Supplement to “Mental Health”
VOL. IX. NO. 3. Eighth Inter-clinic Child Guidance Conference London, Saturday, December 3rd, 1949 ABBREVIATED REPORT Chairman : Dr Alfred Torrie (Medical Director, National Association for Mental Health) MORNING SESSION THE PRESENT POSITION OF CHILD GUIDANCE Dr Alan Maberly {Consulting Psychiatrist, Kent and Essex Child Guidance Services : Chairman, Clinical Services Committees, National Association for Mental Health)
I want, very briefly, to outline what we have been trying to do at the National Association for Mental Health to solve the problems that have arisen in Child Guidance largely as a result of the National Health Service Act. In 1944, when the Education A-ct went through, we felt that a very large part of our work had been done : Child Guidance was on the map ; it was an obligation of the Local Education Authority to organize Child Guidance Clinics, and we turned our efforts to increasing training facilities in order to meet the shortage of suitably Qualified staff. There matters stood, until the National Health Service Act laid upon Health authorities the obligation of providing everyone With medical and, therefore, psychiatric treatment. For guidance, the Ministry of Education, in August, 1948, published Circular 179, which is headed, The School Health Service and Handicapped pupils : Effect of the Establishment of the National Health Service. The general principle is that the Regional Hospital Boards will, in agreement with the Local Education Authorities, assume administrative and financial responsibility for all arrangements. ? ? . In addition, where Authorities require the services of a specialist for the discharge of the ?unctions which fall to them, e.g. for the ascertainment and subsequent examination and supervision of handicapped pupils … the Regional Hospital Board may in some instances, if desired, be able to make available the part-time services of a wholetune specialist in the Board’s service.
But : 44 Local Education Authorities, however, will be in no way precluded from directly providing : ? ? any specialist service for school children which it appears to them desirable to provide notwithstanding the facilities otherwise available.” Those two clauses give powers either to the Regional Board or to the Local Authority to provide these services under which Child Guidance falls, but the Local Education Authority will, however, ” remain responsible for meeting the cost of arrangements for the medical inspection of the pupils, including the specialist examination and supervision required in respect of the physical and mental disabilities of handicapped pupils in special schools.”
Now follows the heading Child Guidance. ” Child Guidance work of the type at present undertaken by Local Education Authorities is in the main an educational service closely linked with the school and home. Thus the needs of most of the children who are maladjusted, whether to a degree which calls for their ascertainment as handicapped pupils or to a lesser degree, can be met by social and educational adjustments. Much of the work is carried out at the schools in co-operation with the parents and teachers by the educational psychologists and specially qualified social workers appointed by Authorities. The educational, physical and psychiatric aspects of the work are, however, inseparable and at the Child Guidance Centres established by local Authorities the team of workers includes a psychiatrist and also, as a rule, a paediatrician.” Now we come to the sentence which has caused us all a lot of difficulty.
” Some of the children may be found to need psychiatric treatment ; the Minister, in agreement with the Minister of Health, considers that these children should normally be referred by the authority to the clinics which will be provided in due course by the Regional Hospital Boards and which in some instances are already available ; similarly, these clinics will refer appropriate cases to the Child Guidance Centres.”
In this proposal, the term ” Child Guidance Centres ” refers to any clinic, as we understand it, which is run by a Local Education Authority. The Child Psychiatric Clinic, on the other hand, is any clinic which is run by a Regional Hospital Board. That is a purely administrative distinction. The same team may staff both. One is a Centre, the other a Clinic. We felt that this particular paragraph was confusing. It states that the psychiatric aspect of the work of a Centre is essential: psychiatrists must be on the staff: yet it seems to imply that the psychiatrist’s work must be limited to diagnosis, that if treatment is required, the child and parent must be referred to another Clinic where all the work is carried out again. We did not feel this to be a desirable position. The only other clauses which concern us are two :
” It will be open to Authorities to arrange, as and when practicable, for the specialist service required at their Centres to be provided by the Hospital and Specialist Services if they are of the opinion that the work of their Centres can be suitably organized on this basis.”
and “A part of the work at the Child Guidance Centres established by the Authorities is, however, concerned with the ascertainment of maladjusted pupils under Section 34 of the Education Act, 1944, and the Authorities will be financially and administratively responsible for the specialist service required for this purpose.”
It is obvious, therefore, that the Child Guidance Service presented the Authorities, as it has so often done before, with an administrative problem. Whatever they did, the Local Education Authority remained responsible for supplying a specialist service in relation to ascertainment and, as far as Centres were concerned, they could supply the specialist themselves or ask the Regional Hospital Board to do it. The Regional Hospital Board could accept the invitation or it could decline ; but it remained the obligation of the Local Education Authority to supply the local Child Guidance Service if no one else did it. At this point I think it is imperative that we all remember that financial considerations, in the last resort, will govern what Regional Boards do. Some Boards will supply the service and some will not, and it cannot be said with any certainty that the Child Psychiatric Clinics which, according to this circular, will soon be available, will necessarily soon be available in any area at all.
