also in a position to cope withthe inevliable and often transient crises which arise in children and which cannot be handled easily in the classroom. One measure of the success of this form of the TA program is the fact that referrals mounted rapidly, so that a waiting list for TA time soon developed. Indeed, with a total primary-grade enrollment of nearly 200 youngsters, there were more than 40 referrals (20% of thegroup) to the TA program. Teachers seemed to find this outlet a veryuseful one for them. Relationships between teachers and TAs appeared to improve considerably as a function of the revision of the program;certainly so in terms of subjective reactions of members of both groups. As part of the modification in program format, consultation was changed so as to involve jointly the projectmental health professionals with both the 341 EARLY IDENTIFICATIONAND PREVENTION concerned with a specificchild (or children).The focus of teacher and TA and how consultative-resource activity wasoriented to the child this type of reduced some of the best to meet hisneeds. This modifiedsupervisory format inadvertently heightenedisola- sourcesof irritation of theprior format which TAs. Joint supervisionaround the child tion and oppositionof teachers and Indeed, it was regarded as sobasic to the func- was verypositively received. substitute teacher wasemployed to tioning of the programthat a part-time classrooms for periodsof time to relieve teachers whoneeded to leave their likely that these meetings,in Ii take part in supervisoryconferences. It is with the child, havebegun to addition to assisting theteacher in dealing viewpoint whichwill be found usefulin dealing with provide her with a through a prob- In other words, asthe teacher works other children as well. which she lem with one youngster,she acquires apsychological know-how In this way teachereducation and sophistication can usewith other children. focus of the mental health havebecome an important in matters relevant to increasingly to serve a pri- project in a mannerwhich, hopefully, may come mary preventive program.

THE AFTER-SCHOOLPROGRAM comprehensive A second major programintroduced as part of our prevention withemotionally disturbedprimary-grade effort at early secondary of Rochester undergraduate volunteersfrom the University children involved This program, who participated in anafter-school day-care activities program. effect for two years. Thefirst the TA one describedabove, has been in undertaken primarily todevelop a meaningfuland use- year's activities were only two and The initial pilot program wasin effect for ful working model. consider to be one-half months (a periodmuch shorter thanthat which we exercise in programde- optimal); hence it is tobe regarded primarily as an basis for formalevaluation of velopment and "debugging"rather than as a substantive change in itsparticipants.4 consisted of 17 The target group forthe after-schoolday-care program by teachers, theproject psy- primary-grade youngstersspecifically designated children who might,for one or chologist, and the projectsocial worker as from the type ofinterest and specialattention that another reason, profit with acting could provide. The groupincluded youngsters such a program educational problems of shyness andwithdrawal, and failure in out problems, who, although they werenot achievement. It alsoincluded several youngsters completed a second year'sexperience with this 4 At the time ofwriting, we have the same of the model to bedescribed, approximately program,involving a continuation research assess- and college studentvolunteers, and comparable numbers of child referrals still in process, for present since data analysesfor the second year are ment. However, data from the initial year.The major descriptive purposes the accountwill be limited to their operation: twoand a half monthsfor difference in the programsis the length of the first year and sixmonths for the second. 342 NEW APPROACHES IN THE SCHOOLS currently manifesting difficulties, seemedto be high-risk cases for the early future development of emotional problems. In actual fact, a total of 34 suchyoungsters were nominated for the after- school program. In eachcase a behavioral symptom checklist including an overall adjustment rating, an adjective checklist for personality attributes, and a prose referral statement containinga descriptive account of the child's principal difficulties was submitted by the referringperson (usually the teacher). For purposes of a crude, prelimary evaluation, one-half of the total group was included in the program and became our experimental group. The remaining 17 youngsters, roughly matched with respectto the variables of age, sex, grade, and judged overall severity of problem, became a control group. In this case, the figure 17 represents the maximal number of studentvolunteers that could be accommodated, given the limitations ofsupervisory time available for this purpose. The original master plan for the after-schoolprogram was a relatively simple and straightforwardone. A university undergraduate was to be assigned to a particular child, with whom heor she would spend about 70 minutes on each of t wo afternoons during the week. Thiswas to be done within the confines of the school building and grounds, and participantswere to be free to utilize most of the school's facilities (e.g., gymnasium, auditorium, playground, home economicsroom, shops, music room, cafeteria, etc.). It was felt that a variety of activities emphasizing expression, recreation, and/or academic work would provide suitable vehicles through which the undergraduate volunteer and child might interact. The overriding emphasis, however, was on the relationship to be developed between the volunteer and the child. It was hoped, particularly, that children in theprogram might benefit from having contact with an interested, energetic, enthusiasticyoung adult who would provide attention, at times affection, and,at the very least, a model of someone who was doing something constructive with hisown life. In addition to providinga meaningful relationship and beneficial experience for the emotionally disturbed child in need of such contact, this type of program, in principle, might contain the seed ofsome modest contribution to primary prevention. To maximize this likelihood, volunteers were sought from among elementary education majors in the College of Educationat the University of Rochester. These represented people whowere themselves about to become teachers and for whom an emotionally meaningful engagement in a mental health practicum exercise could, ultimately, have beneficial effects for many children. The administrative staff of the College of Education concurred in the belief that an after-schoolprogram of the type described was of considerable potential value to the elementary education major. Accordingly, theywere most cooperative in bringing the prospective program to the attention of their majors and agreed that participation in theprogram could be substituted for one of the classroom observation experiences in which the elementary educa- EARLY IDENTIFICATION AND PREVENTION 343 tion student ordinarily participatesduring the junior year. Eight elementary education majors volunteered for and wereaccepted into the program. An additional 9 volunteers wereneeded, and these were obtained via a soliciting announcement made tothe students of a large lecture sectionin abnormal psychology. A brief descriptionof the prospective program was provided, with an indication that no morethan 10 additional student volunteers could beaccommodated. This notwithstanding,there were over 30 volunteers who were strongly interested inparticipating in the program. All of the education majors and about15 of the psychology students were interviewed, individually, by one ofseveral advanced clinical psychology graduate students. Unlike the housewifevolunteer program, our concern here was not to selectfor preconceived positive attributes.Rather the goal was to try to weed out the fewstudents who seemed flagrantly maladjusted orgrossly unsuited for the purposes of the program.Three prospective candidates were dropped for such indicators. Another 3 could notbe taken on because their free hours did not match thescheduled program hours, leaving atotal of 17 acceptable volunteers. Clearly, our screening was a gross one,and no attempt wasmade to prejudge what would makefor an effective volunteer worker with very young children. Instead, thedeliberate decision was made to allow a wide range of(nonovertly disturbed) types to enterthe program in an effort to determine empiricallythose attributes which seemed to be mosteffective in actual practice. In retrospect,and at a grossly clinical level, it may turn out that some of thepeople prejudged to be less promisingactually did very effective jobs. After the final volunteer grouphad been constituted, the clinical psychologist directing the program metwith them to discuss conceptsof prevention, the underlying philosophyof the program, its objectives,and their place in the overall plan. Somepossible ways in which the programmight operate were considered;however, this was not overstructuredand it was emphasized that the volunteer would haveconsiderable freedom and latitude. In asubse- quent meeting thevolunteer group was taken to theschool to go through the building, to become acquaintedwith the flcilities and equipmentthat would be at its disposal, and to meetand talk with key school personnel. The volunteers were encouraged to viewthemselves as neither therapists norintellectualized dissectors of children'spersonalities. Indeed, an effort was made to withhold background and casematerial information on the assumption that this might foster anexcessively "objective, case-historical" orientation.5 Instead, our efforts weredirected toward the encouragementof a spontaneous, warm, relaxed,"friend" relationship with thechild, one which

5 Experience during the initial yearsuggested that this concern might have been excessive. Additional background informationpertaining particularly to the reasons for the child's referral to the program and histeacher's impressions of him was made available to volunteers during the second year. 344 NEW APPROACHES IN THE SCHOOLS provided the youngster with a genuine interest by an adult, someadditional individual attention, and a grown-up identification model. Volunteers were assigned to children on a one-to-one basis;however, they tended to group in their play activities fairly often. Three groupsof 5-7 volunteers were formed, each under the direct supervision of anadvanced graduate student in clinical psychology who was himself under supervision of the clinical psychologist in charge of the program. Each group went tothe school twice a week. Youngsters met their volunteers at a designatedlocation in the school building when the school day was over,around 3:30 P.M. Activities went on until about 4:40 P.M. when the child left the schooland returned to his home. Virtually the entire resources of the school wereplaced at the disposal of the group.Headquarters were located in the small cafeteria- playroom area, but children and volunteers were to be found, at varying times, in most of the special activity rooms in the schoolbuilding. Many different individual patterns of interaction emergeddepending on the particular child, the volunteer, and the stage of therelationship. Some indication of the nature of these activities was obtained by having each volunteer fill out, three times during the course ofthe program, a type of process- analysis form summarizing how he (or she) and his assigned child spenttheir time together. Preliminary analysis of these data suggestthat there were indeed marked variations as a function of (1) the specificvolunteer-child configuration and (2) the stage of the relationship. Very grossly,and for the group as a whole, running around and cathartive physical activity occupied perhaps 15% of the time overall, but with a clear-cut decrease infre- quency over time.Semiorganized play and organized play accounted for another 15% and 10% respectively. Controlled exploratorybehavior represented another 7%-8% of the total time commitment, as did competitivetable games. In the latter categorythere was, however, a sharp drop from approximately 15% at the first evaluation period to 5% at the last one.Noncompeti- tive table activities accounted for perhaps 12% ofthe total time, with a sharp increase from 8% to 18% between the initial andfinal measurement points. Artistic activities (painting, drawing, construction) represented some8% of total time. Finally, talking and conversation (independent ofother on-going activity) accounted for some 12% of total time, with verydefinite evidence of increasing frequency of occurrence over time. Recognizing,then, the tremendous range of variation, the foregoing summarizes globallythe actual activity patterns for volunteers and children. Upon completion of the afternoon's activity the volunteer groupand the graduate student leader returned, each time, directly and in a single group, to the campus for a postmortemdiscussion session from 5-6 P.M. Here volunteers discussed specific children andthe problems they presented, critical incidents which they had experienced, some of their own anxieties and concerns, and problems oftechnique and handling of children. These sessions provided an opportunity for the volunteers to learn around very recent, quite 345 EARLY IDENTIFICATIONAND PREVENTION Over impactful experiencesthey had had. vivid, concrete,and emotionally not thatof suggested that theleader's optimal role was time our experience discussion-oriented, therapist; rather it was oneof being anissue-centered a sought to bringrelevant problems to contributing memberof the group who for the volunteer'sperceptivity anddiagnostic the surfacewith full respect hour catalyzing-educative one.The:e was, then, an acumen.His role was a 70-minute contactmeeting withthe child which groupmeeting for each useful vehicle forrelaxed explorationand appears tohave provided a very consolidation of experience. theme of a singlediscussion Perhaps a concrete resumeof the principal and purposesof these meetings meeting can serve toillustrate the nature volunteers beganthe meeting effectively. One ofthe undergraduate more "puzzling andperplexing" experience by reportingwhat she described as a she At the end of theday's activitieswith her youngster, she had just had. His mother his home, which was veryclose to the school. had brought him to remained per- seemingly in afriendly way, yetthe volunteer greeted her, further As the leader and groupmembers inquired plexed by the encounter. detail. Thoughthe the story unfoldedin greater about her puzzlement, had, first, completelyfor- been friendlyand smiling, she mother had indeed apologetic" aboutthis but gotten thevolunteer's name.She was "most exactly who shewasi.e., "the teenager assured the volunteerthat she knew school." The conversationbetween mother who baby-sitswith Jimmy after of the child.The latter was trying and volunteercontinued in the presence throughout, successfullyignored by to showoff his pet guineapig but was, of the ensuingconversationbetween his mother.Several further aspects the sameunrecognizedcontradiction, mother and volunteereach contained external mannerand facade wasquite namely thatalthough the mother's underlying communicationwasalways cutting, pleasant andfriendly, the reach a crude Gradually the group as awhole was able to biting, and hostile. and the volunteer wasbetter understanding of thisinternal inconsistency, original vaguefeelings of puzzlement. able to comprehendthe basis for her in the volunteer was experiencinga typeof "double-bind" In essence, the possible to explore the mother.Once grasped, it was communication from might inhere inthe element ofdouble-binding that profitably the potential how this mightaffect the communicationwith her son, mother's day-to-day difficulties. Thus,the total dis- child, and how itmight relate tohis present in small measureto thevolunteer's (as cussion period mayhave contributed of herself, theadult interaction, well as to the entiregroup's) understanding be- the dynamicsof the child's present the volunteer-childinteraction, and havior. were, in formed betweenvolunteers and youngsters The attachments brought games,food, instances, quiteclose ones.Volunteers frequently many with the children.Arrangements were and materialsfor special activities strong andpersistent requestsof volun- also made (in responseto the very SCHOOLS NEW APPROACHESIN THE 346 individual pair or a activities oneither an teers) to haveadditional special to the volunteers broughttheir youngsters up large-group basis.Thus, many ball game, have dinner withthem, to watch a campus to seethe university, to and to thehumane societyanimal shelter, etc. Trips tothe downtown area, the vacation periods(for the youngsters or to the zoo werearranged. During developed. volunteers) severalbrief correspondences to knowthe specificeffects of this program, Although it is premature much. Many that the youngstersenjoyed it very it is alreadyquite clear the end of the pro- highlight of theschool week. At viewed this contact as a reactions fairly lengthy accountsdescribing their gramvolunteers submitted the experience was,by and large, a very It is clear that of to the program. volunteers; one or twodescribed it as one valuable one foralmost all the tendency of students college experiences.The oft-noted their most exciting psychology reflects favorably withlecture classes in to contrastthe experience in a situa- doing and beingconcretely involved the satisfactionof learning by tion ofpsychological import. for student-volunteer program wasset upand field tested Although the identify aneffective primarily with theidea of helping to several months concerted attempt was longer-range utilizationin the future, a model for of its aspects.There least a crudeevaluation of various made to undertake at is theeffectiveness with the obviousquestion of wtiat was concernnot only emotionally disturbed, its consumers(i.e., the referred, of this program on with a numberof related andim- primary-grade schoolchildren) but also included thefollowing questions.What, portant issues.Among the latter are of attributes of thevolunteer for a program if any, are thedistinguishing in thevolunteer's attitudesand orienta- this type? Whatchanges take place in theprogram? 'Whatvolunteer attributes, tions as a resultof participation behavioral, predict tofavor- peTsonality,demographic, or be they attitudinal, exposed to theprogram? outcomeswith children able or unfavorable these pertinentissues, of shedding somepartial light on In the interest undertaken. To startwith, graduate a modestamount ofdata collection was and be- did a series ofratings ofrelevant personality student interviewers based on theinterview contact.In havioral dimensionsfor all volunteers of how muchthey liked thevolunteer addition, they madeoverall judgments he would be inthe program.Before the and how effectivethey estimated atti- the 17 volunteerscompleted a 17-item program gotunderway, each of 1961) and a (Gildea, Glidewell,& Kantor, tudes-to-childrenquestionnaire Tannenbaum, 1957) differential ratings(Osgood, Suci, & series of semantic applied to concepts of scales (primarilyevaluative ones) based on a variety disturbed children,and mental health,schools, emotionally such as children, also made semantic the graduatestudent interviewer "myself." Additionally, frame of referenceof of the concept"myself" from the differential ratings ratings. Thus, adiscrepancy how he judgedthe volunteerhad made these self-image wasavailable for eachvolun- between actualself-image and judged 347 EARLY IDENTIFICATION ANDPREVENTION that these data were not to teer. It was made quiteclear at the very otylset but rather were part be used for selection purposes(which they were not), of a research appraisal ofthe overall program. A control group of 8education majors and 9psychology majors, com- did not actually volun- parable to the volunteers exceptfor the fact that they instruments. This made teer for the program, wastested on the same set of the revelant dimen- possible comparison ofvolunteers and nonvolunteers on volunteer group retook the same sions. At the veryend of the program the the protest battery sothat attitude changeresulting from participation in gram couldbe assessed. Each volunteer submitted, at our request,periodic objective ratingsof the child and the natureof their relationship, aswell as the process sum- the various activity cate- maries describing theiractual allocation of time to view of the total gories. In this way ithas been possible to reconstruct a of informa- process and its rangeof manifestation, as ithas evolved. This type understanding of the most tion may contribute tothe development of an achieving certain effective types of contacts, activities,and experiences for the end of the ex- behavioral objectives. Asnoted above, each volunteer, at project and his perience, submitted a prose accountof his reactions to the These reactions, in addition to suggestions for modificationin the future. identifying needed areasof im- reflecting enthusiasm, havebeen helpful in the greatest concernof the volunteers wasthat contact provement. Perhaps the with the child was for tooshort a period of time,this accompanied by preoccupation that beneficialeffects might not endure.Our concurrence, as led to the extension viewers of the total process,with this particular critique of the program over afull half-year periodduring the second year. evaluating out- A variety of criterion measures areavailable as a basis for which may make for more orless come andfor assessing input variables favorable outcome. In thefirst place, postexperienceratings of behavior checklist by the referring source symptoms, overalladjustment, and adjective and control Ss have been collected. These areavailable for both experimental thereby provid- and parallel exactly thecomparable pre-experience measures, framework for eval- ing a basis for determiningchange scou -, and a crude which may relate toeffectiveness. uating programeffectiveness and variables the school may becontaminated Since posttest measuresby referring agents in experimental or control group, by awareness of thechild's assignment to the classroom an attempt wasmade to supplementthem by observation of actual To this end an 18-item behavior by naive judgestrained for this function. behavior rating scale hasbeen developed, andreliability has been established experimental on aprimary-grade sample drawnfrom another school. Each for 45-minute periods in his and control child hasbeen observed twice totally naive with respect natural classroom setting.Since the observers were control status of thechildren, this pro- to knowledgeof experimental versus independent of the project vides a type of criterionjudgment that is entirely 348 NEW APPROACHES IN THE SCHOOLS personnel. From the foregoing cluster of measures, as well as from a seriesof actual behavioral measures taken primarily from school records(e.g., attendance data, report card data,nurses' referrals), a network of evaluative criteria which provide a reasonably comprehensive and solid base forevaluation is available. Data analyses based on the first-year group have, by and large,been completed. These analyses are limited primarily by the relatively small size of our child and volunteer samples. However, on the basis ofcompleted analyses, preliminary impressions concerning several guiding research questions are available. Although these data have been written up more extensively in another paper (Cowen, Zax, & Laird, 1966b), it may be appropriate to recapitulate several highlightsof the findings to date here. For one thing, it appears that our volunteer group was initially significantlydifferent from their demographically comparable nonvolunteer controls with respect to attitudes. The principal substance of this difference resides in the characteristically over-idealistic initial response of the volunteers. Schools, teachers, principals, mental health, mental health workers and other such "institutional" concepts were all seen by the volunteers in an unswervingly favorable light. In a very substantial way the foregoing findings parallel those reported in an earlier chapter in this volume by Holzberg, Knapp, andTurner for their college student volunteer groups. Participation in the program apparently affected the attitudes and perceptions of the volunteers so that the idealized halo attached to these institutional concepts wore off. Relevant posttest ratings, though still quite positive, were so to a significantly lesser degree than hadbeen the original ratings. It might be said that the postexperience ratings of "institutional" concepts by volunteers was more "healthily realistic." Nor did this change appear to be a reflection of a global change in response style, since on another concept, emotionally disturbed children, rated initially in a rather neutral-negative way by the volunteers, the postexperience ratings were significantly morefavorable. Thus, apparently, exposure to and interaction with these youngsters became the basis for more positive and accepting attitudes toward them. Finally, there is some evidence suggesting that certain types of actual volunteer-child interactions (e.g., amount of time spent in talking and conversation), as reflected in our on-going process description measure, appear to relate to pre-post behavioral change scores inthe youngsters. This type of datum mu ultimately contribute to a better understanding of the nature of helpful, as opposed to inert, interactions and interventions. It should, however, be reemphasized that this program was set up primarily to determine, clinically, whether or not it was a workable one. The impression of those involved in the program is that it makes good sense,that it works well, and that children, parents, teachers,school personnel, and volunteers all seem to think very highly of it. Symptomatic of this judgment is the fact that the volunteering per cent by invited parentsfor their children 349 EARLY IDENTIFICATIONAND PREVENTION feedback from the sourcesmentioned above was 100and that the consistent during the programperiod. Consider- was positiveand highly reinforcing judgment. In several instances,for ex- able anecdotal evidencesupports this school on a programday were unwilling ample, youngsterswho became ill in did not wish to miss out onthis highly valued to be senthome because they than 50% absenteeism experience. In another case, ayoungster with a greater On the other hand,how- history did not miss asingle program day session. evaluative data entire first-year programperiod on which the most ever, the vacation periods, available was extremelybrief, broken by two is currently small group of fundamentally exploratory in nature,and targeted to a very Hence it would beunduly optimistic to expectsweeping subjects (N=17). because the control change on our criterion measures.This is especially true that its members were group is aparticularly severe one, byvirtue of the fact and impact of theTA program in also exposed to theeveryday experience manifested in a verydifferent the classrooma programwhich, although objectives. For this reason,it is prudent form, had at its coresimilar aims and primarily in terms ofthe development of to view theresearch venture again and the establishmentof workable appropriateinstruments and techniques of grandiose expectationsabout dra- evaluative models,rather than in terms matic substantivechange.

OVERVIEW in order. Thefuture Perhaps a few final summarycomments are now with the several course of the programwill be guided byactual experience plan is to modifyand shore up experimental programsdescribed. The future developed up to this pointand gradually tointroduce new aspects of program that arise elements into our overalleffort, depending onspecific problems efforts will be made tomake it and new needs that areidentified. Continued compatible with the concreteschool situation. both more effective and more teachers are indi- In this regard, it isclear that more groupmeetings with unit is a moreeffective way cated and that treatmentof teacher and aide as a earlier thinking. Thelatter of operating than hadbeen apparent to us in our been an incompleteand unsatisfactory is but one symptomof what has, to us, problem of definitionof role- attempt towork through fullythe complex and aides. At thistime, it appearsthat a com- relationships with teachers proved to bined role for the TAof classroom participantand consultant has participant role. be more effectivethan the full-time Conspicuously absent from our newprogramsthus far has been ongoing beyond that reflectedby the involvementof first grade contact with parents that as a result of mothers in the socialwork interview. Ithas been hoped school mental healthworker early their introduction toand contact with a might more willingly turn toschool in their child'sschool career parents 350 NEW APPROACHES IN THE SCHOOLS mental health personnel in times of future need.Although there is quite likely merit to this viewpoint, it should be possible todo more to encourage parents to use such services and to viewthe school as an interested and helping organism, long before they are forced to becauseof psychological crisis and emotional emergencies. An initial venture in this direction was undertaken in alimited way during the late stages of the second project year. A groupof 25 mothers of primary-grade children classifiable as underachievers was invited toattend a series of four morning meetings at the school dealingwith the general issue of how parents can be helpful in promoting theirchildren's achievement in school. Seventeen of those invited expressed interest. Ofthese, 7 worked and were therefore unable to attend atthe scheduled time. Of the remaining 10, 8 have regularly attended the meetings, conductedjointly by the project psychologist, the social worker, and the consulting psychiatrist.The discussions have ranged across topics such as sex instruction,discipline, and authority and have been active and ego involved in termsof feeling tone. Evidence of the mothers' tendencies to overprotect their childrenhas been strong. Much of the discussion hastaken place among the mothers themselves, and the professionals involved have attempted tokeep the focus on the child and his problems rather than encouragingthe mothers to introduce or to emphasizetheir personal problems. There has been a calculated decision to confine theparents' meeting, for the initial run, to a group with a relativelyhomogeneous focus (i.e., their underachieving children), but not because this is the only parent groupto work with or the most important one. Rather it provides aparadigmatic and relatively focused situation in which a model canbe worked out which subsequently may be broadened so as to include other parent groups.Certainly, future efforts will increasingly be devoted to thedevelopment of this phase of the program. It is to be emphasized that the foregoing is a descriptionof a set of programs which is barelyoff the drawing board. They are types of programs which make very good sense to the authors on logicaland intuitive grounds. Their salient features include: emphasis on the very young,focus on early detection and early secondary prevention in an effort toforestall later full- blown development of serious and frequently immutablepathology, recasting of the roles of professional specialists in a waywhich may have potential for reaching much larger segments of our populationcurrently requiring help, utilization of subprofessional manpower with focaltime-limited training as a paradigm for a needed type of geometric expansionof our helping structures. All of this seems to make perfectly good sense in viewof the growing body of knowledge about professional manpowershortages, the ineffectiveness oftraditional techniques with large segments of our population,and the fact that mental health needs far outstripavailable resources (disproportion- 351 EARLY IDENTIFICATIONAND PREVENTION ethnic, and socio- ately so as a function ofgeographic, educational, economic, rather economic factors). But, inthe last analysis, it isclear that this is logic than empirics. The socialsituation in the mentalhealth area is sufficiently On this acute to demandvigorous exploration of newhelping approaches. than warranted. basis, it is felt that programssuch as the foregoing are more basic recasting of the However, one should notlose sight of the fact that of models of the helpingprofessions must await thepainfully slow accretion solid empirical data.

REFERENCES

Cowen, E. L., Izzo, L. D., Miles,H. C., Telschow, E. F.,Trost, M. A., & Zax, M. setting: Description and A preventive mentalhealth program in the school evaluation. J. gen. Psychol., 1963,56, 307-356. Cowen, E. L., Zax, M., Izzo,L. D., & Trost, M. A.The prevention of emotional consult. Psychol., disorders in the school setting:A further investigation. J. 1966, 30, 381-387 (a) volunteer program in the Cowen, E. L., Zax, M., &Laird, J. D. A college student elementary school setting.Comm. Ment. Health J., 1966,2, 319-328. (b) Maternal attitudes and gen- Gildea, M. C.-L., Glidewell,J. C., & Kantor, M. B. Glidewell (Ed.), Parental eral adjustment inschool children. In J. C. Thomas, 1961. attitudes and child behavior.Springfield, Ill.: Charles C Pp. 42-89. of meaning. Osgood, C. E., Suci, G.J., & Tannenbaum, P.H. The measurement Urbana, Ill.: Universityof Illinois Press, 1957. 19 PROJECT RE-ED:EDUCATIONAL INTERVENTION INDISCORDANT CHILD REARING SYSTEMS

W.W.Lewis George Peabody Coliege forTeachers

Project Re-ED is a combineddemonstration, training, andresearch endeavor sponsored by George PeabodyCollege for Teachers and theState Departments of Mental Health inTennessee and North Carolina.Reduced the feasibility of a to simplest terms,the objective of the project is to test brief, high impact residential treatment programfor emotionally disturbed children, reinforced by mobilizationof resources in children's"natural" environments. Each of the two statesmaintains a small residentialschool, with financial assistance from the federalgovernment.1 Peabody Collegeprovides research program to evaluate a training programfor staff of the two schools, a the effectiveness of the schools,and general coordination ofthe total project. Conventional treatment programs foremotional disturbance inchildren reflect what Thomas Szasz (1961) andothers have referred to as the"medical the med- model" of behavior disorders. Briefly,the central assumption behind ical model and much of ourelaborate network of treatmentfacilities for children is that emotional disturbancereflects an underlying pathologywithin a child which,if not corrected, will develop into moreserious behavioral manifestations during adolescense oradulthood. In the early partof the century, as the mentalhygiene movement was beginning,disordered behavior could often accurately be attributed to anunderlying physical disease embraced the process such asgeneral paresis. The mental hygiene movement assumption of a disease process andextended it, by analogy, to thetotal range of behavior disorders. AdolphMeyer was most articulate andinfluential in developing our basic pattern ofsecondary prevention of mentalillness through child guidance clinics.Contemporary patterns of treatmentof emotional disturbance continue toreflect his conception of abroader disease process and hisconviction that many of the"mental tangles" of adult patients could have been prevented by treatmentwhen the problem was first manifest during childhood (Kanner,1962). 1 The program to be described hasbeen supported by an NIMH grant,MH 929. 352 353 PROJECT RE-ED:EDUCATIONALINTERVENTION alternative modes There are twosound reasons forexperimenting with children. The first,obviously, is short- of treatment forbehavior disorders in George Albee (1959) putit most concisely age ofmental health manpower. mental health manpowerneeds. "We must in his summaryof nationwide that our countrywill continue tobe conclude this surveywith the prediction all fields related tomental illness faced with seriouspersonnel shortages in of a for many years to come.Barring the possibility and mental health the social changes effort in all areas ofeducation, with all of massive national sharp breakthroughin such an effortwould imply, orthe possibility of a the prospects arepessimistic forsignificant improve- mental health research, services in thesefields" ments inthe quantity orquality of professional (p. 259). of the efficacyof methods The second reason isthe current questioning Studies of theeffectiveness of traditionally used insecondary prevention. summarized ratherbriefly by saying that psychotherapy withchildren can be of the treated casesshow durableimprovement two-thirds to three-fourths training of the of treatment setting,the professional regardless of the type would seem to be therapist, or the ageof the childrentreated. While this effectiveness of clinical treatment, favorable commentary onthe general a who have notreceived psycho- studies of children onclinic waiting lists the two-thirds tothree-fourths range therapy also reportimprovement rates in be raised aboutthe appropriate- (Lewis, 1965). Anumber of questions may controls in outcomestudies. However,the ness ofwaiting list defectors as but that there is important point is notthat psychotherapyis ineffective, been clearlydemonstrated in reasonable dodbt, sinceeffectiveness has not compel someexperimentation the research that isavailable. These two issues based on different conceptsregarding with alternative patternsof treatment discordant behavior inchildren. initiated in September, Project Re-ED is onesuch experiment. It was Peabody College forthirteen 1961, with a nine-monthtraining program at school teachers. Theteachers were selected on carefully selected elementary and teaching competence, asjudged by their supervisors the basis of unusual they used, colleagues, adaptability andcreativity in theteaching techniques disturbed children. and a genuine interestin the educationof emotionally for the first groupof teachers, latercalled teacher- The training program work at the graduate counselors, consisted of twoacademic quarters of course established residentialschool level followed by athree-month internship in an including someplacements in England for emotionallydisturbed children, and Scotland. Elementary During the school yearof 1962-1963,Cumberland House North Carolina began to operate School in Tennesseeand Wright School in teachers who had gonethrough limited basis, staffedby the group of on a Peabody has con- the first year's training program.The training program at schools as vacancieshave occurred tinued to supplementthe staff of both 354 NEW APPROACHES IN THE SCHOOLS and as the program has expanded. Each school is organized into groups of eight children, who live and attend school together and who are the responsibility of two teacher-counselors. The average length of enrollment is six to seven months. The general patternthat has been followed in both schools is a five-day-a-week residential program, withchildren returning to their own homes on the weekends. The two teacher-counselors are responsible for de- signing and carrying out an intensive treatment program for each child, based on his needs, presentingproblems, and the common objectives shared by the child's family, :he referring mental health agency, and fix Re-ED school. The initial thrust of the demonstration was directed toward a total educational milieu for a troubled child. Traditional residential treatment centers provide a few hours each week with highly skilled, and highly paid, professional personnel, but also long periods of inactivity and idleness, supervised by staff of marginal competence. They also tend to isolate the child from his natural environmentfamily, school, and friendsto which he must eventually return. The Re-ED staffing pattern is intended to address itself to both these problems. It seeks, first, to provide an engaging, goal-oriented educational climate during all of a child's waking hours and, second, to keep him related to his own child rearing systems by weekends at home and by careful liaison work that prepares the way for his return after a brief stay at the Re-ED school.

AN OVERVIEW OF THE PROGRAM

The Re-ED schools emphasize the educational quality of their program in designation of rolesteacher, student, principal; in designationof activitiesenrollment, recess, student council; and in designation of limited goals which lend themselves to direct teaching. The language of mental hospitals and clinics is intentionally avoided, This does not represent a denial of shared responsibility with the mental health professions. It represents, rather, an assessment of the potency of teachers and educational processes inthe socialization of children, "disturbed" as well as "normal." While the staff of the schools are as comfortable in dealing with an outburst of negative feeling as with a problem in remedial reading, they prefer todefine their role as educational rather than therapeutic. The reason for making this distinction is the emphasis in the Re-ED program on short-term, specific, and usually rather concretegoals toward which the individual child and his teacher-counselors work. There is none of the emphasis on psychotherapeutic treatment for intrapsychic problems that characterizes many programs. Most treatment programs are based on the notion that an uncovering of hidden psychic processes will lead indirectly to significant behavior change. In treating a child with a reading block due to emotional factors, for example, both the child and his parents are required 355 PROJECT RE-ED: EDUCATIONALINTERVENTION psychotherapy. to work throughthe feelings they haveabout each other in The expectation is that oncethe participants haveachieved an understand- reading block or other pre- ing of the emotionalfactors in the problem, the problems, this approach senting symptoms willdissipate. With deep-seated but it is a long and expensive to emotionaldisturbance may be necessary; problems also route and may notbe required with lesscomplc.1 behavior grouped under the generalheading of emotionaldisturbance. The Re-ED demonstration is exploring the extentto which directeducational programming can be effective inmodifying relationshipsbetween children identified asemotionally disturbed andtheir socializing systems. The Re-ED treatment pattern assumesa basicvalidity in the traditional child-rearing arrangements in ourculture, that they are, onthe whole, effec- disruption of child-rearing tive and wholesome for achild's development. A emotionally disturbed, functions, as manifest in theidentification of a child as influencing that is therefore looked upon as adisturbance within the systems disruption in the child-rear- child, rather than withinthe child himself. If the provided by a ing systems for achild is not completelyenervating, the relief the fairly rapid shift in symptoms, orin demands on thechild, may allow socialization systems to recovertheir potential for growthand continue the hypothesis in mind, goals are setfor processrelatively unaided. With this reading skills, learning children at the Re-ED schoolsemphasizing things like in a classroom forextended periods of time,trusting adults, to tolerate sitting this ap- and living with peers with aminimum of conflic. In many ways, rather than psychi- proach to a child's problems maybe thought of as social, the effects of thechild's atric, treatment. TheRe-ED strategy is to look at specific ways his behavior at an overt, symptomaticlevel and to see in what which he is a member. behavior creates conflictswith the social systems of Then an attempt is made to constructa sequenceof learning experiences the child's behavior. that will influence, quitedirectly, the area of concern in The process begins with areferring agencychildguidance clinic, family involved in the identifica- service agency, school, orother community agency children. The Re-ED school is tion or treatment ofemotional disturbance in facility, but as a resource not seen as asufficient or autonomous treatment children. In most cases for agencies in the communityalready working with will continue to workwith the agency referring achild to a Re-ED school the parents while the child isenrolled in the school. Theadmission conference; reviews the history of between the referring agencyand the Re-ED school, date, and the the child's problem, any treatmentof the problem attempted to goals current status ofthe child, his family,and school. Preliminary treatment conference, with an emphasis onspecific areestablished at the admission changes that can be maderather quickly in thechild's behavior, or in his limits imposed by the intent to natural environment,within the realistic addi- return him homequickly. Planning forthe child's release, including mobilized, is initiated at thead- tional community resourcesthat need to be

i 356 NEW APPROACHES IN THE SCHOOLS mission conference and is an integral part of the treatment pattern.These plans remain flexible to allow for the unpredictable inhuman and institutional behavior, and the thrust is forward, anticipating futurebehavior rather than explaining past events. There has been a gradually diminishing concern with thekind and degree of pathology in making the decision to enroll a particular child.When the schools were first opened, rigorous use was made of exclusioncriteria like severe psychosis, brain injury, and mental retardation. Asthe confidence and skill of the staff have grown, the admission decisions have come to reflect a judgment that a child and his socializing systems canrespond in specified ways to the group-centered educational program andmobilization of community resources. This attitude has resulted, of course, inthe admission of children with a wide range of diagnosticlabels, although each child must have some uniquestrengths that can be exploited. By and large, children admitted to the Re-ED program rangein age from six to twelve years. The modal age is ten, and perhapstwo-thirds to three-fourths of the youngsters in residence at any given time arebetween the ages of ten and twelve. Of the thirty-two youngstersaccommodated by the program twenty-four are boys and eight are girls. Althoughthis is largely a matter of administrativeand housing convenience, the numbers reflect quite faithfully the ratio of referral of boys to girlsby community agencies and clinics. Following the admission conference, the child is assigned to aparticular group; and the specific preparationfor his enrollment begins. He visits the school, with his parents, and meets the children andteacher-counselors with whom he will be living for the next few months. Theteacher-counselors begin to outline a specific program of remedial education andsocial living experiences, based on their analysis of thedetails in the clinical and education records on the child. In addition, they preparethe other children in the group for the coming of the newchild, so that on the day of his enrollment he will be received warmly, on the basisof realistic expectations, including whatever problem behavior he is likely to present to the group. The school day typically begins about 9:00, proceeds until noon,with time out for a recess period, and resumes after lunch untilabout 3:00, when the recreation period begins. The school day is heavily loadedwith instruction in basic academic skills: reading, arithmetic, and useof language. Since the placement of children in groups is based more on socialbehavior than educational development, much of the instruction in basic skills is individualized; and the convent is determined by the social utility of askill for a particular child. However, units of instruction that will supportheterogene- ous educationalabiliOes, such as preparing for a field trip to the Smoky Mountains National Park, are also a vital part of the schoolcurriculum. The nonacademic part of the school day also emphasizes thelearning of skills which have social currency for elementary school agechildren, but PROJECT RE-ED: EDUCATIONAL INTERVENTION 357 which, for some reason, have not been developed. The ability to kick a foot- ball, for example, or to roller skate, swim, or ridea bicycle may have a social utility as great as arithmetic skills in a child's reintegration into his normal school and home environment. Thus, a program of planned instruction, reflecting an assessment of a child's need for socially adaptive skills, is extended beyond the bounds of the usual school day. This is true also of the evening program, which emphasizes the skills required in living harmoniously with a group of peers and the adults to whom a child is responsible. It is one of the important strengths of the Re-ED staffing pattern that the afternoon and evening hours, including the homely child-care tasks of eating, dressing, and getting ready for bed, are supervised by sensitive, competent personnel. While much of the interaction of this time is not planned in any specific sense, it is a time that is rich in opportunities for learning skills in social living and exploration of personal feelings. The way an adult responds to a child's refusal to eat or to go to bed, or his strong impulse to hurt another child, can make an important contribution to the child's social and emotional development. The intensity and intimacy of group living provide opportunity for personal growth that is not encountered elsewhere. Each child's progress toward his goals is reviewed periodically, along with the progress being made in planning with the child's family, school, and community resources. As soon as a judgment can be made that the child is functioning just well enough, and/or the systems in his commtmity are changing their tolerance thresholds enough to support his behavior without undue conflict, and with a reasonable prognosis for his continued healthy development, plans will be made to return him to his own home and school. During this time the teacher-counselors become more active in working with the child's parents and regular teacher. The Re-ED staff, the referring agency, thc child's family, his school, and the child himself are all actively involved in planning the return.

