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A study of mental health services provided to mentally retarded adults in a metropolitan area Gordon, Wendy Lorraine 1980

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A STUDY OF .MENTAL HEALTH SERVICES PROVIDED TO MENTALLY RETARDED ADULTS IN A METROPOLITAN AREA by WENDY LORRAINE GORDON .A., The University of B r i t i s h Columbia, 1974 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF ARTS in THE FACULTY OF GRADUATE STUDIES (Faculty of Education, Special Education) We accept t h i s thesis as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA 1980 (c) Wendy Lorraine Gordon, 1980 In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of Brit ish Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the Head of my Department or by his representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. Department of S p e c i a l Education The University of Brit ish Columbia 2 0 7 5 W e s b r o o k P l a c e V a n c o u v e r , C a n a d a V 6 T 1 W 5 Date S e p t e m b e r 1 5 . 1 9 8 0 i i ABSTRACT The main purpose of t h i s study was to obtain information on the provision of mental health services to mentally retarded adults by mental health professionals i n the metropolitan areas of Vancouver and Richmond i n the Province of B r i t i s h Columbia. The four main areas of investigation were: i) the preparation and experience of mental health professionals i n the area of mental retardation; i l ) the provision of mental health services to mentally retarded adults; i i i ) the reactions of mental health professionals and parents towards the provision of mental health services to mentally retarded adults; and iv) the background of mentally retarded adults presently receiving mental health services. Two questionnaires were developed i n order to gather information pertaining to the four main areas of i n v e s t i g a t i o n , one for mental health professionals and one for parents of mentally retarded adults. There was a smaller rate of return than expected, which may be assumed to e f f e c t the g e n e r a l i z a b i l i t y of the results of the survey. Conclusions, however, were drawn and discussed i n r e l a t i o n to e a r l i e r studies. Some of the major findings were: 1. There appears to be a d i r e c t ' r e l a t i o n s h i p between the l e v e l of mental retardation and the value and effectiveness of counselling and/or psychotherapeutic a s s i s t a n c e . 2. There i s an a p p a r e n t l a c k o f i n v o l v e m e n t i n p r o f e s s i o n a l p r e p a r a t i o n and c o n t i n u i n g e d u c a t i o n o p p o r t u n i t i e s by m e n t a l h e a l t h p r o f e s s i o n a l s i n t h e a r e a o f m e n t a l r e t a r d a t i o n and s p e c i f i c a l l y i n t h e a r e a o f the c a r e and t r e a t m e n t o f t h e m e n t a l l y r e t a r d e d a d u l t . 3. Of the m e n t a l h e a l t h p r o f e s s i o n a l s s u r v e y e d , s o c i a l w o r k e rs appeared t o be t h e most i n v o l v e d i n the p r o v i s i o n o f m e n t a l h e a l t h s e r v i c e s t o t h e m e n t a l l y r e t a r d e d a d u l t , and t h i s i n t u r n appeared t o r e f l e c t the t y p e o f m e n t a l h e a l t h s e r v i c e s p r o v i d e d t o t h i s p o p u l a t i o n . 4 . The m a j o r i t y o f m e n t a l h e a l t h p r o f e s s i o n a l s s t a t e d t h a t a g e n e r i c agency c o u l d p r o v i d e c o u n s e l l i n g and/or p s y c h o t h e r a p e u t i c a s s i s t a n c e t o m e n t a l l y r e t a r d e d a d u l t s , however, a s i g n i f i c a n t m a j o r i t y o f p a r e n t s i n d i c a t e d t h a t t h e y would p r e f e r t h e i r son o r d aughter t o go t o a s e p a r a t e s e r v i c e f o r t h e m e n t a l l y r e t a r d e d . S u g g e s t i o n s f o r f u r t h e r r e s e a r c h i n c l u d e d : 1. e x a m i n i n g f u r t h e r the n a t u r e o f "mental h e a l t h " problems c a u s i n g t h e m e n t a l l y r e t a r d e d a d u l t t o be p l a c e d i n t o an i n s t i t u t i o n ; 2. e x a m i n i n g f u r t h e r t h e i n v o l v e m e n t o f v o c a t i o n a l , r e s i d e n t i a l , r e c r e a t i o n a l , and " o t h e r " c o u n s e l l i n g p e r s o n n e l i n t h e p r o v i s i o n o f c o u n s e l l i n g and/or p s y c h o t h e r a p e u t i c a s s i s t a n c e t o m e n t a l l y r e t a r d e d a d u l t s i v r e s e a r c h i n g the need o f parents of m e n t a l l y r e t a r d e d a d u l t s , f o r p a r e n t a l and/or f a m i l y c o u n s e l l i n g or therapy; and e v a l u a t i n g the use o f g e n e r i c s e r v i c e s f o r the p r o v i s i o n of mental h e a l t h s e r v i c e s to m e n t a l l y r e t a r d e d a d u l t s and t h e i r f a m i l i e s . y TABLE OF CONTENTS ABSTRACT i i LIST OF TABLES v i i ACKNOWLEDGEMENTS x i CHAPTER I - THE PROBLEM 2 INTRODUCTION 2 STATEMENT OF THE PROBLEM 7 SIGNIFICANCE OF THE PROBLEM 8 DEFINITIONS 1 6 CHAPTER I I - REVIEW OF THE LITERATURE 22 PART I THE CARE AND TREATMENT OF EMOTIONALLY DISTURBED MENTALLY RETARDED PERSONS 22 HISTORICAL REVIEW OF THE RELATIONSHIP BETWEEN EMOTIONAL DISTURBANCE AND MENTAL RETARDATION 23 PRESENT DAY UNDERSTANDING OF THE RELATIONSHIP BETWEEN EMOTIONAL DISTURBANCE AND MENTAL RETARDATION 29 PREVALENCE OF EMOTIONAL DISTURBANCE IN MENTALLY RETARDED PERSONS 35 THERAPEUTIC INTERVENTION WITH THE EMOTIONALLY DISTURBED MENTALLY RETARDED 39 PART I I PROVISION OF MENTAL HEALTH SERVICES TO MENTALLY RETARDED ADULTS 50 VARIABLES EFFECTING THE PROVISION OF MENTAL HEALTH SERVICES TO MENTALLY RETARDED ADULTS 50 PROVISION OF MENTAL HEALTH SERVICES TO THE MENTALLY RETARDED OUTSIDE OF BRITISH COLUMBIA 6 0 PROVISION OF MENTAL HEALTH AND MENTAL RETARDATION : - !, SERVICES WITHIN BRITISH COLUMBIA 75 CHAPTER I I I - METHODOLOGY 81 INTRODUCTION 81 POPULATIONS 81 MENTAL HEALTH PROFESSIONALS 81 PARENTS OF MENTALLY RETARDED ADULTS 82 DEVELOPMENT OF THE QUESTIONNAIRE 83 THE PROFESSIONAL QUESTIONNAIRE 83 THE PARENT QUESTIONNAIRE 85 v i PILOT STUDY 8 6 PROCEDURE 8 8 METHOD OF DATA ANALYSIS 8 9 LIMITATIONS OF THE STUDY • 92 POPULATION' 9 2 INSTRUMENT 9 3 CHAPTER IV - RESULTS 96 RESPONSE TO THE MENTAL HEALTH PROFESSIONAL QUESTIONNAIRE 96 RESPONSE TO QUESTIONNAIRE BY PARENTS OF MENTALLY RETARDED ADULTS- 152 CHAPTER V - INTERPRETATION AND DISCUSSION OF RESULTS 169 QUESTIONNAIRE RETURNS 170 PROFESSIONAL PREPARATION AND EXPERIENCE OF MENTAL HEALTH PROFESSIONALS IN MENTAL RETARDATION 173 PROVISION OF MENTAL HEALTH SERVICES TO MENTALLY RETARDED ADULTS 184 BACKGROUND INFORMATION ON MENTALLY RETARDED ADULTS CURRENTLY RECEIVING MENTAL HEALTH SERVICES 191 MENTAL HEALTH SERVICES CURRENTLY BEING PROVIDED TO MENTALLY RETARDED ADULTS 194 OPINIONS OF THE DELIVERY OF MENTAL HEALTH SERVICES TO MENTALLY RETARDED ADULTS •• 214 CHAPTER VI - SUMMARY, CONCLUSIONS, AND SUGGESTIONS FOR FURTHER RESEARCH . 223 SUMMARY OF STUDY 223 CONCLUSIONS 227 SUGGESTIONS FOR FURTHER RESEARCH 239 REFERENCE NOTES 242 REFERENCES . 243 APPENDICES APPENDIX A - PROFESSIONAL QUESTIONNAIRE 249 APPENDIX B - PARENT QUESTIONNAIRE 265 APPENDIX C - LETTER FROM MINISTRY OF HUMAN RESOURCES ... 273 i v i i LIST OF TABLES Table 1 Educational C l a s s i f i c a t i o n of Mental Retardation Compared to the A.A.M.D. C l a s s i f i c a t i o n System 17 Table 2 Therapy Choice Model Developed by Rosen, Clark, and K i v i t z 48 Table 3 Number of Respondents to the Mental Health Professional Questionnaire 9 8 Table 4 ' Place of Professional Practice of Respondents 100 Table 5 Number of Years of Experience Professionals Have Had Working With the Mentally Retarded 103 Table 6 Number of Professionals Who Have Taken Courses i n Mental Retardation During Their Professional Preparation 106 Table 7 Number of Professionals Who Have Had Fieldwork Placements With the Mentally Retarded . . 109 Table 8 Respondents' Ratings of Their Preparation i n Mental Retardation 112 Table 9 Recommendations of Professionals for Preparation i n Mental Retardation 114 Table 10 Respondents' Rating of Their Further Education i n Mental Retardation 117 Table 11 Future P a r t i c i p a t i o n i n Further Education i n Mental Retardation 119 Table 12 Number of Professionals Who Had Mentally Retarded Adults on Their Caseloads 119 Table 13 Factors Which Prevent Professionals From Providing Services to Mentally Retarded Adults 121 Table 14 Resources Mentally Retarded Adults Would be Referred to for Mental Health Services 123 Table 15 Number of Mentally Retarded Adults Currently Receiving Service 124 v i i i Table 16 Source of Referral of Mentally Retarded Clie n t s 126 Table 17 Mental Health Services Provided to Mentally Retarded Adults 128 Table 18 Number of Mentally Retarded Adults Who Had Received Counselling and/or Psychotherapeutic Counselling i n the Following Selected Problem Areas 131 Table 19 Respondents' Ratings of Their Use of Theoretical Approaches i n Counselling and/or Psychotherapy with Mentally Retarded Adults 134 Table 20 Respondents' Ratings of Their Use of Methodological Approaches i n Counselling and/or Psychotherapeutic Approaches with Mentally Retarded Adults and/or Their Parents 137 Table 21 Respondents' Ratings of the Effectiveness of Counselling and/or Psychotherapeutic Assistance with Mentally Retarded Adults in Selected Problem Areas 139 Table 22 Average Number of Sessions Respondents Had With Their Mentally Retarded Clients 140 Table 23 Age Range of Mentally Retarded Adult Clients 142 Table 24 Number of Male and Female Mentally Retarded Adult Clients 142 Table 25 Liv i n g Situation of Mentally Retarded Adult Clients 143 Table 26 Daytime A c t i v i t y of Mentally Retarded Adult Clients 144 Table 2 7 Respondents' Opinion of Their Agency's Provision of Mental Health Services to Mentally Retarded Adults 145 Table 28 Respondents' Opinion of the Provision of Mental Health Services to Mentally Retarded Adults by other Community-based Agencies 147 Table 29 Responsibility for the Provision of Mental Health Services to Mentally Retarded Adults by Location of i x Professional Practice of Respondents 149 Table 30 Responsibility for the Provision of Mental Health Services by Professional Group 149 Table 31 Respondents' Opinion of the Use of Generic Vs. Specialized Agency for the Delivery of Mental Health Services to Mentally Retarded Adults 151 Table 32 Number of Respondents to the Parents of Mentally Retarded Adults Questionnaire 152 Table 33 Age, Sex, and Level of Mental Retardation 153 Table 34 Living Situation of Mentally Retarded Adults 154 Table 35 Daytime A c t i v i t y of Mentally Retarded Adults 155 Table 36 Number of Mentally Retarded Adults Who Have Received Services and Mean Rating of that Service 157 Table 37 Number of Mentally Retarded Adults Who Have Received Mental Health Services and Mean Rating of the Services 159 Table 38 Number of Mentally Retarded Adults Who Have Received Counselling and/or Psychotherapeutic Assistance i n a Specific Problem Area 161 Table 39 Source of Referral of Mentally Retarded Adults 163 Table 40 Amount of Service Provided to Mentally Retarded Adult 164 Table 41 Location of Mental Health Service 165 Table 42 Number of Mentally Retarded Adults i n Need of Service 167 Table 4 3 Preferred Source of Counselling and/or Psychotherapeutic Assistance 168 Table 44 A Sample of Comments Regarding Recommenda-tions for Professional Preparation i n Mental Retardation 179 X Table 45 Level of Mental Retardation as Reported By Mental Health Professionals and.by Parents 192 Table 4 6 The Type and Frequency of Mental Health Service Provided to Mentally Retarded Adults as Reported by Professionals and Parents 198 Table 47. Most Common Problem Areas for Which Mentally Retarded Adults have Received Counselling and/or Psychotherapeutic Assistance 205 Table 4 8 Comments of Professionals as to Why They F e l t I t was Not Their Responsibility to Provide Mental Health Services to Mentally Retarded Adults 217 Table 49 Mental Health Professionals' and Parents' Response to Generic Vs. Specialized Services 221 x i ACKNOWLEDGEMENTS The author would l i k e to express her sincere gratitude to her advisor, Dr. Stanley Perkins, for his attentive super-v i s i o n , i n t e r e s t , and assistance throughout the study. Appreciation i s also extended to Dr. Harold R a t z l a f f , Dr. S a l l y Rogow, and Robert Poutt for t h e i r valuable assistance and d i r e c t i o n . The author would also l i k e to extend appreciation to Mr. Doug Denholm, Executive Director of the Vancouver-Richmond Association for the Mentally Retarded; Mr. Arthur Brown, Executive Director of the Northshore Association for the Mentally Handicapped; and Mr. Hugh M i l l e r , Executive Director of the B.C. Association of Social Workers, for t h e i r kind support i n making available to me the membership l i s t s of t h e i r respective associations. Appreciation i s also extended to Ms. Hil a r y Bookham, for her expertise and advice i n typing and proofing t h i s t h e s i s . Gratitude i s also afforded to the Canadian Mental Health Association - B.C. Di v i s i o n , for t h e i r generous f i n a n c i a l support of t h i s study. 1 "There w i l l always be concerns with the mentally retarded getting services when other people are not, and the feeli n g of many that the money should be used towards the greatest good for the greatest number. This dilemma w i l l never be solved short of solving a l l the problems of society. On the way to this utopia, getting a f a i r share of help and tre a t -ing people with mental handicaps as human beings w i l l require major advances not just i n science and technology, but also i n human re l a t i o n s . Robert I. (1975) Jaslow, M.D. 2 Chapter I THE PROBLEM Introduction The trend today i n the provision of services for the mentally retarded i s the development of community-based services that w i l l enable the mentally retarded to remain i n th e i r homes as well as to f a c i l i t a t e the return to the community of those mentally retarded individuals l i v i n g i n i n s t i t u t i o n s (Jaslow, 1975; Rosen, Clark & K i v i t z , 1977; Scheerenberger, 1976; MacCoy, Note 1 & 2). This trend i n provision of services for the mentally retarded r e f l e c t s the influence, over the past decade, of the pr i n c i p l e s of d e i n s t i t u t i o n a l i z a t i o n and normalization. While d e i n s t i t u t i o n a l i z a t i o n pertains to the right of the in d i v i d u a l to receive services and treatment i n the least r e s t r i c t i v e environment (Scheerenberger, 1976, p..,127) , normalization i s the " u t i l i z a t i o n of means which are as c u l t u r a l l y normative as possible i n order to establish or maintain personal behaviours and char a c t e r i s t i c s which are as c u l t u r a l l y normative as possible" (Wolfensberger, 1972, p.28). Both these p r i n c i p l e s r e f l e c t a concern for the legal and human r i g h t s , as well as for the personal dignity of mentally retarded people. D e i n s t i t u t i o n a l i z a t i o n depends upon each community being able to provide the array of services required by the mentally retarded throughout t h e i r t o t a l l i f e span (Scheerenberger, 19 76, chap. 5). Such services must be offered along a continuum of 3 care, from the specialized services of a special program for the mentally retarded to the services offered by generic agencies. D e i n s t i t u t i o n a l i z a t i o n places great emphasis on freedom, independence, i n d i v i d u a l i t y , mobility, personalized l i f e experiences, and a high degree of interaction within one's own community (Scheerenberger, 1976, p. 125) . To make these p r i n c i p l e s a r e a l i t y for the mentally retarded and to successfully maintain the mentally retarded i n d i v i d u a l i n the community, a comprehensive continuum of generic and specialized services i s es s e n t i a l . As the move away from the closed and isolat e d society of the i n s t i t u t i o n and the special school takes place, we are becoming more aware of the psychological discomfort which so often accompanies i n t e l l e c t u a l d e f i c i t i n a competitive, achievement-oriented society (Robinson & Robinson, 19 76, p.39 2; Simmons, 1968). The mentally retarded are vulnerable to f a i l u r e i n adaptation to the s o c i a l environment, not only because of t h e i r c o n s t i t u t i o n a l endowment but also because of th e i r interpersonal experiences (Philips & Williams, 1975). How well one adapts to the s o c i a l milieu i s the c r i t e r i o n used by society to determine one's place i n society. Emotional and behavioural problems often prevent the successful adjustment of the mentally retarded i n d i v i d u a l i n the community. C r i t e r i o n for successful adjustment of the mentally retarded i n the community i s usually l i m i t e d to s p e c i f i c adaptive behaviour s k i l l s , i . e . , steady employment, money management s k i l l s , law abiding behaviour, a b i l i t y to get along with 4 neighbours and co-workers. But Rosen et a l . (1977, p.,. 118) report that i n t h e i r follow-up work of mentally retarded persons discharged from in s t i t u t i o n s , t h e y found many individuals who, although judged to be successfully employed, l i v i n g i n suitable accommodation, and not i n c o n f l i c t with the law, were found to be s o c i a l l y withdrawn, lonely, frustrated economically, and generally unhappy. Persons can appear to be vocationally and s o c i a l l y successful but at the same time be experiencing severe emotional stress. This i s a common consideration made when judging the o v e r a l l adjustment of an i n t e l l e c t u a l l y normal person,, but often overlooked when evaluating the adjustment of individuals who are considered to be mentally retarded. More attention must be given to the emotional health and personal adjustment of the mentally retarded as we continue to provide them with t r a i n i n g i n adaptive behaviour s k i l l s for l i v i n g i n the community. A better understanding of emotional d i f f i c u l t i e s and s p e c i f i c stress situations experienced by the mentally retarded i s needed so that programs and services may be better planned to f a c i l i t a t e the successful adjustment of the mentally retarded (Philips & Williams, 1975; Rosen et a l . , 1977, p. 123) . It i s no longer a question of whether or not the mentally retarded can benefit from psychological treatment or psycho-therapeutic intervention (Bialer, 1967, p. 171; Rosen et a l . , 1977, p. 301) . Numerous investigations have indicated that benefits have accrued to mentally retarded individuals i n terms of posit i v e behavioural and personality changes by the use of planned psychological procedures ( i . e . , verbal and non-verbal 5 techniques, i n d i v i d u a l and group approaches, and behaviour modification techniques) by professionally trained therapists (Balthazar & Stevens, 1975, chap. 6; B i a l e r , 1967; L o t t , 1971; Moody, 1972; Rosen et a l . , 1977, chap. 18; Singh, 1972; Tarjan, 1977). Rosen et a l . (1977), as did B i a l e r i n 1967, posed the more relevant question: Rather than ask whether the mentally retarded are suitable for psychotherapy one might better ask whether any s p e c i f i c form of therapy or counselling i s suitable for the p a r t i c u l a r i n d i v i d u a l , s p e c i f i c problem, and unique setting to which the treatment i s to be applied (p. 301). A good deal of work i s s t i l l required to examine the variables which contribute to the success and f a i l u r e of psychotherapeutic approaches with the mentally retarded. Potter, i n 1965, c a l l e d for the "re-awakening" of modern psychiatry i n the provision of f u l l p sychiatric care to the mentally retarded and t h e i r f a m i l i e s . I t i s the r e s p o n s i b i l i t y of i n d i v i d u a l p s y c h i a t r i s t s to acquire a substantive professional sophistication about mental retardation and to make t h e i r s k i l l s available to the mentally retarded and t h e i r families (1965, p. 547). Authors today continue to examine the role of the mental health professional i n the provision of services to the mentally retarded (Gunzburg, 1974, IX; Hume, 1972; Rutter, 1975; Tarjan, 1977; Wortis, 1977). There appears to be a consensus among these writers that the mental health professionals do have a role to play i n the provision of services to the mentally retarded, but that the care, treatment, and management of the mentally retarded must 6 involve a host of d i s c i p l i n e s , including psychiatry,and a number of medical s p e c i a l t i e s , psychology, special education, s o c i a l work, r e h a b i l i t a t i o n , and nursing (Jaslow, 19 75; Rosen et a l . , 1977, chap. 18; Tarjan & Keeran, 1974, p. 6; Wortis, 1977). Psychotherapeutic treatment must be an i n t e g r a l part of any community adjustment, vocational preparation, or l i f e - s k i l l s t r a i n i n g program for the mentally retarded. In i s o l a t i o n from these programs, psychotherapeutic assistance would have no l a s t i n g e f f e c t . On the other hand, the emotionally disturbed mentally retarded individual's chance of benefiting from any educational, s o c i a l , or vocational program w i l l be greatly enhanced i f also provided with appropriate psychotherapeutic assistance (Potter, 1965; Rosen et a l . , 1977, chap. 18). Strategies are being developed to provide comprehensive, community-based programs and services for the mentally retarded (Balthazar & Stevens, 19 75; Robinson & Robinson, 19 76, chap. 22; Rosen et a l . , 1977; Scheerenberger, 1976; MacCoy, Note 3 & 4). In so doing, attempts are being made i n d i f f e r e n t communities to i d e n t i f y e x i s t i n g community resources that are best able to provide the appropriate and necessary services to the mentally retarded (Burton, 19 71; Scheerenberger, 19 70; Delparte & Narvey, Note 1; MacCoy, Note 3 & 4; Sparc, Note 5). In addition to looking at the e x i s t i n g specialized services for the mentally retarded, one must investigate the a c c e s s i b i l i t y and u s a b i l i t y of generic services for the mentally retarded and t h e i r f a m i l i e s . 7 Statement of the Problem The main purpose of t h i s study has been to obtain informa-t i o n on the provision of mental health services to mentally retarded adults by mental health professionals i n the metropoli-tan areas of Vancouver and Richmond i n the Province of B r i t i s h Columbia. The study provides a descriptive analysis of selected.variables involved i n the provision of mental health services to mentally retarded adults. The descriptive analysis centres around four main areas of investigation: i) the preparation and experience of mental health professionals i n the area of mental retardation, i i ) the provision of mental health services to mentally retarded adults, i i i ) the reactions of mental health professionals and parents towards the provision of mental health services to mentally retarded adults, iv) the background of mentally retarded adults currently receiving mental health services. I t i s anticipated that the results of this study w i l l provide agencies and professionals i n the f i e l d s of mental health and mental retardation with a description of a) the mental health services currently being provided to mentally retarded adults and t h e i r f a m i l i e s , b) the population receiving the services, and c) the population d e l i v e r i n g the services. I t i s hoped that t h i s information w i l l a s s i s t i n evaluating the a b i l i t y of the e x i s t i n g mental health services to meet the 8 mental health needs of the mentally retarded adult l i v i n g i n Vancouver and Richmond. Significance of the Problem A review of the l i t e r a t u r e indicates that there e x i s t a number of concerns surrounding the care and treatment of the mentally retarded i n d i v i d u a l who has emotional and behavioural problems. In addition, there are several concerns regarding the delivery of mental health services to t h i s population. The following are some of the major issues which have given r i s e to the present,study. •' The f i r s t major concern i d e n t i f i e d by P h i l i p s (1971, p. 44), i s the misconception that many people have about the relationship between emotional and behavioural disorders and mental retardation. P h i l i p s has found that i t i s commonly thought that the problem behaviour of the mentally retarded i s a function of his or her retardation rather than h i s or her interpersonal relationships. P h i l i p s states that: The co n s t i t u t i o n a l endowment of any c h i l d i s not the only factor determining his a b i l i t y to learn and develop. The c h i l d may have ultimate l i m i t a t i o n s on h i s capacity to develop, but his l i f e experiences also may interfere with the f u l l e s t development of his innate potential (1971, p. 44) . P h i l i p s (1966, p. 113) argued e a r l i e r that the organic defect r e s u l t i n g from inj u r y , metabolic abnormality, congenital anomaly, i n f e c t i o n , and so forth may l i m i t the l e v e l of functioning,;, but that i t i s not the only factor determining the individual's a b i l i t y to learn and to develop. Emotional 9 disorder developing from l i f e experiences of emotional deprivation, f r u s t r a t i o n , separation, traumatic experiences, etc., may also i n h i b i t or d i s t o r t an individual's a b i l i t y to grow and develop. The c h i l d , then, who i s retarded because of organic defect may also evidence emotional disorder that interferes with his maximal development. We recognize that although deficiency or disease may be a major con-t r i b u t i n g stress, the child's emotional disorder probably i s not an organically inevitable concomitant of hi s defect, but i s , rather, a function of the same kinds of processes that give r i s e to emotional disorder i n children who have no definable "disease" ( P h i l i p s , 1966, p. 113) . Freeman (1971, p. 14) also expressed the view that much of the emotional and behavioural d i f f i c u l t i e s i n the mentally retarded are the re s u l t of l i f e experiences (e.g., repeated f r u s t r a t i o n , lack of successful experiences) rather than being inherent i n the handicap i t s e l f . Freeman had pointed out e a r l i e r that undoubtedly multiple factors are operative i n producing psychological disturbance i n a handicapped c h i l d . "Environmental factors can be assumed to be of at least as much importance i n the genesis of emotional disturbances of the handicapped as that of the non-handicapped" (1967, p. 282). A second concern described by P h i l i p s (1971, p. 45) is. the misconception that emotional and behavioural problems of the mentally retarded are of a di f f e r e n t nature than those of the non-retarded population. Several authors have found that the emotional and behavioural problems encountered within the mentally retarded population may vary as widely as those problems encoun-tered i n the i n t e l l e c t u a l l y normal population (Beier, 19 6:4;. P h i l i p s & Williams, 1975; Rosen et a l . , 1977, p. 336). Although the 10 l i m i t e d i n t e l l e c t u a l capacities of the mentally retarded person may be a major contributing factor to the emotional or behavioural problems expressed, these problems are probably not an organically inevitable r e s u l t of the retardation but rather a function of the same kind of processes that give r i s e to emotional and behavioural disorders i n i n t e l l e c t u a l l y normal individuals ( P h i l i p s , 19 71, p. 45). Cytryn and Lourie (19 72) add that: This handicap fZmental retardation^. • • i f not handled properly, may produce a great v u l n e r a b i l i t y to emotional disturbance, which may lead i n turn to any of the whole range of adjustment problems, including behavioural, neurotic, psychotic, character and habit disorders (p. 178). A t h i r d concern i s that, i n addition to the evidence that any major or minor emotional or behavioural disturbances can and do occur i n association with mental retardation, there appears to be a higher incidence of emotional and behavioural disturbances among the mentally retarded than i s found i n the general population (Beier, 1964; pp. 478-479; Rutter, 1975, p. 347). What the actual rate i s and the s p e c i f i c reasons for the higher incidence of emotional disturbance i n the mentally retarded are yet unknown. Beier (p. 4 79) suggested though, that the mentally retarded i n d i v i d u a l , because of his deficiences and inadequacies, i s probably subject to "more fr u s t r a t i o n s , c o n f l i c t s , and pressures" than an i n d i v i d u a l of normal i n t e l l i g e n c e . Potter (1965, p. 544) also described- the mildly mentally retarded i n d i v i d u a l as having a poor s e l f image as well as an "unfavourable competi-t i v e position" i n the world, and thus are especially prone 11 to anxiety. Eighty-five percent of the mentally retarded are mildly retarded, and of th i s percentage, a large but unknown number are poorly adjusted, with emotional problems contributing s i g n i f i c a n t l y to t h e i r a b i l i t y to learn and adapt (Potter, 1965, p. 544). A fourth major concern regarding the emotional develop-ment of the mentally retarded i s the ef f e c t of the family and home l i f e on the i n t e l l e c t u a l and emotional development of the mentally retarded c h i l d l i v i n g at home. Professionals recognize that due to the change i n emphasis from i n s t i t u -t i o n a l to community care of the mentally retarded i n d i v i d u a l , attention must be focussed on the family and the home environ-ment (Gath, 1975). Freeman (1971, p. 12) stressed that "the relationship of the c h i l d to the parents i s absolutely c r u c i a l to his s o c i a l , emotional and perhaps i n t e l l e c t u a l and physical development." Early intervention and support for the parents of newborn handicapped infants i s a high p r i o r i t y today i n many parts of the world. Of equal importance, but as of yet not a p r i o r i t y , i s the need for family support and counselling as the handi-capped c h i l d develops into adolescence and adulthood (Mowatt, 1971). New problems and new concerns arise within the home environment and within family relationships as the c h i l d grows up (Kirman, 1975, p. 54 8). More assistance i n terms of family counselling and education must be made available to help the family adjust to the maturing needs of the i r mentally handicapped son or daughter (Mowatt, 19 71/ p. 159; Wolfensberger, 1967). Rosen et a l . , 1977, presented a f i f t h major concern for professionals working i n habilitation"'' programs for the mentally retarded. Rosen et a l . asked that we go "beyond normalization" and t r a i n i n g i n adaptive behaviour s k i l l s i n the programs we provide to mentally retarded individuals for preparation for l i v i n g i n the community (1977, p. 25). The authors agreed that adaptive behaviour s k i l l s ( i . e . , the a b i l i t y to maintain oneself independently and to meet s o c i e t a l demands for s o c i a l and personal r e s p o n s i b i l i t y ) are indisputedly important c r i t e r i a of functioning for successful adjustment to community l i v i n g . However, they argued strongly that adaptive behaviour s k i l l s , e.g., the a b i l i t y to balance a budget, to shop and prepare meals, to maintain steady employment, and to pa r t i c i p a t e i n appropriate l e i s u r e a c t i v i t i e s , are only minimal c r i t e r i a for adult l i f e i n the community. These adaptive behaviours are performance c r i t e r i a and, when measured for the purpose of evaluating an individual's adjustment to the community, the many personality, motivational, and emotional variables that may determine a person's adaptive and maladaptive behaviour are not taken into account (1977, p. 25). Rosen et a l . went on to warn that "the acceptance of adaptive behaviours as the sole c r i t e r i a of adjustment of the ^ Rosen et al.(1977) define " h a b i l i t a t i o n " as the teach-ing of new s k i l l s rather than the restoring of s k i l l s l o s t by i l l n e s s or injury as i n r e h a b i l i t a t i o n . They fe e l the term h a b i l i t a t i o n better describes programs for the mentally retarded (see introductory note i n H a b i l i t a t i o n of the Handicapped). 13 mentally handicapped could be more detrimental than acceptance of the IQ alone as a c r i t e r i o n " (1977, p. 26). The authors f e l t that i n the enthusiasm for the development of powerful new t r a i n i n g techniques and strategies i n our h a b i l i t a t i o n programs, we may have l o s t sight of basic constructs of emotional health and personal adjustment commonly accepted for i n t e l l e c t u a l l y normal populations (1977, p. 118). The authors recognized "thaf'to include c r i t e r i a of emotional adjustment and quality of l i f e dimensions within the evaluation process for the mentally retarded would be an ambitious undertaking" (1977, p. 26). Measurement of these subjective variables i n the mentally retarded, who c h a r a c t e r i s t i c a l l y have problems with communication and introspective thought, would be- d i f f i c u l t . Rosen et a l . , however, f e l t that i n working with the mentally retarded, psychologists can no longer afford to ignore the following basic dimensions as: self-concept, independence, and r e s p o n s i b i l i t y for one's own behaviour, an accurate perception of r e a l i t y , a b i l i t y to f e e l and express a f f e c t appropriately, s a t i s f a c t i o n with job, a b i l i t y to maintain s a t i s f y i n g interpersonal relationships, and the c a p a b i l i t y for appropriate heterosexual relationships (19 77, p. 26) . A sixth major concern i n the provision of mental health services to the mentally retarded, i s the lack of involvement of mental health professionals, e.g., p s y c h i a t r i s t s , psycholo-g i s t s , and s o c i a l workers, i n the care and treatment of the mentally retarded. Several authors have i d e n t i f i e d reasons for t h i s apparent lack of interest on the part of mental health professionals i n the f i e l d of mental retardation (Potter, 1964, 1965; Savino et a l . , 1973; Tarjan, 1977; Tarjan & Keeran, 1974). 14 These reasons w i l l be reviewed i n a l a t e r section, but one of the major issues i d e n t i f i e d i s the lack of appropriate t r a i n i n g programs for mental health professionals i n the f i e l d of mental retardation (Ash, 19 74; Menolascino & Dutch, 196 7; Potter, 1964; Tarjan, 1977). Ash (1974) recognized that, although many facets of mental retardation are of more d i r e c t interest to other d i s c i p l i n e s , e.g., education, vocational r e h a b i l i t a t i o n , and s o c i a l work, the psychiatric aspects of mental retardation have suffered greatly from a lack of interest on the part of inadequately trained p s y c h i a t r i s t s for work with the mentally retarded. He f e l t that t h i s has resulted i n a large proportion of the mentally retarded receiving less than adequate care and that opportunities for c l i n c i a l research have largely been ignored (1974, p. 55). From a h i s t o r i c a l viewpoint, Tarjan (1977, p. 401) expressed a s i m i l a r opinion that "as r e l a t i v e l y fewer ps y c h i a t r i s t s continued to have t h e i r primary i n t e r e s t i n mental retardation, the quality and quantity of psychiatric care of mentally retarded individuals diminished." The l a s t major concern i s the role of psychotherapeutic assistance and counselling i n h a b i l i t a t i o n programs for the mentally retarded (Potter, 1964, 1965; Rosen et a l . , 1977). Rosen et a l . (1977, p. 302) adopted the view o r i g i n a l l y stated by Gunzburg i n 1958, that "the goal of psychotherapy, l i k e a l l phases of h a b i l i t a t i o n treatment, i s to enable the i n d i v i d u a l to deal better with problems of l i v i n g and working i n the community." With t h i s goal i n mind, i t follows that psychotherapy 15 or counselling ; can only be seen as a treatment that has the same basic objectives of any other part of an h a b i l i t a t i o n program and thus must be considered as an in t e g r a l component of the h a b i l i t a t i o n e f f o r t (Rosen et a l . , 1977, p. 303). Psychotherapy or counselling alone though w i l l not ensure the successful adjustment of the mentally retarded i n the community. Psychotherapeutic assistance must be integrated into a comprehensive range of community-based services that w i l l meet the educational, vocational, r e s i d e n t i a l , s o c i a l , medical, and recreational needs of the mentally retarded population. I t has been stressed by several professionals i n the f i e l d , however, that the a v a i l a b i l i t y of appropriate psychotherapeutic and counselling assistance w i l l greatly enhance the emotionally disturbed, mentally retarded individual's chances of benefiting from any community adjustment, vocational preparation, or l i f e - s k i l l s t r a i n i n g program (Potter, 1964, 1965; Rosen et a l . , 1977, chap. 18). Emotional stress and beha^-viou r a l disturbance i n h i b i t the growth and development of any i n d i v i d u a l . The prevention and early treatment of such disturbances should be a primary consideration i n any program or service for mentally retarded persons (Tarjan, 1977, p. 403). I t i s w e l l recognized that the disturbing, maladaptive behaviour of an emotionally disturbed mentally retarded i n d i -v idual i s the major reason today for the i n s t i t u t i o n a l i z a t i o n of a mentally retarded person (Beier, 1967, p. 457; Cytryn and Lourier, 1972, p. 178). Not only w i l l the provision of appropriate mental health services to the mentally retarded 16 enhance t h e i r chances for successful adjustment to the t community, i t w i l l prevent the unnecessary i n s t i t u t i o n a l i z a -t i o n of many mentally retarded persons. The above discussion, which has emphasized the need for community-based mental health care for the mentally retarded, has not intended to imply that each mentally retarded person and his or her family are i n need of psychotherapeutic ass i s -tance. As Tarjan (1977, p. 401) wrote, "many mentally retarded individuals are well adjusted most of the time, and have higher p r i o r i t y needs than mental health care." In e f f e c t i v e l y meeting the educational, vocational, medical, s o c i a l , and recreational needs of the mentally retarded, the need for d i r e c t mental health care w i l l be greatly reduced. Definitions Mental Retardation. For the purpose of t h i s study, the following d e f i n i t i o n of the American Association on Mental Deficiency (A.A.M.D.) i s used: Mental Retardation refers to s i g n i f i c a n t l y subaverage general i n t e l l e c t u a l functioning e x i s t i n g concurrently with d e f i c i t s i n adaptive behavior, and manifested during the developmental period (Grossman, 1973, p. 11). The d e f i n i t i o n requires that general i n t e l l e c t u a l func-tioning be assessed by an ind i v i d u a l standardized test of in t e l l i g e n c e , e.g., Wechsler Scales, Stanford-Binet Intelligence Scale, and that the measured IQ must be two or more standard deviations from the mean of the test ( i . e . , Wechsler IQ 69, S.B. IQ 68). At the same time, the ind i v i d u a l must demonstrate 17 d e f i c i t s i n adaptive behaviour. Adaptive behaviour i s defined i n the A.A.M.D. Manual as "the effectiveness of degree with which the i n d i v i d u a l meets the standards of personal independence and s o c i a l r e s p o n s i b i l i t y expected of his age and c u l t u r a l group" (Grossman, 197 3, p. 11). These concurrent d e f i c i t s i n i n t e l l e c t u a l functioning and adaptive behaviour must appear before the i n d i v i d u a l reaches 18 years of age. This serves to distinguish mental retardation from other adult disorders of human behaviour. For the purpose of th i s study, an educational c l a s s i f i -cation system i s used to distinguish between the d i f f e r e n t levels of retardation (Robinson & Robinson, 1976, p. 371). This educational c l a s s i f i c a t i o n system d i f f e r s from the A.A.M.D. c l a s s i f i c a t i o n system as i l l u s t r a t e d i n Table 1. Table 1 Educational C l a s s i f i c a t i o n of Mental Retardation Compared to the A.A.M.D. C l a s s i f i c a t i o n System Educational A.A.M.D. C l a s s i f i c a t i o n C l a s s i f i c a t i o n Descriptive Term IQ Levels IQ Levels (Wechsler) Mild Retardation 50 - 75 55 - 69 Moderate Retardation 3 0 - 4 9 40 - 54 Severe Retardation Under 29 25 - 39 Profound Retardation Under 25 This educational c l a s s i f i c a t i o n scheme w i l l include individuals with a Wechsler IQ score of 70-75 which represents 18 the lower portion of the A.A.M.D. borderline i n t e l l i g e n c e category (individuals with a Weschler IQ score of 70 or above are not considered by the A.A.M.D. to be mentally retarded). According to the educational c l a s s i f i c a t i o n adopted for t h i s study, these borderline i n t e l l i g e n c e individuals would f a l l into the older educational category referred to as the Educable Mentally Retarded (IQ 50-75) and would more than l i k e l y have received t h e i r education i n a special class for E.M.R. students. I t was of i n t erest to the researcher to examine the type of mental health services graduates of special education classes may be receiving, and for t h i s reason they were included i n the study. The Mentally Retarded Adult. In the province of B r i t i s h Columbia, the age of majority (or f u l l l egal age) i s 19. An i n d i v i d u a l at 19 years of age i n B.C. i s e l i g i b l e to vote i n pro v i n c i a l elections, marry without parental consent, and purchase alcohol. For the purpose of t h i s study, a mentally retarded adult i s an in d i v i d u a l who i s considered to be functioning at a retarded l e v e l according to the d e f i n i t i o n given above and i s 19 years of age or over. Emotional Disturbance and Behaviour Disorder. The terms emotional disturbance and behaviour disorder w i l l be used i n this study to refer to the psychiatric or mental health problems of the mentally retarded. The d i f f i c u l t i e s i n a r r i v i n g at a unitary d e f i n i t i o n of emotional disturbance, behaviour disorder, and psychiatric disorder have been w e l l documented i n the 19 l i t e r a t u r e (for references see B i a l e r , 1970; Rutter et a l . , 1970). Upon examining the-definitions of these terms put forth by Beier (1964, p. 454), Bi a l e r (1970, p. 609), and Rutter et a l . (1970, p. 165), there appeared to be some common features. In the d e f i n i t i o n s put forth by these authors, there was an emphasis on the observable behavioural reaction to whatever psycho-l o g i c a l discomfort the in d i v i d u a l was experiencing, and i t was t h i s abnormal behaviour, which had a disturbing e f f e c t on the person's family or community, which most often became the reason for r e f e r r a l for therapeutic intervention. B i a l e r (1970, p. 609) used the term emotional disturbance to refer to: any emotional deviation--from f a i r l y severe tension states, to frank psychotic reactions—which makes i t d i f f i c u l t for the retardate to meet or adjust to the demands of society or to achieve an e f f e c t i v e relationship with his environment. In Beier's (1964, p. 454) description of behavioural d i s -turbance, i t was again the individual's a b i l i t y (or i n a b i l i t y ) to deal with emotional stress i n a s o c i a l l y acceptable manner that determined the degree of behaviour disturbance. Beier described the behaviourally disturbed as: persons whose effectiveness and e f f i c i e n c y are so impaired that they have varying degrees of d i f f i c u l t y dealing with emotional or stress si t u a t i o n s , and they display varying degrees of p e c u l i a r i t y i n adaptive behavior (1964, p. 454). Rutter et a l . (1970, p._165) took a c l i n i c a l - d i a g n o s t i c approach to defining psychiatric disorder i n children. He used a developmental assessment as opposed to a s t a t i c description, to determine psychiatric disorder i n a c h i l d . The child's function was assessed i n r e l a t i o n to what was normal 20 for his age and in r e l a t i o n to the process of psychic develop-ment. This developmental approach to determining p s y c h i a t r i c disorder appears relevant for the assessment of emotional and behavioural problems i n mentally retarded in d i v i d u a l s , whether they be a c h i l d or an adult. For the purpose of t h i s study, Rutter et a l . ' s description of the presence of p s y c h i a t r i c disorder i s used to,refer to the presence of emotional disturbance or behavioural disorder i n the mentally retarded adult. Rutter et a l . (1970, p. 165) stated: psychiatric disorder Cisll judged to be present when there C i s I ] an abnormality of behavior, emotions or relationships which CisD s u f f i c i e n t l y marked and s u f f i c i e n t l y prolonged to cause handicap to the c h i l d himself and/or distress or disturbance i n the family or community, and which CcontinuesI] up to the time of assessment. Rutter went on to explain that for p s y c h i a t r i c disorder to be considered present, the disorder had to be abnormal i n the broader context of the individual's development; i t had to be persistent and be a handicap which involved either the family, community, or the in d i v i d u a l himself. Mental Health Services. For the purpose, of t h i s study, the following description of Mental Health Services has been adapted from Hume (1972, pp. 21-22) and Robinson and Robinson (1976, p. 392). Mental Health Services include: 1) Diagnostic assessment with a p s y c h i a t r i c , psycho-l o g i c a l , or s o c i a l emphasis; 2) C r i s i s intervention; 2 1 3) Counselling or psychotherapeutic assistance characterized by a regular series of interchanges between a professionally trained person, i . e . , a therapist and one or more patients or c l i e n t s , which can occur i n a variety of settings such as an o f f i c e , a home, a playroom, a workroom, and may include the use of a variety of therapeutic approaches such as verbal and/or non-verbal communication, behaviour modification techniques, with the goal being to a l l e v i a t e emotional d i s t r e s s , decrease s o c i a l l y maladaptive behaviour, and strengthen adjustive behaviour patterns; 4 ) Drug therapy; 5 ) Parents and/or family counselling or therapy; 6) Follow-up assistance to p a t i e n t s / c l i e n t s ; 7) Consultation with s i g n i f i c a n t others i n the patient's/ c l i e n t ' s l i f e , e.g., teacher, group home supervisor; 8) Referral for additional service, e.g., educational, vocational, recreational, when i n combination with any of the above services. 22 Chapter I I REVIEW OF THE LITERATURE Part I The Care and Treatment of Emotionally  Disturbed Mentally Retarded Persons The purpose of t h i s section i s to review the l i t e r a t u r e on emotional disturbances and behavioural disorders i n mentally retarded persons. This section begins with a h i s t o r i c a l account of the relationship between mental retardation and emotional disturbance and then reviews the l i t e r a t u r e that discusses the present day understanding of the relationship between these two conditions, the prevalence of emotional disturbance found i n the mentally retarded, and methods and techniques of therapeutic intervention appropriate for use with mentally retarded adults. I t should also be noted here that although the author's main area of int e r e s t i s with the emotionally disturbed mentally retarded adult, much of the l i t e r a t u r e reviewed w i l l be of studies involving children. To r e s t r i c t the review only to l i t e r a t u r e dealing with the adult mentally retarded popula-ti o n would be too l i m i t i n g . Emphasis though w i l l remain on l i t e r a t u r e concerning the adult mentally retarded. H i s t o r i c a l Review of the Relationship Between Emotional Disturbance and Mental Retardation^ Beier (1964, p. 454) reports that i n the primitive understanding of psychopathology, mental retardation , and behavioural disturbances were considered a single disorder. The equating of these disorders, Beier points out, was due to the many observable s i m i l a r i t i e s between psychotic behavioural reactions and the behaviour of the more severely and profoundly retarded. Gradually, though, psychotic behaviour did become d i f f e r e n t i a t e d from mental retardation. In 1672, S i r Thomas W i l l i s recognized mental retardation as a condition separate from other forms of mental disorders and provided t h i s early description: Stupidity (whose pathology we here c h i e f l y deliver) hath many degrees; for some are accounted u n f i t or incapable as to a l l things, and others as to some things only. Some being wholly fools i n the learning of l e t t e r s , or the l i b e r a l sciences, are yet able enough for mechanical a r t s . Others of either of these incapable, yet e a s i l y comprehend agriculture, or husbandry and country business. Others u n f i t almost for a l l a f f a i r s , are only able to learn what belongs to eating or the common means of l i v i n g . Others merely dolts or d r i v e l i n g fools, scarce understand anything at a l l , or do anything knowingly (1683, chap. X I I I ) . Withstanding the language of the day, W i l l i s had recognized degrees of retardation which bear a remarkable resemblance to the present day categories of mild, moderate, severe and For more complete reviews on the history of the care and treatment of the mentally retarded, the reader i s referred to Kanner, • 19'6.7.; Menolascino, 1970, 1971; Rosen, Clark, & K i v i t z , 1976, 1977, chap. 1; Wolfens-berger, 1969. 2 4 profound retardation. Once mental deficiency was d i f f e r e n t i a t e d from mental disorders, descriptions of t h e i r co-existence were i n i t i a t e d (Balthazar & Stevens, 1975, p. 16). During the period of Itard (1774-1838) and Seguin (1812-1880), attention was given to the emotional reactions of the mentally retarded, with the l a t t e r noting some cases of "idiocy" complicated by psychoses (Beier, 1964, p. 454). Itard (1801), i n his monograph, Du L'Education d'un Homme Savage, appeared "to recognize the significance of motivation, needs,and transference i n his therapeutic work with V i c t o r , the so-called Wild Boy of Avegnon" (Potter, 1965, p. 539). Although Itard's work i s most often recognized as the beginning of special education for the retarded (Robinson & Robinson, 1975, p. 365) his monograph i s described by Potter as the f i r s t published report on dynamic psycho-therapy. Potter (p. 539) explained that much of Itard's e f f o r t s with Victor were directed towards ego development and the strengthening of ego controls through the use of i d e n t i f i c a t i o n . Seguin, who followed i n Itard's footsteps as a founder of education for the mentally retarded (Balthazar & Stevens, 1975, p. 21), i s also described by Potter (1965, p. 540) as having employed dynamic p r i n c i p l e s of psychotherapy i n his work with the retarded. Beier reported that Seguin, who recognized cases of psychoses i n " i d i o t children," c l a s s i f i e d the dominant psychotic reaction patterns found i n the mentally 25 retarded as being "of the over-reactive, aggressive, acting-out variety and withdrawn, under-reactive type" (1964, p. 454). In 1860, Griesinger of B e r l i n , introduced the concept of psychogenic causology i n mental retardation. In the second e d i t i o n of his textbook Mental Pathology and Thera- peutics, he described cases of mental deficiency "where the mental development remains stationary from want of any external impulse - from extreme neglect and inattention -association with other elements, and unfavorable outward rel a t i o n s , etc...." (Potter,. 