Then, very briefly, I want to read you a quotation from a letter (drafted by Dr Soddy, then Medical Director), which we sent in to the Authorities expressing our disquiet at this situation. We said that we felt that the proposal of this dichotomy in the Service ” would involve the running of a service for ascertainment of maladjustment and for educational treatment by one authority alongside a separate therapeutic service by another authority. Such a proposal has serious drawbacks, not the least being the use of two separate organizations to do what could be done more efficiently by a single body.” The drawbacks we suggested were many :
1. The ascertainment of emotional disorders in the schools would become the lone responsibility of educational psychologists, many of whom are now without clinical experience and who, with the continuation of such a system, would tend more and more to lack this essential experience.
2. To absolve the psychiatrist from responsibility for intimate contact with the source of his clinical material and for ascertainment of illness is a retrograde step contrary to modern trends in preventive mental hygiene.
3. To divorce the responsibility for diagnosis from that of providing treatment is widely condemned in medical practice as tending to irresponsibility on the part of the diagnostician and to unreality in the therapist.
4. Experience has shown that the work of the educational psychologist away from a clinical setting may become sterile and lose its distinctive contribution to mental health. This Association agrees with the view held by the Committee of Professional Psychologists (Mental Health) that any administrative measure tending to divorce psychologists either in work or training from clinical experience is to be deplored. We are agreed that clinical practice is an essential part of the work of psychologists in both the educational and therapeutic aspects of child guidance if the latter is to develop realistically. A proposal to establish parallel organizations cannot fail to accentuate a tendency (already regrettably apparent) to regard the training of psychologists for this work as something apart from that of the other members of the team.
5. A proposal which must necessarily split the team by sending one member out into the field and withdrawing another into a more clinical or hospital setting must be condemned as fundamentally disruptive to a movement which owes its distinctive contribution to the combination of psychiatric, psychological and sociological approaches in as close a connection with the community it serves as possible.
Lastly, we said : “This Association urges strongly that the lesson of experience is that all workers must be based on the clinic team, must owe allegiance to the team as a unit and must carry on their respective functions in day-to-day collaboration with other team members.”
. That is part of a memorandum which we sent jn after the issue of Circular 179. We were assured, both officially and unofficially, that there had been n? intention on the part of the authorities at either ?f the Ministries to separate diagnosis from treatment. They failed to understand how we could have read such an intention into the document, ^hey gave us an assurance that any recommendation t? refer to the Hospital Clinic would be made ?y the Child Guidance Centre and no child should Pe referred from the Centre to the Hospital Clinic rf the psychiatrist at the Centre considered that he could treat the child properly at the Centre. This ?s important, because, although it is not intended by either Ministry that any idea of separation should arise from Circular 179, it is our experience, and I arn quite certain it is your experience, that many Local Authorities are interpreting it in precisely that way.
Now, what has happened in the last eighteen jnonths ? In effect, some of the old organizations have gone on more or less unaffected ; in other cases there have been very considerable changes. Under the Regional Boards, we have established clinics such as the Tavistock Clinic and the Training Centre and the Hill End Clinic in Hertfordshire. There are Clinics connected with small voluntary hospitals, which now come under Regional Boards ; niany of them have full teams, exactly equivalent to Child Guidance Centres under Education Authorities, but they are Child Psychiatric Clinics. There are what we know as Child Guidance Clinics, fun in association with mental hospitals, or with children’s hospitals, again with a full team, and known as Child Psychiatric Clinics. There are, here and there, Child Psychiatric Clinics set up oy Regional Boards from scratch, usually beginning ^th a psychiatrist alone, and sometimes ending there. Then there are the Child Guidance Clinics ,n Association with Teaching Hospitals, independent Regional Hospital Boards, independent of Local Education Authorities, many of which have tull teams. There are the Local Education Authority Clinics still going on, as at Manchester ; about that you will hear from Dr Burbury to-day. Lastly, there are proposals for a combined clinic and centre which we feel might meet our point of yiew better than any other : that is a situation where the Local Education Authority continues to organize the clinic and to provide the Educational psychologist and Psychiatric Social Worker, while the Regional Hospital Board appoints, in co-operation with the Local Authority, the Psychiatrist and seconds him, as it were, for service in the Child Guidance Centre. I call it ” Child Guidance Centre ” because we have to do that, as it is organized by the Local Education Authority, but it serves both functions. It serves the purpose of a Child Psychiatric Clinic in so far as it unquestionably carries out all treatment, serves the whole area, and takes every child, irrespective of the type of school they attend. It is also a Child Guidance Centre and, therefore, it has one team and there is no question of a child, after full examination and diagnosis, being referred for treatment elsewhere. I might just say here that this separation of function is probably worse for our patients than it is for us. We can doubtless all think of examples of separation of responsibility, and it is a state of affairs to be avoided in our field.
DISCUSSION
Dr W. J. T. Kimber (Medical Director, Hertfordshire Child Guidance Service). The Child Guidance Service was started in Hertfordshire fifteen years ago (1934) with one clinic at St. Albans. It had three sessions every week, and was staffed by a full clinic team. To-day there are five clinics, which hold, in all, over the years, forty-eight sessions weekly. The main change has been in the relationship between the community and the clinic ; this change has brought in its train certain problems which may be met with elsewhere in due course. At first, only the seriously maladjusted or neurotic children were referred to us, whereas to-day, in addition, we get a large number of less severe behaviour problems and other cases.