SELECTION AND TRAINING OP STAFF

One of the innovations in Project Re-ED is the development ofa new professional role identity, the teacher-counselor. The teacher-counselor is an educator whose role definition has been radically expanded from that of the classroom teacher. He is, of course, first a classroom teacher with skills in teaching basic tool subjects to elementary age children,. He is also a counselor, recreation supervisor, camper, parent surrogat; and general handyman. In addition to the multiple skills required for wor;:ing effectively with children in a total educational milieu, he must be cony exsant with the language of the mental health specialists who refer children to the school and to whom he turns for consultation, The teacher-counselor role is an attempt to provide one model that may THE SCHOOLS 358 NEW APPROACHES IN ease the acuteshortage of highly specializedmental health professionals. Basically, the idea is to recruitsuccessful, young publicschool teachers, provide them with a brief butrigorous training program,and give them suppositions of responsi- port from mentalhealth professionals as they move into bility on the staffs of the Re-EDschools. This plan ofinduction into a professional role has severaladvantages over the training inthe traditional mental health professions. Thefirst, obviously, is time. Lessthan one year of graduate study is reauired.The shorter time in training ispossible because the teachers selected for the programhave already demonstrated competence and developed a repertory ofskills with children in apublic school classroom. The second advantage is thatthe experience theseteachers have had in regular classrooms allows arealistic estimate of theirfuture performance, take based on supervisors' andcolleagues' evaluations. It is an attempt to advantage of the natural variationof behavior among teachersand to bring into a training program personswith demonstrated empathywith children's problems, creativity in approachinghuman relationships, and so on,rather than depending on thedevelopment of these necessarycharacteristics in a training program. A thirdadvantage is in the efficientutilization of mental health professionals in trainingand consultation. The yearof formal training which brings only launches theteacher-counselor on a course of experiences him much later to mature,well-rounded professional competencein planning a total educational programfor disturbed children. Akey ingredient in these experiences is theavailability of frequent consultationwith psychologists, psychiatrists, andsocial workers. The training for teacher-counselorsconsists of three academic quarters of course work and practicumthat lead to a master of artsdegree in special education, with emphasis in the areaof emotional disturbance. The program of study presumes an acquaintancewith educational proceduresfor normal children and builds upon thisbackground. Course work introducestrainees working to conceptsand procedures used by themental health professions in with emotionally disturbedchildren, educational procedurescurrently being milieu treat- used in school programs foremotionally disturbed children, and ment techniquesused in residential settings.In addition to the courses that are aimedspecifically at work withemotionally disturbed children, trainees take courses in remedialreading, clinical-educationaldiagnosis of learning difficulties, and techniques ofcounseling. Each trainee is also engaged in apracticum throughout thethree academic varters. The practicumemphasizes three kinds of experiences:(1) clinical education with individualchildren, (2) small group teaching,and (3) liaison work with families,schools, and community agencies. The practicum is centered inthe program at CumberlandHouse, the Re-ED demonstration school inNashville. Each trainee has opportunityfor observation and increasingly responsibleparticipation in all parts of the program. Whilethe work of the school does notdepend upon teacher-counselors 359 PROJECT RE-ED: EDUCATIONALINTERVENTION provide a real service in the training program,all assignments are intended to as well as anopportunity for the trainee tolearn more effective techniques with of educational planning fordisturbed children. The assignments vary the needs of the trainee, but mayinclude tutoring a child who isnearing the end of his stay; developing aremedial reading program for anonreader; music, art, and providing an enrichment programfor a group of children in science, etc.; or working as anassistant to a teacher-counselor orliaison teacher.

THE STAFFING PATTERN

There are four roles which,in combination, providethe unique operational pattern in a ProjectRe-ED school as it attempts toinfluence not only the behavior of a child but theprimary socializing systems towhich the child will return. These roles are(1) teacher-counselor,(2) social worker, (3) liaison teacher, and (4)consultant.

THE TEACHER-COUNSELORROLE It will already be quite clearthat the SIMMS of a Re-EDschool is highly correlated with the successof individual teacher-counselorsin planning and carrying oneffective programs for children.Two teacher-counselors work as a team with a groupof eight children, setting goals,planning daily the plans program,evaluating progress, andarticulating their efforts with foi parents, home schools, andcommunity agencies. In consonancewith the objective of helping smooththe child's return to hishome, school, and community, theteacher-counselor's initial goal-settingreflects a kind of "social created systems" diagnostic thinking.Specific behaviors that have in the past discordance are likely to be reflected inthe goals set for a child.Since most of the children referred have ahistory of academic difficulties,goals involving school achievement arelikely to be given prominenceand can be formulated quite specifically. Problemsrelated to social responses oremotional reactivity are likely to bestated in general terms atthe time a child is admitted to the school and sometimes mayrequire a period ofobservation by the teacher-counselorsbefore particular goals can beformulated. There is a continuous applicationof two criteria: (1) goals mustbe responsive to the social milieu to which thechild will return and (2) goals mustbe feasible in a program of briefeducational treatment. The program planned for a groupof children by the twoteacher- counselors also reflects two kindsof concerns, the individual goalsjust mentioned and group process goals.The work toward individualgoals takes place largely in the contextof group interaction. Mostchildren referred for residential treatment need tolearn new techniques forrelating to peers and to important adults intheir lives. Planning for anovernight camping 360 NEW APPROACHES IN THE SCHOOLS trip, a car-wash to earn extra money, or the building of a tree house provides a task orientation around which conflicts ocuirand problem-solving processes evolve. The teacher-counselors engage in a constant cycle of planning, carrying out of plans, and evaluation of ,:esults in giving direction to the group process and the achievement of goals for individualchildren. Two slightly diffe:ent roles have emerged for the two teacher-counselors working with a group o children. Although both come from aneducational background and have received similar training, one works with the group during the day, primarily in the classroom, and emphasizes the formal teaching aspects of the role. The other works with the group afterschool and during the evening and emphasizes the informal counseling, group work aspects of the role. They met each day for one to twohours to review goals and day-to-day planning in order to maintain maximum consistency in an educational milieu during each child's waking hours.

THE SOCIAL WORKER ROLE The only representative of the traditional mental health disciplines in a full-time staff position at a Re-ED school is the social worker. It is a somewhat unusual social work role, eschewing direct service and working as a coordinator of the total program for achild enrolled in the school. Initially, this involves development of referral information with an agency or clinic and planning with the agency and family for the child's enrollment. The total plan will involve four aspects: (1) the work of the teacher-counselors with the child, (2) the work of the referring agency with the child's parents, (3) the work of the liaison-teacher with the child's regular school, and (4) any special community resources that need tobe developed for a particular child, such as remedial tutoring, YMCA membership, a part-time job, etc. The total plan is cast in broad outline before a child is enrolled and is monitored and modified, if necessary, by the social worker. The strategy ofworking with all the child's socializing "systems" is seen mostclearly in this coordination of several different attempts to facilitate the functioning of a child in his various social milieus. Since the general treatment goal encompasses more than change in thechild's behavior, a shift in parental attitudes, a move by the family to a newneighborhood, or the availability of a particular classroom placement may hasten the return of the child to hisnatural environment. It is the social worker's responsibility to be sensitive tothese changes as they occur and to articulate the several efforts as they interact in developing a mutually positive relationship between the child and the social system to which he will return.

THE LIAISON-TEACHER The liaison-teacher role reflects our perception of the importance of school in a child's life. To some extent, the success a child has in coping with problems arising from demands made on him at school influences more PROJECT RE-ED: EDUCATIONAL INTERVENTION 361 global appraisals of him made at home and elsewhere. The liaison-teacher has the same background of experience and training as theteacher-counselor; some are formerteacher-counselors. The role revolves around articulation of the public school and Re-ED experiences for a child.Initially, before enrollment in a Re-ED school, theliaison-teacher makes a caeeful appraisal of the sources of discordancebetween a child and his school, ranging from specific reading disabilities to mannerisms that annoy his teacher or peers.This appraisal receives careful consideration in setting goals for the child.During the time the child is enrolled in the Re-ED school, the liaison-teacherhelps him maintain contact with his home school through conferences withhis teacher, approximating assignments wherever possible, exchange of letters with classmates, etc. As the planning for his return gets under way, the liaison-teacher discusses with the home school teacher the remedial techniques that have been used, any special management problems that may stillbe anticipated, and program modifications, within the realistic limitations of a public school situation, that may be required. Following the child's return, the liaison-teacher helps ease the transition by maintaining regular contact as an educational consultant tothe classroom teacher. THE CONSULTANT ROLE The mental health specialist in the Re-ED schools functions as a consultant. One of the general aims of the project is to develop moreefficient use of theavailable supply of psychiatrists, psychologists, and social workers. In line with this aim, the Re-ED schools use only educators indirect service roles with children, with mental health specialists in consulting roles. After experimenting with a variety of consulting patterns, three have emerged as ways of integrating the body of knowledge of the mental health professions into the operational pattern of a residential school. First, consultants are used to help evaluate existing clinical records on a childbefore he is enrolled. Second, many kinds of specialists are on call to meet with teacher-counselors on unusual problems, not only mental health professionals but specialists in pediatrics, physical education, social group work, elementary education, etc. The third pattern of consultation is the regular program consultant, usually a psychologist, who meets at least once a week with the two teacher-counselors to help evaluategoals and techniques for individual children. The consultant comes to each session with his background of professional skills and specific knowledge of the child being discussed but with no authority to make decisions in programplanning. Decisions are made by the two teacher-counselors and are clearly defined as workinghypotheses to be tested in the program and continued ordiscarded on the basis of feedback from a child's behavior. The relatively heavy investment in consulting time is intended not only to provide teacher-counselors withwhatever help they need in solving problems of the moment but to provide a learning experience that will allow teacher-counselors to develop into behavior specialists in their own right. 362 NEW APPROACHES IN THE SCHOOLS

INTERVENTION IN SOCIAL SYSTEMS

The initial impetus for Project Re-EDcame from a desire to create a staffing pattern that would substitute for the more expensive traditional patterns of treatment for emotionally disturbed children. In choosing to use educational personnel and techniqueswe made an implicit choice not to use the psychotherapeutic model, but to evolve our own conceptual framework from experience with thenew staffing pattern. We were obliged to limit ourselves to specific goals relevant toa child's natural environment which could be achieved ina short-term program relying on direct teaching and an educational milieu. Themore conventional treatment programs do not always aspire to complete "cure" of a child's problems, but they do tend to set ambitious goals with respect to the development of new response patterns. They also tend to accept more or less total responsibility for modification of a child's behavior to allow him to cope with all of the possible stresses he might encounter as he moves back into his natural environment. The emphasis on specific, short-term goals in the Re-ED schools has led to a different way of thinking about emotional disturbance. One begins with the premise that the identification ofa child as "emotionally disturbed" reflects a state of discordance between a child and the primary agents of his socialization, rather than a psychological condition within the child. It isa judgment that the normal process of socialization has been interrupted. The socialization of a child proceeds through the mediation of a set of small social systems, primarily his family and his school, with support from informal and formal peer group units such as boy scouts, church groups, and so on. One may think of a family or a school classroom as a miniature, relatively self-contained social microcosm with a system of values regarding mutual expectations of the participants toward each other. In a family unit the parents, as the socially-sanctioned transmitters of the culture, value certain behaviors, attitudes, and feelings in their children as evidence that the system is maintaining satisfactory progress toward one of its goalsdeveloping a fully socialized adult. A child's responsibility in the socialization process is to learn the valued attitudes and behaviors of his socializing systems. Most children do. Those who do not, or who do not seem to be making reasonable progress toward the desired behaviors, may be identified as emotionally disturbed. Operationally, this takes place when a parent's assessment of the discrepancy between expectations and behavior is so great that homereme- dies are no longer sufficient and assistance is required from professional child- socializing agencies in the community. This mode of thinking leads to reconceptualization of objectives. Instead of concentrating, as therapeutic programs do, on the intrapsychic life of the child and aspiring to a fundamental reorganization of personality, one concen- trates on the needs of the social systems of which the child is an integral 363 PROJECT RE-ED: EDUCATIONALINTERVENTION the part; the goalbecomes one of making quitespecific changes to facilitate goal functioning of the child's socializing systems.The achievement of this might be furthered by anumber of interacting events:by changes in the the program behavior of the child, by greaterfamily stability, by changes in and child access to a of the child's own school,by providing the family community center, and so on.All components mightimprove a little or one development could gat the systems component might*rove a lot; either above threshold for sustainingthe child and make them"go." While the child and his patternof behavior are importantin the planning of treatment, he is notthe sole focus of concern.One thinks of the entire complex of socializing systemsthat influence the child asthe locus of discordance and the field intowhich one introduces change.The concept is similar in some ways towhat Barker and Wright(1955) have called psychological ecology. Their interest,however, is in the influenceof behavior of settings on individualbehavior, while ours is inthe location of points discordance between a particularchild and all of thebehavior settings that that the specific make up a set of socializing systemsfor him. This means child to behavior settings with which we areconcerned will change from child, but will includehis home, his school, andthe formal or informal peer constellation group activitiesin which he is currentlyengaged. The particular emotionally disturbed is seen as of systems for a childwho is identified as leads tempora rily outof balance. The specificationof the discordance, in turn, parents' to the specificationof objectiveswith regard tothe child's behavior, expectations, school programs,additional resources in the community,etc. that would be expected tofacilitate the functioning ofthe entire system. How shall we talk about the contentof discordance andthe planning of programs to reduce it?We are still groping toward aninternally consistent language that will give substance tothe bare ribs of ourumbrella concept the vocabulary of edu- of discordance inchild-socializing systems. Neither the cation, emphasizing cognitive aspectsof normal child development, nor vocabulary of mental health,emphasizing idiosyncraticemotional develop- theory ment, offers theperspective we are seeking.One possibility is role concepts, liberallyreinterpreted to fit our need totalk about relationships within a complex of social systems(Brim, 1959). Role theory concepts arebased on an interaction of two personswith complementary expectations. Whateverthe nature of the tworolesparent- implies a child, teacher-pupil, etc.theidentification of a role-relationship set of mutualexpectations that structurefor each participant hisobligations and privileges with respect tothe partner. Most parents,for example, include in their concept ofparent-child roles an expectationthat the parent provides food, clothing, and protectionagainst physical hazardsand that the child conforms to household routineslike mealtime, bedtime, and careof family share the parent's property. Thechild in the relationship may or may not role expectations, but hewill have a role concept of somekind. "That's not 364 NEW APPROACHES IN THE SCHOOLS fair!" or some variant reflects the child's perception of another person's viola- tion of his expectation. The "presenting symptoms" attributed to an emotionally disturbed child may be construed as a judgment by his parents that the child's role performance is not meeting the parents' expectations. The concepts of role prescription and role performance are used to distinguish betwe.en a generalized social norm and the behavior displayed by a person in the role. A slightmodification must be made in analyzing the role- relationship between two particular persons to make the concept of role prescription flexible, depending on the context in which the relationship exists. That is, the child's role prescription for the father-son interaction diffe .5 from that for the older brother-younger sister, but the father-son role prescription also changes with the settingfor example, it is different at the supper table than itis at the swimming pool. A child's role prescriptions also change through time as a function of generalized expectations of children of different ages"He should be able to keep dry at night." "He should be out playing with other boys his age," or "He should be getting interested in girls." They change, less predictably, according to parents' moods or momentary concerns, and thus there is an implicit requirement of children to be sensitive to the current arrangement of values inthe hierarchy of role prescriptions held for them by the natural evaluators in their lives. As psychological constructs for thinking about problems of emotionally disturbed children, role prescription and role performance focus our attention on the visible aspects and judgmental consequences of disturbing or discordant behaviors. Rather than inquiring into the cause of the problem at the level of the psychodynamics of the child, we approach themanifesta- tions of the problem quite directly from the parents' statemen t of presenting symptoms, or the statements of other "natural evaluators." Reeducation, from the child's point of view, involves the learning of new roles and the unlearn- ing of old roles. For other participants in the child's socializing systems, reeducation may also involve the learning of new roles, but particularly will involve learning of new role prescriptions held for the child. Our efforts in reeducation are therefore directed toward two complementary goals: (1) increasing the congruence between the role prescriptions held by the systems and those held by the child and (2) increasing the congruence between these role prescriptions and the child's role performances. It is the achievement of these goals that reinstates a balance of mutual positivereinforcement and reduces discordance in a system. What is the content of these role prescriptions and role performances? What is it that a parent has in mind when he thinks about how his child should be? Clearly, one aspect is observable behavior manifested by the child. "He ought to pick up his clothes" or "He ought to read better," for example. In other ways the content of role prescriptions is related to inferred aspects of behavior, a child's motivation or feelings. "He should try harder in school," "He should love his parents," etc. A third element in the content of role 365 PROJECT RE-ED: EDUCATIONALINTERVENTION performance on other prescriptions has to do withthe effect of the child's role should persons. "Heshould be popular withother children" or "His parents be able to trust him." Whatever the content ofthe role prescriptions heldfor a particular child, role behis task is to learnthe role prescriptions,and their accompanying haviors, as they apply tothe social interactions inwhich he participates. He better than others, that learns that certain waysof thinking and feeling are others, and that certain reactions certain ways ofbehaving are better than also learn that "better" from other people arcbetter than others. But he must and under what par- varies with whichparticular person is the role partner ticular circumstances theinteraction takes place. In this context, emotionaldisturbance might be defined as an accumu- and role prescriptionsheld lation of discrepanciesbetween role performances be for the child by achild-socializing system, suchthat he can no longer tolerated by the system in its presentstate. By thisdefinition, there are two broadly con- sourcescontributing to the discrepancy:the child's behavior, of his behavior; strued to include motivationand the social consequences well as explicit, and and the parent's expectations,implicit or unconscious as relative to the vagaries of timeand place. It may be helpful to analyzethis discrepancy from thepoint of view Three conditions may pre- of a child whose roleperformance is inadequate. lead to vent roleperformance that can beevaluated as successful and may have the ability a judgmentof discordance. First, thechild simply may not Second, he may not be aware to perform therole prescription held for him. Third, he may find of, or comprehend fully,what the role prescription is. the consequences of therole performance lesssatisfying than those of competing roles. Let us examineeach of these limitingconditions. With regard to ability, ourunderstanding of individualdifferences re- If quires that we establishrealistic limits for ourexpectations of a child. of reducing the discrepancy an inabilityinvolves reading, our expectations the by working with thechild would be structuredby our understanding of limitations of the child to learn.Assuming for the momentthat most of the discordant behavior we encounteris not a functionof mental or physical deficits in specific role handicaps, some problems canbe classified as simple be dealt performance ability. These involvemostly technical skills and can The child knows clearly with by straightforwardremedial programming. what is expected of him, ismotivated to acquire theskill, and is guided performance, as in a through a sequence of experiencesthat improve his children whose pre- remedial reading or physicaleducation program. While senting symptoms are assimple as this are notoften referred for treatment, ability deficits which do need at- most of Ihechildren we encounter have tention during thelater stages of their treatment.There have been other, learning of more pervasive,role behaviors thathave interfered with the these specific skills. Aboy, for example, who hasbeen unable to formulate 366 NEW APPROACHES IN THE SCHOOLS for himself a role prescriptionas an active, assertive male will need considerable practice in athleticgames, fighting, or whatever skills are appropriate as he begins to develop hisnew role. The second source of discrepancy, the failureof a child to understand what his valued role prescriptionsare, presents a more serious kind of problem and will account formany children referred for treatment. Lack of clarity in a child's knowledge of the valued roleprescriptions held for him may be based on incompleteor inaccurate information. A boy in a fatherless family may not be able to display role performancecongruent with his mother's unverbalized masculine role prescriptions forhim simply because he has had no models, human or verbal, available to him. Children's understanding of role prescriptions for themmay also be unclear because of conflicting information from differentsources, like father and mother or family and neighborhood, or from thesame source, which shifts unpredictably between conflicting role prescriptions. Whatever thesource, when a child's inadequate role performance is based on inadequate formulation of his roleprescriptions, the program of reeducation must include behavior modelsin the form of stable adults and verbal analogies. Having children live and workin the company of adequate, responsive adults allows the childrento use them as role models. The same general notion is present in theexamination of the lives and motivation of great men in history. The more specific aspects ofa child's formulation of his own role prescriptionscome about in the intimacy of group living, and the conflicts stimulated by thisintimacy, with the opportunity for discussion and resolution of varied role performances. Assuminga continuous and realistic evaluation of the role performances thatoccur naturally in group interaction, new role prescriptionsare developed, tested, and clarified, and emerge as new role performances. In problems that involve failurein role performance due to ability and in problems attributable toa lack of clarity in the child's role prescriptions, one assumes a generally favorable orientation toward other human beingsas a source of motivation for new learning. A withdrawn childcan entertain and try out new roles if he regards the adultsin his new surroundings asgen- erally rewarding. Thesame will be true of a child who has some sort of serious gap in his repertory of role prescriptions dueto absence of experience in some areas of behavior. He will be willingto engage in new role performances if the support andencouragement of adults is gratifying to him. The most difficult problem encounteredin the reeducation of disturbed children is one in whichwe cannot assume the efficacy of social reinforcement. Where a child's inability in role performancecan be attributed to unconcern with, or outright rejection of, other human beingsas a source of reinforcement, the quality of the problem and the relearning requiredto cope with it seem very different. We encounter children whoare unresponsive to appeals to try new role PROJECT RE-ED: EDUCATIONAL INTERVENTION 367 behaviors based on acceptance and approval. Their engagements withliving are solitary or, where otherpeople do become involved, antisocial and disruptive. It may be useful to think of this kind of problem as primarilymotiva- tional and prior in time to the learning of new role prescriptionsand role performances in the sequence of reeducation experiences. The twoother kinds of relearning depend heavily upon relationships with other persons as a source of motivation.With motivational problems it is the ability to relate that must be relearnedthe experiencing of other humanbeings as dependable sources of gratification. One promising approach tothis problem has evolved from an operant learning paradigm, making useof whatever tangible rewards the child is presently motivated toward. Abehavior modification program in our setting has adual function: first, to help the child learn some simple skill, such asconforming to basic classroom routines; and second, to help him learn that there ispredictability and gratification in relationships with adults. Simple desensitization routines have alsoproved useful with children who have school avoidance problems. Another possibility for a child whose failure in role performance is due primarily to motivation is the development of a separate "vestibule" program before being enrolled in the regular Re-ED school. The readiness ofthese children for learning academic skills and for discussion of mutual role performances is probably no greater than that of developmentally normal children who are some two or three years younger. Perhaps it is less because of the range of negative responses already learned with respect to other persons. The kind of unstructured, primitive camping program we operate at oneof the Re-ED schools may be uniquely appropriate withchildren whose learning objective is an attitude of basic trust andenjoyment in a relationship with another person. Without the conflicts and antagonismsaroused by schedules and group management problems, a few ofthese children in the presence of a protecting, nurturingadult can begin to attach a positive valence to the adult which generalizes toother phases of the program. Only after people become rewarding can a child engage himself in thelearning of new role prescriptions and role performances. While it is convenient to separate these three sources ofdeficit in role performance for purposes of discussion, it is probably not realistic tothink of a single child as deficient in ability or understanding or motivation.Prob- ably most children referred as emotionally disturbed will have a mixtureof all three kinds of difficulties contributing to discordance in their socializing systems. The usefulness of the rolelearning concepts is that they emphasize specific behavior modification in a program for a child and guide our aspirations for, and our evaluation of, his progress. At the same timethey identify contributions of the socializing systems to the perceived discordance and suggest modifications in the child's ecologywhich will support the changes in his behavior. A different parental response to the child's aggressivebehavior, 368 NEW APPROACHES IN THE SCHOOLS a different teacher,enrollment in a community recreation program, andother modifications in the child's natural environment areequally important in a plan to reestablish equilibrium in the totalchild-socializing system.

REFERENCES

Albee, G. W. Mental health manpower trends. New York: BasicBooks, 1959. Barker, R. G., & Wright, H. F. Midwest and itschildren. New York: Harper & Row, 1955. Brim, O. G. Personality development as role learning. In I.Iscoe & H. W. Steven- son (Eds.),Personality development in children. Austin, Texas: University of Texas Press, 1959. Pp. 127-159. Kanner, L. Emotionally disturbed children: A historical review.Child Develpm., 1962, 33, 101-102. Lewis, W. W. Continuity and intervention inemotional disturbance: A review. Except. Children, 1965, 31, 465-475. Szasz, T. The myth of mental illness. NewYork: Hoeber-Harper, 1961. 20 A SCHOOL DISTRICTPROGRAM FOR SCHIZOPHRENIC, ORGANIC,AND SERIOUSLY DISTURBEDCHILDREN George T. Donahue Jewish Vocational Service, Milwaukee,Wisconsin

INTRODUCTION

For many years, professional disciplinesinvolved in the educational and developmental problems ofchildren have been concerned withthe school age child who cannotbe taught in a regular classroombecause of emotional problems. Research has developed reasonablygood techniques for their early identification and diagnosis. Onceidentified, the children, moreoften than not, are thenexcluded from school. If andwhen they are again readyfor school, they return as educationalcrippleshandicapped educationally in comparison to their age-gradepeerswhich in turn can lead tofurther maladjustment. More serious is thefact that most of these youngstersbecome the nation's "attic" children, aliability to themselves, theirfamilies, and the community. The problem ofdeveloping a program of educationadapted to the needs of these children wasfaced by the Union Free SchoolDistrict #16, Elmont, New York, which believes inthe philosophy that the publicschools the needs of all of the are responsiblefor an educational program adapted to children of all of the people. Elmont is in Nassau County,Long Island. It is contiguous toQueens and is midway between thenorth and south shores of LongIsland. The greater part of the westernboundary marks the dividingline between this school district and the borough ofQueens. The unincorporated area inthe district is a part of the town ofHempstead. The community isflat, with paved, orderly, treeless streets,and, like many communities inNassau County, devoid of large open areas for therecreational use of residents. Elmont's location is such that it cannotbe classified as urban or surbur- ban. It is technically a suburb ofNew York; but in actuality, it is asuburb with many urban characteristics.The community itself is notcurrently self- supporting, and probably neverwill be, since there is almost noland remaining for industrialdevelop, lent. The community consistslargely of private i 369 370 NEW APPROACHES IN THE SCHOOLS residences and their supporting neighborhood shopping centers. Sincethere is no industry (other, perhaps than the Belmont RaceTrack), most of the residents do not earn their living locally. They commute toNew York or to other Long Island areas which have industry. There are some,however, who do live and work in Elmont; for example, a small number ofprofessional men. In addition, a fewbusinessmen live and work in Elmont; but most of the shopkeepers commute from New York City or from otherLong Island communities. There are four community service organizations: Kiwanis, Chamberof Commerce, Lions Club, and Italian Mutual Aid Society; but none of these appears to be a strongunifying influence in the community. The school district has mushroomed to its present size only recently. Fifty years ago a one-room rural school house adequately served theneeds of Union Free School District #16, and the annual school budget atthat time totaled less than $1000. There have been severalperiods of rapid school population growth, each accompanied by increases in schoolfacilities. These occurred in 1924, 1929, and during the post-World War IIperiod, which marked an era of growth that has been equaled by few communities in the country. In the 1930's, there were approximately2,000 pupils in kindergarten through eighth grade; by 1946, there were 3,000 school children in the district; by 1949, the kindergarten to eighth gradeenrollment had reached 3,600; by 1960, there were approximately 6,000 pupils in grades kindergarten through six alone, and another 3,000 in grades seven to nine. The gross population in Elmont today is close to 50,000 people. Asnoted above, the vast majority of this population is housed in private dwellings that, at today's market price, would be salable in the $15,000 to $25,000 price range, with a few runninghigher, and some running quite a bit less. Some of the housing is substandard, especially in those areas found adjacent to the race track, where garages have been converted into living quarters. As might be expected, Elmont's residents consist primarily ofrelatively young families who moved from NewYork City to an area considered suburban to secure the advantages of suburban living for their children.The Elmont School District, certainly in comparison to many of its Long Island and Westchester neighbors, is not an especially affluent one. Its ability to pay for education, asdetermined by the relationship of its real estate value to the number of students to be educated, islow.

FACILITIES OF THE SCHOOL DISTRICT

To accommodate the special educational needs of pupils with varying degrees of emotional disturbance, this school districtutilizes a variety of diagnostic and educational facilities. These include the following: 371 A SCHOOL DISTRICTPROGRAM

MEDICAL SERVICES school physician Each of the seven schools inthe district has its own supervising and its ownnurse-attendance teacher.There is, in addition, a school physician. As aresult of his exposure tothe many psychological school physician has, problems faced by theschool district, the supervising training and is now a himself, undertaken a programof further study and knowledge and insightshe psychiatric resident atHillside Hospital. The who, in turn, can gains there are passed on tothe other school physicians the school district facilitate understanding andcommunication between of the district's children.There is also a supervising and the family doctors otologist, and an nurse-attendance teacher, aswell as a psychiatrist, an opthalmologist, who areavailable on a part-timebasis.

SPEECH AND HEARINGSERVICE and hearing teachers. The district employsthree full-time speech children They have a directremedial teachingresponsibility for individual classroom and small groups ofchildren. In addition,they work closely with effectively with childrenwho teachers in order to helpthem to function more teachers also have responsi- have less serious defects.The speech and hearing of annual speech andhearing bility for the identificationof defects by means tests which areadministered to all children.

PSYCHOLOGICAL SERVICES psychologists and a part- The district employsthree full-time school provide diagnostic andappropriate time psychiatrist.Their function is to and to assist parents inob- follow-up services forchildren who are troubled contributing to the malad- taining treatmentfor themselves if they are seen as Community justment of theirchildren. The services ofthe West Nassau welfare, clinical, and familyservice Mental HealthCenter, as well as other diagnostic and treatment pro- agencies, are utilized tohelp implement this is discharged gram. This teamhas a preventiveresponsibility as well, which principals and teachers primarily through group andindividual meetings with of relevant areas. These for the purpose of increasingtheir skills in a number children, include methods andtechniques for interactingand dealing with mental health climates inall the establishment andmaintenance of good permit early identification classrooms, the developmentof sufficient skills to optimal of children in needof psychological services,and a consideration of for mechanisms for combiningtheir respective resourcesin providing service troubled children. 372 NEW APPROACHES IN THE SCHOOLS

VISITING TEACHERS The district employs two full-time visiting teachers. Their function is to work with the permanently and temporarily homebound children of elementary school age. They provide instruction for the homebound child in basic subject areas that parallel the programs of instruction in the same age and grade level in the schools.

ITINERANT TEACHERS

The district employs four part-time itinerant supplementary teachers. They have no classroom assignments. Their function is to work with emotionally disturbed children in the school buildings on a one-to-one or small group basis outside the regular classroom. They do this by providingperiods of tutoring and/or remedial instruction similar to that provided by the previously mentioned visiting teachers. They provide instruction in basic subject areas that parallel the teaching program that is goingforward in the classroom. These services are scheduled on an individualbasis as they are needed.

READING TEACHERS The district employs three full-time helping teachers with a specialization in reading. These are teachers who work in a staff capacity for the purpose of improving instruction in basic subject areas. They function in a consulting capacity to classroom teachers and in a directteaching capacity with individual children and/or small groups of children who require remedial tutoring. Among those requiring reading help are a number of youngsters whose academic deficits are quite likely a direct result of anemotional problem.

SPECIAL SUBJECT TEACHERS

The district employs special subject teachers in the areas of art education, music education, physical education, and library services. In addition to their responsibilities to the general school population, these special subject teachers are an important adjunct to the district's program of special adaptations for the child with emotional problems who cannot tolerate a full day in the self-contained classroom and whose program is, therefore, structured to include extra periods of art, music, physical education, library work, etc. The subject matter as well as the close relationship with a special teacher seems to help. The decisions concerning special programming for these children are made on the basis of interdisciplinary staffing conferences which include representatives from all the special services, classroom teachers, and 373 A SCHOOL DISTRICTPROGRAM shed light on anyothers whose involvementwith the child in question may diagnosis and/orrecommendations.

GROUPING POLICY recognize its neces- The philosophy of groupingin District #16 is to the group. sity, but to accomplishit in such a way thatthe child is not lost in limited sense, that Instead, the grouping itselfbecomes an instrument, in a This is accomplished helps the child's intellectualand emotional growth. by evaluating:

1.various :acets of anindividual child's personality; teachers and classmates; 2.the child's social andemotional adjustment to achievement; 3.the strengths and weaknessesof the child's academic 4. the teaching andpersonality strengths andweaknesses of individual teachers so that, to the extentthat it is feasible, each youngsteris matched to a teacher who islikely to contribute more tohis development than otherteachers in the same grade. The objective, then, inSchool District #16 is thatof "harmonious" grouping, something of acompiomise between the moretraditional extremes Using of completely heterogeneous orcompletely homogeneous groupings. ability, but such a procedure, there isoverlap among groups with respect to purely hetero- within somewhat narrower rangesthan would be the case in a principal and teachers geneous grouping system.Therefore, when the building grouping, the school have completed the preliminarywork in connection with insure the proper im- psychologist reviews theplacement of each child to plementation of the district'sgrouping policy. Retentionsand accelerations, too, are reviewedindividually by the* schoolpsychologist. adaptation and accommoda- Despite these notinconsiderable facilities for district has in its pupil tion to the educationalneeds of children, the school population, as does everyschool district, a numberof youngsters whose preclude their progress degree of emotionaldisturbance is serious enough to inhibit the educational prog- in normal classroomsand disturbing enough to educational ress of theother children in the class.To provide some organized embarked on the Project facility for these atypicalchildren, the school district for Disturbed Children.