1964, p. 358). Griesinger recognized the e f f e c t of the s o c i a l , emotional, and physical environment on an individual's development and functioning. In 18 76, the 7American Association on Mental Deficiency was founded with a l l of i t s eight charter members being p s y c h i a t r i s t s . The Association was dedicated to the proposi-tion that through the application of psychotherapeutic p r i n c i p l e s and dynamically-oriented education, " i d i o t i c and imbecile" children could substantially improve (Potter, 1965, p. 540). Unfortunately t h i s met with opposition in the years that followed. Before the end of the nineteenth century, another trend had developed. Bourneville (1893) and his co-workers seemingly had established that most of idiocy was a r e s u l t of some form of brain pathology or was associated with neurological disease. This conceptualization, s t i l l i n evidence today i n the 26 postulation of the defect theories (Robinson & Robinson, 1976, pp. 169-171), implies a d i s t i n c t l i m i t a t i o n on the learning and adaptive a b i l i t y of the retarded person, which because of damaged i n t e r n a l mechanisms, i s seen as beyond the scope of therapeutic intervention (Menolascino, 1970, p. 713). I t i s i n t e r e s t i n g to note at t h i s point, that Bourneville 1s case studies did not include any individuals who are referred to today as mildly mentally retarded, for the simple reason that mild mental retardation had not been generally recognized (Potter, 1964, p. 354). At the end of the nineteenth century, the studies of Bourneville and his co-workers had become widely known and accepted. The r e a l i t y of brain pathology i n idiocy had a sobering e f f e c t upon the optimism and enthusiasm for "educating the minds of i d i o t s , " and i n only a few years, custodial care for the moderately and severely retarded had p r a c t i c a l l y replaced a l l remedial e f f o r t s i n t h e i r behalf (Menolascino, 1970, p. 713). As the twentieth century approached, concomitant changes i n s o c i e t a l views of the retarded and developments i n education and psychiatry ( i . e . , i n t e l l i g e n c e testing and psychoanalysis) swung the emphasis of the e a r l i e r remedial approaches of the late nineteenth century from the treatment of the retarded to protecting society from "the deviant" (Menolascino, 1970, p. 714). The Binet Scale for te s t i n g i n t e l l i g e n c e , introduced to America i n 1908, had a resounding impact on the care and treatment of the mentally retarded that i s s t i l l being f e l t today (Menolascino, 1970; Potter, 1965). The Binet Scale and 27 i t s subsequent modifications became accepted as the c r u c i a l diagnostic modality for mental deficiency and came to be used as the one and only guide for educational programs; as well as prognosis for s o c i a l and vocational effectiveness (Balthazar & Stephens, 1975, p. 22; Potter, 1965, p. 541). I t was by the administration of the i n t e l l i g e n c e test to an increasing number of school children that the "moron" or mildly retarded i n d i v i d u a l was f i r s t i d e n t i f i e d (Potter, 1964, p. 355). This i d e n t i f i c a t i o n of a large number of individuals of having "below normal i n t e l l i g e n c e " and who were also recognized as "s o c i a l misfits'/" created a great deal of concern. As Potter (1965, p. 541) pointed out, "the fact that i t was mostly the 'social m i s f i t s ' that came under scrutiny Coften due to t h e i r contact with the criminal j u s t i c e system and i t s subsequent institutions^] was overlooked and the conclusion was drawn that a l l morons were s o c i a l problems or p o t e n t i a l l y so." During t h i s period of "crude data-gathering" and "census-taking, " hypothesis were developed which led to the "alarmist studies" t y p i f i e d by the surveys of Dugdale i n 1900, Davenport and Danielson i n 1912, and Goddard i n 1912 (Beier, 1963, p. 454) . These and s i m i l a r studies resulted i n views of mental retardation as a stream of malevolency from which flowed delinquency, pauperism and disharmony, as the source of problems and burdens i n every phase of human existence (Beier, 1964, p. 454). Potter (1965, p. 542) reported that by 1920 and for a decade or more l a t e r , i t was believed that most of the "s o c i a l ineffectiveness and maladjustment of the moron" was a d i r e c t r e s u l t of his i n t e l l e c t u a l d e f i c i t s , and when emotional problems 28 were found i n these mildly retarded i n d i v i d u a l s , these were also believed to be "additional manifestations of his co n s t i t u t i o n a l i n f e r i o r i t y . " As Potter pointed out, "such a hopeless concept of mental deficiency l e f t no room for therapeutic optimism." The sounding of the "eugenic alarm" and the b e l i e f s and attitudes that resulted from the genealogical studies of Dugdal Davenport, and Goddard cumulated i n the i n t e n s i f i c a t i o n of preventive control through segregation of the mentally retarded i n i n s t i t u t i o n s and the use of s t e r i l i z a t i o n techniques (Beier, 1964, p. 455; Potter, 1965, p. 541). Menolascino reported that from the early 20th century u n t i l 1960, the " i n s t i t u t i o n a l l e i f m o t i f " became "protect society from the deviant" and even larger i n s t i t u t i o n s were b u i l t to house the dangerous retardate" (1970, p. 716). The education and tr a i n i n g p r i n c i p l e s of Itard and Seguin were generally forgotte Rather than prepare the mentally retarded to adjust to and l i v e i n society, e f f o r t s were directed towards preventing "at a l l costs, t h e i r contamination of the race" (Rosen et a l . , 1977, p. 8). . Rosen et a l . reported-thatthe return to h a b i l i t a t i o n philosophy did not occur rapidly, and that the period between 1920 and 1960 was one of contradictory developments. In many quarters there was a reawakening of the o r i g i n a l h a b i l i t a t i o n and education p r i n c i p l e s , a re-affirmation that retarded persons could be trained, some s u f f i c i e n t l y to permit t h e i r func-tioning within a community setting. Yet the large i n s t i t u t i o n s continued t h e i r domination as the treatment of choice for many retarded i n d i v i d u a l s , 29 and i n many instances, conditions within these i n s t i -tutions were d i r e c t l y a n t i t h e t i c a l to the idea of h a b i l i t a t i o n (1977, p. 8). Evidence today suggests that these early e f f o r t s of i n s t i t u t i o n a l i z a t i o n contributed further to deficiencies i n personality and behaviour of the mentally retarded (Balthazar & Stevens, 1975, p. 27). The effects of i n s t i t u t i o n a l i z a t i o n on the personality development and behaviour of the mentally retarded are being revealed today i n more recent studies of mental retardation and personality development (Balthazar & Stevens, 1975; Rosen et a l . , 1977, chap. 7; M i t t l e r , 1977, V. I ) . Present Day Understanding of the Relationship Between Emotional  Disturbance and Mental Retardation Emotional and behavioural disturbances and mental retarda-t i o n have been h i s t o r i c a l l y considered either as d i s t i n c t e n t i t i e s or as co-existent and inseparable (Balthazar & Stevens, 1975, p. 54). In 1964, Benton provided the follow-ing summary of the various interpretations that had developed over the years regarding the nature of the association between neurotic, psychotic, or psychopathic behaviour, and mental retardation: 1. The association between emotional disturbance and mental retardation has been interpreted as being of a coincidental nature, I.e., as r e f l e c t i n g the occurrence of two independent pathologic processes i n the same i n d i v i d u a l . 2. The association has been interpreted as the expres-sion of a single basic process, e.g., brain disease leading both to i n t e l l e c t u a l subnormality and to defective emotional control, the l a t t e r i n turn giving r i s e to a n t i s o c i a l , neurotic, or psychotic behavior. 30 3. The psychopathological t r a i t s have been interpreted as resul t s of the primary i n t e l l e c t u a l d e f i c i t and as representing the reactions of the defective i n d i v i d u a l to adverse or s t r e s s f u l circumstances. 4. The i n t e l l e c t u a l d e f i c i t has been interpreted as a r e s u l t of the primary psychopathologic process and as representing a p a r t i c u l a r form that the neurotic or psychotic reactions may take (p. 28). Over the years, each of these interpretations has had i t s proponents. However, each one of these diverse points of view carries s p e c i f i c implications for management and treatment (Benton, 1964, p. 28). The f i r s t and t h i r d interpretations put forth by Benton are the hypotheses most widely accepted today. The second interpretation Benton gives was strongly supported i n the early 1900's. As described e a r l i e r , emotional problems i n the mentally retarded were considered to be a concomitant result of the individual's "constitutional i n f e r i o r i t y , " and would lead to " s o c i a l ineffectiveness, delinquency, degeneracy, pauperism, etc." (Beier, 1964; Potter, 1965) . The accepted mode of treatment for the mentally retarded became segregation and i n s t i t u t i o n a l i z a t i o n . The fourth interpretation ( i . e . , that a proportion of cases diagnosed as mentally retarded are, i n essence, psychotic or severely neurotic) received a l o t of attention i n the f i r s t half of the 20th century (Benton, 1964, p. 28). Discussions concerning the diagnostic d i s t i n c t i o n between emotional disturbance and mental retardation have centered around the concept of "pseudoretardation" and the issues pertaining to " d i f f e r e n t i a l diagnosis." The concept of pseudoretardation has been used as a diagnostic 31 term to refer to "so-called psychogenetic retardation" (retarda-t i o n associated with physical, environmental deprivation, and/or emotional disturbances). B i a l e r described how the concept of pseudoretardation i n a prognostic and e t i o l o g i c a l framework has perpetuated the older views of genetic or physiological "capacity" or "potential" and of " i n c u r a b i l i t y " as ess e n t i a l defining c h a r a c t e r i s t i c s of mental retardation (1970, p.-614). The concept of pseudoretardation also r e f l e c t s the notion that "true" or " r e a l " mental retardation can be e t i o l o g i c a l l y based only on the existence of neuropathic d e f i c i t (p. 615). The currently accepted A.A.M.D. d e f i n i t i o n of mental retarda-t i o n makes no reference to the cause of retardation or i t s i n c u r a b i l i t y (Grossman, 1973). Mental retardation i s defined s o l e l y on the l e v e l of i n t e l l e c t u a l and social/adaptive behaviour the i n d i v i d u a l currently displays. The A.A.M.D. d e f i n i t i o n , by making no mention of permanence, makes i t quite acceptable for an i n d i v i d u a l to be considered mentally retarded at one point i n time and not mentally retarded at another (Ingalls, 1978, p. 58) . In addition, there i s no reference i n the A.A.M.D. d e f i n i t i o n to the cause of the d e f i c i t the i n d i v i d u a l may show i n i n t e l l e c t u a l and s o c i a l behaviours. Emotional disturbance or c u l t u r a l depri-vation or other adverse circumstances are known to r e s u l t i n mental retardation j u s t as can brain damage (Ingalls, 1978, p. 59; Robinson & Robinson, 1976, Part II) . I f the defect states represent a "true r e f l e c t i o n of the individual's functional a b i l i t y at the time they are diagnosed, why apply to them the l a b e l "pseudoretardation?" 32 Why not include them within a broad c l a s s i f i c a t i o n schema as cases of mental retardation with s p e c i f i c e t i o l o g i c a l components.... The A.A.M.D. c l a s s i f i c a t i o n system, i n doing so, apparently renders the term "pseudoretardation" completely meaningless as a diagnostic construct. The interests of a l l concerned thus would seem to be served best by discarding the concept altogether (Bialer, 1970, p. 615). However, as B i a l e r went on to point out, eliminating the concept of pseudoretardation does not solve the problems of serving those individuals considered to be mentally retarded due to psychogenetic causes. "When we face the necessity of moving from c l a s s i f i c a t i o n to action, the question of d i f f e r e n t i a l diagnosis comes to the fore" (1970, p. 615). B i a l e r described the issue of d i f f e r e n t i a l diagnosis as the attempt to i s o l a t e and i d e n t i f y a l l relevant variables involved when an i n d i v i d u a l i s i d e n t i f i e d as functioning at a retarded l e v e l so as to determine the most ef f e c t i v e treatment plan to a s s i s t the i n d i v i d u a l (1970, p. 615). Si m p l i f i e d , the questions that arise are: Is the apparent mental retardation due to severely l i m i t i n g emotional problems? or; Is the mental retardation due to some other cause, with the emotional problems merely associated with the retardation? The most v a l i d reason for asking these questions i s to acquire answers that w i l l lead to e f f e c t i v e programming (Bialer, 1970, p. 615). B i a l e r suggested that, assuming one can make a d i s t i n c t d i f f e r e n t i a l diagnosis between the c h i l d whose severe emotional disorder has s i g n i f i c a n t l y depressed his behaviour e f f i c i e n c y , as opposed to the mentally retarded c h i l d who demon-strates a severe emotional problem, two important consequences ensue. The decision w i l l determine the type of treatment 33 provided to the c h i l d and the type of f a c i l i t y to which the c h i l d i s referred for treatment. For example, i f the diagnosis suggests that the c h i l d i s functioning at a retarded l e v e l due _ to severe emotional d i s t r e s s , appropriate psychotherapeutic assistance may w e l l r e l i e v e the emotional disorder, with a con-comitant improvement i n the child's i n t e l l e c t u a l a b i l i t y . Secondly, the type of treatment f a c i l i t y to which the c h i l d i s referred has often been the main reason given for the necessity of d i f f e r e n t i a l diagnosis (Bialer, 1970, p. 617). This stems from a reaction to services that appear to vary i n quantity and quality depending on the l a b e l assigned to a c h i l d . B i a l e r c i t e d the example that children who may need psychiatric treatment are often relegated to i n s t i t u t i o n s for the mentally retarded, which usually lack the necessary psychotherapeutic resources (1970, p. 617). This i s equally inappropriate and unacceptable for the c h i l d who i s mentally retarded with emotional problems as i t would be for the emotionally disturbed c h i l d who i s functioning at a retarded l e v e l . B i a l e r pointed out that i t i s extremely d i f f i c u l t ( i f not impossible) to make such d i s t i n c t i o n s as stated above, and urged that we "direct our diagnostic energies towards a determination of the multiple-affected child's major strength, i . e . , which of his d i s a b i l i t i e s lends i t s e l f most to treatment (or i s l e a s t d e b i l i t a t i n g ) , or to a delineation of the c h i l d ' s most urgent needs with a view toward assigning that c h i l d to the most feasible and/or appropriate treatment program" (1970, p. 618). Robinson and Robinson (1976) also concurred on t h i s point. 34 Given the current state of our knowledge and the evidence- of the intimate relationship between mental retardation and emotional disorder, the diagnostic goal i n most cases should be not whether emotional d i s t u r -bance of mental retardation i s "primary" but rather to determine the depth and nature both of the child's emotional troubles and of his i n t e l l e c t u a l d e f i c i t (1976, p. 206). Robinson and Robinson distinguished between the deviant behavioural patterns of primarily the mildly retarded i n d i v i d u a l as they struggle to cope with t h e i r i n t e l l e c t u a l d e f i c i t , as compared with "the more severely c r i p p l i n g and intractable emotional conditions, e.g., childhood and adult psychoses, which are exhibited by a small minority of individuals at a l l levels of mental retardation (1976, chaps. 9 & 10). The authors suggested that although there may be some forms of malfunction of the central nervous system which r e s u l t more or less d i r e c t l y i n deviant behavioural patterns, for the vast majority of mildly retarded individuals there i s no evidence of any such d i r e c t r e l a t i o n s h i p . They stated that the behavioural disturbances found i n the mildly mentally retarded are much more related to aspects of personality, motivation, and self-perception. Rosen et a l . (1977, p. 335) also recognized that the personality and emotional problems of a large number of mentally retarded adults may be secondary to i n t e l l e c t u a l d e f i c i t s and be a consequence of "hi s t o r i e s of over-sheltering, f a i l u r e , r e j e c t i o n , l a b e l i n g , and exclusion from experiences available to the ordinary c i t i z e n . " Robinson and Robinson, however, stressed the role of organic factors i n the more severe emotional disturbances found i n a much smaller number of mentally retarded individuals (1976, p. 210). The severe emotional disturbances i n mentally retarded individuals 35 can range from short-lived, episodic reactions which emerge only under unusual stress, to long-term, continuous, bizarre and i n -tractable psychotic behaviours (1976, p. 1976). These severely disturbed, handicapped people continue to present the greatest challenge when i t comes to diagnosis and treatment. Rosen et a l . (1977, p. 336) pointed out that "with greater acceptance of d e i n s t i t u t i o n a l i z a t i o n and normalization p r i n c i p l e s , the need to deal with more severe behavioural problems becomes increasingly s a l i e n t . " The authors went on to discuss methods of treatment of the more severely disturbed problem c l i e n t that would enable that c l i e n t to remain i n and benefit from community-based h a b i l i t a t i o n programs. Prevalence of Emotional Disturbance Found i n Mentally Retarded  Persons A high incidence of emotional disorder i n the mentally retarded has been reported and discussed by many authors (Balthazar & Stevens., 1975, pp. 7-9; Beier, 1964; B i a l e r , 1970, p. 627; P h i l i p s , 1975; Robinson & Robinson, 1976, p. 197; Rutter, 1975; St e r n l i c h t & Deutsch, 1972, p. 87, Webster, 1970). Balthazar and Stevens reported i n t-heir review of the l i t e r a t u r e that "emotional disturbances of one sort or another occur between 10 and 44 percent of those who indicate high r i s k cases" (1975, p. 8). Robinson and Robinson (1976, p. 197) reported a range from 100 percent (see Webster, 1970) to lower than 25 percent. Balthazar and Stevens, however, pointed out that a number of d i f f i c u l t i e s arise when one compares d i f f e r e n t sets of s t a t i s t i c s . Consideration of the population sampled, when rates of occurrence 36 are being compared^ i s extremely important. Not only w i l l the environment i n which the subjects l i v e have an ef f e c t on the rate of emotional disturbance, so w i l l the age of the subjects and t h e i r degree of mental retardation. D i f f e r i n g amounts - of 1 environmental stress may w e l l account for the varying degrees of emotional disturbance or behavioural disorders found i n groups of mentally retarded i n d i v i d u a l s . An often reported study, even today, i s one by Duvan i n 194 8 (Balthazar & Stevens, 1975, p. 7; Robinson & Robinson, 1976, p. 184) which revealed that 47 percent of Canadian Army r e c r u i t s who were retarded, were considered to be emotionally unstable by psychiatric examination as opposed to 20 percent i n the non-retarded group. Balthazar and Stevens suggested that the mentally retarded r e c r u i t s examined were "subject to rather intense m i l i t a r y d i s c i p l i n e that provided some mental d i f f i c u l t i e s with which a normal person might cope" (1975, p. 9). The authors reported however, Heber's suggestion that the mentally retarded army r e c r u i t s were ac t u a l l y a more representative sample of the mentally retarded population because they were not i n s t i t u t i o n a l i z e d . Studies done with i n s t i t u t i o n a l i z e d subjects suggest a higher prevalence of.personality disorders among the population of i n s t i t u t i o n a l i z e d mentally retarded than found i n a community-based population (Heber, 1964, p. 145; S t e r n l i c h t & Deutsch, 1972, p. 87). This i s not surprising since i t has also been frequently reported that one of the most common reasons for r e f e r r a l of a mentally retarded i n d i v i d u a l to an i n s t i t u t i o n i s the presence of disturbed behaviour (Ballinger & Reid, 1977; Beier, 1964, p. 479; 37 Heber, 1964, p. 145; Miron, 1972, p. 101). Differences i n age and l e v e l of retardation of the subjects being examined for psychiatric disorders w i l l also be responsible for fluctuations i n data obtained i n studies using d i f f e r e n t populations. Webster (1970) described examinations of 159 children for application to a pre-school program for mentally retarded children. Only s i x c u l t u r a l - f a m i l i a l mentally retarded children (retardation generally due to psycho-social factors) were found i n the group. Webster reported that he was unable to fin d a c h i l d who was "simply retarded" with no emotional disorders (1970, p. 17), and i n a l l the children studied (100%), there was indicated some degree of emotional disturbance. Robinson and Robinson (1976, p. 197) however, pointed out that pre-school children i d e n t i f i e d as mentally retarded, constituted a biased sample. Typically, children with organic causes of mental retardation are diagnosed much e a r l i e r and would be more highly represented i n a pre-school population than children whose mental retardation i s due to environmental/psycho-social factors r e s u l t i n g generally i n a milder degree of retardation and often not i d e n t i f i e d u n t i l the c h i l d enters school. Diagnostic c r i t e r i a to establish the presence of the conditions of mental retardation and behavioural or emotional disturbance w i l l also have a major e f f e c t on the v a l i d i t y of generalizations regarding prevalence made from one group of men-t a l l y retarded individuals to another (Ballinger & Reid, 1977, p. 526; Blathazar & Stevens, 1975, p. 9). As reported by P h i l i p s and Williams (1975, p. 1267), accurate diagnosis according to category 38 i s d i f f i c u l t to obtain i n children and i s even more complicated when there i s the presence of mental retardation. Pilkington (1972) reviewed the various studies of the pre-valence of psychiatric i l l n e s s i n the mentally subnormal and commented on the lack of precision and standardized assessment necessary for comparative studies. B a l l i n g e r et a l . (1975) con-ducted a study to determine the v a l i d i t y of a standardized interview schedule for use with mentally retarded patients to determine the presence of psychiatric disorder. Based upon the results of t h e i r study, they f e l t i t appeared possible to use a standardized interview c a l l e d C l i n i c a l Interview Schedule (Goldberg et a l . , 1970), to make an i d e n t i f i c a t i o n of psychiatric symptoms and i l l n e s s i n the mentally handicapped (1975, p. 543). Subsequently, B a l l i n g e r and Reid (1977) conducted a study using a " s l i g h t l y " modified version of the C l i n i c a l Interview Schedule to ascertain and compare the prevalence of psychiatric disorder among mentally retarded adults i n two situations - a r e s i d e n t i a l h o s p i t a l and a community-based t r a i n i n g centre. The researchers reported findings of the presence of mild, moderate, and severe psychiatric disorder i n 13 percent of the community t r a i n i n g centre group, as compared to 31 percent i n the ho s p i t a l residents. These findings support the e a r l i e r reports of a higher frequency of psychiatric problems found i n i n s t i t u t i o n a l i z e d mentally retarded individuals as compared to individuals l i v i n g i n the community. These results are also more useful for t h i s present study, i n that they were obtained on samples from the adult population. 3 9 "The knowledge i s certain that there i s a r e l a t i v e l y high pre-disposition for emotional disturbance among the mentally retarded. The character and frequency of stress situations, however, as well as the problems incurred by d e f i n i t i o n , make i t d i f f i c u l t to determine the degree of involvement with exactitude" (Balthazar & Stevens, 1 9 7 5 , p. 9 ) . Robinson and Robinson concluded that precise figures were probably not important. "The point i s that p s y c h i a t r i c disturbance i s , for several reasons, a frequent con-comitant of mental retardation" ( 1 9 7 6 , p. 1 9 8 ) . Therapeutic Intervention with the Emotionally Disturbed Mentally  Retarded No single d e f i n i t i o n of psychotherapy would be agreed upon by a l l therapists or p r a c t i t i o n e r s , however, for the purpose of t h i s section, the following description of psychotherapy by Robinson and Robinson w i l l be adopted: IT Psychotherapy i s characterized byZ3 a more-or-less regular series of interchanges between a professionally trained resource person, the therapist, and one or more patients or c l i e n t s who come to him because of t h e i r problems i n l i v i n g . . . and i t may occur i n an o f f i c e or i n a play setting, may involve one in d i v i d u a l or several i n a group, may be sought at the i n s t i g a t i o n of the retarded c l i e n t or of someone else, and may include verbal and/or non verbal means of communication, manipulation of the reinforcement con-tingencies (behavior modification), and other means of behavior change ( 1 9 7 6 , p. 3 9 2 ) . Psychotherapy does not include any kind of physical treatment, e.g., psychopharmacology, speech therapy, etc., although these can be associated with psychotherapy (Balthazar & Stevens, 1 9 7 5 , p. 8 6 ) . Teaching or guidance procedures are not usually included under the term psychotherapy. Robinson and Robinson added .that.some workers distinguish between "counselling" oriented towards a set 40 of problems of coping with the environment, and "psychotherapy," oriented toward thorough-going personality change (1976, p. 392). Such a d i s t i n c t i o n w i l l not be made here. Several reviews of research have already been conducted on studies examining the effectiveness of psychotherapeutic assistance with the mentally retarded covering the period between 1940 and the late 1960's (Bialer, 1967; Cowen & Trippe, 1963; Stacey & DeMartino, 1957; S t e r n l i c h t , 1966). The following discussion w i l l include a summary of these e a r l i e r reviews, followed by a review of more recent research on psychotherapeutic intervention with the mentally retarded. Since the very early work of Itard and Seguin, i t was not u n t i l the 1940's that mental health and mental retardation professionals again began to consider psychotherapeutic approaches as appropriate for use with mentally retarded persons (Robinson & Robinson, 1976, p. 392). Stacey and DeMartino (1957) provided a c o l l e c t i o n of the early work of therapists who undertook one or another form of psychotherapy with the mentally retarded. Papers included i n the c o l l e c t i o n , report early attempts at modifying t r a d i t i o n a l psychoanalytic approaches for use with the mentally retarded, using group as w e l l as i n d i v i d u a l therapy and counselling with mentally retarded adolescents and adults; developing play therapy techniques and psychodrama for use with the mentally retarded; and providing counselling to parents of mentally retarded children. In the introduction to t h e i r book, Stacey and DeMartino (1957, p. 9) stated that, although the b e l i e f that psychotherapy, 41 as w e l l as other forms of therapy : are i n e f f e c t u a l with the mentally retarded, has been upheld for many years, c l i n i c a l and empirical studies reported over the past years have proved t h i s contention to be incorrect. In fact, they report that the results of these studies achieved through the use of counselling and psychotherapy with the mentally retarded have generally been very encouraging (1957, p. 9). The authors concluded that psycho-therapeutic research with the mentally retarded i s i n i t s "infancy," and that the future rate of therapeutic progress, with the mentally retarded, w i l l depend on both the s k i l l and t r a i n i n g of those engaged i n therapy and research as well as the amount of work done i n t h i s area (p. 461). Stacey and DeMartino stressed the need for future research that would improve upon methodologies and techniques of therapeutic intervention for use with mentally retarded c l i e n t s . In 1963, Cowen and Trippe c r i t i c a l l y reviewed the available studies i n psychotherapy and play therapy conducted with excep-t i o n a l children. Included i n the review are studies reporting the use of interview therapy, play therapy, and other expressive media, and group therapy provided by psychoanalysts, d i r e c t i v i s t s , n o n - d i r e c t i v i s t s , and e c l e c t i c s who have worked with i n s t i t u t i o n -a l i z e d and non- i n s t i t u t i o n a l i z e d mentally retarded populations (.1963, p. 562). Cowen and Trippe commented,on the many methodological and technical weaknesses of the e a r l i e r work, e.g., d e f i n i t i o n of the population, sampling techniques, lack of control groups, measurement techniques, poorly defined outcome goals, etc. "Though many of these reports are open to serious c r i t i c i s m i f considered 42 alone, altogether they underscore the conclusion that therapy, with at least some defectives, can be successful" (1963, p. 562). Cowen and Trippe concluded that there can be l i t t l e question of the effectiveness of psychotherapy with some mentally retarded persons, however, much needed information on the effectiveness of the d i f f e r e n t types of therapies with d i f f e r e n t diagnostic groups of mentally retarded individuals i s s t i l l lacking. Cowen and Trippe provided the following caution which remains applicable today: Psychotherapy should not be oversold; nor should i t be sold down the r i v e r . There i s , indeed, an important place for i t i n a balanced and reasoned o v e r a l l approach to the mental health problems of the disabled (1963, p. 582). Ste r n l i c h t (1966) reviewed research studies from 1955 to 1966 dealing with psychotherapeutic procedures with the mentally retarded. S t e r n l i c h t commented on the paucity of material i n th i s area and noted that only 50 o r i g i n a l investigations into the e f f i c a c y of psychotherapy with the mentally retarded could be compiled out of several thousand reports found dealing with mental retardation. S t e r n l i c h t begins his review with the premise, supported by several other researchers and c l i n i c i a n s , that mentally retarded individuals are subject to emotional trauma and d i f f i c u l t i e s i n c i d e n t a l to t h e i r i n t e l l e c t u a l l i m i t a t i o n s and that they do respond i n varying degrees, to psychotherapeutic assistance. S t e r n l i c h t reported-one writer as saying that "most retardates are incapacitated more by t h e i r emotional problems than by thei r low i n t e l l e c t u a l functioning and therefore psychotherapy with t h i s group i s of v i t a l importance (1966, p. 20) . 43 Stern l i c h t ' s survey of the l i t e r a t u r e i l l u s t r a t e d the variety of available psychotherapeutic techniques that may be employed with the mentally retarded. The numerous procedures available provide the c l i n i c i a n with a choice of therapeutic tools to use depending on the presenting problem and c l i e n t concerned (1966, p. 284). In addition to reporting on modifi-cation of t r a d i t i o n a l i n d i v i d u a l and group approaches, S t e r n l i c h t presented numerous accounts of innovative therapeutic procedures involving the use of projective techniques, the fine arts (music, a r t , dance), play therapy, psychodrama, relationship therapy, and educational therapy (use of an educational m i l i e u ) . These procedures were used within either a d i r e c t i v e , non-directive, or e c l e c t i c approach and were applied i n either i n d i v i d u a l or group sessions (p. 287). Ste r n l i c h t repprted that the l i t e r a t u r e on the varied techniques employed with a mentally retarded i n d i v i d u a l i n a one-to-one session, shows one factor common to a l l the studies -"the importance of communication" (p. 289). "The special problems of reaching the mentally retarded owing to his l i m i t e d v e r b a l i -zation, means that the therapist must use other, less sophisticated therapeutic tools" (p. 299) . As reported e a r l i e r , the use of various expressive media (art, music, drama, and dance) and play techniques have been used to r e a l i z e an e f f e c t i v e means of communication with the emotionally disturbed mentally retarded i n d i v i d u a l i n a therapeutic setting. In concluding h i s review of group psychotherapeutic approaches, S t e r n l i c h t formulate . the following hypothesis regarding the 44 conditions necessary for a favourable psychotherapeutic outcome with mentally retarded children, adolescents, or adults: Assuming that (a) the group i s balanced and (b) the therapy i s of s u f f i c i e n t duration (at least 1 hour per week for at least a 6 month period), successful therapeutic result s (in terms of elimination or modification of personality d i f f i c u l t i e s ) w i l l best be achieved by a combination of a non-verbal and a d i r e c t i v e psycho-therapeutic approach (1966, p. 325). In his review of psychotherapy with the mentally retarded, B i a l e r (1967) pointed out that the few comparative studies of therapy reported with the emotionally disturbed mentally retarded and the maladjusted c h i l d of average i n t e l l i g e n c e do not support the b e l i e f that the therapeutic prognosis i s automatically poorer for mentally retarded persons (1967, p. 154). Bi a l e r stated that psychotherapy has been shown to be successful with some children, under some conditions, and with some therapists,, and that research should now address the question of f e a s i b i l i t y of a p a r t i c u l a r psychotherapeutic procedure producing a p a r t i c u l a r behavioural change i n an i n d i v i d u a l . Again the question i s not "Is psychotherapy feasible with mentally retarded persons?" but rather "What methods and procedures work best with which populations and what i s the nature of therapeutic experience under these approaches?" (Bialer, 1967, p. 171). Bi a l e r presented several psychotherapeutic approaches that he f e l t may serve as "examples of p o t e n t i a l l y f r u i t f u l l i n e s of investigation" (1967, pp. 156-165). He b r i e f l y reviewed such novel and unusual techniques as: i) shadow therapy, making use of shadows cast i n a treatment setting to f a c i l i t a t e therapeutic communication and 45 fosters the integration of the severely disturbed chi l d ' s fantasy l i f e with r e a l i t y ; i i ) use of audio-visual feedback i n group counselling with mentally retarded adults generally oriented towards improving s o c i a l and emotional maturity; i i i ) use of unorthodox non-verbal techniques i n group treatment, such as Indian-arm wrestling, " s i l e n c e - i n s u l t " technique, and the use of mirrors and balloons both diagnostically and therapeutically; iv) hypnosis; v) the alternative-guidance approach i n which the therapist serves as a "source of data, a l i b r a r y of alter n a t i v e s " from which the c l i e n t chooses one tentative approach. B i a l e r (1967, p. 158) also reviewed the application of behaviour-shaping strategies and techniques ( i . e . , c l a s s i c a l and operant conditioning principles) to psychotherapeutic goals. The vast majority of the research pertaining to the use of behaviour-shaping strategies with the mentally retarded has been applied i n learning situations (e.g., t o i l e t - t r a i n i n g , feeding, e t c . ) . B i a l e r used the term "behavior therapy" when these techniques are used i n a psychotherapeutic s e t t i n g , and stated that the research into more formal conditioning procedures may eventually be employed p r o f i t a b l y i n behaviour therapy with thexmentally retarded. B i a l e r concluded that "those investigators, t h e o r i s t s , and c l i n i c i a n s who i n s i s t that a major therapeutic element i n psychotherapy i s the establishment of a 'close' c l i e n t - t h e r a p i s t 46 'relationship 1 may object that behavior therapy i s not ' r e a l l y ' psychotherapy since the major source of reinforcement therein may not necessarily be the therapist" (1967, p. 162). B i a l e r pointed_out though that "the most distinguishing c h a r a c t e r i s t i c of psychotherapy i s considered to be the fact that i t i s psychological treatment applied with r e g u l a r i t y and consistency, toward the amelioration of emotional or behaviour d i s t r e s s . There i s l i t t l e doubt that behaviour therapy i s such treatment applied toward such goals" (1967, p. 162). Balthazar and Stevens (1975, chap. 6) stressed that " i t i s behavior that i s the c r i t i c a l issue c a l l i n g for treatment" and that any therapeutic program must be based upon either eliminating or modifying t h i s behaviour. Balthazar and Stevens favoured the behavioural approach, suggesting that i t provides the most ef f e c t i v e results i n a s s i s t i n g the emotionally disturbed mentally retarded i n d i v i d u a l . Robinson and Robinson (1976, p. 406), i n a more recent review of psychotherapy with the mentally retarded, also concluded that "despite the great shortcomings i n the research l i t e r a t u r e , i t appears safe to say that psychotherapeutic practices of several kinds have shown to be successful with some children, under some conditions, and with some therapists" (1976, p. 406), with the approaches based on operant conditioning being the most highly developed. Other approaches such as play therapy, a r t i s t i c expression, role playing, and even some verbal techniques such as catharsis, reassurance, alternative guidance, i n t e r -pretation, etc., were described by the authors for use with the 47 mentally retarded and were recommended as "showing promise" for use with t h i s population (1976, pp. 396-406). Rosen, Clark, and K i v i t z stated that a l l persons enrolled i n an h a b i l i t a t i o n program should be exposed to-therapy and counselling, and that such counselling should be s p e c i f i c a l l y designed to deal with problems shared by a group of mentally retarded i n d i v i d u a l s , i n addition to problems unique to any i n d i v i d u a l person (1977, p. 304). Rosen, Clark, and K i v i t z (1977, pp. 307-314) went on to describe how therapeutic approaches d i f f e r along several dimensions and that the d i f f e r -ences may be s i g n i f i c a n t i n terms of c l i e n t factors, s i t u a t i o n a l factors, therapist variables, treatment goals, and therapy factors. Table 2 presents Rosen, Clark, and K i v i t z ' s Therapy Choice Model (1977, p. 313). The major factors are given, with a "rough" ordering of certain c r i t i c a l dimensions that may vary within these factors. The table outlines a general d i r e c t i o n for selecting a treatment strategy from the factors given. For example, the more s p e c i f i c the behavior change accepted as a treatment objective, the more necessary i t w i l l be to choose a behavior modification strategy, and the greater the need to e f f e c t environ-mental control to achieve generalization. The more general the personality change objective, the greater the need to .select a less structured, nondirective approach and to work intensively with the c l i e n t on an i n d i v i d u a l i z e d basis. In such cases a generally therapeutic m i l i e u i s required rather than t i g h t control of enviornmental contingencies (Rosen, Clark, & K i v i t z , 1977, p. 314) . Rosen, Clark, and K i v i t z recognized that t h e i r model was Table 2 Therapy Choice Model Developed by Rosen, Clark, and K i v i t z , 1977 "Given" Variables Manipulated Variables 1 Client Factors Condition Factors Therapist Factors Treatment Goals Therapy Choice Situational Control Verbal and abstract reason-ing r e l a t i v e l y intact D e f i c i t s in verbal and abstract reasoning processes General personal-i t y and develop-mental problems Emotional deprivation Broad s o c i a l learning d e f i c i t s interpersonal problems Affective problems (anxiety, depres-sion) Inappropriate behavior Specific disrup-tive behavior Humanistic orienta-tion Global personality Nondirective change counselling Therapeutic milieu Psychodynamic orientation Cognitive orientation Behavioral orienta-tion Enhancement of self-awareness Emotional control Teach social information and s k i l l s Pastoral counselling Art/music therapy A c t i v i t i e s programs Analytic/ relationship therapy CO Behavior control Education therapy Contingency management by parents, house-parents Self-help d e f i c i t s Occupational therapy Reality therapy Behavior therapy Operant conditioning For further description of the Therapy Choice Model, see Rosen, Clark, K i v i t z , 1977, p. 313. 49 "not perfect," but f e l t that "the value of the approach l i e s i n i t s focus on current factors a f f e c t i n g behavior of the :'. i n d i v i d u a l rather than on presumed e t i o l o g i c a l factors that may be l i t t l e related to current behavior or prognosis" (1977, p. 314). 5 0 Part I I Provision of Mental Health Services to  Mentally Retarded Adults This section w i l l review the l i t e r a t u r e that examines the issues surrounding the delivery of mental health services to mentally retarded adults i n the community- This section i s divided into three parts. The f i r s t part w i l l present l i t e r a t u r e that discusses variables e f f e c t i n g the provision of mental health services to mentally retarded adults; the second part w i l l review l i t e r a t u r e that has examined the delivery of mental health services to mentally retarded adults outside of B r i t i s h Columbia; and the f i n a l part w i l l discuss the delivery of mental health services within B r i t i s h Columbia, and more s p e c i f i c a l l y within the municipalities of Vancouver and Richmond. Variables E f f e c t i n g the Provision of Mental Health Services to  Mentally Retarded Adults There are both attitudes and p r a c t i c a l problems that impede the delivery of mental health services to mentally retarded adults i n the community. Some of these problems r e s u l t from the "unexplored and often erroneous notions of uninformed professionals" working i n the f i e l d s of mental health and mental retardation (Robinson & Robinson, 1976, p. 393). Others l i e in the p r a c t i c a l problems of delivering services by both public and private organizations, often stemming from the h i s t o r i c a l development of these services. S t i l l others arise from the l i m i t a t i o n s of mentally retarded persons themselves. 5 1 Attitudes Towards the Mentally Retarded. As previously noted i n the h i s t o r i c a l review, during the f i r s t h a l f of the 20th century, professional i n t e r e s t ( p a r t i c u l a r l y that of psychiatrists) moved away from the f i e l d of mental retardation. The care and treatment of the mentally retarded was relegated to custodial programs, and for many years following, the mentally retarded were confined to large i n s t i t u t i o n s . This segregation not only kept the mentally retarded i s o l a t e d from the general community, but the majority of mental health professionals had l i t t l e opportunity to come in contact with a mentally retarded i n d i v i d u a l , unless they themselves worked within an i n s t i t u t i o n . Like the general public, professional people developed attitudes toward the mentally retarded based upon very l i t t l e knowledge, understanding, or personal contact with mentally retarded persons. As mentioned e a r l i e r , the notion of i n c u r a b i l i t y at one time so dominated thinking about the mentally retarded that e f f o r t s at h a b i l i t a t i o n appeared useless (Robinson & Robinson, 1976, p. 393). Savino et a l . described professionals as being "human," and thus were l i k e l y "to f e e l threatened by patients with problems for which t h e i r previous t r a i n i n g and experiences have not prepared them. Where the condition i s perceived as a s t a t i c or 'hopeless' one, the f e e l i n g of threat and inadequacy may be even more accentuated" (1973, p. 160). Today, though, mental retardation i s viewed as a symptom that may r e s u l t from a number of causes including a variety of psychological factors (Robinson & Robinson, 1976, p. 394). The interplay between b i o l o g i c a l , psychological, and 52 c u l t u r a l factors in the shaping of human personality i s now emphasized, and permits the reintegration of mental retardation with the f i e l d of mental health (Cytryn, 1970, p. 655). There i s also today a greater appreciation for the basic human rights of a l l individuals, whatever t h e i r l e v e l of capacity, to as normal and rewarding a l i f e as possible" (Robinson & Robinson, 1976, p. 394). Professional Preparation i n Mental Retardation. Potter, i n 1965, expressed concern over the lack of preparation of the "modern p s y c h i a t r i s t " for a contemporary understanding of mentally retarded persons and t h e i r needs. The modern /American p s y c h i a t r i s t , by virtue of his tra i n i n g and indoctrination, i s far more of a behavioral s c i e n t i s t than a medical s c i e n t i s t . Most modern /American p s y c h i a t r i s t s have had but minimal i n s t r u c t i o n i n mental retardation and most tend to entertain a defect p o s i t i o n about a l l retarda-t i o n . That 75 or 80 percent of a l l retardation i s mild retardation and that mildly retarded children have nothing i n common with seriously retarded children but much i n common with normal children, has escaped them (1965, pp. 542-543). The modern p s y c h i a t r i s t "by virtue of his bias" and lack of contemporary knowledge about mental retardation i s "not i n c l i n e d " to provide service to the mentally retarded. Nevertheless, Potter claimed that p s y c h i a t r i s t s do have the knowledge of adaptive behaviour and the understanding of the impact of environmental and b i o l o g i c a l factors on emotional, i n t e l l e c t u a l , and s o c i a l development that make them well prepared to provide assessment and treatment of the personality problems and learning impairments of mentally retarded persons (1965, p. 543). 53 In a more recent study conducted by Ash (1974) , a question-naire was sent to 16 Canadian u n i v e r s i t i e s o f f e r i n g post-graduate t r a i n i n g i n psychiatry. A major concern as a r e s u l t of t h i s study was the absence, at over 50 percent of the u n i v e r s i t i e s , of a faculty member who was a fu l l - t i m e s p e c i a l i s t i n the f i e l d of mental retardation. Ash also found that f u l l use was not being made of mental retardation f a c i l i t i e s as teaching resources and concluded that only by making a d e f i n i t i v e place for the teaching of mental retardation as a subspeciality i n both undergraduate and graduate psychiatric education programs, w i l l there be any s i g n i f i c a n t increase i n the number of psychiatric s p e c i a l i s t s i n the area of mental retardation. -. , Cytry.n, 1970, expressed a si m i l a r concern that the imple-mentation of professional preparation for pediatricians and psy c h i a t r i s t s would depend upon the a v a i l a b i l i t y of s u f f i c i e n t numbers of s p e c i a l i s t s with interest and expertise i n mental retardation. A coordinating team of s p e c i a l i s t s would also be imperative to cut across specialty l i n e s to provide a cohesive m u l t i - d i s c i p l i n a r y approach to the problems of mental retardation (.1970, p. 659). Cytryn also stressed.the need for diagnostic and treatment f a c i l i t i e s for teaching purposes. Although the views expressed by Potter and Ash relate to the psychiatric profession, many of t h e i r concerns and recommendations apply equally w e l l to other mental health professions. Tymchuk and Mooring (1975) conducted a survey with psychologists p r a c t i s i n g i n Southern C a l i f o r n i a , to determine the need for further education programs i n the area of mental 54 retardation. They concluded that there i s a d e f i n i t e need for tr a i n i n g i n the f i e l d of mental retardation for psychologists who have already completed t h e i r professional degree. The authors stated that the evidence of t h i s need for continuing education comes from the di r e c t affirmative response of 73 percent who f e l t additional t r a i n i n g would be "helpful." Sterns and J a r r e t t (1976) conducted a survey with accredited graduate schools of s o c i a l work i n the United States, i n an attempt to determine how much mental retardation content i s present i n thei r curriculum. The study showed that only seven schools (13%) out of the t o t a l sample of 54 offered courses which dealt s p e c i f i c a l l y with mental retardation. The researchers recommended a further survey with mental retardation agency supervisors, to study the job performance and educational background of s o c i a l workers within t h e i r employ, to see i f there i s a relationship between l e v e l of performance and specialized educational preparation i n mental retardation (1976, p. 18). The researchers suggested that the results of such a study could w e l l have a bearing on the much wider issue of whether the focus of s o c i a l work education should be generic p r i n c i p l e s or f i e l d s p e c i a l i z a t i o n or both. Stern and J a r r e t t stressed the need for and importance of s k i l l e d s o c i a l workers to provide services to the mentally retarded and t h e i r f a m i l i e s : H i s t o r i c a l l y i t i s apparent that without s k i l l e d s o c i a l workers, the mentally retarded are often neglected and forgotten. Consequently they l i v e i n c h i l d - l i k e dependency upon t h e i r families or languish i n i n s t i t u t i o n s (1976, p. 17). 