As an administrator I have sought to protect the clinic team from this heterogeneous crowd. It is possible in most cases, from a brief history of the case, to divide the children into three groups and allocate them for appropriate action. 1. Disturbed, maladjusted or neurotic children.
These require full-team help and are legitimate Child Guidance Clinic cases. 2. Children reacting (possibly normally) but also exasperatingly to their environment, approaching the ” beyond control ” category. A full history by a psychiatric social worker should “reveal these, and an approach to the mother, and visits to the home may be all that is necessary. The psychiatric social worker will be working in consultation with the psychiatrist, with whom, for such cases, she will have a weekly individual session.
Patients may, if necessary, be referred for full treatment by the psychiatrist. 3. Children failing in school, generally or in specific ways, with or without disturbing conduct patterns.
Such are essentially educational and not psychiatric or sociological problems. They should be seen by an educational psychologist.
When the individual problem has been elucidated and the special needs of the child are understood, suitable provision can or should, under this statute, be made for such children.
In my view, unless such means of accurately determining the needs of a child who is failing at school are provided, a child guidance service which has gained the confidence of its public will be forced to deal with a large number of such children to the detriment of its own proper work. This is a waste of skilled and scarce psychiatric time, and a waste of public money.
Administratively, this provision can be made by the Local Education Authorities in a number of ways. I hold no brief for any particular one, but in my view, as a matter of practical, clinical importance, any scheme should ensure that the educational psychologist works both in the schools, doing purely educational assessments, and in the Child Guidance Clinic, as a normal member of the team. In Hertfordshire this has always been the case, the psychologist being employed by the Clinic authority (National Health Service), but by arrangement spending days in the schools and working there independently. I am concerned at proposal that this school work may be curtailed or discontinued. I believe that failure in school, particularly failure to read fluently?the cause of which is not always readily understood?is not infrequently a factor in causing serious maladjustment. Recurring failure conditions children against school and so against authority. It is a door to delinquency and, although it is true that other influences may be sufficient to prevent a child from passing through this door, it is far better that they should never be brought there.
Dr W. Mary Burbury (Medical Director, City of Manchester Education Committee Child Guidance Clinic). As Director of the City of Manchester Child Guidance Clinic, a psychiatrist on the staff of the Children’s Hospital, and a member of the Psychiatric Sub-Committee formed by the Manchester Regional Board, I have, as it were, a foot in various camps. Further, the Manchester City Child Guidance Clinic extends its work far beyond the scope of Manchester City and covers many of the surrounding districts in the Counties of Cheshire and Lancashire.
I have now been twelve years in Manchester and I can truly say that the Local Authority have given us a very good deal. We have a complete staff of fully qualified people ; our quarters are good ; and no objection is ever raised to providing us with the material for which we ask.
The qualification for attendance at the Manchester Child Guidance Clinic within the City of Manchester is that you should live in the City of Manchester. It does not matter how you come ; you can come from the Local Authority, from the School, from a private doctor?there is no limitation.
So far, so good. We have been very satisfied and we have been very happy, but there are difficulties. It seems, for example, to be tacitly assumed that if you are under a Local Education Authority you have absolutely free access to their schools, and in Manchester we have found that not to be the case ; we can go into the schools, yes ; but, except where we go in about our own cases, we are not very welcome?I refer not to the schools themselves, but to the Authority behind the schools. We are trying, gradually, to build up a different attitude about that.
Also, we are a teaching Clinic now, and the attitude of the Authority to teaching work is far from satisfactory. They accept it on sufferance, if they are persuaded that, in fact, they get a lot of work done for nothing. The other point about the teaching position is that, because we are a Local Authority Clinic, we are very much cut off” from the rest of the medical teaching work. In the University of Manchester the Professor of Psychiatry and the Professor of Child Health are very anxious to have our co-operation, but it is a friendly relationship and carries no official recognition.
Then?and this is something that people in London probably find it extraordinarily difficult to realize?the work in the Local Authority set-up is very much cut off from the rest of the medical personnel and particularly from the rest of the psychiatric personnel in the area. Since there has been so much meeting together since the Health Act, I have begun to realize how little I know of my psychiatric colleagues in the area.
And lastly, one of the drawbacks?a very important one in a Clinic of this considerable size? is that when I say to the Local Authority, ” We should like to do this or that in the way of research “, the answer I invariably get is, ” There is not any time for research as long as your waiting lists are as they stand at present.” That seems to me one of the most deplorable things in this attitude of the Local Authority.