THE PROJECT FORDISTURBED CHILDREN intelli- The youngsters in question,generally speaking, are of normal however, they are characterizedby a more than usual amountof vari- gence; IQ testing as well as in ability. This variabilityshows up at the level of functioning. Their behavior terms of theirday-to-day and even hour-to-hour THE SCHOOLS 374 NEW APPROACHES IN impulsive, and is oftentimes unpredictable;they are hyperactive, distractible, irritable; they havdifficulty in abstract thinking;they are anxiety ridden, emotionally immature, perseverative;usually they are schoolfailures. Not all of these children showall these characteristics, butall show some. It is this fact that makes it unwise towork with them in a normalclassroom s;Luation. District #16 was convinced thatspecial classes were not the answer to this problem. From a characterizationof these children, as well asfrom related literature, it appeared thatthe kind of program neededwould have to be custom made for each child inorder to reduce distractibility to aminimum teacher. Group and to establish a one-to-onerelationship between pupil and activities would need tobe included, and on-goingpsychiatric and psychological guidance would have tobe provided both forchildren and staff. No school district, including District4 16 which is relativelyunfavored economically, could afford to provide ateacher for each pupil andthe space needed to minimize distractions. Recognizing these factors and facedwith the problem of an ever present for group ofseriously disturbed children, thedistrict set about to create the 1959-1960 school year, aspecialized program within theestablished educational framework of the community.The general objectives were toprovide each of these seriously disturbedchildren with an individualeducation and training program based on hisidentifiable needs. This program was tobe developed around the conceptof total programming forseriously disturbed children, using the combined conceptsof educational training,psychological identification, and psychiatricinsight. If this could 1,successfully achieved, there would evolve a concept ofthe educational settingbeing organized for education, but concomitantlybecoming a therapeutic milieu. To structure such a programbecame, then, an administrativeproblem. The task was one of findingseveral available classrooms andteachers for the six original children (whohad been identified as needingthis program) on assist with the a one-to-onebasis,well as a sponsoring organization to financial support. The ultimategoal of the educational program was tobe individualized training through optimumrelationships and final reintroduc- tion of the child to theregular classroom setting without evertotally separating the child from thefamily or community structure.By providing the necessary specialized programwithin the context of a one-to-onerelationship and preventing the child'sexclusion from the community, it wasfelt that the educational program itselfcould become therapeutic tothe child. A basic premise of this approach isthat proper education and training canbe a therapeutic process. By workingwithin the established frameworkof the family and the community, thedisruptive effects of separation anxietywhich impede progress in residential treatment programscould be eliminated. It was alsolikely that successfully treatedchildren could be returned to regular classrooms sooner and wouldbe better able to function in a group,free of 375 A SCHOOL DISTRICTPROGRAM 1 educational deficits seriousenough to constitute abarrier to their adjustment ,, in the normaleducational setting. that all of the potential In casting about for apossible solution, it seemed problem were at resources neededfor an approach tothe resolution of this unorganized or under juris- hand in the community,but they were either could not be provided dictions apart from theBoard of Education. Since space already 6,000 children inbuildings with a rated in the schoolsthere were free of capacity of 4,800spacewould have to bedeveloped elsewhere, and not normallyused charge. As in almostall communities, there were areas fire department meet- during school hours, e.g.,church halls and basements, A neighbor, the ElmontJewish ing halls,American Legion dugout, etc. arts andcrafts Center, was just completing abuilding with ten classrooms, an outdoor swimming pool.This room, akitchen, a playground, and even an for the use of six class- seemed ideal. Permission wasrequested and granted needed. The Board rooms and anyof the other facilitieswhich the program the children, a teacher super- of Education agreed tosupply transportation for consultant services, andbooks and visor, the psychologicaland psychiatric supplies which werenormally a part of thedistrict's equipment. and to provide The Elinont Kiwanis Clubagreed to sponsor the project paid the premiums to insure some financial support.For instance, the club be injured. The club the center and the stafffrom suits should a youngster two-sided provided about $600 forspecial equipmentneeded, such as the electric answer boards,large easels and flannel boardsused for each child, and equipment, and locked steel cabinets inwhich to store and secure gear daily snack periods. the milk and cookiesprovided for each child during teaching The most difficult problem,however, was how to procure a relationship with staff in numbers sufficient tomake possible a one-to-one neededwarm, empathic, ma- the children. Furthermore,the kind of people difficult enough to find, evenif ture, emotionallystable, and dedicatedare communities, women salary were available.There were in Elmont, as in most who of this kind who havedone a good job withtheir own children and community activities. were in a position tocontribute some of their time to From among such women camethe "teacher-moms."No widespread appeal of refusing was madefor these "teacher-moms" -'rorder to avoid the necessity children. By the help of people notdeemed suitable forworking with these contribute two morn- personal contact, a number ofmothers were invited to under the ings each week toworking with a child,the work to be done psychiatric director. supervision of the professionaleducational staff and the administrator and the These mothers wereinterviewed by the educational psychologists. Every effort wasmade to discouragethem by painting a black interviews provided a picture of what they wereabout to get into. These insights with regard good opportunity for theprofessionals to obtain some to the volunteerherself. It was felt that if two mothers wereteamed and assigned to aparticular NEW APPROACHES INTHE SCHOOLS 376 week each, this would come veryclose to providing the child two mornings a being able to theoretically desirable one-to-onerelationship, in addition to four mornings a weekof instruction.There was no trouble in account for with the original six securing the originaltwelve "teacher-moms" to start for the program wassuch children. Indeed, theenthusiasm of the mothers twelve given that it was possible torecruit an initial groupof eighteen, with placed on an "on-call" orsubstitute actual assignments andthe remaining six thirty-eight "teacher-moms," basis. The program is nowexpanded to include currently twenty-eight assigned to active statuswith the fourteen youngsters enrolled and the remaining tenin a standby status. whom they The teams werethoroughly briefedabout the child with They were given appropriate would be working bythe professional staff. educational materials and asketchy introduction toteaching methodology, specializing at the primary- and the enterprise wasunder way. A teacher grade level was detailed tothe project to be assistedby the "teacher-moms" supervise and coordinatethe details of supply,transportation, as needed, to physician, and district's psychologists,the supervising school etc. The school "teacher-moms" as they the psychiatric consultantworked closely with the began to feel their way inassisting these childrentoward personality integration and educationaldevelopment. charge, the principles As a direct extension ofthe elementary teacher in "teacher-mom" assigned to be used bythe "primary-gradeteacher" and the of the program to meetthe child's to assist wouldinclude: individualization needs; integration of the judged psychological,emotional, and educational to the greatest pos- child's activities with thoseof other children in the group such as motor, visual, sible extent; the use ofmultiple combined modalities maximal utilization of a tactile, and auditory, inthe overall teaching process; child and a warm,interested close interpersonalrelationship between the the child's limited adult; keeping learningperiods brief so as not to overtax limiting attention capabilities;providing rewards for appropriate responses; external controls and limitsin extraneous stimuli;and providing sufficient the child. A typical"pre- order to reduce impulsiveacting out behavior in charge and the scription" which serves as aguideline for the teacher in "teacher-moms" follows:

Name of Child:Stevie Reading: Weekly Reader 3 and 4 Ginn "Roads to Everywhere"4th Book Dictionary NovemberFingerplays DecemberPoems Book about MissilesScience Social Studies:Indians, Settlers, and Pioneers Spelling: Silver BurdettBook 4 Language RoundupBook 4 377 A SCHOOL DISTRICTPROGRAM Math: Modern ArithmeticBook 4 Manipulative Material

Divided Curriculum:Mrs. N. R. (Teacher-Mom, Mon.and Wed.) will pick up the responsibility for the readingand arithmetic. Mrs. B. K. (Teacher-Mom, Tues. andThurs.) will pick up the responsibility for reading, spelling, andlanguage book. Last 15 minutes may be used foroutdoor activity. Of necessity thisplan must be flexible. Materials will be added andsubtracted as progress is noted. Repetitionis built into plan. hand in some areas to Psychological: I.Anticipate his clinging to the work at the exclusion of other areas, e.g.,arithmetic. Skillfully manipulate him toward another area. 2.Stevie may have trouble functioning inthe group because he wants to be the centerof the group while havingambivalent feelings about it. If he cannot bemaintained with these adaptations, he should be removed. 3.Because Stevie, at times, lives in his ownworld, limits and boundaries must be provided fromwithout. 4.If Stevie appears to be living inhis own world, every attempt should be made to bring him back tothe reality world.

A typical morning for a child and his"teacher-mom" follows:1

The teacher-mom meets her projectchild as he gets off the station wagon, escorts him to his assigned roomand helps him stow his gearand clothing. She then takes him to the "good-morning" room,where the professional teacher-incharge is waiting to conduct the opening groupexercises. These consist of the salute to the flag and a short reading anddiscussion period. The reading anddiscussion evolves from what theteacher-in-charge has written on theblackboard, or from "show and tell." She tries toinclude sentences at the readinglevel of each of the children which, when puttogether, make a paragraphabout the day's weather, or a holiday or an event, orsomething with which the children are familiar. Discussion is encouraged. Theopening exercises may last a veryfew minutes or as long as fifteen, contingent uponthe manageability of the groupthat day. While this is going forward theteacher-mom has secured thebooks, games, and equipment she plans to use thatmorning, and is in her assigned roomready to receive her childwhen he returns from theopening exercises. She sits next to, and close to, the child, and the day'swork begins. She may begin with reading,usually using the reading series andsupple- mentary materialsavailable to the professional teachersof the district. She is encouraged to follow the teacher'smanual more closely than aprofessional teacher, because the manuals are well developedguides and provide comprehensivedirec-

I Reprinted with permission ofThe Macmillan Company fromTeaching the Troubled Child by George T. Donahueand Sol Nichtern. Copyright, @The Free Press a Division of The MacmillanCompany 1965. 378 NEW APPROACHES IN THE SCHOOLS tions on how to teach the series with which she is working. From reading she moves to other subject areas, such as arithmetic, spelling, language skills, social studies, science. These activities, interspersedat her discretion with games, or talk, or a walk, or listening to records,go forward until 10:30 A.M., at which time there is a snack break. She takes her child toa large room with a long table and benches. One of the children and his teacher-mom have laidout the cookies and milk beforehandwhich is doneon a rotating basis. All the children as a group sit down and have their snacks under the supervision of the professional teacher-in-charge. While the children are having their snacks, the teacher-moms usuallyas- semble in the kitchen for coffee and cookies. Here there is much discussion of the project children, although sometimes it ismore social conversation than professional. The snack-time and coffee break takes fifteenor twenty minutes, at the end of which the teacher-mom returns to herroom to continue work with her child, following the plan for the dayas agreed upon with the teacher-in-charge. If other group activities are scheduled they usuallyoccur during the time between the end of snacks and the end of the morning. At 11:45 the teacher-mom begins to get her child ready to go home. At this point she completes her log of what transpired with the child that day, and leaves it with the teacher-in-chargeso that it is available for her teammate teacher-mom. In the course of the morning she has probably been visited by the teacher- in-charge, who provides on the spot direction and suggestions for furtheringthe child's educational program. This is a reasonably normal morning. Thereare some mornings that are not normal, however, because these childrenvary in their behavior and response from day to day, hour to hour, and sometimes minuteto minute. What the teacher-mom brings to the child is her own emotional climatethat ofan affectionate, understanding mother. Her empathy with the emotional needs of the childmay result in her altering his academic program, even to the point where it is discontinued. When she senses tension building in the child she is freeto lead him away from the academic learning experience by playing agame, taking him on her lap, going for a walk. This leads to a relationship learning experience, which frequently obviates academic or emotional failure for the child. Shemay even decide to remove the child completely from the structure by taking him to the firehouse, or the post office, or just out on the playground. She must be perceptive enough not to respond to provocation by the child. Here she may lean heavily on the teacher-in-chargeor the psychologist, even to the point of having the other professionals takeover completely for a short period of time. Sometimes the teacher-moms have teamedup to handle an acting-out child. In short, the teacher-momsare constantly interfering with the expected, disturbed patterns of these children. This theyare in a position to do promptly by virtue of the one-to-one relationship. She must use her judgment and imaginationat times to help the child overcome his academic learning difficulties. The result has been the utilization ofsome highly unorthodox teaching methods and materials. With theassistance of the teacher-in-charge and the psychologist, because the teacher-mom recognizedthat the child retained little or nothing of what had been taughtover the past few weeks, learning programs have been modifiedeven to the point where a child has

1 379 A SCHOOL DISTRICTPROGRAM been stopped and started all overagain. Incentives such ascookies, candy, stamps teacher-mom found that byallowing or coins for acollection have been used. One her project child, a girl, tofix her (the teacher-mom's)hair she could return the learning task. A teacher- child to concentration foranother period of time on the taught, for, as mom began torecognize in one child aneed to be fed as he was by ingesting food and he put it, it was "brain-food."Perhaps for him it was, since learning simultaneously he wasproviding himself with twoingredients essential teacher-mom, working with aboy, found that allowinghim for survival. Another made use of his to stand upand move about helpedhim concentrate. She even preoccupation with clocks, notby removing the clock butby keeping one close another part enough so that his preoccupation waschannelized, thereby permitting of him to concentrate onreading or arithmetic. toward the A group activity of about twentyminutes' duration is provided education, physical middle of the morning, whichincludes arts and crafts, music education, or story time.Other group experiences includethe daily snack-break of milk and cookies, andthe children's riding togetherin the school district's station-wagon bus to andfrom school. Each child'sbirthday is celebrated by a these group activities simple party during snack time.The teacher-moms supervise on a rotatingassignment basis, usually two orthree to an activity. Increasing use and is being made of theplayground facilities for freeplay and organized games, seems to beworking reasonably well (Donahue& Nichtern, 1965).

The women are accepted asthe fourth member of theprofessional team is that the and are treated as professionals.The theory behind the program teacher in charge will get herwork done, as will thepsychologist and the psychiatrist, through these women.Close supervision of their work is accomplished by the teacher in charge,who is at the project full-time.She works advising and with the "teacher-moms"indivieually and in small groups, coaching them. She helps themadvance the child's education byevaluating what they are doing and howthey are doing it. She is alert tothe interpersonal dynamics between thechild and his "teacher-mom" andfrequently is the bridge between the"teacher-mom" and the psychologist orpsychiatrist whom she may contact at any time.The psychologist isscheduled to work at the projectone-half day every two weeks,although she is "on call" at all times if needed. Thepsychiatrist visits three or fourtimes a year, or as needed. Group meetings of the"teacher-moms" are scheduled twice a year with the combination of teacherin charge, psychologist,psychiatrist, and school administrator. But again,this is flexible. If the needarises, a meeting is scheduled.

PROGRAM OUTCOME

Periodic comprehensive evaluationof the children in the program academic year. wasundertaken, usually at thebeginning and the end of the Such evaluation included:traditional clinical diagnosticprocedures with THE SCHOOLS 380 NEW APPROACHES IN tests such as theRorschach, Wechsler IntelligenceScale for Children, Bender- Gestalt, Draw-A-Person, and Children'sApperception Test administeredby the psychologist; direct observationof the child by the psychiatristand psychologist; standard educational assessmentprocedures such as report card grades, achievement test scores, and teacherjudgment; and, often times, interviews with parents. Thesevaried data were typicallybrought together into a clinicalconference concerning the child in question,and judgments with respect to progress anddisposition were made by participatingprofessional personnel at that time. Perhaps some of the outcomes ofthis program can be illustratedby a series of brief clinical resumespresented in the form of case vignettesabout specific children. The informationprovided, in each instance, derivesfrom the sources described above. D. C.Male-7 years, 5 months.His diagnosis was schizophrenicreaction of childhood. The situation wascomplicated by considerable pathology inthe total family situation. His motherhad been hospitalized formental illness, and his father was also disturbed.The child developed muchbetter controls, a longer attention span,real enthusiasm for the work andlearning situation, and a positive relationship to his"teacher-moms" and some of theother children. His hyperactivity was greatlyreduced, and coordination showedmarked improvement. He was phased into 11regular first grade of twenty-eightchil- dren and is now in sixth grade. B. T.Female-7 years, 7 months.Her diagnosis was mild cerebralpalsy and mental retardation, poorcoordination, short attention span, littleinterest in other children, poorhand-eye coordination, distractibility,and hyperactivity. B. T. progressed to the pointthat she could handle a penciland produce basic forms. Her attention spanincreased, and her interests broadened.She acquired some impulse control,completed the readiness program,learned to identify and write her name,developed arithmetical conceptsof most-least, first-last, sequence, bigger-smaller, etc.,and left to right progression. She is now successfullyfunctioning in one of the district'sclasses for the educable, mentally retarded. J. A.Male-8 years, 8 months.His diagnosis was schizophrenic reactionof childhood with the severe regressive symptomof soiling. He was hyperactive, harmful to others, and so disruptivethat he could not be contained inthe regular classroom. In addition,there was considerable familypathology. His parents would not cooperatewith the therapeutic proposalsoffered by the local mental health center.When placed in theeducational-therapeutic milieu, this child progressed rapidly,both academically and socially. Hissoiling ceased. His relationships athome improved. He began torelate well to the other children in the programand was phased into a regularthird grade on a half-time program.J. A. is now functioning well insixth grade. 381 A SCHOOLDISTRICT PROGRAM aphasic child withorganic involve- C. M.Female-8 years,1 month. An problems, this child wasknown to manyclinics ment andextensive emotional which City as well as to somelocal mentalhealth facilities in New York from completely hopelessand should betotally exempted advised that she was enjoys physical completely withdrawnchild. She now school. C. M. was a be a happy, attrac- has improved impulsecontrol and appears to contact. She aleadership tive little girlwho plays withothers and occasionally assumes second grade, inthe middle groupin role. She wasinitially phased into a and is now insixth grade whereshe is reading on a reading in her class, spells appropriately sixth-grade level. She isanxious to learnand writes and fact, at times she is achat- for her age. Mostimportant of all,she speaksin understand, she has asizable vocabulary terbox. Though notalways easy to and a desire tocommunicate. schizophrenic child with R. L.Male--8 years,1 month.Diagnosed as a hurt other children,did not participate bizarre behavior,violent at times, he respond to reasoning,and was egocentric,autistic-like, with the group, did not sulking. R. L. given to extreme tempertantrums, and immature, demanding, relation- poorly coordinated.He now has positive wasphysically large and coordination is im- ships with his peers,and particularlywith adults. His and is receptive tosuggestions proved. He has lostmuch of his impoliteness successfully with otherchildren and sometimes and authority. Hetries to play high degree ofacademic ability, shares willingly andvoluntarily. He has a In mathematicshe can solve prob- particularly inmathematics and science. and paper to solve.His resistance lems mentally that mostof us need pencil and he is reading ongrade level. He is now to readinghas been overcome, residential setting. in a junior highschool program in a schizophrenic C. C.Male-8 years,9 months.C. C. was diagnosed as a be a severe behaviorproblem. He child who on the surfacewould appear to conceptualization andvisual-motor percep- demonstrated grossdistortions in His deficitsinhibited his tualization and extreme unevenessof performance. in the special program,it was adjustment in all areas.When he was entered the beginning.He needed much necessary to starthis academic program at He progressed to afourth-grade level repetitition and varietyof approach. regular seventh grade;this and is now functioningwith competence in a including severemarital discord and despite a familywith much pathology, handling of the child. extremeinconsistencies in the One was in the project anaverageof two years. The children remain professional team, months; another, five years.It is always the kept only six decision psychologist and teacherin charge,who make the i.e., psychiatrist, be phased progressed to the pointwhere he is ready to as towhen a child has The decision isdetermined by thechild's into a regularclassroom program. 382 NEW APPROACHES IN THE SCHOOLS ability to relate to other children, to his "teacher-moms," and tothe teacher in charge. He must be able to sustain himself in groupactivities, work as independently as some other children in his normal age-grade group,and compete academically with at least someof the other children in the normal group. The psychologistand psychiatrist jointly evaluate the child to determine whether or not enough integration of personality hasdeveloped for the child to survive in the normal group setting. The "phasing-in" is carefully accomplished. A critical factor is the classroom teacher. A decision ismade jointly by the psychologist and building principal as to which of the available teachers at the child's age-gradelevel will provide the optimal circumstances for his development. If inthe child's neighborhood school none of the teachers, by temperament, disposition,and method of operating, is thought right for the child, he will betransported to another school in the districtwhere there is such a teacher. No criticism of teachers is implied here because it takes a particular kind of personwith the insights necessary and a tolerance level appropriate to workwith a disturbed child. The child might start a half day a weeksometimes on aFriday afternoon when there mightbe assembly programs or other special activities scheduled. The time is built up as rapidly as the child can take it.Sometimes a child will remain in the project part-time and regular school part-time.Often the "teacher-moms" will be asked to stand by in the schoolbuilding as the child starts back to regular class so that should he need to be releasedfrom the regular classroom, the familiar person is immediately available.A child's schedule can be structured so that, temporarily, he is given some time bythe supplementary teacher in the building on a one-to-one or small groupbasis. Or, he may get extra time with the art, physical education, or musicteacher, the librarian, or the school nurse-teacher, depending on his needs. The building psychologist has the primary responsibility for working closely with the child and with the building staff to help make the child's transition as smooth as possible. Perhaps the most fundamental evaluative criterion that can be used in a project of this type is the functional one of the child's ability to return to the normal classroom situation and to function effectively in that context. By that criterion some initial success for this program has been achieved. Of the first twenty-one youngsters referred to the program, eleven have been returned to their regular classes and have demonstrated an ability to make normal progress in that setting, both educationally and interpersonally. Given the fact that these are youngsters selected initially because of the extremity of their difficulties and a total inability to profit from the normal educational regimen, preliminary findings along this very concrete dimension are encouraging. Youngsters participating in our program are those who mightformerly have been viewed as "unsalvageable"children destined for continuing, and perhaps increasing, frustration and failure in their school careers. The 50% 383 A SCHOOLDISTRICT PROGRAM such a sampleand seems to warrant "return" rate is anappreciable one for program-development ofthe type described continuation andextension of earlier in thischapter. has been the impact onthem? They What of the"teacher-moms"? What of operation onlythree of theoriginal have persisted.During a second year replacedone for reasonsof pregnancy, onewith a com- eighteen had to be to continuebut situation, and onewho just did not want plicated family twelve active substitute whenneeded. Of the original did agree to act as a operation. It is with the programafter five years of its workers, seven were satisfaction from the thought that they arederiving a good dealof personal child. In addition,they have contribution they aremaking directly to a because of theirparticipation in achieved a certain statusin the community formally recognizedby testimonialdinners the program.This has been more with the other women,too, hashelped and some publicity.Perhaps socializing reduce the separationrate. professionals workingin connectionwith They have beentreated by the and, undoubtedly,have profited in these children asfellow professionals problems and of insights into someof their own terms ofdeveloping keener untrained people children better.While they were understanding their own of train- the months,acquired a good deal when they started,they have, over Coupled with their ownintrinsiccharacteristics, ing in anunorganized way. increased their stature. this has greatly has and substantialgratifications, the program Despite these numerous has real problemsfor our"teacher-moms." There also presented some very has resulted inthe mechanism operativewhich, at times, been a transference with these with their pupils tooclosely. Progress "teacher-moms" identifying the "teacher-moms"be- understandably beenslow. Sometimes children has gains beingmade. Part of the discouraged and wereunable to see the came these reactionsand, through professionals hasbeen to be alert to job of the with the"teacher-moms," to discussions andindividual consultations group impact of theirexperience influencetheir help them toavoid having the family and personallives in anundesirable way. become somewhatcompetitive intheir At times the"teacher-moms" have their pupil. Thisis bothdesirable and zeal to makeacademic progress with cognizant of both important that the"teacher-moms" be undesirable. It is the need for assistingthe academic progressand, concomitantly, the need for supervision ofthe individual child toward moreadequate and integrative and theirdevelopment over time. "teacher-mom"-child interactions impact on theentire had a catalyticand contagious The program has the part of princi- has developed a greaterawareness on community. There needs successful adaptations tothe individual pals and someteachers that time, satisfying investmentsof imagination, of children areprofitable and expansion oftheir efforts ingrouping and effort. Therehas been a great placed with theteacher who, as a particu- children so that this orthat child is SCHOOLS 384 NEW APPROACHES IN THE lar personality, will provide theoptimal conditions for the child'stotal growth. Some children with problems are nowbeing accommodated by part-time programsweighted with more art, or music, orphysical education. In general, the resources of the school district arebeing mobilized and adaptedfor ac commodating children's individual needs.Teachers are developing notonly early, children who are in an awarenessbut also some skill in identifying, need of specialized help. Most importantof all, professional educators are undergoing a subtle improvementof attitude, brought about,perhaps, by greater knowledge,which has led to understandingof children, acceptance of them as they are, and as aresult, adaptation to theirneeds.

CONCLUSIONS

It is believed that the schools can andshould adapt to the needsof the emotionally disturbed child.First, the school system inAmerica is the only social institution in our culture which issufficiently impactful to begin to come to grips,systematically, with the problems of theemotionally disturbed child. Second, it has theadvantage of a staff of professionalpeople who are oriented, in part at least, to someof the developmental problemsof children. Third, it is believed in this countrythat separating the severely disturbed child from his normal environment is notdesirable for most of these children. It is true that, given some family situations,professional people would regard the family pathology as being sodetrimental that a child wouldbe better off outside the home. But it hasbeen our experience that wehave not had to refuse towork with a single child, even whenthere was a lack of cooperation or a lack ofunderstanding on the part of thefamily. Despite such circumstances, children getbetter, although perhaps not soquickly as they might were the family to cooperateand receive from the community agencies the therqy and otherkinds of supportive help thatthese agencies are in a position togive. Some parents are not able to acceptoutside assistance with emotional problems perhapsbecause there is, among these people, afear, as well as alack of understanding, of what thepsychologist and psychiatrist can contribute.But, despite all his shortcomings, theeducator is in a position in most communities which is notthreatening to parents. Theeducator has a good deal tocontribute in assisting people to get to thekinds of help which would be beneficial for them. Therefore,the educator should be provided with the necessary resources, inthe schoolnot in agencies separateand apart from theschool. The shortage of trained clinicalpersonnel has been noted by the Ameri- can PsychiatricAssociation (1964), among others. "In theface of the manpower problem, newand creative ways of trainingsemi-professional personnel and volunteers are beingdeveloped and should be further explored.They 385 A SCHOOL DISTRICTPROGRAM shortages and for improv- hold much promise,both for mitigating manpower effectiveness of treatment programs.New types of service ing the range and Thus, the use of are alsostimulating new patternsof training" (p. 27). fits in with thephilosophy the volunteer inthe Elmont community program representing mentalhealth pro- and the desiresexpressed by organizations Psychiatric Associationand the fessional groups,including the American Association. American Psychological On It might be arguedthat the educative processis itself therapeutic. locus for mental health pro- those grounds, therefore,the school is a logical has much to offer,especially with the supportof psychologists and grams and educator's psychiatrists. The successof such programswill depend upon the learning process, the responsibility foraltering the object of the acceptance of the group the child, in order toenable the youngster toprofit maximally from intellec- educative process. It is notunusual to find adisparity between the A child emotional developmentallevels of youngsters. tual, physical, and three emo- chronologically andintellectually, but only two or may be six normally in a tionally. Such a youngstercannot beexpected to function make an effort to reducethis kindergarten or first-gradeclass. Someone must accommodate to the group developmental disparitytoenable the child to felt, is a proper functionof situation and to find acceptancein it. This, it is for early identificationbe education. It requires,however, that a ,tructure developed. psychological services, thework of In our school districtwith its limited been concentrated at thekindergarten, first- andsecond- the psychologist has working out grade levels; it consistsof early identificationof problems and the approach will limit ongoing of necessary adaptations.It is felt that such an fewer problems will destructive processes in manychildren, and eventually arise at the upper-gradelevels. emotional problems is One further asset of theeducator in dealing with coordinate that he is in a position tomaintain a focus onthe child and to in the the efforts of specializedcommunity agencies.The fragmentation seen effective help to theneedy social agency field is a realdetriment to bringing diverse agencies so that child. Someone must coordinatethe functions of problem everything they have tocontribute is brought tobear on the specific be provided for allwho are of a given youngster. Inthis way direction can dealing with him. There is little evidencethat professionals with amajor clinical invest- when one ment can dosuch a job successfully.This seems most obvious estimated that there are examines the scope of theproblem. It is generally problems in the public one-half million childrenwith serious emotional which schools. One can add tothis figure the 10% ofthe school population the National Instituteof Mental Healthand the Mental is estimated by the face of Health Association to require someprofessional attention. In is devised to usethe such totals it becomesevident that unless some way SCHOOLS 386 NEW APPROACHES IN THE skills of the psychologist and psychiatrist on amuch broader basis than is currently being done, little progresswill be made toward alleviatingthe problem. This implies that such professionals must operatethrough other nonprofessional and professional people who canimplement recommended approaches. The school system may bethe vehicle through which such programs are bestoperated. The fragmentation of the child and hisfamily through a proliferation of agencies is a condition that needs correcting.The personnel and resources that are ordinarily spent on such agenciesmight well be put to a moreuseful purpose if invested inthe Rile l syaem. To be sure, schoolpersonnel would require considerable reeducatim.The retraining of guidancecounselors, principals, etc., by people in Lk psychiatricfield as well as by other mental health professionals might make themcapable of coordinating functions so that the child is served most effectively.Perhaps the Elmont project is an example of one form such a programmight take.

REFERENCES

American Psychiatric Association. Planningpsychiatric services for children. Wash- ington, D.C.: Amer. Psychiat. Ass'n.,1964. Donahue, G. T., & Nichtern, S. Teachingthe troubled child. New York: Free Press, 1965. v SUMMARY 21 EMERGENT APPROACHES TO MENTAL HEALTH PROBLEMS: AN OVERVIEW AND DIRECTIONS FOR FUTUREWORK'

Emory L. Cowen University of Rochester

Whatever has been said thus far is most readily understood inthe context of the three principalobjectives that have guided this volume. The first aim was to delineate a set of issues which are considered tohave prime significance for any searching examination of the mental healthproblems of modern society. In so doing, some limitations oftraditional and historically dominant mental health stratagems and practices have beencited; and an attempt has been made to identify centralproblems which must be engaged, conceptually as well as concretely, if a sounder mentalhealth order is to emerge. Next, severalchapters have been addressed to matters of conceptualization and guiding orientations to mental health problems. Thoughthese reflect differences both in the aspect of the total problem to whichthey are targeted and in the substance of the viewpoint represented, they encompass a spectrum of possibilitieswhich may have heuristic value for implementing specific mental health programs. And, finally, descriptions havebeen presented of a number of concrete program models, varied in objectivesand in substance, but sharing as a common denominator the attempt tointroduce fresh, new approaches to basic and long-standing problems inthe mental health area. Viewed against this backdrop, there may now be merit in trying to get some distance from specificchapter contributions so as to: (1) achieve a type of preliminary consensus concerning the underlying issues raised inthe opening chapter, (2) crystallize alternative modelsand their implications, (3) develop a frame of reference and a sense of direction forfuture work,

I The author wishes to express his sincerest appreciation tohis friend and colleague, Dr. Melvin Zax, who, during the course of his sabbatical stay at theKommunehospitalet in Copenhagen, Denmark, made important substantive andeditorial contributions to this chapter. Moreover, some of the ideas expressed herein have evolved over anumber of years marked by close interaction, researchcollaboration, and discussion of issues and practices in the mental health fields with him. 389 390 SUMMARY and (4) highlight those questions whichare still open and must be engaged if the emergent approaches orientation isto be pursued in an optimally effective manner. In contrast to the problem-definingposture of the first chapter, the present one emphasizes the expression ofa point of view. Indeed, the phrase "point of view"may be little more than a socially desirable euphemism for a network of systematized biases and prejudices.

SCOPE OF THE PROBLEMAND PROFESSIONAL RESPONSIBILITY

Any responsible effort directedat overcoming the mental health difficulties of modern society shouldstart with a reaffirmation of the enormity and complexity of the problems that confrontus. Illustratively, there is good reason to suppose that the principal, help-oriented techniques utilized in the past are limited in their clinical effectiveness. Ofeven greater concern is the fact that such techniquesare limited in their reach, most often according to the rule that those who most require help findit least available. Moreover, we are grossly deficient with respect to the availability of technology for engaging vast segments of our population whose mental health needs have remained essentially unmet. By and large,we have ignored er repressed these lacunae or have felt helpless in approaching them. And, not the least ofour problems is the fact that professionalmanpower and resources in the mental health sphere, either in the presentor in terms of the most optimistic extrapolations into the future, are woefully inadequate for the taskat hand. Accordingly, the issue seems less that of makinga case for the magnitude of this particular set of problems and more that of making decisions about optimal starting points toward their resolution. Inherent in the foregoing remarks is the conviction thatconcern with mental health problems cannot, and shouldnot, be the exclusive responsibility of any single disciplineor professional subgroup. Taken together, the helping professions, as presently defined.,represent a numerically weak and poorly equipped army. That their efforts might be furtherdiluted by squabbles of possession and prerogative, "brush-fires," and internecine warfarecan only guarantee a disastrous backsliding for the total mental health operation. In this vein, we would emphasize that thepresent volume, not accidentally, transcends professional lines both in editorship and authorship,reflects view- points bearing on mental health problems from responsibleprofessionals sharing a common focuson such problems, whatever their disciplinary fields, and seeks to avoid parochial identification. There is need also for a sobering reminder that the helpingprofessions, even assuming that they represent a welded and homogeneous force,are not themselves in a position to be the sole contributorsto knowledge about and solutions for mental health problems (Cottrell, 1964). There shouldbe an EMERGENT APPROACHES TO MENTAL HEALTHPROBLEMS 391 important place for theoretical andempirical contributions from other relevant disciplines, including physically oriented ones such asbiology, biochemistry, and neurophysiology, and socially oriented areassuch as education, economics, political science, and sociology. In fact, it isappropriate to go one step further by pointing out that the very conceptof "helping professions" may be little more than an artificial abstraction growing outof a mental health orientation that begins at the point of pathologyand focuses on subsequent rehabilitation. In that sense the actual termhelping professions is better understood as a product of historical accident ratherthan as one which has an intrinsic logical justification. It is conceivablethat future patterns of mental health programming, professional interdependencies,communication, and cooperation might sooner involve a combinationof some members of the presently constituted helping professions togetherwith sociologists, educators, political scientists, and economists, rather thanthe historically typical intra- helping profession team of psychiatrist, clinicalpsychologist, and social worker.

CONCEPTUAL APPROACHES

It would be gratifying to have available a masterplan which one might hope to apply, with reasonable confidence, to theresolution of our major mental health problems. Unfortunately, such ablueprint does not exist; and we must expect much ambiguity as we strive to movefrom the level of ideas to that of concr6.e action. Perhaps the principaltools now available are those of logical andco-,ceptual analysis buttressed, only to aminimal extent, by beginning indications of supportingempirical data. Perhaps the most central need in the mental health area atthis time is that of conceptualization, since programdefinition, implementation, and articulation, as well as much of our research effort, should restlogically on such a base. This point has already been givenconsiderable emphasis in the chapters by Albee, Turner and Cumming, and Reiff.Many of the shortcomings in our present mental health structure mayreflect either the fact that we haveoverlooked underlying conceptual issues or that ourpartial and implicit conceptualizations have not been in tune withsocial reality. Although the importance of the conceptual elements of the totalproblem cannot be overemphasized, wedo not mean to imply that there is a unified and dominant conceptual orientation thatcharacterizes the chapters of this volume. Indeed, if there is a common denominator, itwill be found, structurally, at the level of dissatisfaction with aspects of our presentmental health order and in terms of attempts to deal in innovative wayswith problems that have been refractory to traditional approaches.Substantive programs described in this volume have not, necessarily,started from a base of systematic conceptualization. This is entirely understandable!Programs often develop in response to relatively concreteneeds or unresolved problems as these arise in 392 SUMMARY particular settings. Their profile and format aredetermined, to a considerable extent, by the structure andsubculture that characterize those settings.Con- ceptualization is sometimes explicit, but perhaps moreoften implicit. Mcreover, the enormity of our mental healthproblems is such that no single program can be expected to grapplewith them in their full complexity at this time. Accordingly, eventhose who have been concerned with conceptual issues have gravitated toward partialconceptualizations geared to salient aspects of specific programs. Ourfailure to have identified a comprehensive and agreed-upon conceptual "leitmotif" inthis volume should, therefore, be regarded as neither surprising noralarming. Since the current state of our knowledge is so limited, there isample need for exploration, trial and error, and probingthe limits of varied approaches, evenwhere underlying conceptualizations are, at best, partial andimplicit. Maximal utility from a systematic,conceptual orientation may be expected toderive at the level of long-range and global mental health planning,since it will help to establish needed priorities and to point up relatively morepromising courses of action within a social framework where limited resources mustbe allocated with particular judiciousness. At the risk of oversimplification, it maybe said that there are two principal models that warrant primeconsideration for their pertinence to mental health problems. The first of these may becalled the medical model; the second, the public health or preventivemodel. It would be incorrect to suppose, notwithstanding the availability of ready stereotypesfor each of these concepts, that preference for one oranother model corresponds to one's membership in a particular professional group.Such is not the case, either within the relatively limited confines of this volume or inthe world at large. If we were to study theconceptualizations and belief systems of mentalhealth professionals, we would find individualpsychiatrists, social workers, and psychologists who, in the factorial sense, arecloser to each other than they are to colleagues in their respective professions.Perhaps because of this, some issues can bebetter drawn, in that disagreement andconflict can follow ideological, rather than professional, lines. AsReiff cogently remarks (Ch. 5), "A power struggle on the basis of ideology can be animportant catalyst for institutional change" (p. 86). Since ideological orconceptual models appear to be so important for the mentalhealth fields, a more specific examination ofsuch models is in order.

