Psychiatric Social Work among Children in New York and Neighbouring States
- Author:
LESLEY SAMBROOK and CLARENCE A. WOLLEN
General Trends The first thing that strikes the English visitor, examining post-war social work in the U.S.A., is the ” psychiatric invasion ” of all fields. In work among children this has led to a de-centralizing of the functions of the Child Guidance Clinic and to the establishment of a psychiatric case-work section within each agency or department concerned with child welfare. This is true of schools, the Juvenile Courts, Family Agencies, Child Placement Agencies and Institutions serving children (both Residential Schools and Homes). More details ‘of the functioning of these schemes will be given later.
Child Guidance Clinics proper may function in their own right like the Judge Baker Clinic at Boston and the Philadelphia Clinic, or may be part of the Mental Hygiene Clinic of a Psychiatric Hospital, like Bellevue, New York, or attached to a Children’s Hospital like the ” Harriet Lane ” at Baltimore.
Training of Workers
Case-work has swept the country and in practice the term ” case-worker ” covers the psychiatric as well as the general social worker. Far more men in America than in England go into this field and this was felt to be a healthy trend, contributing robustness and balance to the profession. Modern psychological theories have strongly influenced the training and a good deal of psychiatric knowledge is incorporated in training schemes for all caseworkers.
There is no special course for psychiatric social workers as such; they merely take a further series of psychiatric lectures (which are optional for the case-worker going into other fields), and have their practical work in a psychiatric clinic.
All candidates for training in social work take an 18 months to 2 years’ course in a post-graduate School of Social Work, ending in a ” Mastership of Social Science Great stress is laid on having a college degree, and possession of this academic qualification seems to be considered more important than previous experience or personal suitability. Owing to the different educational systems in the two countries, a degree does not mean quite the same in the U.S.A. as it does in England?but the insistence on it as a pre-requisite for admission to a School of Social Work, does constitute a difficulty for English students desiring further training in the States. It would be well therefore if some evaluation of English training could be made which would satisfy the authorities there.
Further In-Service Training
On completing the post-graduate course in a Social Work School, the worker may get further specialized in-service training within the Clinic or Agency in which she is thus employed.’ An outstanding example of this is the Jewish Board of Guardians which uses case-workers for therapy, both with parents and children in its Child Guidance Service. Workers entering the service have during their first year, weekly seminars on diagnosis conducted by a psychiatrist. In the second year there are similar seminars on treatment, and for workers going in for group therapy, seminars in this branch of work also. There is also an efficient system of control by the psychiatrist, in part exercised direct by means of conferences with individual workers and in part exercised through the supervisors. These supervisors have a reasonable number of case-workers attached to them for frequent discussion and supervision of cases. The conferences with the psychiatrist are at less frequent, though regular, intervals. In case of difficulty the psychiatrist is always available to the worker for direct consultation.
In many other clinics and agencies, somewhat similar though much less complete arrangements are made for continuing the instruction of workers in their function.
The Role of the Psychiatric Social Worker From a position of great responsibility and scope such as that given to the case-worker in the Jewish Board of Guardians, there are varying degrees in the use made of P.S.W.s reaching the other extreme in some clinics attached to hospitals where their work is at a minimum. This occurs in hospitals primarily concerned with training psychiatrists where to the young doctors is given much of the work ordinarily the province of the P.S.W. In the end this has an unfavourable repercussion on psychiatric social work as psychiatrists trained in this way do not appear to know what responsibility to delegate, and how to use the services of P.S.W.s in clinics where they ultimately work.
Between these two extremes there are many clinics and hospitals working with the usual team, though there is a growing tendency to allow more elasticity in the respective roles in treatment, between psychiatrist and P.S.W. For example where suitable the child may be allocated to the P.S.W. and the psychiatrist may take the parent. The extensive use of case-workers for therapy made by the Jewish Board of Guardians is open to criticism, but it is an attempt to meet the need for treatment which is an urgent problem in the U.S.A. as it is in England. This need is so widespread that it is impossible to meet it through treatment given direct by psychiatrists only. Therefore this attempt is being made in using the psychiatrist as a remote control for other psychiatric personnel in the field of psycho-therapy.
Social Work in Public and Private Agencies The emphasis between these two types of work varies very much in different states. In New York and the Atlantic sea-board, although there are State Schemes for the care of dependant and delinquent children, there is a tendency for much of the work to be done by private Agencies. These are a development of old Charitable - Societies . which have grown and modified to keep pace with modern needs. In line with the very strong feeling in America in favour of private enterprise as against any State Schemes, these Agencies handle a great deal of the social and psychiatric work amongst children and often fill gaps for which the State has made no provision.
De-centralizing Psychiatric Work
While in England the P.S.W. usually functions within the setting of the Child-Guidance Service, in the U.S.A. she has moved out of this specific field, and, under the title of ” case-worker ” is making her contribution in all areas of child care. The following are examples:
(a) Child Guidance, or Counselling Service within the Educational System This operates slightly differently in different localities, but the general principle is that schools have facilities for handling their educational and ‘ some of their psychological problems themselves. In New York, Child Guidance Units under the Board of Education operate in different centres, each of which is located in a school, and serves a certain number of schools in that area.