Now, though I must be brief, I want to turn to the other side of the picture?the Clinic at the Manchester Children’s Hospital. It is a one-man Clinic. I run it entirely myself, except when I get any kind of voluntary help, or when the extremely over-worked Almoner sends me a report on a case that has to be seen. I have to do my own testing. I have to spend a great deal of time with the parents of the children, because there is no psychiatric social worker to take the history for me. So there it is? no staff. If there is anything worse than that, it is the premises. The premises are truly awful, ordinary clinic rooms with tiled floors and walls and medical apparatus all over the place. The redeeming feature of this appalling situation is that it gives me the opportunity to come into contact with all the specialists in children’s work on the physical side ?n the City ; it gives me the opportunity of contact with those cases which are on the borderline between the physical and the psychological ; and, as I have realized increasingly recently, since the Health Act came into full operation, since the hospitals adopted the plan of appointments and sending cards to the doctors to fill in for appointments, it has given me an ‘nsight into the needs and demands of the general Practitioner which I never had before. The cards came into operation in this hospital at the beginning of June. At the end of April the waiting list for that Clinic was three weeks. It is now nine months, and 11 is quite impossible to keep pace with it. I spent some time, a day or two ago, looking through the hst because I felt sure that some of the doctors must be finding a quick way round the mental deficiency problem, but I only eliminated about ten and sent them back as educationally sub-normal or uneducable and needing to be referred to the Local Authority for testing on those grounds. . I think perhaps this illustration of having a foot ln both camps does emphasize the enormous importance of what the chairman called ” Combined Operations “. In the first place there is a shocking jyaste. I find from time to time that cases have been referred to me which either have been seen already in other Clinics in the area or which I have already seen in my own Clinic. Secondly, there is a tendency to play off” one against the other ; and if we have something combined, while it may be Perfectly true that one kind of case is more suited to one kind of doctor, it will be a matter of choice jn co-operation and not, as it sometimes appears to be, in opposition. Thirdly, if we can have a combined kind of work, it will mean a saving of staff.
I hope you agree that some co-operation is necessary, perhaps on Dr Kimber’s lines, perhaps? ‘P I hope in my own area?by setting up a Joint Committee of the heads of the Local Authorities and the Regional Board for the organization of Child Guidance work throughout the Region.
GROUP DISCUSSIONS
For lack of space, the findings of the eleven groups cannot be printed in full. The point, however, Jyhich stands out above all others is the concern tett at the proposal of dichotomy in the Service, as embodied in Circular 179. One group, unanirnous in condemnation of the division, suggested that ” the best administrative compromise was to have the Clinic under dual or multiple control of a Local Committee where Health, Education, and the Regional Hospital Boards were represented ; and, on balance, it was felt that the smaller the area to administer the needs of a particular Clinic, the betterAnother group emphasized the need for finding a way of working harmoniously under the two Authorities, because the Service extended into both fields. There was considerable resistance to the new terminology (Child Guidance Centre and Child Psychiatric Clinic) and it was clear that the familiar term ” Child Guidance Clinic ” would be long in vogue.
Other points put forward were :
1. There was a fear of recommendations of the Centre being ignored and intake being restricted to educational problem cases in Centres run purely by the Local Education Authority. It was felt that, as a general rule, applications should not be sieved by School Medical Officers, nor should initial referrals have to be made to them or to their Departments.
2. Difficulties were often encountered in connection with referrals of children of preschool age, children who had left school and children who attended private schools. 3. The new Health Act had made little difference, so far, to the way in which Centres were run. They showed great diversity of method. The quality of local relationships was more important than the ” set-up “, and the onus would continue to rest on the Clinic team, whatever the final form of the Service.
4. Working under Regional Hospital Boards would involve more difficulty in getting into the schools than working under Local Education Authorities.
5. There was wide-spread awareness of the dangers of specializing solely on work with children.
6. It should be the responsibility of the educational psychologist, with his particular knowledge, to ascertain educational subnormality. The disposal of the educationally sub-normal should not be made without a full-team investigation.
Dr Jacobs (St. George’s Hospital) and Dr Creak (Great Ormond Street Hospital) spoke by invitation of the Chairman at the end of the morning session.
AFTERNOON SESSION SUGGESTIONS FOR FUTURE POLICY Dr R. F. Barbour
Medical Director, Bristol Child Guidance Clinic ; Vice-Chairman Clinical Services Committee, National Association for Mental Health In the past we have been?and I gather from this morning’s Conference we still are?what I might term a professional anomaly. We apparently were in the past, and we still are, an administrative nuisance. One Director of education said, in a rather unguarded moment, “You make problems.” With a blush, he quickly amended that to, ” You discover them for us.” I think that the first phrase was more from his heart, and I feel that at present there is a risk that we may find ourselves, not consciously but possibly subconsciously, tending to serve the administrator rather than help the child. While we are on this subject we might? most of us?be thinking of means of improving our techniques in our relationships with officials. This leads to my second point the importance of preserving this principle of the team. The basic assumption of child guidance is that behaviour problems in childhood arise from a variety of causes and as a result will demand a variety of techniques for their solution. Most of us say perfectly frankly that we are in favour of a team. On the other hand there are people who feel that abbreviated teams have a really useful function to perform. We all know that at the present moment Clinics have to work short-staffed, and obviously we may have to accept this as?but only as?an emergency measure, like rationing. Nevertheless I should like to see those Clinics which have not the full team, keeping the fact in the eyes of the public, listing their establishment at the top of their letter-paper : psychiatrist, with the name opposite ; psychologist, with the name opposite ; psychiatric social worker, with the name opposite ; and against any of those positions that they are unable to fill for the time being, the word ” vacant ” should be put. It is all too easy for our administrators to become accustomed to our working short-staffed. Some of us have had to work short staffed for two or three years and possibly longer. They may even get the idea that a psychiatric social worker is not essential, or even that a psychiatrist is something of a luxury and that a School Medical Officer really can do the work just as well.