THE MEDICAL MODEL ASAPPLIED TO MENTAL HEALTH PROBLEMS There has been no necessary unanimity in past usageof the term medical model, and in speaking of it, variouswriters have emphasized different of its attributes as salient(Bloom, 1965). Indeed, the very concept itself is a somewhat projective onethat conjures up a spectrum of images 393 EMERGENT APPROACHES TOMENTAL HEALTH PROBLEMS ranging from the highlylaudatory to the entirely pejorative.Specific reference of the chapters of to one or more aspectsof this model has appeared in many this volume, and detailedconsideration of it is presented inthe chapters by Albee and Turner and Cumming. Certainly one broad notionwhich is central to theextended usage of the medical model concept inthe mental health sphere isthe belief that emo- the tional and psychological disorder maybe regarded, structurally, much in same way asphysical illness or dysfunction.An extension of this belief, perhaps caricatured, is to be found inthe popularized andsomewhat overworked cliché that mental illness is the same as anyother illness (Joint Commission on MentalIllness and Health, 1961). Though the foregoing principle isbasic to the model, there maybe differences in the level of literalnesswith which it is espoused.In a more nar- disease row sense,emotional disorder may beviewed, quite specifically, as a Such is a involving specific biological,chemical, or physiological pathogens. "disease model," and those subscribing toit place heavy emphasis oncurative interventions involving chemical,surgical, shock, and other typesof physically-based therapies. In addition,research stratagems, given this view, are directed toward the developmentof more effective therapeutic agentswithin this same genus. For others, stillwithin the framework of themedical model, a givenpathological condition, be it an anxietyneurosis or schizophrenia, may be viewed as a typeof "illness" without recourse toliteral assumptions about its disease nature or itsetiology. It is quite possible, forexample, to view the determinants of currentmalfunction as largely psychologicalin nature andtherefore accessible topsychologically-based ameliorative procedures, such as psychotherapy. Ineither case, there is a focus onpathology or pathogenic onineffectual functioning. There isthe tacit assumption that the source mustbe identified through utilizationof some combination of tools from our diagnostic armamentariumand that a type of remedial intervention, be it physical or psychological, mustbe directed toward theelimination or reduction of that source. Though not necessarily definingcharacteristics of the medical model, several other of its attributesshould be noted as logicalderivatives. Given a primary focus on pathology, itfollows that the model is largelypassive-receptive in its social stance.People with intrapersonaldifficulties, when they become sufficiently unhappy or theirfunctioning reaches a certain pointof ineffectiveness, seek out, or are brought infor, help. At such a momentthere is the tendency to view thehelping professional as bothknowledgeable and authoritative, much as the physicallysick individual views his doctor.More- over, expectancyand, indeed, actual practice issuch that subsequent diagnostic and therapeutic contactsinvolving the helper and the personseeking help proceed largely via the same one-to-onepattern thatcharacterizes the clinical interaction between aphysician and his patient. At several points in this volume,particularly in the introductorychapter 394 SUMMARY and the chapter by Albee, detailed consideration has been directed tothe question of why the medical model has emerged as thedominant ideology behind our approaches to mental health problems. This evolution hasbeen multiply determined. In the first place, the very earliest general"practice of medicine" grew up in response to concrete needs of people who hadphysical (or emotional) problems which perturbed them or others around them.Un- like the physical sciences, mental health practices did not develop outof a curiosity to understand nature's intricacies. For the individual, as long ashis body (or mind) functioned properly, there was little impetus to think about medical phenomena. Accordingly, the earliest precursors of the medical model grew, quite logically, as the responseof a few relatively perceptive members of primitive society to the acknowledged needs of other membersof that society. The earliest healers invoked magical incantations andtheir spiritual powers and probably had some success.Only over a period of many centuries has there been a gradual replacement of the primitive practices ofthe healer by scientifically-based alternatives. In particular, the markedadvances in physiological and biological research in the eighteenth and .'^enth centuries resulted in the conquest of disease entities which, up tietio)e, had been totally enigmatic (Bloom, 1965). The physician was providet:ith the means for far greater success,and the use of the age-old model was sharply reinforced. The healers' magic had become quite formidable. At the same time, an intellectual climate was developing which was strongly reinforced by the early psychoanalytic movement and was characterized by a growing concern about psychological dysfunction, again in response to the complaints of people with troublesome symptoms.The potential conquest of emotional disorder took on the qualities of a newand exciting fron- tier. Under such circumstances it is not surprising that a model whichhad had astonishing success and seemingly limitless potential in a related area should have been seized upon to fill the vacuum in the psychological sphere. This is especially so since it was a model with which medical men were familiar and one that seemed to fit certain situations with which they were grappling. Certainly it was to be preferred to the prior mystical and spiritu- alistic explanations of maladaptive behavior. Moreover, for many decades alternative ideologies about mental health problems simply did not exist because our perceptions of whatsuch problems entailed had not yet changed. We have, therefore, been in a prolonged "proving period," with this particular set of conceptions guiding mental health operationsin our society.

Criticisms and Limitations With the growth and evolution of modem society, the success we have experienced in overcoming physical disorders, our ever-increasingability to meet physical and materialneeds, and technological advances making for more comfortable livingand increased leisure time, we have entered an era EMERGENT APPROACHES TO MENTALHEALTH PROBLEMS 395 where higher-order concerns about the emotionalweneing of man, concepts of his optimal functioning, andself-actualization have come increasingly into focus. Otherwise stated, we haveidentified new types of problems iuthe mental health realm. We have movedsteadily, in recent years, toward the conviction that a "square deal" with respect tomental status is desirable for everyonenot just a luxury forthe enlightened few. That thishas been something more than idle philosophizing is wellreflected in concerted social planning at the highest and most influentiallevels. Huge sums of money have been allocated and many new programshave been implemented seeking to improve the emotionalwell-being of members of oursocietyincluding those who do not clearly perceive suchproblems in themselves. One aspect of this significant socialtrend has been the implicit need to scrutinize, as realistically aspossible, the pros and cons of priormental health programs and operations. As aresult of this process, it hasbecome more apparentitscontributions and merits notwithstandingthatthere are fundamental limitations to the scope andeffectiveness of the medical model which require careful reexamination. First, it is necessary to recognize that, in mostinstances, the etiology and nature of psychological disorder isfundamentally different from what is involved in physical disorder (Schofield,1964). Emotional problems do not characteristically result from tissue damage orinvasion by viruses or bacteria. Rather, they are likely to reflect complexpsychological determinant., and multiple sources of influence deriving from exposure tokey social institutions and important "others" in the individual'slife experience. That currently manifest psychological problems may havelong-standing and deep-seated determinants is more likely to be the rulethan the exception. If we take as an example a twenty-five-year-old adult experiencing severecurrent emotional disturbance, one way of looking at such a personis to say his lifetime has extended some 200,000 hoursmuch of thisliving potentially under the influence of profound daily irritants andpathological processes. As a basic long-range mental health stratagem, isthere genuine reason to believe that a given treatment approach, whetherit extends over 10 hours or 100hours, should be viewed as the method of choice inseeking to aiter an already well- entrenched style of life and ineffectualmode of adaptation? In the senseof long-range social planning (choice ofmodels), could we not be more optimistic if we were able to orientouTselves to an understanding of theinfluence systems and social processesthat underlie presently observableunfortunate outcomes, to modify such systemsand influence processes, and to build positively beforehand rather than beingrestricted largely to a type of after-the-fact "counterpunching"? The fact is that this sameorientation can be, and is, developed in medicineparticularlypublic health medicinewhen its concerns turn to issuessuch as the maintenance of thegeneral health of the public or stemming the developmentof epidemics. The magnitude of this concern ismultiplied by certain additional con- 396 SUMMA RY siderations. Helping professionals, as they presently define themselves, are in no position to look for troubled peopk. Instead, people seektheir help via the hospital, clinic, or consulting roomwhen personal difficultiesreach alarming proportions. Often, because of financial considerations, lack of readily available piofessional services, social stigmata, or personal anxieties about the meaning and implications of seeking professional help, the level ofdisturb- ance at the point such help issought may be profound. The moment of initial contact or action by the professional is, therefore, likely to be when symptomatology is rather well entrenched and morbidity relatively advanced. It must seriously be questioned that such is the optimal time for intervention. While the focal challenge-point for utilization of the medical model in the mental health sphere lies in the breakdown of its implicit assumption of an analogy between psychological and physical disorder (i.e., in its application to types of problems for which it was notdeveloped), this, in no sense, is the sole basis for social concern about it. A further order of criticism is to be found in a cluster of factors which may be encompassed under the umbrellaof "limited scope." This cluster includes at least three separate dimensions. In the first place, the medical model based as it is largely on the one-to-one clinical interactionis a very costly one from the standpoint ofprofessional manpower. We simply do not have a sufficient number of helpingprofessionals co provide mental health services for those who need it; and future extrapolations, as Albee has so amply demonstrated, indicate clearly that this disparity is likely to become exacer- bated over time. In this sense, it is fairest to think of this model as a hold- the-dike operation at the very outside. A second dimension of the "scope" argument has been stated earlier. The medicalmodel is intrinsically a passive one which engages disorder onlywhen disorder seeks it out. For this reason it necessarily fails to have impact for tremendous numbers of individualswith psychological disorder because, for any one of a score of reasons, their problems are not well enough defined to prompt them to seek assistancewithin that framework. And third, there is the issue of restrictions in scope imposed by limited technology. It has been strongly emphasized in the chaptersby Reiff, Riessman, and Gardner that the form, "lingo," andmochis operancliof the medical model, in its typical implementations in the mental health sphere, are so alien and meaningless topotential consumers in vast segments of our population that there does not exist a basis for even initial, superficial contact. It is as if there were no overlap in groundrules as those are defined by the helper and potential recipient, and there is consequently no basis for "playing the game." Effectively, this means that mental health services have, until very recently, been defined, functionally, as out-of-bounds for the poor. There remains yet another set of considerations, somewhat beyond those of assumptions and scope, which constitute a final important componentof any assessment of themedical model as it has operated in the mental health arena. These pertain toits effectiveness, and are, perhaps, less a critique of the model itself than of the forms in which it has been implemented. No one HEALTH PROBLEMS 397 EMERGENT APPROACHESTO MENTAL denotable areas ofphysical disorder, would argue, even inthe relatively more and practices of themedical model havebeen 100% suc- that the operations health sphere granted, our "battingaverage" in the mental cessful. This much of failings reasonable criteriahasbeen far lower. Two types using any example, schizo- should be noted.First, fundamental entitiesof disorderfor assault. Although ourability phreniahave provedlargely resistant to curative community has improvedin recent years, to maintain somepatients in the pathology has beenreached, the for many patients, once acertain point of still that of languishingfor the remainderof one's days expected prognosis is have setting. Second, for manytypes ofemotional disorder we in a custodial caused it to be attach a savior quality topsychotherapy which has come to data offer little oversold for both thebuyer and the seller.Presently available psychotherapy and its variantshold the key support forthe assumption that It ap- resolution of majormental health problemsof modern society. to the the prognosis isbest pears tobe a limited-effectivenessapproach in which be expected to recoverwithout it. for the healthiest, forthose who might best distinction of some importance maybe made between A qualitative and those per- criticisms relevant tothe assumptions ofthe medical model what is essentially taining to its scope oreffectiveness. In the latter two cases, fallible, one which mustbe modi- implied is that the modelis a sound, albeit otherwise, one might fied in certain waysfor more effectiveresults. Phrased viable model but that wehave failed to dis- say thatthe medical model is a order of business thenbecomes that pense the correct"medicine." The major "medicines" (approaches) of searching for, trying out,and evaluating new addressed or haveheretofore beendealt for problems thathave not yet been fundamental assumptionsand tenets with ineffectively.When, however, its implied which wouldlead to quali- are challenged,alternative ideologies are different order of"practice." tatively differentapproaches ane o n emphasis in recent years,within the mental Clearly, one discernible has been on health field in general aswell as in this volumein particular, number of itsvulnerable points the need to shore upthe medical model at a Health, 1961;Williams, 1962; (Joint Commission onMental Illness and Forstenzer, & Foley,1964). We have come torecognize Glasscote, Sanders, approaches for their poten- increasingly the need toexplore briefer treatment Implicit well as to extendthe scope of existing resources. tial positive values as the level of psycho- has been someshift in focus from in this development efforts to in- dynamics to that ofactual behavior. Wehave also accelerated with disorder earlier inits history crease thelikelihood of having contact to be a primeobjective of the and at a point oflesser morbidity. This appears Community Mental HealthAct of 1963 Joint CommissionReport and the efforts to establish anetwork and is the guidingmotivation behind current the nation. There hasbeen a of community mentalhealth centers around and flexible adaptationsof technique in an greaterwillingness to try out new Such a statement, whileintended effort to reach theheretofore unreachable. approaches with the poor,is suf- primarily to refer tothe mental health 398 SUMMARY ficiently broad to include other new developmentssuch as learning theory- based applications to behavior modification. We have witnessed concerted attempts, in manydirections, to improve both the continuity and reality-basis of traditional treatmentapproaches. The isolation of mental hospitals from the community(Coffman, 1961) is being eroded at multiple levels. New hospital constructionis designed, geographically and structurally, to facilitate two-way accessbetween patient and community. There is a growing emphasis onthe integration of treatment and living to the fullest extent possible. Day hospitaland night hospital approaches, halfway houses, home-visit networks,and programs of aftercare, each represents an effort to adapt treatment tothe existing potential and resources of the individualand to aim for his earliest possible restoration to adequate functioning in the community(Williams, 1962; Bellak, 1964a; Greenblatt & Levinson, 1965). A substantial effort has been made to providemental health helping services in institutional settingscourts, prisons,schools, enforcement agencies, etc.where such services were, inthe past, unknown. And therehas been a growing climate of receptivity about using new sourcesof manpower, often nonprofessionals, in ancillary roles.This reflects the objectives of free- ing the trained professional forhigher-order functions and of extendingthe reach of mental health helping services. The foregoing endeavors, individuallyand collectively, represent attempts, largely within theframework of the medical model, to improvethe scope andeffectiveness of our mental health operations.As such, they are to be encouraged. Though the medicalmodel has clearly not solved all of our problems, it represents an effort to meetwith a class of very real problems that must be engaged. While it is easy to sitback and take potshots at the model, it would be irresponsible to dismiss it.We are called on to deal with the present problems of gross emotionaldysfunction and will be called on to do so for as long as we can see in thefuture. No approach gives promise of eliminating psychological disorder altogether,and many instances of malfunction will continue to slip through eventhe most efficient of conceivable dragnets in the future. Moreover, democraticand humanitarian considerations dictate that continuing, serious effort bedirected toward the amelioration of manifest disturbance. Given the fact ofpsychological disorder, the types of recent developments wehave witnessed should be regarded,potentially, as a more flexible and constructiveimplementation of the medical modelor, to use our earlieranalogy, better "medicine." THE PREVENTIVE MODEL ASAPPLIED TO MENTAL HEALTH PROBLEMS It is largely when the distinction ismade between existing problems and optimal long-range planning and stratagemsin the mental health sphere that limitations of the medical model arehighlighted. This model has, for 399 EMERGENT APPROACHESTO MENTAL HEALTHPROBLEMS people of decades now, been implemented byhighly skilled professionals, resolved, nor good faith, working with energyand devotion. But it has not problems. Even does it give promise of resolving, ourmajor mental health though improvements may befound in methods of treatment,and even though cure rates for certaindisorders may slowly edge up,there is little or basis for believing that societytoday is "healthier" than it was a cents:try two ago. Tothe contrary, with the conquestof physical disorder, ny.reasing and the awareness ofthe nature and vagaries ofpsychological dysfunction, population explosion, it is fair to assumethat problems of emotionaiperturba- tion are, in the absolute sense,of greater concern todaythan they have been what has been our in the past (Sanford,1965a). Moreover, if we remain on historical course, such problems give everypromise of increasing,rather than decreasing, in the future. The critical gap in our struggle to conquerpsychological disorder resides opposed to those of in our long-standingorientation to issues of cure as genesis or flow. Whilethis historical inclination maybe entirely understandable in terms of the needs and pressuresto do somethingabout visible, palpable disorder, there can be, atbest, only limited long-rangepromise to involved any systemthat does not accord centralprominence to the problems in cutting down theflow of disordersi.e., to issuesof prevention. There principle as an should be little basis fordisagreement with the foregoing abstraction. More concretely, however, evenwithin the limits of the presentvolume, approach as a replacement we mayidentify those who regard the preventive for the medical model asopposed to those who view it as aneeded supplement. Preference for one oranother of these alternatives isprobably a func- long-range planning or tion of whether onefocuses almost exclusively on future plan- addresses himself simultaneously toboth present problems and mental ning. In either case,the realities and thedemands of our present health situation place the highestpriorities on the need forexplicit conceptualizations aimed at delineationof the attributes of acomprehensive, preventively-oriented mental healthmodel. The following preliminaryeffort in conceptual credo for this this direction may beregarded as something of a volume.

Systems-Centered Operations To fulfill the promise of the preventiveorientation, there is a central need to view the primaryinstitutions of society as key targetsfor concerted, be regarded mental health-orientedendeavors. Mental health problems must in the broadest sense, they as logicalderivatives of a particular social context; are interwovenwith the very fabric of society.Such a view inevitably underscores, onceagain, that mentalhealth-relevant actions and interventions may not beregarded as the exclusivebailiwick of the helping professions and 400 SUMMARY poses a series of questionswhich should assume focal importance forprofessional specialists. These are the following: What isthe nature of the primary institutions of modern society? In what waysdo these institutions affect human development, particularly personalityand emotional development? How can influential social systems be modified?What types of modifications are related to what typesof outcomes along dimensions that areconsidered to be most criticallyrelevant to mental health problems? Obviously,these are complicated and profound questions whichwill not be resolved overnight. Indeed, in the present volume, there is perhapsonly one chapterthat of Zimileswhich begins to approach them directly. Given this orientation, certain shifts in emphasisand transformations in roles for the helping professional emerge aslogical consequences. For one thing, it seems highly desirable that a greater proportionof his total effort be spent in work with social systemsrather than in one-to-one contacts with troubled individuals. Intrinsically, such a shift carrieswith it the potential for involving many more people in our mental health operation,both as purveyors and recipients. Second, it important that the professional adopt aproblem-engaging, problem-seeking stance as opposed w his traditionally passive,problem-awaiting posture. The potential ramifications ofsuch a change in orientation are substantial. A system of practice which begins whenproblems show up carries with it an implicit focus on the aberrantand the pathological and suggests that the prime objectiveof our helping operations is the restoration of the individual after malfunction has been identified.Certainly this bias may be detected in thethings that fledgling helpers are taught duringtheir graduate training and in the types of clinical experiences to whichthey are exposed in their clinical practicum and internship activities. Anideology which focuses exclusively, or primarily, on pathology allows us todo little more than tread water,and sometimes, not even that. A generalized shift by the helping professions to what we havedescribed as a problem-seeking stanceimplies a new and different set of roles. For one thing it suggests a greater emphasis on early detection ofdisorder in the life cycle of the individual, combined with interventionsdesigned to forestall aggravation of the particular condition. Morefundamentally, however, it suggests that we turn our attention tohuman assets and resources, toward attempts at building psychologicalstrengths, and toward the circumvention of pathology before it develops. This point of viewhas not gone unrecognized! Hollister (1965) grants it so much importance thathe has coined a new termstren, defined as "an experience inthe individual's life that builds strength into his personality" (p. 31). It is hisbelief that we need such a concept to "help us to focus moreof our efforts on the challenge of building strength...rather than devoting the major part of our time to repairing the impact of traumas andmaklevelopment" (p. 31). Aspirations we may have to work systematically on theproblems of building resources and psy- 401 EMERGENT APPROACHES TOMENTAL HEALTH PROBLEMS chological strengths rest primarily on ourapproaches to primary social institutions, rather than on what canbe achieved in theconsulting room, and depend, quite focally, on theadaptation of a problem-engagingorientation long-range to mentalhealth issues. Implied is thebelief that a successful health would mduce to more programdesigned to build for psychological manageable proportions the restorativeefforts required when moreadvanced pathology is identified.Logically, it would seem thatthis type of approach has much greater promisefor breaking the vicioussocietal circle and for elevating our efforts in the mentalhealth sphere to something morethan the "holding operation" that theyhave been. In view of the foregoingconsiderations, there is need for ashift in orientation from the office, clinic,hospital, and consulting room tothe community natural and for a greater willingness to engagepsychological problems in their habitat. This point merits further comment,even at riskof digressing, mo- mentarily from the principal argument.The terms community psychiatry, community psychology, and communitymental health are very much part of our current Zeitgeist.They are, without question,"in" concepts. But they are alsoill-defined ones as Glidewell (1966)succinctly observes: "The most aggravating thing about communitymental health is its expansive, vague, nebulous and varied definition"p. 33).Critics of this movement (e.g., Dunham, 1965) have decried, withconsiderable justification, thetendency of professionals to rallyaround the community "banner,"sometimes quite uncritically, in what may representlittle more than the substitution of a new and poorly understood championfor an old one. The title of the recent paper "Community Psychiatry: The NewestTherapeutic Bandwagon"(Dunham, 1965) is to be understood in this context.The community approachhas been allowed people to infer an amorphouslydefined, mammoth inkblot which has whatever they wished to infer. Thishas been facilitated by asocial and professional climate which accords the community anincreasingly central role and particularly by recent appropriationsof huge sums of moneyearmarked for community-relevant programswhich pertain directly orindirectly to mental health problems. It should therefore be emphasized, inthe strongest terms possible,that a simpletransplantation of existing mentalhealth practices to new community settings is likely to resultin little progress and seriousdisappoint- ment (Kelley, 1966).Function, not locus, is thecritical element, and the potential shift of our mental healthoperations to .... communitybase should be a means rather than an end.Inherent in such a shift are theopportunities to study morerelevant and meaningful questions, toextend the reach of mental health operations, to look at resourcesrather than deficits, and to develop specific mental health programswith greater social utility.Without recognition of the salience ofthese functions, there is thedanger that the community approach will, inthe final reckoning, offer little morethan the oft-maligned "old wine in newbottles." One of the most tellingcriticisms 402 SUMMARY that can Fe leveled at the Community Mental Health Act of 1963 is that its specifications for "essential services" may be so tightly drawn that they preclude the possibility of genuinely transcending long-established, sometimes well-rutted, mental health practices. Reorientation of our mental health focus from the office to the community offers considerable potential for approaching the vast, unresolved problems uf reaching the heretofore unreachedparticularly the poor. Much has been written in this con text in recent years (Duhl, 1963; Brager, 1964; Riessman, Cohen, & Pearl, 1964; Beiser, 1965; Pearl & Riessman, 1965; Peck, Kaplan, & Roman, 1966; Sarason et al,1966), and four chapters in the present volumethose by Reiff, Riessman, Klein, and Gardnerare specifically addiessed to issues of conceptualization and implementation in this area. Once again, the message that comes through is that a mere transfer of traditional helping services (no matter how substantially these may be increased) to more accessible community locations is doomed tofailure. Our critical needs in this area revolve much more around "how" questions than "where" questions. Thus, matters such as definition of what constitutes mental health services for this group and optimal modes for delivery of such services are of central importance. Answers to the latter questions should be predicated on the fullest possible understanding of the way in which the poor see their problems (Reiff, Ch. 5; Clausen, 1966). Both Reiff and Riessman have emphasized the deep-seated alienation experienced by people from the lower socioeconomic classes vis-à-vis the mental health professional and his practices. Fundamental concepts of what is health and what is pathokty differ sharply between the poor person and the helping professional, as do definitions of psychological versus moral problems. For the poor, needs are experienced largely as immediate, practical, crisis- related, and physicalistic rather than in terms of futurism, neurotic suffering, higher-order functions, and actualization. Moreover, preferred modes and loci of interaction differ for the poor person and the typical helping professional. All of the foregoing adds up to a gross deficiency in what Riessman calls the "style-match" between the frame of reference and modus operandi of the helping professional and the needs and problems of the poor. Recall the concluding remarks in Reiff's chapter which are highly relevant here: "The task is to develop concepts, methods, programs, and services that are appropriate, effective, and related to the life styles of low-income people and to their needs, in a way which will create an effective demand for them. This will require significant institutional changes" (p. 87). To a considerable extent, the posture of the helping professional in his work with the poor has been: "This is what I have to offer! Can you use it?" and the answer has effectively been, "No!" Hopefully, by shifting the focus toward the more fundamental questions of "How do you see your problems?" and "What do you need?" we may be able to develop a more realistic basis, EMERGENT APPROACHES TO MENTAL HEALTH PROBLEMS 403 using Reiff's words, "to convert the very great existing need into effective demand for services" (p. 74). It should not be assumed, however, that delivery of services is the sole or fundamental problem that we face in mental health work with the poor. The present situation of this group is such that a more basic thrust in the direction of primary preventive actions must constitute a central component in our long-range planning (Fantl, 1964). Deutsch (1964) discusses this issue as it applies to educational approaches with the poor and the need for their revision in the tight of what we are coming to know about life styles and preferred modes of interaction of this group. The more general point is underscored by both Reiff and Riessman. Indeed, the latter, in his description of the Neigh- borhood Service Center program (Ch. 10), makes itquite explicit that provision of services is largely an instrumental function designed to engage the poor. Hopefully, this initial, meaningful type of contact will establish the building blocks for "increasing social cohesiveness" through community action and, ultimately, for initiating institutional change. There may be some merit, at this point, in bringing in a thread that has appeared several times thus far. With our emphasis on the need for a mental health system of broader scope, a focus on the community and its primary institutions, activity rather than passivity, and an effective system for delivery of mental health services to the poor, greater dignity is accorded to operations oriented to visible, palpable, everyday behavior touching many, as opposed to an intrapsychic, psychodynamic approach which has been a luxury of the few (Clausen, 1966; Rae-Grant, Gladwin, & Bower, 1966). Whether our concern is defined narrowly in terms of behavior modification or broadly in terms of social system modification, there is little reason to believe that formal psychotherapy is the best or only way to achieve such ends. As Klein (Ch. 9) has intimated, a decent and meaningful job may be the best of all therapies for some individuals. This is a simple example of the larger problem of skill deficit in this group and the utilitarian value of training in skill acquisition and coping techniques (Beiser, 1965). Moving away from the specifics of mental health programming for the poor, attention should next be given to the question of what are the natural habitats for preventive work? In general, it can be said that the appropriateness of a given setting is a function of the breadth and depth of its influence on people. By these criteria, two primary institutions in societythefamily and the schoolshare certain unique characteristics which suit them particularly well for the task. First and foremost, they exert profound and enduring influence on the child in his formative stages of development. The bulk of his time for many years is spent in one or the other of these two settings. The way he comes to see his world, and the people in it, is largely determined by what he experiences in these settings; and his most influential identification models will be found there as well. Thus, both the family and school suggest themselves as prime, face-valid targets for preventive endeavors. 404 SUMMARY At a practical level, however, certain considerations favor theschool as the more promising of the two settings, in the foreseeablefuture. Not the least of these considerations is the fact that the school is ageographically intact entitya system which provides access to large numbersof individuals simultaneously. Difficult and complex as it may be, the prognosisfor establishment of a meaningful preventive program for, let us say, 500children housed under a single school roof and monitored through a singleadminis- trative organization may be considerably better than trying towork individually with these 500 families in their separate homes. From thestandpoint of likelihood of cooperation, comprehensiveness of program, demands for professional time, facility of management, availability of relevant contributory persomiel, or potential for formal evaluation, the control andmanipulability of the school situation make it a more sensible starting point forsystematized approaches to mental health problems. This is not to downgrade the importance of the home as a determinant of humandevelopment, particularly personality development; the opposite (i.e., recognition of the prime importance of the family) is closer to the truth. Hence, the present bias is tobe defended largely on pragmatic rather than logical grounds. Parenthetically, itshould be noted that schools may represent the most promising avenuefor a systematic approach to families. Preventively oriented school mental health programs would do well to keep this possibility firmly in mind. This point isillustrated in the chapters by Morse and Gildea, Glidewell,and Kantor, and elsewhere in the literature (Brim, 1961; Glidewell, 1961;Hereford, 1963; Klein, 1965). The attractiveness of the school as a focus for preventive mental health programs has long been recognized,and much has been written on this subject (Caplan, 1956; Krugman, 1958; Gildea, 1959; Glidewell, 1959;Al lin- smith & Goethals, 1962; Lambert, 1965a; Torrance & Strom, 1965;Sarason et al., 1966; Westby-Gibson, 1966). In fact, in the presentvolume, eight of the substantive chapters are devoted to varying types of school programs. Each of these represents a departure from traditional mental health services for school children beset by emotional difficulties or ineffective functioning. Anchoring these approaches at one extreme is the social systems analysis approach of Zimilesa precursor to primary preventive work. A second approach is that of Roen, who has directly infused mental health-relevant content into the curriculum at the fourth-grade level.Upgrading the competence and knowledgeability of teachers with respect to the mental health area has been the special focus of Morse, while Gildea, Glidewell, and Kantor have attempted to work with parents in this same area. Programs of early identification and early secondary prevention have been emphasized by Iscoe,Pierce- Jones, Fr:-,dman, and McGehearty and by Zax and Cowen. And, finally, two special types of early secondary prevention with more seriously disturbed youngsters have been described by Lewisand Donahue. Each of the latter two is predicated on the assumptionthat an optimally effective educational regimen is also likely to be personally helpfulindeed,therapeuticfor the child. HEALTH PROBLEMS 405 EMERGENT APPROACHESTO MENTAL influential social system In short, the school, as apervasive and highly society, represents a mostpromis- which affects the livesof all people in our It is a system that canbe ing field of operationfor prevention programs. through teacher training approached in very primarywaysfor example, 1962) and cur- (Allinsmith & Goethals,1962; Sarason,Davidson, & Blatt, 1961; Allinsmith &Goethals, riculum modification(Biber, 1961; Ojemann, 1962)and it has vast and as yethardly explored potentialfor early detection prevention of emotionaldisorder (Cowen, Izzo,Miles, and early secondary 1965b; Telschow, Trost, & Zax,1963; Bower, 1965;Hollister, 1965; Lambert, Sanford, 1965b; Cowen,Zax, Izzo, & Trost,1966a). preventive actionsshould Because of the convictionthat system-relevant impact, initial possible, with institutionsthat have maximal start, wherever these two consideration has beendirected to the familyand the school. That obscure the fact thatthere are other settings are "logicalfirsts" should not preventively-oriented mental agencies and institutionswith potential for Among the moreobvious of these are courts,detention health activities. and community homes, prenatal andwell-baby clinics,settlement houses, Leighton, 1960; Spiegal,1964; Sara- centers (Peck,Harrower, & Beck, 1958; son etal., 1966).

People-Centered Operations for an order which While we have spoken,centrally, to the need system-relevant activities,this is not to saythat places greater emphasis on limits to our people-relevant interventions areimmaterial. With realistic increasingly important total mental health resources,however, it may become admissible people-centered for the professional toattach priorities to the many the guide, two broadprinci- functions. Using potentialimpact once again as times First, people-orientedinterventions should occur at ples are suggested. placed on this Two constructions,both intended, can be of maximal impact. episode; principlethe first, in termsof the nature andchronology of a given Second, in our the second, in termsof the life historyof the individual. those individuals in society people-oriented approaches weneed to focus on influential position vis-à-vis men- whose everyday functionsplace them in an using single words orbrief tal health problems.If it were possible to captufe, principles, the appropriate termswould phrases, the issuesreflected by these and "care-givers."Each bears some be "crisis," "earlychildhood orientation," elaboration.

Crisis The concepts of "crisistheory" were introducedby Lindemann those who survived the (1944) following hisstudies of grief reactions among impression that certainpotentially disastrous CoconutGrove fire. It was his could be circumventedby appro- deleterious consequencesof such experiences 406 SUMMARY priate actions of key figures during the crisis period and that there were important implications to be drawn from this for mental health preventive work. Others (Caplan, 1960, 1961, 1964a, 1964b; Bower, 1964) have further articulated this concept and discussed its relevance to the broaderarea of prevention. Crises are defined as relatively brief periods of transition and disturbance which, by their very nature, require adaptations that are important in the mental health sense. The salient subjective attributes of the crisis situation for the individual include a sens., of ineffectiveness or helplessness in coping with the problem, vacillation and disequilibrium, a heightened susceptibility to influence by others, and concurrent emotional upset. These are earicaturizations of what theorists have elsewhere described as "new psychological situations" (Lewin, 1936; Wright, 1960; Meyerson, 1963). Crises of two general orders can be identifiednormal, developmental crises (Erik- son, 1959) and accidental crises ralecting "life hazards involving a sudden loss of basic supplies, the threat of it,, or challenge associated with the opportunity for increased supplies accompanied by heightened demands on the individual" (Caplan, 1964a, p. 35). All people experience crises and, almost by definition, the manner in which the crisis situation is resolved will have implications for one's mental health status. Successful crisis resolution may contribute to future immunity, whereas failure to resolve the crisis is likely to increase vulnerability. To a considerable extent crisis outcome depends on the types of choices that the individual can perceive and the guidance available to him during a relatively brief critical period. The crisis situation is therefore one of unusual influence potential, and the choices and decisions made by the individual can be modified in constructive ways through the participation of significant others in the resolution process (Caplan, 1964a). One of the implicit hopes residing in the establishment of community mental health clinics is that problems which normally appear as entrenched pathology may be engaged earlier, in a crisis phase, when the potential for constructive influence of outcome is much greater. Important as crisis intervention may be, it should not be regarded as a "savior" notion. Indeed, given our underlying philosophy, it represents an approach with some noteworthy limitations. Though all people experience both developmental and accidental crises, they do not experience the same number of crises, with the same intensity, or with the same outcomes. Thus, far short of the concept of crisis intervention, there are those whose conditions of life, exposure to influence systems, and personality makeup insulate them against occurrence of crisis or its deleterious sequelae thereafter. The study by Ladieu, Hanfmann, & Dembo (1947), in which it was found that the best predictor of adjustment to amputation was the pretraumatic adjustment level of the individual, supports this argument. Implicit is the conviction that there are significant phenomenological determinants of what is crisis and what is not, not unlike those identified by 407 EMERGENT APPROACHES TOMENTAL HEALTH PROBLEMS Lazarus (1966) in his discussionof the stress state. Crisis, in its rawform, need not therefore be accepted as aneternal and immutable "factof life." Caplan himself (1965a) reflectsthis awareness when he identifiesand speaks of the importance of "training incrisis coping" (p. 12)and "anticipatory guidance or emotional inoculation"(p. 18). The essence of theseapproaches is to anticipate crisis, to arouseit as vividly as possible inanalogue form and under relatively nonthreateningcircumstances, and to offer practiceand guidance in coping. Hopefully,such experiences may contribute tothe development of an immunitywhich will help the individual tohandle real-life crises more effectively. Quite beyond this fascinatingspecific technique, however, primary preventive work, involving constructivemodification of influential social systems, might well be expected to reduce,spontaneously, the incidence, severity,and negative consequences of crises.Put another way, one objectiveof long-range mental health planning should be thereduction of the "flow of crises" aswell fully as thereduction of the flow of pathology.That the former will not be achieved, even in the best of worlds, isthe basis for according arelatively high priority to crisis intervention amongthe many potential people-centered approaches.

