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Brief service in a child guidance clinic : a preliminary survey : a descriptive study based on Child… Freer, Nell Wilson 1957

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BRIEF SERVICE IN A CHILD GUIDANCE CLINIC;  A PRELIMINARY SURVEY A D e s c r i p t i v e Study Based on C h i l d Guidance C l i n i c Cases, Burnaby, 195k>57 b y •NELL WILSON FREER "Thesis S u b m i t t e d i n P a r t i a l F u l f i l m e n t 'of the Requirements f o r the Degree o f MASTER OF SOCIAL WORK/' I n the S c h o o l o f S o c i a l Work A c c e p t e d as c o n f o r m i n g t o the s t a n d a r d "required f o r t h e degree o f M a s t e r o f S o c i a l Work S c h o o l of S o c i a l Work 1957 The U n i v e r s i t y o f B r i t i s h Columbia ABSTRACT The main purpose of t h i s study i s to survey a sampling of b r i e f s e r v i c e cases i n a c h i l d guidance c l i n i c i n an e f f o r t to d i s c o v e r why these cases could be t r e a t e d on a b r i e f or short-term b a s i s . Because of the need to help more people i n a given length of time and the l i m i t e d agency s t a f f and high case loads, i t i s very de-s i r a b l e that treatment on a b r i e f s e r v i c e b a sis be expanded i f i t can be done without s a c r i f i c i n g good casework p r a c t i c e . Making use of the t r a n s c r i b e d notes made during the C l i n i c Diag-n o s t i c Conferences, the p r e s e n t i n g problems, diagnoses, number of contacts and person to whom s e r v i c e was given were t a b u l a t e d f o r each of 62 cases which were designated by the C l i n i c as b r i e f s e r v i c e cases I t was found that there i s no f o r m a l i z e d d e f i n i t i o n of b r i e f s e r v i c e at the C l i n i c and the g i v i n g of b r i e f s e r v i c e does not appear to be a planned p a r t of the general program. The data assembled from the d i a g n o s t i c conference notes i n d i c a t e that there has been no organi zed e f f o r t to d e l i n e a t e p r o p e r l y what a b r i e f s e r v i c e case i s . Because of the success of w e l l organized b r i e f s e r v i c e programs i n other agencies, i t i s suggested that such a program should be planned f o r at the C l i n i c and some of the steps i n o r g a n i z i n g such a program are suggested. ACKNOWLEDGMENTS I wish to acknowledge indebtedness to Miss Kay Daly and Mr. Ilonald Ricketts of the Provincial Child Guidance Clinic for allow-ing me freely to Use material in the notes and minutes made and conferences and committee meetings and for their helpful suggestions concerning the development of brief services at the Cl i n i c . It is a pleasure to express my gratitude to Mr. Adrian Marriage for his helpful criticism and suggestions and to Miss Muriel Cunliffe and Dr. Leonard Marsh of the faculty of the School of Social Work. I wish also to make special acknowledgment to Mrs. Estelle Chave for her timely encouragement and for information about the policies and history of the Cli n i c . TABLE OF CONTENTS Page Chapter 1. The Concept of B r i e f S e r v i c e The need f o r b r i e f s e r v i c e , Development of b r i e f s e r v i c e and i t s use i n other agencies . . 1 Chapter 2. Development of B r i e f S e r v i c e s at the P r o v i n c i a l  C h i l d Guidance C l i n i c D e s c r i p t i o n of C l i n i c program and e v o l u t i o n of the S o c i a l S e r v i c e Department. Attempted d e f i n i t i o n of b r i e f s e r v i c e 10 Chapter 3 . A n a l y s i s of B r i e f S e r v i c e Cases at the C h i l d  Guidance C l i n i c . Scope of the s tudy . L i m i t a t i o n s of the sample. T a b u l a t i o n of da t a 19 Chapter 4. C o n c l u s i o n . C h a r a c t e r i s t i c s of a b r i e f s e r v i c e case . Suggested c r i t e r i a f o r s e l e c t i n g b r i e f s e r v i c e cases and suggest ions f o r i n s t i t u t i n g 30 a b r i e f s e r v i c e program Appendices : A . B i b l i o g r a p h y TABLES Table 1. C l a s s i f i c a t i o n of P re sen t ing Problems i n B r i e f S e r v i c e Cases i n the C l i n i c 21 Table 2 . Team Diagnoses of B r i e f S e r v i c e Cases at the C h i l d Guidance C l i n i c 22 Tab le 3 . Length of Contacts i n B r i e f S e r v i c e Cases a t the C h i l d Guidance C l i n i c 24 Table 4 . Purpose of Casework Treatment i n B r i e f S e r v i c e Cases at the C h i l d Guidance C l i n i c 27 Table 5. Person to Whom S e r v i c e was Given 28 Chapter 1 THE CONCEPT OF BRIEF SERVICE The common desire to help