Let me repeat, we are an anomaly, and I think we have got to face that fact and take the responsibility for our policy based on that fact. We do not fit nicely into any of the administrative compartments. We serve two Local Authorities, the Education Authority and the Health Authority ; we serve the Regional Hospital Board, and in certain cases, in University towns, we serve the Hospital Board of Governors. In theory, this should present no difficulties, as the “joint user ” principle is stressed time and time again in the National Health Act, but in practice it tends to be cumbersome. The question, I think, is whether we are capable, whether we are good enough psychologists, good enough psychiatrists, good enough psychiatric social workers, to handle these people, whether we can get all these authorities to come to an agreement. It is a hard task, but I am certain it is no harder than our work with a large number of parents, or even teachers or general practitioners, and I think that at times we have tended to fold our hands and, so to speak, cross them off the treatment list.
If, however, we do succeed, there is practically nothing that cannot be done under the National Health Act or under the Education Act. Almost every clause starts with the phrase ” has the power to … ” but it is permissive and not compulsory. On the matters of referrals, around which there was considerable discussion earlier to-day, I cannot resist saying that I should like to see open referrals made the general rule that it is in Bristol?open referrals by parents, by teachers, by School Medical Officers, by social agencies. I do not see why certain parents should have to tell other Authorities or someone who may not be understanding, before they can arrange for a child to have treatment. I am looking forward to the developments of the next fifteen years in Child Guidance. The last twenty years have seen many advances, chiefly, however, on the educational side, and I hope that we are going to see equal progress on what I would call the medical side. The broad interpretation of ” maladjustment” makes it possible for us to finance the treatment of the maladjusted child fairly easily ; and I think it is time, as Dr Creak was saying this morning, that we should now woo the paediatrician as enthusiastically, and let us hope as successfully, as we have courted the teacher. Much research is needed on the whole question of the development of the central nervous system and the influence of the endocrine glands on behaviour. I think that in about ten years’ time, provided we can get adequate staff and adequate interpreters, the electro-encephalogram will probably be found as part of the routine set-up of every Child Guidance Clinic. Here again let me stress that it is team-work. In Bristol the psychologists are asking for certain children to have E.E.G.s. Why ? Because they are beginning to see that certain types of dysrhythmics, when they reproduce the TermanMerrill designs, tend to make specific errors. It is team work again.
It is only too difficult, as you know, to obtain foster homes, and our schools for handicapped children are woefully inadequate as far as maladjustment is concerned. It is my opinion that ?ther forms of homes are necessary for residential treatment. Staffing may be difficult and financing J]ay be difficult, but at any rate under the National Health Act they have got as far as planning them and I think the staff and the finance will be forthcoming. Let us look for a moment at the composition of the team, and the question of standards of training. We do not know how long it is going to be possible tor the N.A.M.H. to make arrangements for training Fellows. Are we going to say that any Person who has the Diploma of Psychological Medicine is automatically capable of running a Child Guidance Clinic ? One of the big differences, as you know is that at the present moment there is no selection for the Diploma of Psychological Medicine. It is a matter of finding the time and the money. On the other hand, for the Fellowships, every Potential Fellow was seen by psychiatrists and quite a fair percentage were in fact rejected. Can we accept this position in the future as satisfactory ? ^Jso, there is a danger in one or two places of the Psychiatrists themselves becoming administrators, ?r at best diagnosticians, rather than therapists, the real therapy being left to play-therapists, Psychologists and other selected people. . Psychologists seem to be in better supply than either 0f the other two members of the team and this often means that it falls to them to double jor the other members, regardless of whether this is the best use of their ability and training. My biggest problem, as a Clinic Director, is the shortage of psychiatric social workers. Pre-war, as s?nie of you may remember, the ratio was one Psychiatric social worker to a half-psychiatrist and a naif-psychologist. The ratio in many clinics now is almost the reverse, and this has meant rather serious changes. Outside contacts have had to be cut to a minimum. It has severely limited the ume the psychiatric worker can spend in meetand discussing Child Guidance problems Wlth other social agencies, and I am thinking, in Particular, of people like Children’s Officers, robation Officers, and the like. Do not forget that ^hild Guidance started originally and chiefly as a ??rnrnunity service, and although treatment of the individual is important, there are certain problems Wiich are best tackled at the social level. In some ^-hnics the home visit, which used to be more or less routine, is now regarded almost as a luxury. It seems to me that two sections of our work which will present easier organization under the National Health Act are : (1) the whole question of treatment of parents ; and (2)?a big problem at present?treatment for the boy of about fifteen to nineteen, who has left school : treatment for such cases should be possible in a Child Guidance Clinic, but at present, in general, that need is not met. My final point is that we must make a drive on this whole question of training, and if we believe that the team approach is not only desirable but practically essential for us, it is very important that the teaching staffs of these various disciplines should work in close co-operation.