Early Childhood Orientation Maximally impactful intervention timesfor people-centered mental health activities may be approachedfrom the framework of the lifehistory of the individual, as well as fromthat of mediating crisis. This notion rests upon the view that the young child is moreflexible and malleable than theadult and that the early childhood period is oneof maximal potential for the modifiability of the organism (Eisenberg,1961, 1962a). Such modifiabilityshould be interpreted broadly toinclude the potential for building resourcesand strengths through the influenceof impinging social systems, aswell as the amelioration of defect resultingfrom the earlier life experiencesof the child. The first of these potentials isthe one of primary prevention,the centrality of which has already beenunderscored on several occasions inthis discussion; the second is that of earlyidentification and early secondary preventionwhich remain to be considered. In our view there is neithermutual exclusiveness nor intrinsiccontradic- tion between an early childhoodorientation and one whichemphasizes crisis intervention. This position is notshared by Caplan (1964b) who says:"The basic model for prevention is nolonger that of intervention early inthe person's life history. This is supersededby intervention in crisis situations at any phase of life" (p. 6). By his choiceof the word "superseded,"Caplan implies that early childhood interventionand crisis mediation shouldbe regarded as alternative approaches to the samebasic problem. Our own preference is to view these orientations aspotentially supportive of each other(e.g., "training 408 JUMMARY in crisis-coping," "emotionalinoculation"). If there isany conflict between them, it is primarily in emphasisand how (givenvery real limitations in our total mental health resources)priorities for scarce professional time should be allocated. For themoment, such choices are largely value judgments;ultimately, we might hope that theycould be madeon the basis of empirical evidence. It would, however, be misleadingto dismiss Caplan's preference for crisis interventionover early childhood interventionas a specific or circumscribed one. Instead, it reflectsa disillusionment and sense of pessimism which many people feel aboutthe cumulative impact ofour mental health efforts with chiidrzna muchbroader issue. Such disenchantmentis epito- mized in a statemept by Hunt quoted in the Joint CommissionReport (1961). "Our hopes ofpreventing mental illness by mental healtheducation and child guidance clinics have been disappointed, andthere is nocon- vincing evidence thatanyone has ever been kept out of thestate hospital by such measures" (p. 71). Thesesentiments are echoed by Caplan (1964b), who cites the collective failuresof child guidance clinics andargues that treatment of children may bemore time-consuming and less effective than similar work with adults. Indeed,considerable support for thisposition is found in the critical review ofthe literature by Levitt (1957)on the effects of psychotherapy with children.Insofar as this particulartype of intervention is concerned, results havenot been especially encouraging. Still another set ofarguments has been advanced which speaksagainst a child-centered orientation inour mental health efforts. As Allinsmith and Goethals (1962) have pointedout, though they do notsupport the position, there are those who believethat the emotional problemsof young children are basically ephemeral and transitory andthat theymay not be regarded as meaningful predictors ofpsychological difficulties laterin life. Otherwise phrased, it might be said that most emotional problems of early childhoodare part of a normal developmentalsequence and that youngsters will, by and large, outgrow them in duetime. Indeed, data have been presentedrecently (Onondaga County School Studies,1964) which lendsome credence to the argument. Implicit in this view is the furtherbelief that amelioration of dysfunction early in the child'shistory does not substantially alterthe likelihood of hissuccess in dealing with subsequent difficulties. Whatis called into question by this positionis the wisdom of the ancient aphorism"As the twig is bent, sogrows the bough" as this might be appliedto the understanding of human emotionaldevelopment. Though empirical evidenceon this issue is, unfortunately, sharply limited, it is at least possibleto point to some relevant data,a good deal of which derives from school settings.Recent extensive work directedtoward the development of techniques for the early identificationof ineffective functioning in the young school child, reported byBower and his associates(Bower, lash- novian, & Larson, 1958; Bower,1960, 1961; Bower & Lambert,1961), has HEALTH PROBLEMS 409 EMERGENT APPROACHESTO MENTAL (Cowen facilitated study of suchproblems. A later seriesof investigations Trost, 1964; Cowen etal., 1966a) has et al., 1963;Zax, Cowen, Izzo, & emotional problems,diagnosed shown that childrenwith manifest or incipient group-testing, andclass- basis of social workinterviews with parents, on the school year, are, atthe end of observations at thebeginning of the first room poorly on almost any typeof three school years,doing considerably more intellectually comparablebut emotion- criterion measureused than are their broad spectrum ofthe child's ally healthier peers.These criteria reflect a such as reportcard grades or functioning, includingachievement indices behav.ioral measuressuch as attend- standard, system-wide,achievement tests; self ratings, peer ratings,teacher ratings, ance and nursereferral data; and It seems probable, atleast within and personality testsreflecting adjustment. covered by these studies,that the child the three-year periodof development does, in fact, getstarted on a course with early-identifiedemotional difficulty of the significant areasof his which moves himrapidly downhill in most school functioning. predictive meaningfor the That such earlydysfunction may have some findings reported byCowen, Beach, child's later career issuggested in the Trost, and Zax (1968).These investigatorsfollowed Izzo, Laird, Rappaport, original early-identified emotionaldifficulties, from their upchildren with functioning still dif- studies, and foundthat a similar patternof ineffective their peers, four yearslater, as they weregetting ready ferentiated them from applied a modified high school. T.n like manner,Stennett (1965) to enter disorder to fourth-, technique for identificationof emotional Bower screening 22% of his sample as fifth-, and sixth-gradechildren and identified some emotionally. The centralquestion either moderately orseriously handicapped concerned was: "Towhat extent are theadjustment with which he was self-healing?" (p. 445). problems of theseemotionally handicapped youngsters emotionally handi- Follow-up over aseveral-year periodsuggested that the behind their peerswith the passageof capped group fellincreasingly farther key conclusion: "Asignificant num- time, leading theauthor to the following handicapped are notlikely to resolve ber of childrenidentified as emotionally problems without help.For this group'emotional handicap' their adjustment 1965, p. 448). should be viewed as a'disease' and not a'phase" (Stennett, this same issue on a more Another series ofinvestigations approaches clinical criteria. In a compre- long-range basis and in :termsof "bellwether" (1958a, 1958b) followed up,after thirty hensive study, O'Nealand Robbins been seen forcomprehensive years, asizable group ofindividuals who had in the mid-1920's.At that evaluation around some typeof problem behavior twelve years, and allhad had time the average ageof the subject group was clinical work-up. Acontrol group psychometric eva luationand an adequate for age, sex, race,and IQ, was of 100 youngsters,problem-free, and matched incidence of pathology atthe adult level forthe "prob- also studied. The of the categories of lem-child" group wasquite high,particularly in terms SUMMARY 410 sociopathy, psychosis, and alcoholism.Indeed, only 21% of the group was considered to be problem-freethecomparable figure for the controls being 60%. In further detailing thesefindings (O'Neal & Robbins, 1958b),evicknce is presented indicating thatthose who later beca ne schizophrenichad histories which were characterizedby significantly more symptoms,particularly antisocial ones, more areas of disturbedfunction, more hospitalizations, and more arreststhan their "problem-child" controls.Support for these findings is found in the investigationby Bower, Shellhamer, and Dailey(1960), who report significantly poorerhigh school mental health and schoolrecord ratings for a group of Ss who laterbecame schizophrenic, in comparison to their nonschizophrenic controls. Also based on the retrospectiveapproach, but using somewhat less extreme criteria, the recentimportant study by Westman,Rice, and Berniann (1967) is pertinent to the issue wehave been considering. Having at their disposal detailed and excellent records ofbehavior starting at the preschool level and close later follow-up, these investigatorsfound a correlation of .88 between maladjustment ratingsdating back to the child's early school career and theutilization of mental health clinical services over aneighteen- year period. As inthe case of the three prior studies, thesefindings indicate that early emotional difficulty does notgenerally dissipate spontaneously and that it seems to predict fairly well tolater difficulty. Relevant to the "twig is bent" assumption, these authors conclude:"The evidence obtained in this follow-up study contradicts the time-honorednotion that children outgrow behavior problems seen in early life and supportsthe thesis that drastic shifts in manifest behavior tend nnt to occurduring the first eighteen years oflife. Children with adjustment problems in nurseryschool tend to have adjust- i ment problems in laterschool life, and these problems tend tobe of the same order"(Westman et al., 1967, p. 728). The findings of the studies citedabove are consistent and mutually supportive. Collectively, they give pause tothose who see no special merit in directing a major portion of our mentalhealth effort toward children. Though there clearly are such things as thenormal developmental problems of growing up as well as other atypicaldifficulties that will be overcome spontaneously, many emotional problems orearly childhood are danger signswhich meaningfully predict to later, perhaps moreserious, troubles. We are in need of a fuller taxonomy of such earlychildhood difficultiesthose about which we shouldbe concerned as well as the less serious ones.Moreover, we may not regard screening ordetection as an end in itself. Rather,they should serve to identifythe targets of new types of programmingsand interventions which aim for early secondary prevention at atime when the flexibility and modifiability of the organism augur wellfor the potential of constructive change. That there have been serious shortcomings to ourprior coaective efforts with emotionally disturbedchildren cannot be denied. Suchfailures, how-

1 EMERGENT APPROACHES TO MENTALHEALTH PROBLEMS 411 ever, do notjustify focusing our mental healthefforts elsewhere; rather, they suggest that wehave not yet identified maximallyeffective approaches and methodologies for work with thisvitally important age-group. Asindicated above, our basic hopes forsignificant forward movement in this areareside in social system modificationand primary prevention. Beyond that,however, recognizing that there will becontinued need for people-centered mental health activities, our belief is that a primefocus of such activities shouldbe upon the youngchild and his environment. Thisparticular bias is shared with Smith and Hobbs who, in a recentposition paper(1966)have stated: facilities, peopleshould "...fully half our mental health resourcesmoney, be invested in programs forchildren and youth, for parents of youngchildren, for teachers and others who workdirectly with children. This would bethe preferable course even if the remaining50% were to permit only aholding action with respect to problemsof adults" (p. 505). We should be reminded by this quotethat undifferentiated use of the broad-gauge concept of secondary prevention inthe mental health area may be quite misleading. In fact, the concept coverstwo distinct, andperhaps factorially unrelated, components: preventiveinterventions which occur early in the ontogenetic history ofthe organism and those whichtake place relatively early in the chronology of a currentepisode. Much of the force of the present CommunityMental Health Center movement isdirected to the lat- tradi- ter (Glasscote etal.,1964).Though this, per se, is to be preferred to tional patterns of tertiary prevention,knowledge of the nature of human development, the learning facility, and themodifiability of the young suggests that the mostmeaningful contribution of the secondarypreventive approach may reside in that componentwhich involves early intervention in the individual's life history(Eisenberg & Gruenberg,1961).For similar reasons, while one maywelcome crisis intervention as asignificant addition to the armamentariumof people-centered helping techniques,it would be both premature and indefensible to viewthis as a replacement for an early childhood orientation.

Care-givers It is, by now, a well-established factthat only a relatively small percentage of peoplewho see themselves as having personal oremotional problems requiring outside assistancetake those problems to mental health hdping specialists. A convincing basisfor this statement may be found in the data of one of the subreports of theJoint Commission series, that of Gurin, Veroff, and Feld(1960),entitled Americans View their MentalHealth. Based on a series of questionsdirected to a stratified sample ofAmerican adults, it was found that roughly 25%of all respondents had, on one or more occasions in their lives, felt theneed for help with an emotionalproblem and that some 15% had actuallysought it out. What is most germane,however, 412 SUMMARY is the fact that less than 20% of thoseseeking help took their difficulties to members of the helping professions. Rather, thepreponderant majority of calls for assistance were directed either toclergymen (42%) or to physicians (29%). The preceding statistics are limited topeople who recognize a personal problem and who request formal help.Without question, there are many others in objectively similar circumstances whodo not seek such help. Various reasons may accountfor this, for example, ones of definition orideology with the poor, or fear of stigmatization, whetherdue to conscious or unconscious determinants; however, the result is to inhibitsolicitation of outside help. Thus, it is somewhat ironic that while there are notenough mental health specialists to meet existing, spontaneouslycrystallized demands for their services, at another level suchspecialists are not the ones who are called on to deal with mostmental health problems. The professional"carries" only a limited fraction of the "total national caseload" inthe area of psychological dysfunction (Schofield, 1964). We may assume that mental health-relevant experiences,problems, and sometimes, crises are ever-occurring aspectsof human existence. The structure of society ordinarilyprovides people with readily available linesof approach for dealing with personal unhappiness orineffective functioning. Without attaching the formal label "I need help,"individuals are capable of resolving many difficulties through commerce andverbal interaction with family members, friends, colleagues, neighbors, orrespected others who are part of their natural environmentsergo,the oft-maligned bartender or hair- dresser. It is fortunate that such outlets exist since, in manyinstances, they not only work effectivelybut they also constitute a first line ofdefense against more chronicdysfunction. All of us have doubtless had the experienceof contact with individuals who areparticularly helpful. Were our society entirely populated by such, the need for theprofessional helping specialist might well be obviated. There are circumstances, however, where spontaneousfirst-line resources are either notavailable or insufficient to cope with a given set ofdifficulties. At such times, the individual is likely to seekhelp, in either an open or veiled fashion, from any one of several trusted,authoritative, influential people in his life spacemost often professionals,but not mental health specialists. Caplan (1964a), in his insightful discussionof this problem, has defined the latter as "care-givers," i.e., people who are"agents of the community in fostering the well-being of a citizenand in helping him deal with unfavorable circumstances" (p. 50). Schofield (1964)refers to them as "in- visible therapists." Care-givers may be inthis position either because their traditional roles involve dealing with crisis orbecause they have prolonged and close contact with individuals. Asnoted above, Gurin et al. (1960) have found that the prime exemplars ofthese two categories are physicians and clergymen. In addition,special mention of the care-giving func- PROBLEMS 413 EMERGENT APPROACHESTO MENTAL HEALTH teachers should tions of nurses, pediatricians,lawyers, school principals, and also be made. Whetherthey choose to do so or not,such care-givers that troubled are oftencalled upon to deal withmental health problems people thrust upon them.Their actions and handlingof such situations will, of the individual in by design or otherwise,affect the emotional well-being potentially significant ways. As Caplan (1964a) haspointed out, although oursocietal care-givers sophisticated about emo- have, in recent years,become more sensitive to and with other strands of the tional perturbationsand their potential interactions designated in regard person's existence, "theirfunctioning is not traditionally These professionals to its effect onthe mental health oftheir clients" (p. 50). complex are trained todeal with some delimited segmentof the individual's psychological problems. In existencea segmentwhich does not include his mental practice, however,the extent of involvementof the care-giver in health problems, when he isconfronted with them, islikely to vary consider- and experience, his ably as a function of hispersonality makeup, his training opinions and attitudeswith respect to mentalhealth matters, and oftentimes, in the community. quite concretely, theavailability of alternative resources becomes enmeshed in the For whatever reasonsthen, the care-giver role in our total personal problems of humanbeings. His is an impactful He can be helpful orharmful depending onhis menial health operation: and the personal attributes and sensitivities,background and orientation, denying this ready availability of competent"backstopping." Rather than evident reality, our problembecomes one of utilizingprofessional mental maximized. health resources so thatthe effectiveness of thecare-giver can be the care-giver is in a Indeed, it should berecognized that in many ways better position to deal withemotional difficulty than isthe mental health natural habitat and professional. He encountersproblems closer to their considerably earlier in theirchronological sequence, andhe often enjoys the factors are confidence of the individualseeking help. Both of these trust and neither can be related to the effectivenessof mental health interventions; dismissed lightly! The mental health professional canmake an extremely important contribution, working within theframework of social reality,by supporting the principal care-giver, whatever thelatter's culturally-definedrole may be. The of support to the method recommended byCaplan (1964a) for provision consultation. It is beyondthe care-giving professional isthat of mental health detail, the many aspects and scope of the presentdiscussion to consider, in potential formats of suchconsultation. This hasalready been done elsewhere 1964a, 1965c; Kazan- thoroughly and effectively(Caplan, 1959a, 1961, 1963, Ch. jian, Stein, & Weinberg,1962; Hay lett &Rapoport, 1964; Spielberger, consultation for the care- 12). It is sufficient here to notethat mental health suggested alternatives in circum- giver is designed toprovide information and competencies, to help him to stanceswhich go beyond his experience or 414 SUMMARY achieve a fuller recognition of the mental health implications of a varietyof situations which are encountered in his typical practice, and to establish a backstopping, resource relationship which may allow him to approach mental health problems with a greater sense of security or confidence. The attractiveness of mental health consultation with care-givers resides in its geometric potential. Care-givers, by definition, have high-influence contacts with large numbers of individuals. Illustratively, a groupconsultation arrangement, involving one mental health professionaland, let's say, a dozen or so pediatricians, could conceivably affectthousands of individualschildren and their familiesin constructive ways. Moreover, those contributions to the effectiveness of the care-giver which are made through consultation around a singk incident potentially carry over to his subsequent, everyday work. There are certain situations in which consultation with care-givers may be the only available approach to mental health problems, either currently or in the foreseeable future. This is true in impoverished, rural, and geographically isolated areas or in small urban centers that are devoid of professional mental health services. Another of the subreports comprising the Joint Com- mission series (Robinson, De Marche, & Wag le, 1961) indicates that the almost complete unavailability of professional mental health resources in many such places around the country constitutes aproblem of considerable proportions. In such settings, the physician, clergyman, or teacher is forced to double as a mental health specialist, since there is no viable alternative. The immediate problem is that of helping well-intentioned, sometimes struggling, individuals to establish competencies in dealing with mental health situations that are far beyond their know-how and their overtaxed resources. Effective mental health consultation has much to contribute in this direction. In this volume, Spielberger (Ch. 12) has described a consultative program aimed at professional care-givers in a small urban community in the South which lacked professional mental health personnel. Here, group mental health consultation was the method of choice due to limits upon available consultative time and specific positive attributes of this approach. Elsewhere, Kies ler (1965), Huessy (1966a), Libo and Griffith (1966) report a number of different mental health consultative activities applied in various geographical regions, each characterized by insufficient professional mental health services. For the most part, professional care-givers become involved in people's personal difficulties because they are brought to them voluntarilywhether in blatant or subtle form. There are people other than care-givers who, by virtue of their positions in society, necessarily come into frequent contact with people in crisis, and do so under circumstances which could have potentially important mental health reverberations. Policemen, sheriffs, judges, welfare investigators, bartenders, beauticians, barbers, and truant officers are in this category. Kelley (1964) has used the term "urbanagents" to describe such individuals. Though contacts with such community agents often arise in informal, unsolicited, and entirely unpredictable ways, this does not negate HEALTH PROBLEMS 415 EMERGENT APPROACHESTO MENTAL of mental health con- potential. In otherwords, the concept their influence care-giver, need notbe highly relevant tothe professional sultation, though specialist can also limited to him. It maybe hoped thatthe mental health second category ofinvoluntary, situa- come tohave increasingimpact on this through the mediumof hiscommunity-based educative tional-influence agents urban agents may, asKelley and consultativefunctions. In this manner "important mediatorsbetween the larger popu- (1964) suggests,become... formal health andwelfare resources"(p. 479). lation and the consultation with careof the potential ofmental health Most discussions particular value ofworking Caplan, 1964a)emphasize that the givers (e.g., important crisis situations individuals resides intheir proximity to with such in crisis resolution. ability to exercise aconstructive influence and in their another, perhaps even Though this isundoubtedly true, itshould not obscure who may beprovided with a set moresignificant potentialof the care-giver, to worktoward the buildingof psychological of unique opportunities he has con- fostering of resources inindividuals with whom strengths and the in the totalmental health tact. Thecritical role thatthe care-giver plays the need for systematicaugmentation operations of modernsociety indicates educational experiences aspart of thetraining of mental healthpracticum and called upon to dealwith such problems of all those who,realistically, will be Caplan, 1964c;Sheeley, 1964). in theirprofessional careers(Bellak, 1964c; professional care-givers, aspeople who To return to ourearlier criteria, mental health activitiesto a very capable of extendingthe reach of our are constitute a centralfocus for people- significant degree,should certainly preventive framework. centered interventionswithin a largely

Problems andLimitations model, to in ourconsideration of a preventive We have attempted, credo which may provide a unifyingconceptual analysisand philosophical mental health fieldsand provide serve as anaid to long-rangeplanning in the of new approachesand programs. It seems some impetusfor the development of as an this is a muchneeded emphasis,whether conceived clear to us that dominant models. alternative or as asupplement totraditional and historically of evolution inthis direction isevident That there aresignificant indications volume. from many ofthe chapters ofthe present of prevention, we mustalso recognizethat there Whatever the promise implementation. For one approach andobstacles to its arelimitations to the nonpalpability, and it islargely thing, it ischaracterized by thequality of mental health operationsstart withvisible and future-oriented. Typically, child- Just as the allureof fund-raisingcampaigns for immediate suffering. dystrophy comes from polio, cerebralpalsy, or muscular hood diseases such as braces, on (usually quiteattractive) child in postersshowing a young the allure of mentalhealth fund-raising crutches, or in awheel-chair, so does SUMMARY 416 campaigns and theallocation of funds formental health-related purposes This vital come largelyfrom knowledge of theplight of the severe psychotic. ingredient, certainly for thelay publicand perhapsfor a number of pro- fessionalscannot be readilyenvisioned in contemplatingprevention pro- be high since grams.Further, the immediate costof such programs tends to relatively long periods of they utilize expensiveprofessional personnel over activities where time. Understandably,there may be a reluctance to support benefits have intangible immediate payoff cannotbe seen, where long-range basis to expect positive qualities, and wherethere is little prior empirical ou tcomes. Perhaps the strongest counter tosuch a reservation is tobe found in certain types of other costaccounting figures which arerarely considered by (Duggan, 1965) that it costs the lay public. Forexample, it has been noted juvenile court system in $4,000 to process just oneadolescent through the for New York City and thatthe average cost to alarge urban community approximately $30,000 per high school dropouts whoend up on welfare is individual. Certain types ofresidential treatment foremotional disorder cost lifetime of simple upwards of $15,000 per year.And, in the extreme case, a hospital may cost the custodial care for a singlepsychotic patient in a state social taxpayers up to a quarterof a million dollars. Allthis is far short of the of monies to na- value questions lurkingbehind the relative apportionment mental health expen- tional defense and spaceexploration in contrast with that the mere promise ditures. These considerationsunderlie the present view supportespecially consid- of a preventive approach issufficient to justify its prior mental health ering the failures andshortcomings of our cumulative efforts. quality do not exhaust The interacting argumentsof cost and unproven A the list of potentialdeterrents to the establishmentof preventive programs. cogently discussed byBower series of such deterrentshas been identified and the social problem we (1963, 1965). One is thecomplexity and enormity of t defeatism, for many. At a 1 face, which is a source ofpessimism, if not total of ambiguity at- less extreme level, for mostprofessionals there is an aura understanding of its tached to the prevention area,characterized by a lack of and its means-end con- specific aims and objectives,its relevant parameters, tingencies. And, evenwhere there is some clarity onthe foregoing matters, specialists are unclear since the area itself islargely uncharted, professional ready-made tech- as to howperceived ends may beachieved. The absence of undermining of one's nology can easily lead to a senseof threat and to an professional security. These typesof difficulties can onlybe eroded gradually training programs over timethrough the establishmentof academic and field designed to plug presentlyexisting gaps. have spoken Bower (1965) also notesthat critics of prevention programs privacy. In response,he of them as a kind ofmeddling or as invading human does touch upon the livesof indi- argues thatalthough primary prevention EMERGENT APPROACHES TO MENTALHEALTH PROBLEMS 417 1 viduals before they are singled out asneeding especial help, it may beregarded good" (1965, p. 2), as a "necessaryand, indeed, mandatory step for common very much as we nowregard a smallpox vaccination. Farfrom meddling, as Eisenberg (1962b) has pointed out, preventionis at least as much the responsibility of the helping professional ascontaminated water is the problemof the microbiologist or lead base paintsthat of the pediatrician. Community agents, care-givers, andmental health specialists, becauseof their job descriptions and the natureof their day-to-day interactionswith other human beings, inevitablytouch upon the emotionalwell-being of 1 others in significant ways. If suchpeople fail to act underthese circumstances, they haveacted! If they act inappropriately,they have also acted! The real choice does not, therefore, seem tobe one of action versus inaction; rather it is one of inappropriate orrandom action versus maximallyinformed and expeditious action. To be sure, there will be very realproblems in the establishmentof a preventive framework as a genuinelymeaningful one. But, perhaps it istime for those interested in mentalhealth problems to accord asomewhat more central position to the philosophythat "an ounce of preventionis worth a pound of cure." Certainly the promiseof ultimate savings inhuman misery, as well as indollars, is more than enough tojustify such an emphasis.

NONPROFESSIONALS IN MENTALHEALTH ROLES

Whatever the conceptual model onechooses to adopt, it seems evident that the mental health problemsof modern society cannot beadequately handled by existing professional resources(Felix,1962; Nichols, 1963). Given the heavy new demands forprofessional specialists placed upon usby the establishment of a nationwidenetwork of community mentalhealth centers and populationextrapolations viewed against ourpotential for training additional helping professionals, thealready existent trend suggeststhat our shortages will become greater over time(Albee, 1963). Amplification of our mental health manpower structure isurgently required, and our need-incre- inents in this regard are morenearly geometric than arithmetic.While partial resolutions of this difficulty might emergefrom new conceptualizationswhich, through modification of ourfundamental approaches to mentalhealth problems, could ultimately relieve some manpower pressures,there is immediate need for the recruitment and trainingof nonprofessionals andsubprofession- als for mental health functions. Having made this judgment, manyquestions and ramifications pertaining to the philosophy andmechanics of their utilization suggestthemselves. In our further considerationof these issues, two central and recurrentthemes appear basic.First, the way in whichnonprofessionals are utilized must reflect the types of conceptualizations wehold about an optimal mental health 418 SUMMARY order. Second, it must reflect the needs and attributes of a specific setting or program. In that sense few absolute "rights" and"wrongs" can be categori- cally enunciated. Volunteers have performed a variety of functions in the mental health area for many years.Historically, however, such work has all too often been characterized by a "hit-and-run" or menial quality. Fundamentally, this is not what we are talking about here. The nature of our mental health activities is such that a meaningful and stable relationshipa committed human relation- shipis often at the core of things. Several implications derive from this. First, there must be genuine involvement and a substantial ongoing commitment in time by the worker. This, in turn, suggests that careful attentionbe given to problems of recruitment, training, and supervision of the nonprofessional. Second, his roles and functions should be meaningful onesnot simply passing out chalk, putting test scores in a grade-book, pouring tea, or scrubbing blackboards. With the crystallization of new roles for the nonprofessional, there is a parallel need for rethinking and reconceptualizing the roles and functions of the professional, leading potentially to a very different sort of helping structure. The latter aspect of theproblem will be considered more fully below, in the section onprofessionals. Before we can address matters pertaining to the recruitment of nonprofessionals for mental health roles, we must deal with a prior, somewhat hidden, issue. When troubled people are helped through human interaction, does such help stem primarily from the intellective and training attributes or the personal characteristics of the helping person? Over the years the helping professions have placed their bets on the first of these two clusters and have set up their advanced specialty training curricula accordingly.Graduate training is long and arduous, involving the learning of theory, the accumulation of fact, and the acquisition of practical experience. There is surprisingly little evidence, thus far, to indicate that these are the attributes that predict meaningfully to success in modification of human behavior or in helping people. If the elements that make one an effective helper are other than intellective training ones, then, insofar as advanced professional training is aimed at producing helpers, a great deal of our efforts may be for naught. It is entirely conceivable that the natural endowments or helping reflexes of many nonprofessionals may equal or exceed those of the professional. On a strictly logical level, this argument would seem to justify intensive exploration of the nonprofessional's utility in mental health roles. In addition, need and parsi- mony combine to make the issueimmediate. A recent, highly significant study (Poser, 1966) suggests that the foregoing considerations are neither academic nor abstract. Poser compared the effectiveness of entirely naIv2 college undergraduates and experienced profes- sionalslargely psychiatrists and social workersas group therapists with chronic, hospitalized adult male schizophrenics. The students were totally untrained; few had had a single psychology course, and none had any ex- 419 MENTAL HEALTHPROBLEMS EMERGENTAPPROACHES TO They were hired aspart-time pressed interest infuture mentalhealth careers. the same token,the professionals were employees to do aspecific job. By years people, highlytrained and with many clearly qualifiedand competent of professionalexperience. sizable one. the study was awell-defined and The patientsample used in of minimum ofthree unbroken years All of these werechronic cases with a study and an averageof fourteen years hospitalization prior tothe start of the assigned, followingappropriate match- of hospitalizationin all. Patients were student-led or profes- control group (notherapy) or to a ing procedures, to a student With 10 patients pergroup,there were 13 sional-led therapy group. (N = 150) and63 controls for (N = 130), 15professional groups groups placed on thetherapists in either atotal of 343 Ss.Few restrictions were the have them all try topromoteinteraction among group,other than to therapists and their between bothprofessional and lay patients. The contact one-hour meetingsextending patients was not atall superficial.With daily, recorded well over100 sessions. over afive-month period,each group evaluated by acomprehensive battery con- The effects oftherapy were with and perception testsfrequently used sisting of sixpsychomotor, verbal, admin- word association,tapping speed), schizophrenics (e.g.,reaction time, basis. Anymismatih on these istered on apreexperiment-postexperiment covariance methods. variables waspartialed out using subjects, findings of thestudy wereclear-cut. Treated The principal improved significantly morethan specific groupassignments, whatever their this improvement was However, withinthe treated group untreated ones. than thosetreated lay therapistsregistered greater gains uneven;those seen by five of the six measures, This was the casedirectionally for by professionals. significant on three(speed of differences, favoringstudents, highly with the Moreover, thechanges brought time, andverbal fluency). tapping, reaction proved to bestable over athree-year about by theseuntrained therapists follow-up evaluation. period, asdemonstrated through One might challenge this study onseveral grounds. It is not difficult to particularly the the absence ofclinical-behavioral criteria, justifiably question possibility of someconfound- "payoff"discharge rates.There is the logical patient drop-out ratesin the student ing of results as afunction of higher bias in therapist sexin that alllay Furthermore, thereis a systematic groups. professional therapists weremales. therapists werefemales, whereas most explain why patients seenby lay therapists Even so, one ishard-pressed to morethan those seenby professionals. should haveimproved significantly experiential than intellective,training, and The data oblige us tolook at other improvement inthis situation.Both variables as the viablefactors underlying that the criticalchange agent and Rioch(1966) hypothesize Poser (1966) enthusiasm, and energywhich the students well have beenthe interest, may do not belongexclusively to brought to thesituation.Variables of this type 420 SUMMARY the professional; indeed, there are many circumstancesunder which we might more readily expect tofind them in the nonprofessional. The findings of the Poser investigation, in addition tohighlighting the potential of the nonprofessional as a mental healthworker, provide considerable food for thought. The study is clearly paradigmaticrather than definitive. It is limited by the particular conditionsof the researchi.e., a mental hospital setting, chronic schizophrenic patients, a grouptherapy approach, and a particular criterion test battery. Poser recognizesthese limitations but, within the framework established by them, concludes:"the present findings health ...support the conclusion thattraditional training in the mental professions may be neither optimal nor even necessaryfor the promotion of therapeutic behavior change in mental hospital patients"(1966, p. 289). The results of this striking study support the contentionthat we should explore further the utility and the potential of the nonprofessionalin mental health settings.

ROLES AND FUNCTIONS When attention is turned to questions of the roles and functions of the nonprofessional, the determining quality of our guiding conceptualizationsis underscored. How nonprofessionals (or, for that matter,professionals) are utilized rests largely on the model we hold, the goals and aims we see as primary, and the programs we devise to implement theseobjectives. These principles can best be illustrated in the context of ourearlier discussion of conceptual models. For example, if helping programs arebuilt in the image of the medical model as we have defined it, thenwhat is called for is a type of taxonomy of job components with categorizationof some elements as higher-order and some as lower-order. In this case,higher-order would refer to functions which, presumably, could only be performedby the professional; lower-order would refer to those which couldbe handled by a nonprofessional. Relevant to this point Reiff (Ch. 5) draws ananalogy to the industrial model in which we seek to "...break up complex highlv skilled operations into a series of more simple tasks. Thesimplification of production processes reduces the amountof training necessary and this makes increases in the manpower pool feasible" (p. 80). This approach does not challenge the assumptions ofthe guiding model; instead, it is addressed to meeting what is seen as acentral shortcoming of the modela lack of "manpower muscle"! For example,clinical psychologists tend to define psychometric functions as amongthe least interesting and least demanding of their professional activities.Accordingly, there is considerable interest in training people at the M.A.level to function as psychom- etrists. The presumed consequence of thiswould be to free the Ph.D. psychologist to engage in activities requiring higher-levelskills. The delegation of these "expendable" skills is proposed as anaid toward a more efficient total EMERGENT APPROACHES TO MENTAL HEALTH PROBLEMS 421 operation within the presently defined frameworkand as the basis for achieving an arithmetic increment in its scope. However, theneed to free the time of the highly trained professionals may prove to be a less important matter than the issue of how that time is utilized. Earlier we noted a general inclination todivide professional activities into higher-order and lower-order onesand to relegate the nonprofessional to the latter functions.This bias, though recognizable in many programs designed for the nonprofessional to date, is notmandatory. Indeed, the very designation of what is or is not a high-levelprofessional function is, in itself, a value judgment.Rioch (Ch. 7), for example, selected anactivity from among the mosthighly prized functions of the professionali.e.,the conduct of psychotherapyand successfully trainedmiddle-aged housewives to do this work. Within the framework of the medicalmodel, there are nearly as many potential roles and functions for thenonprofessional as there are separate professional activities which can currently beidentified. Particularly in the light of findings of people such as Poser (1966) andRioch, Elkes, Flint, Usdansky, Newman, & Silber (1963), it would beunwise to assume that there is any type of interpersonally-based help fortroubled individuals which can only be renderedeffectively, or best be rendered, by the mentalhealth professional. The nonprofessional in the mental health fieldhas been used prepon- derantly within the classic framework of the medicalmodel in a variety of direct service activities with emotionally disturbedindividuals. Several illustrations of such functions appear in the presentvolume, for example: as social or milieu therapists in a state hospital setting(Sanders, Ch. 8), as psychotherapists (Rioch, Ch. 7), and as companions to mentalhospital patients (Holzberg, et al., Ch. 6), as well as in the literature(e.g., Greenblatt & Kantor, 1961; Greenblatt, 1962; Holzberg, 1962;Kantor, 1962; Umbarger, Dalsimer, Morrison, & Breggin, 1962; Holzberg & Knapp,1965; Klein & Zax, 1965). Though most of these examples involve collegestudents working with adult mental hospital patients, other usages havealso been reportedfor example, as case-aides in mental hospital work withchildren (Reinherz, 1963a, 1963b), as big brothers for troubled children inrural settings (Mitch- ell, 1964, 1966), and as staff in a halfway house(Huessy, 1966b). Indeed, several recent reports have described the use ofhigh school students as mental health aides. Fellows and Wolpin (1966) report aproject in which they served effectively as group leaders, counselors, tutors,and operant conditioners on a state hospital wardfor adolescents and preadolescents. Similarly,Cytryn and Llihlein (1965) found that high schoolstudents, functioning in instruc- tional and recreational capacities with youngmental defectives, were capable of making important contributions to thedevelopment of these youngsters. Nonprofessionals have also performed mental healthfunctions in situations other than standard clinical settings,in situations aimed at individuals who would not, under ordinary circumstances,have been objects of concern SUMMARY 422 for the helping professions. Many ofthese functions can be seen as integral to programsemphasizing early secondary prevention.Examples of these latter roles are represented in the presentvolumecounselors in a pregnancy or well-baby clinic as described in Rioch'ssecond program (Ch. 7), the "teacher- mom" who works intensively with theseriously disturbed child (Donahue, Ch. 20), the teacher-therapist who isfriend, companion, parent-surrogate, teacher, and helper to disturbed youngsters on around-the-clock basis (Lewis, Ch. 19), the mental health aide andday-care activity leader in the school (Zax & Cowen, Ch. 18)and elsewhere inthe literature (Hereford, 1963; Donahue & Nichtern, 1965; Rockefeller, 1965;Cowen, Zax, & Laird, 1966b; Huessy, 1966c, Zax, Cowen, Izzo, Madonia,Merenda, & Trost, 1966). Still other roles and functioning will befound for the nonprofessional in mental health programs outside theorbit of the medical modelthosewhich are preventivelyoriented, directed to community actionand social system modification. Since this type of program tends tobe newer and less well articulated than traditional services, it followsthat it is more difficult to define the place of the nonprofessional withinthe program. The problem in this instance is not one of breakingdown complex, old, and clearlyspecifiable functions into simpler and more manageablesubunits; rather itis one of carving out new, seemingly "foreign,"and "difficult to conceive" functions from scratch. The very definition ofwhat is a mental health problem is a central issue here and, with it, what actions maybe encompassed under the banner of mental health operations. As anexample of the latter, it is interesting to note some recent promisingdepartures from traditional modes of rendering helping services to the poor,such as treatment in the home (Levine, 1964) and role playing(Riessman & Goldfarb, 1964). If we bear in mind, as Reiff (Ch. 5) hasemphasized, that improvement of the mental health status of the poor isdependent on social systems modification and community action, and thatproblems of" self-determination and coping skills far outweigh those ofpsychodynamics or self-actualization for this group, then an alternative set ofhighly viable mental health functions for the indigenous nonprofessional can bespecified. In the main, these functions, some of which have been describedby Reiff and Riessman (1965), by Brager (1964) in connection with theMobilization for Youth project,and by the Howard University group(Fishman, Klein, MacLennan,Mitchell, Pearl, & Walker, 1965; MacLennan,Klein, Pearl, & Fishman, 1966), are directed toward resolution of the highly concrete,mundane, everyday problems of the poor. Some of these newroles, particularly in the contextof community action programs, are asfollows: housing service aidetoprovide information about available housing and toorganize neighborhood improvement; homemakertohelp families become more competent inhome management, offercompanionship or psychological support,furnish information on community facilities, actually takepeople to agencies or community meetings, or providebabysitting services to make thispossible; community action aide 423 EMERGENT APPROACHES TOMENTAL HEALTH PROBLEMS to establish closerelations between the communityaction agency and community institutions and organizations(such as area schools, churches, and civil rights groups);expediterto bring together a personneeding service and the agency thatprovides it. In addition to thesecommunity action roles for the nonprofessional,Reiff and Riessman (1965) and theHoward group (Fishrnan etal., 1965; MacLennan et al., 1966;Klein, Ch. 9) have described a number of human service orcommunity mental healthroles for the poor such as home serviceaides, child service or child careaides, casework aides, recreational aides,and research aides. Despite the variety of roles andfunctions for the nonprofessionalwhich have already been explored, thesurface of this area hasscarcely been scratched. This is a period ofconsiderable ferment and exploration,triggered by a recognition, independent ofthe model we hold, of the vastpotential of this resource. In the nearfuture we are likely to witnessincreased efforts identified roles, as well as to scrutinize andevaluate the impact of already mental anintensification of our search formeaningful, contributory, new health-relevant functions for thenonprofessional.

