Three distinctly different blueprints for building and delivering child and adolescent psychiatric services are presented. First is a public health model; second a general hospital model; and third a private medical practise model.
This booklet contains the blueprints of three medical models that can be used as guides for building and delivering child and adolescent psychiatric services. The first is a public health (prevention-oriented) model, second a low-no-cost general hospital (community mental health) model and third a small office private practice model. These three models are mixable, flexible, not cut in stone.
A public health approach needs a small, high-quality core staff to support readily available PHNs and community consultations. Its unique character, as devised by me, entails highly mobile ‘roving casualty teams’ that go out to reach front-line workers wherever children are: in schools, courts, social agencies, hospitals, homes. Prompt response is critical.
My unusual hospital model calls for sometimes happenstance innovation. Like the public health approach, it is also community oriented, but the key to ‘low-to-no-cost’ is recruiting and bringing in ‘donated’ front-line workers as indigenous volunteers for part-time training and ongoing use at the hospital. Such workers concurrently apply their newfound training back out in the field.
In private practice, professionals often bury themselves in moneymaking only to get lost to the wider community. They can also lose out on teaching, research and other pastimes that may make solo work less isolated and more fun. My private practice model shows how to go about incorporating all of the best and still make ends more than meet. Within it one can pick and chose any of many ingredients.
One after the other, in the above sequence – over almost half a century – these distinct types of services were customized for different localities. Together, they encapsulate one bit of Canadian health care history. That in itself may be of value. Having researched, set up, launched and fine-tuned each, I am intimately familiar with the value and shortcomings of each. To pass this information on is the main purpose of this booklet. At a more abstract level, it is also a compendium on how to go about a tough job that has little or no prior ‘job’ description.i
In setting up each of these model services in three different venues – in public health, general hospitals, and in private medical practice – no outside, preconceived blueprint was ever laid on. The specific form within the particular setting was chosen consonant with an on-site evaluation of the particular host and its surrounding community. The phrase ‘consonant with’ means that planning was ongoing. It didn’t take months of deliberation in committee meetings before delivery. A small practical core clinical service was immediately begun and, as the larger effort emerged, new ideas were implemented and fine-tuned. Thus the ‘wrinkles were ironed out as we went along.’ The delivery method peculiar to the site (home base) of each of the three types of models is unique but generally applicable. The starting points were, admittedly, idiosyncratic to my own level of experience at the time.
Completely green out of speciality training, my first ‘solo’ job (1965) was to set up a new children’s mental health service for the city of Hamilton, Ontario – within its Public Health Department. Amazingly, on arrival (after some disputatious dickering) I was given almost cart blanch, but fortunately, I didn’t barge ahead. I couldn’t! For I had to learn things on the job that were totally new to me.
1. Public health, as a home base, presents a huge opportunity while posing a few dilemmas. Core public health principles call for an emphasis on prevention. In 1965 barely anything was known about treating let alone preventing child mental health problems. A cycle of ongoing research fed by evolving services became a first way of finding out. Consultations for front line workers already in the community, or ‘roving casualty clinics’ as they were called by me, did the trick in the original setup. These were on the spot, flexible efforts that had never been heard of before. Today, the whole creative process would be recognized as evidence-based. It ultimately was honoured by professional visitor-observers from the US, Japan and all over the world. Part 1 of this booklet recounts the detailed development of this public health model of service.
An interlude working in paediatrics and teaching child and family psychiatry – and how to deliver it – came next at McMaster University’s Field Unit. The job also entailed helping smooth raspy relations between the new medical school, its hot-shot imported professors and the doctors long established in Hamilton. It was indeed fascinating, but innovative work, creating new-fangled delivery systems, was much more up my alley, so I headed up north to the Soo (1971).
The powers that be in Sault Ste. Marie wanted a standard hospital bed-based department. Beds and more beds. Government was unwilling to comply as money was tight. I had been sent, in conjunction with CMHA and McMaster, to fly up north to convey the bad news – no more expensive beds. In the process, a community mental health program was proposed. Months later, I was asked to implement what had been outlined.