55 Begab (1970, p. 108), i n an e a r l i e r study, reported that "despite increasing e f f o r t s of schools of s o c i a l work to integrate mental retardation content into t h e i r c u r r i c u l a , graduate students for the most part have not been i n c l i n e d to seek careers i n th i s f i e l d of practice." Begab found that current e f f o r t s of s o c i a l work schools .have not s i g n i f i c a n t l y affected students' knowledge or attitudes or t h e i r willingness to work with mentally retarded c l i e n t s (1970, p. 807). A s i g n i f i c a n t finding of t h i s study was that how much one knows i s not as important i n attitude change as the nature of learning experiences and the sources of information. "How, rather than how much, one learns i s c r i t i c a l to whether information i s absorbed and integrated into attitudes" (1970, p. 807). Begab suggested that the " f i e l d i n s t r u c t i o n system" i s best suited to t h i s end, but only i f cases assigned to fieldwork students are c a r e f u l l y selected and the faculty supervisor and agency setting provide suitable motivations and learning opportunities. A d i r e c t educational approach was taken by Kunze et a l . (.1969) in an attempt to inte r e s t students from f i v e professional d i s c i p l i n e s (medicine, nursing, s o c i a l work, psychology, and speech audiology) i n choosing a career i n the f i e l d of mental retardation. A m u l t i - d i s c i p l i n a r y program i n mental retardation was provided to 12 students. On completion of the program, f i v e out of twelve students anticipated professional careers which included work with mentally retarded individuals (1969, p. 19). Kunze et a l . concluded that based on test results of knowledge of and attitudes toward mental retardation, the expressed opinions of 56 the students and s t a f f , and the students' pursuit of further t r a i n -ing and professional positions i n mental retardation, the mu l t i -d i s c i p l i n a r y approach to professional preparation i n the f i e l d of mental retardation demonstrated i n the study appears to be e f f e c t i v e . Limitations of Mentally Retarded Persons Themselves. Robinson and Robinson (1976, pp. 394-395) reviewed some examples of the limi t a t i o n s , o f t e n found i n the mentally retarded person that have implications for psychotherapeutic assistance. The authors cautioned though that one must keep i n mind how widely mentally retarded^individuals vary i n th e i r behaviour, t h e i r problems, and t h e i r talents (1976, p. 394). Communication problems, whether they be related to speech, language, cognition, or emotion are commonly found to some degree i n the majority of mentally retarded persons. The verbal a b i l i t y of mentally retarded individuals has often been c i t e d as one of the main reasons why psychotherapy i s not feasible with t h i s population (Stacey & DeMartino, 1957; S t e r n l i c h t , 1966, p.280). Robinson and Robinson,pointed out however, .along with a host of other writers (see Cowen & Trippe, 1963; Stacey & De Martino, 1957; S t e r n l i c h t , 1966), that the d i f f i c u l t y of the mentally retarded person i n formulating and understanding ideas through words requires that the psychotherapeutic approach involve an eff e c t i v e non-verbal component (e.g., play therapy, socio-drama, art and music therapy, e t c . ) . Poor impulse control i s another commonly reported ch a r a c t e r i s t i c of the mentally retarded. Although Robinson and Robinson presented evidence that.now refutes t h i s notion as 57 a blanket rule (1976, p. 394), i t has often been maintained that mentally retarded individuals are impulsive and r e l a t i v e l y unable to substitute s o c i a l l y appropriate a c t i v i t i e s for more primitive ones when they are frustrated. But Robinson and Robinson and Ingalls (1978, p. 287) stressed that instead of denying the mentally retarded therapeutic assistance due to the i r i n a b i l i t y to deal "cognitively with acting out impulses," an important goal of therapy with the mentally retarded should be to a s s i s t the c l i e n t s to learn ways to better control t h e i r impulses as well as t h e i r emotions. Passivity i n problem-solving situations was the t h i r d example reported by Robinson and Robinson (1976), of a c h a r a c t e r i s t i c of the mentally retarded that may e f f e c t t h e i r a b i l i t y to par t i c i p a t e i n the therapeutic process. The authors reported that the d i f f i c u l t i e s experienced by the mentally retarded to i n i t i a t e problem-solving strategies, seem to l i e much less i n structural l i m i t a t i o n s than i n the selection, a c t i v a t i o n , a n d use of e f f e c t i v e strategies (1976, p. 395). Rosen et a l . (1977, p. 225) hypothesized that while i n e r t i a and i n a b i l i t y to act may r e f l e c t i n t e l l e c t u a l d e f i c i t s , they may also represent personality d e f i c i t s developed during years of overprotection and oversheltering. Thus, i t would seem that another goal of therapy would be to a s s i s t the mentally retarded to make use of the strategies one already possesses for problem-solving i n c e r t a i n situations and to teach new strategies for solving problems i n other s i t u a t i o n s . In summary, instead of re j e c t i n g the mentally retarded 58 for mental' health services ( s p e c i f i c a l l y counselling or psychotherapeutic assistance), due to the l i m i t a t i o n s discussed above, the therapists may instead view them as a "challenge" and develop new approaches to providing mentally retarded persons with the therapeutic assistance they need. Trends i n the Development of Services for the Mentally  Retarded. "Although voluntary associations have sometimes served a key determining role i n the ac q u i s i t i o n and provision of services for the retarded, some of t h e i r patterns of functioning have actually impeded the provision of service" (Savino et a l . , 1973, p. 163). T r a d i t i o n a l l y , the associations for the mentally retarded have been providers of services. With the majority of the membership consisting of parents of mentally retarded children, often i t i s found that there i s a "strong emotional need" among the membership to create d i r e c t services to meet the needs of t h e i r sons and daughters as they perceive them. This attitude or fe e l i n g i s currently i n contrast with the present emphasis of the majority of the associations' directors and s t a f f on generating and supporting services and programs by public and other private organizations and to get out of the business of providing d i r e c t services (Savino et a l . , 1973, p. 162). Although Savino et a l . recognized both a c t i v i t i e s as legitimate and necessary i n the in t e r e s t of mentally retarded persons, they believe that the - . , voluntary agency must emphasize "the role of serving as a vehicle and catalyst for obtaining the f u l l spectrum of 59 service needed for the mentally retarded population (p. 162). The National Association for Retarded Citizens i n the United States has stated that only under two sets of conditions should a l o c a l association be involved i n the delivery of dir e c t services. The f i r s t condition i s one i n which the l o c a l chapter would be involved i n the innovation, demonstration, and experimentation with new and d i f f e r e n t programs. The second condition i s to operate programs when there are no other agencies with the potential for taking the r e s p o n s i b i l i t y to operate the program. Savino et a l . (1973, p. 62) applied these c r i t e r i a to psychiatric and other services of a l o c a l mental health centre, and found that neither of the c r i t e r i a applied. I t has been demonstrated how emotionally disturbed mentally retarded people can be assisted i n a therapeutic setting, as w e l l as the fact that mental health centres have the r e s p o n s i b i l i t y for providing mental health services to a l l c i t i z e n s i n need. Community mental health centres and programs claiming to be comprehensive i n scope have no grounds for con-tinuing t h e i r frequent exclusion of the mentally retarded. Any system for the delivery of public mental health services must be s u f f i c i e n t l y f l e x i b l e and capable of responding r e a l i s t i c a l l y to/a population that i s not merely at r i s k of mental breakdown i n a theoreti c a l sense, but also i n a state of f l u x with respect to both i t s actual mental health needs and the mental capacities of i t s members (Hume, 1972, pp. 22-23). As presented e a r l i e r i n th i s report, the trend i n the delivery of services to the mentally retarded and t h e i r families has been to make use, whenever possible, of generic based community programs and services. Although the l o c a l 60 associations are community-based, they have over the years become "mini" i n s t i t u t i o n s within t h e i r own communities. They have become s p e c i a l i s t s i n providing services to the mentally retarded i n th e i r communities but i n doing so have become is o l a t e d . In addition, i t has never been possible for one agency "to be a l l things to a l l people." There are advantages and disadvantages to making use of generic agencies over s p e c i a l i s t agencies, and vice versa. Jaslow (1967) recommended the use of the best elements of both systems, to provide quality comprehensive care to the mentally retarded. Savino et a l . described another weakness i n the service delivery system of the l o c a l associations for the mentally retarded. Typically a l o c a l association i s made up of parents of moderately and severely retarded children (1973, p. 163) which leaves the mildly retarded person underrepresented when i t comes to developing appropriate programs and services. In r e l a t i o n to mental health services, Savino et a l . pointed out that "since the mildly retarded (the vast majority of retarded) might most p r o f i t from psychiatric and other services provided i n a l o c a l mental health se t t i n g , t h e i r gross underrepresenta-ti o n i n l o c a l voluntary agencies may impede the provision of services" (1973, p. 163). Provision of Mental Health Services to the Mentally Retarded  Outside of B r i t i s h Columbia Chandler et al.(1962) reviewed the data on services to the mentally retarded provided by psychiatric c l i n i c s throughout the 61 United States. The authors reported that services provided by outpatient psychiatric c l i n i c s to mentally retarded patients were primarily diagnostic or evaluative. "Nationally i n 1959, treatment including such services as counselling and manipulation of the environment, were reported for only 7% of the children, and 16% of the adults with mental deficiency" (1962, p. 222). This i s compared to an average treatment rate of 39 percent for children and 56 percent for adults who are patients of the c l i n i c s . The number of interviews provided to patients was also reported. The median number of interviews for non-mentally retarded patients was f i v e , for the mentally retarded i t was only two (p. 223). I t i s unclear as to the length of reporting period for these figures, whether or not i t i s an annual figure or the t o t a l for patients since i n i t i a l contact with the c l i n i c . However, for each type of service, the mentally retarded patients generally received fewer interviews. In the description of the d i s p o s i t i o n of service, i t was shown that about two-thirds of the mentally retarded received evaluative services (diagnosis or psychological t e s t i n g only) and were then referred to other agencies (p. 223). I t i s inter e s t i n g to note that "drop-out" rates are lower for mentally retarded patients than for patients with other disorders, regardless of. the type of service received. A high proportion of the mentally retarded were referred to schools and welfare agencies, representing primarily r e f e r r a l back to o r i g i n a l source after evaluation. I t i s also reported that about o n e - f i f t h of the mentally retarded patients were referred to 62 inpatient f a c i l i t i e s i n d i c a t i n g the c l i n i c ' s additional role of screening for inpatient care. In summarizing the contribution of the outpatient psychiatric c l i n i c i n the care of the mentally retarded, Chandler et a l . (1962) concluded that the diagnosis of mental retardation and/or "brain syndrome" i s l i k e l y to lead to the provision of a r e l a t i v e l y b r i e f service. The authors suggested reasons for t h i s , such as lack of professional s t a f f , i n s u f f i c i e n t treatment time available for c l i n i c patients i n general, administrative c l i n i c intake p o l i c i e s , etc. These factors could be overcome i f the c l i n i c s had within t h e i r mandate the r e s p o n s i b i l i t y of providing mental health services to mentally retarded persons i n need of such service. In a survey study conducted by Woody and B i l l y (1966), a questionnaire regarding counselling and psychotherapy for the mentally retarded was mailed to each Doctoral-level Fellow i n the section on psychology of the American Association on Mental Deficiency. From the t o t a l group of 113 subjects, 94 or 8 3.2 percent responded. Three questions were posed to determine the professional frame of reference of the psychologists responding to the questionnaire. F i f t y - s i x subjects or 87.5 percent indicated that they had had c l i n i c a l experience i n providing counselling and psychotherapy to mentally retarded c l i e n t s , and that for percent of time of c l i n i c a l experience serving the mentally retarded i t was between 20 and 60 percent. The authors con-cluded that the responses to the survey were provided by 63 well-trained psychologists (as evidenced by t h e i r Doctoral degree) who had a considerable amount of applied c l i n i c a l experience i n mental retardation (p. 21). The subjects were then asked to rank nine approaches to counselling and psychotherapy (e.g., e c l e c t i c , client-centered, learning theory, etc.), from the approach that was most s i m i l a r to the one they practiced or espoused, proceeding down to the approach that was least l i k e t h e i r s . The E c l e c t i c Approach received the highest mean rank. This approach was described as encompassing any technique deemed by the therapist to be appropriate for the p a r t i c u l a r c l i e n t . Client-centered Approach was ranked second highest, followed by Learning Theory, Ego Psychology, Psychoanalytic, Individual Psychology Rational, Conditioning, and Psychodrama. The authors noted that i n "view of the acceptance accorded by e c l e c t i c psychologists to certain aspects of client-centered theory, the second position of client-centered counseling seems compatible with the first-ranked theory" (p. 21). I t i s inte r e s t i n g to note that Rogers, author of the client-centered approach, discourages any form of psychotherapy with mental defectives'(Robinson & Robinson, 1976, p. 394; St e r n l i c h t , 1966, p. 280). Orthodox client-centered therapy r e l i e s heavily on verbal communication and the a b i l i t y to deal cognitively with maladaptive behaviour. The rank assigned, however, to the therapeutic approaches r e f l e c t s the approach which i s "most s i m i l a r " to that which the psychologist-subjects practice or espouse, and not necessarily the approach best 6 4 suited to the mentally retarded. The subjects were then asked to rank three modes of therapy (i n d i v i d u a l , group, and i n d i v i d u a l and group concurrently) to indicate t h e i r opinion as to the r e l a t i v e effectiveness of the three modes with mentally retarded c l i e n t s . The results to th i s question showed that the subjects f e l t the mentally retarded could benefit most from i n d i v i d u a l counselling and psychotherapy as opposed to group or a combination of i n d i v i d u a l and group procedures. The psychologist subjects were also asked to rate the value of counselling and psychotherapy for each of the following groups: Dull-Normal (IQ 75-90); Educable (IQ 50-75); Trainable (IQ 25-50); Severely Retarded (IQ 25 or l e s s ) . The results indicated that the respondents considered the relationship between l e v e l of int e l l i g e n c e and the value of counselling and psychotherapy to be s i g n i f i c a n t . The relationship suggested i s that "the higher the l e v e l of i n t e l l i g e n c e , the greater the value of counselling and psychotherapy!' (p. 22) . The researchers also attempted to determine i n what s p e c i f i c problem areas the psychologist-subjects f e l t the mentally retarded could benefit from counselling and psychotherapy. The subjects were asked to indicate the appropriateness of counselling and psychotherapy with the mentally retarded i n 11 d i f f e r e n t problem areas: i n s t i t u t i o n a l adaption, motivation for learning, peer group associations, f a m i l i a l r e l a t i o n s h i p s , control of unacceptable behaviour, authority figure resolution, improvement of measurement i n psychodiagnostics, return to the home, 65 personality modification, return to community i n an active r o l e , and improve employability. In every area except "improvement of measurement i n psychodiagnostics," the respondents f e l t that counselling and psychotherapy would be of "some value," the second highest rank on the five-point scale. Improvement i n psychodiagnostic measurement was given an "undecided" r a t i n g , the middle value on the scale. The subjects were also asked to indicate the frequency of current use of counselling and psychotherapy as they may apply i t , i n the same selected problem areas. The resul t s indicated that a l l but two of the areas are "often" encountered, the second highest rating on the scale, when providing counselling or psychotherapy to the mentally retarded. The two areas "Authority Figure Resolution" and "Improvement of Measurement in Psychodiagnostics," seem to be less frequent aspects of counselling or therapy with t h i s population (p. 23). F i n a l l y , the researchers t r i e d to determine what might be some of the factors l i m i t i n g the psychologist-subjects' involvement with counselling and psychotherapeutic services with the mentally retarded. I t seems that "Lack of Adequate Time" was the most l i m i t i n g factor, and that providing counselling and psychotherapy to the mentally retarded was deemed to be "occasionally... incompatible with the philosophy of the se t t i n g i n which the psychologist was employed" (p.23). This r e s u l t compares with Chandler et al.'s suggestion that lack of treatment time and c l i n i c intake p o l i c i e s might w e l l e f f e c t the amount and type of psychotherapeutic services a 66 mentally handicapped person may receive. Woody and B i l l y , however, struck an opt i m i s t i c note, that t h i s problem may be al l e v i a t e d i n part by the "rapid growth of programs to t r a i n counsellors for the mentally retarded" (1966, p. 23). The author of t h i s present study has not been able to locate any l i t e r a t u r e that supports Woody and B i l l y ' s e a r l i e r optimism. Burton (1971) reported that several States have attempted to resolve the problem of community-based services for the mentally retarded by assigning the r e s p o n s i b i l i t y to mental health agencies. As a r e s u l t , there i s a considerable controversy among professionals who f e e l that the psychiatric orientation of the mental health c l i n i c s reduces the effectiveness of the services that the agencies can, or w i l l , provide to the mentally retarded. Burton studied 1,040 psychiatric outpatient cases that were i d e n t i f i e d as mentally retarded to determine what services had been rendered to the retarded patients by the mental health c l i n i c s during the period 1963-1965. To begin with, Burton found that the data describing the cha r a c t e r i s t i c s of the mentally retarded appeared to point to a trend i n the type (level) of mentally retarded persons referred to the mental health c l i n i c s . The author suggested that although one might assume that the severely retarded (in t h i s study c l a s s i f i e d as IQ 0-50) would account for a substantial number of r e f e r r a l s to the c l i n i c s , the data indicated that the largest number of mentally retarded referred f e l l into the two categories of mild (IQ 70-85) at 26 percent of r e f e r r a l s of the mentally retarded and the moderate (IQ 59-69) at 27 percent of r e f e r r a l s (p.39). 67 The combined percentage of the service of diagnosis or evaluation without treatment accounted for 69 percent of the services provided to the mentally retarded. When treatment was provided to the mentally retarded c l i e n t , the p r i n c i p a l method of treatment was in d i v i d u a l therapy. Ten percent of the mentally retarded c l i e n t s received i n d i v i d u a l treatment (defined as diagnosis from which a plan i s developed by the c l i n i c for treatment of the symptomology), 76 percent received no treatment, with 8 percent receiving chemotherapy and 6 percent receiving other. Of the 76 percent who received no treatment within the c l i n i c i t s e l f , Burton pointed out that on the basis of the diagnosis or evaluation provided, r e f e r r a l may have been made to another agency better able to provide the treatment. F i f t y - n i n e percent of the population was "terminated" from the c l i n i c , with r e f e r r a l to another agency. In addition, 31 percent of the mentally retarded c l i e n t s were terminated under the category "Further Care Not Indicated." Burton speculated that t h i s may be "misleading" i n view of the po s s i b i -l i t y that "a substantial portion of t h i s population may have needed further care, but the service was not available" (p. 40). Burton also presented data that substantiated the notion that since mental health c l i n i c treatment i s involved p r i n c i p a l l y with diagnosis and r e f e r r a l , the c l i n i c could not have been expected to contribute s i g n i f i c a n t l y to any improvement i n the "condition" of the mentally retarded c l i e n t . The outpatient c l i n i c records indicated that out of 1,040 mentally retarded individuals referred to the mental health c l i n i c , 13 percent were 68 considered improved, 73 percent were unchanged, 1 percent were worse, and 13 percent were undetermined at the time of termina-t i o n (p. 40). Burton concluded that mental health c l i n i c services to the retarded are e s s e n t i a l l y l i m i t e d to evaluation and diagnosis without further treatment. He suggested that the mental health c l i n i c s , for the most part, are f u l f i l l i n g the ro l e of the agency best equipped to do the i n i t i a l evaluation and r e f e r r a l of the mentally retarded for other agencies possessing the expertise for treatment or service outside the realm of mental health c l i n i c r e s p o n s i b i l i t y . Based on the resul t s of his study, Burton (1971, p. 40) made the following recommendations to persons responsible for the organization of community programs for the mentally retarded: "1) other community agencies providing services which would be b e n e f i c i a l to the retarded and his family must be i d e n t i f i e d ; 2) cooperative planning and r e s p o n s i b i l i t y among these agencies i s e s s e n t i a l ; and 3) no one single agency can, or should, provide the array of services needed by the retarded and h i s family." Scheerenberger (1970) noted that comprehensive programming for the mentally retarded must provide for greater u t i l i z a t i o n of generic services. Scheerenberger conducted a study i n 1968, i n which a questionnaire was sent to 504 representatives from various generic agencies (medical, guidance and counselling, r e l i g i o u s , and socio-recreational) and 232 parents of mentally retarded children were contacted for an interview. The study 69 attempted to investigate the a c c e s s i b i l i t y of generic services to the mentally retarded and t h e i r f a m i l i e s . Secondly, the study attempted to i d e n t i f y problems encountered by professional persons i n providing generic services to the retarded as w e l l as to i d e n t i f y problems encountered by parents i n obtaining generic services for the retarded. Scheerenberger (1970, p. 11) cautioned that three factors had to be taken into consideration when interpreting the resul t s of his study. F i r s t i t i s indicated that a "do not serve" response does not mean " w i l l not serve." Scheerenberger reported only a few cases, a l l of which were confined to generic guidance and counselling and socio-recreational agencies, i n which an organization did not serve the retarded as a matter of poli c y . Secondly, the number of mentally retarded served were for the most part estimated by the respondent (p. 12). C r i t e r i a used for c l a s s i f i c a t i o n are unknown so consequently r e l i a b i l i t y of the data i s "suspected." Scheerenberger observed, however, that unless a generic agency had a special program for the moderately, severely, or profoundly retarded, primarily mildly retarded population was served. The t h i r d factor to be considered i s that due to the finding that the number of persons serving the mentally retarded i n any generic category provided to be quite small, responses to questions concerning services and the d i f f i c u l t i e s encountered, provided only an in d i c a t i o n of some of the e x i s t i n g programs and associated problems (p. 12). A much larger sample would be 70 required to achieve any firm conclusions. Of the 474 generic agencies that responded, a t o t a l of 124 (26%) indicated that they served the retarded. The highest l e v e l of provision of services to the retarded involved guidance and counselling agencies; however, of the 14 agencies serving the retarded, 6 received state aid for that s p e c i f i c purpose. On a t o t a l l y voluntary basis, the church was most active i n providing for the retarded. The frequently estimated l e v e l of mental retardation found i n the general population i s 3 percent. Only four agencies reported that the percent of mentally retarded served i n terms of t o t a l c l i e n t population, approximated or exceeded 3%: pediatricians (2%), mental health c l i n i c s (9%), s o c i a l centres (7 and YMCA/YWCA's (12%). The 6-percent l e v e l recorded for generic guidance and counselling services again r e f l e c t s the c l i n i c s receiving f i n a n c i a l aid to serve the mentally retarded (p. 12). Scheerenberger also noted that the r e l a t i v e l y high incidence of mentally retarded persons served by s o c i a l centres and YMCA/ YWCA's was attributed to the fact that most of the f a c i l i t i e s were located i n poverty areas. In the "non-poverty" areas, estimated retarded population being served by the YMCA/YWCA's;.was below 1 percent. Regarding r e f e r r a l s to other agencies, the results of the study showed that most generic agencies referred the mentally retarded to other services for assistance (p. 13). This finding corresponds with Burton's (1971) results reported e a r l i e r , for generic mental health c l i n i c s . Socio-recreational 71 agencies, as reported by Scheerenberger, had l i t t l e involvement i n r e f e r r i n g the mentally retarded to other agencies because "they did not believe i t was within the realm of t h e i r professional r e s p o n s i b i l i t y to become involved with the broad ramifications of retardation" (p. 13). Reasons given for r e f e r r a l of the mentally retarded patient or c l i e n t to other agencies varied according to profession. General p r a c t i t i o n e r s referred mentally retarded patients to mental health c l i n i c s for diagnosis and treatment, and the majority of pediatricians referred mentally retarded patients to specialized hospitals and c l i n i c s , primarily for further diagnosis. The generic guidance and counselling services referred to a variety of community agencies sponsoring special.programs for the mentally retarded. Most generic agencies reported that they do provide counselling to parents about mental retardation. Exceptions included dentists and socio-recreational services. Few agencies, however, reported providing s i m i l a r counselling to normal s i b l i n g s of mentally retarded children. Three mental health c l i n i c s did indicate that they provide counselling programs for both s i b l i n g s and parents. The question regarding problems associated with serving the mentally retarded and t h e i r families revealed that the two most frequently encountered problems were with communication and finding s u f f i c i e n t time to provide required services (p. 13). I f the problem of communication refers to d i f f i c u l t i e s i n verbal communication with mentally retarded persons, S t e r n l i c h t 72 (1966), as reported e a r l i e r , reviewed numerous studies that demonstrated the use of non-verbal techniques and other approaches with less emphasis on verbal communication that appeared e f f e c t i v e with the mentally retarded. The "problem" of finding s u f f i c i e n t time to provide required services substantiates the findings of Chandler et a l . (1962) and Woody and B i l l y (1966), discussed e a r l i e r . I f an agency recognizes the r e s p o n s i b i l i t y to provide services i n such a way that i t w i l l not only meet the needs of the general public but also those of the mentally handicapped population i n the community, " s u f f i c i e n t " time would be made available to serve the mentally retarded. Primary problems reported by Scheerenberger, when working with parents of the retarded, were the parents' acceptance and understanding of mental retardation and following the recommendations of professionals. Scheerenberger pointed out that approximately 50 percent of the respondents indicated that they had not encountered any serious problems i n serving either the mentally retarded or t h e i r parents (p. 14). The professional agency representatives summarized the needed community services for the mentally retarded as an acute need for additional community resources, central points of r e f e r r a l and information, and increased professional manpower (p. 14). The parents of the mentally retarded were also primarily concerned with expansion of community programs (73%), development of l o c a l community residences (43%) and creation of central points of r e f e r r a l (p. 15). In addition, 73 15 percent of the parents f e l t i t necessary to increase f i n a n c i a l assistance for the retarded (p. 15). In analyzing the results of the parent interviews, Scheerenberger found that a l l parents had received diagnostic counselling services for t h e i r mentally retarded c h i l d with the two primary resources being hospitals, used by 54 percent of the parents, and mental health c l i n i c s , used by 2 8 percent of the parents. This corresponds with the frequency of r e f e r r a l , by generic professionals and agencies, of the mentally retarded to hospitals and c l i n i c s for the purpose of diangosis and counselling or treatment. In summarizing his r e s u l t s , Scheerenberger (1970, p. 14) indicated several problems with the provision of services to the mentally retarded and t h e i r families by generic agencies: a) there are too few of them, especially i n poverty areas, b) t h e i r a c t i v i t i e s were uncoordinated with those of other generic agencies as well as specialized programs, c) services, especially among non-medical agencies, have low v i s i b i l i t y and parents are unaware of t h e i r existence, d) there i s an absence of external support and guidance from persons professionally trained i n programming for the retarded, e) f i n a n c i a l considerations preclude the use of generic services by some parents, and 74 f) there i s an absence of specialized programs es s e n t i a l to complement generic services. Generally parents reported a greater lack of service than did professionals, however, professionals reported very few problems associated with serving the mentally retarded. Scheerenberger was able to i d e n t i f y an "inchoate" need of the parents of mentally retarded children inferred on the basis of t h e i r responses: Parents must have access to a program of guidance and counseling which w i l l a s s i s t them i n making decisions concerning t h e i r mentally retarded son or daughter at each stage i n his l i f e . As evidenced i n t his study, parents i n general did not possess s u f f i c i e n t information about mental retardation and community programs nor did they have access to any agency which could provide the continuity of assistance required (1970, p. 16). The r e s u l t s of Scheerenberger 1s study do not at t h i s point, j u s t i f y conclusions. Scheerenberger, however, f e l t the resul t s do emphasize the need to implement the four following recommen-dations put forth by Jaslow (1967): 1) Open every generic community agency to the mentally retarded insofar as these agencies' competence and a b i l i t y permits. 2) Provide basic t r a i n i n g i n mental retardation for every health worker. 3) Place a mental retardation s p e c i a l i s t , either f u l l - t i m e or part-time, i n every generic agency of any size of signif i c a n c e . 4) Establish a coordinating mechanism within each community to ensure balanced services. The present author would only add that with regard to Jaslow's recommendations one and two, generic agencies should be made "competent," i n t h e i r a b i l i t y to meet the needs of 75 the mentally retarded for services as provided by the agency. To do so w i l l require the provision of appropriate basic, as wel l as s p e c i a l i s t , professional preparation i n mental retarda-ti o n not only for "health workers," but also for a l l s o c i a l service personnel, educators, r e h a b i l i t a t i o n and mental health professionals, etc. Provision of Mental Health and Mental Retardation Services  Within B r i t i s h Columbia Within the Province of B r i t i s h Columbia, the provision of mental health services i s the r e s p o n s i b i l i t y of the Ministry of Health, whereas the r e s p o n s i b i l i t y for provision of s o c i a l services to mentally retarded persons (and to other c i t i z e n s ) l i e s with the Ministry of Human Resources. The following i s a b r i e f description of the services of these two M i n i s t r i e s relevant to t h i s study. Ministry of Health. Within the Ministry of Health, the development of mental health services at the community l e v e l i s the sole r e s p o n s i b i l i t y of Mental Health Programs, with the operation of the Province's mental health i n s t i t u t i o n s coming under the j u r i s d i c t i o n of the Division of' Government Health I n s t i t u t i o n s (Ministry of Health, Annual Report, 1977) . I t i s with the former that t h i s study i s most concerned. Mental Health Centres have been established i n 30 communities throughout the Province, excluding the Greater Vancouver Area which w i l l be described l a t e r . The function of each centre i s to develop, i n cooperation with e x i s t i n g 76 resources within the coitraiunity, a variety of services designed to meet the s p e c i f i c mental health requirements of the area served. A centre i s staffed by a team of experts i n mental health and may include a p s y c h i a t r i s t , a psychologist, psychiatric s o c i a l workers, mental health nurses, and other professional personnel. The majority of the centres provide services such as: d i r e c t treatment for adults and children; consultative services to physicians, health, welfare, educational, and correctional agencies; educational programs, both profesi-sional and non-professional; and programs such as long-term patient, preventive programs, boarding-home care, and special group homes. Burnaby, one of the 30 communities with a mental health centre, i s described as the Province's only t r u l y "regionalized, decentralized, integrated and comprehensive program" for adults, families and children who are resident within the community. In the municipalities of Vancouver and Richmond, the 3 Greater Vancouver Mental Health Service (GVMHS ) was established i n 1973, when the Metropolitan Board of Health of Greater Vancouver accepted the r e s p o n s i b i l i t y from the Minister of Health for the development and administration of the GVMHS. The GVMHS currently operates eight Community Care Teams (seven i n Vancouver and one i n Richmond), with an average patient-load for each team of 250-350. 3 The following description of the Greater Vancouver Mental Health Service i s taken from an unpublished paper provided to the author by Mr. Ron Lakes, Research Director, Greater Vancouver Mental Health Service. 77 The essential mandate of the service i s to provide direct treatment services to the seriously mentally i l l person i n the community so as to minimize or remove the necessity for psychiatric inpatient hospital care. The target population of the Community Care Teams of the GVMHS,, described as the "seriously mentally i l l , " includes not only previously hospitalized people, but persons who without adequate community care would have to be hospitalized. Characteristics of the seriously mentally i l l persons, as defined by GVMHS, would be any one of the following: 1. People deemed to be a threat to themselves or others because of t h e i r mental condition. 2. People with severe disturbances of cognition i n t e r -fering with t h e i r a b i l i t y to assume and function i n important l i f e roles such as school, work, family, and community. 3. People with a f f e c t i v e disorders i n t e r f e r i n g with those a b i l i t i e s and functions. Recognizing the wide range of problems t h e i r patients encountered, i n employment, d a i l y - l i v i n g s k i l l s , s o c i a l s k i l l s , f i n a n c i a l and l e g a l matters, etc., a m u l t i - d i s c i p l i n a r y team was set up i n each community area. The teams are staffed by a Team Coordinator, Senior Mental Health Worker, Occupational Therapist, one or more f u l l or part-time P s y c h i a t r i s t s , a number of Community Mental Health Workers, with psychiatric nursing, general nursing or other appropriate c l i n i c a l back-grounds, and two c l e r i c a l s t a f f . This m u l t i - d i s c i p l i n a r y approach i s said to u t i l i z e the advantages of both the medical and s o c i a l models, and leads to the c l i n i c a l model. The established c l i n i c a l model of the teams emphasizes i) in-depth 78 d i r e c t patient care to the seriously mentally i l l ; i i ) a close working relationship with Public Health, P o l i c e , l o c a l general hospitals, the private medical sector, and other agencies; i i i ) continuity of care and access to acute beds when necessary; iv) j o i n t p r a c t i t i o n e r and private p s y c h i a t r i s t ; and v) strong in-service t r a i n i n g programs i n c l i n i c a l s k i l l s i n order to maintain a high l e v e l of service. A primary therapist i s assigned to each patient, and who's role may be "a frie n d and advocate, advisor or therapist, teacher or helper." In addition to services provided d i r e c t l y by the Community Care Teams, GVMHS has available several support f a c i l i t i e s , i . e . , community residences, emergency after-hours services, a program for agoraphobics, and a boarding home program. I t was stressed i n an a r t i c l e by Bigelow and Beiser (1978) describing the services of GVMHS, that the Community Care Teams have retained t h e i r focus on the severely, c h r o n i c a l l y , mentally i l l person, and that i t i s these patients that require the intensive, comprehensive services of the community-based teams. The authors point out that private p s y c h i a t r i c services are at least t h e o r e t i c a l l y available to residents of B.C., through the Medical Services Plan of B.C., and that mildly and moderately i l l patients can get help from the private sector. Ministry of Human Resources The Ministry of Human Resources of the Province of B r i t i s h Columbia, provides a wide range of s o c i a l services including 79 various forms of income assistance to families and children, and those disadvantaged because of age, handicap, and unemploy-ment (Ministry of Human Resources, 1978). The Ministry's service delivery system i s composed of 16 management regions throughout the Province with 138 l o c a l o f f i c e s delivering d i r e c t c l i e n t services. Vancouver i s divided into four manage-ment regions with a t o t a l of 36 l o c a l o f f i c e s . Richmond has two l o c a l o f f i c e s . The primary worker i n the l o c a l o f f i c e i s usually a s o c i a l worker, who attempts to coordinate the delivery of services available through Human Resources and other community organizations that w i l l meet the needs of the mentally retarded i n d i v i d u a l and t h e i r family. The main services provided to mentally retarded adults and t h e i r families,either by d i r e c t government programs or through funding by the Ministry of non-profit organizations, cover the areas of r e s i d e n t i a l services, s o c i a l work services, vocational t r a i n i n g or sheltered workshop programs, health care, and income assistance. A mentally retarded adult may f i r s t come i n contact with t h e i r l o c a l Human Resources o f f i c e when applying for income assistance (Guaranteed Available Income for Need-Handicapped Benefits) upon turning 18 years of age. I f determined to be e l i g i b l e , the mentally retarded i n d i v i d u a l receives $295.00. a month with accompanying extended medical benefits, a bus pass for public transportation, and a rental allowance i f l i v i n g on t h e i r own. In addition to a s s i s t i n g a c l i e n t with obtaining income 8 0 assistance, the Human Resources Social Worker may provide counselling and r e f e r r a l services. The majority of d i r e c t r e s i d e n t i a l , vocational, recreational, and s o c i a l work services for the mentally retarded (with the exception of the r e s i d e n t i a l i n s t i t u t i o n programs) are provided by community-based non-profit organizations. These organizations receive either t o t a l or p a r t i a l funding from Ministry of Human Resources. The l o c a l Associations for the Mentally Retarded are the main providers of such services. When i n i t i a l enquiries were made by the writer into the provision of mental health services to the mentally retarded by Human Resources, a government o f f i c i a l explained that mental health services are provided by the Ministry of Health and would be available to mentally retarded individuals through the programs and services of the Ministry (see Appendix C). I t was also indicated that the Ministry of Human Resources, although providing s o c i a l services and counselling to the mentally retarded and th e i r f a m i l i e s , do not have on s t a f f , personnel who would be providing therapeutic assistance for "mental health problems." I t i s the main purpose of the present study, to obtain a clearer picture of who i s providing community-based mental health, services to the mentally retarded adult i n Vancouver and Richmond, and what i s the extent..of these services. 81 Chapter I I I METHODOLOGY This study was conducted by the descriptive method using questionnaires for the c o l l e c t i o n of data. Recognizing the importance of consumer, as well as professional,involvement i n the development and evaluation of services, two populations were surveyed: 1) professionals i n the f i e l d of mental health - p s y c h i a t r i s t s , psychologists and s o c i a l workers, and 2) the parents or leg a l guardians of mentally retarded adults, recognized for the purposes of t h i s study as consumers of mental health services on behalf of t h e i r mentally retarded sons or daughters. Separate questionnaires were developed for the populations. The following sections w i l l describe the populations surveyed, the development of the questionnaires, the procedures, the method of data analysis, and the l i m i t a t i o n s of the study. Populations Mental Health Professionals. For the purpose- of t h i s study, mental health professionals are defined as p s y c h i a t r i s t s , psychologists, and s o c i a l workers licensed or registered to practise i n the Province of B r i t i s h Columbia. The population i s further r e s t r i c t e d to those professionals working i n the municipalities of Vancouver and Richmond. The source of mailing l i s t and the size of the population and sample drawn i s : 82 P s y c h i a t r i s t s Psychologists Medical Directory College of Physicians and Surgeons of B.C. 1978-1979 B.C. Psychological Association Popula-ti o n 104 179 Sampl (40%) 41 72 Social Workers B.C. Association of Social Workers Associated Profes-sional Social Workers of B.C. 716 286 The t o t a l number of professionals surveyed was; 399 Parents of Mentally Retarded Adults. Parents of mentally retarded adults l i v i n g i n the Vancouver-Richmond area were surveyed to obtain information from the "consumer" on the use of mental health services by mentally retarded adults. The parents were surveyed as opposed to the mentally . retarded individuals themselves for the following reasons: 1) the majority of mentally retarded adults would not have the reading comprehension or wr i t i n g s k i l l s that would enable them to complete the questionnaire as designed, 2) to have someone i n the home a s s i s t the adult i n completing the questionnaire could not be adequately controlled and would af f e c t the v a l i d i t y of the responses and rate of return, 3) to have a researcher go into the home and either assis 83 with the completion of the questionnaire or conduct an interview as opposed to the written questionnaire was not possible within the f i n a n c i a l l i m i t a t i o n s of th i s study. The population of parents of mentally retarded adults was obtained, with permission, from the 1978 membership l i s t of the Vancouver-Richmond-Association f o r the Mentally Retarded. There were 260 members of V.R.A.M.R. who have a mentally retarded son or daughter over the age of 19. The size of the sample survey was again 40 percent or 104 parents. Development of the Questionnaire Preliminary questionnaires were developed for a p i l o t study to determine the v a l i d i t y of the questionnaire p r i o r to being used i n the f i n a l study. The items contained i n the preliminary questionnaires were derived from the l i t e r a t u r e (Ash, 19 74; Burton, 1971; Freeman, 1967; Savino et a l . , 1973; Scheerenberger, 1970; Woody & B i l l y , 1966), from discussions with advisors, and from personal experiences. The preliminary questionnaires were subjected to several revisions over the previous year i n an attempt to ensure that the questionnaires were asking the ri g h t questions, that the questions were unambiguous, and that they were prepared i n such a way as to f a c i l i t a t e the analysis of the returns. In r e l a t i o n to the.four main areas of investigation, the questionnaires were divided into sections. The Professional Questionnaire. The professional question-naire, (see Appendix A) had three sections. ..." -8 4 Section A: Professional Preparation and Practice i n Mental  Retardation, was designed to determine the amount and type of professional preparation ( i n i t i a l professional degree as w e l l as further education) the mental health professional had i n the area of mental retardation. Also included were questions regarding t h e i r opinion of t h e i r professional preparation i n mental retardation, future p a r t i c i p a t i o n i n , and recommendations for the same. Section A also asked questions regarding place of practice, professional work experience i n mental retardation, current caseloads of mentally retarded adults, and factors preventing a professional from working with mentally retarded adults. Section B: Mental Health Services Presently Being Provided  to Mentally Retarded Adults i n Vancouver and Richmond, was to be answered only by those'professionals who currently had (or since January 1, 19 79) mentally retarded adults on t h e i r caseloads. This section contained questions regarding the provision of mental health services to retarded adults. Based on t h e i r work with mentally retarded adults, the professionals answered questions on the type of service provided, amount of service provided, number of mentally retarded adult c l i e n t s being served, and access and a v a i l a b i l i t y of services. Also included i n Section B were questions on the background of t h e i r mentally retarded c l i e n t s , e.g., age, type of residence, day-time a c t i v i t y , etc. Section C: Personal Reactions to the Delivery of Mental  Health Services to Mentally Retarded Adults, asked the professionals 85 for t h e i r opinions regarding the quality of service provided, the r e s p o n s i b i l i t y for del i v e r i n g these services, and the use of generic versus specialized services for the delivery of mental health services to mentally retarded adults. The Parent Questionnaire. The questionnaire for parents of mentally retarded adults (see Appendix" B) was not divided into sections as was the professional questionnaire. Although organized i n a s l i g h t l y d i f f e r e n t manner, the questions to parents were designed i n such a way as to permit, where appropriate, comparisons of answers given by the mental health professionals and those given by the parents. The parent questionnaire f i r s t asked for background information on t h e i r mentally retarded son or daughter. These questions were s i m i l a r to those asked i n the professional questionnaire regarding the background of t h e i r c l i e n t s . The parents were then asked a series of questions regarding services, f i r s t provided by r e s i d e n t i a l , vocational, recreational,and "other" counselling personnel and then as provided by mental health professionals such as p s y c h i a t r i s t s , psychologists, and so c i a l workers. The parents were asked questions regarding amount, type, q u a l i t y , a v a i l a b i l i t y , and a c c e s s i b i l i t y of services. They were also asked a question regarding t h e i r son's,or daughter's need for mental health servicers)., and whetherc-or not they would prefer a generic based mental health service for t h e i r son or daughter or a special service for mentally retarded i n d i v i d u a l s . 