SELECTION, TRAINING, ANDSUPERVISION We shall probably find that the rangeof human beings who canbe used effectively to perform significantfunctions in the mental' health enterprise is extraordinarilybroad. This likelihood is reflected evenwithin the relatively limited confines of the presentvolume where programs utilizing college students (Holzberg et al.,Ch. 6; Zax & Cowen, Ch. 18),college graduates (Sanders, Ch. 8), teachers(Lewis, Ch. 19), and highlyeducated housewives (Rioch, Ch. 7), aredescribed. Each of the foregoing categories of nonprofessionals is morefully represented in the literaturesome(e.g., college students and indigenousnonprofessionals) rather extensively. Inaddi- tion, other, more specialized groupshave been utilized as nonprofessional helpers in a variety of recent experimental orpilot projects. Examples of these groupsinclude delinquents (Hubbard, 1963;Slack, 1963; Schwitzgebel, 1964), criminals (Briggs, 1963;Hawkinshire, 1963; Oberhauser, 1963),children, and retired oldsters. Theseexplorations of new sources of manpower reflect a perceived need and a growing awarenessof the special potential of the nonprofessional. Thediversity of recruits in existing programs spansbasic dimensions of human individualdifferences, such as age, sex, education, socioeconomic level, and social status.However, we still have minimalknowl- edge of what these people can do,who is likely to be most effective inwhat setting, etc. Tactics and stratagems for recruitmentof the nonprofessional worker have been marked by theirvariability. In some instances, the prime recruitment attribute isself-defining. For example, the indigenousnonprofessional must indeed beindigenous (Reiff & Riessman, 1965).If the change agent 424 SUMMARY is a current or former member of a target group (e.g., ex-delinquent with delinquents, ex-addict with addicts, ex-criminal with criminals)a factor which is central to many programs (Calif. Dept. of Corrections, 1963) that criterion is the prime (but not, necessarily, the only) element in selection. Many programs, particularly those involving college students, have been largely self-selecting or at least self-scre, ning (e.g., Umbarger et al., 1962; Holzberg et al., Ch. 6). Others have involved only gross negative screening (e.g., Zax & Cowen, Ch. 18, for college students) to rule out the few who may be either seriously disturbed or grosslyunsuited. Still other programs have specifically selected workers, generally using individual or group screening techniques (e.g. Rioch, Ch. 7; Sanders, Ch. 8) on the basis of a set of positive criteria thought to be relevant predictors of subsequent performance. For example, Reiff and Riessman (1965) speak of desirable attributes of the indigenous nonprofessional other than his neighborhood roots. These include a concern about neighborhoodproblems, an interest in and ability to work comfortably with others, a willingne.;s to communicate across class lines, and a capacity to learn and to develop.Zax and Cowen (Ch. 18), in selecting housewives for roles as mental health aides in the classroom, placed considerable emphasis on attributes of personal warmth, a relatively successful child- rearing history, an interest in working with young children, and a non- crusader orientation toward the schoola selection pattern similar to that utilized by Rioch (Ch. 7). It should be recognized that when such selection criteria are specified, they largely reflect best guesses for a given situation. At this time we have very little empirical evidence as to whatattributes in the worker relate to what outcomes in the recipient. Establishment of positive selection criteria for nonprofessionals is often associated with programs that have heavy training or supervisory investments, the feeling being that if so much effort is to be put into the program, it is best to respect those hunches which could maximize the possibility of hoped-for outcomes. Failure to adopt selection criteria or use of minimal criteria mirrors greater acceptance of our present limited understanding of "who-can-help-whom" contingencies and, consequently, a more open approach to their resolution. Training of the nonprofessional is directly related to the basic model we hold, as well as to the prospective roles and functions of the worker (Riess- man, Ch. 10). Two principal issues reflected here are,first, the question should there be training, and, second, if there is, what should its form and content be? For example, if we see the nonprofessional as someone who should be taught to take over specific components of the professional's activities, then a period of concrete background and skill training directed toward achievement of mastery of those functions is clearlyindicated. The length of that period will vary with the group being trained, the skills to be imparted, and the amount of background context considered relevant. In practice, such training has run the gamut from a relatively brief, circumscribed course of 425 EMERGENT APPROACHES TOMENTAL HEALTHPROBLEMS extensive and five or six weeks (e.g., Zax 8cCowen, Ch. 18) through a more rounded one-year program to preparesocial therapists (Sanders,Ch. 8), to didactic, and prac- nearly two years of full-timestudy including theoretical, ticum components, as inthe case of the preparation ofRioch's (Ch. 7) initial of housewife group for careers aspsychotherapists. In this regard, one note caution should be sounded.To the extent that training programsfor nonprofessionals require several years or moreof intensive training, they are the usual ter- likely to be professional training programsin disguise, minus minal degree. In any large-scalesocial sense, it will not bepossible to maintain such programs for the very same reasonsthat limit our potentialfor training the full-fledged mental healthprofessional. If, as many have come tofeel, personal and motivationalqualities are more importantthan specific skills as activeingredients in the helping proc- In this ess, thenless importance will beattached to the need for training. latter instance, training may beused more to activatesystematized and searching reflection aboutrelevant people or situationsand to help build confidence impart a and security under relativelynonthreatening circumstances than to specific body of knowledge.From this viewpoint, the selectednonprofessionals what- are assumed tobe individuals who, bypersonality, life experience, or ever, have agood deal to offer others; itwould be unwise to tamper excessively with their styles and naturalreflexes by teaching them the"right" way to do things. Once a decision about the needfor training has been made, anumber of procedural questions pertaining toboth content and form must beengaged. Though content is often determinedby the functions for whichthe worker is prepared, the rule is notalways so simple. In some instances we maywish find that sub- to prepare theindividual for a variety of functions, or we may stance cannot reallybe engaged before a change invalues and attitudes has been effected. Klein (Ch. 9)utilizes the personally-oriented"core-group" approach to bring about such change.The purpose of this group is toenable the trainee to learn "moreabout himself, the community,and the world he lives in" and how his job performanceis related to "his personallife, aspirations, and relationships withother trainees" (Ch. 9, p. 150). Likewise, the form of training programs may varyconsiderably. In this regard, one obvious and highly salientdimension is level of abstractness or concreteness. There arelargely didactic approaches,those featuring a discussion orientation, and thosethat largely emphasizeexperiential components; and within each of those gross categories,there are many exemplars. As with length of training, both the formand content of training programs mustbe determined by the attributes of the groupbeing trained and by their contem- plated roles. What is appropriatefor the college student who willwork with schizophrenics in a state hospitaldoes not make sense at all for ahard-core delinquent from a slum neighborhoodwho will be working as a child care aide. The characteristic trainingneeds and styles of a given group,rather SUMMARY 426 knowl- than our own rigid preconceptionsand preferred ways of imparting edge, should shape the training program.With some groups,particularly among the poor, it maybe, as some have suggested(Reiff & Riessman, 1965; Klein, Ch. 9), that a "job-first,training-next" approach is theonly feasible one. Experience with specific training situations putsone in abetter position Reiff and Riess- to establish moreinformative guidelines for such training. they be- man (1965),for example, have identifiedcertain principles which lieve are basic to the trainingof the indigenousnonprofessional. These in- beginning, clude "continuous on-the-jobtraining" starting from the very building from simple to morecomplex functions, emphasizingactivity rather than a lecture approach (i.e.,doing in preference to talking),building group time," "a solidarity, provision of"informal individual supervision at any down-to-earth teaching style," andhelping workers to become awareof their personal styles and to feelfree to utilize them. Thisparticular recipe is born of experience. We shallneed others suited to other groupsand situations. One of the very real problemsfacing the would-be trainerof nonprofessionals is that we are unsure ofthe training "whats" and"hows." Curricula developed from scratch for a par- are unavailableand usually have to be ticular situation; to a considerable extent, ourforms of approach are"trial balloons." We have neither proventraining methods norexperienced and knowledgeable trainers, and one of ourstriking needs is thatof training fair people for training"metatraining."Itistherefore necessary that a amount of theprofessional's time be devoted to training, resource,and supervisory functions. Suchsupervision carries with it thepotential for education, ends support, andpersonal growth of the worker.In many instances, these alien or may befurthered by group supervisorytechniques unless these are inimical to the life style of thetrainees.

SPECIAL ASSETS OF THE NONPROFESSIONAL Quite apart from the standpointof social need, it is entirelypossible because of special, that the nonprofessionalbelongs in mental health activities and sometimes unique,contributions that he can make.More boldly stated, there may be helpful things thatthe nonprofessional offers or cando which simply cannot be duplicatedby the professional. One illustration of this point was seenin the discussion of Poser's(1966) untrained college students, who werefound to have more impressive"batting averages" than trainedprofessional specialists in grouptherapy work with findings, both chronic schizophrenics. Inseeking to explain these surprising Poser (1966) and Rioch(1966) hypothesized that thecritical factor under- have been the energy, lying the observeddifferences in patient groups may enthusiasm, and involvementof the nonprofessional.These qualities have 427 EMERGENT APPROACHESTO MENTAL HEALTHPROBLEMS been noted in many reportsof programs utilizingnonprofessionals (Um- Cowen, et al. 1966b). barger et al., 1962; Holzbera1963; Klein & Zax, 1965; and enthusiastic, he It is reasonable to supposethat if a helper is interested ingredient may be an communicates thosefeelings to the recipient. Such an Some critics, even thoughthey important determinantof constructive change. recognize this point,have gone on to "look the gifthorse in the mouth." Thus, Rosenbaum (1966), commenting onthe Poser findings, states:"Certainly, respond to young, vibrant people who have beenrejected by the culture will people who are humaneand extend warmth. Buthere we are speaking of of psy- compassion andhumaneness. Is this to beequated with the process chotherapy?" (p. 294). Giventhe known difficultiesof effectuating positive that change is true change change in human behaviorby any means, to insist only when it followspsychotherapy, or interventionsby trained professionals, is a luxury we canill-afford! hypothesis The more cogent concernabout the "involvement-enthusiasm" distinguishing attributes of the non- is whether thesecharacteristics are basic professional, or whether they arecharacteristics of most humanbeings as for the first they become involved in exciting orchallenging new experiences she suggests that the suc- time. Rioch (1966) raisesprecisely this issue when repeated the cess ratesof the nonprofessional mightwell taper off if they and same activities over afive-year period. Such anhypothesis is both tenable testable. If confirmed, it might point toconstructive modificationof programs activi- for the mental health worker toinclude continuing exposure to new interest could be maxi- ties and experiences. Inthis way involvement and could be more mized, and the benefits to bederived from human enthusiasm effectively harnessed. We may note,in passing, that the same argumentcan activities under also be applied to theprofessional who, performing repetitive burn out. conditions of limited positivereinforcement, may eventually Another possible advantage ofthe nonprofessional hasbeen pointed out bring "fresh points by Rioch (1966). Sheobserves that such individuals may methods into the field"(p. of view, flexible attitudesand sometimes new 291). The nonprofessional is notbogged down by the absoluteknowledge and illusion of certaintywhich often encumbersthe professional. In his naiveté he may be morelikely to stumble oneffective and pragmatic new have rejected ways ofapproaching problems whichthe professional would profes- asunsophisticated, improbable, orfoolish. Thus, the open-minded sional may actually be in aposition to learn andprofit from his associations with nonprofessionals. A special element of theflexibility argument is that thenonprofessional role-prescrip- can dothings that the professional,by virtue of breeding and be less formal tions, ordinarily cannot orwill not do. He is in a position to less clearly and less rigid (Huessy,1966b). Limits on his participation are prescribed. As Reiff andRiessman (1965) observe,"he can be invited to weddings, parties, funerals,and other gatheringsandhe can go" (p. 7): 428 SUMMARY The importance of this potential should not be underestimated, particularly so as we place increasing emphasis, in our mental health models, on the value of concrete, everyday, coping experiences incontrast to intrapsychic determinants. While the nonprofessional's freedom of action will undoubtedly vary as a function of particular circumstances, with some groups, especially the poor, it may be a factor of considerable potential. He is ina position to cut through certain types of role-distance problems inherent in many existing, middle-class-based, helping procedures where technique is inconsistent with the life style or expectancies of the poor (Riessman, 1965). There is another, not entirely unrelated, point to be made. Rioch (1966), in her discussion of Poser's findings, has suggested that one possible explanation for the relative success of the nonprofessionals was "that the patients cooperated more readily with people who were felt to be closer to themselves in the social hierarchy, that is close to the bottom of the ladder" (p. 292). This principle is the central element in a variety of helping approaches, for example, "AA," Recovery Incorporated,or Synanon (Yablonsky & Dederich, 1963; Volkman & Cresscy, 1964), where efforts are made to reduce social distance factors to zero by using a former victim of a condition as the helping agent for current victims. But, the argument is not limited to such specific instances. In the broader sense, we are speaking to the variable phenomenology of people who need help. Among them there are undoubtedly some who perceive the professional as an unapproachable authority, as someone who is removed from their problems, or as a person with whom they cannot communicate because he is what he is. For such individuals, and they need not be lower-income people, these perceptions may block the possibility of being helped. There are, of course, many others for whom the authoritative and status-related attributes of the professional may be a helpful or facilitating element. Thus, the key to being helped will be found, for some individuals, in an authority relationship; for others, in a peer relationship. It is more than admissable that the nonprofessional will have advantages over the professional in establishing the latter. So far, we have attempted to identify in a general way some of the potential special assets of the nonprofessional. In particular circumstances these assets may assume even greater importance; and other attributes, not yet identified, may take on significance. Illustratively, Reiff and Riessman (1965) emphasize the social distance factor as one of the truly critical advantages of the indigenous nonprofessional. He, like the people he serves, is poor. He shares a common background with them, comes from the same neighborhood, and has suffered similar agonies. These factors facilitate his acceptability from the consumer's standpoint and, at the same time, make it easier for him to identify and to establish rapport with them. "Know-how" is another attribute of the indigenous worker. He is thoroughly familiar with the neighborhood, its heartaches and difficulties, and ways of dealing with problems in such settings, far more so than is true of almost any professional. This puts him in PROBLEMS 429 EMERGENT APPROACHESTO MENTAL HEALTH natural context and to a goodposition to perceiveindividual needs in their be seen as such.Finally, undertake sensible and appropriateactions that will coming from Reiff and Riessman(1965) identify thespecial contributions nonprofessional and hisclientele. the "style-match"between the indigenous natural way. It isreadily under- His natural way of doingthings is also their characteristics of theindigenous stood and comfortablyaccepted. Sr...ne of the problems which areboth worker's stylistic preferencefor approaching life's and his setting arethe follow- salient and highlyadaptive to his functions of human difficulty, a con- ing: practicality, anexternal view of the causes militant stance with respect toauthority crete action-directedposture, and a and social action.

CHANGES ,IN THEWORKER of programs, there is grow- Through experiencegained with a variety of genuine ing reason to believethat one potentiallysignificant consequence health functions is construc- involvement of thenonprofessional in mental change may occur atdifferent levels tive personal changein himself. Such of groups and programs,and a modest amountof depending on the specifics For ex- objective evidence canbe cited in supportof the basic proposition. positive ample, Holzberg etal. (Ch. 6) andCowen et al. (1966b) report following their participationin change in the attitudesof college students and public schoolchildren, helping programs formental hospital patients further that such anexperience respectively. Klein andZax (1965) indicate future mental the likelihood ofcollege students going on to may increase Ch. health careers. And at a verydifferent level it hasbeen shown (Klein, 10) that formerdelinquents, high schooldropouts, and 9; Riessman, Ch. functions, welfare cases may,through participation inmental health-related go on to careersin the human servicefields. being genuinely helpful to For many nonprofessionals,the process of have considerablepersonal value.Riessman another human being may Rioch (Ch. 7) (1965) has referred tothis as the"helper"-therapy principle. multiple social problemsin has spoken of this in termsof bringing together been recog- their resolution. It is aprinciple which, atleast implicitly, has such and, indeed, lies atthe root of venerable programs nized for many years further by Recovery Inc. Riessmancarries this point one step as "AA" or well be for the suggesting that theprincipal values ofsuch programs may helper, rather thanfor the target person. their life experience orthe There are many peoplewho, by virtue of in a position ofbeing able to do little very structureof society itself, are put characterized by a void, alack of fulfillment, more thanexist. Their lives are of direction or purposefor the future. Rioch(Ch. 7) and no clear sense whose chil- observes that this isthe fate of manymiddle-aged housewives For very different reasons,the same dren have grown upand left the home. 430 SUMMARY end-result may typify large numbers of low-incomepeople and groups as diverse as delinquents, offenders, and retiredoldsters. Such people can be viewed as an important potential resource inthe mental health field, since, through the act of helping others, they mayalso be able to help themselves. Because, in some instances, these representlimited prognosis groups, the latter potential is not to be overlooked. There isneed to plan for more systematic utilization of nonprofessionalswho may need th,: opportunity tobe genuinely helpful to others and can grow fromsuch activity. A variety of mechanisms have beenhypothesized (Reiff & Riessman, 1965; Riessman, 1965) to account for thepositive personal changes which some nonprofessionalshave undergone through their human serviceexperi- ences. There is thevalue of having a stake in, and aresponsibility for, a meaningful job, including the satisfactionderived from acquiring new skills. That these skills can actually help someonewho needs help may serve to bolster one's self-image either directly through thedemonstration of concrete achievement or indirectly through the cognitionthat to help others one must, himself, be in reasonably good shape.There may also be straightforward benefits accruing to some because of an increasein status and prestige derived from their new role. Finally, the needfor the helper to be able to impart knowledge may force growth by putting him in amandatory learning position. These mechanisms may bethought of as helpful either individually or interactively and will certainly operate differentiallyin individual cases. The help that the nonprofessional mentalhealth worker, particularly the more vulnerable one, derives through helpingothers contributes directly to the resolutionof one set of social problems, creating moreeffective workers, and thereby establishes a potent force for theresolution of other social problems. There is an intrinsic appeal in thepyramidal or multiplicative potential of the approach, which is opposite in its structure tothe better known and oppressive vicious circles that haveplagued mental health specialists for so long.

POTENTIAL PROBLEMS Despite a growing willingness, sometimesborn of desperation, to examine what the nonprofessional maybe able to offer in various mental health programs, judgments about hiscontributions have largely been im- pressionistic. Since such personnel have notbeen used systematically for very long, we have not really had a chance to learn whatthe nonprofessional can or cannot do or toidentify essential parameters that relate toeffective functioning in various roles and settings.Accretion of such information is -a vital prerequisite for building a more efficientand effective mental health order. To acquire this information will require openness, aninquiring spirit, and a willingness to explore freely in new directions.The guidelines of overinclu- siveness and respect for thegood hunch are to be preferred to those of con- 431 MENTAL HEALTHPROBLEMS EMERGENTAPPROACHES TO danger of such a courseis that itvirtually striction andpreconception. The these will be mis- be made.Hopefully, however, guaranteesthat mistakes will profit! takes from which we can Riessman, advocates ofnonprofessionalism (e.g. Even the strongest pitfalls, such as pro- careful to cite somespecific potential 1965) have been unsophisticated worker orthe com- jection of one's owndifficulties by the problem-freeindividuals with whom munication of theworker's problems to specific to the Additional concernsof this type, he may come in contact. and Riessman(1965). nonprofessional, arediscussed by Reiff indigenous but the hope isthat th', strengthsand Difficulties willundoubtedly arise, has to offer willoutweigh theinevitable resourcesthat the nonprofessional does not nonprofessional manpowerresources debits. Thedevelopment of calls for a re- of professionalresponsibility. Rather, it imply an abdication the form of monitor- responsibility, some ofwhich will take definition of such part-vehicle for the nonprofessional.This may provide a ing and supervising above. of potentialdifficulties alluded to minimization of the types nonprofessional move- major problemsfacing the Ironically, one of the in it mental healthprofessionals, who perceive ment lies inthe stance of many the encroachment on theirterrain (Sanders,Ch. 8). Whether the danger of is not particularly rooted in economics,prestige, or status threatened needs are strongly vested in professionals,who represent germane.The fact of resistance and influ- from positionsof considerable power interests and often operate this type ofdevelopment. could prove to be asignificant deterrent to ence, jurisdiction disputes,such the case in priorinterprofessional As has been (1966) highlights easily approached on arational basis. Rioch matters are not the Poser study."If we in the courseof her comments on this issue succinctly achieving a highprofessional status, have invested long yearsof hard work in and many examinationsthat were including many coursesthat were dull of a girl with notraining can nerve-wracking, and we aretold that some bit than we can, it isnatural that we should try do the job just aswell or better to find someobjections" (p. 291). of non- by the professionalabout utilization Verbalization of concern such as their pre- people clustersaround arguments professionals as helping particularly, thedanger understanding andqualification and, sumed lack of llak, 1964b). Even irreparable harm toanother person (Be that they may do that it is, founded, and thereis no basisfor assuming if this concern were harm is being done every overlooks the factthat still greater the argument it. The mental offer any help toindividuals who need day by our inability to than suffered more fromits errors of omission health movementhas probably begin to and we wouldbe well advised to from its errorsof commission, Conceivably, in the of the former, evenat riskof the latter. correct some toreevaluate our present course of sodoing we mighthave the opportunity "error" in themental health field. fairly rigiddefinitions of what is notwithstanding, itwould be indefensible to The foregoingdiscussion 432 SUMMARY argue that only personal reasons promptprofessiouals to object to the use of nonprofessionals in mental health programs. Emphasishas been placed on these types of reactions because they areidentifiable, strong, and dangerous ones. But it is clearthat reservations can be formulated onsolid intellectual grounds and in perfectly good faith. Indeed, earlier inthis discussion, it was noted that even ardent advocates of the use ofnonp,:ofessionals are somewhat skeptical about the approach and have spoken to someof its danger points. Reiff (Ch. 5), for example, speaks of thedangers of power struggles which may developbetween the professional and thenonprofessional and of the tensions around such struggles. . Finally, there are certain practical problems,albeit thorny ones, that should be noted. One of these pertains to thelevel of specificity at which the nonprofessional should be trained (Sanders, Ch. 8).In highly oversimplified form, two orientations to training can beidentifiedone which emphasizes the agency needs that have to be met and theother, the development of the trainee. Since many early training programshave developed in specific institutions, clinics, or agencies, there hasbeen an understandable inclination to orient training rather specifically to theneeds of the setting. Trainee-centered programs, while they recognizethe necessity of providing skills and "know- how" suited to work in a particular setting,seek to go beyond such specificity. They assume that there are certain values,attitudes, and work habits which, for some groups, must be achieved as aprerequisite to effective function in almost any type of human service work.Further, justification for such an emphasis comes from the difficulty ofknowing beforehand where a trainee will be placed and whether he will remainthere. For these reasons, a more flexible type of preparation is to be preferred.Klein (Ch. 9) exemplifies this latter approach and utilizes the "coregroup" situation, plus on-going exposure to varied types ofjob activities during the training period, as themechanisms for achieving the desired leeway. In some instances arrangements can be madebeforehand to absorb the nonprofessional in a "captive" agency where he isbeing trained. In other circumstances, however, especially where newroles and functions are being carved out and where training is conductedby an organization which is largely performing a service function (e.g., aUniversity or a Community Mental Health Center), issues attached to the absorptionof workers by community agencies can become both complexand central. Job functions for which people are to be trained have to beconceived in the light of their potential utility in certain settings. Even if responsibleadministration in these settings, as an abstract principle, accepts thefact that a nonprofessional could be useful, practical problems may beexpectedsuch as the lack of available budget or the absence of the proper spots in theagencies' table of organization. These realities point to theabsolute necessity of the professional's working closely with representatives ofpotential recipient agencies from the very beginning. They point also to the need for close on-goingliaison between HEALTH PROBLEMS 433 EMERGENT APPROACHESTO MENTAL problems can be institutions. Unlessthese mundane trainers and recipient naught; in theirresolution, resolved, the best oftraining mayhave been for health professionalwill be required. somestrikingly new rolesfor the mental other difficulties maybe anticipated. After the workerhas been placed, which the resistance, inword and deed, One of the mostimportant of these is who interest employeesof the recipient agency, may bethrown up by vested of encroach- in thenonprofessional thetime-honored spectres may perceive previously by Reiff(Ch, 5) and threat. Anotherproblem, noted ment and and furthereducation Klein (Ch. 9), isthe striving forupward mobility This type ofreaction maybe a perfectly which somenonprofessionals have. and, with it, agrowing of early satisfactionand success natural consequence that there willbe sufficient one's potential.It is to be hoped recognition of be respectedand accom- flexibility in our systems sothat such needs may modated. obvious to point outthat is a matter ofunderscoring the In conclusion it know-how, the experience, few professionalswho have the there are relatively nonprofessionals. Our systemwill not and the interestrequired for training people are usurpedin trying to meet expand in neededincr-ments if these needs. A primenecessity is thatthey be circumscribed andrepetitive service that the promiseof multiplicative utilized for thetraining of trainers, so Beyond that, the timeof the qualifiedprofes- expansion maybe furthered. models, in the establishmentof training sional trainer maybest be used in and in workingtoward absorptionof the evaluationof their effectiveness, possible, a con- appropriate communityagencits. Insofar as the product in participation be made to helpthe agency toincrease its certed effort should This implies agradual and ultimately to assumeresponsibility for training. vis--vis a giventraining program,from shift in the roleof the professional, consultation. As this isachieved, he willbe free one ofleadership to one of and evaluation of newmodels. to worktoward the development

THE MENTALHEALTHPROFESSIONAL health problemsand redefini- Change in ourapproaches to mental professions demandthat carefulconsideration tion of the scopeof the helping several changing role ofthe professionalspecialist. Indeed, be given to the & Raush, 1964; been devoted tothis theme (Hoch recentconferences have Cooper, Hassol,Klein, & Rosenblum, Goldston, 1965a;Bennett, Anderson, 1966). There islittle basis forsuggesting that 1966; Hoch,Ross & Winder, training formental healthprofessionals be all of thesubstance of present Berlin, the point hasbeen made(Bernard, 1964; dropped. To the contrary, of personality least some of what we nowtrain forknowledge 1965) that at for theindividualis not self-awareness, anabiding concern development, functioning in emergentroles. It will only useful but necessaryfor effective SUMMARY 434 those aspects of cur- be some time before we canpinpoint with confidence Given the shifts in orien- rent trainingthat are viable and those that are not. tation already proposed inthis chapter, however,certain recommendations about utilization of themental health professionalfollow almost automat- ically. Some of these, atleast in fragmentary form,have appeared in our is to achieve a discussion of earlier issues.The aim of the present section more coherentand systematized presentationof these views. The critical problem inthis area is optimalutilization. A basic redistri- become bution of our limitedprofessional resources isneeded so that they the mental health problemsof modern more potentforces in efforts to reduce reapportionment will society. The most importantdeterminants of any such be found in the conceptualmodels that we hold. balance of the professional's As one basic focus, werequire a shift in the activities so that arelatively greater proportionof his time becomes system- reLtively smaller portion isindividual-centered. orinstitution-directed and a currently favored one-to-one Given limited total resources, wemust reduce judiciously clinical functions such aspsychodiagnostics andpsychotherapy and also necessary for the allocate those one-to-one servicesthat remain. It is preferred passive stance professional to exchange portionsof his historically This means replacing asignifi- for a more activeproblem-seeking orientation. time with mentalhealth-relevant cant amountof office, clinic, and hospital (Felix, 1962; Caplan, activities in the communityand its primary institutions technology from one 1965b). It does not mean asimple transfer of the same of the communityresides in set of buildings toanother. The attractiveness modification of influence systems, the opportunities itoffers for constructive extension of the scopeand effectiveness moresensible timing of intervention, of disorder. Grantedthat of our helping operations,and stemming the flow different ways, they these are diverse endswhich are to be achieved in very neglected ends. Unless asubstantial por- are also verybasic and historically be funneled in thesedirections, tion of our totalprofessional resources can tread water (Hobbs,1964). weshall find ourselvesstruggling eternally to contributions markedly More concretely, theprofessional can extend his (and other people in society through consultationwith impactful care-givers health status becausethey inevitably have contactwith who influence mental and individuals in crisissituations), as well aswith key community agencies will be institutions. The fullpotential of the latterof these two approaches modification of systems, more nearlyachieved to the extentthat constructive becomes a focus of consultation. rather than simplyindividual or case review, will be insufficient to If, as we haveassumed, professional resources resolution to this problemlies in the meet mentalhealth needs and a part that a greater portion of the judicious use ofnonprofessionals, then it follows (Duhl, professional's activities willbe devoted to workwith such individuals nonprofessional in many ways 1965). He will need tobe concerned with the conjunction with appropriate including: definition ofroles and functions in EMERGENT APPROACHES TO MENTAL HEALTH PROBLEMS 435 community agencies; recruitment and selection; development of a variety of training curricula; conduct of training; and initial placement as well as continuity of function. Linder some circumstances, effective execution of these functions may bring the professional into community action and quasi-political roles, since program implementation cannot always be divorced from the social context in which it is to take place. In the aggregate, however, the bas":: shift in professional roles which is called for lies in the substantial replacement of clinical service with educational, supervisory, consultative, and resource activities. If we may compartmentalize functions of the mental health specialist, we are speaking of a movement by the professional away from the traditional clinical-practitioner mold toward two relatively new and evolving onesthose of the mental health "quarterback" and the "social engineer." There are no special difficulties attached to envisioning and operationalizing these two new molds (indeed, for the first we have done so already), but there are some very fundamental issues that must be raised about the qualifications of the mental health specialist for the role of social engineer. The essence of this role involves the analysis and understanding of social systems, their relation to human development, and ultimately, how their modification may constructively affect such development. When we try to point to the specific skills that will be needed to meet such objectives, as has been done at a recent training conference (Bennett et al., 1966), areas such as the following receive prime designation: group action, epidemiology, community organization, public administration, evolution and change strategies in social systems, principles of ecology, biostatics, etc. Given the underlying objectives, one can readily see the relevance of each of these areas to the task; yet few, if any, are even approximated in presently existing curricula for the advanced graduate training of the mental health professional. The social psychologist would come somewhat closer to such training than the clinical psychologist, and perhaps the sociologist would come closer than either. Sarason et al. (1966) use the term preciousness to describe the tendency of mental health professionals "to view what they are and do as unique, and to believe that they are the only ones to 'truly' understand, grapple with and effect changes in individuals beset with problems in living and adjustment" (p. 34). It would be an act of extraordinary preciousness for any one or all of the helping professions combined to assume that they had special calling or unique qualifications for social engineer functions. To be sure, the helping professions have a vital stake in the furtherance of this role, and unquestionably, they can contribute much both by helping to frame meaningful questions and by contributing to their resolution. But itis not for the helping professions to go it alone. They do not have the skills to do so. Again quoting Sarason et al. (1966), "To study and understand the community with the intent of serving it will require a type of personnel that now does not exist" (p. 648). Indeed, we may question whether there will ever be a single pro- 436 SUMMARY fession with the requisite skills for such abroad and demanding task.When mental health problems are approached atthe level of the basicfabric from which society is fashioned, then appropriatemodifications of the training of the professional can help him tounderstand relevant issues anddeterminants more fully, propose more cogentquestions for study, widen hisrepertoire for answering these questions,and work more effectively withother groups toward achieving shared objectives.All this, however, will not alter thefact that the intrinsic complexityand depth of roots of mental healthproblems are such that weshall always require significant, continuinginvolvement of other groups working toward thefurtherance of their resolution. More specific discussion of issues ofprofessional training in this area raises a series of troublesome questions.(Based on a survey of chairmenof departments of psychiatry, one source hasrecently categorized well over one hundred such questions [Goldston,1965b].) On logical grounds, the most basic of these is what is really meantby the term this area? Most existing training program; utilize the word communitysomewhere in their descriptive i titles (e.g., community psychology,community psychiatry, or community I J mental health). But, as we have suggestedearlier, this is a highly amorphous term whichdefines neither the conceptual model guidingthe training nor its logical derivativesi.e., the scope and contentof the activities for which the professional is being prepared. Accordingly, twoprogramseach labeled as a training program in communitymental healthneed not have similar content at all. As anillustration, a program set up in the imageof the mental health "quarterback" might place much heavieremphasis on care-giver and agency consultation, crisis intervention, andsupervision of nonprofessionalsthan would one which is in the "socialengineer" tradition. The latter, impinging as it does onmethodologies and skills drawn fromdiverse areas, should have a much strongercross-disciplinary flavor. Structural variations are also found inprofessional training programs, and these exist at severallevelsintradiscipiinary versus cross-disciplinaryand postdoctoral versus predoctoral. One ofthe earliest programs to bedeveloped was thatof Caplan (1959b), designed to provide one tothree years of train- i ing essentially forexperienced postdoctoral specialistsfrom various of the helping professions (i.e.,psychiatrists, psychologists withthe Ph.D. plus some experience,and senior social workers). Thefirst year of this program, leading either to an M.A. in PublicHealth or an MS. in Hygiene, islargely didactic and cross-disciplinary in nature,including work inbiostatistics, Later ecology, community organization,and epidemiology, among other areas. years aredevoted primarily to practicum trainingin affiliated field stations. More recent modifications ofthis program are describedelsewhere (Baler, 1965). Other types of postdoctoral training incommunity work exist, sometimes less well articulated or specializedthan Caplan's program. Such training may be intradepartmental orinterdisciplinary and is most oftenavailable in a EMERGENT APPROACHES TO MENTAL HEALTH PROBLEMS 437 medical setting. There has been a highly noticeable trend, for example, to provide for rotation through one or more community-relevant activities as part of many residency and postresidency training programs in psychiatry (Bernard, 1964, 1965; Hume, 1964; Daniels & Margolis, 1965; Goldston, 1965a, 1965b; Daniels, 1966). Portions of the recent volume by Goldston (1965a) are devoted to significant issues connected with this development; for example, How extensive should this new training be? What, exactly, should it include? When should it take place? How can we best introduce it into venerable and entrenched curricula, which are already overstretched (Caplan, 1965d)? Similar problems are encountered in the area of clinical psychology where postdoctoral internships featuring part or extensive exposure to community work are rapidly developing. Relevant training at the doctoral level is quite limited and, for a variety of reasons, is confined largely to psychology. As recently as several years ago, the results of a survey (Golann, Wurm, & Magoon, 1964) indicated that there was only one formal training program for community psychology in existence, although discrete elements of such training were reflected in a number of clinical programs. Since that time, several new programs have evolved, both in the intradisciplinary and cross-disciplinary traditions. There has also been a marked expansion of community-type offerings in standard clinical training programs to the point where several institutions offer a community "track" as one type of predoctoral specialization available to the clinical student. The substance of these programs, be they "whole" or "part" programs, is variable and is governed largely by the models and conceptions held by the trainers. There is, however, a strongly felt need for training community mental health personnel at the doctoral level, evidenced by the reports of several recent conferences dealing with such matters (Hoch & Raush, 1964; Bennett et al., 1966). The salient attribute of the program approaches that have been presented in this volume is their newnessmeasured in terms of the history of science or the history of the helping professions. Accordingly, training prece- dents are virtually nonexistent. The fact of the matter is the mold isnew, and we are not at all clear on how best to train tomorrow's professional (Bri- gante, 1965; Caplan, 1965b; Srole, 1965). Universities, which to an overwhelming degree govern the nature of professional training, are, in general, not yet ready for this operation. Once a graduate training program becomes fixed, it is extraordinarily difficult to eliminate existing courses and to add new ones. In other words, revamping professional training programs inevitably entails fighting the cumulative inertia of many decades. Sarason et al. (1966), in a remark that combines good humor with archetypic wisdom, have observed: "We are fully aware that changing training programs is a task to be undertaken only by those who need to indulge their masochistic tendencies" (p. 648). Traditional training methods for professionals, though they do not necessarily prepare students for the most needed or most meaningful mental SUMMARY 438 established, health functions, do havethe tremendousadvantage of being We have had muchexperience highly operational, andreadily communicable. sevens" in the diagnosticclinical with the Rorschachand the use of "serial believe that we understandwhat these techniques mean, examination. We who are what their use is, how toteach them, andhow to supervise students certain aura of"rightness," which using them. This,intrinsically, gives them a that they are likely to"die hard"! in turn means built on the types of Much the opposite is truefor professional training than hard- approaches vie havebeen discussing. We are more emergent clear form, what orhow we pressed to delineate, evenif only in moderately situation is a new one;and since its should be teaching.The entire training it is potentially verythreaten- basic dimensions cannotbe clearly identified, defined; and perhaps moreimportant, ing. Relevant coursework is not amply models needed to makethis largely without the typesof identification we are 1965; Sabshin, 1965). type oflearning "come alive"(Caplan, 1965b; Duhl, that the types -jf practicumexperience We have little difficultyin recognizing whether defined in termsof activities or set- which will be most germane, essential to the sharply from thoseheretofore regarded as tings, should differ do not have aclear training of the mentalhealth specialist. But, as yet we 1965b). Hopefully, what these differencesshould be (Caplan, awareness of experiences will be more questions about the natureand extent of practicum and objectives. We readily approached as we come tosharpen our ideologies will lead us must keep inmind, also, the possibilitythat emergent practice which, though important con- logically to institutions,agencies, and settings goals, do not havepersonnel ceptually to the furtheranceof mental health training. who are in a position to assumeresponsibility for professional that new developmentsin Given the foregoingambiguities, it is certain will be a slow,mistake-making the training of mentalhealth professionals "learning by experi- characterized by thetime-honored attributes of process have to build on thebase of ence" and "boot-strapping."Such training will in existence.Indeed, one of the the few concretemodels and programs now emphasis on thedescription of fundamental purposes ofthis volume, with its in action, is tomake some of this workbetter known. concrete programs avail- Although the compositepicture that wehave painted of currently might justifiably bedescribed in able professional trainingin this new area and hastily conceived, words such as groping,fragmented, variable, pragmatic, necessarily used in adiscrediting let it not be assumedthat these terms are It must be emphasizedthat these same training programs or pejorative sense. responsiveness, intel- often flow from awell-spring ofopen-mindedness, social willingness to explore,and dedicated pursuit.This latter lectual curiosity, substance of new and characteristics isthe sorely needed cluster of attitudes develop- discovery. If the price we mustpay forthem, at this stage of our then it is still a bargain. ment, is somegroping and vagueness, possible, some of the sourcesof It is well toconsider, as realistically as PROBLEMS 439 EMERGENT APPROACHESTO MENTAL HEALTH There is, first, theproblem of resistance to changesin professional training. which we have viewed as intellectual inertia. Manyof the new approaches order will require some essential to the improvementof our mental health professional acts (e.g.,diag- breaking away from theroutine and humdrum have performed for so nosis and therapy)that our professional ancestors and above all, that wehave long, that we ourselveshave been bred to do, Understandably, this m ill come tofeel sPcure, cozy, andcomfortable doing. the behavior ofprofessionals is not be easy toaccomplish. In most instances doing now is important,help- governed by the convictionthat what they are basis for ful, and the best they cando, whether or notthere is an objective changes in training arelikely to chal- such feelings.Accordingly, proposed lenge entrenched beliefsand powerful motivational systems. already in evidence evenwhile These cognitive andconative systems are functioning professional. is a student andlong before he becomes a a person the components of a Discriminations arequickly made by students among established for these variousele- training program,and value hierarchies are others are ments. Some arescorned, some aretolerated as necessary evils, higher- accepted because they areclearly instrumental tothe performance of zenith of order functions; stillothers are seen ascherished goalsthe very psychotherapy has come professional function. As ageneral rule, training in who see it as the to be perceivedin the latter light,and there are many Indeed it is possiblethat "be all and end all" ofthe professional's activities. individuals go on to graduatetraining in one ofthe helping profes- many pinnacle. Where value is so sions primarily toachieve the psychotherapy and the subsequent nigh, the struggle toachieve the objective so great, extraordinarily refrac- rewards, in whatever sense,substantial, the function is the system is tory to extinctionin the individual andthe perpetuation of assured until a comparablealternative is established. cathexis that mostprofessionals But the problem goesbeyond the strong and the fact that theyderive have for the specifics oftheir present functions further and underscore much gratification fromthese. We must go one step characterized by the fact that theneeded alternativeroles may often be attributes which, at least inthe short-range sense,reduce their attractiveness. effort may extend muchfurther Visible and palpableresults of professional likely to be blurred, inthat it into the future.Means-end contingencies are point to a way in whichhis will be much more difficultfor the professional to professional actions relate toconstructive change inthe life situation of a proportion of the given person whohas come to hin. :assistance. A greater impersonal in contrast to professional's everyday operationswilt Je relatively clinical dialogue. This may the closeness and intimacyof the one-to-one understand- thwart the gratificationof some power andcontrol needs, which, of many professionals. ably, are importantelements in the psychic economy of the foregoing con- To be at all realistic, it mustbe recognized that each 440 SUMMARY siderations represents a significant potential source of resistance to change in professional training and function. How these resistances may be overcome is a vexing problem. That we need to overcome them is suggested in the following statement by Rioch (1966): "If our mental health system is to change in an orderly, evolutionary manner rather than a chaotic revolutionary one, I suggest that the professionals would benefit if they would identify themselves with the advancement of knowledge rather than the practice of a craft, or, if you prefer, of an art. This would leave some very large keys for them and at the same time make it possible for them to unlock the doors for many others" (p. 291). The crux of the matter is that we need to provide a basis for the reorganization of professional goals which does not do violence to the fundamental gratifica- tions of being a professional. Phrased otherwise, the professional must come to believe that only through the utilization of alternative technologies and participation in different types of activities will he do a better, more significant, and more socially utilitarian job. This will not be accomplished by rhetoric, no matter how elegant or convincing, but rather through slow, painstaking accretion of data that provide a compelling basis for reorganization of central values of the professional. For this reason the prime need at the present time is that of doingof establishing workable and viable programs in the emergent tradition (Caplan, 1965b). Convincingdemonstra- tions of the effectiveness of new approaches will constitute their best "sales pitch" and the prime grounds for modifying professional training. Another salutary outcome of such demonstrations would be the increasing infusion of our influential training centers with knowledgeable,experienced, ego-involved "identification" models who will be in a position to convey conviction and to generate enthusiasm in the process of teaching their students new ways of approaching old problems. Before concluding this discussion of professional training, there is one additional point to be made, perhaps the most important of all. We can never aspire, even in the best of training programs, to prepareprofessionals for the full spectrum of situations and challenges that they will be called upon to face in their subsequent careers. There is, in fact, nogood way of anticipating what these will be. Therefore, one major emphasis of all professional training should be to develop a healthy skepticism for what is presently assumed to be the proper way of doing things, to foster a problem- solving orientation, and to instill a generalized set of expectations that one will be called on to engage the new and the unexpected. To use a concept which is admittedly overworked these daysand often underspecifiedwe are speaking of "training for innovation" or, as Reiff (1966) has phrased it, training for "versatility." The essence of both of these concepts is the ability of the pn 'essional to implement his conceptual grasp through flexible and constructive adaptations to the novel situationto be able to recognize, and to capitalize upon, opportunities for utilizing new combinationsof skills and 441 MENTAL HEALTHPROBLEMS EMERGENTAPPROACHES TO for theresolution ofmental health which seeminglyhold promise regi- resources likely to be theproduct of training problems. Suchattributes are not technique boundand situationbound. mensthat are largely for innovationwill be maxi- health fields,the possibility In the mental of professionaltraining are that threebasic components mized to the extent the fullestpossible understand- The first ofthese is providing given priority. social problemsthat and themagnitude of the ing of the natureof the issues systematic con- emphasis on thedevelopment of we face.The second is an approached. which theseproblems may be ceptualizations aboutthe ways in learn a good quite pragmatic,and we may Isolated ad hocsolutions may be virtue of a morecomprehensivenetwork deal from them.However, the great the specifics provides a basisfor transcending of conceptualizationsis that it orderly, encountered situations.As a generalized, of known andpreviously preferred of reference, itintrinsically conveys consistent frame its and internally number of situationswhich fall within approaches to analmost limitless note thatthe well as the old.It is of interest to scopethe newand strange as empha- conference (Bennett etaL, 1966)placed much recentBoston training professional who,through "participant-conceptualizer"--a sis on the term would have entree tothe specialrole participation inthe community process, psychological knowl- within theframework of of "conceptualizingthat process opportunity last of thethree elementsis the edge and concepts"(p. 19). The them- and mentorswho, even if not to work inclose associationwith models sense their activitiesand their teachings a selves innovators, atleast convey in of the unknown. for engagingthe challenges of excitementand enthusiasm