DISCUSSION
Professor D. R. McCalman (Department of Psychiatry, University of Leeds). There have been times when I have wondered whether we were tending to lose sight of the real object of Child Guidance? the problem child. Too many of us spend too much time on administration and organization, but this afternoon Dr Barbour has brought us back to our proper place in the clinical field.
Although there has been a great increase in the number of clinics we must, as Dr Barbour has indicated, make every attempt to increase our potential for training. In many areas there is a need and a demand for Child Guidance which cannot be fulfilled because adequately trained staff cannot be obtained. Such a situation always increases the danger of untrained personnel being employed by Authorities whose enthusiasm outstrips their good sense. We know how many Authorities have for years been eager to employ psychiatric social workers and who, despairing of ever attracting a fully-trained worker, are now contemplating appointing the next best thing. The same is true of psychiatrists:
We should resist the assumption made by some authorities that a psychiatrist is qualified to work in a Child Guidance Clinic, as a consultant, merely because he has obtained a D.P.M. There is, therefore, a great need for the number of training centres to be increased. So long as the standard is maintained, there is no reason why a number of Regions should not undertake, in conjunction with the appropriate University Departments, the training of psychiatrists, psychologists and psychiatric social workers, until the present need is met. The second question I should like to raise, concerns the use which is being made of existing clinics. The orthodox Child Guidance team is an expensive instrument which must be used to the best advantage. I have always felt that it should be used in a consultant capacity, and called in to help in the diagnosis and treatment of unusual and difficult cases. In the process of dealing with such cases the clinic should, indirectly, educate a number of persons and agencies in the community, and they, in turn, should be better able to deal with less pathological cases along the same lines. Methods should gradually be evolved whereby the clinic could safely act as a consultant agency to probation officers, teachers, doctors, health visitors, parents, etc., who might in time be regarded as the general practitioners in the field of mental hygiene. This, in turn, would free the clinic to tackle the very type of caste for which it was originally designed. I was glad to hear from Dr Kimber that developments along these lines are already taking place. Thirdly, are we, as a Child Guidance movement, making the determined effort which is necessary to tackle some of the more pressing problems in the broader aspects of mental hygiene. Often, when investigating a case of delinquency, we find environmental conditions so conducive to asocial behaviour that we wonder whether it is worth while instituting individual treatment. Do we then move outside the bounds of medicine and education in an attempt to modify these wider social and cultural problems ? Any such attempt pre-supposes that we know how to educate and whom to educate in the general principles of mental hygiene. It is not sufficient for us to provide the community with a method of dealing with children after they begin to show psychopathological symptoms; we must also try to prevent such maladjustments by encouraging positively beneficial influences upon early development.
Have we learned from our study of pathological conditions enough about mental hygiene to be able to carry out this type of educational propaganda ? How many statistically evaluated facts do we know about child development ? What figures have our clinics produced ? If it can be shown that 34 per cent of mothers in an unselected group of delinquents went out to full-time work, and 8 per cent went out to do part-time work, that statement is more convincing to a lay person than any story, no matter how pathetic, about one delinquent whose mother went out to work.
Again, is there anyone following up the earliest cases to attend Child Guidance Clinics in this country ? There must now be men and women in their twenties or thirties, perhaps parents themselves, and, if so, how are their children faring ? Only facts of this type can justify the value of our methods and our claims that Child Guidance provides a method whereby problem children can be successfully treated.
Dr Mary Capes (Medical Director, Southampton Child Guidance Clinic). I, too, feel that I must refer to the rather wide ignorance among school teachers, for example, and on Local Authority Committees, as to what Child Guidance sets out to do ; Regional Hospital Boards are also ignorant. For example, recently we found that it had been thought a nice idea to switch us from the excellent premises of the Local Authority, into the Regional Hospital building where there literally was not a room for us to work in. Nobody had considered that as a practical detail, and the Regional Hospital Board did not appear to realize that there was an educational problem at all or how much work was being done in the schools. In my own area, the Education Officer and 1 are the best of friends, but he makes it clear quite often that he would like the Clinic to be run from ao educational and not from a medical standpoint. We have a system, under the Local Authority, however, which seems to be working happily, and by which the educational psychologist works half-time in the Clinic, and half-time in the schools, apart from the Clinic. During the past year, in her work in the schools she has tested and interviewed 349 children, and from that number she has only referred 15 to the Clinic, that is 4-3 per cent. Children may be referred by anyone and the number seen at the Clinic itself last year was 221. It is my policy to ask the psychiatric social worker and the educational psychologist to see them first. (I do not work full-time ; they do.) Of the 221 who have been referred, 200 have been sent on to me, which means that about 90 per cent, of the Clinic children are psychiatric problems.
I feel that if the Education Authorities could realize what scope an educational psychologist has in the schools, when in the team set-up, they would feel less anxious altogether and they would not say, as they have in the past, ” Keep out the psychiatrist
This leads me on to mention that we must beware of our own ignorance as well as of the ignorance of people who cannot know altogether what we are attempting, and I feel that we must know what training a member of the team should have had. I speak as one who has suffered as an untrained child psychiatrist ; I entirely endorse what was said of those who have taken the Diploma in Psychological Medicine and studied adult psychiatry, but not child psychiatry. I am apalled by what I have done myself, starting work with inadequate training, and I think it is up to us all to see that we are trained to the extent that the National Association has set down.