86 t P i l o t Study A p i l o t study was carried out to assess the content v a l i d i t y of the questionnaires as w e l l as to determine c l a r i t y and d i s t r i b u t i o n of responses. I t was anticipated that the p i l o t study would reveal questions that lacked d i s c r i m i n a l i t y or were ambiguous or poorly worded, extremely sensitive items that subjects would not answer, areas of poor i n s t r u c t i o n , and any other administrative problems. The p i l o t study was carried out using samples of populations l i v i n g and working outside the study area. A sample of 115 mental health professionals (25 p s y c h i a t r i s t s , 40 psychologists, and 50 s o c i a l workers) were randomly drawn from the members of the professional organizations from which the f i n a l study population was to be drawn but who worked on Vancouver Island. Permission was given to draw a random sample of 40 parents from the membership l i s t of the Northshore Association for the Mentally Handicapped. I t was f e l t that i t would be necessary to go outside the geographical area of the f i n a l study to conduct the p i l o t study so as to reduce the l i k e l i h o o d of the p i l o t subjects conversing with the study population. An envelope containing a covering l e t t e r , the questionnaire, and a stamped return envelope was mailed to each subject. The covering l e t t e r explained the purpose and the objectives of the study, and the subject's p a r t i c i p a t i o n i n the p i l o t study. The anonymity of t h e i r responses was stressed and written comments directed at the i n d i v i d u a l questions was also s o l i c i t e d . Of the 115 mental health professionals surveyed i n the 87 p i l o t study, 31 (27%) responded to the questionnaire. Based upon the response to the p i l o t professional questionnaire, several changes were made. One question was omitted and two questions were combined. In the f i n a l questionnaire, Questions 16, 17, 19, 20, 21, 24, 27, and 28 were reworded asking the professionals for the s p e c i f i c number of c l i e n t s involved as opposed to a percentage category. I t was f e l t that the actual number would be easier for the professionals to provide as well as that i t provided the researcher with more meaningful data as compared to a percentage category. Question 29 was changed to include not only the professionals' opinion of t h e i r own service but also t h e i r opinion of the quality of service provided by other community-based agencies. Question 31 was reworded, making the question s p e c i f i c to the provision of psychotherapeutic assistance and/or counselling as opposed to mental health services i n general. Of the 40 parents surveyed, 14 (35%) returned the questionnaire. Based upon the parents responses to the p i l o t questionnaire, a number of changes were made for the f i n a l questionnaire. Generally i t appeared that the questionnaire directions were not clear enough or were too complicated. The majority of changes made were to enhance the c l a r i t y of the instructions and to reduce the amount of d e t a i l asked for i n any one question. For example, i n the f i n a l questionnaire, the parents were asked separately for the type of service provided by r e s i d e n t i a l , vocational, recreational, and "other" counselling personnel, from that provided by mental health professionals 88 such as p s y c h i a t r i s t s , psychologists, and s o c i a l workers. In addition, two questions were omitted from the f i n a l questionnaire because i t appeared that the parents did not have the information that enabled them to answer the questions. Three questions were combined into one question for the f i n a l question-naire, which reduced the length of the f i n a l questionnaire by two questions. Overall, i t was f e l t that the f i n a l questionnaire was much easier for the parents to answer, and asked for less d e t a i l . Procedure Using a random number table, a random sample of 40% of each population, i . e . , p s y c h i a t r i s t s , psychologists, s o c i a l workers, and parents, were drawn from the associations' d i r e c t o r i e s and membership l i s t s as outlined e a r l i e r . An envelope containing a covering l e t t e r , the questionnaire, a stamped return envelope, and a postcard for respondents to request a copy of the results of the study was mailed to each subject. The covering l e t t e r described the purpose and objectives of the study, and the person's p a r t i c i p a t i o n i n the study. The anonymity of t h e i r responses was stressed. A deadline for return of the completed questionnaire was given as three weeks from mailing. The mental health professionals were followed up with a second mailing about three weeks aft e r the deadline for return of the o r i g i n a l questionnaire. The parents were followed up by telephone about two weeks aft e r the deadline for the return 89 of the o r i g i n a l questionnaire and a second questionnaire was sent to those parents who indicated that they had misplaced the o r i g i n a l questionnaire and were prepared to respond to the follow-up. A l l the returns were numbered and prepared for key punching. Method of Data Analysis The data from the questionnaires was tabulated to provide a descriptive analysis of the selected variables involved i n the provision of mental health services to mentally retarded adults. The descriptive analysis covered the four main areas of i n v e s t i -gation. The number and percentage of respondents choosing each alternative i n a question was computed,. Chi square test of significance, and chi square test of association from percentages was computed on some factors. The following are the four main areas of investigation with the variables to be described l i s t e d under each, with t h e i r corresponding question number. 90 Related Questions Variables Professionals Parents 1. The preparation and experience of  mental health professionals i n the  area of mental retardation. a) preparation for i n i t i a l profes-sional degree: - professional degree 2 - number of courses i n mental retardation 4 - type of courses i n mental retardation 4 - amount of fieldwork placements 5 - type of fieldwork placements 5 - year of completion 2 - appraisal of preparation 6 - recommendation for preparation 7 b) further education i n mental retardation: - type of further education 8 - year of p a r t i c i p a t i o n 9 - appraisal of further education 8 - future p a r t i c i p a t i o n i n further education 10 c) years of professional practice i n the f i e l d of mental retardation 3 The provision of mental health services  to mentally retarded adults. a) number of mentally retarded adults receiving service 14 5,7 b) number and type of mental health professionals providing service 11 5,7 c) amount of service 2 3 11 d) type of service 17,19,20,21 6,8,9 e) source of service 1 11 f) behavioral and emotional problems 21 9 91 Related Questions Variables Professionals Parents g) a v a i l a b i l i t y and a c c e s s i b i l i t y of service: - source of r e f e r r a l 16 10 - fee for service 13 - w a i t l i s t for service 24 14 - factors which affect service 12 - r e f e r r a l to other resources for service 13 - need for service 14 3. Reactions of mental health professionals  and parents regarding the delivery of  mental health services to mentally  retarded adults. a) q u a l i t y of service provided 29 6,8 b) r e s p o n s i b i l i t y for provision of service 30 c) appropriate resource for service 31 15 d) effectiveness of counselling or psychotherapeutic assistance with mentally retarded adults 22 4. Background information on mentally retarded  adults who are currently receiving mental  health services. a) age 25 1 b) sex 26 1 c) type of residence 27 2 d) day-time a c t i v i t y 28 3 e) l e v e l of retardation 14 4 92 Limitation of the Study Population. The study was limi t e d due to the nature of two of the populations surveyed. The population of Social Workers was obtained through the active membership l i s t of the B.C. Association of Social Workers. Unlike the College of Physicians and Surgeons of B.C., and the B.C. Psychological Association of which a l l p s y c h i a t r i s t s and psychologists licensed to practise^: i n B.C. must be members, membership with the Association of Social Workers i s voluntary. An in d i v i d u a l may be employed to provide " s o c i a l work services" and be ca l l e d a "Social Worker" but i s not required to be a registered member of the Association. In addition, there are a large number of persons working within the s o c i a l services f i e l d providing " s o c i a l work-like" services, e.g., c h i l d care worker, family worker, or counsellor, that would not necessarily be registered with the Association. By drawing the population of Social Workers from the B.C.A.S.W., the resu l t s of the survey of professionals are l i m i t e d i n i t s g e n e r a l i z a b i l i t y to P s y c h i a t r i s t s , Psychologists, and Registered Social Workers. The population of "s o c i a l services personnel" not registered with B.C.A.S.W. who may be providing mental health services to mentally retarded adults, were not included i n t h i s survey for there i s no professional organization to whom they belong, therefore, i t was not possible to obtain a l i s t of subjects. Secondly, the nature of the population of parents of mentally retarded adults was also a l i m i t i n g factor for t h i s study. Parents who are members of an association for the mentally retarded cannot be considered to be representative of a l l parents 93 of mentally retarded adults (Savino et a l . , 1973, p. 163). Typically there i s a higher proportion of members who are parents of moderately and severely retarded individuals as opposed to parents of mildly retarded i n d i v i d u a l s . Differences can be expected between the l e v e l of mental retardation of the adult c l i e n t s , and the amount and type of service provided. The study was also li m i t e d to a discussion of community-based mental health services i n the metropolitan areas of Vancouver and Richmond as opposed to those mental health services that may be available at Woodlands, the i n s t i t u t i o n for the mentally retarded serving the lower mainland of B r i t i s h Columbia; or the services of Riverview, the mental health hospi t a l serving'the same area. Instrument. Questionnaires are d i f f i c u l t to construct properly and are plagued by several defects that, unless con-t r o l l e d or accounted for, could severely weaken a survey study. Two of the major weaknesses of questionnaire studies are: possible lack of response; and the i n a b i l i t y to check the responses given (Moser & Kalton, 1971, p. 260). When dealing with lack of response i n a mail questionnaire study, i t i s not so much the loss i n sample numbers that i s serious, but the l i k e l i h o o d that the non-respondents d i f f e r s i g n i f i c a n t l y from the respondents, so that estimates based on the l a t t e r are biased (Moser & Kalton, 1971, p. 262). I t has been shown a number of times that mail questionnaires tend to r e s u l t i n an upward bias i n s o c i a l class composition and 9 4 educational l e v e l and that response i s correlated with interest i n the subject of the survey (Moser & Kalton, 1 9 7 1 , p. 2 6 8 ) . Both these findings were expected to appear i n the returns of the present study. I t i s recommended that the only safe way of dealing with non-response bias i s to reduce i t to a l e v e l s u f f i c i e n t l y low as to ensure that i t cannot cause a serious bias (Moser & Kalton, 1 9 7 1 , p. 2 6 8 ) . I f though the response rate i s not high enough, care must be taken to examine the extent of the unrepresentativeness and to refer to any l i m i t a -tions of g e n e r a l i z a b i l i t y i n the discussions of the r e s u l t s . In an attempt to determine a reasonable return rate for the present study, three survey studies using s i m i l a r populations and topic areas were reviewed. In a survey of C l i n i c a l Programs for Mentally Retarded Children, Freeman (Note 2 ) was able to achieve a return rate of 8 2 percent. Woody and B i l l y ( 1 9 6 6 ) obtained a return rate of 8 3 . 2 percent for questionnaires sent to psychologists who were members of the /American Association on Mental Deficiency. And i n a t h i r d study, i n which both profes-sionals and parents were surveyed, Scheerenberger ( 1 9 7 0 ) received a rate of return of 9 0 percent of persons responding on behalf of generic agencies, and 6 1 percent for parents of mentally retarded children. These studies indicate that a return rate of about 8 0 percent could be expected for the professional questionnaire and a return rate of 6 0 percent for the parent questionnaire. I t was f e l t that interest i n the survey topic on behalf of the professionals would greatly a f f e c t the rate of return. 95 The i n a b i l i t y to check responses i s a l i m i t a t i o n of questionnaire studies that i s d i f f i c u l t to remedy. Follow-up studies using telephone surveys or personal interviews are one way of c l a r i f y i n g ambiguous responses, or completing unanswered questions, but this technique i s not appropriate when anonymity of the subjects i s to be ensured. Consistency of responses can be checked by constructing matched items, but the length of the questionnaire i s another very important concern i n acquiring a high rate of return. In the end, the investigator i s usually at the mercy of the respondents, and can at most assume that the survey was conscientiously completed, with every e f f o r t made to provide accurate responses by those completing the questionnaire. 96 Chapter IV RESULTS Chapter IV reports the results obtained by the question-naires. The results of the questionnaire sent to mental health professionals are presented f i r s t , followed by the results of the questionnaire sent to parents of mentally retarded adults. The results for each question are reported separately and are summarized i n tables. For further reference, a copy of the professional questionnaire i s found i n Appendix A and a copy of the parent questionnaire i s found i n Appendix B._ Response to the Mental Health Professional Questionnaire Sample Size and Number of Respondents A t o t a l population of 998 mental health professionals i n the Vancouver and Richmond area was compiled from the membership l i s t s of the College of Physicians and Surgeons of B.C. - Psychiatry, B.C. Psychological Association, B.C. Association of Social Workers, and the Associated Professional Social Workers of B.C. From t h i s population, a random sample of 40%, a t o t a l of 39 9 ind i v i d u a l s , was drawn. Table 3 presents, for each professional group, the t o t a l population i n Vancouver and Richmond, the sample s i z e , and the number of respondents. Also shown are the number of returns that indicated that the respondent had not work i n the 97 Vancouver-Richmond area. This type of return was necessary, p a r t i c u l a r l y i n the case of the members of the B.C. Association of Social Workers, where the membership l i s t of t h i s association had only the member's home addresses and not t h e i r work addresses. I t was not possible to i d e n t i f y those who worked within the Vancouver and Richmond area only. Therefore, questionnaires were sent to 40% of a l l members who l i v e d i n the Greater Vancouver area, asking those who did not work within Vancouver or Richmond to. return a form in d i c a t i n g t h i s (see Appendix A). Individuals who indicated that they did not work within Vancouver or Richmond were considered not to be i n the population and were withdrawn from the sample. Also shown i n Table 3 are the number of individuals who returned the questionnaire unanswered. Six respondents who returned the questionnaire unanswered replied that although they worked within Vancouver-Richmond, they did not have any mentally retarded adults as patients or c l i e n t s . Of these respondents, three indicated t h e i r " l i n e of work" was not at a l l related to the study, and one indicated that she could not provide the information requested. Of the 41 p s y c h i a t r i s t s surveyed, 4 respondents indicated that they were not i n the population, 2 returned the question-naire unanswered, leaving a f i n a l sample size of 35, with a t o t a l of 11 (31%) p s y c h i a t r i s t s responding. Of the 72 psycholo-g i s t s surveyed, 12 respondents indicated they were not i n the population, 2 returned uncompleted questionnaires, and 16 (28%) of the 58 i n the f i n a l sample responded. Of the 286 s o c i a l 98 workers s u r v e y e d , 80 i n d i c a t e d t h e y were n ot i n t h e p o p u l a t i o n and 6 r e t u r n e d t h e q u e s t i o n n a i r e unanswered, l e a v i n g a f i n a l sample s i z e o f 200. A t o t a l o f 60 (30%) s o c i a l w o r k ers responded t o t h e q u e s t i o n n a i r e . Table 3 Number of Respondents to the Mental Health Professional Questionnaire Group Popula-t i o n Sample (40%) Not i n Popula-t i o n Returned Not Answered F i n a l Sample Respon-dents N (%) P s y c h i a t r i s t s 103 41 4 2 35 11 (31) Psychologists 179 72 12 2 58 16 (28) S o c i a l Workers 716 286 80 6 200 60 (30) T o t a l 998 399 96 10 293 87 (30) 99 Place of Professional Practice Table 4 shows the response to Question 1, asking for the location of professional practice of the respondents. The numbers of professionals shown for each place of practice w i l l not correspond with the t o t a l s because a professional may work i n more than one location. Eleven p s y c h i a t r i s t s responded to Question 1. Of those, 8 (72%) were i n private practice, 3 (27%) were with Greater Vancouver Mental Health Services, 2 (18%) practiced within a hospit a l or i n s t i t u t i o n , 1 (9%) was with a university, and 1 (9%) was with the Vancouver City Health Department. Of the 16 psychologists who responded to Question 1, 5 (31%) were at u n i v e r s i t i e s , 4 (25%) were i n private practice, 4 (25%) practiced within a hospital or i n s t i t u t i o n , 3 (19%) were at a community college, 2 (12%) were with non-profit organizations, 2 (12%) were with school boards, and 1 (6%) was with Greater Vancouver Mental Health Services. Of the 60 s o c i a l workers who responded, 20 (33%) were with the Ministry of Human Resources, 14 (23%) were with non-profit organizations, 11 (18%) were within a hospital or i n s t i t u t i o n , 5 (8%) were at a university, 2 (3%) were i n private practice, 1 (2%) was with Greater Vancouver Mental Health Services, 1 (2%) was with, a school board, and 6 (10%) worked within other govern-ment agencies. . Table 4 Place of Professional Practice of Respondents Private Mental Human School Non-profit Hospital/ P r a c t i c e Health Resources Board Society I n s t i t u t i o n University Other N (%) N (%) N (%) N (%) N (%) N (%) N (%) N (%) P s y c h i a t r i s t s (11) 8 (72) 3 (27) - -J> - 1 ( 9 ) 2 (18) 1 ( 9 ) 1 ( 9 ) Psychologists (16) 4 (25) 1 ( 6) - 2 (12) 2 (12) 4 (25) 5 (31) 3 (19) S o c i a l Workers (60) ' 2 ( 3) 1 ( 2) 20 (33) 1 ( 2) 14 (23) 11 (18) 5 ( 8) 6 (10) T o t a l (87) 14 (16) 5 ( 6) 20 (23') 3 ( 3 ) 17 (19) 17 (19) 11 (13) 10 (11) 101 Degree In response to Question 2, which asked for an in d i c a t i o n of university degrees held by the respondents, 7 (64%) of the ps y c h a i t r i s t s indicated that t h e i r highest degree was FRCP (c), while the remaining 4 (36%) indicated that they held MD degrees. Of the 16 psychologists, 6 (37%) indicated that t h e i r highest degree was a Ph.D., 6 (37%) recorded an M.A. degree, and 4 (25%) recorded an M.Ed, degree. Of the 60 s o c i a l workers, 4 (7%) indicated that they did not hold a degree,while 33 (55%) indicated that t h e i r highest degree was an M.S.W., 7 (12%) indicated an M.A. degree, 6 (12%) a B.S.W. degree, 6 (10%) a B.A. degree, and 3 (5%) a B.Sc. degree. Also included i n Question 2 was an in d i c a t i o n of the decade in which the degree was completed. Of the 87 respondents, 41 (68%) completed t h e i r degree i n the 1970's, 27 (31%) completed t h e i r degree i n the 1960's, 10 (17%) i n the 1950's, and 5 (.08%) i n the 1940's. Experience Working With the Mentally Retarded The respondes to Question 3, which asked for the number of years of experience the respondents had i n working with mentally  retarded children and with mentally retarded adults, are recorded i n Table 5. In most cases the largest percentage of respondents indicated that they had no previous experience i n working with the mentally retarded. Of the p s y c h i a t r i s t s , 50% indicated that they had no experience i n working with mentally retarded children, and 37% indicated that they had no experience i n 102 working with mentally retarded adults. Of the psychologists, 37% indicated that they had no experience working with mentally retarded children, while 71% indicated that they had no experience working with mentally retarded adults. Of the s o c i a l workers, 62% indicated no experience with mentally retarded children, while 60% indicated no experience with mentally retarded adults. Thirty-three respondents (44%) indicated that they had experience working with mentally retarded children. Of those, 21 (64%) recorded one to f i v e years experience, and 12 (36%) recorded more than 25 years experience. Three s o c i a l workers indicated that they have had more than 25 years experience work-ing with mentally retarded children. Of the 30 (40%) respondents who indicated that they had experience working with mentally retarded adults, 21 (70%) recorded one to f i v e years experience, and 9 (30%) recorded six to more than 25 years experience. Six s o c i a l workers indicated that they had between s i x and ten years experience, and two indicated that they had more than 25 years experience. Table 5 Number of Years Experience Professionals Have Had Working With the Mentally Retarded PROFESSIONALS. None YEARS b . T o t a l 1 2-3 4-5 6-10 11-15 16-20 21-24 25+ MENTALLY RETARDED C P s y c h i a t r i s t ( 8 ) a Psychologist (16) S o c i a l Worker (50) N (%) ^ILDREN:, 4 (50) 6 (37) 31 (62) N (%) N (%) N (%) N (%) N (%) N (%) N (%) N (%) 2 (25) 1 (12) 1 (12) - - - - • -2 (12) 3 (19) 1 ( 6) 2 (12) 1 ( 6 ) - 1 ( 6 ) -4 ( 8) 4 ( 8) 3 ( 6) 3 ( 6) 2 ( 4) - - 3 ( 6 ) N (%) . 4 (50 10 (63) 19 (38) T o t a l 0 41 (55) 33 (45) MENTALLY RETARDED Al P s y c h i a t r i s t ( 8 ) 3 Psychologist (14) S o c i a l Worker (52) DULTS: 3 (37) 10 (71) 31 (60) 2 (25) 2 (.25) 1 (12) - - - - -1 ( 7) 2 (14) 1 ( 7 ) -5 (10) 2 ( 4 ) 5 (10) 6 (11) 1 ( 2 ) - - 2 ( 4 ) 5 (63) 4 (29) 21 (40) c Total .44 (51) 43 (49) a b c Number of respondents to t h i s question. Total: number of respondents i n t h i s category who have had experience with the; mentally retarded. T o t a l number of respondents. 104 Course Work i n Mental Retardation Table 6 shows the responses to Question 4,in which a l l professionals were asked for an ind i c a t i o n of the number of courses they had taken i n the area of mental retardation i n general, and then s p e c i f i c a l l y i n the care and treatment of the mentally retarded adult. The respondents were asked to record t h e i r answers separately for courses i n which mental retardation was a major topic (50% or more of course content) and courses i n which mental retardation was a minor topic (less than 50% of course content). For courses i n which mental retardation was a major topic, of the 70 respondents to t h i s question, 58 (83%) indicated they had not taken any courses i n th i s area,while 12 (17%) i n d i -cated they had taken courses i n th i s area. The majority of professionals who had taken courses i n t h i s area were psychologis s i x (43%). Only two p s y c h i a t r i s t s and four s o c i a l workers recorded taking courses i n which mental retardation was a major topic. For courses i n which the care and treatment of the mentally  retarded adults was a major topic, of the 34 respondents to thi s question, 2 7 (79%) indicated they had taken courses i n t h i s area. Of the seven respondents who indicated that they had taken courses i n t h i s area, there were three psychologists, two p s y c h i a t r i s t s , and two s o c i a l workers. For courses i n which mental retardation was a minor topic, of the 81 respondents to t h i s question, 47 (58%) indicated that they had taken no courses i n t h i s area, while 34 (42%) indicated 105 they had taken courses i n th i s area. The majority of professionals who had taken courses i n t h i s area were s o c i a l workers, 16 (28%) . Nine psychologists and nine s o c i a l workers had also taken courses i n which mental retardation was a minor topic. For the courses i n which the care and treatment of the  mentally retarded adult was a minor topic, of the 44 respondents, 25 (57%) had taken no courses i n t h i s area, while 19 (43%) had taken courses i n t h i s area. Again the majority of professionals who had taken courses i n t h i s area were s o c i a l workers, with f i v e p s y c h i a t r i s t s and three psychologists also having taken courses i n t h i s area. In t o t a l , of the 87 respondents to the questionnaire, 39 (45%) indicated that they had some course work i n mental retardation, while 48. (55%) indicated that they had no course work i n mental retardation. Table 6 Number of Professionals Who Have Taken Courses in Mental Retardation During Their Professional Preparation 3 Number of Courses on Mental Retardation Number of Courses on the Mentally Retarded Adult Professional 0(%) 1(%) 2(%) 3(%) 4(%) 5(%) 6(%) T o t a l c N b 0(%) K%) 2(%) 3(%) 4(%) 5(%) 6(%) T o t a l c MENTAL RETARDA TION MAJOR TOPIC OF COURSE: Psychiatrist 5 3(60) 1(20) 1(20) - - - 2(40) 4 2(50) 1(25) 1(25) - - - - 2(50) Psychologist 14 8(57) 1( 7) 4(29) 1( 7) - - 6(43) 10 7(70) 3(30) 3(30) Social Worker 51 47(92) - 1( 2) 2( 4) - 1 ( 2) 4( 8) 20 18(90) - 1( 5) - - - 1( 5) 2(10) Totals 70 58(83) 12(17) 34 27(79) 7(21) MENTAL RETARDA TION MINOR TOPIC OF COURSE: Psychiatrist 9 5(56) 3(33) 1(11) - - 9(100) 7 2(29) 3(43) 1(14) 1(14) - - - 5(71) Psychologist 15 6(40) 2(13) 6(40) 1( 7) - - 9(60) 10 7(70) 2(20) 1(10) - 3(30) Social Worker 57 41(72) 6(10) 6(10) 2( 3) K 2) - 1 ( 2) 16(28) 27 16(59) 8(30) 2( 7) - 1( 4) - - 11(41) Totals 81 47(58) 34(42) 44 25(57) 19(43) Total number of respondents to questionnaire = 87; t o t a l number of respondents who took some courses = 39 (45%); t o t a l number of respondents who took no courses = 48 (55%) . N = number of respondents for this question. Total =number of respondents in each category who have taken courses. 107 Fieldwork Placements - i n Mental Retardation Question 5 asked the professionals to indicate the number of fieldwork placements i n the area of mental retardation i n which they have participated. Fieldwork placements i n an i n s t i t u t i o n a l s e t t i n g and fieldwork placements i n a. community setting were recorded separately (see Table 7). Of the 79 respondents to the f i r s t part of Question 5, 62 (78%) indicated that they had not participated i n a fieldwork placement with mentally retarded children i n an i n s t i t u t i o n a l  s e t ting, while 17 (22%) indicated that they had. Psychologists recorded the most fieldwork placements i n t h i s s e t t i n g , nine :(64%) . Only four p s y c h i a t r i s t s and four s o c i a l workers recorded fieldwork placements i n t h i s s e t t i n g . For fieldwork placements with mentally retarded adults i n  an i n s t i t u t i o n a l s e t t i n g , of the 60 respondents, 46 (76%) indicated that they have had no fieldwork placements i n th i s s e tting, while 14 (24%) indicated that they had. The majority of placements were recorded by psychologists and s o c i a l workers, with both groups recording f i v e individuals with placements i n thi s area. Of the 79 respondents to the second part of Question 5, 60 (76%) indicated that they had no fieldwork placements with mentally retarded children i n a community setting, while 19 (24%) indicated that they had. The majority of fieldwork placements i n t h i s setting were recorded by psychologists, nine (60%). Four p s y c h i a t r i s t s and s i x s o c i a l workers recorded fieldwork placements with mentally retarded children i n a community s e t t i n g . 108 For f i e l d w o r k placements with m e n t a l l y r e t a r d e d a d u l t s i n  a community s e t t i n g , of the 58 respondents to t h i s q u e s t i o n , 48 (83%) i n d i c a t e d t h a t they had no f i e l d w o r k placements i n t h i s s e t t i n g , with 10 (17%) i n d i c a t i n g t h a t they had. Again p s y c h o l o g i s t s and s o c i a l workers recorded the m a j o r i t y o f f i e l d w o r k placements i n t h i s s e t t i n g , w i t h both groups r e c o r d i n g f o u r i n d i v i d u a l s with placements i n t h i s a r ea. Only two p s y c h i a t r i s t s recorded f i e l d w o r k placements wi t h m e n t a l l y r e t a r d e d a d u l t s i n a community s e t t i n g . Of the 87 respondents t o the q u e s t i o n n a i r e , i n t o t a l , 27 (31%) i n d i c a t e d having some f i e l d w o r k placements with the m e n t a l l y r e t a r d e d , while 60 (69%) i n d i c a t e d having no f i e l d w o r k placements with t h i s p o p u l a t i o n . Table" 7 Number of Professionals tWho..Have Fieldwork Placements with the Mentally Retarded a Number of Fieldwork Placements with Mentally Retarded Children Number of Fieldwork Placements Mentally Retarded Adults with Professionals N b 0(%) M % ) 2(%) 3(%) 4 ( % ) T o t a l c N b 0(%) 1 ( % ) 2(%) 3(%) 4 0 T o t a l c IN AN INSTITUTIONAL SETTING: P s y c h i a t r i s t 9 5 ( 5 6 ) 3 ( 3 3 ) 1 ( 1 1 ) " - 4 ( 4 4 ) 8 4 ( 5 0 ) 4 ( 5 0 ) - - 4 ( 5 0 ) Psychologist 1 4 5 ( 3 6 ) 7 ( 5 0 ) K 7 ) 1 ( 7 ) - 9 ( 6 4 ) 1 2 7 ( 5 8 ) 4 ( 3 3 ) - 1 ( 8 ) - 5 ( 4 2 ) S o c i a l Worker 5 6 5 2 ( 9 3 ) 2( 4 ) 1 ( 2 ) K 2 ) 4 ( 7 ) 4 0 - . 3 5 ( 8 7 ) 2( 5 ) 1 ( 2 ) - 2( 5 ) 5 ( 1 3 ) Totals 7 9 6 2 ( 7 8 ) 1 7 ( 2 2 ) 6 0 4 6 ( 7 6 ) 1 4 ( 2 4 ) IN A COMMUNITY SETTING: P s y c h i a t r i s t 9 5 ( 5 6 ) 4 ( 4 4 ) - - 4 ( 4 4 ) 7 5 ( 7 1 ) 2 ( 2 9 ) - - 2 ( 2 9 ) Psychologist 1 5 6 ( 4 0 ) 4 ( 2 7 ) 5 ( 3 3 ) - - 9 ( 6 0 ) 1 1 7 ( 6 4 ) 3 ( 2 7 ) - 1 ( 9 ) - 4 ( 3 6 ) S o c i a l Worker 5 5 4 9 ( 8 9 ) 2( 4 ) 2 ( 4 ) 1 ( 2 ) K 2 ) 6 ( 1 1 ) 4 0 3 6 ( 9 0 ) 2( 5 ) 1 ( 2 ) - K 2 ) 4 ( 1 0 ) Totals 7 9 6 0 ( 7 6 ) 1 9 ( 2 4 ) 5 8 4 8 ( 8 3 ) 1 0 ( 1 7 ) Total number of respondents to questionnaire = 87; t o t a l number of respondents who had some fieldwork placements = 27 (31%); t o t a l number of respondents who had no fieldwork placements = 60 (69%Y,. N = number of respondents to t h i s question. Total number of respondents i n each category who have had fieldwork placements.. 110 Appraisal of Professional Preparation Table 8 presents the results of Question 6, which asked respondents to rate t h e i r professional preparation i n the area of Cmental retardation. Five s p e c i f i c areas were l i s t e d , and the respondents were asked to rate separately t h e i r preparation in the care and treatment of mentally retarded children from that of mentally retarded adults. The rating scale was: (0) No Preparation; (1) Poor; (2) F a i r ; (3) Good; and (4) Excellent. In the area of diagnostic assessment of the mentally retarded c h i l d , 32 (40%) of the respondents had received preparation,and the mean rating of t h e i r preparation was 2.1 ( F a i r ) . In the area of diagnostic assessment of the mentally retarded adult, 25 (35%) respondents had received preparation, giving a mean rating of 1.8 (F a i r ) . Twenty-five (31%) of the respondents indicated they received preparation i n i n d i v i d u a l program planning for mentally retarded children, assigning a mean rating of 1.8 ( F a i r ) . In th e i r preparation for i n d i v i d u a l program planning for mentally retarded adults, 17 (24%) of the respondents received preparation, assigning a mean rat i n g of 1.6 ( F a i r ) . In the area counselling and/or psychotherapeutic assistance for mentally retarded children, 28 (35%) of the respondents indicated that they received preparation i n th i s area, and the rating of t h e i r preparation was 2 ( F a i r ) . In counselling and/or psychotherapeutic assistance with mentally retarded adults, 23 (32%) of the respondents •received preparation, andassigned a mean rating of 1.8 ( F a i r ) . I l l In the area of counselling and/or psychotherapeutic assistance for parents and families of mentally retarded children, 37 (46%) of the respondents r e p l i e d that they had • received preparation i n t h i s area. They assigned a mean rati n g of 2.3 ( F a i r ) . In counselling and/or psychotherapeutic assistance with parents of mentally retarded adults, 28 (39%) respondents recorded receiving preparation and assigned a mean rat i n g of 2 ( F a i r ) . There were 34 (42%) respondents who indicated that they had received preparation i n inter-professional case consultation concerning mentally retarded children. The rat i n g assigned for t h i s area was 2.2 ( F a i r ) . In the same area with mentally retarded adults, 26 (37%) of the respondents indicated that they had received preparation and assigned a mean rat i n g of 2.2 ( F a i r ) . Table 8 Respondents' Rating of Their Preparation i n Mental Retardation Preparation 3 Psychiatrist 0 1 2 3 4 b Psychologist 0 1 2 3 4 Social Worker 0 1 2 3 4 "XR T c (%) MENTALLY RETARDED CHILDREN: Diagnostic Assessment Individual Program Planning Counselling and/or Psycho-therapeutic Assistance Parental/Family Counselling and/or Psychotherapeutic Assistance Inter-professional Consultation 1 1 6 2 0 4 3 2 1 0 4 2 3 1 0 2 3 3 1 1 3 2 4 0 1 5 3 2 5 1 9 1 3 3 0 8 2 4 0 1 8 0 4 3 1 9 0 4 2 1 42 6 5 1 0 43 7 3 1 1 38 4 9 0 2 35 3 11 5 2 35 7 6 4 3 (N=81) 2.1 32 (40) 1.8 25 (31) 2.0 28 (35) 2.3 37 (46) 2.2 34 (42) MENTALLY RETARDED ADULTS: Diagnostic Assessment Individual Program Planning Counselling and/or Psycho-therapeutic Assistance Parental/Family Counselling and/or Psychotherapeutic Assistance Inter-professional Consultation 1 3 5 1 0 5 4 1 0 0 4 3 3 0 0 3 3 4 0 0 5 1 4 0 0 9 1 3 2 1 13 1 1 1 0 11 2 1 1 0 12 1 2 0 1 11 1 2 1 1 36 5 3 1 0 36 5 2 1 1 31 4 7 0 2 30 5 7 3 2 30 5 4 4 3 (N=71) M 1.8 25 (35) M M 1.6 17 (24) 1.8 23 (32) 2.0 28 (39) 2.2 26 (37) For complete description of areas of preparation see Appendix A, page 251. Ratings = (0) No Preparation, (1) Poor, (2) Fair, (3) Good, (4) Excellent. Total = number of professionals who received preparation i n the area. Percent = percent of respon-dents for this question. 113 Recommendation for Professional Preparation Question 7 asked for the respondents 1 recommendations for the educational preparation of individuals who work within t h e i r respective professions. Table 9 reports the number of professionals who selected the alternatives provided. The respondents were asked to select one choice pertaining to course work and one choice pertaining to s p e c i a l i s t t r a i n i n g . The written comments recorded i n the category "other," are. discussed i n Chapter V. Of the 85 respondents to the question regarding course work, 33 (38%) recommended one compulsory course i n mental retardation, 31 (36%) recommended two compulsory courses i n mental retardation, 8 (9%) recommended that course work i n mental retardation was not necessary, and 13 (15%) made other comments. There were 82 respondents to the question regarding s p e c i a l i s t t r a i n i n g . Of these, 64 (78%) indicated that they f e l t mental retardation should be an area of s p e c i a l i z a t i o n within t h e i r profession, 14 (17%) f e l t that i t should not be, and 4 (5%) made other comments. Table 9 Recommendations of Professionals For Preparation i n Mental Retardation Preparation P s y c h i a t r i s t (%) a Psychologist N (%) Soci a l N Worker (%) Tot a l N (%) COURSE WORK: One compulsory introductory course i n mental retardation. 7 (64) 6 (40) 20 (34) 33 (38) Two compulsory courses i n mental ret a r d a t i o n . 3 (27) 4 (27) 24 (41) 31 (36) Course work in.mental retardation not necessary. 0 0 3 (20) 5 ( 8) 8 ( 9) SPECIALIST TRAINING: Mental retardation should be an area of s p e c i a l i z a t i o n . 9 (82) 8 (53) 47 (84) 64 (78) Mental retardation should not be an area of s p e c i a l i z a t i o n . 2 (18) 6 (40) 6 (11) 14 (17) N = number of respondents, % = percent of respondents i n professional group. Percentages do not equal 100 because response to "other" category i s not included here. 115 Further Education i n Mental Retardation Table 10 records the respondents' answers to Question 8, which asked for a rating of t h e i r further education i n mental retardation. Six categories were given, asking the respondents to rate how well t h e i r further education experiences better prepared them for working with mentally retarded children and mentally retarded adults. The rating.scale was: (1) Poor; (2) F a i r ; (3) Good; and (4) Excellent. Of the t o t a l 87 respondents to the questionnaire, 12 (14%) indicated that they had participated i n a graduate degree program. For t h e i r preparation to work with mentally retarded children, the respondents assigned a mean-rating of 2.3 (F a i r ) , and for t h e i r preparation to work with mentally retarded adults, the respondents assigned a mean rat i n g of 1.6 (F a i r ) . Eleven (13%) of the respondents indicated they had taken university or.college credit courses (not leading to a graduate degree). For t h e i r preparation to work with mentally retarded children, the respondents assigned a mean rat i n g of 1.7 (F a i r ) , and for work with mentally retarded adults the mean rating they assigned was 1.8 (F a i r ) . Twenty-one (24%) of the respondents indicated that they had attended conferences, workshops, or seminars. The mean rating for t h e i r preparation to work with mentally retarded children was 2.6 (Good). In the same category, but for preparin them to work with mentally retarded adults, 22 (25%) of the respondents indicated they had participated i n conferences, etc. and assigned a mean rating of 2.5 ( F a i r ) . 116 For s t a f f development at place of employment, 15 (17%) respondents indicated that they had participated i n s t a f f development and i n the area of preparing them to work with mentally retarded children, assigned a mean rating of 2.2 (Fair) Seventeen (.19%) of the respondents indicated that they had participated i n s t a f f development i n preparation for work with mentally retarded adults, and assigned a mean r a t i n g of 2.2 (Fai In the area of reading or self-study, 22 (25%) of the respondents recorded that they had done so i n preparation for work with mentally retarded children and assigned a mean rating of 2.5 (Good). Twenty-four (27%) of the respondents indicated that they had done reading or self-study for work with mentally retarded adults and assigned a mean rating of 2.4 ( F a i r ) . T a b l e 10 Respondents' R a t i n g 3 o f T h e i r F u r t h e r E d u c a t i o n i n Mental R e t a r d a t i o n P s y c h i a t r i s t P s y c h o l o g i s t S o c i a l Worker T o t a l 1(%) 2(%) 3(%) 4(%) 1(%) 2(%) 3(%) 4(%) 1(%) 2(%) 3(%) 4(%) N (%) XK MENTALLY RETARDED CHILDREN: Graduate Degree Program 0 3(75) 0 1(25) 2(29) 3(43) 0 2(29) 1(100)0 0 0 12 (14) 2 3 U n i v e r s i t y o r C o l l e g e C r e d i t Courses 2(67) 1(33) 0 0 2(67) 0 0 1(33) 2(40) 2(40) 1(20) 0 11 (13) 1 7 C o n f e r e n c e s , Workshops, Seminars 2(50) 0 1(25) 1(25) 1(20) 2(40) 2(40) 0 1( 8) 2(17) 8(67) K 8) 21 (24) 2 6 S t a f f Development 0 0 1(50) 1(50) 2(50) 1(25) 1(25) 0 3(33) 2(22) 4(44) 0 15 (17) 2 2 Reading o r S e l f - s t u d y 1(25) 1(25) 1(25) 1(25) 1(20) 2(40) 1(20) 1(20) K 8) 7(54) 3(23) 2(15) 22 (25) 2 5 Other 0 0 1(50) 1(50) 1(100)0 0 0 0 1(100)0 0 4 ( 4) 2 5 MENTALLY RETARDED ADULTS: Graduate Degree Program 2(50) 1(25) 0 1(25) 4(57) 3(43) 0 0 1(100)0 0 0 12 (14) 1 6 U n i v e r s i t y or C o l l e g e C r e d i t Course 3(100)0 0 0 2(67) 1(33) 0 0 1(20) 1(20) 2(40) 1(20) 11 (13) 1 8 C o n f e r e n c e s , Workshops, Seminars 2(50) 0 1(25) 1(25) 3(60) 1(20) 1(20) 0 1( 8) 2(15) 8(61) 2(15) 22 (25) 2 5 S t a f f Development 0 0 1(50) 1(50) 2(50) 1(25) 1(25) 0 2(18) 5(45) 4(36) 0 17 (19) 2 2 Reading o r S e l f - s t u d y 1(25) 1(25) 1(25) 1(25) 2(40) 3(60) 0 0 0 9(60) 3(20) 3(20) 24 (27) 2 4 Other 0 0 1(50) 1(50) 1(100)0 0 0 0 0 0 0 3 ( 3) 2 6 R a t i n g s c a l e = (1) Poor, (2) F a i r , (3) Good, (4) E x c e l l e n t % = p e r c e n t a g e o f t o t a l r e s p o n d e n t s . 118 Years of P a r t i c i p a t i o n i n Further Education Question 9 asked respondents to indicate t h e i r l a s t year of p a r t i c i p a t i o n i n further education i n the area of mental retardation. Of the 31 respondents who completed t h i s question, 15 (48%) indicated 1978-1979 as t h e i r l a s t year of p a r t i c i p a t i o n , 5 (16%) indicated between 1974-1977, 3 (10%) indicated between 1970-1973, and 8 (26%) indicated before 1970. Future P a r t i c i p a t i o n i n Further Education In Question 10, respondents were asked to indicate whether or not i n the future they would participate i n further education i n the area of mental retardation. The respondents' answers to Question 10 are. recorded i n Table 11, i n d i c a t i n g the reasons why the respondents would not pa r t i c i p a t e i n further education i n mental retardation. T h i r t y - f i v e (41%) of the 85 respondents indicated that they would pa r t i c i p a t e i n further education i n the area of mental retardation, and 50 (59%) said they would not. Of the reasons given for not p a r t i c i p a t i n g , 4'4 (88%) stated they would not participate i n further education because they did not work with the mentally retarded, 1 (2%) indicated having had enough preparation and experience i n the area, and 5 (10%) gave other reasons. 119 Table 11 Future P a r t i c i p a t i o n i n Further Education i n Mental Retardation Yes No Reasons Why Not a N % N o, "o Do Not Work With M.R. Adults N % Have Enough Preparation N % Other N % P s y c h i a t r i s t 3 (27) 8 (73) 7 (88) 0 1 (12). Psychologist 5 (36) 9 (64) 8 (88) 0 1 (12) So c i a l Worker 27 (45) 33 (55) 29 (88) 1 (2) 3 ( 9) Totals 35 (41) 50 (59) 44 (88) 1 (2) 5 (10) For further d e s c r i p t i o n of "reasons why not," see Appendix A, p. 253. Current Caseload Table 12 record the number of mental health professionals who indicated that since January 1, 1979, they had mentally retarded adults as patients or c l i e n t s (see Question 11). Of the respondents, 13 (15%) indicated that they did have mentally retarded adults as c l i e n t s , while 73 (85%) indicated they did not. Table 12 Number of Professionals Who Had Mentally Retarded Adults on Their Caseloads P s y c h i a t r i s t N. (%)'b Psychologist N (%) S o c i a l Worker N ;(%) T o t a l a N (%) Mentally Retarded Adult C l i e n t s 3 (27) T ( 6) 9 (15) 13 (15) No Mentally Retarded Adult C l i e n t s 8 (73) 15 (94) 50 (85) 73 (85) One respondent did not answer question, % = percent of t o t a l respondents. % = percent of professionals i n that category. 120 Factors Which Affect Provision of Service Respondents who indicated that they did not have mentally retarded adults as c l i e n t s were asked i n Question 12 to check as many factors as appropriate which prevented them from providing mental health services to mentally retarded adults. Table 13 shows for each group of professionals, those factors which they f e l t prevented them from providing services to mentally retarded adults. Of the 72 respondents to Question 12, 33 (46%) indicated that they had not received any r e f e r r a l s of mentally retarded adults, 29 (40%) indicated that t h e i r place of employment did not have a mandate to serve mentally retarded adults, 18.(25%) recorded that within t h e i r place of employment i t was not t h e i r r e s p o n s i b i l i t y to provide services to mentally retarded adults, 9 (12%) indicated that they preferred to provide services to c l i e n t s other than mentally retarded adults, and 7 (10%) f e l t that they had i n s u f f i c i e n t preparation for providing services to mentally retarded adults. 121 Table -131 Factors Which Prevent Professionals From Providing Services to Mentally Retarded Adults P s y c h i a t r i s t Psychologist S o c i a l Worker Totalb N (%) a N (%) N (%) N (%) Place of Employment does not have mandate to serve M.R. adults. 4 (33) 11 (50) 14 (22) 29 (40) Within place of employment not my r e s p o n s i b i l i t y to provide services to M.R. adults. 0 3 (14) 15 (24) 18 (25) Prefer to provide services to c l i e n t s other than M.R. adults. 2 (17) 2 ( 9) 5 ( 8) 9 (12) Have i n s u f f i c i e n t preparation f o r providing services to the M.R. adults. 0 2 ( 9) 5 ( 8) 7 (10) Have not received r e f e r r a l s of M.R. adults. 6 (50) 4 (18) 23 (37) 33 (46) % = percent of responses given by pr o f e s s i o n a l group (column percentage). % = percent of the 72 respondents to the question. 122 Referral to Other Resources for Service If a professional did not provide mental health services to mentally retarded adults, they were asked i n Question 13 to indicate to whom they would refer a mentally retarded i n d i v i d u a l for services. Table^-14-> shows that 19 (30%) of the respondents indicated that i f they received r e f e r r a l s of mentally retarded adults and did not provide services to mentally retarded adults, they would refer to a Mental Health Service; 16 (25%) indicated that they would refer to the Ministry of Human Resources; 9 (14%) would refer to a non-profit organization, i n most cases the l o c a l association for the mentally retarded; 2 (3%) would refer to a private p s y c h i a t r i s t ; 2 (3%) would refer to an i n s t i t u t i o n ; and 1 (2%) would refer to Aid to the Handicapped, now c a l l e d Community Vocational Rehabilitation Services. Fifteen (23%) checked o ff the "other" category, ind i c a t i n g some combination of the above depending upon the needs of the c l i e n t s involved. 123 Table 14'. Resources -Mentally Retarded Adults .Would ^Be Referred to for Mental Health Services Referrals Made to Referrals Made By Tot a l N=62(%) Ps y c h i a t r i s t N Psychologist N S o c i a l Worker N Family Physician 0 0 0 0 Private" P s y c h i a t r i s t 1 0 1 2 ( 3) Private Psychologist 0 0 0 0 Mental Health Service 1 2 16 19 (30) Aid to Handicapped 0 0 1 1 ( 2) Human Resources 3 2 11 16 (25) Non-profit Association; 0 2 7 9 (14) I n s t i t u t i o n 2 0 0 2 ( 3) Other 1 5 9 15 (23) 124 Number of Mentally Retarded Adults on Current Caseloads Table 15 records the answers to Question 14, which.asked the professionals who provided mental health services to mentally retarded adults, how many mentally retarded adults they had on thei r caseloads since January 1, 1979. The professionals were asked to record t h e i r answers separately for the three levels of mental retardation given: mild mental retardation (IQ 75-50); moderate mental retardation (IQ 49-30); and severe mental retardation (IQ 29-below). Table 15 shows that of the 29 2 mentally retarded c l i e n t s whoc~w.ere. receiving mental health services from 13 respondents, 147 (50%) were considered to be mildly mentally retarded, 126 (43%) moderately mentally retarded, and 19 (7%) severely mentally retarded. Table 15 Number of Mentally Retarded Adults Currently Receiving Services P s y c h i a t r i s t Psychologist S o c i a l Worker Tot a l Mild Retardation 10 6 131 147 (50) Moderate Retardation 1 0 125 126 (43) Severe Retardation 1 0 18 19 ( 7) Totals 12 6 274 292 (100) 125 Percentage of Caseload , From Question 15, 7 (54%) of the professionals indicated that t h e i r mentally retarded c l i e n t s made up l % - 5 % of t h e i r caseload, while 3 (21%) indicated they made up between 80%-100% of their caseloads. Of the remaining 3 respondents, 1 (7%) respondent each indicated, that t h e i r mentally retarded c l i e n t s made up between 11%-15%, 40%-59%, and 60%-79% of t h e i r caseloads. Source of Referral In Question 16, the respondents were asked to indicate how t h e i r mentally retarded c l i e n t s were referred to them for service. Table 16 shows the number of c l i e n t s referred to the mental health professionals by a p a r t i c u l a r source of r e f e r r a l . A source of r e f e r r a l was not i d e n t i f i e d for a l l 292 mentally retarded c l i e n t s receiving services. Of the 249 c l i e n t s for whom a source of r e f e r r a l was i d e n t i f i e d , 83 (33%) were referred by s o c i a l workers, 61. (24%) were referred by "other" which included Public Health Nurses, Associations for the Mentally Retarded, and other agencies, 49 (20%) by parents, 36 (14%) by school personnel, 12 (5%) by family physicians, 5 (.2%) by s e l f , and 3 (1%) by p s y c h i a t r i s t s . 126 Table 16 Source of Ref e r r a l of Mentally Retarded C l i e n t s Number of Mentally Retarded to C l i e n t s Referred Source of Ref e r r a l P s y c h i a t r i s t N Psychologist N S o c i a l Worker N T o t a l N=249(%) Sel f 0 0 5 5 ( .2).; Parents 0 0 49 49 (20) P s y c h i a t r i s t 1 2 0 3 ( 1) Family Physician 3 0 9 12 ( 5) Psychologist 0 0 0 0 Ps y c h i a t r i c Nurse 0 0 0 0 So c i a l Worker 0 2 81 83 (33) School Personnel 0 0 36 36 (14) Other e.g., Public Health Nurse, Associa-t i o n for M.R., other agencies. 6 2 53 61 (24) 127 Services Provided to Mentally Retarded Adults Table 17 l i s t s the services provided to mentally retarded adults and the number of c l i e n t s receiving each service as asked for i n Question 17. The respondents were asked to record the number of c l i e n t s , according to the l e v e l of mental retardation of the c l i e n t s , to whom they provided the service. The same levels of mental retardation applied as were given for Question 14. Of the 292 mentally retarded adults who were receiving services from the respondents, as shown e a r l i e r i n Table 15, 164 (56%) received an i n i t i a l intake interview, 24 (8%) received diagnostic assessment, 140 (50%) received counselling and/or psychotherapeutic assistance, 74 (25%) received parental and/or family counselling and/or psycho-therapeutic assistance, 35 (12%) received r e f e r r a l to another resource for counselling and/or psychotherapeutic assistance, and 8 (3%) received drug therapy. Additional services, e.g., f i n a n c i a l , educational, r e s i d e n t i a l , etc., were provided to 215 (74%) c l i e n t s , while 73 (25%) were referred to other resources for such services. Follow-up assistance was provided to 97 (33%) of the c l i e n t s . Consultation with s i g n i f i c a n t others i n the c l i e n t ' s l i f e was provided i n 206 (70%) of the-cases, written reports to parents were provided i n 60 (20%) cases, while written reports to s i g -n i f i c a n t others i n the c l i e n t ' s l i f e were provided i n 67 (23%) cases. Other mental health services, i . e . , h o s p i t a l i z a t i o n and emergency service, were provided for 12 (4%) cases. Table 17 Mental Health Services Provided to Mentally Retarded Adults Psychiatrist Number Of Mentally Re Psychologist tarded Adults Social Worker Total Mild N(%) Mod. N(%) Sev. N(%) Mild N(%) Mod. N(%) Sev. N(%) Mild N(%) Mod. N(%) Sev. N(%) N(%) Intake Interview 8(14) 1(12) 0 0 0 0 85(16) 61(13) 9(10) 164(56) Diagnostic Assess-ment 6(11) 1(12) 1(50) 0 0 0 12( 2) 2(.4) 2( 2) 24 ( 8) Counselling and/or Psychotherapeutic Assistance 8(14) 1(12) 0 2(14) 4(14) 0 51(10) 61(13) 13(15) 140(50) Parental/Family Counselling 3( 5) 1(12) 0 0 0 0 16 ( 3) 45(11) 9(10) 74(25) Referral to other resource for coun-selling/psycho-therapeutic assistance 1( 2) 1(12) 0 2(14) 4(14) 0 I K 2) 14 ( 3) 2( 2) 35(12) Drug Therapy 7(12) 1(12) 0 0 0 0 0 0 0 8( 3) Provision of additional services eg.financial, educational, r e s i d e n t i a l K 2) 0 0 2(14) 4(14) 0 95(18) 95(20) 18(21) 215(74) Referral for other services, eg., f i n a n c i a l , educa-ti o n a l , r e s i d e n t i a l 8(14) 0 0 2(14) 4(14) 0 49 ( 9) 10 ( 2) 0 73(25) Follow-up Assistance 3( 5) 1( 2) 0 2(14) 4(14) 0 26 ( 5) 50(11) 11(13). 97(33) continued... Table 17 continued... - Number of Mentally Retarded Adults Psychiatrist Psychologist Social Worker Total Mild Mod. Sev. Mild Mod. Sev. Mild Mod. Sev. N(%) N(%) N(%) N(%) N(%) N(%) N(%) N(%) N(%) N(%) Consultation with s i g n i f i c a n t others in c l i e n t ' s l i f e 4( 7) 1(12) 0 2(14) 4(14) 0 91(18) 88(19) 16(19) 206(70) Written reports to parents 2( 3) 0 0 0 0 0 29 ( 6) 27( 6) 2( 2) 60(20) Written reports to sign i f i c a n t others in c l i e n t ' s l i f e 2( 3) 0 1(50) 0 0 0 48( 9) 13( 3) 3( 3) 67(23) Other mental health services 3( 5) 0 0 2(14) 4(14) 0 3(.5) 0 0 12 ( 4) %.