RESEARCHASPECTS health pro- proposition, it canbe said thatthe mental As a general scientific tradi- in the clinicalrather than the fessions haveevolved primarily complex and time of programdevelopment are tions. In thesefields, problems personnel nearly insatiable,and qualified demands for service are priorities on consuming, historically, to placerelatively lower is lacking.This has caused us, be indulged them as somethingof a luxury to research functionsand to regard affluence of favored settingscharacterized by an only in therelatively few values may beadaptive as this particularhierarchization of personnel. While pressures, as along-range strategemit a responsetoimmediate, day-to-day fossilization of practice. the point ofguaranteeing can wellbe self-defeating to either the fancy orthe participation Past failuresof research to capture from two of itsbasiccharacteristicsi.e., that of the helpingprofessional stem probabilistic. It through research isboth slow and the accretionof knowledge able to know professional to hearthat he may be comfort for the obliged is of limited and distantfuture when he is about problemX in the vague rele- more maximally certain terms,right now. The to dealwith thatproblem, in 442 SUMMARY vance and pay-offpotential of research is usually so removed fromthe practitioner that, for him, there is always theillusion of its postponability. This is not to imply that the mental health fields,particularly when it comes to the evaluationof specific practices and treatment approaches,have been devoid of research. Rather it is to suggest thatthe research that has been done is characterized by certain critical and recurrent typesof shortcomings. The chronicity and seriousness of two of theseproblems warrant their specific citation. First, since advancedprofessional training of mental health specialists has not emphasized preparation forresearch, its products do not ordinarily acquire some rudimentary tools of the trade.As a consequence, substantial portions of the mental health research literature mustbe seen as' unsophisticated and assailable. Such work is often characterizedby problems of design, inadequate controls, lack of refinement of technique,and inappropriate criterion measures. Second, and perhaps moreinsidiously, much of the evaluation of our mental health methods and programs iscarried out by professionals who, for any one of a score of reasons, have a verydeep stake in the program or system. When impressionisticappraisal is the prime vehicle of evaluation, the dangers of experimenter bias (Orne, 1962;Rosenthal, 1964a, 1964b, 1966) are profound. To place the matter in a slightly different perspective,the professional, if he is to be effective, must believe in what he isdoing and must be invested in his everyday activities. His role, understandably,does not conform to the stereotype a detached objectivitythat we have for the scientist. To the extent that he serves simultaneously in the roles of participatorand evaluator of a given set of events, he must be regarded as abiased observer for whom certain outcomes, whether consciously orotherwise, may be inimical and unaccept- able. Though the observations of the participatingprofessional may represent one admissible sourceof data, and, indeed, may constitute an especiallyfer- tile basis for generating hypothesis, to the extentthat they are Ltilized as the prime vehicle for assessing the effectiveness ofmethods, we expose ourselves to systematic error that will obstruct progress.Unfortunately, we have, in the past, been forced to depend tooheavily on this type of evaluative criterion because it has been the only one available to us.This may be a factor in the perpetuation of technologies or systems inthe mental health area that might well have crumbled under more rigorousresearch scrutiny. Unquestionably, the principal aims of this volume havebeen the codifi- cation of ideas and conceptions and thedescription of concrete programs which, seemingly, exemplify emergent approaches tomental health problems. It is apparent that, in striving to meet theseobjectives, a sense of disappointment and dissatisfaction withthe total amount of our societal effort todate in the mental health area has been reflected.Moreover, specific questions have been raised about the defensibility of many currentmental health practices; and at least by implication, the charge has been madethat the empirical base which justifies such practices is extraordinarily weak. PROBLEMS 443 EMERGENT APPROACHESTO MENTAL HEALTH of long-range Much of what we havepointed toward, especially in terms from what has beenthe typical stratagems andplanning, departs significantly sphere. At the same time, and preferred tnoclusoperancli in the mental health empirical base for the however, it should beclearly understood that the proposed "new order" is no moresubstantial than that forthe challenged old squarely upon a one. Theweight of both our argumentand our plea rests simply vulnerable amalgam oflogic and faith. It wouldbe a tragedy were we have sought to to trade anancient set of faithsfor a new one. What we rationality and logic (and, establish in this volume isthat there is enough justify increasingly vigor- perhaps, even a slow,beginning trickle of data) to somehow, the combinationof evident ous pursuitof these approachesthat, adds up to a "huntingli- shortcomings of the oldand promise of the new the future shape of the cense" in this area. In thefinal reckoning, however, by empirics which are, as yet, mental health order canonly be governed sophisticated research unknown to us. This meansthat comprehensive and sound and orderly is a necessity ofthe highest priorityif we are to aspire to the decades to come. progress in plagued the While the problemsof inadequateresearch which have there are additional, mental health fields arechronic and generalized ones, importance of research in somewhat particular, reasonswhich underscore the (Ch. 2) observes, the very the emergent areas we areconsidering. As Romano by some, with of these approaches causesthem to be seized upon, newness The pathways to truth are evangelistic fervor and atotally uncritical attitude. point, we may antici- hardly made of such components.As a derivative of this approaches which are tobe explored pate that someof the multitude of new "Hawthorne-effects." In otherwords, will be highly susceptible tothe so-called be its obviousattributes or the active ingredientof a given program may not those who are carry- substance, but the inordinate energyand enthusiasm of that it may ing it out. There isnothing per se wrongwith the latter, except applications. If that isthe case, we are not besustained in repeated program wherein results attributed misled through a confoundingof form and content, of the foregoing is a to the latter arein fact a functionof the former. Each research. very realdanger for which our bestprotection is careful presented It would be illusory and naïve toassumethat what has been materialized out of under the banner of emergentapproaches has suddenly multiplied appreciably in nowhere. While developmentsof this genre have full-blown, have existedfor some recent years, precursors,both vestigial and failing of this priorwork has been itsisolation from the time. A collective projects or pilot mainstream of knowledge.Often done as demonstration the studies in specific settingsand lacking any typeof research evaluation, Sherwood, social benefits that haveaccrued are sharplylimited (Freeman & such projects 1965). It is highlyprobable that the totalnational investment in have not beersufficiently felt has been considerable,but their contributions (1965) develops this same and have most certainlybeen nonadditive. Brooks ,

444 SUMMARY argument as it applies to evaluation of communityaction programs. Without sound, serious research and its logicalby-productcontributions to knowledge in the scientific literatureweare doomed to restricted progress and the waste- ful fate of unwittingly retraversing blindalleys. In this sensewe can no longer afford not to do good research. It is disappointingto note that several recent authoritative publications which have addressed themselvesto research needs in the mental healtharea have not done so with sufficient strength.In thesummary of the Joint Com- mission Report (1961), the relevantstatement is as follows: "States should be required ultimatelyto spend 21/2 per cent of State mental patientservice funds for research" (p. xxii).Given the foregoing expression of valuesand allocation of monies,one cannot help but wonder whetherwe are guarantee- ing that tomorrow's mental health orderwill look very much like today's. More recently Smith and Hobbs (1966)in a position paperon the community mental health center adopted by theAmerican Psychological Associationpro- pose an annual research expenditure between 5per cent and 10 per cent of total budget. This recommendationis accompanied bysome comments which 1 appear to be highly supportive of research efforts, for example:"Only through explicit appraisal ofprogram effects can worthy approaches be retained and refined, ineffectiveones dropped" (p. 508). The force of thissentence, however, is diluted by the one that follows: "Evaluativemonitoring of program achievements mayvary, of course, from the relatively informal, to thesystem- atic and qualitative, dependingon the importance of the issue, the availability of resources, and the willingnessof those responsibleto take the risks 1 of substituting informed judgment for , evidence" (p. 508). The softspot of

V 1 this second statement resides inits willingness to anticipate conditions under which research willnot or need not be done, or can be done half-heartedly.If this is not the intent of thecomment, then its wording is sufficiently ambiguous to allow for interpretation along those lines by thosewhose values do not prominently feature research. In our view there is little basisfor equivocation wherematters of research in the mental health fieldare concerned. If viable new approachesare to develop, there isurgent need for serious, comprehensive, andentirely "hard- nosed" research. Thisis true whetherwe are talking about understanding social systems and theirimpact on behavior (Freeman & Sherwood,1965) or about specific mental health-orientedprograms such as consultation withcare- givers (Cohen, 1966), early secondaryprevention in the schools, training of indigenous nonprofessionals,etc. Indeed, itis our conviction that formal research should be built intoevery programthat it should be regardedas a basic necessity rather thana luxury. Our research technology in the mental health sphere, though far fromperfect, has advanced strikinglyin the past several decades, and alreadyexisting know-how is such thatmost relevant problems are, indeed, researchable. Thereal issue then is the value thatwe PROBLEMS 445 EMERGENT APPROACHESTO MENTAL HEALTH which responsibleauthor- come to attach tosuch functions and the extent to meaningfulnecs of research. ity can abet thedignification and perceived

CONCLUDING REMARKS

Few can argue thatthe cumulative result ofprior mental health reduction of the number and efforts has been thedesired one of substantial society. Our greatestfailing seriousness of mentalhealth problems in modern placed on the treatmentof lies in the imbalancedemphasis that has been efforts directed at stem- evident, oftentimesflorid, pathology as opposed to been magnified by the circum- ming the flow ofdisorder. This failing has scribed reach of existingmethods as well as bytheir limited effectiveness. through There is greater hope thatflow of disorder maybe slowed down modification of influentialsocial systems which shapehuman development Thus, the key to our rather than through the one-to-oneclinical interaction. future mental health welfare is tobe found in thefundamental conceptualiza- these become morecrystal- tions, assumptions, andmodels that we adopt. As and "fall lized, many variations in programapplication will become apparent blueprint does not exist,and there into line." In otherwords, a specific master needs and will always be the needfor particular tailoringof programs to the attributes of specific settings. volume has been a The choice of the word emergentin the title of this young and deliberate one. It implies a setof developments whichare still very certain lack ofspecificity and verymuch inprocess.As such, it also betrays a Accordingly, there is anincomplete knowledge of thefuture shape of things. willingness to try out and need for a high level oftolerance of ambiguitya such work be researchedwith to discard.Througho, itis essential that dedication and rigor. We areonly just beginning toexplore models for the professional. We also need to training and function ofthe mental health utilization of many dif understand a great deal moreabout the potential for roles. And, much effort ferent types of nonprofessionalsin mental health must be directedtoward effective extensionof our mental health program- necessarily, require the applcationi- ming to thc heretoforeunreached. This will, of newperhaps as yetunknowntechniques tolong-standing, neglected problems. The one thing that we canbe sure of is that weface disappointment, of the price that uncertainty, and a constantstruggle. Perhaps this is part change. But with emphasis onthe must be paidfor growth and constructive affecting the young community and its primaryinstitutionsespecially those fundamental shift in emphasis tothe prevention ofdisorder, and hard- a strides in the mental health area nosed research, ourhopes for making greater maybe fulfilled. 446 SUMMARY

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New York: Basic Books, 1961. Pp. 378-397. PROBLEMS 453 EMERGENT APPROACHESTO MENTAL HEALTH L. N. The relationof childhood behaviorproblems to O'Neal, P., & Robbins, subjects. Amer. J. Psy- adult psychiatric status: a30-year follow-up of 150 chiat., 1958, 114, 961-969.(a) L. N. Childhood patternspredictive of adult schizo- O'Neal, P., & Robbins, (b) phrenia: a 30-yearfollow-up. Amer. J.Psychiat., 1958, 115, 385-391. No. 1. Persistence ofemotional Onondaga County SchoolStudies, Interim report children. Syracuse, disturbances reported amongsecond and fourth grade 1964. N.Y.: N.Y. State Dept.of Mental Hygiene,Mental Health Res. Unit, Orne, M. T. On thesocial psychology of thepsychological experiment: with particular reference todemand characteristics andtheir implications. Amer. Psychol., 1962, 17, 776-783. New York: Free Press, 1965. Pearl, A., & Riessman, F.New careers for the poor. pattern for mentalhealth Peck, H. B., Harrower,M., & Beck, M. B. A new Thomas, 1958. services in a children's court.Springfield, Ill.: Charles C and social action: Peck, H. B., Kaplan, S. R., &Roman, M. Prevention, treatment disadvantaged urban area. Amer.J. Orthopsy- a strategyof intervention in a chiat., 1966, 36, 57-69. therapeutic outcome. J. Poser, E. G. The effect oftherapist training on group consult. Psychol., 1966, 30,283-289. health, social compe- Rae-Grant, Q. A. F., Gladwin,T., & Bower, E. M. Mental 36, 652-664. tence and the war on poverty.Amer. J. Orthopsychiat., 1966, of clinical psychology. In Reiff, R. The ideologicaland technological implications C. C. Bennett, L. S.Anderson, S. Cooper, L. Hassol,D. C. Klein, & G. confer- Rosenblum (Eds.), Communitypsychology: a report of the Boston Boston: ence on theeducation of psychologists forcommunity mental health. Boston University Press, 1966.Pp. 51-64. strategy of change Reiff, R., and Riessman, F.The indigenous nonprofessional: a health programs. Comm. Ment. in community actionand community mental Health J., Monogr. No. 1,1965. hospital for chil- Reinherz, H. College studentvolunteers as case-aides in a state dren. Working Papers inComm. Ment. Health, 1963, 1,35-49. (a) hospital for chil- Reinlierz, H. College studentvolunteers as case-aides in a state dren. Amer. J. Orthopsychiat.,1963, 33, 544-546. (b) Work, 1965, 10, 27-32. Riessman, F. The "helper"therapy principle. Social Riessman, F., Cohen, J., &Pearl, A. (Eds.) Mentalhealth of the poor. New York: Free Press, 1964. In F. Riessman, J. Cohen, Riessman, F., & Goldfarb, J.Role playing and the poor. New York: Free Press, 1964. & A. Pearl (Eds.),Mental health of the poor. Pp. 336-347. psychotherapists. J. consult. Rioch, M. J. Changing conceptsin the training of Psychol., 1966, 30, 290-292. Rioch, M. J., Elkes, C., Flint,A. A., Usdansky, B. S.,Newman, R. G., & Silber, E. National Institute ofMental Health pilotstudy in training of mental health counselors. Amer. J.Orthopsychiat., 1963, 33, 678-689. in nzental Robinson, R DeMarche, D.F., & Wagle, M. K. Community resources health. New York: BasicBooks, 1961. Rockefeller, W. New roles fortrained volunteer workers inmental health. In Understanding mental health: a R. L. Sutherland & B.K. Smith (Eds.), 454 SUMMARY common need, a less frequent aOtievement. Princeton, N.J.: Van Nostrand, 1965. Pp. 167-174. Rosenbaum, M. Some comments on the use of untrained therapists. J. consult. Psychol., 1966, 30, 292-294. Rosenthal, R. Experimenter outcome-orientation and the results of the psychological experiment. Psychol. Bull., 1964, 61, 405-412. (a) Rosenthal, R. The effect of the experimenter on the results of psychological research. In B. A. Maher (Ed.), Progress in experimental personality research. Vol. I. New York: Academic Press, 1964. Pp. 79-114. (b) Rosenthal, R. Experimenter effects in behavioral research. New York: Appleton- Century-Crofts, 1966. Sabshin, M. Theory and practice of community psychiatry training in the medical school setting. In S. E. Goldston (Ed.), Concepts of community psychiatry: a framework for training. Bethesda, Md.: U.S. Dept. of H.E.W., Public Health Serv. Public. No. 1319, 1965. Pp. 49-56. Sanford, N. The prevention of mental illness. In B. Wolman (Ed.), Handbook of clinical psychology. New York: McGraw-Hill, 1965. Pp. 1378-1400. (a) Sanford, N. Ego processes in learning. In N. M. Lambert (Ed.), The protection and promotion of mental health in the schools. Bethesda, Md.: U.S. Dept. of H.E.W., Public Health Serv. Public. No. 1226, 1965. Pp. 22-29. (b) Sarason, S. B., Davidson, K., & Blatt, B. The preparation of teachers: an un- studied problem in education. New York: Wiley, 1962. Sarason, S. B., Levine, M., Goldenberg, I. I., Cher lin, D. L., & Bennett, E. M. Psychology in community settings. New York: Wiley, 1966. Schofield, W. Psychotherapy: the purchase of friendship. Englewood Cliffs, N.J.: Prentice-Hall, 1964. Schwitzgebel, R. R. Delinquents with tape recorders. In F. Riessman, J. Cohen, & A. Pearl (Eds.), Mental health of the poor. New York: Free Press, 1964. 582-588. Sheeley, W. F. The general practitioner's contribution to community psychiatry. In L. Bellak (Ed.), Handbook of community psychiatry and community mental health. New York: Grune & Stratton, 1964. Pp. 268-279. Slack, C. W. SCORE: a description. In Experiment in culture expansion. Sacra- mento, Calif.: Calif. Dept. of Corrections, 1963. Pp. 59-64. Smith, M. B., & Hobbs, N. The community and the community mental health center. Amer. Psychol., 1966, 21, 499-509. Spiegal, A. D. (Ed.) The mental health role of settlement houses and community centers. Boston: Mass. Dept. of Mental Health, 1964. Srole, L. Selected sociological perspectives. In S. E. Goldston (Ed.), Concepts of community psychiatry: a framework for training. Bethesda, Md.: U.S. Dept. of H.E.W., Public Health Serv. Public. No. 1319, 1965. Pp. 33-46. Stennett, R. G. Emotional handicap in the elementary years: phase or disease. Amer. J. Orthopsychiat., 1965, 35, 444-449. Torrance, E. P. & Strom, R. D. (Eds.) Mental health and achievement: increasing potential and reducing school dropout. New York: Wiley, 1965. Umbarger, C. C., Dalsimer, J. S., Morrison, A. P., & Breggin, P. R. College students in a mental hospital. New York: Grune & Stratton, 1962. Volkman, R., & Cressey, D. R. Differential association and the rehabilitation of 455 HEALTH PROBLEMS EMERGENT APPROACHESTO MENTAL health of Cohen, & A. Pearl(Eds.), Mental drug addicts. InF. Riclsman, J. York: Free Press,1964. Pp. 600-619. the poor. New Brockbank & D.Westby-Gibson (Eds.), Westby-Gibson, D. Theschools. In R. New York: Grune& Stratton, Mental health in achanging community. 1966. Pp. 76-82. school behaviorand later Rice, D. L., &Bermann, E. Nursery Westman, J. C., 1967, 37, 725-731. school adjustment.Amer. J. Orthopsychiat., Wash- of disability inmental disorders. Williams, R. H.(Ed.) The prevention Public. No. 926, H.E.W., PublicHealth Serv. ington, D.C.:U.S. Dept. of 1962. Harper psychological approach.New York: Wright, B. A.Physical disabilitya & Row, 1960. for trainingex-offenders Dederich, C. E.Synanon: as a program Yablonsky, L., & in cultureexpansion.Sacramento, therapeutic agents.In Experiment as 1963. Pp. 37-48. Calif.: Calif. Dept.of Corrections, A. ; J., & Trost, M. E. L., Izzo, L.D., Madonia,A. J., Merenda, Zax, M., Cowen, emotional disturbancein youngschool A teacher aide programfor preventing 406-415. children. Ment.Hygiene, 1966, 50, emotional dis- E. L., Izzo, L.D., & Trost, M.A. Identifying Zax, M., Cowen, Orthopsychiat., 1964,34, 447-454. turbance in theschool setting.Amer. J. "`""'"^".'"*"0""."!1RANIMIVIIMAIWWW1110411.1.1.111111MW91,0111111014111PPW-