2. The standard hospital approach is oriented toward active clinical treatment and a strict biomedical model of hierarchical doctor-doctor referrals. Child psychiatry long pioneered in evaluating social and psychological factors as well. How might all three perspectives be integrated smoothly? An improvised community register leading to serendipitous innovations sufficed. This truly became a patchwork type of program. Its vicissitudes are detailed in Part 2.
In the Soo my learning began all over again, for a very stark provincial austerity budget came into effect within the very week of my arrival. Innovation of a radical sort was called for. However, having absorbed a few tricks in and around Hamilton, things went much faster if not always smoother. Although set up to enable ongoing clinical research, the Soo experience left little free time to do so. (However, my first article that related to ‘Cracking the Family Code’ was published in the USA at that time.)
Before moving on, I took a year’s interlude to brush up on core medical skills: nighttime emergency calls, delivering babies, doing surgery, looking after heart attacks and the like. This was done through the Algoma Clinic, an early HMO supported by Algoma Steel. Thus reequipped, I headed back south to do private family practice. I settled down in my home town of Fort Erie in the Niagara region.
3. Private general medical and family practice must focus on practical results or go broke. In Canada, introduction of universal Medicare solved that problem, but created many more of its own, as we’ll later see. (As a hint, 25 years before eHealth ON floundered on a billion dollar scandal, I’d coded a free computerized history-taking program (HxFE) for office use.) Much of it is recounted in Part 3.
Oddly, despite much effort on my part, very little I had learned in all my travels could be, or ever was, implemented in Niagara. So, I spent time with my family, playing (skiing and sailing), working as both general medical practitioner and paediatrician and thinking and teaching in Buffalo NY.
The University of Buffalo liked the idea of my experience in public health, community and child psychiatry and especially in general family medicine. Upon ascertaining that there was no Spanish-speaking African-American female with the exact same qualifications (UB did a six month mandated search), I was offered a part-time triple appointment in 1. family medicine (as a preceptor), 2. public health (biostatistics and epidemiology research) and in 3. social psychiatry (project research). (At UB my work on ‘Cracking the Family Code’ continued. Real time TV learning for GP’s was pioneered – a methodology for assessing children and families ‘on the run’ was introduced. An annual symposium on ‘The Family in Health, Disease and Disorder’ was launched at world-renowned Roswell Park Institute and preliminary findings on pragmatic communication were presented at the annual meeting of the American Association for the Advancement of Science in Washington, DC.) The UB job also entailed adult clinical work at ECMC, sorting out failed suicides held overnight in the ICU. It is notable that, for the first time, American family practice residents came over to Canada for experience in small town emergency work under my aegis.
At various points, I also worked at the psychiatric unit in Welland, the Niagara regional holding centre (jail), and as acting medical director of a large schedule ‘A’ mental hospital in Brockville. But never could I get the various Niagara agencies to support development of a high quality service for children and families. (The reason for this latter retrogressive situation was that government supported social agencies had become very proprietary and no longer entertained the idea of significant outside ‘medical’ input.)
To reiterate, in setting up services in three different venues – in public health, general hospitals, and in private medical practice – no outside, preconceived blueprint was ever laid on. The specific form within the particular venue was chosen consonant with an evaluation of the particular host community. It didn’t take months of committee deliberation before delivery. A small practical clinical service was immediately begun and, as the larger, wider effort emerged, new ideas were implemented and fine-tuned. Thus the wrinkles were ironed out as we went along.
As intimated, the big tasks noted above are in the same sequence in which my experience gradually grew. In my peripatetic phase, long stays were creative in nature, building a new service. Those jobs lasted from 3-5 years. I did not become a long term maintenance man. Shorter stays were primarily consultative, creative consultations (which later became the name of a firm), lasting from a few weeks to a year or so. My guiding principles became: watch and listen, zero in and explore wherever the action is, learn from those on the spot, laugh and have fun, innovate, pass on the torch, leave. Another principle was: wherever you go, it is always possible to set things up so as to do ongoing clinical research.
Obviously, the above list of three exclusively ‘medical’ models is not all there is to it. That’s the very exclusive way it once was. Nowadays, children’s mental health services are found in more than just the medical venue. The old tripartite team of doctor, psychologist, and social worker has evaporated, or it seems that way. In Ontario, that change subtly came about when charitable social agencies became tax supported government departments. Nevertheless, despite the dispersal of children’s services between many widely separated agencies and independent disciplines, everything that is recounted in this short historical monograph still has relevance.