I would like to add this controversial note : that we have to remember that we probably all experience a struggle in the urge for power. The Ministry of Health and the Ministry of Education may be happy together : I do not know ; but in the Local Authorities very often one meets, in the Counties or the Boroughs, struggles between the educational side and the medical side, and in the Clinics, often, we also should take ourselves off to a quiet spot and consider whether we, as psychiatrists, are perhaps abusing the power that we have ; perhaps our psychologist friends should also do the same if they are running the Clinic. In fact I think that the happiest Clinic is probably one in which the psychiatrist deals with the psychiatric aspects, the educational psychologist with the educational aspects, and the psychiatric social worker, besides all the other work she does, runs the Clinic !
GROUP DISCUSSIONS
There was, unfortunately, only time for seven ?f the eleven groups to report their findings. Briefly t”e main points arising were : 1. The urgent need for facilities for training Child Guidance Staff, and the responsibility of the Universities in this connection. 2. Some of the training must take place in the Clinics where the practical problems arise. If, however, a Clinic has a teaching function, the responsibility for teaching must be recognized in the form of extra staff or extra time. 3. The status of the psychiatric social worker must be improved. 4. Disposal facilities caused considerable anxiety.
5. Various suggestions were made for avoiding the splitting of the Service, for example, that the Local Education Authority should employ the lay members and provide the premises, while the Regional Hospital Board supplied the psychiatrist. Another group suggested Joint Committees at all levels. 6. The Service should concern itself with validating and justifying its work and selecting its cases, while avoiding ” overselling “.
7. In the present state of affairs, waiting lists seemed irreducible.
8. More guidance from the Clinics was needed in regard to schools for the maladjusted.
9. Inter-Clinic Conferences were regarded as very valuable for the sifting and exchanging of views.
SUMMING UP
Miss Lucy Fildes, Ph.D. (Chief Psychologist, ?ndon Child Guidance Training Centre). Perhaps useful way of summing up would be for me to tress one or two points that have developed. Hiis morning the problem, as it appears at present, CVi PUt before us very precisely. It is clear that nild Guidance is on the map. I have been ?rking in it since the start, and it is very satisfactory 0 see it on the map. Clearly, however, with the ajriv.a?f the National Health Act, difficulties in ^ministration and organization must arise, and lose difficulties were clearly presented to us. The Education Authority is ultimately responsible ofir^ld guidance, as stated in the Education Act , 1944. If that Authority finds that the work is not eing done by anyone else, it is obliged to do somelng about it. In other words, it cannot shelve its uancial responsibility.
The Health Authority is free to develop any medical treatment which it considers desirable, but it is under no compulsion to develop it in the form of Child Guidance as we know it. It can develop Child Guidance as a preventive service ; it can develop it as a therapeutic service, and quite certainly is doing so ; but the final legal responsibility rests with the Education Authority. It was very interesting to hear from later speakers this morning that in general, Clinics are functioning in much the same way as they were before the Health Act. All the same, we must face the fact that problems will make themselves felt when the Regional Hospital Boards have had time fully to familiarize themselves with the nature and intricacies of the Service which has been presented to them. Will they, or will they not, advocate team service ? It is up to us to decide what we think of team-work and whether we are going to press for it. If we consider that team work is essential, we should have some clear idea of the responsibilities of the different members of the team in relation to the whole general Service, both preventive and therapeutic. What the nature of that Service should be has been revealed in the discussions : the idea, for instance, that the psychologist should serve the schools as well as the Clinic : that the psychiatrist should in no sense become merely a diagnostician in a Child Guidance Centre?and I notice that nobody here has used that word, except from the platform : that the danger of this dichotomy between an education service and a service under the Health Authority must in some way be met, and that we should have a definite general policy as to the best way of meeting what is undoubtedly likely to become an increasing danger to Child Guidance work as we know it.
We have heard much about what is essential for the general future of Child Guidance : the need for extension of training ; for variety of experience ; for co-operation ; for research ; and the importance of making known the real function of Child Guidance work, without ” overselling ” the Service. If our services are?and can be shown to be?of value, the question of finance will cease to haunt us. It will not be as easy to show the results of Child Guidance, as it is to prove the effectiveness of much physical treatment, but it will be incumbent on us to present our facts.
On the question of general policy, can we make up our minds, for instance, that it would be the best policy for Child Guidance services to be run by the Authority which is obliged to run them, if nobody else will, while co-operating with the Health Authority by having psychiatrists seconded from that Authority ? If so, let us say so.