= percent of t o t a l number of services provided to c l i e n t s by that professional group, column percent. % = percent of the 292 c l i e n t s who received services. 130 Problem Areas Question 19 asked the respondents to record the number of mentally retarded adult c l i e n t s who came to them for counselling and/or psychotherapeutic assistance i n the selected problem areas l i s t e d . Table .18 provides the answers of the respondents, giving the number of c l i e n t s i n each l e v e l of mental retardation who received counselling and/or psychotherapeutic assistance i n a p a r t i c u l a r problem area. For further description of the selected problem areas see Question 19 i n Appendix A. Of the 29 2 mentally retarded c l i e n t s who had received services from the respondents, 28 7 (98%) had received counselling and/or psychotherapeutic assistance i n the area of "inadequate l i f e s k i l l s . " The professionals also provided counselling and/or psychotherapeutic assistance to 69 (24%) mentally retarded adult c l i e n t s for "resistance to p a r t i c i p a t i n g i n h a b i l i t a t i v e programs," 36 (12%) for "aggressive behaviour," 113 (39%) for "poor s o c i a l relationships," 60 (20%) for "behavioural regression," 50 (17%) for "neurotic t r a i t s , " 30 (10%) for "psychotic t r a i t s , " 24 (8%) for " a n t i - s o c i a l behaviours," 31 (11%) for "neurological disorder,"; 32 (11%) for "inappropriate sexual behaviour," 114 (39%) for "learning problems," and 12 (4%) for " s u i c i d a l behaviour." Table 18 Number of Mentally Retarded Adults Who Had Received Counselling and/or Psychotherapeutic Counselling in the Following Selected Problem Areas 3 Psychiatrist Psychologist Social Worker Total Mild. N(%) Mod. N(%) Sev. N(%) Mild N(%) Mod. N(%) Sev. N(%) Mild N(%) Mod. N(%) Sev. N(%) N(%) c Inadequate L i f e S k i l l s 26(36) 0 0 2(11) 4(11) 0 77(30) 115(34) 63(47) 287(98) Resistance to Participating in Habili t a t i v e Programs 4(5) 0 0 2(11) 4(11) 0 24( 9) 16 ( 5) 9( 7) 69(24) Aggressive Behaviour 5(7) 1(33) 0 2(11) 4(11) 0 13( 5) 7( 2) 4( 3) 36(12) Poor Social Relationships 6(8) 0 0 2(11) 4(11) 0 32(12) 57(17) 12( 9) 113(39) Behavioural Regression 5(7) 1(33) 0 2(11) 4(11) 0 19 ( 7) 20 ( 6) 9( 7) 60(20) Neurotic Traits 5(7) 0 0 0 0 0 21 ( 8) 16( 5) 8( 6) 50(17) Psychotic T r a i t s 6(8) 0 0 2(11) 4(11) 0 9( 3) 11 ( 3) 5( 4) 30(10) Anti-social Behaviour 3(4) 0 0 2(11) 4(11) 0 I K 4) 2(.5) 2( 1) 24 ( 8) Neurological Disorder 2(3) 0 0 2(11) 4(11) 0 14 ( 5) 7( 2) 2( 1) 31(11) Inappropriate Sexual Behaviour 0 0 0 0 0 0 9( 3) 15( 4) 8( 6) 32(11) Learning Problems 8(11) 1(33) 0 0 0 0 23( 9) 70(20)' 12( 9) 114(39) Suicidal Behaviour 3(4) 0 0 2(11) 4(11) 0 2 (.7) K . 2 ) 0 12 ( 4) For further description of selected problem areas, see Appendix A, p. 257. % = percent of t o t a l number of services provided to clients by that professional group, column percent % = percent of the 292 c l i e n t s receiving service. 132 Theoretical Approach In Question 20, respondents were asked to rate 16 the o r e t i c a l approaches to counselling and psychotherapeutic assistance according to how often they would use a p a r t i c u l a r t h e o r e t i c a l approach with t h e i r mentally retarded adult c l i e n t s . The rating scale applied was: (0) 0% of the time; (1) l%-25% of the time; (2) 26%-50% of the time; (3) 51%-75% of the time; and (4) 76%-100% of the time. Table 19 provides the ratings of the respondents, by professional group, for the th e o r e t i c a l approaches used with d i f f e r e n t levels of mentally retarded c l i e n t s . Not a l l respondents rated a l l t h e o r e t i c a l approaches, with the zero rating being used very infrequently. Except for those th e o r e t i c a l approaches which the respondents indicated some degree of use, most often the approaches were not rated. Consequently i t i s unclear as to whether or not a respondent used a p a r t i c u l a r t h e o r e t i c a l approach or whether he or she avoided answering the question. The few zero ratings provided have not been recorded i n Table 19 because they were found not to be very meaningful. The approach used by the largest number of respondents, 8 (73%) , was Directive Counselling (Williamson), who indicated the mean use of t h i s approach to be 2.3, or 26%-50% of the time. Of the respondents, 7 (64%) indicated using Reality Therapy (Glaser), assigning a mean rating of 2.6; 5 (45%) of the respondents indicated using Behaviour Therapy (Skinner), assigning a mean rat i n g of 2.3; 4 (36%) of the respondents indicated using Client-Centered Therapy (Rogers), assigning a 133 mean rating of 3.1; 2 (18%) of the respondents indicated using Ego Psychology (Erikson), assigning a mean rating of 2.6, and 2 (18%) indicated using Transactional Analysis (Dusay), assigning a mean rating of 1.6. The remaining approaches were each used by one respondent, except for Individual Psychology (Adler) which was not used by any of the respondents. Two respondents recorded "other," and specified that they used t h e i r "own" approach, and that the approach depends on "needs and circumstances" of the c l i e n t . Table 19. Respondents' Ratings 3 of Their Use of Theoretical Approaches in Counselling and/or Psychotherapy with Mentally Retarded Adults Psj f c h i a t r i s t Psychologist Social Worker Total Mild Mod. Sev. Mild Mod. Sev. Mild Mod. Sev. 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 N=ll b (%)c3?Rd Psychoanalytic (Freud) - 1 ( 9) 2.0 Individual Psychology (Adler) - - -Ego Psychology (Erikson) 2 (18) 2.6 Client-centered Therapy (Rogers) 4 (36) 3.1 Humanistic Psychotherapy (Maslow) 1 ( 9) 4.0 E x i s t e n t i a l Analysis (Frank) 1 1 ( 9) 1.0 Gestalt Therapy (Perls) 1 ( 9) 2.0 E c l e c t i c (Thorne) 1 ( 9) 4.0 Rational-Emotive ( E l l i s ) 1 1 ( 9) 1.0 Psychodrama (Moreno) 1 ( 9) 1.0 Learning Theory (Shoben) 1 1 ( 9) 1.0 Desensitization (Wolpe) - 1 ( 9) 2.0 Transactional Analysis (Dusay) 1 2 (18) 1.6 Reality Therapy (Glaser) - 1 1 - 1 - 1 1 - 1 2 1 1 1 - - 2 - 7 (64) 2.6 Directive Counselling (Williamson) 1 1 1 - 1 1 1 1 1 1 2 - - 1 2 - - - 3 - - 8 (73) 2.3 Behaviour Therapy (Skinner) - 1 5 (45) 2.3 Other 1 2 (18) 4.0 a The following scale applies: 0 = I use this approach 0% of the time 3 = 1 use this approach 51- 75 % of the time. 1 = 1 use this approach 1-25% of the time 4 = 1 use this approach 76-100% of the time. 2 = 1 use this approach 26-50% of the time N = number of respondents who responded to question. Row s column totals w i l l not equal N because respondent may use same approach or more than one approach with different levels of mentally retarded c l i e n t s . c % = percent of N = 11 ^ XR~ = mean rating (see a) 135 A r t therapy, drama therapy, and parents i n group therapy were a l l used by one respondent, while no respondent i n d i c a t e d u s i n g p l a y therapy. 1 136 Methodological Approach In Question 21, respondents were asked to rate 13 methodo-l o g i c a l approaches to counselling and/or psychotherapeutic assistance, according to how often they would use a p a r t i c u l a r methodological approach with t h e i r mentally retarded adult c l i e n t s and t h e i r parents and/or famil i e s . The same rating scale as was used i n Question 20, applied. Table 20 provides the ratings of the respondents, by professional group, for the methodological approaches used with d i f f e r e n t l e v e l s of mentally retarded c l i e n t s . Again, the "0" ra t i n g , i n d i c a t i n g that respondents did not use a p a r t i c u l a r approach, was used infrequently and thus, the zero rating i s not recorded i n Table 20. Most often the respondents only rated those approaches that they used, and did not c i r c l e "0" when they did not use an approach. The methodological approach used by the largest number of respondents, 9 (75%), was Individual Therapy, in d i c a t i n g a mean use of t h i s approach to be 3, or 51%-75% of the time. Of the respondents, 6 (50%) indicated that they used the following approaches with the mean rating for each approach given i n brackets: i n d i v i d u a l and group therapy (2.6), i n d i v i d u a l and family therapy (1.9), and family therapy (1.4). Five (42%) of the respondents indicated that they each used group therapy, with a mean rating of 1.5, and both parents i n therapy with a mean rati n g of 1.6. Drug therapy was used by 4 (33%) of the respon-dents and was assigned a mean rating of 3. Music therapy was used by 2 (17%) respondents, and was assigned a mean rating of 1.5. Table 20 Respondents' Ratings 3 of Their Use of Methodological Approaches in Counselling and/or Psychotherapeutic Approaches with Mentally Retarded Adults and/or Their Parents' Psychiatrist Psychologist Social Worker Total Mild Mod. Sev. 1 2 3 4 1 2 3 4 1 2 3 4 Mild Mod. Sev. 1 2 3 4 1 2 3 4 1 2 3 4 Mild Mod. Sev. 1 2 3 4 1 2 3 4 1 2 3 4 N=12b (%)CXRd Individual Therapy Group Therapy Individual and Group Therapy Individual and Family Therapy Play Therapy .Art Therapy Drama Therapy Music Therapy Drug Therapy 1 1 2 3 1 - 1 3 - 1 1 3 1 1 1 - 1 1 - - 2 1 1 - 1 1 1 1 - 2 9 (75) 3.0 5 (42) 1.5 6 (50) 2.6 6 (50) 1.9 1 ( 8) 1.5 1 ( 8) 1.0 2 (17) 1.5 4 (33) 3.0 PARENTS/FAMILY THERAPY Psychiatrist Psychologist Social Worker Total 1 2 3 4 1 2 3 4 1 2 3 4 Individual Parent i n Therapy Both Parents i n Therapy Parents i n Group Therapy Family Therapy 1 - - -1 - - -2 1 - --1 1 2 1 1 3 - -1 - - -2 2 - -6 (50) 2.3 5 (42) .1.6 1 ( 8) 1.0 6 (50) 1.4 The following scale applies: 0 = 1 use t h i s approach 0% of the time 3 = 1 use this approach 51-75% of the time 1 = 1 use this approach 1-25% of the time 4 = 1 use this approach 76-100% of the time b 2 = 1 use this approach 26-50% of the time N = number of respondents who responded to question. Row s column totals w i l l not equal N because respondents may use same approach or more than one approach with different levels of mentally retarded c l i e n t s . c % = percent of N = 12 XI? = mean rating (see a) 138 Effectiveness of Counselling and/or Psychotherapeutic  Assistance Nine of the 13 professionals who indicated that they had mentally retarded adults as c l i e n t s answered Question 22, which asked the respondents to rate the effectiveness of counselling and/or psychotherapeutic assistance with mentally retarded adult c l i e n t s . Table 21 shows the respondents' rating of counselling and/or psychotherapeutic assistance for each of the selected problem areas given i n Question 22, for each l e v e l of mental retardation. The rating scale provided was: (0) Not Ef f e c t i v e ; (1) Poor; (2) F a i r ; (3) Good; and (4) Excellent. Counselling and/or psychotherapeutic assistance was assigned a mean rating of 2.5-3.0 (Good) with mildly.mentally retarded c l i e n t s i n a l l the selected problem areas except for Neurological Disorders and Learning Problems which were assigned a mean rating of 1.7 and 1.9 ( F a i r ) . The effectiveness of counselling and/or psychotherapeutic assistance with moderately mentally retarded c l i e n t s was given mean ratings between 1.3 (Poor) and 2.6 (Good) i n a l l the selected problem areas. For the severely mentally retarded c l i e n t , counselling and/or psychotherapeutic assistance was given a mean rating of 0 (Not Effective) and 1.0 (Poor) i n a l l the selected problem areas. Table 21 Respondents' Ratings 3 of the Effectiveness of Counselling and/or Psychotherapeutic Assistance with Mentally Retarded Adults i n Selected Problem Areas Psychiatrist Psychologist Social Worker Mild 0 1 2 3 Mod. 4 0 1 2 3 4 0 Sev. 1 2 3 4 Mild 0 1 2 3 4 0 Mod. 1 2 3 4 0 Sev. 1 2 3 4 0 Mild 1 2 3 Mod. 4 0 1 2 3 4 0 Sev. 1 2 3 4 dild Mod. Sev. Inadequate L i f e S k i l l s - - 1 2 2 1 1 - 1 _ 1 4 2 - - 4 1 - 4 2.9 2.1 0.8 Resistance to Ha b i l i t a t i v e Programs - 1 1 1 1 1 - 1 1 - 1 _ - 1 4 1 - - 3 2 - 3 1 - 2.8 2.6 1.0 Aggressive Behaviour 2 1 1 1 1 _ _ _ - _ _ 1 - 1 _ _ _ _ - - - 2 2 1 - 1 2 2 - 2 1 1 - - 2.7 2.3 0.6 Poor Social Relationships 3 - - - 1 1 - - 1 _ _ _ - _ _ _ _ 1 - 1 _ - - - - - - 1 4 1 - 1 2 2 - 1 3 _ 2.8 2.3 0.6 Behavioural Regression - 1 2 - - - 1 1 - - 1 _ _ _ - _ _ _ _ 1 - 1 _ _ _ _ - - - 2 2 1 - 2 2 1 - 2 2 _ 2.5 2.1 0.4 Neurotic Traits - 1 1 1 2 1 - 1 - 1 _ - - - 2 3 - - 2 2 1 - 3 1 - - - 2.5 1.9 0.2 Psychotic T r a i t s - - 1 2 2 - - - 1 - - 1 - 1 - - - 1 3 2 - 1 2 1 1 - 3 1 - 2.7 2.1 0.6 Anti - s o c i a l Behaviour 2 1 1 1 - - - 1 - - - - - - 1 - 1 - _ _ _ - - 1 3 1 1 2 - 2 1 - 3 1 - - _ 2.5 2.0 0.6 Neurological Disorder 2 1 - 1 1 - 1 - - _ _ _ _ 1 - 1 _ _ _ _ - 1 4 1 - - 2 2 1 - - 3 1 - - _ 1.7 1.4 0.6 Inappropriate Sexual Behaviour - 1 2 - 2  1 - _ _ _ _ 1 - 1 - _ _ _ - - - 2 3 1 - 2 - 3 - 2 1 1 - - 2/6 2.4 0.8 Learning Problems - 1 2 1 - - 1 1 1 - - - 1 - 1 _ - 1 2 2 1 - 3 1 1 - - 3 1 - 1.9. 1.3 0.4 Suicidal Behaviour - - 1 2 1 1 - - 1 - 1 - 1 _ - - - 2 2 2 1 - 3 1 - 3 1 - - - 3.0 2.3 0.4 VO The following scale applies: (0) Not Eff e c t i v e , (1) Poor, (2) Fair, (3) Good, (4) Excellent XR = mean rating across professionals 140 Amount of Service Provided Table 22 shows the amount of service provided by the respondents to th e i r mentally retarded adult c l i e n t s . Of the 13 respondents to Question 23, 9 (69%) saw th e i r mentally retarded c l i e n t s two to three times per month or more, and 4 (31 saw t h e i r mentally retarded adult c l i e n t s once per month or less Table 22 Average Number of Sessions Respondents Had. With Their Mentally Retarded Adult C l i e n t s P s y c h i a t r i s t s Psychologists S o c i a l Workers To t a l N N N N Once per year - - 1 •1 2-6 times per year - - 2 2 7-11 times per year 1 - - 1 2-3 times per month - 1 2 3 Once per week - - 3 3 2+ times per week 1 - 2 3 Waiting L i s t In Question 24, the respondents were asked to indicate the average length of time a mentally retarded adult c l i e n t would have to wait to receive service. There were 18 responses to t h i question, with 13 (72%) indi c a t i n g no waiting at locations such as private practice, Mental Health, Human Resources, non-profit organizations, hospital or i n s t i t u t i o n . One respondent indicated a waiting. l i s t - ; o f up to two"-weeks atCa""Merital~_Health 141 Service, while another indicated up to two weeks at a hospital or i n s t i t u t i o n . One respondent indicated a waiting period of 2-4 months i n private practice and for non-profit organiza-tions , one respondent recorded a w a i t - l i s t period of 8-11 months, while another respondent indicated one year or-.-more. Age and Sex of Mentally Retarded Adult Clients Questions 25 and 26 asked for the age range and sex of the respondents' mentally retarded adult c l i e n t s . Table 23 -shows the number of mentally retarded adult c l i e n t s i n the age categories provided i n Question 26, and Table 24 shows the number of male and the number of female adult mentally retarded c l i e n t s . Of the 292 mentally retarded adult c l i e n t s who received services from the mental health professionals, 122 (42%) were between 19-25 years of age, 62 (21%) were between 26-30 years of age, 44 (15%) were between 31-35 years of age, 32 (11%) were between 36-40 years of age, 16 (5%) were between 41-45 years of age, and 16 (5%) were over 46 years of age. There were 169 (58%) male mentally retarded c l i e n t s , and 123 (42%) female mentally retarded c l i e n t s . 142 Table 23 Age Range of Mentally Retarded Adult C l i e n t s Years N = 292 (%) 19-25 122 (42) 26-30 62 (21) 31-35 44 (15) 36-40 32 (11) 41-45 16 ( 5) 46+ 16 ( 5) Table 24 Number of Male and Female Mentally Retarded Adult C l i e n t s Sex N = 292 (%) Male 169 (58) Female 123 (42) L i v i n g Situation and Daytime A c t i v i t y of Mentally Retarded Clients Question 2 7 asked the respondents to indicate the number of th e i r c l i e n t s who l i v e d i n the di f f e r e n t r e s i d e n t i a l situations l i s t e d . S i m i l a r l y , Question 28 asked for the number of c l i e n t s who participated i n the di f f e r e n t daytime a c t i v i t i e s l i s t e d . Table 25 provides the responses to Question 27 and Table 26 provides the responses to Question 28. Of the 292 mentally retarded adults who received services from the mental health professionals, 191 (65%) l i v e d i n t h e i r family home, 44 (15%) l i v e d i n a group home s i t u a t i o n , 19 (7%) 143 l i v e d i n a boarding home, 18 (6%) l i v e d i n a long-term care home, 15 (5%) l i v e d i n t h e i r own home or apartment, and 5 (2%) l i v e d i n o ther s i t u a t i o n s (e.g., i n s i t u t i o n or were c o n s i d e r e d to be t r a n s i e n t ) . For daytime a c t i v i t i e s , 207 (71%) of the mentally r e t a r d e d a d u l t s attended a s h e l t e r e d workshop program, 42 (14%) were not i n v o l v e d i n any program, 14 (5%) attended s c h o o l , 11 (4%) p a r t i -c i p a t e d i n v o l u n t e e r work, 9 (3%) attended a v o c a t i o n a l school or community c o l l e g e , 4 (1%) were employed i n the r e g u l a r labour f o r c e , 3 (1%) were employed i n s h e l t e r e d i n d u s t r i e s , and 2 (.6%) were i n v o l v e d i n oth e r i n s t i t u t i o n a l programs. Table 25 Li v i n g S i t u a t i o n of Mentally Retarded Adult C l i e n t s L i v i n g S i t u a t i o n N = 292 (%) Boarding Home 19 ( 7 ) Family Home 191 (65) Foster Home 0 ( 0 ) Group Home - 44 (15) Long-term Care Home 18 ( 6) Own Home or Apartment 15 ( 5 ) Other: e.g., I n s t i t u t i o n , Transient 5 ( 2) 144 Table 26 Daytime A c t i v i t y of Mentally Retarded Adult C l i e n t s Daytime A c t i v i t y N = 292 (%) Attending a Sheltered Workshop 207 (71) Employed i n a Sheltered Industry 3 ( 1) Employed i n Regular Labour Force 4 ( 1) Attending School 14 ( 5) Attending a Vocational School or Community College 9 ( 3) Volunteer Work 11 ( 4) Not Involved i n any Programs 42 (14) Other: e.g., I n s t i t u t i o n 2 (.6) Opinion of the Provision of Mental Health Services In Question 29, the respondents were asked f i r s t of a l l to rate how well they f e l t the agency for which they worked provided mental health services to mentally retarded adults (see Table 27). Secondly, they were asked to rate how well they f e l t other community-based agencies provided mental health services to mentally retarded adults (see Table 28). The rati n g scale provided was: (0) Do Not Provide This Service; (1) Poor; (2) Fa i r ; (3) Good; and (4) Excellent. Table 27 shows that the mean rating for a l l services provided f e l l between 1.9 (Fair) and 2.9 (Good). The lowest ra t i n g , 1.9, was assigned to the provision of i n d i r e c t mental health services (e.g., s t a f f t r a i n i n g , development of services, Table 27 Respondents' Opinion of Their Agency's Provision of Mental Health Services to Mentally Retarded Adults Private Practice Mental Health Human Resources School Board Non-Profit Organi. Hospital I n s t i t . Univ. Other Agencv o6 0 1 2 3 4 0 1 2 3 4 0 1 2 3 4 0 1 2 3 4 0 1 2 3 4 0 1 2 3 4 0 1 2 3 4 0 1 2 3 4 XR Intake Interview 7 - - 3 - 2 2 - 3 1 5 7 2 1 1 - - - 8 - 2 5 4 101 - 3 1 _ 7 1 38 2.9 Diagnostic Assessment 6 3 2 2 3 - 9 3 3 3 - 1 - 1 - - 9 1 1 5 - 11- - 2 1 5 _ _ _ 1 7 1 50 2.3 Counselling and/or Psychothera-peutic Assistance 6 3 2 2 - 1 1 - 8 1 5 3 - 1 - 1 - _ 9 - 3 4 - 101 - 2 1 6 1 6 2 48 2.5 Parental/Family Counselling 5 - - 3 2 1 - 1 2 - 6 2 5 4 - 1 1 - - - 8 3 1 4 - 101 1 2 1 6 _ _ _ 1 6 1 1 - - 43 2.4 Referral to Other Resource for Counselling/Psychotherapeutic Assistance 6 - 1 1 3 1 1 1 - 2 1 5 8 1 1 - - 1 6 1 5 3 1 9 2 3 7 4 1 2 1 - 35 2.6 Drug Therapy 6 2 2 2 _ _ 4 _ 14- 3 - - 2 - 13 - 1 1 1 11- - 1 2 6 _ _. _ 1 8 62 2.6 Provision of Additional Services, eg., f i n a n c i a l , educational, r e s i d e n t i a l 7 - 3 - 1 2 - 2 1 1 4 10 2 1 1 8 - 2 4 2 121 1 - - 7 6 2 - 44 2.6 Referral for Additional Services, eg., f i n a n c i a l , educational r e s i d e n t i a l 6 3 2 1 - 3 - 1 - 6 10 1 1 - - 1 6 - 2 6 1 9 3 - 2 - 7 3 1 2 2 - 33 2.6 Follow-up Assistance 8 1 - 2 - 2 1 - 1 - 4 3 6 4 - 1 1 - - - 8 1 4 2 1 12 - - 1 - 7 8 50 2.2 Consultation with Significant Others i n Client's L i f e 6 1 - 3 1 1 3 - 3 1 7 6- 1 - 1 - 7 - 1 8 - 9 2 1 3 - 7 5 1 - 2 - 39 2.5 Written Reports to Parents 8 2 1 2 - 1 1 - 10-6 2 - 9 1 3 2 1 12- - 1 1 6 _ 1 7 1 56 2.5 Written Reports to Significant Others in Client's L i f e 6 - 2 2 1 2 - 1 1 - 8 1 6 1 - 1 1 8 1 2 5 - 11- 1 2 - 6 . _ . 1 7 1 49 2.6 Provision of Indirect Mental Health Services 9 - 1 3 - 1 6 4 6 2 - 1 - 1 - - 8 3 3 2 - 13- - 1 - 6 - 1 - - 6 1 - 1 - 52 1.9 Other Mental Health Services 39 2.E AR 2.8 2.6 2.3 2.0 2.6 2.6 3.8 2.3 b Rating scale: 0 - Do not provide thi s service, 1 - Poor, 2 - Fair, 3 - Good, 4 - Excellent Total number of respondents who did not provide this service. This number of respondents i s not used to calculate the mean rating. 1 4 6 etc.) while the highest r a t i n g , 2.9, was assigned to intake interviews. The zero rating shows the number of mental health professionals who indicated that they did not provide t h i s service. As shown i n Table 28, the mean ra t i n g of other community-based agencies' provision of mental health services to mentally retarded adults f e l l between 1.9 (Fair) and 2.5 (Good). The lowest r a t i n g , 1.9, was assigned to written reports to s i g n i f i c a n t others and provision of i n d i r e c t mental health services. The highest r a t i n g , 2.5, was assigned to intake interview, counselling and/or psychotherapeutic assistance, and r e f e r r a l to other source for counselling. Table 28 Respondents' Opinion of the Provision of Mental Health Services to Mentally Retarded Adults by Other Community-based Agencies Rating a 1 2 3 4 XR Intake Interview 3 11 13 3 2.5 Diagnostic Assessment 5 10 15 2 2.4 Counselling and/or Psychotherapeutic Assistance 1 15 13 2 2.5 Parental/Family Counselling 9 12 _-9 3 2.2 Re f e r r a l to Other Resource for Counselling/Psychotherapeutic Assistance 2 16 11 4 2.5 Drug Therapy 7 12 7 3 2.2 Provision of A d d i t i o n a l Services, eg., f i n a n c i a l , educational, : ' r e s i d e n t i a l 4 21 10 1 2.2 R e f e r r a l f o r A d d i t i o n a l Services, eg., f i n a n c i a l , educational, r e s i d e n t i a l 4 15 12 1 2.3 Follow-up Assistance 10 12 12 - 2.0 Consultation with S i g n i f i c a n t Others i n C l i e n t ' s L i f e 5 13 16 - 2.3 Written Reports to Parents 9 16 8 - 2.0 Written Reports to S i g n i f i c a n t Others i n C l i e n t ' s L i f e 10 14 7 - 1.9 Provision of I n d i r e c t Mental Health Services 9 14 7 - 1.9 Other Mental Health Services 2 2 2 1 2.3 Rating scale: 1 - Poor, 2 - F a i r , 3 - Good, 4 - Excellent 148 Responsibility for Provision of Mental Health Services Question 30 asked the respondents to indicate whether they or someone else within t h e i r agency should be responsible for the provision of mental health services to mentally retarded adults. Table 29 shows the respondents' answers to t h i s question,, according to th e i r place of professional practice. For those professionals i n private practice, 7 respondents indicated Yes,, they f e l t they were responsible for providing mental health services to mentally retarded adults, and 5 respondents indicated No, they did not fe e l responsible. For those respondents from Mental Health Services, 2 recorded Yes and 3 recorded No; from Ministry of Human Resources, 11 recorded Yes and 7 recorded No; from school boards, 0 recorded Yes and 3 recorded No; from non-profit organizations, 5 recorded Yes and 10 recorded No; from hospitals or i n s t i t u t i o n s , 6 recorded Yes and 9 recorded No; and from u n i v e r s i t i e s , 3 recorded Yes and 5 recorded No. In t o t a l , 37 (43%) of the respondents recorded Yes and 49 (.57%) of the respondents recorded No. Upon ca l c u l a t i n g a % 2 test of significance, t h i s r e s u l t was found not to be s i g n i f i c a n t at p=.10. However, a s i g n i f i c a n t difference (p <.03) did r e s u l t from a 7- 2 test of association between the professional groups i n t h e i r rate of response, i n d i c a t i n g that the two factors, professional group and opinion of r e s p o n s i b i l i t y for providing mental health services to mentally retarded adults, are not independent of one another. Of the p s y c h i a t r i s t s , 3 (33%) recorded No, while 6 (67%) recorded Yes; of the psychologists, 1 4 9 1 2 ( 6 7 % ) r e c o r d e d N o , w h i l e 2 ( 3 3 % ) r e c o r d e d Y e s ; o f t h e s o c i a l w o r k e r s , 3 0 ( 5 4 % ) r e c o r d e d N o , w h i l e 2 5 ( 5 6 % ) r e c o r d e d Y e s ( s e e T a b l e 3 0 ) . Table 29 Res p o n s i b i l i t y for the Provision of Mental Health Services to Mentally Retarded Adults by Location of Professional Practice of Respondents Re s p o n s i b i l i t y f o r Provision Of Service Location of Professional Practice Yes No Private Practice 7 5 Mental Health Services 2 3 M i n i s t r y of Human Resources 11 7 School Board 0 3 Non-profit Organization 5 10 Hos p i t a l or I n s t i t u t i o n 6 9 U n i v e r s i t y 3 7 Other 3 5 Total N=86 37 (43%) 49 (57%) ( X 2 = 1.6, df = 1, p > .10) Table 30 Res p o n s i b i l i t y f o r the Provision of Mental Health Services by Professional Group Professional Group Re s p o n s i b i l i t y f o r Provision of Services Yes No P s y c h i a t r i s t s 6 (67%) 3 (33%) Psychologists 2 (33%) 12 (67%) S o c i a l Workers 25 (56%) 30 (54%) To t a l 33 (42%) 45 (58%) (•X. 2 = 6.91, df = 2, p < .03) 150 Generic Versus Specialized Services In Question 31, the respondents were asked to indicate whether they f e l t counselling and/or psychotherapeutic assistance can be provided to mentally retarded adults by the same agency which provides t h i s service to the general population (generic),, or whether they f e l t these services should be provided by a special agency for the mentally retarded (specialized). Table 31 reveals the respondents' answers to this question for each group of professionals. Of the respondents, 42 (56%) f e l t that counselling and/or psychotherapeutic assistance could be provided by the same agency as the general population with personnel trained i n the provision of such assistance to the mentally retarded, while 33 (44%) said they f e l t counselling and psychotherapeutic assistance should be provided by a special agency for the mentally retarded. This r e s u l t was found not to be s i g n i f i c a n t at the .10 l e v e l of significance (?c 2 = 1.08, df = 1). However, i t was again found that there i s a s i g n i f i c a n t difference' (% 2 = 8.42, df = 2, p < .01) between the professional groups i n t h e i r rate of response, indicating that the two factors, professional group and opinion of generic agency versus speci a l i z e d agency, are not independent of one another. Approximately 50 percent each of the p s y c h i a t r i s t s and s o c i a l workers recorded generic agency and 50 percent recorded specialized agency, while 12 (92%) of the psychologists chose generic agency, compared to one who chose specialized agency. 151 Table 31 Respondents' Opinion of the Use of Generic Vs. Spe c i a l i z e d Agency f o r the Delivery of Mental Health Services to Mentally Retarded' Adults Generic Agency Special Agency P s y c h i a t r i s t s Psychologists S o c i a l Workers 4 (50%) 12 (92%) 26 (48%) 4 (50%) 1 ( 8%) 28 (52%) T o t a l N=75 (%) 42 (56%) 33 (44%) 152 Response to the Questionnaire by- Parents of Mentally Retarded Adults Sample Size and Number of Respondents A t o t a l population of 260 parents of mentally retarded adults (19 years and over) was compiled from the 1978 member-ship l i s t of the Vancouver-Richmond Association for the Mentally Retarded (V.R.A.M.R.). From th i s population, a random sample of 40% was drawn, a t o t a l of 104 parents. Table 32 presents the number of parents who responded to the questionnaire. From the sample of 104 parents, 5 individuals indicated that t h e i r son/daughter l i v e d out of the area and did not receive services from professionals i n the Vancouver-Richmond area. These re p l i e s were therefore not considered to be i n the population. Three individuals returned the questionnaire unanswered because they f e l t they could not answer i t or that i t did not apply to t h e i r son/daughter. Of the f i n a l sample of 96 parents, 50 parents (52%) responded to the questionnaire. Table 32 Number of Respondents to the Parents of Mentally Retarded Adults Questionnaire Population Sample (40%) Not i n Population Not .Einal Ahsweredc Sample Respondents N (%) Parents 260 104 5 3 96 50 (52%) 153 Age, Sex, and. Level of Mental Retardation Table 33 shows the age range, sex, and l e v e l of mental retardation of the mentally retarded adults whose parents responded to the questionnaire. Question 1 asked the parents to c i r c l e the age category to which t h e i r son or daughter belonged, and Question 4 asked the parents to indicate from the three levels of mental retardation - mild, moderate, or severe - at which l e v e l they f e l t t h e i r son or daughter was functioning. Of the 49 parents who responded to Questions 1 and 4, 19 (39%) indicated that t h e i r son/daughter was mildly mentally handicapped, 27 (55%) indicated that t h e i r son/daughter was moderately mentally handicapped, and 3 (6%) indicated that t h e i r son/daughter was severely mentally handicapped. There were 26 males and 23 females, with 21 (43%) between 19-25 years of age, 13 (27%) between 26-30 years of age, 10 (20%) between 31-35 years of age, 3 (6%) between 36-40 years of age, 1 (2%) between 41-45 years of age, and 1 (2%) over 46 years of age. Table 33 Age, Sex, and Level of Mental Retardation 19-25 26-30 Years 31-35 of Age 36-40 41-45 46+ Tota l Level M F M F M F M F M F M F N=49a. (%) Mil d 3 7 2 1 3 2 0 0 0 1 0 0 19 (39) Moderate 5 4 6 3 4 1 1 2 0 0 0 1 27 (55) Severe 2 0 0 1 0 0 0 0 0 0 0 0 3 ( 6) Totals (%) 21 (43) 13 (27) 10 (20) 3 (.6) 1 (2) 1 (2) One respondent l e f t question unanswered. 154 L i v i n g Situation and Daytime A c t i v i t y Question 2 asked the parents to indicate where t h e i r son/ daughter currently l i v e s , w h i l e Question 3 asked the parents to indicate t h e i r son's/daughter's current daytime a c t i v i t y . Table 34 shows the number of adults i n each l i v i n g s i t u a t i o n provided i n Question 2, while Table 35 gives the responses to the daytime a c t i v i t i e s l i s t e d i n Question 3. Of the 50 mentally retarded adults recorded i n the survey, 31 (62%) l i v e d i n t h e i r family home, 13 (26%) l i v e d i n group homes, 3 (6%) l i v e d i n t h e i r own home or apartment, 2 (4%) l i v e d i n some other adult t r a i n i n g program, and 1 (2%) l i v e d i n an i n s t i t u t i o n . For daytime a c t i v i t i e s , again of the 50 adults, 36 (72%) attended a sheltered workshop, 3 (6%) each were employed i n a sheltered industry, volunteer work, or were involved i n some other adult t r a i n i n g program. There were 2 (4%) adults each employed i n the regular labour force or attending school. One adult was recorded as not being involved i n any program. Table 34 L i v i n g S i t u a t i o n of Mentally Retarded Adults Mild Moderate Severe T o t a l L i v i n g S i t u a t i o n N N N N=50 (%) Family Home 15 15 1 31 (62) Own Home/Apartment 2 1 0 3 ( 6) Group Home 1 11 1 13 (26) Boarding Home 0 0 0 0 ( 0) In s t i t u t i o n / H o s p i t a l 0 0 1 1 ( 2) Other: e.g., Training Centre 2 0 0 2 ( 4) 155 Table 35 Daytime A c t i v i t y of Mentally Retarded Adults Daytime A c t i v i t y M ild N Moderate N Severe N T o t a l N=50 (%) Attending Sheltered Workshop 11 23 2 36 (72) Employed i n Sheltered Industry 1 2 0 3 ( 6) Employed i n Regular Labour Force 2 0 0 2 ( 4) Attending School 1 1 0 2 ( 4) Attending Vocational School or Community College 0 0 0 0 ( 0) Volunteer Work 2 1 0 3 ( 6) Not Involved i n Any Program 1 0 0 1 ( 2) Other: e.g., I n s t i t u t i o n a l Program 2 0 1 3 ( 6) 1 156 Services Provided Questions 5 and 6 asked the parents whether or not t h e i r sons or daughters had received counselling, training,, or in s t r u c t i o n from either a r e s i d e n t i a l counsellor, vocational counsellor, recreational counsellor, or other counselling personnel. The parents were asked to rate what they f e l t was the quality of the service t h e i r son or daughter received. The rating scale provided was: (0) Never Received; (1) Poor;. (2) F a i r ; (3) Good; (4) Excellent. Table 36. L i s t s the •. services and gives the number of adults who received each service from the d i f f e r e n t types of personnel l i s t e d , as well as the parents' mean rating of the quality of the services. Forty-two (8;4'%') of the 50 mentally retarded adults i d e n t i f i e d i n the survey, ">. had received some type of service from one or more of the personnel l i s t e d . Eight parents (16%) indicated that t h e i r son/daughter had not received any service. In terms of services provided, 36 (72%) of the adults had received an assessment or evaluation, and the parents assigned a mean rating of 2.8; 33 (66%) received l i f e s k i l l s i n s t r u c t i o n with a mean rating of 2.9; 19 (38%) received personal counselling with a mean rating of 2.6; 39 (78%) received vocational t r a i n i n g with a mean rating of 3.1; 26 (52%) received recreation i n s t r u c t i o n with a mean rating of 2.7; and 9 (18%) received job placement with a mean rating of 2.9. Table 36 Number of Mentally Retarded Adults Who Have Received Services and Mean Rating of that Service Residential Personnel Vocational Personnel Recreational Personnel Other, eg. Clergyman Tot a l N .' XR a N XK N N XK N=50b (%) XK Assessment or Evaluation 12 2.6 17 3.1 4 3.0 3 2.6 36 (72) 2.8 L i f e S k i l l s Instruction 15 2.8 11 2.8 5 2.8 2 3.0 33 (66) 2.9 Personal Counselling 7 2.3 7 2.3 2 2.5 3 3.3 19 (38)' 2.6 Vocational Training 5 3.0 29 2.7 4 3.0 1 4.0 39 (78) 3.1 Recreation Instruction 6 2.8 8 2.5 12 2.9 '•0 0 26 (52) 2.7 Job Placement 3 3.3 6 2.5 0 0 0 0 9 (18) 2.9 Other 0 0 0 0 0 0 0 0 0 0 0 Totals 48 2.8 78 2.7 27 2.8 9 3.2 XPT = mean r a t i n g N = 50, t o t a l number of mentally retarded adults recorded i n survey 1 5 8 Mental Health Services Provided In Question 7 and 8 the parents were asked to indicate i f t h e i r son/daughter had received mental health services from a ps y c h i a t r i s t , psychologist, or s o c i a l worker. The parents were once again asked to rate the quality of the services t h e i r son/ daughter received. The rating scale was the same as for Question Table 37 shows the number of mentally retarded adults who received mental health services from the d i f f e r e n t professionals l i s t e d , and the parents rating of those services. Twenty-two (44%) of the parents indicated that t h e i r son/ daughter received some type of mental health service, while 28 (56%) said that they had not received any mental health service. Of the mental health services provided, 14 (28%) received an i n i t i a l intake interview, 11 (22%) received diagnostic assess-ment, 8 (16%) received counselling and/or psychotherapeutic assistance, 4 (8%) received parental and/or family counselling, 1 (2%) had been referred to other resource for counselling and/or psychotherapeutic assistance, 5 (10%) received drug therapy, 15 (30%) received other services, 13 (26%) had been referred for other services, 10 (20%) received follow-up assistance, 18 (36%) received consultation with parents, 8 (16%) received written reports, and 3 (6%) received some other mental health service. The mean ratings for the mental health services f e l l between 2 (Fair) and 2.9 (Good), with the only exception being the "other" category, e.g., emergency service, which was assigned 4 (Excellent). Table 37 Number of Mentally Retarded Adults Who Have Received Mental Health Services and Mean Rating of the Services Psychiatrist Psychologist Social Worker Total N N XR N XR N=50b (%) m I n i t i a l Interview 5 2.6 2 2.5 7 2.4 14 (28) 2.5 Diagnostic Assessment 4 2.3 3 2.3 4 2.3 11 (22) 2.3 Counselling/Psychotherapeutic Assistance 4 2.8 1 3.0 3 3.0 8 (16) 2.9 Parental/Family Counselling 1 1.0 1 3.0 2 2.5 4 ( 8) 2.2 Referral to Other Resource for Counselling/Psychotherapeutic Assistance 0 0 0 0 1 2.0 1 ( 2) 2.0 Drug Therapy 3 2.3 0 0 2 3.0 5 (10) 2.7 Provision of f i n a n c i a l , educational, r e s i d e n t i a l services, etc. 1 2.0 2 3.0 12 2.9 15 (30) 2.6 Referral for f i n a n c i a l , educational, r e s i d e n t i a l services, etc. 2 2.0 3 2.7 8 3.0 13 (26) 2.6 Follow-up Assistance 2 2.0 2 2.0 6 2.7 10 (20) 2.2 Consultation with parents 4 1.8 2 2.0 12 2.4 18 (36) 2.1 Written reports to parents 2 2.0 2 2.5 4 2.5 8 (16) 2.3 Other mental health services 2 4.0 0 0 1 4.0 3 ( 6) 4.0 Totals 30 2.3 18 2.6 62 2.7 3 XK = mean rating of service, L - Poor 2 - Fair, 3 - Good, 4 - Excellent N = 50, Total number of mentally retarded adults recorded i n survey. 160 Counselling and/or Psychotherapeutic Assistance In Question 9, parents were asked to indicate whether or not t h e i r son/daughter had received counselling and/or psycho-therapeutic assistance i n any of the problem areas l i s t e d . I f they had received t h i s type of service, the parents were asked to indicate from which mental health professional t h e i r son/ daughter had received assistance. Table 38 shows how many mentally retarded adults had. received counselling and/or psycho-therapeutic assistance i n a p a r t i c u l a r problem area. Of the 50 respondents, 13 (26%) indicated that t h e i r son/ daughter had received some counselling and/or psychotherapeutic assistance, 16 (32%) indicated that t h e i r son/daughter was i n need of counselling and/or psychotherapeutic assistance but had not received i t , and 21 (42%) indicated that t h e i r son/daughter was not i n need of counselling and/or psychotherapeutic assistance. For those who had received counselling and/or psychothera-peutic assistance, 9 (18%) respondents indicated that t h e i r son/daughter had received counselling or psychotherapeutic assistance i n the area of inadequate l i f e s k i l l s , 5 (10%) i n the area of resistance to r e h a b i l i t a t i o n programs, 3 (6%) i n the area of poor s o c i a l r elationships, 2 (4%) i n the area of behavioural regression, 3 (6%) for neurotic t r a i t s , 1 (2%) for neurological disorder, 1 (2%) for inappropriate sexual behaviour, and 7 (14%) i n the area of learning problems. No mentally retarded adults were recorded to have received counselling and/or psychotherapeutic assistance i n the areas of psychotic t r a i t s , a n t i - s o c i a l behaviour, or s u i c i d a l behaviour. .Table 3.8' Number of Mentally Retarded Adults Who Have Received Counselling and/or Psychotherapeutic Assistance i n a S p e c i f i c Problem Area Have Received Counselling/Therapeutic Assistance From Needed But P s y c h i a t r i s t Psychologist S o c i a l Worker Other Total Not Received' = N=50 (%) . N=50 (%) Inadequate L i f e S k i l l s 0 1 4 4 9 .(18) 15 (30) Resistance to R e h a b i l i -t a t i o n Programs 0 1 2 2 5 (10) 3 ( 6) Aggressive Behaviours 2 0 0 1 3 ( 6) 1 ( 2) Poor S o c i a l Relation-ships 0 1 0 2 3 ( 6) 9 (18) Behavioural Regression 0 0 0 2 2 ( 4) 4 ( 8) Neurotic T r a i t s 1 0 0 2 3 ( 6) 4 ( 8) Psychotic T r a i t s 0 0 0 0 0 0 1 ( 2) A n t i - s o c i a l Behaviour 0 0 0 0 0 0 0 0 Neurological Disorder 0 0 0 1 1 ( 2) 0 0 I nappropr i a t e S exual . . ._-Behaviour 0 1 0 0 1 ( 2) 0 0. Learning Problems 0 1 2 4 7 (14) 13. (26) S u i c i d a l Behaviours 0 0 0 0 0 0 1 ( 2) For examples of problem areas see Appendix B , p. 269. % = percent of the 50 mentally retarded adults i d e n t i f i e d i n survey. A t o t a l 'of 16 parents out of the 50 respondents, indicated that t h e i r son/daughter needed counselling and/or psychotherapeutic assistance. More than one problem area was indicated by some of the parent. 162 Referral for Service Table 39 - shows how the mentally retarded adults were f i r s t referred for service, as asked for i n Question 10. The table l i s t s to whom the r e f e r r a l was made, along with the source of r e f e r r a l . Fifteen r e f e r r a l s were made by family physicians, 16 re f e r r a l s were made by s o c i a l workers, 6 r e f e r r a l s were made by school personnel, and 4 r e f e r r a l s were made by other personnel. Ten of the respondents contacted the professional person d i r e c t l y . Table .39 Source of Re f e r r a l of Mentally Retarded Adults Referral-Made To To t a l R e f e r r a l Made by P s y c h i a t r i s t Psychologist S o c i a l Worker Resrd. Worker Voc. Worker Rec. Worker N=51a <%) Family Physician 5 4 5 0 1 0 15 (29) S o c i a l Worker 1 0 4 4 5 2 16 (31) School J' Personnel 1 0 1 1 3 0 6 (12) Other 0 0 1 0 1 2 4 ( .08) Contacted D i r e c t l y 2 2 2 1 2 1 10 (20) A mentally retarded adult may have been r e f e r r e d to more than one pr o f e s s i o n a l . 164 Amount of Service Question 11 asked the parents to indicate how often t h e i r son/daughter received services from the professional people l i s t e d . As shown i n Table 40, three respondents indicated that t h e i r son/daughter received services from a p s y c h i a t r i s t 2-6 times per year. From a psychologist, one respondent indicated 2-6 times per year, and one indicated once per month. From a so c i a l worker, ten respondents indicated receiving services once per year, four indicated 2-6 times per year, one indicated each day. From other personnel, two respondents indicated receiving services once,: per year, three indicated two or more times per week, and two indicated each day. Table 40 Amount of Service Provided to Mentally Retarded Adult P s y c h i a t r i s t Psychologist S o c i a l Worker Other To t a l Frequency N N N N N Once per year - - 10 2 12 2-6 times per year 3 1 4 - ...8 7-11 times per year - - - - -Once per month - 1 - - 1 2-3 times per month - - - - -Once per week - - - - -2+ times per week - - - 3 3 Each day - - 1 2 3 165 Location of Mental Health Service As asked for i n Question 12, Table 41 shows the place of work of the mental health professionals from whom the mentally retarded adults received service. Of the respondents, 5 indicated that the professional t h e i r son/daughter saw was i n private practice, 11 indicated that the professional was with the Ministry of Human Resources, 1 was with a school board, 8 indicated they were with a.non-profit association, "8 indicated they were i n a hospital or i n s t i t u t i o n , and 1 indicated they were at some "other" location. No respondent received service from a professional at a Mental Health C l i n i c . Table 41.-Location of Mental Health Service Location P s y c h i a t r i s t N Psychologist N S o c i a l Worker N Other N To t a l N Private Practice 3 1 1 0 5 Mental Health C l i n i c 0 0 0 0 0 Human Resources 1 0 10 0 11 School Board 0 0 1 0 1 Non-profit Association 0 0 4 4 8 Hospital'/ I n s t i t u t i o n 3 3 2 0 8' Other 0 0 0 1 1 166 Fees for Service In Question 13, the parents were asked to indicate whether or not they had ever been charged a fee for service from a professional. Two respondents indicated they they had been charged a fee by a p s y c h i a t r i s t and one respondent was charged a fee from some "other" source. No other respondents indicated that they had ever been charged a fee for service for t h e i r mentally retarded son/daughter. Need for Service The parents were asked to indicate i n Question 14, whether t h e i r son/daughter was i n need of a p a r t i c u l a r service, was on a w a i t l i s t for a p a r t i c u l a r service, or had requested a service i n the past but had not received the service. Recorded i n Table 4 2 are the answers to Question 14. Of the 50 respondents, 4 parents f e l t that t h e i r son/ daughter was i n need of diagnostic assessment, 2 indicated a need for counselling and/or psychotherapeutic assistance, 2 indicated a need for r e s i d e n t i a l placement, 6 indicated a need for a vocational program, 5 indicated a need for a s o c i a l -educational program, 2 indicated a need for a recreation-leisure program, 2 indicated a need for f i n a n c i a l assistance, and 1. indicated a need for parental and family counselling. Of the parents, 4 indicated that t h e i r son/daughter was on a waiting l i s t for r e s i d e n t i a l placement, and 1 for-vocational program; 3 parents indicated that they had requested a vocational program for t h e i r son/daughter but had not 167 received one, 3 indicated having requested a social-educational program, 1 requested f i n a n c i a l assistance and 2 requested parent r e l i e f . - Table 42 " Number of Mentally Retarded Adults i n Need of S e r v i c e 3 Service In Need Of Service On W a i t l i s t For Service Requested Service But Was Unsuccessful Diagnostic Assessment 4 0 0 Counselling and/or Psycho-therapeutic Assistance 2 0 0 Res i d e n t i a l Placement 2 4 0 Vocational Program 6 1 3 Social-Educational Program 5 0 3 Recreation-leisure Program 2 0 0 F i n a n c i a l Assistance 2 0 1 Parent/Family Counselling 1 0 0 Parent R e l i e f 0 0 2 a N=50 Preferred Source of Counselling and/or Psychotherapeutic Assistance In Question 15, the respondents were asked to indicat e , i f they f e l t t h e i r son/daughter needed counselling and/or psychotherapeutic assistance; whether they would prefer to have t h e i r son/daughter go to a service that i s available to the general community (generic service), with personnel trained In the provision of counselling and/or psychotherapeutic assistance for the mentally retarded, or would they prefer to have them go to a separate service s p e c i f i c a l l y for the mentally retarded. 168 As shown i n Table 43, of the 29 respondents to Question 15, 10 (34%) i n d i c a t e d t h a t they would p r e f e r to have t h e i r son/daughter go to a g e n e r i c agency, while 19 (66%) i n d i c a t e d t h a t they would p r e f e r to have t h e i r son/daughter go to a s p e c i a l s e r v i c e f o r the m e n t a l l y r e t a r d e d . The d i f f e r e n c e i n the r a t e o f response of parents s e l e c t i n g a s p e c i a l i z e d agency over a g e n e r i c agency, was found to be s i g n i f i c a n t a t p < .10. Table 43 Preferred Source of Counselling and/or Psychotherapeutic Assistance N (%) Service f o r the General Public 10 (34) Separate Service for the Mentally Retarded 19 (66) (J*. 2 = 2.8, <£ = 1, p < .10) 169 Chapter V INTERPRETATION AND DISCUSSION OF RESULTS The purpose of t h i s chapter i s to integrate and interpret the results of the study. The results w i l l be discussed i n r e l a t i o n to the four main areas of investigation: i) the preparation and experience of mental health professionals i n the area of mental retardation, i i ) the provision of mental health services to mentally retarded adults, i i i ) the reactions of mental health professionals and parents towards the provision of mental health services to mentally retarded adults, iv) the background of mentally retarded adults currently receiving mental health services. In Chapter IV the results of the two questionnaires were presented separately. In the present chapter, the results of the two questionnaires w i l l be discussed simultaneously i n r e l a t i o n to the four areas of investigation. 