It should be pointed out that there are several ways, besides mine, that the nuts and bolts of each of these delivery methods may be set up nowadays.ii But in bad theory only.iii Peculiar semiprofessional or bureaucratic, lay-managed, widely-flung and poorly integrated sub-models, only somewhat related to the various key venues, all too often paradoxically wasteful of money and manpower and ineffective in patient care, will be touched upon in due course.iv v
This small booklet-monograph will be a mixture of hard facts on what and how to develop and do concrete things – along with soft warnings about personal actions and frustrations. It is as much the account of a personal Odyssey and a how-to-do as a guide to what is possible. Knowledge comes but wisdom lingers. In fact, the lessons I learned in a golden era are more crucial than ever. This may be particularly true in the USA as President Obama tries to institute a form of universal medical coverage.
By extracting key pointers from the venues of public health, hospital medicine and private practice, an ideal template for a child and adolescent centre of excellence for teaching and research can be devised. Part 4 of this booklet attempts to do exactly that.
For the rest of this prologue I’ll tell you something about the state of child psychiatry and its teaching since around the middle of the twentieth century, the economic climate that supported it in Canada (and how that all has changed), and how, at any time, despite historical events and changes, one can acquire the tools of the trade when a job description is vague. There often, in fact, is no job description at all.
One thing I discovered very early on is that the recipients of a proposed service have very little, if any, say in what they are about to get, although, after the fact they may praise or complain vociferously, usually to little effect. In child psychiatry, consumer input is absolutely nil. Physically ill and disabled children have their advocates and PR campaigns, but upset families and emotionally disturbed children are the real modern day Cinderellas. Sadly, they are often seen as nuisances at best and troublemakers at worst. And I could find no feasible, democratic, or timely, way to personally elicit viewpoints and gather facts beforehand. So, much – all – is usually left up to the expert to do. The secret is – not to lay it all on with too heavy brush.
The best alternative source of input advice, if it exists, is a social planing council. Another in some cases might be a local academy of medicine. Next, believe it or not, are honest and concerned local politicians – if properly informed. Next, and almost worst, are all the front line semi-pro workers; while well-meaning, they often are blindly self-serving. Last, are the vocal special interest groups. Beware of them! Incumbent public service clinicians are well-advised to hear out the wishes of the foregoing and then proceed with single-minded due diligence. It’s also good sense to be rather cautious of fashionable bandwagons, movements or causes, to whose propaganda clinicians themselves are easily prone.
For example, when I began in Hamilton, I knew little about community-wide services and that turned out to be an advantage. But, by the time I went to the Soo, the ‘community mental health movement’ was in vogue. While noble in intent, it was an ideal that was being primarily pushed to save money and therefore could never achieve its genuine true potential. The initial program in the Soo suffered accordingly.
Bureaucrats, wherever found, can be a boon or a bugaboo. One must learn to rapidly assess them. Some are enlightened enablers, others skilled obstructionists. They all like to be in control. Enough said, for now, on that.
Above all, and however trite this may seem, it is of utmost importance to know ones own assets and limitations. The latter, in terms of what goes on in a community, very often must be learned on the job through trial and error or success. Ones learned knowledge, trained skills and imbued attitudes are three things, however, that every clinician should clearly have in full awareness right at the outset.
Having always liked children, and relating easily with them, I chose paediatric psychiatry as my medical speciality. But I also did so for a more rational reason. Adult psychiatry entails questionably valid retrospective recall of events of childhood. Memory can fail. It may be distorted unwittingly as well as deliberately. It amazes me still that Freud, while emphasizing childhood experience as the core of adult being, himself never saw a child directly. Even his famous case of Little Hans was formulated through the eyes of Hans’ father. Dealing with a child directly, I figured, may avoid the pitfalls of parental distortion of current family events. By observing events unfold over time in front of one’s very eyes the errors of others’ faulty recall are avoided or reduced. This sort of thinking is encapsulated in a general principle that I brought into psychiatry with me: Do not accept secondhand or circumstantial information about long gone or even recent events. If at all possible go to the source and directly dig out the facts.