In Philadelphia and other places, the Board of > Education appoints ” counsellors” (sometimes called visiting teachers). These are teachers considered suitable for a psychiatric training. This is given as an in-service training course and the counsellors then deal with children individually in school, in consultation when necessary with a psychiatrist. They also do home visits and interview parents. Referals must come through the head teacher.
This means that a number of problems arising from low intelligence and the more superficial behaviour problems are dealt with, without reference to a separate psychiatric clinic.
(b) Child Guidance Services attached to the Juvenile Courts
The Juvenile Court in New York maintains its own clinic and children are referred by the Magistrate (” Judge “) for diagnosis, and for treatment. Case-workers under the supervision of the psychiatrist give treatment in selected cases, and at present an experiment is being made in group-therapy among some children on probation.
In New York, there is also a psychiatric service attached to the Remand Home?Youth House.
This is operated by case-workers under the guidance of supervisors and in consultation with a psychiatrist.
In Boston, the Juvenile Court uses the Judge Baker Clinic for seriously disturbed children. For less serious cases there is a ” Citizen Training Department ” which is really a compulsory evening club for boys on probation. This is in charge of two case-workers?one of whom (a man), is also a group-worker (recreational officer). (c) Psychiatric Case-work departments attached to Children’s Aid, Child Placing Agencies (Fostercare), Family Agencies, and State Welfare Departments
All these maintain a staff of case-workers, supervisors and psychiatrists for consultation. TTiey have definite schemes for orienting their caseworkers to their special function and policy. This is done by frequent conferences and seminars. As far as possible they deal with problems arising in their own work. All boarding out in private foster homes and all adoptions are done by caseworkers and this child-placement is considered a very skilled job.
(d) Psychiatric Services attached to Institutions serving Children
A very important development is the setting up of psychiatric case-work departments in almost all institutions for children. As far as possible all normal dependent children are placed in private foster Homes, and the Institutions cater for children who are disturbed or delinquent.
The emphasis has shifted from custodial care, through an educational phase, to a therapeutic goal. This means that the Director may be a psychiatrist, or a psychiatrically trained case-worker, not necessarily an educationalist. In most institutions the Board of Education sends in daily a school unit and this operates independently, the only liaison with the institution staff being a friendly relationship. It has certain advantages now that the main aim of institutions is therapeutic, not educational, but it means that the Director has no official control of the educational programme. Most institutions are known as ” schools ” because of this included educational unit, and the children prefer this name. Case-workers -attached to a school may be resident, or visit daily or at intervals. They not only collect Social Histories and do after-care, but each has a certain number of children allocated to her (or him) for regular interviews during their stay in the institutions.
The frequency and nature of these interviews varies in different institutions and also with the needs of the particular child. They may be merely a friendly contact and a bridge between home and school, or they may be of a definitely therapeutic nature.
The amount of supervision given to a caseWorker and the frequency of consultation with a psychiatrist varies from institution to institution. This development would seem to be one of great significance. It recognizes the need of the institution child, whether he be there for long or short term placement, for an individual contact. To be able to count on the undivided attention of a sympathetic individual is a great help, but if he is to make progress this person must be a skilled worker with whom he can discuss his problems and who can help him resolve his difficulties whether in connection with the home situation or the school. The case-worker should also be of great service to the parent-substitute in discussing and mediating the child’s difficulties as they impact on the living situation. In actual fact this relationship is one demanding great tact from the worker if a jealousy situation is to be avoided.
In the best institutions great care is taken that the case-worker who first contacts the child should carry through with him, visiting his home, interviewing him while in the institution and undertaking his after-care when he has left. If he is transferred to another institution or foster home, the worker personally introduces him to the new case-worker? and this is also done if for practical reasons there has to be a change of personnel. In some institutions visited this valuable principle of continuity was not adhered to and the child might have to make several adjustments to different workers?on admission, during residence and again on leaving. In these cases, much of value, i.e. continuity of relationship, was felt to be lost. This development of case-work can be a powerful factor in making placement in an institution part of a constructive treatment plan, not the last resort of desperation. There is one danger, however, which was noted in some institutions visited, viz. case-work must never be allowed to replace good child-care in the living situation. In some institutions where groups in cottages were too large and parentsubstitutes inadequate, there was a disposition to try to patch up poor child-care with case-work. This can never be satisfactory.
General Conclusions
All these ways in which psychiatric work is decentralized, does mean that the bottle-neck of the local Child Guidance Clinic is avoided and that treatment, at any rate on a case-work level is available to many more children. It inevitably places a heavy responsibility on workers to which in some cases it was felt they were not equal, but, those Agencies demanding the most from their workers have a very thorough system of in-service training and a close liaison maintained between case-worker, supervisor (a more experienced P.S.W.) and psychiatrist. The success and even safety of any such scheme depends on the effectiveness of this liaison and of the psychiatrists’ ultimate control. It was felt that these trends should be closely watched and methods of working examined, both with a view to guarding against what may prove to be pitfalls and to applying what proves to be useful in the reconstruction and development of psychiatric social work serving children in this country. Correspondence on this article is invited.?Ed.
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