170 Questionnaire Returns A return rate of 30 percent was achieved for the survey of mental health professionals, which included a follow-up mailing to the members of the sample who had not responded to the o r i g i n a l mail out. This rate of response was lower than what was anticipated and effects the g e n e r a l i z a b i l i t y of the r e s u l t s . There i s a concern that the non-respondents may i n some way d i f f e r systematically from those who did respond. An assumption however could be made that those mental health professionals who did not respond to the survey were individuals who did not have mentally retarded adults as c l i e n t s . I t could also be assumed that the number of professionals involved i n providing mental health services to mentally retarded adults represents a small percentage of a l l mental health professionals. I t i s suggested here that the low return of questionnaires from mental health professionals • does, in. part, r e f l e c t the small percentage of mental health professionals who provide services to mentally retarded adults. Secondly, the length of and d e t a i l requested i n the professional questionnaire i s also considered to have had an eff e c t on the rate of response of the professionals. The length and time involved i n answering the questionnaire (estimated at 15 minutes for those professionals who did not have mentally retarded adult c l i e n t s , and 20 minutes for those who did) may have discouraged some of the professionals from responding. The l e v e l of response to the parent questionnaire was 52 percent, which included a telephone follow-up and- subsequent 171 mail-out to members of the sample who did not respond to the o r i g i n a l questionnaire. This l e v e l of response i s somewhat higher than the professionals and may be a r e s u l t of two factors. F i r s t , the parents were a l l known to be parents of mentally retarded adults so one could expect a higher l e v e l of i n t e r e s t i n the questionnaire from the parents than from mental health professionals who may have had no involvement with mentally retarded adults. Secondly, the parent questionnaire was about half the length of the professional questionnaire and the number of questions asking for a detailed response was much fewer. The response from the parents, although lower than what was anticipated, appears to be reasonable when compared to a recent survey done with the same population. The March 19 80 Newsletter of the Vancouver-Richmond Association for the, Mentally Retarded (Note 6), reported the results of a survey of t h e i r member parents whose sons or daughters t r a v e l l e d to and from programs by a special bus service. The l e v e l of response to that survey was again just over 50 percent. In summary, i t i s f e l t that the low number of responses does aff e c t the g e n e r a l i z a b i l i t y of the r e s u l t s , p a r t i c u l a r l y those of the professional questionnaire. I t could be assumed, however, that the low l e v e l of response by the professionals i s i n part due to the l i t t l e i nterest and/or involvement on the part of mental health professionals i n the provision of mental health services to mentally retarded adults. This assumption i s supported by e a r l i e r reports (Potter, 1965; 172 adults on the i r current caseloads, 8 (62%) had Master's degrees or higher, while 3 indicated having a Bachelor's degree and 2 had no degree. Forty-three (49%) of the 87 respondents indicated that they had past experience i n working with the mentally retarded, while 44 (51%) indicated no past experience with t h i s population. Those with experience recorded from one to twenty-five years experience with the mentally retarded, while the majority f e l l between one and fi v e years experience. Of the 13 respondents who presently have mentally retarded c l i e n t s , 10 (77%) indicated having previous experience with the mentally retarded while 3 recorded having no previous experience with t h i s population. With 77 percent of the respondents holding a Master's degree or higher, and approximately 50 percent i n d i c a t i n g previous work experience with the mentally retarded, i t i s of inte r e s t to examine further the preparation the mental health professionals received i n the area of mental retardation. From the t o t a l number of respondents (87) to the professional questionnaire, only 39 (45%) indicated that they had taken a course(s) i n mental retardation. Of these, 34 respondents indicated that of the courses they took, mental retardation was only a minor topic of the course (less than 50 percent of the course content). Only 12 respondents indicated taking courses i n which mental retardation was considered a major topic (50 percent or more of course content). The respondents were also asked to indicate how many of 173 Savino et a l , 1973; Tarjan & Keeran, 1974, p.20-21). Recog-ni z i n g the l i m i t a t i o n s imposed upon the study by the low number of responses, the results of the study w i l l be discussed i n comparison with the findings of e a r l i e r research, i n an attempt to point out trends apparent i n the results of the study. Professional Preparation and Experience of Mental Health  Professionals i n the Area of Mental Retardation One of the major issues reported i n the l i t e r a t u r e , a f f e c t -ing the provision of mental health services to mentally retarded adults, i s the preparation of mental health professionals i n the care and treatment of the mentally retarded adult. Several authors, reviewed e a r l i e r , expressed concern over the inadequate preparation of professionals i n t h i s area (Ash, 1974; Cytryn, 1970; Katz, 1972; Menolascino & Dutch, 1967; Potter, 1965; Sterns & J a r r e t t , 1976; Tymchuk & Mooring, 1975). I t was'therefore considered important i n t h i s present study, to acquire some background information on the professional preparation and experience of mental health professionals i n working with the mentally retarded. Of the 87 professionals who responded to the questionnaire, 17 (20%) indicated that t h e i r highest degree was a Doctoral degree (including M.D. degree), 50 (57%) indicated t h e i r highest degree was a Master's degree, and 16 (18%) indicated t h e i r highest degree was a Bachelor's degree. Only four s o c i a l workers indicated that they did not hold a post-secondary degree. Of the 13 respondents who indicated having mentally retarded 174 the courses they took i n mental retardation covered the care and treatment of the mentally retarded adult. Only 2 6 (30%) of the respondents indicated having taken a course dealing with the mentally retarded adult. Again, 1.19 of these respondents indicated that the care and treatment of the mentally retarded adult represented a minor topic of the course, while only 7 respondents indicated that i t was a major topic of the course. In terms of the number of courses taken by any one in d i v i d u a l , the majority of respondents who had taken courses recorded taking only one or two courses i n mental retardation, with a smaller number ind i c a t i n g having taken three or four courses. One respondent did record having taken s i x courses i n the area of mental retardation. Of the 13 respondents who currently provide service to mentally retarded adults, only 6 (46%) recorded having taken courses i n mental retardation. Of the s i x who took courses, f i v e indicated having taken only one course i n which the care and treatment of the mentally retarded adult was a minor topic. Twenty-seven (31%) of the 8 7 respondents indicated that during t h e i r professional preparation, they had fieldwork placements with the mentally retarded. Twenty-four indicated having fieldwork placements with mentally retarded children while only 17 indicated that they had fieldwork placements with mentally retarded adults. About half the fieldwork placements were i n an i n s t i t u t i o n a l s e t t i n g , with the other half i n a community setting. Again, as i n course work, the majority of respondents had only one or two fielldwork placements 175 with the mentally retarded. Of the 13 respondents presently providing services to mentally retarded adults, only three indicated having a fieldwork. placement with mentally retarded adults, with the remaining 10 having had no fieldwork experience with t h i s population. The respondents were also asked to rate t h e i r professional preparation i n the care and treatment of mentally retarded children and adults. The rating scale used was: (0) No Preparation; (1) Poor; (2) F a i r ; (3) Good; and (4) Excellent. Mean ratings assigned to the areas of professional preparation l i s t e d i n Question 6 were between 1.6 and 2.3, a l l within the category F a i r . Although 77 percent of the respondents held a Master's degree or higher, and approximately 50 percent indicated previous work experience with the mentally retarded, only 30 percent indicated having had courses that dealt with the care and treatment of the mentally retarded adult, and only 20 percent indicated having had a fieldwork placement with mentally retarded adults. On further analysis of the 13 respondents who indicated having mentally retarded adults as c l i e n t s , only 6 (46%) had courses i n mental, retardation and only 3 (23%) had a fieldwork placement with mentally retarded adults. The amount of professional preparation of mental health professionals i n the area of mental retardation, corresponds, i n part, with the findings of e a r l i e r studies. I t i s d i f f i c u l t , however, to compare the results of the present study with those of previous studies due to d i f f e r e n t methods 176 of recording and reporting information. When Ash (1974) surveyed 16 Canadian u n i v e r s i t i e s o f f e r i n g post-graduate t r a i n i n g i n psychiatry i n 19 71, he found that three u n i v e r s i t i e s offered anywhere from four to ten lectures perv.jyear in the area of mental retardation while six u n i v e r s i -t i e s offered one to f i f t e e n seminars per year. Two u n i v e r s i t i e s did not o f f e r either lectures or seminars, while nine provided assigned readings i n mental retardation. It i s unclear, however, whether or not these lectures, seminars, or readings were compulsory. Ash also looked at the extent of the psychiatric residents' c l i n i c a l experience. Once again, i t i s d i f f i c u l t to compare studies because of the d i f f e r e n t ways in which c l i n i c a l experience i s provided. Ash did report that 12 u n i v e r s i t i e s provided c l i n i c a l exposure during c h i l d psychiatry rotations, while three u n i v e r s i t i e s provided, as an option, a "full-mental retardation rotation" of six months or more. One could assume that during a " c h i l d psychiatry rotation" the p s y c h i a t r i c resident would not necessarily come in contact with mentally retarded adults. In the present study, i t was found that only 20 percent of the respondents experienced a f i e l d work placement with mentally retarded adults. However, of the 11 p s y c h i a t r i s t s who responded, approximately 40 percent did indicate a f i e l d work placement with mentally retarded adults. Sterns and J a r r e t t (1976) conducted a study to gather information from accredited Schools of Social Work in the United States, regarding students' preparation i n the area of 177 mental retardation. The results of t h e i r study showed that only seven (13%) of the t o t a l sample of f i f t y - f o u r schools offered courses which dealt s p e c i f i c a l l y with mental retarda-t i o n . Nineteen schools (35%) reported that mental retardation was an area of school i n t e r e s t but that they did not o f f e r any courses that dealt s p e c i f i c a l l y with the mentally retarded. Only two schools l i s t e d mental retardation as an area of school i n t e r e s t as w e l l as an area of school emphasis. To be better, able to i d e n t i f y what i s available for the preparation of mental health professionals for work with mentally retarded adults, one would need to survey u n i v e r s i t i e s and colleges, s p e c i f i c a l l y asking for information about course content and c l i n i c a l experience. Due to the fact that university programs vary widely, s p e c i f i c s l i k e number of lecture or seminar hours, number of hours of c l i n i c a l experience or f i e l d work placements, compulsory versus e l e c t i v e courses, etc. would have to be acquired. In the present study the respondents were also asked for t h e i r recommendations regarding professional preparation i n the area of mental retardation. There was a f a i r l y equal number of respondents selecting^ the options for course work i n mental retardation. Thirty-eight percent recommended one compulsory introductory course i n mental retardation, whileu3.6 percent recommended two compulsory courses i n mental retardation. Only 9. .percents, indicated, that they f e l t course work i n mental retardation was not necessary for people working i n t h e i r profession. With respect to s p e c i a l i s t t r a i n i n g , the majority 178 of respondents (78%) indicated that mental retardation should be an area of s p e c i a l i s t t r a i n i n g for people i n t h e i r profession. Table 4 4 provides a sample of the comments recorded regarding recommendation for professional preparation. Of the 15 respondents who provided written comments, the majority favoured only optional courses i n mental retardation, with only those who plan to work with the mentally retarded being required to take courses i n t h i s area. Although the written comments favoured preparation i n mental retardation as optional, i t should be noted that 74 percent of the t o t a l respondents recommended either one or two compulsory courses i n the area of mental retardation. In addition, 7 8 percent of the respondents recommended mental retardation as an area of s p e c i a l i z a t i o n within t h e i r profession. Based upon t h i s response, at least one introductory course i n mental retardation i s recommended for students preparing to work i n the mental health professions, with an. .option for further s p e c i a l i s t t r a i n i n g . Several authors have described what they have f e l t to be positive approaches to the preparation of mental health professionals i n the area of mental retardation (Cytryn, 19 70; Katz; 1972; Kunze et a l . , 1969; Potter, 1964). However, a major concern of several authors i s the a v a i l a b i l i t y of a mental retardation s p e c i a l i s t on s t a f f at the u n i v e r s i t i e s i n the various professional schools and f a c u l t i e s (Ash, 1974; Cytryn, 1970; Potter, 1964). In order to make available to students i n the mental health d i s c i p l i n e s , coursework, seminars, f i e l d - -work experiences, etc. i n the area of mental retardation, a 179 Table 4 4 A Sample of Comments Regarding Recommendations for Professional Preparation i n Mental Retardation Social Workers "...not sure whole course i s needed. Depends on what you are going to do. Certainly, however, much more should be provided than when I was i n school." " I f people are interested i n working with s p e c i f i c groups then i t i s up to them to take courses." "...none required, only optional courses i n mental retardation, unless you s t a r t requiring courses on Native Indians, deaf, etc." "...should be offered as an optional course." "One compulsory introductory course, one optional advanced course-covering methods and approaches." "An area of emphasis, but not s p e c i a l i z a t i o n . " "If one i s wanting to work solely with mental retar-dation i t i s a s p e c i a l i z a t i o n - i f not everyone needs some knowledge of i t . " "M.S.W.'s need f l e x i b i l i t y . Perhaps mental health/ mental retardation combined." Psychologists "There i s primarily a need of well trained generalists who work with atypical children." "...courses should be available for those who plan to work with mentally retarded c l i e n t s but should not be required for other." 180 s u f f i c i e n t number of s p e c i a l i s t with i n t e r e s t and expertise i n mental retardation w i l l be required. In addition, appropriate community-based f a c i l i t i e s w i l l have to be made available to allow for c l i n i c a l experiences for the students outside of an i n s t i t u t i o n a l s e t t i n g . Also emphasized i s the importance of a m u l t i - d i s c i p l i n a r y approach i n the preparation of individuals i n the area of mental retardation (Cytryn, 1970, p. 659; Kunze et a l . , 1969). The mu l t i - d i s c i p l i n a r y approach provides the students with an opportunity to learn how to work together with the many d i f f e r e n t d i s c i p l i n e s and professions involved i n the care and education of mentally retarded i n d i v i d u a l s . P a r t i c i p a t i o n i n further education, e.g., graduate studies, conferences, workshops, s t a f f development, etc., was also recorded i n the present study. Again there are so many ways in which individuals can p a r t i c i p a t e : i n further education, that i t makes i t d i f f i c u l t to make comparisons between studies. However, the ongoing professional development of s t a f f i s an important aspect to consider when evaluating the provision of services. In the present study, 57 (66%) of the respondents indicated that they had not par t i c i p a t e d i n any further education i n the area of mental retardation. This i s not surprising when one considers that only 49 percent of the respondents indicated having worked with the mentally retarded before, and that currently 85 percent of the respondents do not have mentally retarded adult c l i e n t s . One could assume that i f a professional 181 had no previous work experience with the mentally retarded and was not currently providing service to the mentally retarded, i t would be u n l i k e l y that they would pa r t i c i p a t e i n further education i n t h i s area. Of the 87 respondents, 30 (34%) indicated that they have participated i n further education i n mental retardation. For the majority of respondents, the further education involved both mentally retarded children and adults. Of the 13 respon-dents who currently have mentally retarded adults on t h e i r caseloads, 10 (77%) recorded having participated i n further education i n the area of mental retardation. Three indicated having no further education i n t h i s area. The mean ratings of the areas of further education were between 1.7 and 2.6, f a l l i n g within the F a i r to Good categories. The highest mean ratings were assigned to conferences, work-shops Or seminars, and to the "other" category i n which the respondents recorded work experience, as a consultant or summer student i n a program for the mentally retarded, as further education i n t h i s area. Asked whether or not they would pa r t i c i p a t e i n the future, i n further education i n the care and treatment of the mentally retarded, only 35 (41%) of the respondents indicated Yes, while 50 (59%) of the respondents indicated No. Of those who recorded No, 43 (89%) said they would not pa r t i c i p a t e because they do not work with mentally retarded adults. Only one indicated that they f e l t they had enough preparation i n th i s area. Five respondents gave other reasons for not p a r t i c i p a t i n g i n 182 further education i n mental retardation, such as: "Cthe mentally retarded}:are only a very small part of my work w i t h a generalized caseload." "about one-half to one percent of my caseload i s mentally retarded and time i s better spent elsewhere." ". . . I would not choose... further education i n mental retardation as a p r i o r i t y . " "As a counsellor I would see the odd mentally retarded persons, but t h i s i s not often." "...not interested." Of the 13 respondents who indicated that they currently had_ mentally retarded adults on t h e i r caseload, 11 said that they would pa r t i c i p a t e i n further education i n this area. The fact that the majority of respondents indicated i . ' " they would not participate i n further education because they did not work with mentally retarded adults, i s t i e d to the factors which prevent the mental health professional from working with mentally retarded adults. These factors w i l l be discussed l a t e r . What also might e x i s t , however, i s a si t u a t i o n where individuals are not working with mentally retarded adults because they do not have the preparation or experience to do so. But.on the other hand, they may not have the int e r e s t or motivation to par t i c i p a t e i n further education i n th i s area, because they do not have as c l i e n t s mentally retarded adults. In l i g h t of what appears to be very l i m i t e d opportunities for the i n i t i a l preparation of professionals i n the area of mental retardation and s p e c i f i c a l l y i n the area of mentally retarded adults, the opportunity to participate i n .continuing 183 education becomes even more important. Tymchuk and Mooring (1975) conducted a survey of psychologists i n an attempt to determine the need for programs i n mental retardation for psychologists who had- already completed t h e i r professional t r a i n i n g , but who may have found' themselves associated with the mentally retarded. They found that over 50 percent of the respondents had attended workshops or conferences i n mental retardation, and 26 percent had received some supervised place-ment. This d i f f e r s s l i g h t l y from the findings of the present study which showed only 34 percent of the respondents having participated i n further education, and only 31 percent had fieldwork experience with the mentally retarded. Tymchuk and Mooring also reported that 61 percent of the respondents described t h e i r preparation for working with the mentally retarded as adequate, which can be compared to the present study's findings of a mean rating of Fair for the respondents' preparation i n mental retardation. Tymchuk and Mooring found , however, that 73 percent of t h e i r respondents f e l t that additional t r a i n i n g would be he l p f u l compared to only 41 percent of the combined number of professional respondents i n the present study showing interest i n p a r t i c i p a t i n g i n further education i n mental retardation. Of the 16 psychologists who responded to the present study, only 5 (31%) indicated i n t e r e s t i n p a r t i c i p a t i n g i n further education. The authors also showed that the preferred method of further education was workshops and c l i n i c a l demonstrations and the least preferred was internships (1975, p. 24). 184 Several authors have presented a concern for the lack of in t e r e s t on behalf of mental health professionals i n work with the mentally retarded (Ash, 1974; Begab, 1970; Cytryn, 1970; Potter, 1965; Tarjan & Keeran, 1974). This may stem from a general f e e l i n g of inadequacy i n t h e i r a b i l i t y to deal with th i s population due to limited experience i n the area, or could be due to t h e i r attitudes towards the mentally retarded and t h e i r r e s p o n s i b i l i t y for providing service to this population. Several authors, already mentioned, have stressed the need for including s p e c i f i c course content and f i e l d work experiences i n the area of mental retardation i n the preparation of mental health professionals. However, Begab (1970, p. 807) notes that after examining the effects of d i f f e r i n g educational experiences on the knowledge and attitudes of s o c i a l work students about mental retardation, i t i s not how much one knows that i s important to attitude change, but rather i t i s the nature of the learning experience and sources of information that i s important. The Provision of Mental Health Services to Mentally Retarded  Adults A major concern of this present study was to examine mental health services currently being provided to mentally retarded adults. An attempt was made to c o l l e c t information on the amount, type, and quality of the mental health services that mentally retarded adults were receiving. Both mental health professionals (providers of services) and parents of 185 mentally retarded adults (consumers of services) were surveyed. Of the 87 mental health professionals who responded to the questionnaire, only 13 (15%) indicated having mentally retarded adults on t h e i r caseloads during the previous 12-month period. Of the 13 professionals, 3 were p s y c h i a t r i s t s , 1 was a psychologist, and 9 were s o c i a l workers. These 13 mental health professionals had i n t o t a l 292 mentally retarded adults as c l i e n t s . F i f t y parents of mentally retarded adults reported that 23 (4 6%) of t h e i r sons and daughters received some service from a mental health professional: 20 (40%) from a s o c i a l worker, 8 (16%) from a p s y c h i a t r i s t , and 3 (6%) from a psychologist. Some of the adults may have seen more than one professional, while 27 (54%) recorded not seeing any mental health professional. In addition, the parents indicated that 42 (84%) of t h e i r sons or daughters had received counselling or i n s t r u c t i o n from either a r e s i d e n t i a l , vocational, or recreational counsellor and/or other personnel, e.g., a clergyman, public health nurse, etc. (see Tables 3 6 and 3 7). The involvement of s o c i a l workers, psychiatrists, and psychologists, i n the provision of mental health services to mentally retarded adults,, as reported by the professionals, can be compared with the number of mentally retarded adults currently seeing mental health professionals i n each category, as reported by the parents. The majority of mentally retarded adults, 87 percent of those receiving mental health services, were receiving some service from a s o c i a l worker, while the 186 majority of professionals who indicated having mentally retarded adults on t h e i r caseloads (69 percent of those providing service) were s o c i a l workers. The next largest group of those receiving services (35%) were receiving services from a psychiatrist,.while the second largest group of professionals reporting to provide service (23%) were p s y c h i a t r i s t s . The smallest number of mentally retarded adults, only 13%, received services from a psychologist, while only one psychologist reported to have a mentally retarded adult on his or her caseload (see Tables 12 and 37). From the results of the study, i t appears that the majority of mentally retarded adults, 84 percent, received some counselling, t r a i n i n g , or i n s t r u c t i o n from either a r e s i d e n t i a l , vocational, recreational, or other type of counsellor, but only 46 percent received services from mental health professionals such as a p s y c h i a t r i s t , psychologist, or s o c i a l worker. Due to the high degree of involvement with mentally retarded adults of r e s i d e n t i a l , vocational, recreational, and other counsellors, further investigation should be made into the nature of counselling and/or psychotherapeutic assistance provided by these counsellors to mentally retarded adults. These counsellors are usually d i r e c t service s t a f f i n programs for the mentally retarded, and may, at times, require the assistance of a p s y c h i a t r i s t , psychologist, and/or s o c i a l worker i n t h e i r work with a mentally retarded adult. These " f r o n t - l i n e " counsellors could, be considered consumers of mental health services on behalf of a handicapped adult, and thus, further enquiry should 187 be made into t h e i r use of the services of mental health professionals on behalf of th e i r c l i e n t s . Also of in t e r e s t would be t h e i r opinion of t h e i r c l i e n t s ' need for involvement with a p s y c h i a t r i s t , psychologist, or s o c i a l worker. In the questionnaire to mental health professionals, the respondents who recorded that they did not have mentally retarded adult c l i e n t s on th e i r current caseload were asked to indicate which factors prevented them from providing services to mentally retarded adults. The majority of respon-dents (46%) who answered th i s question indicated that they had not received any r e f e r r a l s of mentally retarded adults. The second major factor (recorded by 40 percent of the respon-dents) was that t h e i r place of employment did not have a mandate to serve mentally retarded adults. The t h i r d most common factor (recorded by 2 5 percent of the respondents) was that within t h e i r place of employment, i t was not th e i r r e s p o n s i b i l i t y to provide services to mentally retarded adults. On examining further the responses to thi s question, i t i s noted that the majority of respondents who indicated that they worked i n a ho s p i t a l or i n s t i t u t i o n , or at a university or college, recorded that t h e i r place of employment did not have a mandate to serve mentally retarded adults and/or that they did not receive any r e f e r r a l s of mentally retarded adults. I t would seem probable that most university or college faculty would not be involved i n d i r e c t service to mentally retarded adults, and therefore would not receive r e f e r r a l s . I t can be 18 8 argued, however, that although u n i v e r s i t i e s and colleges may not have a mandate to provide d i r e c t service to t h i s population, they would c e r t a i n l y have a mandate for providing i n d i r e c t service i n the area of professional preparation i n mental retar-dation. Without knowing the type of hospitals or i n s t i t u t i o n s i n which, the respondents were providing service, i t i s d i f f i c u l t to discuss s p e c i f i c a l l y t h e i r mandates for service. I t could be assumed, however, that i t would be within the mandate of a general h o s p i t a l to provide service to a mentally retarded adult with a medical or p s y c h i a t r i c condition that required h o s p i t a l i z a t i o n . The two major i n s t i t u t i o n s serving the Greater Vancouver area do have s p e c i f i c mandates. One i s a mental health i n s t i t u t i o n and the other i s an i n s t i t u t i o n for the mentally retarded. A mentally retarded i n d i v i d u a l with a severe behavioural and/or emotional disorder, making i t d i f f i c u l t for him/her to be maintained i n the community, would i n most cases be referred to the i n s t i t u t i o n for the mentally retarded. Without suggesting that the mental health i n s t i t u t i o n would be any more appropriate, a r e f e r r a l to an i n s t i t u t i o n for the mentally retarded,,of a mentally retarded i n d i v i d u a l with, severe emotional and/or behaviour problems, would only be appropriate i f the i n s t i t u t i o n was able to provide the psychotherapeutic assistance that would a s s i s t i n the a l l e v i a -tion of the individual's emotional and/or behavioural problems, allowing him/her to return to the community. It has been noted e a r l i e r that one of the major reasons for i n s t i t u t i o n a l i z a t i o n 189 of mentally retarded adults today, i s the presence of a severe emotional and/or behavioural disorder. Further research should be ca r r i e d out to examine the nature of the emotional and behavioural problems which are causing mentally retarded adults to be placed i n an i n s t i t u t i o n , and whether or not some of these mental health problems of the mentally retarded could be assisted by community-based mental health and/or mental retardation services. While none of the 20 respondents whaworked for the Ministry of Human Resources (the Ministry responsible for s o c i a l services within B r i t i s h Columbia) indicated that it'was not within t h e i r mandate to serve the mentally retarded adult, 10 (50%) did indicate that within the agency for which they work, i t was not thei r r e s p o n s i b i l i t y to provide services to mentally retarded adults. This r e s u l t , supported by comments from respondents, r e f l e c t s the operation of the l o c a l Ministry of Human Resources o f f i c e s which have assigned one or two s o c i a l workers and/or f i n a n c i a l aid workers to provide services to the mentally retarded and t h e i r f a m i l i e s . Also, within each region i n the Vancouver-Richmond area, there i s a "mental retardation consultant" or "coordinator" of services for the mentally retarded. Only a small percentage of respondents, 12 percent and 10 percent respectively, indicated that they preferred to provide services to c l i e n t s other than the mentally retarded or f e l t that they had i n s u f f i c i e n t preparation for providing services to mentally retarded adults. From t h i s examination of the responses to Question 12, i t appears that factors related to the delivery 190 of services and the operation of service agencies are the major factors preventing the provision of mental health services to the mentally retarded adults, as opposed to factors related to the i n d i v i d u a l professional person. Those respondents who indicated not having mentally retarded adults on t h e i r current caseloads were also asked to indicate, i f they received r e f e r r a l s of mentally retarded adults, to whom would they refer them for mental health services. The majority of respondents (30%) indicated that they would refer them to Mental Health Services. This finding i s i n t e r e s t i n g to note i n r e l a t i o n to discussions with the Greater Vancouver Mental Health Services (G.V.M.H.S.) and comments of three respondents who indicated working for G.V.M.H.S. I t was noted by the respondents that, although each one of the G.V.M.H.S. community care teams had a small number of mentally retarded c l i e n t s with severe emotional problems, i t was not considered to be within t h e i r mandate to provide services to the mentally retarded. One respondent did q u a l i f y t h i s by stating that " i f the person i s psychotic" they would then provide service to the in d i v i d u a l . The emotional and/or behavioural disorders of the ind i v i d u a l must be considered "serious" enough to f i t the mandate of G.V.M.H.S., as described e a r l i e r i n Chapter I I , p.77. I f not, the emotionally disturbed adult would be dependent upon hospital programs and/or the private sector for therapeutic assistance. The second most common r e f e r r a l , recorded by 25 percent of the respondents, was to the Ministry of Human Resources. Within 191 the Province of B r i t i s h Columbia, i t i s within the mandate of the Minsitry of Human Resources to provide services to the mentally retarded. In correspondence from the Ministry of Human Resources, however, i t has been stated that the Ministry does not employ "mental health workers" and that "mental health services are provided by the Ministry of Health and are cer t a i n l y available to anyone including retarded and c l i e n t s of t h i s Ministry" (see Appendix C). In the Greater Vancouver area, i t i s the r e s p o n s i b i l i t y of G.V.M.H.S. to provide mental health services to the community on behalf of the Ministry of Health. These findings do suggest that any further enquiry made into the pr.ovisioxbof mental health services to the mentally retarded, must involve the cooperation of the M i n i s t r i e s of Health and Human Resources. I t appears unclear, at t h i s point in time, as to who has the r e s p o n s i b i l i t y for providing mental health services to mentally retarded adults. Background Information on Mentally Retarded Adults Currently  Receiving Mental Health Services As shown i n Table 45, of the 292 mentally retarded adults currently receiving services from the 13 mental health professionals, 147 (50%) are mildly mentally retarded, 126 (43%) are moderately mentally retarded, and 19 (7%) are severely mentally retarded. Of the 49 parents who responded to t h i s question, 19 (39%) i d e n t i f i e d t h e i r son/daughter as mildly mentally retarded, 25 (55%) as moderately mentally retarded, and 192 3 (6%) as severely mentally retarded. Table 45 Level of Mental Retardation as Reported by Mental Health Professionals and by Parents Level C l i e n t s of Professionals (N .= 292) Son/Daughter of Parents (N = 49) Mild 147 (50%) 19 (39%) Moderate 126 (43%) 27 (55%) Severe 19 ( 7%) 3 ( 6%) ("P2 = 2.89, 65 = 2, p > .10) The percentage of males to females was about the same for the c l i e n t s of the mental health professionals as i t was for the mentally retarded adults as reported by parents. In both groups, there were s l i g h t l y more males than females. The age range categories were also s i m i l a r l y represented i n both groups, with the majority of the mentally retarded adults being between 19-25 years of age, and the next largest number between 26-30 years of age. The number of c l i e n t s i n each category decreased as age increased. In addition, the l i v i n g situations and daytime a c t i v i t i e s of both the mentally retarded adults seen by the professionals and the mentally retarded adults i d e n t i f i e d by t h e i r parents, were s i m i l a r . The majority of the mentally retarded adults i n both groups (over 60 percent) l i v e d i n t h e i r family home. The second largest number, 15 percent of the professionals' c l i e n t s and 26 percent of the parents' sons/daughters l i v e d i n a group 193 home s i t u a t i o n . The remaining number of adults were f a i r l y evenly spread among the remaining l i v i n g situations with the exceptions being that no adults l i v e d i n foster homes, and i n the case of the parents, none of t h e i r sons/daughters l i v e d i n boarding homes. In terms of daytime a c t i v i t i e s , the majority of adults i n both groups (over 70%) attended a sheltered workshop program during the day. The remaining number of adults again were f a i r l y evenly spread between the remaining daytime a c t i v i t i e s , with one exception, that with the c l i e n t s of the mental health professionals, 42 (14%) were not involved i n any daytime a c t i v i t y compared to only one son or daughter of a parent not involved i n any daytime a c t i v i t y . The background characteris-t i c s of the adults may be a source of some of the differences recorded i n the mental health needs and the services provided to the two groups of mentally retarded adults. I t should be noted, however, that the difference i n the percentage of mild compared to moderate mentally retarded adults, as reported by the professionals, compared to the percentage reported by the parents, was found not to be s t a t i s t i c a l l y s i g n i f i c a n t (p > .10). I t i s suggested that the results, which show that the major-•ity.'of the adults: i ) are between 19 and 30 years of age, i i ) are l i v i n g at home with t h e i r parents, and i i i ) are attending a sheltered workshop program during the day, r e f l e c t s the tremendous shortage i n alternate l i v i n g and' vocational programs for the mentally retarded adult i n the community. The background information gathered regarding the l i v i n g situations and daytime 194 a c t i v i t i e s of the mentally retarded adults does not necessarily r e f l e c t a matter of choice or even need, but rather i t i s more a r e f l e c t i o n of what i s available. This finding further supports the need for future research into the counselling and psychotherapeutic assistance provided to mentally retarded adults attending a sheltered workshop program or l i v i n g i n a supervised r e s i d e n t i a l program, and the need for mental health consultation within these programs. In addition though, and of equal importance, i s the need for further research into the problems and concerns of parents with mentally retarded, adults l i v i n g at home. There i s an extreme shortage of research into the needs of parents for counselling and/or psychotherapeutic assistance i n dealing with the adult development of t h e i r mentally retarded son or daughter. Mental Health Services Currently Being Provided to Mentally  Retarded Adults Of the 87 respondents to the mental health professional questionnaire, there were 13 (15%) mental health professionals who indicated having mentally retarded adults on t h e i r caseloads. The 13 professionals were seeing a t o t a l of 292 mentally retarded adults. From a t o t a l of 50 parents who responded, 23 (46%) indicated that t h e i r mentally retarded son/daughter had received services from a mental health professional, while 42 (84%) had received other services from personnel such as vocational, r e s i d e n t i a l , and recreational counsellors. Both the mental health professionals who had mentally 195 retarded adults as c l i e n t s and the parents of mentally retarded adults were asked to indicate what the i n i t i a l source of r e f e r r a l of the mentally retarded adult to a mental health professional was. Both groups reported that the most common i n i t i a l source of r e f e r r a l was a s o c i a l worker;with the professionals reporting that 33 percent of the adults were referred to them by s o c i a l workers, while 31 percent of the parents indicated that they were i n i t i a l l y referred by a s o c i a l worker to a mental health professional. The second most common source of r e f e r r a l (24%) for the professionals was from other personnel i n public or private agencies, e.g., public health nurse, and the t h i r d most common source of r e f e r r a l s (20%) was from parents. For the parents, the second most common source of r e f e r r a l to a mental health professional was from t h e i r family physician (29%). I t i s in t e r e s t i n g to note that r e f e r r a l s from family physicians represented only 5 percent of the professionals source of r e f e r r a l . The t h i r d most common source of r e f e r r a l for the parents (20%) was to contact the professional person d i r e c t l y , and t h i s corresponds exactly with the percentage of r e f e r r a l s the professionals reported receiving d i r e c t l y from parents. Within B r i t i s h Columbia, an i n d i v i d u a l must be referred to a p s y c h i a t r i s t by his/her family physician i n order to have psychiatric treatment covered by the B.C. Medical Services Plan. This of course does not apply to psychiatric or mental health services provided through a public or non-profit agency. I t would be of int e r e s t for further research to examine general 196 pr a c t i t i o n e r s ' understanding and assessment of the mental health problems of t h e i r mentally retarded adult patients. I f the general p r a c t i t i o n e r i s i n the position to make the o r i g i n a l diagnosis of an emotional or behavioural disturbance requiring psychotherapeutic assistance, with what kind of knowledge or experience regarding the emotional development of mentally retarded adults would a doctor be basing his/her decision? The f i r s t question regarding actual services provided asked the parents to indicate what services t h e i r son/daughter was receiving i n terms of r e s i d e n t i a l , vocational, and recreational programs. The purpose of t h i s question was to have the parents distinguish between services of these programs from what the author had defined as mental health services (see Chapter I, Def i n i t i o n s , p.20). Seventy-two percent of the parents indicated that t h e i r son/daughter had received an assessment or evaluation, with the majority of assessments being done by vocational and r e s i d e n t i a l personnel. In terms of t r a i n i n g and/or i n s t r u c t i o n , 7 8 percent indicated receiving vocational t r a i n i n g , 66 percent l i f e s k i l l s i n s t r u c t i o n , and 52 percent recreational i n s t r u c t i o n . T h i r t y - e i percent indicated that t h e i r son/daughter received personal counselling for behaviour or emotional problems, again with the majority of t h i s counselling being provided by vocational or r e s i d e n t i a l personnel. Once again i t i s recommended that further research be carried out to determine the amount, type, and outcome of counselling and/or psychotherapeutic assistance being provided to mentally retarded adults with emotional and/or 197 behavioural problems, by the d i r e c t service s t a f f of r e s i d e n t i a l , vocational, or recreational and other programs for mentally retarded adults. As one parent commented, "the r e s i d e n t i a l and vocational s t a f f t r y to handle situations as they a r i s e , but I am not sure they are especially trained to do so. I f e e l there i s a need for professional help to a s s i s t group home personnel and vocational workshop personnel i n dealing with problems of c l i e n t s . " Both the mental health professionals and the parents of mentally retarded adults, were then asked to indicate what "mental health services" were being provided to mentally retarded adults. Table 46 shows the frequency of mental health services provided to mentally retarded adults,, as reported by mental health professionals and as reported by parents of mentally retarded adults. 198 Table 46 The Type and Frequency of Mental Health Service Provided to Mentally Retarded Adults as Reported by Professionals and Parents Professionals - N=292 M.R. Adults Parents - N=50 M.R. Adults 1. Provision of a d d i t i o n a l 75% services, e.g., f i n a n c i a l , education, r e s i d e n t i a l . 2. Consultation with s i g n i f i - 70% cant others i n c l i e n t s ' l i f e . 3. Intake Interview. > 56% 4. Counselling and/or psycho- 50% therapeutic assistance. 5. Follow-up Assistance. 33% 6. Parent/Family Counselling 25% and/or Therapy. 7. R e f e r r a l for a d d i t i o n a l 25% services e.g., f i n a n c i a l , educational, r e s i d e n t i a l . 8. Written reports to s i g n i - 23% f i c a n t others i n c l i e n t s ' l i f e . 9. Written reports to parents. 20% 10. R e f e r r a l to other resource 12% for counselling or psycho-therapeutic assistance. 11. Diagnostic Assessment. .08% 12. Other mental health .04% services, e.g., emergency service. 1. Consultation with parents 36% regarding assessments, program plans, etc. 2. Provision of a d d i t i o n a l 30% services e.g., f i n a n c i a l , educational, r e s i d e n t i a l . 3. Intake Interview. 28% 4. Re f e r r a l for a d d i t i o n a l 26% services, e.g., f i n a n -c i a l , educational, r e s i d e n t i a l . 5. Diagnostic Assessment. 22% 6. Follow-up Assistance. 20% 7. Counselling and/or Psycho- 16% therapeutic assistance. 8. Written reports to parents. 10% 9. Drug Therapy. 10% 10. Parent/Family counselling .08% and/or therapy. 11. Other mental health \ . .06% services, e.g., emergency servi c e s . 12. R e f e r r a l to other .02% resource f o r counselling or psychotherapeutic assistance. 13. Drug Therapy. .03% 199 The mental health services most frequently provided to mentally retarded adults, as recorded by both parents and mental health professionals, was the provision of additional services such as f i n a n c i a l , educational, r e s i d e n t i a l , etc. and consultation with s i g n i f i c a n t others i n c l i e n t ' s l i f e , e.g., parents/guardians, teacher, group home supervisor, or vocational i n s t r u c t o r . This r e s u l t can be explained i n l i g h t of the e a r l i e r finding that the majority of mental health professionals providing services to the mentally retarded adult are s o c i a l workers. Social workers are often involved i n i d e n t i f y i n g appropriate programs and services that can meet the needs of his or her c l i e n t and attempt to make these programs and services available to his or her c l i e n t . Recommendations for services and programs are normally made by s o c i a l workers only a f t e r consultation with s i g n i f i c a n t others i n c l i e n t ' s l i f e . Also, i t should be noted that within the Ministry of Human Resources, the main service provided to the adult mentally retarded i n d i v i d u a l was f i n a n c i a l assistance i n terms of a monthly benefits allowance. The next most frequently provided service was the i n i t i a l intake interview. This r e s u l t does not appear very meaningful due to the fact that there normally i s an " i n i t i a l intake" interview for each c l i e n t when becoming involved with a service, but the results show that only 56 percent of the professionals' c l i e n t s received intake interviews, and only 28 percent of the parents indicated that t h e i r son/daughter received an i n i t i a l interview. One explanation i n terms of the profes-sional would be that the respondent did not conduct the i n i t i a l 200 intake interview him or herself, but rather i t was carried out by an "intake worker" or some other personnel. Looking at the next most frequently provided services, there are some major differences to be noted between what the parents recorded and what the mental health professionals recorded. A major difference i s that while the mental health professionals indicated providing counselling and/or psychothera-peutic assistance to 50 percent of t h e i r c l i e n t s , only 16 percent of the parents recorded that t h e i r son/daughter received counselling and/or psychotherapeutic assistance. This type of finding might indicate that the two populations of mentally retarded adults, the population the professionals are reporting on and the population the parents are reporting on, are d i f f e r e n t i n terms of t h e i r need for counselling and/or psychotherapeutic assistance. Another major difference i n the reporting of services provided i s i n the area of diagnostic assessment. While 22 percent of the parents recorded that t h e i r son/daughter had received a diagnostic assessment, the professionals recorded that only 8 percent of t h e i r c l i e n t s received a diagnostic assessment. This finding might represent a difference i n the professional popula-tions concerned. Again the mental health professional respondents may not be involved i n assessment themselves. Generally, certain professionals with expertise i n diagnosis and assessment are c a l l e d upon to provide t h i s service. Again, with the large percentage of' professional respondents being s o c i a l workers, i t i s l i k e l y that they would be less involved i n per-forming diagnostic assessment, and more involved i n carrying 201 out program plans as a r e s u l t of an assessment. In Burton's (1974) study of Kentucky State Mental Health C l i n i c s ' services to the mentally retarded, he found that 69 percent of the mentally retarded individuals referred to the c l i n i c were provided with diagnosis and evaluation and given no further treatment or service. This notable difference between the number of mentally retarded adults reported i n t h i s present study to have received diagnostic assessments and the finding of Burton's study, could be accounted for by the fact that children aged 1. to 18. years comprised 67 percent of the r e f e r r a l s to the State's mental health c l i n i c s . Diagnostic assessments and evaluation i s a very common procedure carried out on children to a s s i s t with their :educational planning. This present study examined only those services provided to mentally retarded adults and i t appears that diagnostic assessments are carried out less often with t h i s population. I t can ,be argued though that assessments and evaluations are equally as important for the young adult as they leave school, to a s s i s t i n developing i n d i v i d u a l program plans for community l i v i n g and vocational development. Also, diagnostic assessment would be c r u c i a l i n determining an emotionally disturbed mentally retarded adult's need for counselling and/or psychotherapeutic assistance. Another discrepancy i n services provided, reported by the mental health professionals • as compared to parents, i s i n the area of parent and family counselling. The mental health professionals reported providing parent and family counselling to 25 percent of t h e i r c l i e n t s , while only 8 percent of the 202 parents reported receiving such service. Again t h i s difference could be in d i c a t i v e of two d i f f e r e n t populations with a di f f e r e n t need for service. Burton (1974) found that only about 2 percent of the mentally retarded c l i e n t s referred to the Kentucky Community Mental H e a l t h C l i n i c s i n 1965 received some form of family therapy. In contrast though, Scheerenberger's (1970) study of generic services for the mentally retarded and t h e i r f a m i l i e s , found that most generic agencies provided counselling to parents about mental retardation, and that i n the State of I l l i n o i s , a l l mental health c l i n i c s provided t h i s service. I t appears that the mandate of mental health c l i n i c s i n I l l i n o i s d i f f e r s from the mandate of mental health teams and centres here i n B r i t i s h Columbia. The discrepancy i n the findings of these studies could be a r e s u l t of the types of questions asked, as opposed to the actual, a v a i l a b i l i t y of service. In the present study and Burton's, information on the amount and type of service currently provided to mentally retarded individuals was acquired, as opposed to what type of services might be available through the mental health c l i n i c or the professionals. The results of the present study and Burton's study do not show what services,the c l i n i c or professional might provide, but rather what services have been provided based upon the needs of the c l i e n t s referred. A l l the professionals surveyed i n the present study might be quite prepared to provide parent and family coun-s e l l i n g i f needed by a mentally retarded c l i e n t and his/her family. 203 Referral for additional services, e.g., f i n a n c i a l , educa-t i o n a l , r e s i d e n t i a l , etc., was the fourth most frequent service provided as reported by the parents. I t was reported as being provided by the mental health professionals equally as often i n terms of percentage of c l i e n t s who received t h i s service. Follow-up assistance, although ranked s i m i l a r l y i n the order of frequency of services, was reported by the professionals as being provided to one-third of t h e i r c l i e n t s , while only o n e - f i f t h of the .parents reported that t h e i r son/daughter received follow-up assistance. Written reports to parents and s i g n i f i c a n t others i n c l i e n t ' s l i f e were reported by both professionals and parents as being provided almost equally as often. The provision of "other" mental health services, which i n most cases referred to emergency service and/or h o s p i t a l i z a t i o n , was reported by both parents and professionals as being provided very infrequently (6 and 4 percent respectively). S l i g h t differences were found again i n the professionals' reporting of the provison of r e f e r r a l to other resources for counselling and/or psychotherapeutic assistance i n 12 percent of the cases, and the parents' reporting of r e f e r r a l s being made i n only 2 percent of the cases. The frequency of the provision of drug therapy also d i f f e r s , as reported by 10 percent of the parents compared to only 3 percent of the professionals. The infrequent use of drug therapy by professionals can, i n part, be accounted for by the finding that the majority of the mental health professionals responding were s o c i a l workers, and would not be involved i n providing drug therapy. Burton (19 74) though 204 also noticed a sharp drop i n the use of drug therapy between 1963 and 1965, where the percentage of mentally retarded c l i e n t s receiving drug therapy went from 15 to 2 percent. Corresponding with t h i s drop i n use of drug therapy, there was an increase i n treatment alternatives made available by the mental health c l i n i c s , e.g., family therapy, educational therapy, and combina-tions of other therapeutic procedures. The mental health professionals and the parents of mentally retarded adults were next asked questions regarding counselling and/or psychotherapeutic assistance provided to mentally retarded adults. A l i s t of s p e c i f i c problem areas was presented and the professionals were asked to indicate how many mentally retarded adults came to them for counselling and/or psychotherapeutic a s s i s -tance i n the problem areas l i s t e d . The same l i s t of problem areas was presented to the parents and they were asked to indicate whether or not t h e i r son/daughter had received counselling from a mental health professional i n any of the problem areas. Table 47 shows the most common problem areas i n which the mentally retarded adults received counselling and/or psychotherapeutic assistance. There i s a s i m i l a r i t y between the response of the mental health professionals and that of the parents, i n the order of the problem areas and i n terms of the number of mentally retarded adults receiving counselling and/or psychotherapeutic assistance. The most common problem areas reported by both the parents and the mental health professionals were i n the area of inadequate l i f e s k i l l s , e.g., f i n a n c i a l management problems, independent l i v i n g problems, etc., and i n the area of learning problems, e.g., 205 Table 47 Most Common Problem Areas f o r Which Mentally Retarded Adults have Received Counselling and/or Psychotherapeutic Assistance As Reported by Mental Health Professionals As Reported by Parents of Mentally Retarded Adults M.R. Adults N= 292 a M.R. Adults M = 50 a 1. Inadequate L i f e S k i l l s . 