Child psychiatry, with its focus on psychological and social factors, seemingly is about as far from biological medicine as any medical super-speciality can be. Or so I thought at the time.. I also thought it was a privilege to be able to do my preferred work within the venue of a noble tradition – medicine – so I decided to be practical about it from the outset. I always ran a general medical family practise concurrently. Even during training, I worked evenings in Toronto at the Lockwood Clinic – as a part time GP.
Medicare in Canada in 1965
Medicare barely existed yet. Bare hospital expenses were covered. But, even when in hospital, patients still had to pay their doctors out of their own pockets. (OHIP covering doctors’ fees came to Ontario in the early 1970s.) Social agencies were all supported by charity alone – Red Feather Campaigns and the Community Chest. No such bureaucracy as a Ministry of Social and Family services existed or even was dreamed of in 1965.
The state of the psychiatric Art – all over – by 1965
No social workers and very few psychologists were in private practice. A few psychoanalysts practised in the big cities, but most had at least part time university positions. Almost all the big professorships went to analysts – except in Toronto where psychiatry was a sub-speciality of internal medicine. But, so connected to medicine, it had to hoe the scientific line. (That is why I decided to study and train there.) All of the non-analysts pretty well were employees of the huge, government-run mental hospitals. A few were striking out as lone heads of the new-fangled psychiatric units being established in the larger general hospitals. Whereas adult psychiatry was the lowliest stepdaughter of medicine, child psychiatry was psychiatry’s poor Cinderella. But it had some status among paediatricians at the Hospital For Sick Children. And, interestingly, it seemed to be held in high regard all across the country. That was likely due to sentimental psychological movies from the USA and the fact that there was a mere handful of child psychiatrists in the entire country. Little Cinderella was a rare gem.
Psychoanalysis Freudian style reigned supreme. All other theories took a back seat. Talking treatment on the couch was at its height. To get ahead in the psychiatric teaching field, one had to be personally analyzed. In child psychiatry the gurus were Melany Klein and Anna Freud. It was acknowledged that children spoke through their play, so individual play therapy was about all there was for them. While psychotropic drugs were well on their way in the big adult mental hospitals, they were not used on little kids. But the new genetics and chromosome studies were – in mental retardation. PKU screening of the newborn had started. Bowlby’s concept of maternal deprivation – as directly observed – had caught on in theory, but the social workers still interviewed all mothers without ever actually watching or seeing what they actually did with their children. Fathers were perceived as strictly incidental appendages. The reality of different stages of child development (psycho-sexual a la Freud, psychosocial a la Erickson and psycho-intellectual a la Piaget) was interesting but impractical. All that the few psychologists did was study rat-learning in mazes.
In Toronto the centre of outpatient teaching was in a sleepy little old house. There, the trainees did aimlessly non-directive play therapy while social workers endlessly investigated barren social factors through mothers alone. They never talked with teachers or went to a school. The clinical psychologists did psychometrics by running batteries of IQ tests. They poked into the child’s personality with projective tests modified from adult versions founded on psychoanalysis. 1965 was they heyday of the psychiatric team: a doctor at its head, a social worker or two, a clinical psychologist. That trio, while completely openhearted, was not nearly as happy as the hospital duo of nurse and doctor. The psychologists were forever complaining.
That was about it in Toronto. Except for two inspiring teachers, a very smart and well-trained English child psychiatrist (Harvey Alderton) and a wise sociologist from Chicago (Farrel Toombs), the whole theoretical and training outlook was quite bleak. Regardless, if one wanted to rent a little office, buy a doll-house along with a few toys and spend one’s life indoors as a second rate child analyst, the limited learning setup in Toronto was just perfect. But it was appallingly inadequate for my purposes – except for a couple of low-status affiliated venues.
Fortunately, I fought and got assigned to both of them. First, was the children’s clinic run by Toronto’s Board of Education. Through it, I spent a year running around to every grade school and high school in the city, seeing children, on the hoof, in their real life setting. Second, was Thistletown-Warrendale, the Hospital for Sick Children’s almost forgotten, country-placed annex. It had once been used for physically disabled children with polio and the like, but the Salk vaccine had put it out of business, and it was turned into an institution for ninety of the most disturbed children in Ontario. So, what with two good teachers and a couple of venues for really practical learning, I had a reasonable start in paediatric psychiatry.