shorten human suffering coupled with the very practical problems of growing case loads, and the resultant long waiting periods for clients, has produced among social workers a great interest in the poss i b i l i t i e s of "brief services" as a means of helping more people in a given period of time. Pressures on agencies to provide more services have been mounting as people become aware of the sources of help available within the community. Shortages of trained personnel and lack of f a c i l i t i e s to meet the increasing case loads has forced existing agencies to face the problem of finding ways to meet the growing demands of people who need help. Many agencies desiring to be more readily avail-able to the community and to cut down the long waiting l i s t s have begun experimenting with shorter forms of services. This does not seem to be a regressive trend to the time when casework services were brief owing to the s t i l l undeveloped methodst but is seen as a positive response to the economic necessity of treating as many people as possible who need help. In considering any method by which casework services can be short-ened, one must constantly consider the question: are there ways of giving effective help in shorter periods of time without sacrificing basic social work principles and quality of service? Historically, social case-work practice has been influenced by psychoanalytic concepts. The practitioners of psychoanalytic therapy very early gave up the idea of -2-brief analysis when i t appeared that the results were disappointing, and i t became common practice for an analysis to extend over a two or three-year period. Casework, under the influence of psychoanalysis, tended to follow the same pattern and long-term treatment was emphasized. The focus of teaching and practice in casework has for years stressed the value of long-term treatment. Some analysts, however, have in recent years been experimenting with modified techniques that will encourage early improvement and shorten the span of treatment. Alexander and French^ openly advocate shorter methods. These authors have questioned certain traditional psychoanaly-t i c dogmas: 1) that the depth of therapy is necessarily proportionate to the frequency.of the interviews and the length of treatment, and 2) that the results achieved by a small number of interviews are superficial and temporary while those of the classical or standard analysis are more stable and lasting. They conclude that brief therapy i f based on f u l l diagnostic understanding of the patient and the problems, can meet the f u l l thera-peutic needs of the individual. To the previously posed question whether effective casework help can be given in shorter periods of time without sacrificing quality of service, i t can be seen, as a result of brief casework experiments, that there are indications that brief casework has intrinsic value regardless of the staff and time available. Thus, emulation of traditional psychoanalytic concepts Alexander, Franz and French, T. Psychoanalytic Therapy, The Ronald Press Co., New York, 1946 -3-may have i n h i b i t e d to some extent the development o f the idea of b r i e f s e rv i ce s i n some s o c i a l agenc ies . The C o n s t r u c t i v e Use of Time L i m i t s M e l i t t a Schmideberg from her study of shor t - t e rm treatment con-c luded tha t , "shor t therapy as I have p r a c t i c e d i t i s not so much a technique of ' b r i e f * or ' abbrev ia ted* treatments as i t i s a f l e x i b l e method that f r equen t ly acce l e r a t e s t r ea tmen t . " * She observed i n her work wi th parents tha t when they had hopes o f e a r l y improvement they worr ied l e s s and were b e t t e r able to put up w i t h t h e i r c h i l d r e n ' s d i f f i -c u l t i e s . T h e i r t o l e r ance and hopefulness i n t u rn had a b e n e f i c i a l e f f e c t on the c h i l d r e n and made f o r f u r t he r p r o g r e s s . "One i s of ten s u r p r i s e d o how q u i c k l y a c h i l d improves when parents ga in new hope ." Many c l i e n t s a t i n t a k e i n d i c a t e tha t they want to help wi th a s p e c i f i c s i t u a t i o n or problem. They want the help to be g iven q u i c k l y and e f f e c t i v e l y f o r va r ious reasons: i t may be d i f f i c u l t f o r them to get to the agency because of the d i s t ance and t r a v e l time i n v o l v e d , an emer-gency may e x i s t f o r which they want immediate h e l p , they may fea r g e t t i n g i n v o l v e d i n long- term treatment which i s c o s t l y and exposes them to an in tense r e l a t i o n s h i p w i th the worker, or they may f e e l p e r f e c t l y capable of d e a l i n g wi th the problem themselves i f a l i t t l e help i s g iven at the ISchmideberg, M e l i t t a , "Short A n a l y t i c Therapy ." Nervous C h i l d . 