98% 1. Inadequate L i f e S k i l l s . 183 2. Learning Problems. 3. Poor S o c i a l Relationships. 39% 39% 2. Learning Problems. 14% 3. Resistance to 10% H a b i l i t a t i v e Programs. 4. Resistance to 24% H a b i l i t a t i v e Programs. 4. Poor S o c i a l Rela-tionships . 6% 5. Behavioural Regres- 20% sion. 5. Aggressive Behaviours. 6. Neurotic T r a i t s . 7. Aggressive Behaviour. 17% 12% 6. Neurotic T r a i t s . 7. Behavioural Regression. 6% 4% 8. Inappropriate Sexual 11% Behaviour. 8. Neurological Disorder. 9. Neurological Disorder. 111 9. Inappropriate Sexual 2% Behaviour. 10. Psychotic T r a i t s . 11. A n t i - s o c i a l Behaviour. 10% 8% 10. Psychotic T r a i t s . 11. A n t i - s o c i a l Behaviour. 0 0 12. S u i c i d a l Behaviour. 12. S u i c i d a l Behaviour. A mentally retarded adult may have received assistance i n more than one problem area. 206 memory, short attention span. I t i s of int e r e s t to note that both these "problem areas" are also primarily educational concerns. These result s appear to support the notion that mental retardation i s primarily an educational concern, but that the mental health d i s c i p l i n e s have a role to play i n providing comprehensive services and programs that w i l l a s s i s t the mentally retarded adult i n t h e i r o v e r a l l adjustment and development (Jaslow, 1975; Tarjan & Keeran, 1974; Wortis, 1977). Poor s o c i a l relationships and resistance to p a r t i c i p a t i o n i n h a b i l i t a t i v e programs were the next most common problem areas encountered i n counselling or psychotherapeutic sessions with the mentally retarded adult. Following these were the problem areas of behavioural regression, agressive behaviour, neurotic t r a i t s , inappropriate sexual behaviour, and neurological disorder. A small percentage of c l i e n t s were seen by mental health professionals for problems i n the areas of psychoses, a n t i - s o c i a l behaviour, and s u i c i d a l behaviour, but no parents reported t h e i r son/daughter receiving assistance for problems i n these areas. Woody and.„Billy (1966) reported s i m i l a r findings although using s l i g h t l y d i f f e r e n t problem categories. Problem areas often encountered by the psychologists were: control of unacceptable behaviour, return to the community i n an active r o l e , peer group associations, f a m i l i a l r e l a t i o n s , improving employability, i n s t i t u t i o n a l adaption, return to the home, personality modification, and motivation for learning. Two categories that the psychologists-reported only occasionally 207 encountering i n counselling sessions were authority figure resolution and improvement of measurement i n psychodiagnostics. In addition to being asked what problem areas t h e i r son/daughter had received counselling and/or psychotherapeutic assistance i n , the parents were also asked to indicate whether they f e l t t h e i r son/daughter was i n need of assistance i n a p a r t i c u l a r problem area. Of the 50 respondents, 16 (32%) f e l t that t h e i r son/daughter was i n need of counselling and/or psychotherapeutic assistance. Again, inadequate l i f e s k i l l s and learning problems were the two areas i d e n t i f i e d most often by parents, 30 and 2 6 percent respectively, as being problem areas i n which they f e l t t h e i r son/daughter needed counselling and/or psychotherapeutic assistance. Poor s o c i a l relationships was recorded by 18 percent of the parents as a problem area i n which, t h e i r son/daughter needed counselling and/or psycho-therapeutic assistance, while behavioural regression .arid neurotic t r a i t s were i d e n t i f i e d as problem areas by 8 percent of the parents. Only one parent each f e l t that t h e i r son/daughter needed counselling or psychotherapeutic assistance i n areas of aggressive behaviour, psychotic t r a i t s , and suicidal', behaviour, while no parents f e l t t h e i r son/daughter needed assistance i n the problem areas of a n t i - s o c i a l behaviour, neurological disorder, or inappropriate sexual behaviour. The 11 mental health professionals who recorded having mentally retarded adults on t h e i r current caseloads, indicated that the approaches they used- most frequently when providing counselling and/or psychotherapeutic assistance to the mentally 208 retarded were: Directive Counselling (Williamson), Reality Therapy (Glaser), Behaviour Therapy (Skinner), and Client-Centred Therapy (Rogers). In a survey completed i n 1966 by Woody and B i l l y , the E c l e c t i c Approach (Thorne) was ranked by the majority of the respondents as being most si m i l a r to the approach, they used with mentally retarded adults, although i n the present study i t was recorded by only one respondent as the approach they used. Other approaches i n the Woody and B i l l y survey, i n order of use by the respondents, were: Cl i e n t Centred Therapy (Rogers), Learning Theory (Shoben), Ego-psychology (Erickson), and Psychoanalytic (Freud). I t i s d i f f i c u l t to compare the results of the present study with the Woody and B i l l y study due to the fact that the present study provided the respondents with a much greater choice of th e o r e t i c a l approaches. In addition., the subjects responding to the Woody and B i l l y survey were a l l psychologists while i n the present study only one psychologist responded to t h i s question, with the other respondents being p s y c h i a t r i s t s and s o c i a l workers. There i s also the p o s s i b i l i t y that the year i n which the studies were conducted would also have an ef f e c t on the approaches purported to be used by the respondents. I t has been suggested that the th e o r e t i c a l approaches selected by mental health professionals are more of a r e f l e c t i o n of the professional preparation as opposed to the selection of an approach suitable for use with t h e i r mentally retarded c l i e n t s (Rosen, Clark & K i v i t z , 1977, pp. 305-306) . Due to the small number of respondents to t h i s question, i t 209 was not meaningful to examine further the frequency of use of an approach according to the l e v e l of mental retardation. Future research' should take into consideration the l e v e l of mental retardation, along with other c l i e n t , therapist, and environmental variables when examining the s u i t a b i l i t y of one the o r e t i c a l approach over another. The many differences between the mildly retarded population as compared to the moderately and severely retarded, are well recognized and must be taken into consideration when selecting a the o r e t i c a l approach for counselling with mentally retarded c l i e n t s . I t i s no longer considered relevant to ask whether or: not the mentally retarded i n d i v i d u a l can benefit from counselling and/or psychotherapeutic assistance, but rather what t h e o r e t i c a l and methodological approaches are most suitable for the l e v e l of functioning of the mentally retarded i n d i v i d u a l presenting a s p e c i f i c problem i n a p a r t i c u l a r environment. Further to the question examining theore t i c a l approaches used, the mental.health professionals who had mentally retarded adults on t h e i r current caseloads, were asked to indicate from a l i s t of methodological approaches, which approach(es) they used most often with t h e i r mentally retarded adult c l i e n t s and t h e i r f a m i l i e s . Of the 12 mental health professionals who responded to th i s question, 9 (75%) indicated using i n d i v i d u a l therapy, 6 (50%) each indicated using i n d i v i d u a l therapy i n combination with either group therapy or family therapy, 5 (42%) indicated using group therapy, and 4 (33%) indicated using drug therapy. Very few respondents indicated using.the less verbal 210 or non-verbal approaches such as play, a r t , drama, or music therapy. I t i s l i k e l y that no professionals recorded the use of play therapy because i t would seem inappropriate for use with adults. I t i s int e r e s t i n g to note however, that several authors have recognized a r t , drama,and music therapy as being some of the most suitable techniques for work with the mentally retarded adult (Cowen & Trippe, 1964; Robinson & Robinson, 1.1976; B i a l e r & S t e r n l i c h t , 1977). These therapeutic approaches with a non-verbal emphasis, "tend to be p a r t i c u l a r l y useful i n as s i s t i n g the i n d i v i d u a l to develop or enhance an appropriate self-image, and a s s i s t i n producing creative self-expression... and developing needed s o c i a l and personal prowess." (Bialer & St e r n l i c h t , 1977, p. 468). The mental health professionals who had mentally retarded adults on t h e i r current caseloads were also asked for t h e i r opinion of the effectiveness of counselling and/or psycho-therapeutic assistance for mentally retarded adults i n the selected problem areas l i s t e d i n Question 19. The respondents were asked to rank the effectiveness of counselling or thera-peutic assistance separately for the three levels of mental retardation. The ra t i n g scale provided was: (0) Not E f f e c t i v e ; (1) Poor; (2) F a i r ; (3) Good; and (4) Excellent. For the mildly mentally retarded, the mean ratings for a l l the problem areas except two f e l l within the category Good. The highest mean ra t i n g for effectiveness of counselling for the mildly retarded was i n the areas of inadequate l i f e s k i l l s , resistance to habilitatiye< programs, poor s o c i a l r ealtionships, 211 and s u i c i d a l behaviours. The lowest mean ratings of e f f e c t i v e -ness of counselling or therapeutic assistance were for the areas of neurological disorders and learning problems. These two problem areas were given a mean ra t i n g of F a i r . For the moderately mentally retarded, the o v e r a l l mean rating of the effectiveness of counselling and therapeutic assistance i s s l i g h t l y lower In a l l problem areas than for the mildly mentally retarded. Only one problem area, resistance to h a b i l i t a t i v e programs, received a mean rating of Good. A l l other problem areas except two, f e l l within the category of F a i r . Again, the two problem areas of neurological disorder and learning problems received the lowest mean ra t i n g for the effectiveness of counselling or therapeutic assistance with t h i s population. These two problem areas were given a mean rating of Poor. The mean rating of the effectiveness of counselling and/or psychotherapeutic assistance with the severely mentally retarded i s notably lower than for the mildly and moderately retarded. A l l of the selected problem areas received a mean rating of either Poor or Not E f f e c t i v e . I t i s i n t e r e s t i n g to note however, that the highest mean ratings were again assigned to the problem areas of resistance to h a b i l i t a t i v e programs, inadequate l i f e s k i l l s and inappropirate sexual behaviour. The re s u l t s of t h i s study correspond with the results of two e a r l i e r studies which also demonstrated that there appeared to be a d i r e c t relationship between the l e v e l of mental retardation 2 1 2 and the value of counselling and;'psychotherapeutic assistance as perceived by mental health professionals (Deluigi, 1 9 7 7 ; Woody Se B i l l y , 1 9 6 6 ) . Woody and B i l l y suggested, based upon the findings of th e i r survey, that "the higher the l e v e l of in t e l l i g e n c e , the greater the value of counselling and psychotherapy" ( 1 9 6 6 , p. 2 2 ) . I t can be argued, however, that t h i s present relationship r e f l e c t s the use of more t r a d i t i o n a l approaches to counselling and psychotherapy, e.g., verbal, non-directive approaches, as well as more t r a d i t i o n a l outcome goals as a measure of "value" of therapeutic assistance. Much more research must be carried out to examine the effectiveness of innovative approaches to counselling and psychotherapeutic assistance with the more severely and moderately mentally retarded. The measures of "effectiveness" and "value" of therapeutic assistance should also be examined i n work -with the more severely handicapped population. The resul t s of the questions asking both the professionals and the parents for the location of the mental health services, wait l i s t for service, and the amount of service i n terms of number of sessions provided, i s extremely variable. In addition, the small number of respondents answering each question does not allow for any discussion of trends i n the data. The: majority of professionals providing mental health services to mentally retarded adults indicated that they worked for a non-profit agency. The majority of the remaining professionals either worked for Greater Vancouver Mental Health Services or the Ministry of Human Resources. Only one 213 professional serving the mentally retarded adult, indicated that he or she was i n private practice. The response of the parents indicated that for the majority of t h e i r sons/daughters who were seeing a mental health professional, i t was through the Ministry of Human Resources. The majority of these professionals of course were s o c i a l workers. The next largest number received services from a non-profit organization, and i n a l l cases, i t was the Vancouver-Richmond Association for the Mentally Retarded. Five parents indicated that t h e i r son/daughter received mental health services from a professional i n private practice. When asked i f there was a waiting period for c l i e n t s to receive mental health services from the professionals at t h e i r place of practice, 72 percent indicated that there was no waiting l i s t . The longest waiting periods recorded by two respondents, both, i n a non-profit agency, was 8-11 months and one year or more. The parents were also asked i f t h e i r son/ daughter was currently on a waiting l i s t for service. Of the 50 respondents, only f i v e mentally retarded adults were on a waiting l i s t : four for a r e s i d e n t i a l placement and one for a vocational placement. To further determine i f there was a need for service not only i n the area of mental health, but also i n the area of r e s i d e n t i a l , vocational, recreational services, etc., the parents were asked to indicate whether t h e i r son/daughter was in need of a s p e c i f i c service, or whether they had attempted to get the service i n the past but were unsuccessful. Of the 214 50 parents surveyed, only 18 (36%) indicated that they f e l t t h e i r son/daughter was i n need of a service. This r e s u l t may r e f l e c t the fact that the parents surveyed were a l l members of the l o c a l association for the mentally retarded and for the most part, t h e i r sons' and daughters' needs were being met by the programs and services of the association. I f one adds up the results presented i n Table 42, which shows the number of adults i n need of service, on a waiting l i s t for service, and requested service but was unsuccessful, the largest area of need appears to be for vocational programs. The next largest areas of need were recorded for social-educational programs, r e s i d e n t i a l placement, and diagnostic assessment. Only two parents out of 50 indicatedrthat t h e i r son/daughter needed counselling and/or psychotherapeutic assistance,- while only one parent indicated a need for parent/family counselling. I t should be noted, however, that t h i s r e s u l t does not correspond with the response to Question 9, where the parents were asked to indicate whether t h e i r son/daughter needed counselling and/or psychotherapeutic assistance i n any of the selected problem areas l i s t e d . Of the 50 parents who responded, 18 (36%) indicated that t h e i r son/daughter needed counselling or therapeutic assistance i n one or more of the.problem areas. Opinions of the Delivery of Mental Health Services to Mentally  Retarded Adults The mental health professionals were f i r s t of a l l asked to rate how w e l l they f e l t the agency for which they worked or 215 they themselves, i f they were i n private practice, provided mental health services to mentally retarded adults. Again the mental health services were l i s t e d . The mean ratings were rounded o f f to correspond with the rating categories. Those professionals who were i n private practice, mental health services, non-profit organizations, hospitals or i n s t i t u t i o n s , assigned themselves an o v e r a l l mean rating of Good. Those respondents who worked for the Ministry of Human Resources, a school board, and other government agencies assigned themselves a mean ra t i n g of F a i r . One respondent who worked at a university, assigned him/herself a mean ra t i n g of Excellent. Upon examining the mean ratings they assigned to t h e i r provision of s p e c i f i c services, they rated 1 0 of the 1 4 services l i s t e d as Good, and the remaining four as F a i r . The respondents f e l t that they did the best job at providing intake interviews, and the poorest job at providing i n d i r e c t mental health services such as s t a f f t r a i n i n g . The professionals were then asked to rate how well they f e l t other community agencies provided the same mental health services to mentally retarded adults. In t h i s case the respondents assigned a mean rating of Good to only three of the 1 4 mental health services: intake interview, counselling and/or psychotherapeutic assistance, r e f e r r a l to other sources for counselling. A l l the remaining services received a mean rating of F a i r . The parents of mentally retarded adults had also been asked to rate the qua l i t y of service t h e i r son/daughter received from 216 a mental health professional. The parents assigned a mean rating of Good to f i v e of the 12 mental health services l i s t e d , and a mean rating of F a i r to s i x of the remaining services. The highest rating of Excellent was assigned to "other" mental health services which had been described by the respondents as emergency services. I t i s in t e r e s t i n g to compare the parents' mean rat i n g of mental health services to t h e i r mean rat i n g of other services as provided through r e s i d e n t i a l , vocational, or recreational programs (see Table 35). The parents rated the quality of the other services higher, assigning a mean rating of Good to a l l the services l i s t e d , compared to the mean ratings of between Fa i r and Good assigned to mental health services. In the next opinion question, the professionals were asked whether or not they f e l t i t was t h e i r r e s p o n s i b i l i t y to provide mental health services as described i n the previous question, to mentally retarded adults. Of the 86 respondents to t h i s question, 37 (43%) f e l t that i t was t h e i r r e s p o n s i b i l i t y , while 49 (57%) f e l t i t was not t h e i r r e s p o n s i b i l i t y . The majority of professionals i n private practice or who worked for the Ministry of Human Resources f e l t that i t was t h e i r r e s p o n s i b i l i t y to provide mental health services to mentally retarded adults. For a l l other, places of professional practice, the majority of respondents did not fe e l that i t was t h e i r r e s p o n s i b i l i t y to provide mental health services to t h i s population. Table 4 8 provides some of the respondents' comments as to why they didnot f e e l i t was t h e i r r e s p o n s i b i l i t y to provide 217 Table 48 Comments of Professionals as to Why They F e l t I t Was Not Their Responsibility to Provide Mental Health Services to Mentally Retarded Adults Mental Health P s y c h i a t r i s t : "...not within our mandate." Psychologist: "My agency believes t h i s i s the mandate of M.H.R. rather than G.V.M.H.S., unless the person i s psychotic." Ministry of Human Resources Social Workers: "Mental Health Services are provided by Health Department, not Ministry of Human Resources." "Provide mainly f i n a n c i a l services - a sp e c i f i c trained group should provide more intensive services." "I think a subsidized agency such as Cloc a l association for the mentally retarded!] can do a better job. My ministry has a very wide range of services both statutory and non-statutory to deliver." "...not so l e l y responsible Cfor provision of mental health services to the mentally retarded!). This i s not l a i d out as our mandate - but we could a s s i s t i n service." "My agency i s not a mental health agency -provides mainly f i n a n c i a l services to mentally handicapped." "M.H.R....is mandated to provide f i n a n c i a l services to handicapped adults - we have no therapeutic mandate." 2 1 8 Non-profit Agencies Psychologist: "We have a limited: mandate to provide services to another target group." Social Workers: "Our c l i e n t e l e does not usually involve mentally retarded adults however they could be involved i f they came to the centre. "Too many other people that want service, and the mentally retarded would have d i f f i c u l t y f i t t i n g into the set-up." " . . .only p a r t i a l l y Irresponsible for provision of mental health services to the mentally retarded"!, i .e . , basic counselling... for more extensive p s y c h i a t r i c counselling - r e s p o n s i b i l i t y of mental health agency." " . . . f e e l the emotionally disturbed mentally retarded must be referred to properly trained mental health professional." 219 mental health services to mentally retarded adults. The comments once again point out the lack of a clear mandate as to who i s responsible for the provision of mental health services to emotionally disturbed mentally retarded adults. Based upon the comments of the respondents working within the Ministry of Human Resources, i t i s not within t h e i r mandate to provide counselling and/or psychotherapeutic assistance to the mentally retarded adult. I t also seems unclear, however, as to whether Greater Vancouver Mental Health Services recognizes i t to be within t h e i r mandate to provide services to the emotionally disturbed mentally retarded adult, when providing community-based mental health services to the seriously mentally disturbed. It does appear more clear with respect to c e r t a i n non-profit agencies, who have a mandate to provide either a s p e c i f i c service, e.g., recreation, daycare, interpretation services, etc., or to serve a s p e c i f i c target group, e.g., Native Indians, single parents, etc., that the provision of mental health services to the. mentally retarded adult would not come within t h e i r mandates. Several non-profit agencies who appear to provide some community service, although not d i r e c t mental health services, implied that they should be or could be including the mentally retarded within the scope of t h e i r services. There i s the l o c a l association for the mentally retarded with a clear mandate to provide programs and services to the mentally retarded. An often stated goal of t h i s association i s to reduce the amount of d i r e c t service in which they are involved and act more as an advocate and a monitor for the mentally 220 retarded and t h e i r families i n establishing appropriate community-based services to meet t h e i r needs. I t was the opinion of the professionals responding from the association for the mentally retarded that mental health services for the severely emotionally disturbed, mentally retarded adult should be provided by the community mental health services. The f i n a l question, addressed to both the mental health professionals and the parents, asked the respondents to indicate whether they f e l t counselling and/or psychotherapeutic assistance could be provided to mentally retarded adults by the same agency which provides t h i s service to the general popula-tion (e.g., mental health c l i n i c s ) or should t h i s service be provided by a special agency for the mentally retarded (e.g., association for the-'mentally retarded). As shown i n Table 49, there was found to be a s t a t i s t i c a l l y s i g n i f i c a n t r elationship (p <.05) between the two factors: parents and; :professionals, and t h e i r choice between a generic versus a specialized agency for the provision of counselling and/or psychotherapeutic assistance for the mentally retarded adult. Of the professionals, 56 percent f e l t that counselling and therapeutic assistance could be provided to the mentally retarded adult by the same agency that provides t h i s service to the general public (generic agency). However, only 34 percent of the parents f e l t that they would want t h e i r son/daughter to receive counselling or therapeutic assistance from a generic agency. A s t a t i s t i c a l l y s i g n i f i c a n t majority of parents f e l t that i f t h e i r son/daughter needed counselling and/or 221 psychotherapeutic assistance, they would want t h e i r son/daughter to go to a separate service s p e c i f i c a l l y for the mentally retarded with personnel prepared i n the provision of therapeutic assistance for the mentally retarded (see Table 49). Table 49 Mental Health P r o f e s s i o n a l s 1 and Parents 1 Response to Generic Services vs. Spe c i a l i z e d Services Prefer Generic Prefer S p e c i a l i z e d Agency Agency N % N % Mental Health Professionals 42 56 33 44 Parents 10 34 19 66 (% 2 = 4.05, dc = 1, p < .05) This r e s u l t can be understood i n l i g h t of the fact that the parents surveyed were a l l members of an association for the mentally retarded, and based upon t h e i r r a t i n g of services provided to th e i r son/daughter, appeared.to be generally s a t i s -f i e d with the services available. Savino et a l (1973, p. 162) have stated that the National Association for. Retarded . Citizens i n the United States i s currently emphasizing t h e i r goal "to generate and support services and programs by public and other private organizations and not to provide services through the national agency or i t s units." Savino et a l . point out that t h i s emphasis c o n f l i c t s with that of many parent members who have a need or committment to create and provide d i r e c t services to.meet the needs of the mentally retarded and 222 are not interested i n urging development of services or programs by public or private agencies already serving the general community. Generally, though, the mildly mentally retarded are "underrepresented" i n the associations for the mentally retarded. The mildly mentally retarded (which form the majority of the mentally retarded) might benefit most from psychiatric and other services provided i n a community mental health setting, and t h e i r underrepresentation i n the l o c a l association for the mentally retarded may impede the development and provision of such services i n the community (Savino et a l . , 1973, p. 163). The parents' response i n t h i s present study may very w e l l be a case i n point. Future research i s necessary to examine the need for counselling and/or psychotherapeutic assistance of mentally retarded adults not involved with the l o c a l association for the mentally retarded. One way to gain access to the mentally retarded population not involved with an association for the mentally retarded, would be through other community-based programs providing services to t h i s population. 223 Chapter VI SUMMARY, CONCLUSIONS, AND SUGGESTIONS FOR FURTHER RESEARCH This f i n a l chapter summarizes the study, makes conclusions based upon the results of the study, and makes suggestions for further research. Summary of the Study The purpose of the present study was to obtain information on the community-based mental health .services being provided to the mentally retarded adults i n the Vancouver and Richmond area. There were four main areas of investigation: 1) the preparation and experience of mental health professionals i n the area of mental retardation, 2) the provision of mental health services to mentally retarded adults, 3) the reactions of mental health professionals and parents towards the provision of mental health services to mentally retarded adults, 4) the background of mentally retarded adults currently receiving mental health services. Two questionnaires were developed to gather information pertaining to these four areas of investigation. One question-naire was developed for the mental health professional population, the providers of service, and a second questionnaire 224 was developed for parents of mentally retarded adults, representing the consumers of service. The questionnaire to professionals was divided into three main parts; a) Professional Preparation and Practice i n Mental Retardation, b) Mental Health Services Presently Being Provided to Mentally Retarded Adults i n Vancouver and Richmond, and c) Personal Reactions to the Delivery of Mental Health Services to Mentally Retarded Adults. The questionnaire to parents, although not separated into sections, covered three main areas: a) background information regarding t h e i r mentally retarded son/daughter, b) mental health services provided to t h e i r son/ daughter, and c) the parents' reactions to the delivery of mental health services to mentally retarded adults. The items contained within the questionnaires were derived from three sources: research l i t e r a t u r e (Ash, 1974; Burton, 1971; Freeman, 1967; Savino et a l . , 1973; Scheerenberger, 1970; Woody & B i l l y , 1966); the author's discussions with advisors; and personal experiences. After a lengthy process of refinement, including a p i l o t study, the f i n a l questionnaires were sent to a random sample of the populations under study i n the Vancouver and Richmond area. The sample of mental health professionals included 41 ps y c h i a t r i s t s from the B.C. College of Physicians and Surgeons - Psychiatry, 72 psychologists from the B.C. Psychological Association, and 286 s o c i a l workers from the B.C. Association of Social Workers and the Associated Professional Social Workers of B.C. A sample of 104 parents was drawn from the members of the Vancouver-Richmond Association for the Mentally Retarded. 225 Responses were tabulated for each question and frequency tables were prepared giving the t o t a l s , percentages, and where appropriate, the mean scores. Chi square goodness-of-fit test and chi square test of association were carried out when appropriate . The results for each questionnaire item were described as they pertained to each of the four areas of investigation. For the f i r s t main area of investigation ( i . e . , mental health profes-sionals' preparation and experience i n the area of mental retardation), items asked for degrees held, past experience i n working with the mentally retarded, course work and fieldwork placements i n the area of mental retardation, appraisal of and recommendations for professional preparation, and p a r t i c i p a t i o n i n further education i n the area of mental retardation. Items from both the professional and parent questionnaire provided data for the second main area of investigation ( i . e . , mental health services currently being provided to mentally retarded adults). Questions asked for the number of mentally retarded adults receiving certain types of mental health services, the number of adults receiving counselling and/or psychotherapeutic assistance for s p e c i f i c problem'areas, the number of sessions provided, the source of r e f e r r a l s for service, the waiting l i s t for service, etc. In addition, the parents were asked what they f e l t t h e i r son's or daughter's need was for such services, while the mental health professionals were asked about t h e i r use of certain theor e t i c a l and methodological approaches to counselling and/or psychotherapeutic assistance, and t h e i r opinion of i t s effectiveness with mentally retarded adults. 226 Both the parents and professionals were asked a series of questions regarding background information pertaining to t h e i r mentally retarded son/daughter or c l i e n t s . Items covered such things as age, sex, daytime a c t i v i t y , l i v i n g s i t u a t i o n , and l e v e l of mental retardation. F i n a l l y , both parents and professionals were asked for t h e i r reactions to the provision of mental health services to mentally retarded adults. The professionals were asked for t h e i r opinion of the provision of mental health services to mentally retarded adults, as well as whether or not they f e l t i t was t h e i r respon-s i b i l i t y (or the r e s p o n s i b i l i t y of the agency for which they worked) to provide mental health services to mentally retarded adults. Both the parents and professionals were asked t h e i r opinion of whether they f e l t counselling and/or psychotherapeutic assistance could be provided to mentally retarded adults by a generic agency or whether i t should be provided by a special agency for the., mentally retarded. Although mail-out questionnaires have many weaknesses, i t was f e l t that t h i s survey technique would be the most p r a c t i c a l approach for acquiring the information needed for the present study. Recognizing the l i m i t a t i o n s of mail-out questionnaires, the questionnaires were pre-tested i n an attempt to assess the content v a l i d i t y of the questions, as w e l l as to review the c l a r i t y and d i s t r i b u t i o n of responses. Based upon the 2 7 percent return rate of the p i l o t professional questionnaire and the 35 percent return rate of the p i l o t parent questionnaire, several 227 items were revised. The content of the questions appeared relevant to the respondents, although some ambiguous and poorly worded questions were revised. The parent questionnaire was revised the most. The wording of directions was improved and item format was altered so as to f a c i l i t a t e the answering of certain items. Conclusions The response to both the professional questionnaire and the parent questionnaire was not what was anticipated. A 30 percent response rate was achieved for the professional survey which included a follow-up mailing to the members of the sample who did not respond to the o r i g i n a l questionnaire. The response to the parent questionnaire was higher at 52 percent. The parents were contacted by telephone, with a second mailing going to those parents: who indicated on the telephone that they would l i k e to respond, but no longer had a copy of the o r i g i n a l questionnaire. The low number of responses does, of course, af f e c t the g e n e r a l i z a b i l i t y of the results of the study, p a r t i c u l a r l y those of the professional survey. Not withstanding some of the weaknesses of the professional questionnaire, as presented i n Chapter V, the researcher feels that there i s some evidence to support the assumption that the low number of questionnaire returns does, i n part, r e f l e c t the small number of mental health, professionals with an interest i n mental retardation and/or who have mentally retarded adults as c l i e n t s . 228 Recognizing that the length and d e t a i l of the professional questionnaire may have had an e f f e c t upon the number of responses, i t was f e l t that those mental health professionals who had as c l i e n t s mentally retarded adults, would be interested i n and concerned enough with the topic to reply to the questionnaire. Based upon t h i s assumption and the finding that only 15 percent of those mental health professionals who did respond to the questionnaire had mentally retarded adults as c l i e n t s , i t i s concluded here that a very small percentage of mental health professionals are involved i n the provision of mental health services to mentally retarded adults. Whether or not t h i s small number r e f l e c t s the mentally retarded adults' need for t h i s service, the professionals' preparation and interest i n mental retardation, or the system for the delivery of mental health services i n B r i t i s h Columbia, are factors that would have to be investigated i n further research. The small number of respondents, and i n p a r t i c u l a r , those mental health professionals serving the mentally retarded adult, precludes the formation of d e f i n i t i v e conclusions. The findings were s u f f i c i e n t , however, to propose some tentative conclusions with respect to the o r i g i n a l purposes of the study. Conclusions w i l l be presented for three of the four major areas of investigation. No conclusions were drawn s p e c i f i c a l l y i n regards to the background of the mentally retarded adults i d e n t i f i e d i n the survey, but rather, the background information was used i n discussion of the provision of services. 229 Professional Preparation and Experience of Mental Health  Professionals i n the Area of Mental Retardation In t h e i r recommendations for preparation i n the area of mental retardation, the majority of mental health professionals supported the recommendation for one to two compulsory courses i n the area of mental retardation for a l l professionals i n t h e i r f i e l d , but also recommended that i t be or continue to be an area of s p e c i a l i z a t i o n for people i n t h e i r profession. However, by providing exposure to the area of mental retardation through course work, fieldwork placements, or the a v a i l a b i l i t y of s p e c i a l i s t t r a i n i n g , the number of professionals choosing to work with the mentally retarded w i l l not necessarily be increased. As Begab (1970, p. 808) noted, i t was the learning experience, "how one learns, rather than how much one learns" that i s c r i t i c a l "to whether information i s absorbed and integrated into attitudes." Programs for the mentally retarded have changed a great deal over the l a s t decade and so should the preparation of mental health professionals. More and more mental health professionals w i l l be coming into contact with the mentally retarded and t h e i r f a m i l i e s , as the mentally retarded c h i l d grows up i n his or her own community. No longer are fieldwork placements i n i n s t i t u t i o n s , as the sole exposure to the mentally retarded population, appropriate for the preparation of mental health professionals. The q u a l i t y of l i f e of the mentally retarded i n d i v i d u a l has become the r e s p o n s i b i l i t y of the education, health, and s o c i a l service programs available to a l l 230 members of a community. The preparation of mental health professionals must r e f l e c t the role of the professional as a member of an i n t e r - d i s c i p l i n a r y team serving the mentally r e t a r -ded i n d i v i d u a l and his or her family i n the community (Tarjan, 1976; Wortis, 1977) . Based upon the results of the present survey and e a r l i e r studies, there appears to be limited opportunity for preparation of mental health professionals in the area of mental retardation, and p a r t i c u l a r l y i n the area of the care and treatment of mentally retarded adults. Subsequently, there appears to be few mental health professionals who have the preparation or experience for working with the mentally retarded adult. In addition to the need for improving the i n i t i a l preparation opportunities for mental health professionals i n the area of mental retardation, there i s an urgent need for continuing education opportunities for those professionals already working i n the f i e l d , and who f e e l a need for upgrading t h e i r s k i l l s for providing service to the mentally retarded adults and t h e i r f amilies. The need for continuing education opportunities i s already apparent as more and more mentally retarded adults are remaining i n the community and requiring services from community-based generic agencies. The Provision of Mental Health Services to Mentally Retarded  Adults From the results of this study, i t appears that of the three groups of mental health professionals surveyed, s o c i a l workers are the most involved i n providing mental health services 231 to mentally retarded adults. This was also supported by the parents' responses indicating that i f t h e i r sons/daughters were receiving mental health services, the majority were receiving them from a s o c i a l worker. The next most involved were ps y c h i a t r i s t s , followed by psychologists who appeared to be much less involved with mentally retarded adults. It i s interesting to note though that a majority of parents indicated that t h e i r son/daughter had received counselling or i n s t r u c t i o n from either a r e s i d e n t i a l , vocational, or recreational counsellor and/or from other personnel such as clergyman, public health nurse, etc. For the purpose of th i s study, these individuals were not considered "mental health professionals," but i t was of i n t e r e s t to the researcher to investigate how much involvement these other personnel have had i n providing counselling or other "mental h e a l t h - l i k e " services to mentally retarded adults. The involvement of these other "counsellors,"in providing counselling and/or therapeutic assistance for behaviour, emotional, or .adjustment problems of the mentally retarded adult, i s recommended as an important area for further research. In terms of service provided, there was a notable s i m i l a r i t y between what the^professionals recorded as the most frequent mental health service they provided to t h e i r mentally retarded adult c l i e n t s and the most frequent service the parents recorded that t h e i r sons/daughters had received. The most frequently provided services were the "provision of additional services such as f i n a n c i a l , educational, r e s i d e n t i a l , etc." and "consultation with s i g n i f i c a n t others i n c l i e n t s ' l i f e , e.g., 232 parents, guardian, teacher, group-home supervisor, etc." As was discussed i n Chapter V, t h i s r e s u l t probably r e f l e c t s the finding that the majority of mental health respondents providing services to mentally retarded adults were s o c i a l workers. There was a marked s i m i l a r i t y i n the problem areas for which mentally retarded adults received counselling. Both the profes-sionals' and the parents' responses ranked the areas of "Inadequate L i f e S k i l l s " and "Learning Problems" as the two most common areas for which counselling and/or psychotherapeutic assistance was provided. "Resistance to P a r t i c i p a t i n g i n H a b i l i -t a t i v e Programs" and "Poor Social Relationships" were the next two most common problem areas. These problem, areas would disrupt the da i l y l i v i n g routine of families with mentally retarded adults at home (which i s the l i v i n g s i t u a t i o n of the majority of the mentally retarded adults i d e n t i f i e d i n t h i s study), and thus would most l i k e l y be the reason for r e f e r r a l for counselling and/or psychotherapeutic assistance. In addition, i t can be hypothesized that the inadequate l i f e s k i l l s and/or learning problems of the mentally retarded adult may r e s u l t i n fr u s t r a t i o n , anxiety, and f a i l u r e on the part of the mentally retarded adult, i n i t i a t i n g more serious behavioural and emotional problems. I t i s c r u c i a l , therefore, for the mentally retarded i n d i v i d u a l to par t i c i p a t e i n appropriate and ef f e c t i v e l i f e s k i l l s t r a i n i n g programs that recognize his or her learning problems, thus r e s u l t i n g i n a positive learning experience and leading to a more pos i t i v e self-concept for the mentally retarded i n d i v i d u a l . The role of the mental health professional 233 would be to provide the mentally retarded adult, experiencing emotional or behavioural problems, with counselling and/or thera-peutic assistance that would enable him or her to benefit from an h a b i l i t a t i v e program (Potter, 1965; Rosen et a l . , 1977, Chap. 18). The mentally retarded adult's need for mental health services, s p e c i f i c a l l y i n the area of counselling and/or psycho-therapeutic assistance,was of interest to the researcher. The parents were asked i f they f e l t t h e i r son/daughter was i n need of counselling and/or therapeutic assistance i n certain problem areas. Of the 50 respondents, 16 (32%) f e l t that t h e i r son/ daughter was i n need of such assistance (see Table 38). Further research into the area of need for counselling and/or psycho-therapeutic assistance i s recommended. There i s the concern that parents (as well as other professionals and individuals working with the mentally retarded) may not recognize when such a need exists with the mentally retarded adult, viewing the inappropriate behaviour or emotional response as part of t h e i r mental retardation ( P h i l i p s , 1971, p. 39-48). The mental heal.th professionals were also asked for t h e i r opinion on the effectiveness of counselling and/or psycho-therapeutic assistance with mentally retarded adults i n selected problem areas. The r e s u l t s of t h i s survey correspond with the findings of two e a r l i e r studies which suggest a d i r e c t relationship between the l e v e l of mental retardation and the value of counselling and/or psychotherapeutic assistance (Deluigi, 1977; Woody & B i l l y , 1966) . This researcher would argue, however, that t h i s relationship r e f l e c t s the use of more 234 t r a d i t i o n a l approaches to counselling and therapeutic assistance and recommends that research be carr i e d out with the moderately and severely retarded using more innovative approaches. When examining the factors which prevent mental health professionals from providing mental health services to mentally retarded adults, i t appears that factors related to the delivery of services and the operation of service agencies are the major factors preventing the provision of mental health services to mentally retarded adults,as opposed to factors related to the indiv i d u a l professional person. Factors,such as, not having received any r e f e r r a l s of mentally retarded adults, the place of employment does not have a mandate to serve the mentally retarded adult, and i t i s not the individual's r e s p o n s i b i l i t y within t h e i r place of employment to provide service to mentally retarded adults, were the three most common factors a f f e c t i n g the provision of mental health.services to mentally retarded adults. It i s int e r e s t i n g to note, however, that only 1 0 percent of the respondents indicated that i n s u f f i c i e n t preparation i n mental retardation prevented them from providing services to this population. As was discussed i n Chapter V, i t appears unclear at t h i s point i n time as to who i s responsible for the provision of mental/health services to mentally retarded adults. In the Province of B r i t i s h Columbia, i t i s within the mandate of the Ministry of Human Resources to provide " s o c i a l services" to the mentally retarded adult, but as evidenced i n correspondence from the Ministry of Human Resources, t h i s does not include 235 mental health services (see Appendix C). The Ministry of Health, through the Greater Vancouver Mental Health Services (G.V.M.H.S.), i s responsible for the provision of mental health services i n the Vancouver-Richmond area. Comments from respondents who recorded that they work for G.V.M.H.S., however, indicate that i t i s not within t h e i r mandate to provide services to the mentally retarded (see Table 48). These findings, although inconclusive, suggest that further research into the provision of mental health services to the mentally retarded adult requires the involvement of both the M i n i s t r i e s of Health and Human Resources. Reactions to the Provision of Mental Health Services to Mentally  Retarded Adults Both the mental health professionals and the parents were asked for t h e i r opinion as to whether or not counselling and/or psychotherapeutic assistance should be provided to the mentally retarded adult by the same agency which provides t h i s service to the general public, or whether i t should be provided by a separate agency for the mentally retarded. A s t a t i s t i c a l l y s i g n i f i c a n t majority of parents stated,that,: i f t h e i r son/ daughter needed counselling and/or psychotherapeutic assistance, they would prefer that they go to a separate agency for the mentally retarded. The majority of professionals, although not s t a t i s t i c a l l y s i g n i f i c a n t , f e l t that counselling and/or psychotherapeutic assistance could be provided by the same agency which provides t h i s service to the general public. 236 Tarjan (1977, p. 329) discusses the issue of the two service systems: mental health services and mental retardation services. Tarjan opposes the notion of separating the two systems due to the stress i t would put on the families of the mentally retarded i n th e i r search for services. Furthermore, he points out that there i s an overlapping of mental i l l n e s s and mental retardation, best exemplified by autism, and that "mentally retarded persons are highly vulnerable and frequently manifest superimposed emotional problems" (1977, p. 329). As desirable as i t may appear, to f u l l y integrate the two systems from the standpoint of scarce personnel and cost e f f i c i e n c y , i t i s u n l i k e l y , as t h i s present study alsojpoints out, that current parental attitudes would permit implementation of t h i s solution. As Tarjan (1977) suggests: Close cooperation, collaboration, and coordination between the two systems therefore probably represent the most p r a c t i c a l solution. The key requirements from the viewpoint of the retarded person are easy access to both systems and ready transfer between them, with a minimal loss of continuity of care. The best guarantee for these conditions can come from maximum j o i n t u t i l i z a t i o n of professional personnel,(p. 329). This suggests that mental health agencies must make every e f f o r t to coordinate t h e i r services with those of other agencies i n order to work towards a more complete program for the mentally retarded (Chandler et a l , 1962). Summary of Conclusions In summary, the low rate of response to the professional questionnaire does e f f e c t the g e n e r a l i z a b i l i t y of the results 237 of the study and precludes the statement of any d e f i n i t i v e conclusions. The data collected from the study does allow, however, for several tentative conclusions in d i c a t i n g a need for further research. The following i s a summary of the conclusions: 1. There appears to be a lack of preparation of mental health p r o f e s s i o n a l s ^ s p e c i f i c a l l y i n the care and treatment of the mentally retarded adult. Also of equal concern i s the apparent lack of involvement of mental health professionals i n continuing education opportunities that would better prepare them for providing services to mentally retarded adults l i v i n g i n the community. Further to t h i s , attention must be directed at the type of learning experiences made available to the mental health professional i n the area of mental retardation, so as to develop a po s i t i v e attitude on the part of the professional for work with t h i s population. 