But, special people and places beyond Toronto beckoned. I wanted to learn how to do family therapy. Its pioneer, Nathan Ackerman, was in New York City, but one of his students, Nate Epstein, was out, teaching at the Jewish General Hospital connected to McGill. So I jumped on the Go-train every week and headed for Montreal to watch and learn from him. Little did I realize that later he would be my boss at McMaster. Although trained in psychoanalysis, Nate was in the process of unfettering himself, at least slightly. While plodding through Claude Shannon’s mathematical Information Theory, I thought that applied Communication Theory, the science of what actually goes on between people instead of what supposedly happens inside just one person’s head alone, might well be as important in a child’s learning as the welter of intrapsychic theories then extant. But all the new action was out of my direct reach, way off in California. The disparate group at Palo Alto (Ruesch, Bateson, Haley, Jackson) was experimenting on Pragmatic communication in families with mentally disturbed members. Their roving guru, Virginia Satir, became my unknowing teacher when she made swings within range of Toronto. On a trip to explore a possible job at the Children’s Research Institute at Western in London ON, I, by pure chance ran into the great Bruno Bettelheim over on a visit from Chicago. In a private chat he, also quite unknowingly, imparted some hints on how to run a proper children’s service. More about that later.
Anyway, when the time came, I forsook a very certain twenty years of future drudgery and internecine struggle trying to climb the academic ladder at UT and struck out for the tough, lunch-box, steel-city of nearby Hamilton. Although, even in my own mind, no child psychiatric hotshot, I figured I knew enough and had the grounding to start making nonlethal mistakes as a stranger in a strange place.
Summing up: Part 1 will describe the setting up of a community-wide children’s mental health service based in a public health venue. Part 2 describes establishing a similar children’s service (along with an adult OPD), manned by ‘borrowed’ indigenous on the spot personnel, out of a general hospital setting. Part 3 discusses options when doing child psychiatry in private practice.
END of prologue…
iThe irony is that at the outset I had no formal managerial skills. I had to learn these on the spot. My frustrations gave way over the years to a mode of seeing things that I could not immediately figure out, not as obstacles, but as challenges to be overcome. That vague appellation, challenges, eventually evolved into more detailed definitions of all human issues as one or a combination of: 1) Problems to be Solved (PS), 2) Disputes to be Resolved (DR), and 3) Dilemmas to be Decided (DD). This perspective, while seemingly obvious, is unique and not generally known. Most personal trials and tribulations, however important I think they are, will be put in italics or confined to a footnote narrative, except when general principles are involved. In that respect, at a more abstract level, this little book is also a compendium on how to go about a job that has little or no prior job description.
iiAll over, in Canada and the United States, layman-type managers are poking their noses into medical matters. Instead of sticking to balancing budgets or facilitating effective and efficient work places, many are interpreting their job as if they were a land-bound Captain Queeg, martinets steering services. By careless navigating, critical services are curtailed or wrecked outright. I predict that, while entrapped doctors may seem apathetic about or be powerless to stop this trend, the public at large and politicians will not be tolerant much longer. Knowledgeable doctors then will be asked, all over again, to rebuild things and take the helm. This book may help point the way.
iiiNew and separate ministries have tended to fracture the coordination of child and adolescent mental health care. And the influx of lay business-oriented pseudo-psychopathic managers along with layers of bureaucrats mixing themselves into clinical areas are destroying long-established and well-working systems.
ivTwo non-medical pseudo-models merit mention, if only to decry their inherent shortcomings. These are children’s mental services supervised by child welfare agencies (such as children’s aid societies) and the private practises of psychologists and psychiatrists. The first of these ill-situated situations appears to be so irremediable as to call for a complete rethinking. The second could be fixed with a simple change in attitude: Never allow oneself to become a kept consultant! The detailed pros and cons will be discussed in due course.
vSuper-specialized paediatric and child psychiatric facilities serve a crucial need in medical academe (as a compact, convenient means of teaching), but are mainly tertiary resources. Usually, they are not well structured to serve the range of needs of the general population, whether in a city or an outlying small town or rural area. But this common defect can be remedied by applying just a few discoveries made in operations of the three above cited models. These factors will be treated in due course also.