A suggestion was made which carried this intention of avoiding the dichotomy yet further : the establishment of Joint Committees responsible for Child Guidance. I assure you it is not easy to be governed by a Committee which has under its aegis the general hospital, the foot clinic, the Child Guidance Service, and a variety of other departments. But surely it would be much more helpful to try to work towards prevention of this dichotomy on the lines of encouraging co-operation between the various Authorities which are capable of arranging the finance and administering the Service. All I can say, therefore, is that from this meeting some expression of opinion should be given as to what we consider are the essential things we want. Do we want to continue the team work ? Do we stress this question of the need for training in co-operation, at any rate, with Universities ? Do we deplore the possibility of squabbling due to dichotomy of control, through different Authorities setting up opposing Clinics ? Indications of mental ill health on the part of the people controlling the whole matter cannot produce mental health. The Chairman then asked for a show of hands, as follows : Those who are against the idea of going forward on the basis of the present team. (No hands raised.) Those who are against the idea of further training in conjunction with the Universities. (No hands raised.) Those who are against the idea of Joint Committees at all levels. (One.) The Chairman thanked the members for their attendance, saying that next year it was hoped to hold another Conference on the much more happy topic of ” The Child i SOME PERSONAL SECOND THOUGHTS ON THE INTER-CLINIC CONFERENCE
BY ALAN MABERLY, M.B., B.Ch., M.R.C.S., L.R.C.P. The ouststanding impression that remains after the Inter-Clinic Conference is that of the remarkable degree of unanimity of opinion on all issues of ?eal importance, and in particular on the value of jull team work, and on the dangers of any administrative set-up which would split the functions of a team, or of any of its members.
It may not have been realized by all those who ^tended how much encouragement and support ls given by these conferences to those at headquarters of the National Association for Mental Health, in their endeavours to maintain the standards in ^-hild Guidance work.
Group discussion, even in the short time available, )vas singularly successful in presenting and summarthe views of so large a meeting, and it seems Probable that no other method could have indicated ?? clearly the sum total of individual viewpoints. *his, as with most other aspects of the meeting, ^uld have failed in its object had it not been for the ejjiciency of organization by the office staff, and we ah owe a debt of gratitude to those who put in so tfiuch work behind the scenes.
While we would all agree with Professor ^cCalman that our main concern is the problem ?hild, we are not all of us as fortunate as he is, in the justness of his University, to be able to control .he administrative set-up in which he works. ~nless we remain alert, we may find ourselves faced s ki c’rcumstances which make difficult or imposible the implementation of the recommendations relation to the patients we see. It may seem ^trly innocuous when it is suggested that ” General ^ministrative Responsibility ” should lie with the chooi Medical Officer or with the Divisional Rector of Education, but very real difficulties will MUickly arise unless the limitations of this adminisresponsibility, together with the boundaries ‘ clinical direction ” in the hands of the team, *very clearly defined. Only recently, one team ith which I am associated was faced with the eernand that Form 1 H.P. should be completed very time Form 2 H.P. was used to recommend Provision of special education. This was designed 0 ensure that if, when a vacancy arose at a suitable *>01, there should be no delay in over-riding any Ejections the parents might then raise. This was ?twithstanding the relevant clauses in the Educa?n Act prescribing that the form should not be . sed as a routine matter, and ignoring entirely the t. aPPropriate nature of such a regulation in connecon with mal-adjusted children. On the other hand, ls both wise and right that clinicians should be relieved of the responsibility for dealing with window cleaners and gas accounts.
Those of us who have been long in Child Guidance work are familiar with the irritation that the team set-up has caused to many administrators because it has not fallen neatly into any single departmental category. The only new factor that has arisen is that the rivalry between Directors of Education and Medical Officers of Health has now been extended to ministerial level. One hopes that, at this level, integration will prove an easier and more practicable proposition.
In Dr Alexander’s regrettable but unavoidable absence owing to an engagement overseas, his oneman campaign for the introduction of the Scottish form of Child Guidance set-up to England (to which he alludes as the ” British pattern which had its beginnings in the work undertaken at Glasgow under Dr William Boyd “) received perhaps less attention than it deserved. Members of the Conference who are not readers of Education would be well advised to look up the issues of October 28th, 1948, January 14th, 1949 and November 11th, 1949. It will be noted that Dr Alexander makes no reference to the earlier work of Professor Sir Cyril Burt, nor to that of Dr Hamilton Pearson or other pioneers in this country.
We should all heed the warning against overselling our speciality, although at this time the danger might seem to be greater in the field of adult psychiatry in general than in Child Guidance. Furthermore, it is the quality of the salesmanship rather than its quantity which requires attention. We can all of us be modest in our claims, without losing confidence in our methods. We can avoid obscurity of language, but need be none too ready to produce the figures that are often demanded of us, because much of the value of Child Guidance work cannot be assessed in numerical terms at all, any more than can that of the School Health Service, which is predominantly preventive. With the human material with which we deal, it is only rarely possible to produce controlled experiments, and these should be conducted by research workers rather than clinicians. Even if the claim of the Scottish workers that they cure 100 per cent, were true, there is no means of proving that these cases would not have been cured 100 per cent, without any treatment at all. We should not play into the hands of those who regard human personality as capable of being weighed, counted and measured by accepting their premises without question.
Disclaimer
The historical material in this project falls into one of three categories for clearances and permissions:
Material currently under copyright, made available with a Creative Commons license chosen by the publisher.
Material that is in the public domain
Material identified by the Welcome Trust as an Orphan Work, made available with a Creative Commons Attribution-NonCommercial 4.0 International License.
While we are in the process of adding metadata to the articles, please check the article at its original source for specific copyrights.