2. Of the mental health professionals surveyed, s o c i a l workers appear to be the most involved i n the provision of mental health services to the mentally retarded adult. This i n turn appears to r e f l e c t on the type of services most often provided to t h i s population, e.g., provision of services such as f i n a n c i a l , educational, r e s i d e n t i a l , etc. and consul-t a t i o n with s i g n i f i c a n t others i n c l i e n t ' s l i f e . 238 3. The r e s u l t s of t h i s present study support e a r l i e r findings (Deluigi, 1977; Woody & B i l l y , 1966), that there appears to be a d i r e c t relationship between the l e v e l of mental retardation and the value and effectiveness of counselling and/or psychotherapeutic assistance. I t i s suggested i n t h i s study, however, that t h i s r e s u l t r e f l e c t s the use of more t r a d i t i o n a l approaches to theprovision of counselling and/or psychotherapeutic assistance to the mentally retarded, rather than the use of innovative (e.g., non-verbal) approaches. 4. I t appears that the factors r e l a t i n g to the delivery of service and the operation of service agencies are the major factors hindering the provision of mental health services to mentally retarded adults as opposed to factors related to the individual; professional person. In addition, i t appears unclear at t h i s point i n time as to which Ministry of the P r o v i n c i a l govern-ment, Ministry of Health or Ministry of Human Resources, i s responsible for the provision of mental health services to mentally retarded adults. 5. Whereas the majority of mental health professionals f e e l that a generic agency can provide counselling and/or psychotherapeutic assistance to mentally retarded adults, a s i g n i f i c a n t majority of parents indicated that i f t h e i r son/daughter required such 239 services, they would prefer them to go to a separate agency for the mentally retarded. Suggestions for Further Research Based upon the findings and conclusions of t h i s study, the following recommendations are made for further research i n the area of mental health services for mentally retarded adults: 1. Examine further the nature of "mental health" problems causing the mentally retarded adult to be placed into an i n s t i t u t i o n . Do t h e i r emotional and behavioural problems d i f f e r from those experienced by non-mentally retarded adults being hospitalized for mental health problems? Can t h e i r emotional and behavioural problems be assisted by community-based mental health services, preventing unnecessary i n s t i t u t i o n a l i z a t i o n ? 2. Further research i s recommended into the process of therapeutic intervention that w i l l i d e n t i f y appropriate approaches for use with the d i f f e r e n t levels of mental retardation. As presented e a r l i e r i n t h i s study, i t i s no longer a question of whether counselling or therapeutic assistance i s e f f e c t i v e with the mentally retarded, but rather a question of which approach works best for the i n d i v i d u a l , presenting a certai n problem, i n a p a r t i c u l a r environment. Specific attention must be paid to the d i f f e r e n t l e v e l s of mental retardation. 240 3. Examine further the involvement of vocational, r e s i d e n t i a l , recreational, and other "counselling" personnel i n the provision of counselling and/or therapeutic assistance to mentally retarded adults. What i s t h e i r preparation for work with mentally retarded adults, and what do they see as the need for counselling and therapeutic assistance for the mentally retarded adult c l i e n t s with whom they work? 4. Research i s recommended into the need of parents and/ or guardians of mentally retarded adults, for ^ . counselling and/or psychotherapeutic assistance. As t h e i r handicapped son/daughter matures, the parents and families w i l l encounter new problems and concerns. Furthermore, how well the parents adjust to the changing and developing needs of t h e i r mentally handicapped son/daughter w i l l of course e f f e c t the mentally handicapped persons' own adjustment. 5. Research i s also recommended into the implementation, within B r i t i s h Columbia, of the following four recommendations put forth by Jaslow (19 67): i ) Open every generic community agency to the retarded insofar as the agencies' competence and a b i l i t y permits. i i ) Provide basic t r a i n i n g i n mental retardation for every health worker. i i i ) Place a mental retardation' s p e c i a l i s t , either 241 fu l l - t i m e or part-time, i n every generic agency of any size or sig n i f i c a n c e , iv) E s t a b l i s h a coordinating mechanism within each community to ensure balanced services. 242 REFERENCE NOTES 1. Delparte, L. & Narvey, W. Vocational needs and services  of developmentally disabled youth i n the Vancouver area, ages 15-22. Unpublished manuscript, August 31, 1978. (Available from Community Vocational Rehabilitation Services, Ministry of Health, 805 W. Broadway, Vancouver, B.C., V5Z 1K1). 2. Freeman, R. 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Mental Retardation. In E.J. Lieberman (Ed.), Mental health: the public health challenge. Washington: American Public Health Assocation, 1975. Kanner, L. A history of the care and study of the mentally  retarded. S p r i n g f i e l d , 111.: Charles C. Thomas, 1967. Katz, E. (Ed.), Mental health services for the mentally retarded. S p r i n g f i e l d , 111.: Charles C. Thomas, 1972. Kirman, B.H. The c l i n i c a l assessment of mental handicap. In T. Silverstone & B. Barraclough (Eds.) , Contemporary  psychiatry: selected reviews from the B r i t i s h Journal of  Hospital Medicine. Ashford, Kent: Headley Bros. Ltd., 1975. Kunze, L.H., Campbell, M.M., & McBain, K.A. I n t e r d i s c i p l i n a r y student t r a i n i n g i n mental retardation.' Mental Retardation, 1969, 7 (1), 15-19. Lott, G.M. Psychotherapy of the mentally retarded: values and cautions. In F.J. Menolascino (Ed.), Psychiatric aspects  of the diagnosis and treatment of mental retardation. Seattle, Washington: Special Child Publications, 1971. Menolascino, F.J. (Ed.). Psychiatric approaches to mental  retardation. New York: Basic Books, 1970. Menolascino, F.J. (Ed.). Psychiatric aspects of the diagnosis  and treatment of mental retardation. Seattle: Special Child Publications, 1971. 246 Menolascino, F.J., & Dutch, S.J. Training the future p s y c h i a t r i s t i n mental retardation. Psychiatric Quarterly, 1967, 41 (1), 1-11. Ministry of Health. Annual Report. Province of B r i t i s h Columbia, 1977. Ministry of Human Resources. Services for people, annual report. Province of B r i t i s h Columbia, 1978. Miron, N.B.. Behavior problems of the mentally retarded. In E. Katz (Ed.), Mental health services for the mentally  retarded. S p r i n g f i e l d , 111.: Charles C. Thomas, 1972. M i t t l e r , P. (Ed.). Research to practice i n mental retardation (3 vols'.). Baltimore: University Park Press, 1977. Moody, CM. Psychotherapy and mental retardation. In E. 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Barraclough (Eds.), Contemporary  psychiatry: selected review from the B r i t i s h Journal of  Hospital Medicine. Ashford, Kent: Headley Bros. Ltd., 1975. Rutter, M., Graham, P., & Yule, W. D e f i n i t i o n and measure-ment of psychiatric disorder. In A neuropsychiatric  study i n childhood spastics. London: International Medical Publications, 1970. Savino, M., Stearns, P., Merwin, E., & Kennedy, R. The lack of services to the retarded through community mental health programs. Community Mental Health Journal, 1973, 9 (2), 158-168. Scheerenberger, R.C. Generic services for the mentally retarded and t h e i r f a m i l i e s . Mental Retardation, 1970, 8 (6), 10-16. Scheerenberger, R.C. D e i n s t i t u t i o n a l i z a t i o n and i n s t i t u t i o n a l  reform. S p r i n g f i e l d , 111.: Charles C. Thomas, 1976. Simmons, J.Q. Emotional problems i n mental retardation: u t i l i z a t i o n of psychiatric services. Pe d i a t r i c C l i n i c s  of North America, 1968, 15 (4), 957-967. Singh, J. Psychotherapy with behaviorally disturbed mentally retarded. In E. Katz (Ed.), Mental health services for  the mentally retarded. S p r i n g f i e l d , 111.: Charles C. Thomas, 1972. Stacey, C.L., & DeMartino, M.F. Counselling and psychotherapy  with the mentally retarded. Glencoe, 111.: Free Press, 1957. 248 S t e r n l i c h t , M. Psychotherapeutic procedures with the retarded. In N.R. E l l i s (Ed.), International review of  research i n mental retardation (Vol. 2). New York: Academic Press, 1966. S t e r n l i c h t , M., & Deutsch, M.R. Personality development and  s o c i a l behavior i n the mentally retarded. Toronto, Ontario: Lexington Books, 1972. Sterns, C.R., & J a r r e t t , H.H. Mental retardation content i n the c u r r i c u l a of graduate schools of s o c i a l work. Mental Retardation, 1976, 1_4 (3), 17-19. Tarjan, G. Mental retardation and c l i n i c a l psychiatry. In P. M i t t l e r (Ed.), Research to practice i n mental retardation (Vol. 1). Baltimore: University Park Press, 1977. Tarjan, G., & Keeran, C.V. An overview of mental retardation. Psychiatric Annals, 1974, 4 (2), 6-21. Tymchuk, A., & Mooring, I. Interest and t r a i n i n g of region's 2's psychologists i n mental retardation. Mental  Retardation, 1975, 1^3 (3), 24-25. Webster, T.G. Unique aspects of emotional development i n mentally retarded children. In F.J. Menolascino (Ed.), Psychiatric approaches to mental retardation. New York: Basic Books, Inc., 1970. Wolfensberger, W. Counseling the parents of the retarded. In A.A. Baumeister (Ed.), Mental retardation: appraisal, education,and r e h a b i l i t a t i o n . Chicago: Aldine Publishing Co., 1967. Wolfensberger, W. The o r i g i n and nature of our i n s t i t u t i o n a l models. In R.B. Kugel &:. W. Wolf ensberger (Eds.), Changing patterns i n r e s i d e n t i a l services for the mentally  retarded. Washington, D.C: President's Committee on Mental Retardation, 1969. Wolfensberger, W. Normalization. Toronto, Ontario: National I n s t i t u t e on Mental Retardation, 1972. Woody, R.H., & B i l l y , J . J . Counselling and psychotherapy for the mentally retarded: a survey of opinion and practices. Mental Retardation, 1966, £ (6), 20-23. Wortis, J. (Ed.). Mental retardation and developmental d i s a b i l i t i e s IX. New York: Brunner-Mazel, 1977. 250 A STUDY OF MENTAL HEALTH SERVICES PROVIDED TO MENTALLY RETARDED ADULTS IN VANCOUVER AND RICHMOND. The main purpose of t h i s survey i s to obtain information on i ) the p r o v i s i o n of mental health services since January 1, 1979, to mentally retarded adults (19 years and over) i n Vancouver and Richmond; i i ) the preparation and experience of mental health professionals i n the area of mental retardation; and i i i ) the reactions of mental health professionals towards the p r o v i s i o n of mental health services to mentally retarded adults. I t i s anticipated that the r e s u l t s of t h i s study w i l l provide agencies and professionals i n the f i e l d s of mental health and mental retardation with information that w i l l a s s i s t them i n evaluating the a b i l i t y of e x i s t i n g mental health services to meet the mental health needs of mentally retarded adults i n Vancouver and Richmond. P a r t i c i p a t i o n i n t h i s study i s completely voluntary and your responses to the questions are e n t i r e l y anonymous. Your consent for p a r t i c i p a t i o n w i l l be assumed only upon re c e i p t of your completed questionnaire. Your cooperation i n answering t h i s questionnaire i s greatly appreci-ated. I t should take only 15 minutes of your time i f you do not have c l i e n t s who are mentally retarded, and 30 minutes of your time i f you do have c l i e n t s who are mentally retarded. The return of the questionnaire by January 21, 1980 would be greatly appreciated. Please use the stamped return envelope provided. Thank you for your p a r t i c i p a t i o n i n t h i s study. Section A: Professional Preparation and Practice i n Mental Retardation 1. Place of Professional Practice Please indicate with a check mark whether you are i n private p r a c t i c e or work i n one of the agencies l i s t e d , and within which municipality your o f f i c e i s located. If you work i n more than one l o c a t i o n , check as many as are appropriate. Vancouver Richmond 1.1 Private Practice 1.2 Greater Vancouver Mental Health Service 1.3 Mental Health Centre 1.4 Ministry of Human Resources 1.5 School Board 1.6 Non-profit Organization 1.7 Hospital or I n s t i t u t i o n 1.8 University 1.9 Other, please specify 2. Degree Please indicate with a check mark which u n i v e r s i t y degree(s) you hold and i n which decade you completed the degree(s). Check as many as are appropriate. I f you do not hold a degree, check appropriate space below. Decade i n which Degree(s) Completed 1970's 2.1 No degree, check here 2.2 B.A. 2.3 B.Sc. 2.4 B.S.W. 2.5 M.A. 2.6 M.D. 2.7 Ph.D. 2.8 Other, please specify 1960's 1950's 1940's Other 251 3. Past Experience i n Working with the Mentally Retarded Please c i r c l e the number of years you have had working with the mentally retarded since completing your professional degree. I f you have had no past experience i n working with the mentally retarded, please c i r c l e zero. 3.1 Mentally retarded children (under 19 years of age) 0 1 2-3 4-5 6-10 11-15 16-20 21-24 25+ 3.2 Mentally retarded adults (19 years and over) 0 1 2-3 4-5 6-10 11-15 16-20 21-24 25+ Course Work Please c i r c l e the number of courses you completed during your i n i t i a l p r o f e s s i o n a l prepara-t i o n , i n which mental retardation was e i t h e r a major or minor t o p i c . Please c i r c l e a zero where appropriate. Do not include further education or graduate work here ( i t w i l l be recorded l a t e r ) . Of these, how many dealt No. of courses on with care & treatment of mental retardation mentally retarded ADULTS 4.1 Mental retardation, Major Topic (50% or more of course content) 0 1 2 3 4 5 6 7 8 9 10+ 0 1 2 3 4 5 6 7 8 9 10+ 4.2 Mental retardation, Minor Topic (less than 50% of course content) 0 1 2 3 4 5 6 7 8 9 10+ 0 1 2 3 4 5 6 7 8 9 10+ 5. Fieldwork Placements Please c i r c l e the number of fieldwork placements, that i s , internships, practicums, c l i n i c a l experiences, i n which you worked with the mentally retarded. Please c i r c l e a zero where appropriate. No. of fieldwork place-ments with mentally retarded CHILDREN No. of fieldwork place-ments with mentally r e -tarded ADULTS (19 yrs. +) 5.1 Placements i n an i n s t i t u t i o n a l s e t t i n g 0 1 2 3 4 5 6 7 8 9 10+ 0 1 2 3 4 5 6 7 8 9 10+ 5.2 Placements i n a community set-t i n g , eg., c l i n i c , a c t i v i t y program, residence 0 1 2 3 4 5 6 7 8 9 10+ 0 1 2 3 4 5 6 7 8 9 10+ 6. Appraisal of Professional Preparation Please indicate by c i r c l i n g the appropriate r a t i n g , how you perceive your i n i t i a l profes-s i o n a l preparation i n the care and treatment of the mentally retarded c h i l d and/or adult i n the f i v e areas l i s t e d below. I f you received no preparation i n an area l i s t e d , please c i r c l e zero. 0 - No Preparation 1 - Poor 2 - F a i r 3 - Good Professional preparation i n : 6.1 Diagnostic Assessment of mentally retarded c l i e n t s 6.2 Individual program planning 6.3 Counselling and/or psychotherapeutic assistance for mentally retarded c l i e n t s 6.4 Counselling and/or psychotherapeutic assistance fo r parents or fam i l i e s of the mentally retarded 6.5 Providing consultation or collaboration with inter-agency or i n t e r - p r o f e s s i o n a l cases of mentally retarded c l i e n t s 4 - Excellent M.R. C h i l d 0 1 2 3 4 0 1 2 3 4 0 1 2 3 4 0 1 2 3 4 0 1 2 3 4 M.R. Adult 0 1 2 3 4 0 1 2 3 4 0 1 2 3 4 0 1 2 3 4 0 1 2 3 4 2 2 5 2 7. Recommendation for Professional Preparation This question has two parts. Please answer both a S b. In the educational preparation of i n d i v i d u a l s who work within your profession, please indicate with a check mark your recommendation f o r : a) course work, and b) s p e c i a l i s t t r a i n i n g i n mental retardation. a) Course Work (Check only one) 7.1 One compulsory introductory course i n mental retardation should be required of a l l students. 7.2 Two compulsory courses i n mental retardation: one as an introductory course, and one covering methods and approaches to working with the mentally retarded should be required of a l l students. 7.3 Course work i n mental retardation i s not necessary f o r the preparation of i n d i v i d u a l s for working within my profession. 7.4 Other recommendations, please explain: b) S p e c i a l i s t Training (Check only one) 7.5 Mental retardation should be recognized as an area of s p e c i a l i z a t i o n within my profession. 7.6 Mental retardation should not be recognized as an area of s p e c i a l i z a t i o n within my profession. 7.7 Other recommendations, please explain: 8. P a r t i c i p a t i o n i n Further Education i n Mental Retardation From the following l i s t of further education experiences, please indicate by c i r c l i n g the appropriate r a t i n g , how well you f e e l your further education experiences have better pre-pared you for working with the mentally retarded. I f you have not p a r t i c i p a t e d i n further education i n mental retardation, check here and, | 4 go on to question 10, page 4 | The following scale applies: 1 - Poor 2 - F a i r 3 - Good 4 - Excellent 8.1 Graduate degree program 1 2 3 4 1 2 3 4 8.2 University or college c r e d i t courses not leading to a graduate degree 1 2 3 4 1 2 3 4 8.3 Conferences, workshops or seminars sponsored by pro-f e s s i o n a l organizations or educational i n s t i t u t i o n s 1 2 3 4 1 2 3 4 8.4 S t a f f development at place of employment 1 2 3 4 1 2 3 4 8.5 Reading or self-study 1 2 3 4 1 2 3 4 8.6 Other, please specify: M.R. C h i l d M.R. Adult 253 9. Year of P a r t i c i p a t i o n i n Eurther Education Please indicate with a check mark the year i n which you l a s t p a r t i c i p a t e d i n further education i n the area of mental retardation. 9.1 1978 - 1979 9.2 1974 - 1977 9.3 1970 - 1973 9.4 before 1970 10. Future P a r t i c i p a t i o n i n Further Education i n Mental Retardation I f made available to you i n the future, would you p a r t i c i p a t e i n further education programs i n the care and treatment of the mentally retarded adult? 10.1 Yes /• 10.2 No Please indicate why not. (Check only one.) 10.2.1 I do not work with mentally retarded adults. 10.2.2 I f e e l I have enough preparation and experience i n working with mentally retarded adults. 10.2.3 Other, please explain 11. Current Caseload Since January 1, 1979, have you had mentally retarded adults (19 y r s . +) on your caseload? 11.1 Yes | ^ Go on to Section B, page 5 j 11.2 No | Answer questions 12 S 13 below | 12. Factors Which A f f e c t Provision of Service to Mentally Retarded Adults Please indicate with a check mark which of the following factors prevent you from providing services to mentally retarded adults. 12.1 The organization i n which I work does not have a mandate for providing services to mentally retarded adults. 12.2 Within the organization f o r which I work, i t i s not my r e s p o n s i b i l i t y to provide services to mentally retarded adults. 12.3 I prefer to provide services to c l i e n t s other than the mentally retarded. 12.4 I have had i n s u f f i c i e n t preparation for providing services to the mentally retarded adult. 12.5 I have not received any r e f e r r a l s of mentally retarded adults. 12.6 None of the above. 12.7 Other, please explain 4 2 5 4 13. R e f e r r a l to Other Resources f o r Service I f mentally retarded adults are r e f e r r e d to you, but you do not work with mentally retarded adults, to whom would you r e f e r the c l i e n t ? Check the one you r e f e r to most often. 13.1 Family physician 13.2 Private p s y c h i a t r i s t 13.3 Private psychologist 13.4 Community Mental Health Team or Mental Health C l i n i c 13.5 M i n i s t r y of Health - A i d to the Handicapped 13.6 Ministry of Human Resources - Local O f f i c e 13.7 Non-profit Association or Society. Please specify. 13.8 I n s t i t u t i o n f o r the Mentally Retarded 13.9 Other, please specify PLEASE NOTE: For those who have answered questions 12 and 13 | f go on to Section C, Page 14 | • — J 5 255 Section B: Mental Health Services Presently Being Provided to Mentally Retarded Adults i n Vancouver and Richmond PLEASE NOTE: Section B i s to be answered only by those respondents who, since January 1, 1979, have had mentally retarded adults on t h e i r caseload as indicated i n Question 11. 14. Number of Mentally Retarded Adults Currently Receiving Service Please record the number of adult mentally retarded c l i e n t s you have had on your caseload since January 1, 1979 i n the following categories of the Educational C l a s s i f i c a t i o n of Mental Retardation. Note: Corresponding IQ l e v e l s are shown, as measured by the Stanford-Binet Test of I n t e l l i g e n c e . Please record zero i f you have no mentally retarded adult c l i e n t s i n a p a r t i c u l a r category. Educational C l a s s i f i c a t i o n IQ Levels No. of C l i e n t s 14.1 Mild retardation 75 - 50 14.2 Moderate retardation 49 - 30 14.3 Severe retardation 29 - below 15. Percentage of Current Caseload Please indicate with a check mark what percentage of your current caseload your adult mentally retarded c l i e n t s represent. 15 1 1% - 5% 15 2 6% - 10% 15 3 11% - 15% 15 4 16% - 20% 15.5 21% - 39% 15 6 40% - 59% 15 7 60% - 79% 15 8 80% - 100% 16. Source of Referral Please record the number of mentally retarded adults referred to you since January 1, 1979 (as you indicated i n Question 14), by each of the following sources of r e f e r r a l . No. of C l i e n t s Source of Referral 16 1 S e l f 16 2 Parents/legal" guardian 16 3 P s y c h i a t r i s t 16 4 Family Physician 16 5 Psychologist 16 6 P s y c h i a t r i c Nurse 16 7 S o c i a l Worker 16 8 School Personnel 16 9 Other, specify: 6 256 INSTRUCTIONS Please answer the following questions i n Section B according to the level(s) of  functioning of your adult mentally retarded c l i e n t s on your current caseload, as you indicated i n Question 14. I f you have c l i e n t s only within the mild range of retardation, record your answers only i n the column headed mild; i f you have c l i e n t s within the mild and moderate range of retardation, record your answers separately f o r each l e v e l i n the appropriate columns. Educational C l a s s i f i c a t i o n IQ Level Mild retardation 75-50 Moderate retardation 49-30 Severe retardation 29-below 17. Service Provided For each service l i s t e d , please record the number of adult mentally retarded c l i e n t s to whom you have provided t h i s service, since January 1, 1979. Record your answers i n the column(s) according to the l e v e l ( s ) of functioning of your adult mentally retarded c l i e n t s . Service Provided No. of Mentally Retarded C l i e n t s Mild Moderate Severe 17.1 Intake Interview 17.2 Diagnostic assessment, eg., p s y c h i a t r i c , psychological, s o c i a l , etc. 17.3 Counselling and/or psychotherapeutic assistance, which may include the use of verbal and/or non-verbal approaches, behaviour modification, with i n d i v i d u a l or groups occuring i n a v a r i e t y of settings 17.4 Parental and/or family counselling or therapy 17.5 R e f e r r a l to other sources for i n d i v i d u a l and/or parent/family counselling or psychotherapeutic assistance 17.6 Drug Therapy 17.7 Provision of a d d i t i o n a l services as appropriate, eg., f i n a n c i a l , educational, r e s i d e n t i a l , vocational, r e c r e a t i o n a l 17.8 R e f e r r a l for a d d i t i o n a l services, eg., f i n a n c i a l , educational, r e s i d e n t i a l , vocational, r e c r e a t i o n a l 17.9 Follow-up assistance once c l i e n t i s placed i n a program 17.10 Consultation with s i g n i f i c a n t others i n c l i e n t ' s l i f e , eg., parents/guardians, teacher, group-home supervisor, vocational i n s t r u c t o r 17.11 Written reports to parents/guardians regarding assessment, program plans, and progress reports 17.12 Written reports to s i g n i f i c a n t others i n c l i e n t ' s l i f e , regarding assessments, program plans, and progress reports 17.13 Other mental health services, please specify: 257 PLEASE NOTE: I f you do not provide counselling and/or psychotherapeutic assistance to the retarded and/or t h e i r parents and f a m i l i e s , please check here , and | } go on to Question 23, Page 12- | 19. Problem Areas Please record the number of your adult mentally retarded c l i e n t s who come to you f o r counselling and/or psychotherapeutic assistance i n the following selected problem areas. Record your answers i n the column(s) according to the le v e l ( s ) of functioning of your adult mentally retarded c l i e n t s . Problem Area No. of Mentally Retarded C l i e n t s Mild Moderate Severe 19.1 Inadequate l i f e s k i l l s : eg., f i n a n c i a l management problems, independent l i v i n g problems, vocational adjustment problems 19.2 Resistance to p a r t i c i p a t i n g i n h a b i l i t a t i v e programs: eg., vocational, educational, s o c i a l h a b i l i t a t i o n 19.3 Aggressive behaviour: eg., h u r t f u l to others, hard to control, s e l f - i n j u r i o u s 19.4 Poor s o c i a l r e l a t i o n s h i p s : eg., shy, poor peer r e l a t i o n s , over s e n s i t i v e , no self-confidence 19.5 Behavioural regression: eg., p e r s i s t e n t , inappropriate dependent behaviour 19.6 Neurotic t r a i t s : eg., depression, phobias, obsessive-compulsive symptoms, anxiety 19.7 Psychotic t r a i t s : eg., b i z a r r e behaviour, extreme withdrawal, delusional or paranoid thinking 19.8 A n t i - s o c i a l behaviour: eg., c r i m i n a l i t y , alcoholism 19.9 Neurological disorder: eg., epilepsy, perceptual/motor problems 19.10 Inappropriate sexual behaviour: eg., e x h i b i -tionism, voyeurism 19.11 Learning problems: eg., memory, short attention span 19.12 S u i c i d a l behaviour: eg., threats, pre-occupation or attempts 8 258 20. Theoretical Approach Please indicate by c i r c l i n g the appropriate r a t i n g how often you would use the following t h e o r e t i c a l approaches when providing counselling and/or psychotherapeutic assistance to your mentally retarded c l i e n t s . Record your answers i n the column(s) according to the leve l ( s ) of functioning of .your adult mentally retarded c l i e n t s . The following scale applies: 0 - I use t h i s approach 0% of the time 1 - I use t h i s approach 1 - 25% of the time 2 - 1 use t h i s approach 26 - 50% of the time 3 - 1 use t h i s approach 51 - 75% of the time 4 - 1 use t h i s approach 76 - 100% of the time Mild Moderate Severe 20 1 Psychoanalytic (Freud) 0 1 2 3 4 0 1 2 3 4 0 1 2 3 4 20 2 Individual Psychology (Adler) 0 1 2 3 4 0 1 2 3 4 0 1 2 3 4 20 3 Ego Psychology (Erikson) 0 1 2 3 4 0 1 2 3 4 0 1 2 3 4 20 4 Client-Centered Therapy (Rogers) 0 1 2 3 4 0 1 2 3 4 0 1 2 3 4 20 5 Humanistic Psychotherapy (Maslow) 0 1 2 3 4 0 1 2 3 4 0 1 2 3 4 20 6 E x i s t e n t i a l Analysis (Frank) 0 1 2 3 4 0 1 2 3 4 0 1 2 3 4 20 7 Gestalt Therapy (Perls) 0 1 2 3 4 0 1 2 3 4 0 1 2 3 4 20 8 E c l e c t i c (Thome) 0 1 2 3 4 0 1 2 3 4 0 1 2 3 4 20 9 Rational-Emotive ( E l l i s ) 0 1 2 3 4 0 1 2 3 4 0 1 2 3 4 20 10 Psychodrama (Moreno) 0 1 2 3 4 0 1 2 3 4 0 1 2 3 4 20 11 Learning Theory (Shoben) 0 1 2 3 4 0 1 2 3 4 0 1 2 3 4 20 12 Desensitization (Wolpe) 0 1 2 3 4 0 1 2 3 4 0 1 2 3 4 20 13 Transactional Analysis (Dusay) 0 1 2 3 4 0 1 2 3 4 0 1 2 3 4 20 14 Reality Therapy (Glaser) 0 1 2 3 4 0 1 2 3 4 0 1 2 3 4 20 15 Di r e c t i v e Counselling (Williamson) 0 1 2 3 4 0 1 2 3 4 0 1 2 3 4 20 16 Behaviour Therapy (Skinner) 0 1 2 3 4 0 1 2 3 4 0 1 2 3 4 20 .17 Other, please specify 0 1 2 3 4 0 1 2 3 4 0 1 2 3 4 259 21. Methodological Approach Please indicate by c i r c l i n g the appropriate r a t i n g how often you would use the following methodological approaches when providing counselling and/or psychotherapeutic assistance to your mentally retarded c l i e n t s . Record your answers i n the column(s) according to the le v e l ( s ) of functioning of your adult mentally retarded c l i e n t s . The following scale applies : 0 - I use t h i s approach 0% of the time 1 - I use t h i s approach 1 - 25% of the time 2 - 1 use t h i s approach 26 - 50% of the time 3 - 1 use t h i s approach 51 - 75% of the time 4 - 1 use t h i s appraoch 76 - 100% of the time Mild Moderate Severe 21. 1 Individual therapy 0 1 2 3 4 0 1 2 3 4 0 1 2 3 4 21. 2 Group therapy / 0 1 2 3 4 0 1 2 3 4 0 1 2 3 4 21. 3 Individual and group therapy 0 1 2 3 4 0 1 2 3 4 0 1 2 3 4 21. 4 Individual and family therapy 0 1 2 3 4 0 1 2 3 4 0 1 2 3 4 21. 5 Play therapy 0 1 2 3 4 0 1 2 3 4 0 1 2 3 4 21. 6 Art therapy 0 1 2 3 4 0 1 2 3 4 0 1 2 3 4 21 7 Drama therapy 0 1 2 3 4 0 1 2 3 4 0 1 2 3 4 21. 8 Music therapy 0 1 2 3 4 0 1 2 3 4 0 1 2 3 4 21. 9 Drug therapy 0 1 2 3 4 0 1 2 3 4 0 1 2 3 4 If you also work with parents and/or fam i l i e s of your adult mentally retarded c l i e n t s , please rate by c i r c l i n g the appropriate number, your use of the following methodological approaches. The above scale applies. 21.10 Individual parent i n therapy 0 1 2 3 4 21.11 Both parents i n therapy 0 1 2 3 4 21.12 Parents i n group therapy 0 1 2 3 4 21.13 Family therapy 0 1 2 3 4 10 260 22. Effectiveness of Counselling or Psychotherapeutic Assistance i n Selected Problem Areas Please indicate by c i r c l i n g the appropriate r a t i n g , how e f f e c t i v e you f e e l counselling  and/or psychotherapeutic assistance i s i n the following selected problem areas with mentally retarded adults. Record your answers i n the column(s) according to the l e v e l ( s ) of mental retardation you are most f a m i l i a r with. The following scale applies: 0 - Not E f f e c t i v e 1 - Poor 2 - F a i r 3 - Good 4 - Excellent Mild Moderate Severe 22.1 Inadequate l i f e s k i l l s : eg., f i n a n c i a l management problems, independent l i v i n g problems, vocational adjustment problems 22.2 Resistance to p a r t i c i p a t i n g i n h a b i l i t a t i v e programs: eg., voca-t i o n a l , education, s o c i a l h a b i l i t a t i o n 0 1 2 3 4 0 1 2 3 4 0 1 2 3 4 0 1 2 3 4 0 1 2 3 4 0 1 2 3 4 22.3 Aggressive behaviour: eg., h u r t f u l to others, hard to control, s e l f - i n j u r i o u s 0 1 2 3 4 0 1 2 3 4 0 1 2 3 4 22.4 Poor s o c i a l r e l a t i o n s h i p s : eg., shy, poor peer r e l a t i o n s h i p s , over-sensitive, no self-confidence 0 1 2 3 4 0 1 2 3 4 0 1 2 3 4 22.5 Behavioural regression: eg., per-s i s t e n t inappropriate dependent behaviour 0 1 2 3 4 0 1 2 3 4 0 1 2 3 4 22.6 Neurotic t r a i t s : eg., depression, phobias, obsessive-compulsive symptoms, anxiety 0 1 2 3 4 0 1 2 3 4 0 1 2 3 4 22.7 Psychotic t r a i t s : eg., b i z a r r e behaviour, extreme withdrawal, delusional or paranoid thinking 0 1 2 3 4 0 1 2 3 4 0 1 2 3 4 22.8 A n t i - s o c i a l behaviour: eg., c r i m i n a l i t y , alcoholism 0 1 2 3 4 0 1 2 3 4 0 1 2 3 4 22.9 Neurological disorder: eg., epilepsy, perceptual/motor problems 0 1 2 3 4 0 1 2 3 4 0 1 2 3 4 22.10 Inappropriate sexual behaviour, eg., exhibitionism, voyeurism 0 1 2 3 4 0 1 2 3 4 0 1 2 3 4 22.11 Learning problems: eg., memory, short attention span 0 1 2 3 4 0 1 2 3 4 0 1 2 3 4 22.12 S u i c i d a l behaviour: eg., threats, pre-occupation, attempts 0 1 2 3 4 0 1 2 3 4 0 1 2 3 4 11 261 23. Amount of Service Provided Please indicate with a check mark the average number of sessions you have with an adult  mentally retarded c l i e n t and with an adult non-mentally retarded c l i e n t . Mentally Non-mentally Retarded Retarded  23.1 Once a year 23.2 2-6 times per year 23.3 7-11 times per year 23.4 2-3 times per month 23.5 Once a week ; 23.6 Two or more times a week 24. Location of Practice and Waiting L i s t Please indicate with a check mark at which lo c a t i o n you see your mentally retarded c l i e n t s and the average length of time a mentally retarded c l i e n t would have to wait to receive service from you at that l o c a t i o n . I f you have no waiting l i s t , check the column provided. No Wait Up to 3 - 4 2 - 4 5 - '7 8 - 1 1 1 Year L i s t 2 Weeks weeks Months Months Months or More 24.1 Private Practice •_ 24.2 Greater Vancouver Mental Health Service 24.3 Mental Health Centre 24.4 Ministry of Human Resources 24.5 School Board 24.6 Non-prof i t Organization 24.7 Hospital or I n s t i t u t i o n 24.8 University 24.9 Other, please specify: 25. Age Range of Mentally Retarded C l i e n t s Please record the number of your adult mentally retarded c l i e n t s i n each age group. 25. .1 19-25 years 25. .2 26-30 years 25. .3 31-35 years 25. .4 36-40 years 25. .5 41-45 years 25. .6 46+ years 12 262. 26. Male/Female Please record the number of your adult mentally retarded c l i e n t s that are male and the number that are female. 26.1 Male 26.2 Female -27. L i v i n g Situation of Mentally Retarded C l i e n t s Please record the number of your mentally retarded c l i e n t s r e s i d i n g i n the following l i v i n g s i t u a t i o n s . Record a zero where appropriate. 27.1 Boarding home 27.2 Family home 27.3 Foster home /  27.4 Group home 27.5 Long-term care home 27.6 Own home or apartment 27.7 Other, specify: 28. Day-time A c t i v i t y of Mentally Retarded C l i e n t s Please record the number of your adult mentally retarded c l i e n t s who p a r t i c i p a t e i n the following day-time a c t i v i t i e s . Record a zero where appropriate. 28.1 Attending a Sheltered Workshop 28.2 Employed i n a Sheltered Industry 28.3 Employed i n regular labour force 28.4 Attending school 28.5 Attending a Vocational School or Community College 28.6 Volunteer work ' 28.7 Not involved i n any programs 28.8 Other, specify: 13 263 Section C: Personal Reactions to the Delivery of the Mental Health Services to Mentally Retarded Adults F a i r Good 29. This question has two parts. Please answer both a and b. a) Please rate, by c i r c l i n g the appropriate number, how well you f e e l the agency for which  you work or you yourself i f you are i n private p r a c t i c e , provides the following mental health services to mentally retarded adults. I f you or your agency do not provide a p a r t i c u l a r service, please c i r c l e zero. b) Please rate, by c i r c l i n g the appropriate number, how well you f e e l the following mental health services are currently being provided to mentally retarded adults by other  community-based agencies. The following scale applies: 0 - Do not provide t h i s service 1 - Poor 29.1 Intake Interview 29.2 Diagnostic assessment, eg., p s y c h i a t r i c , psychological, etc. 29.3 Counselling and/or psychotherapeutic a s s i s - tance, which may include the use of verbal and/or non-verbal approaches, behaviour modification, with i n d i v i d u a l or groups, occurring i n a v a r i e t y of settings a) You or the agency for which you work 29.4 Parental and/or family counselling or therapy 29.5 Re f e r r a l to other sources f o r i n d i v i d u a l and/or parent/family counselling or psychotherapeutic assistance 29.6 Drug Therapy 29.7 Provision of a d d i t i o n a l services: eg., f i n a n c i a l , educational, r e s i d e n t i a l , vocational, r e c r e a t i o n a l 29.8 Referral f o r a d d i t i o n a l services: eg., f i n a n c i a l , educational, r e s i d e n t i a l , vocational, r e c r e a t i o n a l 29.9 Follow-up assistance once c l i e n t i s placed into a program 29.10 Consultation with s i g n i f i c a n t others i n c l i e n t ' s l i f e , eg., teacher, group-home supervisor, vocational i n s t r u c t o r , parents/guardians 29.11 Written reports to parents/guardians regarding assessments 29.12 Written reports to s i g n i f i c a n t others i n c l i e n t ' s l i f e regarding assessments, program plans, progress reports, e tc. 29.13 Provision of i n d i r e c t mental health services: eg., s t a f f t r a i n i n g i n mental retardation, par-t i c i p a t i o n i n the development of mental health services for the mentally retarded 29.14 Other mental health services, please specify: 4 - Excellent b) Other Community-based agencies 14 2 6 4 30. Do you f e e l you yourself, or the agency for which you work, i s responsible for providing mental health services as described i n question 29, to mentally retarded adults? 30.1 Yes 30.2 No I f no, please explain. . 31. Please indicate with a check mark whether or not you f e e l counselling and/or psychotherapeutic  assistance can be provided to mentally retarded adults by the same agency which provides t h i s service to the general population, eg., mental health c l i n i c , community care team, or should they be provided by a s p e c i a l agency for the mentally retarded, eg., association for the mentally retarded. Check only one. 31.1 Same agency as the general population with personnel trained i n the p r o v i s i o n of counselling and psychotherapeutic assistance for the mentally retarded. 31.2 Special agency f o r the mentally retarded with personnel trained i n the pr o v i s i o n of counselling and psychotherapeutic assistance for the mentally retarded. Thank you very much for completing t h i s questionnaire. Your response i s greatly appreciated. Please return the completed questionnaire i n the stamped addressed envelope provided. I f you wish a copy of the r e s u l t s , complete the postcard provided, and mail separately. 15 A STUDY OF MENTAL HEALTH SERVICES FOR MENTALLY HANDICAPPED OR MENTALLY RETARDED ADULTS IN VANCOUVER AND RICHMOND The purpose of t h i s survey i s to obtain information on, i) the p r o v i s i o n of mental health and other services since January 1, 1979 to mentally retarded adults (19 years and over); and i i ) the reactions of parents towards the p r o v i s i o n of mental health services to mentally retarded adults. I t i s anticipated that the r e s u l t s of t h i s study w i l l provide agencies and professionals i n the f i e l d s of mental health and mental retardation with information that w i l l a s s i s t them i n evaluating the a b i l i t y of the e x i s t i n g mental health services to meet the mental health needs of mentally retarded adults i n Vancouver and Richmond. P a r t i c i p a t i o n i n t h i s study i s completely voluntary and the answers you provide are e n t i r e l y anonymous. Your consent for p a r t i c i p a t i o n w i l l be assumed only upon re c e i p t of your completed questionnaire. Your cooperation i n answering t h i s questionnaire i s greatly appreciated. I t should take only 15 minutes of your time. The return of your completed questionnaire by January 21. 1980 would be greatly appreciated. Please use the stamped return envelope provided. Thank-you for your p a r t i c i p a t i o n i n t h i s study. 1. Please c i r c l e the age category of your son or daughter who i s considered to have a mental handicap or to be mentally retarded. 1.1 Son 19-25 26-30 31-35 36-40 41-45 46+ 1.2 Daughter 19-25 26-30 31-35 36-40 41-45 46+ 2. Please indicate with a check mark where your son/daughter currently l i v e s . 2. .1 Family home 2. .2 His/Her own home or apartment 2. .3 Group Home 2. .4 Boarding Home 2. .5 I n s t i t u t i o n / h o s p i t a l 2. .6 Other, please specify 3. Please indicate with a check mark i n what type of day-time a c t i v i t y your son/daughter i s currently involved. 3.1 Attending a Sheltered Workshop ' 3.2 Employed i n a Sheltered Industry 3.3 Employed i n regular labour force 3.4 Attending School 3.5 Attending a Vocational School or Community College 3.6 Volunteer Work 3.7 Not involved i n any program 3.8 Other, please specify 4. Please indicate with a check mark at what l e v e l of functioning you f e e l your son/daughter presently performs i n d a i l y l i v i n g s k i l l s . 4.1 M i l d l y mentally handicapped 4.2 Moderately mentally handicapped 4.3 Severely mentally handicapped 267 5. Provision of Services Please indicate with a check mark i f i n the past year (since January 1, 1979) your son/daughter has received counselling, t r a i n i n g , or i n s t r u c t i o n from any of the personnel l i s t e d below, who work within the Vancouver and/or Richmond area. Yes No 5.1 Residential Counsellor or Instructor eg. , Group Home Personnel 5.2 Vocational Counsellor or Instructor eg., Sheltered Workshop Personnel 5.3 Recreation Counsellor or Instructor 5.4 Other, eg.. Public Health Nurse, P s y c h i a t r i c Nurse, C h i l d Care Worker, Clergyman Please specify 6. Services Provided I f since January 1, 1979, your son/daughter has received any of the services l i s t e d below, please indicate the q u a l i t y of service you f e e l your son/daughter received (or i s receiving) by c i r c l i n g the appropriate r a t i n g . Please c i r c l e the rating i n the column according to the personnel from who your son/daughter has received the service(s) as you indicated i n Question 5. I f your son/daughter has not received a p a r t i c u l a r s e r v i c e ( s ) , please c i r c l e 0 i n the column headed Never Received. The following r a t i n g scale applies: 0 - Never Received 1 - Poor 2 - F a i r 3 - Good 4 - Excellent Never Received 6.1 Assessment or Evaluation 6.2 L i f e s k i l l s i n s t r u c t i o n , eg., budgeting, cooking, grooming 6.3 Personal counselling or psychotherapeutic a s s i s -tance f o r behaviour or emotional problems 6.4 Vocational t r a i n i n g , eg., work habits and s k i l l s 6.5 Recreation i n s t r u c t i o n or counselling 6.6 Job placement and counselling 6.7 Other, please describe: Residential Personnel 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 Vocational Personnel 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 Recreation Personnel 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 Other, Specify: 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 2 268 7. Provision of Mental Health Services Please indicate with a check mark i f i n the past year (since January 1, 1979) your son/daughter has received services from any of the following mental health professionals who work within the Vancouver and/or Richmond area. Yes No 7.1 P s y c h i a t r i s t 7.2 Psychologist 7.3 S o c i a l Worker Mental Health Services Provided I f since January 1, 1979, your son/daughter has received any of the following mental health  services, please indicate the q u a l i t y of service you f e e l your son/daughter received (or i s receiving) by c i r c l i n g the appropriate r a t i n g . Please c i r c l e the r a t i n g i n the column according to the personnel from whom your son/daughter has received the s e r v i c e ( s ) , as you indicated i n question 7. I f your son/daughter has not received a p a r t i c u l a r s e r v i c e ( s ) , please c i r c l e 0 i n the column headed Never Received. The following r a t i n g scale applies: 0 - Never Received 1 - Poor 2 - F a i r Never Received 8.1 I n i t i a l interview only 8.2 Diagnostic Assessment 8.3 Counselling and/or psychothera-peutic assistance f o r behaviour or emotional problems 8.4 Parental and/or family counsel-l i n g or therapy 8.5 R e f e r r a l to other source for i n d i v i d u a l and/or parent or family counselling or psychotherapeutic assistance 8.6 Drug Therapy 8.7 Provision of other services, as needed, eg., f i n a n c i a l , educational, r e c r e a t i o n a l , vocational, r e s i d e n t i a l 8.8. R e f e r r a l for a d d i t i o n a l services, eg., f i n a n c i a l , educational, r e s i -d e n t i a l , vocational, r e c r e a t i o n a l 8.9 Follow-up assistance once son/daughter placed i n a program 8.10 Consultation with parents/guardians regarding assessments, program plans or progress reports 8.11 Written reports to parents/guardians regarding assessments, program plans or progress reports 8.12 Other mental health services, please describe: . Good P s y c h i a t r i s t 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 Excellent Psychologist 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 S o c i a l Worker 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 3 269 9. Counselling or Psychotherapeutic Assistance Please indicate with a check mark i n the appropriate column, whether or not your son/daughter has received or i s currently r e c e i v i n g counselling or psychotherapeutic assistance from a mental health professional or other personnel for any of the problem areas l i s t e d below. I f your son/daughter has not needed counselling or psychotherapeutic assistance for any of the problem areas l i s t e d , please check the column headed Not i n Need. I f your son/daughter has needed counselling or psychotherapeutic assistance for a problem area(s) l i s t e d , but has not been able to receive counselling or psychotherapeutic assistance, please check the column headed Needed But Not Received. Not In Need 9.1 Inadequate l i f e s k i l l s eg., f i n a n c i a l manage-ment problems, independent l i v i n g s k i l l s problems, vocational adjustment problems Needed But Not Received Psychia-t r i s t Psycholo-g i s t S o c i a l Worker Other, Specify: 9.2 Resistance to p a r t i c i -pating i n h a b i l i t a t i o n programs: eg., vocational educational, s o c i a l 9.3 Aggressive behaviours, eg., h u r t f u l to others, hard to control, s e l f - i n j u r i o u s 9.4 Poor s o c i a l r e l a t i o n s h i p s : eg. , shy, poor peer r e l a -tionships, over-sensitive, l i t t l e self-confidence 9.5 Behavioural regression: eg., p e r s i s t e n t return to inap-propriate dependent behaviour 9.6 Neurotic t r a i t s : eg., de-pression, phobias, anxiety, obsessive-compulsive behaviours 9.7 Psychotic t r a i t s : eg. b i z -zare behaviour, extreme withdrawal, delusion thinking 9.8 A n t i - s o c i a l behaviour: eg., delinquency, alcoholism 9.9 Neurological disorders, eg., epilepsy, perceptual/motor problem _ 9.10 Inappropriate sexual beha-v i o u n eg. exhibitionism, voyeurism 9.11 Learning problems: eg. mem-ory , short attention span 9.12 S u i c i d a l behaviours: eg., threats, pre-occupation with, attempts 4 270 10. Referral f o r Service Please indicate with a check mark i n the appropriate column, how your son/daughter was f i r s t  r e f e r r e d to the personnel whom you have indicated i n questions 5 and 7. Other, Psych-i a t r i s t 10.1 Referred by family physician to 10.2 Referred by S o c i a l Worker to 10.3 Referred by School Personnel to 10.4 Referred by Other, please specify: 10.5 Contacted p r i -vate profes-s i o n a l or agency d i r e c t l y Psych-o l o g i s t S o c i a l Worker Residential Personnel Vocational Personnel Recreational Personnel Specify: 11. Amount of Service Please indicate with a check mark i n the appropriate column, how often your son/daughter receives services. 11.1 Once a year 11.2 2-6 times a year 11.3 7-11 times a year 11.4 Once a month 11.5 2-3 times per month 11.6 Once a week 11.7 Two or more times a week 11.8 Each day Psychia-t r i s t Psycholo-g i s t  S o c i a l Worker Other, Specify: 5 271 12. Location of Mental Health Services Please indicate with a check mark whether or not the mental health professional or other personnel who provides service to your son/daughter i s i n private p r a c t i c e or i s with one of the agencies l i s t e d below, and indicate whether t h e i r o f f i c e i s i n Vancouver or Richmond. Check as many as are appropriate. Place of Work 12.1 Private p r a c t i c e : 12.2 Mental Health C l i n i c : Vancouver Richmond Vancouver Richmond 12.3 Ministry of Human Resources: Vancouver Richmond 12.4 School Board: Vancouver Richmond 12.5 Non-profit Association, please specify: Psychia-t r i s t Psycholo-g i s t S o c i a l Worker Other, Specify: 12.6 Hospital or I n s t i t u t i o n , please specify: 12.7 Other, please specify: 13. Fee for Service Please indicate with a check mark whether or not you have ever been charged a fee for services provided by a mental health professional or other personnel to your son/daughter. Yes No 13.1 P s y c h i a t r i s t 13.2 Psychologist 13.3 S o c i a l Worker 13.4 Other personnel, please s p e c i f y : 6 272 14. Need for Service Please indicate with a check mark from the following l i s t of services, whether you f e e l your son/daughter i s i n need of any of the services l i s t e d and i f they are currently on a waiting l i s t f o r the service. I f i n the past you have attempted to get service(s) for your son/daughter but were unsuccessful, please place an a d d i t i o n a l check mark beside the service(s) i n the column headed Requested Service, But Was Unsuccessful. Requested Ser-' In Need Of On Wait L i s t v i c e , But Was Service For Service Unsuccessful 14.1 Diagnostic assessment 14.2 Counselling or psychotherapeutic assistance for your son/daughter 14.3 Residential placement eg., group home 14.4 Vocational program eg., j o b - t r a i n i n g , sheltered workshop, employment 14.5 Social-educational program eg., l i f e - s k i l l s t r a i n i n g 14.6 Recreational/leisure time program 14.7 F i n a n c i a l assistance 14.8 Parent or family counselling or therapy 14 .9 Parent/family r e l i e f service eg., short stay hostel, homemaker service 15. Source of Counselling or Psychotherapeutic Assistance I f you f e l t your son/daughter was i n need of counselling or psychotherapeutic assistance, would you: (Check only one) a) Prefer to have him/her go to a service that i s a v a i l a b l e to the general community but with personnel trained i n the provision of counselling and psychotherapeutic assistance for the mentally retarded. OR b) Prefer to have him/her go to a separate service s p e c i f i c a l l y f o r the mentally retarded with personnel trained i n the p r o v i s i o n of counselling and psychotherapeutic assistance f o r the mentally retarded. Thank you for your assistance i n completing t h i s questionnaire. Your cooperation i s greatly appreciated. Please return your questionnaire i n the stamped, addressed en-velope provided. I f you would l i k e a copy of the survey r e s u l t s , complete the postcard provided and mail i t separately from your questionnaire. 7 

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