AUTHOR INDEX

236, 315, Albee, G. W., 11, 14, 24,26, 63, 66,Bind man, A. J., 216, 217, 67, 72, 128,143,214,235, 329 353, 368, 417, 446 Bindra, D., 17, 26 Alexander, F. G., 3, 26 Bion, W. R., 130, 143 Allinsmith, W., 271, 289,404,405, Blackford, L, 209, 212 408, 446 Blatt, B., 405, 454 Bloch, D. A., 55, 61 Allison, R. B., 49, 60 Bloom, B. L., 392, 394, 446 Allport, G. W., 46, 47,59, 59 Bockoven, j. S., 75, 87 Altrocchi, J., 217, 218, 221,235 Bower, E. M., 18, 26,. 259,268, 325, Amster, F., 291, 305 329, 403, 405, 406, 408,410, Anderson, A. R., 47, 52, 59 416, 446, 447, 453 Anderson, J. K., 50, 60 422, 447 Anderson, L. S., 433, 435,437,441,Brager, G., 174, 184, 402, Branch, C. H. H., 49, 60 446 Breclemeier, H. C., 20, 26 Armstrong, R. A., 14, 28 424, 427, Arsenian, J., 18, 26 Breggin, P. R., 91, 109, 421, Auld, F., 185, 211 454 Breiter, D., 121, 127 447 Babayan, E. E., 210, 211 Brigante, T. R., 437, Babigian, H. M., 195, 211 Briggs, D. L., 423, 447 Brill, N. Q., 49, 60, 186,212 Bahn, A. K., 186, 212,233, 236 Brim, 0. G., 363, 368,404, 447 Baler, L. A., 436, 446 Brooks, M. P., 443, 447 Barker, R. G., 363, 368 26, 29 Beach, D. R., 409, 448 Brown, B. S., 11, 22, Beach, H. D., 55, 59 Brown, E. L., 130, 143 Bean, L. L., 49, 61 Brown, G. W., 53, 60 258, 268 Beck, M. B., 405, 453 Bruner, J. S., 44, 60, 257, 305 Beiser, M., 402, 403, 446 Buchmueller, A. D., 296, 302, Pe llak, L., 8, 10, 26, 398,415, 431, Buell, B., 196, 212 446 Bullis, H. E., 253, 268 Bemmels, V. G., 196, 211 Burgess, M. E., 10, 26 Bennett, C. C., 433, 435,437, 441,Burnes, A. J., 263, 264,268 446, 453 Bennett, E. M., 8, 9, 12,29, 402, 404,Cain, H. P., 11, 26 405, 435, 437, 454 Campbell. D. T., 50, 60 Berelson, B., 266, 268 Caned!, H.. 57, 60 Berlin, 1. N., 209, 211, 219,221, 230, Caplan, G., 9, 11, 12, 17,18, 22, 26, 235, 286, 289, 433, 446 55, 60, 81, 87,171,172,181, Bermann, E., 410, 455 184,216,217,219,236,311, 408, Bernard, V. W., 433, 437, 446 315,329,404,406,407, 436,437, Biber, B., 241, 242, 251,254, 255. 412,413,415,434, 268, 405, 446 438,440,447,448 Bierer, J., 130, 143 Carstairs, G. M., 53, 60 457 458 AUTHOR INDEX Cc:ter, J. W., 233, 236 Dull, L. J.,7,15, 27, 81, 87, 148, Cartwright, D. S., 17, 26 161, 402, 434, 438, 449 Cartwright, R., 254, 268 Dunham, H. W., 8, 27, 36, 37, 39, Castaneda, A., 208, 212 185, 191, 192, 212, 401, 449 Cher lin, D. L., 8, 9, 12, 29, 402, 404, Durkheim, E., 172, 184 405, 435, 437, 454 Chope, H. D., 209, 212 Ebner, E., 104, 109 Clark, W. W., 265, 270 Eisdorfer, C., 217, 218, 221, 235 Clausen, J. A., 10, 19, 27, 402, 403,Eisenberg, L., 7, 9, 10, 13, 16, 17, 18, 448 27, 407, 411, 417, 449 Cohen, J., 17, 19, 29, 402, 453 Elkes, C., 81, 88, 113, 127, 421, 453 Cohen, L. D., 444, 443 Empey, L. T., 150, 161 Cole, N. J., 49, 60 Erikson, E. H., 47, 52, 54, 56, 58, 60, Coleman, J. S., 286, 289 406, 449 Coleman, S. H., 200, 212 Ewalt, J. R., 49, 60 Cooley, W. W., 260, 268 Eysenck, H. J., 16, 17, 27 Cooper, S., 433, 435, 437, 441, 446 Fairweather, G., 10, 27 Cottrell, L. S., 390, 448 Fantl, B., 403, 449 Cowen, E. L., 14, 25, 27, 208, 212, Faris, R. E. L., 185, 191, 192, 212 331, 332, 348, 351, 405, 409, Feld, S., 13, 28, 411, 412, 450 422, 423, 424, 425, 427, 429, Felix, R. H.,11, 448, 455 18, 27, 232, 236, 417, 434, 449 Cressey, D. R., 428, 454 Fellows, L., 421, 449 Cumming, E., 52, 53, 55, 56, 60, 61 Fishman, J. R., 144, 146, 147, 148, Cumming, J., 24, 52, 55, 56, 60 150, 156, 160, 161, 422, 423, Cutler, R. L., 275, 277, 279, 289 449, 452 Cytryn, L., 421, 448 Fiske, D. W., 50, 60 Fitzgerald, B., 132, 143 Dailey, J. M., 410, 447 Flint, A. A., 81, 88, 113, 127, 421, Dalshner, J.S.,91, 109, 421, 424, 453 427, 454 Foley, A. R., 9, n, 22, 27, 397, 411, Daniels, R. S., 437, 448 449 Davidson, K., 405, 454 Forstenzer, H. M., 9, 11, 22, 27, 397, Davis, J, 53, 60 411, 449 Davis, K., 186, 201, 212 Foucault, M., 5, 27 De Charms, R., 17, 27 Fox, R., 255, 269 Dederich, C. E., 428, 455 Frank, J. D., 49, 62 De Marche, D. F., 414, 453 Franklin, M., 242, 251 Dembo, T., 406, 452 Freedman, A. M., 9, 27 Deutsch, M. P., 403, 449 Freeman, H. E., 40, 53, 60, 443, 444, Dohrenwend, B. P., 57, 60 449 Dohrenwend, B. S., 57, 60 Freud, S., 45, 60, 201, 212 Domke, H. R., 295, 296, 298, 302,Fried, M., 19, 27, 57, 60 305, 306 Friedman, S. T., 25, 318, 323, 330 Donahue, G. T., 25, 377, 379, 386, 422, 449 Gardner, E. A., 24, 186, 195, 196, Duggan, J. N., 416, 449 208, 211, 212 459 AUTHOR INDEX Haylett, C. H., 413, 450 Gewirtz, H., 102, 104,108, 109 Hebb, D. 0., 58, 61 GI ldea, M. C.-L.,25, 290, 291, 295, 296, 299, 302, 305,306, 315,Helpern, J. M., 315, 329 Hendrick, I., 47, 61 329, 346, 351, 404,449 Henry, G. 'N., 4, 29,69, 73 Gilkerson, E., 254, 268 Hereford, C. F., 404, 422,450 Ginsburg, S. W., 50, 60 Hernia, J. L., 50, 60 Ginzberg, E., 50, 60 Heron, W., 58, 61 Gladwin, T., 403, 453 Hersko, M., 185, 213 Glass, A. J., 42, 57, 58,60 11, 22, 27, 35,Fletznecker, W., 196, 208,212 Glasscote, R. M., 9, Hobbs, N., 11, 12, 22,28, 29, 235, 39, 397, 411, 449 450, 454 208, 212, 296, 236, 411, 434, 444, Glidewell, J. C., 25, 450 306, 346,Hoch, E. L., 433, 437, 298, 299, 302, 305, Hollingshead, A. B., 8, 19,28, 49, 57, 449, 450 351, 401, 404, 61,162, 184, 185, 186,212 Coethals, G. W., 271,289, 404, 405, Hollister, W. G., 400,405, 450 408, 446 94, 98, 102, 27, 78, 87, 398,Flolzberg, J. D., 24, 92, Coffman, E., 10, 19, 104, 108, 109, 421,422, 423, 450 424, 427, 429, 450,451 Golann, S. E., 121,127, 437, 450 Huang, I., 265, 269 Goldenberg, I.I., 8, 9, 12, 29,402, 454 Hubbard, F. D., 423, 451 404, 405, 435, 437, Huessy, H. R., 414,421, 422, 427, Goldfarb, J., 422, 453 27, 433, 436, 437, 451 Goldston, S. E., 16, Hughes, H. S., 44, 61 450 Hume, P. B., 437, 451 Gordon, J., 48, 60,81, 87 Hunt, R. G., 185, 186,201, 212 Greenblatt, M., 10,28, 91, 100, 108, 130, 143, 398, 421,450 Iker, H., 186, 212 Griffith, C. R., 214,236, 414, 452 Imber, S. D., 185, 212 Gross, R., 258, 269 329 449 Isaksen, H. L., 315, Gruenberg, E. M., 411, 9, 25, 28, 315,318, 323, Gump, P., 281, 289 Iscoe, I., 329, 330 Gurin, G., 13, 28, 411,412, 450 27, 208, 212, 331, 212 Izzo, L. D., 14, Cursslin, 0. R., 186, 201, 332, 333, 351, 405,409, 422, 448, 455 Haase, W., 19, 28 Haggstrom, W., 172,184 Jackson, D. D., 71, 72 Hallowitz, E., 83, 88 164, 184 Hanfmann, E., 406,452 Jahoda, M., 76, 87, Harper, E., 209, 213 Janis, I. L., 55, 57,61 Harrington, C., 53, 60 Jarvis, P. E., 10, 28 Harrington, M., 185,212 Jones, E., 44, 61 143 Harrison, S. I., 19, 28 Jones, M., 10, 28, 130, Harrower, M., 405, 453 Hartmann, H., 47, 52,60 Kanner, L., 352, 368 437, 441, 446 Kanno, C. K., 35, 39 Hassol, L., 433, 435, 421, 450, 451 Hastings, D. W., 57,61 Kantor, D., 100, 109, Kantor, M. B., 25, 296,298, 299, 306, Hauser, P., 57, 61 Hawkinshire, F. B. W., 423,450 346, 351 460 AUTHOR INDEX Kaplan, S.R.,171, 174, 178, 184,Lewin, K., 406, 452 402, 453 Lewis, N. D. C., 6, 28 Kazanjian, V., 220, 236, 413, 451 Lewis, W. W., 25, 353, 368, 422, Kelley, J. G., 401, 414, 415, 451 423 Kenny, J., 132, 143 Libo, L. M., 214, 236, 414, 452 Ketcham, W. A., 278, 289 Lindemann, E., 55, 56, 57, 61, 405, Kevin, D., 220, 221, 236 452 Kiesler, F., 414, 451 Lippitt, P., 255, 269 Kilpatrick, F. P., 57, 61 Lippitt, R., 255, 269 Kipfer, J. F., 274, 289 Loftus, J. J., 253, 269 Klein, D. C., 55, 56, 61, 83, 86, 87, Lowy, D. G., 92, 109 404, 433, 435, 437, 441, 446,Lucas, R. A., 55, 59 451 Lyle, W. H., 255, 269 Klein, H., 315, 329 Klein, W. L., 24, 53, 144, 146, 147,McCaffrey, I., 53, 61 148, 149, 150, 153, 154, 156,McCandless, B. R., 208, 212 160, 161, 403, 404, 421, 422, McDermott, J. F., 19, 28 423, 425, 426, 427, 429, 432, MeGehearty, L., 25 433, 449, 451, 452 MacLennan, B. W., 144,146,147, Knapp, R. H., 24, 98, 109, 421, 423, 148, 149, 150, 153, 154, 156, 424, 427, 429, 451 160, 161, 422, 423, 449, 452 Krueger, D. B., 19, 29 McMahon, J. T., 185, 213 Krugman, M., 404, 452 McNeil, E. B., 275, 277, 279, 289 Maddux, J. F., 221, 229, 236 Ladieu, G., 406, 452 Madonia, A. J., 422, 455 Laird, J. D., 348, 351, 409, 422, 427,Magoon, T. M., 121, 127, 437, 450 429, 448 Margolis, P. M., 437, 448 Lambert, N. M., 404, 405, 408, 447, May, E., 185, 213 452 Mayer, A. J., 57, 61 Lamson, W. C., 235, 236 Mensh,I.N., 296, 299, 302, 305, Langner, T. S.,14,19, 29, 57, 61, 306 128, 143, 166, 184, 186, 213 Merenda, J., 422, 455 Larson, C. A., 408, 447 Meyerson, L., 406, 452 Lazarus, 11. S., 407, 452 Michael, D., 126, 127 Lebeaus, C. W., 199, 213 Michael, S. T., 14,19, 29, 57, 61, Lecky, P., 55, 61 128, 143, 166, 184, 186, 213 Leighton, A. H., 14, 18, 28, 172, 184,Miles, H. C., 14, 27, 186, 195, 208, 405, 452 211, 212, 331, 332, 351, 405, Leighton, D. C., 14, 28 409, 448 Lemkau, P. W., 19, 29 Miller, K., 315, 329 Levine, M., 8, 9,12. 29, 153, 154,Miller, S. M., 19, 20, 28, 29, 79, 82, 161, 402, 404, 405, 435, 437, 87, 88 454 Minuchin, P., 248, 251 Levine, R. A., 422, 452 Mishler, E. G., 19, 28 Levinson, D. J., 10, 28, 398, 450 Mitchell, L., 144, 146, 148, 150, 156, Levitt, E. E., 17, 28, 255, 269, 408, 160, 161, 422, 423, 449 452 Mitchell, W. E., 421, 452 Levy, J., 17, 27 Monek, E. M., 53, 61 461 AUTHOR INDEX Moore, 0. K., 47, 52, 59 Rae-Grant, Q. A. F., 403, 453 Morrison, A. P., 91, 109,421, 424,Raines, G. N, 50, 62 Rapoport, L., 413, 450 427, 454 Rappaport, J. D., 409, 448 Morse, W. C., 25, 272,275, 278, 279, Raush, H. L., 149, 161, 433,437, 450 281, 287, 289 Redl, F., 281, 284, 289 Murray, 1-1. A., 47, 61 Redlich, F. C., 8, 19, 28, 49,61, 162, Muuss, R. E., 255, 269 184, 185, 186, 212 186, Myers, J.K., 49, 61, 62, 185, Reiff, R., 11, 24, 48, 49, 53,62, 74, 211, 213 75, 78, 83, 88, 171, 173,176, Myerson, A., 130, 143 184, 392, 402, 403, 420, 422, 423, 424, 426, 427, 428, 429, Nash, E. H., 185, 212 430, 431, 432, 433, 440, 453 Nelson, S. E., 10, 28 Rein, M., 79, 86, 88 Newman, R. G., 421, 453 Reinherz, H., 421, 453 Nichols, R. S., 13, 14, 28,417, 452 Rennie, T. A. C., 14,19, 29, 128, NiPhtern, S., 371, 377, 379,386, 422, 143, 186, 213 449 Rice, D. L., 410, 455 Norman, V. B., 233, 236 Rieman, D. W., 216, 221,236 Riessman, F., 17, 19, 20, 24,29, 48, Oberhauser, E. J., 423, 452 53, 62, 77, 78, 83, 88,148, Odoroff, C. L., 196, 208, 212 161, 16. 167, 172, 174,176, Ojemann, R. H., 254, 255,265, 269, 184, 402, 422, 423, 424,426, 285, 289, 405, 452 427, 428, 429, 430, 431,453 O'Neal, P., 409, 410, 453 Rioch, M. J., 24, 81, 88,113, 127, Opler, M. K., 14, 19, 29,128, 143, 419, 421, 422, 423, 424,425, 186, 213 426, 427, 428, 429, 431, 440, Orne, M. T., 442, 453 453 Osgood, C. E., 346, 351 Roach, J. L., 186, 201, 212 Ozarin, L. D., 22, 29 Robbins, L. N., 409, 410, 453 Roberts, D. W., 19, 29 Padilla, E., 23, 29 Robinson, R., 414, 453 Rockefeller, W., 422, 453 Palermo, D. S., 208, 212 Roen, S. R., 25, 258, 260,261, 263, Parker, B., 221, 236 266, 269 Pasamanick, B., 19, 29 147, Rohmer, J. H., 50, 62 Pearl, A., 17, 19, 29, 144, 146, 178, 184, 402, 148, 150, 156, 160, 161,402,Roman, M., 171, 174, 422, 423, 449, 452, 453 453 Romano, J., 9, 24, 34, 39,186, 195, Peck, H. B., 83, 88, 171,174, 178, 211, 212, 443 184, 402, 405, 453 Rosen, B. M., 233, 236 Pepper, M. P., 49, 61 Rosenbaum, M., 85, 88, 427, 454 Perry, S. E., 55, 61 435, J., 25, 318, 323, 329,Rosenblum, G., 315, 329, 433, Pierce-Jones, 437, 441, 446 330 Rosenthal, D., 49, 62 Poser, E. G., 418, 419, 420,421, 426, Rosenthal, R., 442, 454 453 Rosenthal, S., 257, 269 Queen, S., 209, 213 Rosenzweig, S., 17, 29 462 AUTHOR INDEX Ross, A. 0., 433, 450 Stein. S., 220, 236, 413, 451 Rudolph, C., 53, 61 Steiner, G. A., 266, 268 Stennett, R. G., 409, 454 Sabshin, M., 438, 454 Stiles, F. S., 254, 255, 270 Sanders, D., 9, 11, 22, 27, 397, 411,Stone, A. R., 185, 212 449 Storrow, H. A., 49, 60, 186, 212 Sanders, R., 24, 132, 143, 421, 423,Straetz, R., 23, 29 424, 425, 431, 432 Strom, R. D., 404, 454 Sanford, N., 8, 9, 18, 22, 24, 29, 399,Stubbs, T. H., 233, 236 405, 454 Suci, G. J., 346, 351 Sanua, V. D., 13, 19, 29, 68, 73 Sutton-Smith, B., 281, 289 Sarason, S. B., 8, 9, 12, 29, 402, 404,Sweet, B., 149, 161 405, 435, 437, 454 Szasz, T., 41, 62, 77, 88, 352, 368 Schaffer, L., 9, 62, 185, 186, 213 Scheff, T. J., 42, 62 Taba, H., 253, 270 Schilder, P., 47, 62 Tannenbaum, P. H., 346, 351 Schneiderman, L., 20, 29 Tashnovian, P. J., 408, 447 Schofield, W., 6, 12, 13, 17, 29, 395, Telschow, E. F., 14, 27, 208, 212, 331, 412, 454 332, 351, 405, 409, 448 Schorr, A. L., 185, 197, 199, 213 Thorpe, L. P., 265, 270 Schrager, J., 9, 28 Tiegs, E. W., 265, 270 Schwitzgebel, R. R., 423, 454 Tienari, P., 71, 73 Scott, W. A., 49, 62 Topping, G. G., 53, 60 Scribner, S., 74, 88 Torrance, E. P., 321, 330, 404, 454 Seeley, J. R., 253, 269 Trost, M. A., 14, 27, 208, 212, 331, Selesnick, S. T., 3, 26 332, 333, 351, 405, 409, 422, Sexton, P., 172, 174, 184 448, 455 Sheeley, W. P., 415, 454 Turner, J. L., 24, 423, 424, 429 Shellhamer, T. A., 410, 447 Turner, R. J., 24, 55, 62, 196, 208, Sherwood, C. C., 443, 444, 449 212 Shoben, E. J., 299, 306 Tyhurst, J. S., 57, 62 Silber, E., 55, 61, 421, 453 Silberman, C., 172, 184 Uihlein, A., 421, 448 Simmons, 0. G., 40, 53, 60 Umbarger, C. C., 91, 109, 42.1, 424, Slack, C. W., 423, 454 427, 454 Slavson, S., 291, 306 Usdansky, B. S., 421, 453 Smith, A., 132, 143 Smith, M. B., 11, 22, 29, 235, 236,Veroff, J., 13, 28, 411, 412, 450 411, 444, 454 Volkman, R., 428, 454 Smith, R., 132, 143 Snider, B., 255, 269 Wagle, M. K., 414, 453 Spano, B. J., 264, 269 Walker, W., 144, 146, 147, 148, 150, Spiegal, A. D., 405, 454 153, 154, 156, 160, 161, 422, Spielberger, C. D., 24, 217, 218, 221, 423, 449 235, 413, 414 Warner, A., 209, 213 Srole, L., 14, 19, 29, 128, 143, 186,Weinberg, W. L., 220, 236, 413, 451 213, 437, 454 Weinman, B., 132, 143 Star, S., 75, 88 Wertheimer, M., 17, 27 463 AUTHOR INDEX Westby-Gibson, D., 404, 455 Wolpin, M., 421, 449 Westman, J. C., 410, 455 Wood, H., 265, 270 White, R. W., 47, 52, 56,62 Wright, B. A., 406, 455 'What:head, A. IN., 43, 6.9 Wri2ht, H. F., 363, 368 Whiteside, M. F., 255, 269 Wurm, C., 437, 450 Whiting, H. S., 92, 109 Wilensky, H. Z., 199, 213 Yablonsky, L., 428, 455 Wilkins, M. L., 53, 60 York, R. H., 130, 143 Williams, R. H., 10, 18, 29,397, 398, 455 Zax, M., 14, 25, 27,208, 212, 331, Wilson, P., 19, 28 332, 348, 351, 405,409, 421, Wilson, R. N., 55, 62 422, 423, 424, 425,427, 429, Wiltse, K. T., 199, 213 448, 451, 455 Winder, A. E., 185, 213 Zilboorg, G., 4, 29, 69, 73 Winder, C. L., 433, 450 Winsor, C., 254, 268 Zimiles, H., 25, 254 Zwerling, I., 36, 37, 39, 85,88 Wolf, D., 315, 329 ;

SUBJECTINDEX

Case-seminar method, 217 ff.,225 ff. Acceptance, schooland, 241 in, 134-135 Caseworkers, welfare, 229 Activity skills, training 265, 266 Department, 139 Causal learning, 255, 256, Activity Therapies Centralization of administration,209- Adolescents, housewives astherapists 210 for, 114 After-school preventive program,341 ff.Children adjustment level of, 296 Aggressive behavior,moral judgment behavior consultants, trainingof, 314 of, 104 Children, 199n. ff. Aid to Dependent characteristics of consulted, 324-325 Aides early identification in, 332ff. 422-423 community action, early ifitervention in, 407 ff. housing service, 422 of, 144 ff. emotionally disturbed human service, training teacher-counselors for, 352 ff. skills for, 182 range of teacher-moms for, 369 ff. teacher, 336 ff. housewives' counseling of,115, 122 Alcoholism, 193 ff. American OrthopsychiatricAssociation, life space theory and,281-282, 284- 291 Association, 384 285 American Psychiatric primary prevention inclassroom for, Anxiety and, 104-105, 252 ff. Companion program psychological influence of school on, 106 and, 316 239 ff. consultant trainees situational analysis of, 282-283 Apathetic poor, 173 teenagers in care centersfor, 145 Attendants, hospital,129 Children's Anti-democraticScale, 255 Attitude scale formothers, 299 ff. Children's Picture StoryTest, 246, 248 Austin IndependentSchoolDistrict, 311, 312 Chronically ill effectiveness of professional vs. non- Autobiographical Data, 319 professional therapy for,418- 419, 426 Bank Street College,242 ff., 253, 255 socioenvironmental therapy for,130 1 Behavior ClassificationChecklist, 319 Record, 265 ff. Behavior Preference undergraduates as Companionsto, Behavioral sciences inschools, 257 ff. 91 ff. evaluating effectivenessof, 264-266 Civil rights movement, 10 further implementationof, 267-268 Clinical management ofeducation, 275 residential setting and,263-264 ff. Benjamin Rush Clinic,181 Clinical psychiatry, 85 Biological explanation ofbehavior, 4 Closed-system orientation, 44-46 Biological research, 69 Cognitivedevelopment,schooland, 245, 250, 254, 259 California Test ofPersonality, 265 - Cohesion, social, 165-166,173 ( also Nonpro Care-givers, 411 ff. See therapists, 128 ff. fessionals; Professionals. College graduates as 465 466 SUBJECT INDEX College students Consultant Report Form, 320 inaftcr-school preventive program, Consultation, 214 ff. 341 ff. assessment techniques in, 318 ff. "C 2 2 :" cc 1-K """8".5`-' "1"-0"0 5UL, .J31 llllll el&111%..1.11lni 11A, 1, 1 14., as companions to chronically ill, 91 ff. ff. child behavior, 314 ff. effectiveness of, as therapists, 418- community orientation in, 232-234 419, 426-428 by graduate students for teachers, selection of, 424 307 ff. Columbia-Washington Heights Project, locus and time for, 317 196 ministers and, 227-228 Conununity Mental Health Act, 11, 22 primary prevention and, 234-235 Community mental health programs, 37 principles of, 216-217 community action, 83, 171 ff. professional and, 218, 225 ff., 234, consultation with community lead- 314, 317, 3c1 358, 360, 361, ers, 235 413-41, evaluationof, 105-106,137-138, public health nuises n225-227 221, 264-266 public schools and, 229,32 guidelines for, 49, 58, 374 targets of, 221, 223-224, 235, 315 interagency organization in, 235 models of, 91, 92, 113, 115, 129, teachers and, 274 ff. training in, 232, 314 ff. 130, 144-145, 148, 163, 174 ff., utilization of, 223 215, 222, 244, 260, 271ff., 291,308,331-332,336-337, welfare caseworkers and, 229 341, 353-354, 374 Wilmington program, 222 ff. problems with, 140-142 Core concepts success criteria for, 49 for human service aides, 149 ff. Community psychiatry,37-38, 79-80, in school mental health program, 272 110, 126, 401 ff. criticisms of, 38, 79, 81 Counseling mental health team and, 196 ff., 209 housewives, 110 ff. programs in, 69 Neighborhood Service Center, 168 Companion program with undergradu- pastoral, 228 ates, 91 ff. teacher,foremotionally disturbed, activities in, 95-96 352 ff. characteristics of students in, 98-99 See also Consultation effects on patients, 99-101 Crime, children's opinions on, 247 effects on students, 101 ff. Crises Compensating devices, 45 ff. disequilibtia of, 57 Competence, 47 intervention, 215, 305-307 ComprehensiveCommunityMental cesolution, 54-56 Health Centers, 64 eacher, 287 Comprehensiveness of programs, 80 Cumberland House Elementary School, Conceptualization, 391-392 353 Conceptualizer-participant, 82, 441 Curriculum Conflict, stimulation of, 172 content, use of, for mental hygiene, Congress, 67 285 Constituency, political clout and, 86 improvement, 253-254 467 SUBJECT INDEX Day-care centers Environment influence of, 47, 54, 56ff. housewives counseling in,115, 122 therapeutic communityand, 129 ff. ff. prevention in, 341 ff. Ethical choice, 223, 224 Etiology of emotionaldisorder, 395 teenaa0 ers for,145 Decision-making by delinquenttrainees, Father-son role, 364 152 ff. Health Program, Delinquents, training of,145 ff. Federal Community 86 Demand "Fee for service" ethic,78 "effective," 171 Finances, 14-15, 35, 416 for mental healthservices, 12 ff., 20 Opinions, 319 Florida, University of, 264 Dimensions of Teachers sciences, 257 Discontinuity of care,197 Fourth-grade behavioral Disease model, 69 ff.,393 ff. Fragmentation of care, 198-199,386 Disequilibria of crises,57 Disequilibrium, progressive,47 Doctoral training, 437 Graduate students 346 Dramatization for learning,245 ratings of day-care program, consultants, 307 ff. Dropouts, training of,145 ff. as teacher Inventory, Drug therapy, 40, 79 Group Leader Evaluation 137-138 Group sessions, 130ff., 217 ff. Economic OpportunityAct, 171 counselor trainees for, 116,1:7 Economics of Freudiantheory, 44-45 day-care activity program,344-345 Education effectiveness of professional vs. non- clinical managementof, 275 ff. professional in, 418-419,426- ideology, traditional vs.modern, 243, 246 428 human service aide trainingin, 150 levelof,of housewifecounselors, 118, 126 ff. nonintellective, 103, 108 vs. individualconsultation, 234-235 Neighborhood ServiceCenter and, See also Training Effectance motivation, 47 176-177 52-53, 54 for parents, 290 ff. Ego psychology, 45, health and, identity and, 55, 58 teacher's role in mental 276 poor and,181-182 school and, 245, 254,258-259 Grouping, school, 373 231 teachers and, 277 Guidance counselors, 230, Elementary school behavioral sciences in,257 ff. Habit formation, 266 Hampshire County School,263 counselors, 230 Emergency services, 38,181 Harlem, 172, 257 services, 200, 215, Emotional adjustment ofchildren, 296Health Department 222, 293 ff. Hearing and speech smice,371 Emotionally disturbedchildren Helper-therapy principle, 429 early intervention for,407 ff. teacher-counselor for, 352 ff. Heredity, 71 230, 231 teacher-moms for, 369 ff. High school counselors, 468 SUBJECT INDEX Hill-Burton Hospital Law, 35 49, 67,102, 233, 257, 408, Home vs. school influence, 244 444 Homemaker, 422 Hospital Leadersofcommunity,consultation college students as Companions in, with, 235 91 ff. Legislation, 22, 65, 67 psychiatric units, 35, 64 Level-of-organization disorders, 42-43 state, history of, 129 Liaison teacher in Re-Ell, 360-361 Hospitality index, 273 Libido-quantum theory, 45, 52 Housewives Life space theory, 281-282, 284-285 as counselors, training of, 110 ff. Lincoln Hospital Mental Health Serv- selection of, 424 ices, 163, 164, 175 as teacher aides, 336 ff. Local issues, involvement in, 172 as teacher-moms, 375 ff. Local responsibility, 37 Housing service aide, 422 Low-income people, see Poor Human growth and development instruction, 157 Manhattan survey, 19, 128 Human service aides, training of, 144 Manpower problem ff. causes of, 128-129 conceptual models and, 63 ff. Inadequacy syndrome, 53 existing, 14-15 Individual institutional change and, 74 ff. vs. group consultation, 234-235 needs, 12 ff., 63, 72, 80, 110, 128, integration of social process with, 82 214, 232-233, 353, 396, 417 Industrial model, 80-81, 420 reconceptualization of, 68 Inequities in services, 19-20 training problems, 140-142 Inertia, intellectual, 439 Maternal assessment of child's adjust- Innovation, training for, 440-441 ment, 296 Institute of Social Research, 255 Maternal attitude scales, 299 ff. Institute for Youth Studies, 145, 152 Medical model, 41 ff., 392 ff. Institutional change, 166, 177 ff. academic psychologist and, 46 Institutionalroadblockstoteachers, assumptions of, 352, 391, 395, 396 285-286 changes in, 64 ff., 398 Institutions, 5 compensatory vs. open, 47-48 change in, 74 ff. conceptual problems with, 49-51, 397 See also Hospitals criticisms of, 41-43, 49, 53, 64, 394 Insurance programs, 35, 38, 64, 65 ff. Intergroup programs, 177 disease model, 69 ff., 393 Interviewing by housewives, 119-120 historical antecedents of, 43 ff., 394, Introspectiveness, Companion program 399 and, 104-105 individual therapy and, 41 "Involvement-enthusiasm" hypothesis, mental health problems and, 41-42, 427 48 ff., 393-394 nonprofessional role in, 420, 421 Job descriptions, 157-158 principles of, 42, 393 Joint Commission on Mental Illness tools of, 42 and Health, 9-11,13, 21-22, Medical services of school, 371 469 SUBJECT INDEX Moral judgment,Companion Program Medicare, 65 and, 103-104 Medicine educational changes and,34-35 "Moral weakness," 77 Mothers role of, 200 assessment of child'sadjustment, 299 Mental health, definitionof, 42 Menial Health Analysis,265 ff. in poverty, 71 Mental health institutions,history of, unwed, 199 33-34 Mental health movement,33 ff. Motivation for delinquents, 147 causes of,40, 201 conceptualization in, 391-392 effectance, 47 role prescription and, 367 Community MentalHealth Act and, for student Companions, 99 1 i , 22 Multi-agency involvement,197-198, 386 current perspectivesin, 11-12 demand and need in,12 ff., 20, 78- National Committee forMental Hy- 79 of, 1 ff. giene, 7 historical perspective Mental Health, inequities in, 19-20 National Institute of Mental Illness 35, 113 ff., 133, 295,333 Joint Commission on Act, 9, 35 and Health and,9-11, 13, 21-National Mental Health 22, 49, 67, 102,233, 257, 408, Naturalism, 44 319 444 Need for Assistance Scale, services, 12 ff., National Committeefor Mental Hy-Needs for mental health and, 7 20, 148 giene 83, 162 National Mental HealthAct and, 9,Neighborhood Service Center, 35 ff., 403 model, 165-166, objectives of, 36 community action Office of EconomicOpportunity and, 171 ff. 10-11, 164 costs of, 183 prevention and, 7 functions of, 166 ff. psychiatry and, 35 ff. goals of,165-166, 180 11. institutional change and,177 ff. school as focus in,278 ff., 404-405 nonprofessionals in, 167,168, 170, team in, 196ff. 173, 174-175, 181,182 Mental illness, 74 of, 169-171 attitudes toward, 101-102 past failures prevention, 164, 166ff., 180 ff. incidence of, 214 Mental Health, structure of,164 Michigan Society for professional view, 271, 273 Neurosis, popular vs. of, 76 Middle class Association for adjustment of childrenof, 298 ff. New Hanover County Mental Health, 215 housewives as therapistsfor, 115 Newtonian physics, 44-45 Midtown ManhattanSurvey, 19, 128 techniques, resistance Milieu therapy, 129 ff. New workers and to, 141 Million dollars dilemma,246-247 New York City schools,253, 257 Ministers, case-seminarwith, 227-228 Nonintellective education, 103,108 Minnesota MultiphasicPersonality In- Nonprofessionals, 15, 417 ff. ventory, 100, 104 ff. Mobilization for Youth, 168,174, 179 assets of, 426 470 SUBJECT INDEX Nonprofessionals (cont'd) Passivity, 173 changes in, 429-430 Pastoral counseling, 228 college student as, 91 ff., 341 ff., 424 Pathology employment of, 121, 138-140 in children consulted, 325 evaluationof,120-121,126-127, educational intervention and, 356 418-419, 426-428 medical model and, 393 housewives as, 110 ff., 336 ff., 375 rates, 50-51, 172 ff., 424 Patients judicious use of, 434-435 Companions for chronicallyill,91 medical model and, 48 ff. in neighborhood community action, government of, 131-132, 135 83-84, 167, 168, 170, 174-175 professional vs. nonprofessional thera- positive personal changes in, 430 py for, 418-419, 426 problems of, 430 ff. socioenvironmental therapy for, 130 roles and functions of, 420 ff. ff. selection of, 116-117, 132-133, 136,Paying 144-146,174-175, 337,342- human service aides, 152 343, 375, 423-424 Neighborhood Service Center work- struggle of, vs. professional, 86 ers, 183 teenager as, 244 ff. People-centered operations, 405 training of, 424-426, 432. See alsoPersonality development, 45 ff. Training closed systems and, 44-46 Northeast Independent School System, compensation and, 45 311, 312 open systems and, 46-47 Nurses, case-seminar with, 225-227 theory training, 134 Philadelphia State Hospital, 130 Occupational inadequacy, 53 Physics, influence of, 44-45 Office of Economic Opportunity,10- Physiological dysfunction, 52 11, 164 Planning, 37, 222-223 On-the-job experience for human serv-Play, 245, 344 ice aides, 155 ff. Political clout, 86 Openness, 56-57, 58 Poor Open-system orientation, 46-47 adjustment of children of, 298 ff. Opinions about Mental Illness (OMI), alienationof,123,185,196-197, 103 402 Order, attempts at, 43-44 apathetic, 173 Otis Group Intelligence Test, 230 communication problems with, 48- Outpatient care, 195, 201 49, 75, 162 ideological focus of, 77 Paramedical group interest, 38 mental healthservicesfor,74-75, Parents 191 ff. attitude scales, 299 ff. mental illness in, 19, 57, 188 ff. early detection and, 332, 335-336 mothers, 71 emotionaladjustmentofchildren multi-agency involvement of,197- and, 296 ff. 198 group therapy in schools and, 290 ff. neighborhood center for, 162 ff. teachers' meetings with, 276-277 reorganization in psychiatry for, 209- Participant-conceptualizers, 82, 441 210 I SUBJECT INDEX 471 Poor (coned) institutional change and, 74 ff. research techniques for, 186 F. judicious use of nonprofessionals by, self-determinationvs.self-actualiza- 434-435 tion in, 77 misrepresentation as, 141-142 Postdoctoral training, 436-437 for parental group therapy, 291 Power issues, 84-85 poor and, 76 Preciousness, 435 vs. popular view of mental health, Prevention, 18-19, 21, 398 ff. 75-76 consultation and, 216 preciousness of, 435 crisis theory and, 405-407 resistance to change of,141, 431- criticisms of, 408, 415-417 432, 439-440 early detection and, 331ff.,400, responsibility of, 390-391 407 ff. role of, vs. nonprofessional, 420-421 function of, 81, 401 supply of, 36, 66, 80 habitats for, '403-404 teacher-counselorsand,357,358, interdisciplinary struggles in, 83 ff. 360, 361 neighborhood centers and, 166 ff. teacher-moms and, 379 nonprofessional role in, 405, 411 if., training of, 436 ff. dt 422 Protest social action group, 179 people-centered operations, 399 If. Psychiatric ratings, 50 poor and, 402-403 Psychiatrists, nur-ber of, 36, 66 primary,18, 81-82, 240, 252 If., Psychiatry, 85 400, 407 clinics, 35, 64, 201, 401 professional role in, 413, 414 cross-sectional patterns of, 191-192 in schools, 230-240, 250, 252 ff., 331 dissatisfaction with current, 40-41 ff., 375 ff., 400, 404, 407 longitudinal patterns of, 192 ff. secondary,18, 180-182, 400, 405,Psychoanalysis, 36, 85, 253 407, 411 Psychological influence of school, 239 after-school program and, 341 ff. ff., 274275 traditional methods and, 353 Psychology social systems change and, 399 clinical, 85-86 systems-centered operations, 399 ff. mental health worker and, 139-140 target groups for, 341, 403-404 school services in, 371, 385 tertiary, 18, 180-182, 400 study of, in America, 35-36 theoretical basis of, 399 ff. usefulness of, 408-410 theology conflicts with, 228 Private care vs. public care, 63 training in, 437 Problem resolution, 54-56 Psychosis, 76, 194, 195 Problem Situation Test, 255 Psychotherapy Professionals, 14-15, 433 ff. aims of, 77, 78 changing role of, 15-16, 40, 82 ff., alternatives to, 18-19 154, 400-401, 433-434 educative process as, 385 for Companion program, 93-94 hopes for, 16-17 in consultation, '18, 225 ff., 234, housewives and, 114 ff. 413-415 reinforcement in learning about, 317 effectiveness of, vs. nonprofessional, teacher counselors for, 352 ff. 418-419, 426-428 Psychotropic drugs, 40 inequities in services and, 20 Public care vs. private care, 63 ff. 472 SUBJECT INDEX

Public health nurses, case-seminar with, psychological influence of, 239ff., 225-227 274-275 psychological services in, 371, 385 Reading teachers, 372 referral processes, 287-288 Re-ED, 352 ff. self-perception and, 245 Referrals sex differences in influence of, 247- to mental health teams, 202 248, 250 for schools, 287-288 social worker, 335-336 teacher aides and, 340 teacher aides in, 336 ff. teacher-counselors and, 355 teacher tnental health role in, 271 Rehabilitation,neighborhoodcenters ff., 354 ff. and, 182 teacher-moms in, 375 ff. Religion, counseling and, 228 technological change and, 309 Remotivation program, 96n. total atmosphere emphasis in, 253- for characteristics of successful men- 254 tal health workers, 138 traditional vs. modern ideology, 243, for college graduate capability, 137 246 historical role of, 441-442 Secondary prevention, see Prevention, for hospitals, 142 secondary Joint Commission Report and, 444 Self-acceptance,CompanionProgram for schools, 248 ff., 319, 347 ff. and, 103-104 Resources, existing, 14-15 Self-actualization, 77 "Risk category" rating, 144 Self-analysis by teachers, 283-284 Role theory, 361, ff., 367 Self-concept, life space theory and, 281- 282 St. Louis project, 290 ff. Self-critical programming, 158-159 Schizophrenia, 194, 196 Self-definition, 58 case vignettes of, 380-381 Self-perception, school and, 245 group therapy for, 418-419, 426 Seminar teacher-moms for, 369 ff. behavioral sciences, 266-267 School case, 217 ff., 225 ff. Bank Street College study, 242 ff. mental health role and, 276 behavioral sciences in, 257 ff. Sex differences inschoolinfluences, cognitive development and, 245, 250, 247-248 254, 259 Sexual behavior, moral judgment of, comfort in, 259 104 as competent institution, 309-311 consultation in, 229 ff. Short-term services, 38 core concepts and, 272 ff. Situational analysis by teachers, 282- curriculum, 254 ff., 285 283 emotional investment in, 240-241 Skills, learning of future research for, 248 ff. in Re-ED, 356-357 health services in, 370 ff. by teachers, 284-285 home influence vs., 244 Slow learners, 266-267 mental health program, 278 ff. Social action, definition of, 171 parent group therapy in, 290 ff. Social cohesion, 165-166, 173 prevention in, 239-240, 250, 252 ff., Social institutions training, 134 331 ff., 375 ff., 400, 404, 407 Social learning theory, 70-71 SUBJECT INDEX 473 Social movement in mental health, 33Surgeon General's Ad Hoc Committee, ff. 233, 234 Socialorganizations,milieutherapy Symptomatology, 49-50, 53 and, 131 Companion program and, 100 Social sciences maternal assessment of, 297-299 in elementary school, 257 ff. in poor, high level of, 57 study of, in America, 35-36 Systems-centered operations, 399 ff. Social systems change, 81-82 goals, 177-178, 362-363 Talking, Companion and patient, 95 operant learning and, 367 Tattling, 266 prevention and, 180 Task-oriented groups, 177 role theory and, 363 ff. Teacher-moms, 375 ff. school and, 288, 362 ff. Teachers Social work behavioral science, 255, 256, 266- political clout of, 86 267 Re-ED and, 360 conceptual material and, 286-287 volunteers vs. mental illness volun- consultations, 230, 274 ff., 307 ff., teers, 102-103 353 ff. Society for the Prevention of Cruelty crisis, 287 to Children, 200 early detection and, 332 Socioeconomic class ego strengthdevelopment of, 277 adjustment of children and, 2' ff. institutional roadblocks to, 285-286 behavioral sciences and, 264-26, itinerant, 372 housewives as therapists and,115, liaison, 360-361 123 mental health functions of, 271 incidence of disorders and, 186, 191 reading, 372 inequities in services for, 19, 75, 402 referral processes and, 287-288 symptomatology level and, 57 self-analysis by, 283-284 Socioenvironmental therapy, 129 ff. situational analysis by, 282-283 history of, 130 special skillsfor, learning of, 284- training in, 134 ff. 285 Sociometrics, see Testing special subject, 372-373 South Shore Mental Health Center, strain relief for, 280-282 257, 263 visiting, 372 Specialized skill instruction, 154-155 Team, mental health, 196 Speech service, 371 duties of, 334-336 Staff meetings, socioenvironmental ther- evaluation of, 207-208 apy and, 131 Technology State hospital influence of, 308-309 attendants, 129 medical model and, 396 history of, 129 Teenagers, training of, 144 Street argument, 149 Tension-releasing models, 46 Stressors, 57 Tertiary prevention, 18, 180-182, 400 Style and skill expansion, 163 Testing Style match approach, 162, 402, 429 behavioral science, 260, 265 Subprofessional workers, 140-142 of Companions, 98, 100 Suaaestibility, 57 early detection and, 335 Suicide, 172 emotional adjustment and, 299 474 SUBJECT INDEX Testing (coned) Undergraduates, see College students of graduates, 138, 318 ff. Unions, 67 for maternal attitudes, 299 ff. University changes, 33 ff. nonprofessional for, 420-421 Unmet needs of society, 148 school influence and, 246 Unwed mothers, 199 Theology,psychologyconflictswith, Urban agents, 414 228 Therapeutic 'xImmunity, 130 ff. Verbal contagion, 149 Therapeutic intervention, 55 Therapeutic social club, 130 Versatility, training for, 440-441 Therapy, see Psychotherapy Visits, Companions for, 95, 96 Torrance Scale, 321-322 VPcational interest "Total push" treatment, 130 behavioral sciences and, 260 Training Companion program and, 107 abstractness of, 425 socioenvironmental therapy and, 138- behavioral science, 255, 256, 266- 140 267 Volunteers changes, in universities, 33 ff. characteristics of students as, 98-99 child behavior consultant, 314 ff. Companion, 91 ff. Companions, student, 94 housewife, 116 consultants, 232 See also Nonprofessionals counselors, 110 ff. Vulnerability, 56-57 human service aides, 144 ff. innovation and versatility, 440 Walk-in clinic, 79-80 neighborhood centers, 174-175 Welfare organizations new personnel, 140-142 caseworkers, seminars with, 229 nonprofessional, 424-425, 432 professional, 436 ff. history of, 199-200 socioenvironmental therapy, 133 ff. Well-baby clinics, housewives counsel- teacher aides, 337-338 ing, 115, 122 E. teacher-counselors, 353-354, 357-359 Wihnington program, 222 ff. teacher-moms, 376 Wood lawn Organization, 172 transfer of, in first grade, 266 World Wars, impact of, 8-9, 36, 37 Tuberculosis, 308 Wright School, 353