1949-50 v 8, pp . 289-90 2 A d l e r , A l e xand ra , G u i d i n g Human M i s f i t s , New Y o r k , 1948. -4- . right time. There is l i t t l e doubt that a client*s r e l i e f at being told that the counseling service w i l l be brief is frequently a manifestation of resistance.-' However, instead of interpreting this to the client as resistance, the caseworker can attempt to use i t constructively as an ego strength. Theoretically the attempt would be made to transfer the ego energy which at f i r s t is being used as a defense (i . s . for r e s i s t — ance) to an assertion of independence and a determination to overcome the personal d i f f i c u l t y . In other words the resistance to long-term treat-ment could be utilized in making a success of brief counseling with the focus being on the healthy aspects of the personality rather than on i t s impairments. Thus there are many indications that the pressure of time can be a force that helps the client come to grips with his problem more readily and is an incentive for more rapid movement. Knowing that his contacts will be brief he will have to sort out more quickly the peripheral from the v i t a l needs. Within a few interviews he can evaluate with his worker whether he should have continuing treatment or whether he can carry on by himself. For the worker a time limitation may help him evaluate progress in a more conscious and focused manner. It may serve to sharpen diagnostic judgment and therapeutic s k i l l . Furthermore i t may prevent fostering undue dependence in certain dependent individuals since he w i l l release them from treatment as soon as they can function unaided. In functional casework, time is one of the primary instruments of the helping process. Length and frequency of interviews and "end-setting" iFor a discussion of resistance on the part of parents coming to the c l i n i c , Kennedy, Ramona, I n i t i a l Resistance of Parents to Casework Services  in a Child Guidance Setting. M.S.W. Theses, University of British Columbia, 1957. are c a r e f u l l y p l anned . To the f u n c t i o n a l i s t the concept of time " rep re -sents to the i n d i v i d u a l the most f i n a l of l i m i t s , about which he can do no th ing , and i t may be s a i d to be the most f e a r f u l aspect o f h i s e x i s t e n c e . " W i t h i n these two l i m i t s i n t ime ( b i r t h and dea th ) , the p resen t moment i s a l l tha t i s a v a i l a b l e t o the human b e i n g . I t cannot be grasped, h e l d , repeated, or postponed, but can only be used, ( that i s , l i v e d ) and a l lowed to pa s s . I t i s upon t h i s u n i v e r s a l r e a l i t y of the meaning o f t ime to the i n d i v i d u a l human be ing tha t f u n c t i o n a l casework bases i t s use of time i n the h e l p i n g p roces s , wi th i t s emphasis upon the present moment and the present r e l a t i o n s h i p , and i t s dynamic use of tha t r e l a t i o n s h i p . " ' ' Al though he may not h o l d to time l i m i t s as s t r i c t l y as the f u n c t i o n -a l i s t s , the " d i a g n o s t i c " caseworker a l s o makes use of t ime t h e r a p e u t i c a l l y . In te rv iews are planned ahead to s u i t the convenience of both c l i e n t and worker , and the c l i e n t i s expected to keep h i s appointments . U s u a l l y there i s an unders tanding as to the approximate l eng th of time the treatment w i l l c o n t i n u e . The t e r m i n a t i o n of i n t e r v i e w i n g contac ts comes not as an abrupt ending but r a the r as a n a t u r a l step taken by the c l i e n t when he recognizes h i s readiness to be on h i s own. Time i s of fundamental importance i n many types o f casework. For example, i n casework w i t h the unmarried mother the nature of the problem sets time l i m i t s w i t h i n which at l e a s t a minimum amount of p l a n n i n g must be made and c a r r i e d out by worker and c l i e n t . * T a f t , J e s s i e , "Time As the Medium o f the H e l p i n g P roces s " , Jewish  S o c i a l S e r v i c e Q u a r t e r l y . 1949, p . 189 as quoted i n A Comparison of  D i a g n o s t i c and F u n c t i o n a l Casework Concepts , Cora C a s i u s , E d i t o r , Family S e r v i c e A s s o c i a t i o n o f Amer i ca , New Y o r k , 1950. - 6 -Some Examples of Agency Use of Brief Services Some agencies, because of the nature of their work, have had ex-tensive experience with brief contact cases. The Traveler*s Aid has a well established program that might serve as a model of what can be done to help clients in one or two interviews. Miss Townsend"^ says the oppor-tunities for a "sensitive caseworker to give effective help to this never ending stream of human beings in d i f f i c u l t i e s are tremendous i t is possible to render fundamental help in one interview or in a few. Dramatic changes do occur overnight." She emphasizes the importance of having a highly skilled caseworker as the key to successful brief service. Community Information Centers are agencies where the rule is brief service. Here the caseworkers job is to give information about resources the client asks for, to help him find the resources he really needs, to help him decide whether he is ready to use the help available, and to move on. A l l this must be done in less than One hour, Dorothy Eklund report-ing on the experiences of the Minneapolis Community Information Center points out the advantages of short contact interviewing by saying that the caseworker's awareness of the time "sharpens his s k i l l s - he must help the client make a beginning, help him to get to what can be done, and help him bring the interview to an end. One might c a l l this a creative use of time 2 limits." Family agencies are currently giving considerable attention to deter-ming what valid services can be given in one interview or in a limited number, and what- special s k i l l s areineeded to sjo this. A significant study 1 Townsend, Gladys E., "Short-Term Casework with Clients Under Stress", Social Casework. Nov. 1953, pp. 392-398 2 Eklund, Dorothy, "Short-Contact Services in an Information and Referral Center". Social Casework. 1951, p. 432. - 7 -of b r i e f s e r v i c e s conducted by the Family S e r v i c e A s s o c i a t i o n of America (hereaf ter c a l l e d FSAA), has served to r a i s e many questions concerning these s e r v i c e s and to s t i m u l a t e f u r t h e r r e sea r ch . The t rend toward the i n c r e a s -i n g p r o p o r t i o n of b r i e f s e r v i c e cases i n f ami ly agencies was f i r s t d e a l t wi th i n a repor t e n t i t l e d Short Contact Cases i n Family S e r v i c e A g e n c i e s , based on a study of b r i e f s e r v i c e cases c l o s e d du r ing March, 1948 f o r 64 member agenc ies .* As a r e s u l t of t h i s study FSAA suggested that i n d i v i d u a l f a m i l y agencies examine t h e i r cases i n order to achieve an understanding o f shor t contac t cases . Any case c lo sed wi th not more than one " i n pe r son" i n t e r v i e w s i n c e i t s l a t e s t opening, r ega rd les s of te lephone c a l l s or c o r r e s -pondence i s c l a s s i f i e d as " b r i e f s e r v i c e . " Some of the ques t ions r a i s e d were why were so many o f the cases sho r t - con tac t cases? Were these c l i e n t s r e c e i v i n g a v a l i d s e r v i c e w i t h i n a b r i e f time or was the f ami ly agency f a i l i n g them? Should these c l i e n t s have cont inued wi th the agency f o r f u r t he r s e r v i c e ? Dorothy Thomas^" made a fo l low-up study of b r i e f s e r v i c e s i n a f a m i l y s e r v i c e agency at Washington, D . C . , and found that there were v a l i d reasons f o r sho r t - con tac t cases and t h e i r i nc rease i n the past f i v e years i f they were determined by a c a r e f u l d iagnos i s made at i n t a k e . She suggested tha t the i n t ake procedure , s i nce i t i s i n f a c t a d i a g n o s t i c s e r v i c e , cou ld be more c o r r e c t l y and u s e f u l l y desc r ibed by the term " i n f o r m a t i o n , c o n s u l t a t i o n , i n t ake and r e f e r r a l s e r v i c e . " 1 Shyne, Ann W. Short Contact Cases i n Fami ly S e r v i c e Agenc i e s . F . S . A . A . New York , 1948 (mimeographed) 2 Thomas, Dorothy V . , "The R e l a t i o n s h i p Between D i a g n o s t i c S e r v i c e and Short Contact C a s e s , " S o c i a l Casework. 1951, p . 74. -8-Using the FSAA survey as a starting point, the Jewish Family Service of New York made a study of i t s own short-term cases. In this agency a short-term was defined as " a l l activity up to and including one planned intake appointment - which meant a l l telephone calls, letters, and unplanned reception interviews included in the contact, with a planned interview as maximum activity.'' One finding of this investigation was that the use of the term "short-term case" was confusing and deceptive. Grouped under this description was a wide variety of situations having as the only thing in common their shortness of contact. There are other implications in this investigation, the most im-portant being the need for professional re-thinking of the characteristics of brief services in a family agency setting. Family agencies had tra-ditionally looked upon brief services with apprehension, considering them as abortive long-term cases and as somehow second-class. Caseworkers tended to put their greatest effort into the long-term cases and f e l t guilty at giving what they might think of as less than the f u l l treatment to clients.^ This has been so even though the long-term cases are in the minority. (In some family service agencies 50 to 60 per cent of the cases are brief services) The Frings study'' suggested that short-term cases should be looked upon as neither better nor worse than extended services but as different in the demands they made on casework s k i l l s . Furthermore, the Frings study pointed up the need for training to provide caseworkers 1 Frings, John, "What About Brief Services - A Report of a Study of Short-Term Cases." Social Casework. 1951, pp. 236-241 2 Have caseworkers tended to rationalize their passive acceptance of the client's lack of movement by calling i t going "at the clients pace", instead of sharpening their s k i l l s and methods to helping the client in a shorter period of time? V. ' I " " .".:'.:?"• c • with the necessary s k i l l s f o r g i v i n g b r i e f s e r v i c e s . In a l l the s o c i a l agencies examined there seemed to be general agreement on three main categories of p o s i t i v e and l e g i t i m a t e s e r v i c e s that could be given i n short contacts, i . e . r e f e r r a l s , i n f o r m a t i o n - g i v i n g and b r i e f counseling. R e f e r r a l means preparing the c l i e n t f o r other sources of help. E f f e c t i v e r e f e r r a l can be of th e r a p e u t i c value t o the c l i e n t and demands the same s k i l l s e s s e n t i a l i n any good casework. I n f o r m a t i o n - g i v i n g i n v o l v e s such things as a d v i s i n g parents on c h a r a c t e r i s t i c s of normal c h i l d develop-ment, i n t e r p r e t i n g c l i n i c f i n d i n g s and suggesting educational plans f o r c h i l d r e n . Since the simplest request f o r inf o r m a t i o n niay be based oh paren-t a l a n x i e t y , even the b r i e f e s t contacts can c a l l f o r t h a l l the s k i l l at the caseworker*s command. B r i e f counseling u s u a l l y means g i v i n g help on a s p e c i f i c problem. Chapter I I DEVELOPMENT OF BRIEF SERVICES AT THE PROVINCIAL CHILD GUIDANCE CLINIC The P r o v i n c i a l C h i l d Guidance C l i n i c of B r i t i s h Columbia was es-t a b l i s h e d to prevent mental i l l n e s s , delinquency and other forms of dependency and disturbance i n s o c i e t y . I t c a r r i e s out i t s f u n c t i o n by o f f e r i n g guidance s e r v i c e s f o r c h i l d r e n and parents by p r o v i d i n g community education s e r v i c e s . Diagnosis and treatment w i t h i n the agency i s a c o l l a b o r a t i v e e f f o r t using the s k i l l s of s e v e r a l p r o f e s s i o n s . The team approach i s used i n the program and the b a s i c team i s composed of a p s y c h i a t r i s t , s o c i a l worker, p s y c h o l o g i s t and p u b l i c h e a l t h nurse. Intake i n t e r v i e w s are conducted by a s o c i a l worker. When s u f f i c i -ent data i s acquired, u s u a l l y i n one or two i n t e r v i e w s , an intake conference i s held at which the c l i n i c teams come to a d e c i s i o n about the d i s p o s i t i o n of the case. I f the d e c i s i o n i s to accept the case f o r d i a g n o s t i c study, a planning conference i s he l d at which various members of the team are assigned to the case. Diagnostic i n t e r v i e w s are scheduled, followed by a d i a g n o s t i c conference at which the t h i n k i n g of the various d i s c i p l i n e s i s pooled and a. treatment p l a n i s evolved. Most of the treatment given by the c l i n i c at the present time i s casework treatment. In 1951 Glover*-, i n h i s study of i n t e r v i e w i n g methods 1 Glover, Ernest Geoffrey, Casework I n t e r v i e w i n g Methods i n a C h i l d  Guidance S e t t i n g , M.S.W. Thesis, U n i v e r s i t y of B r i t i s h Columbia, 1951 (unpublished) -11-at the c l i n i c said, "It became recognized that social workers in most instances could take over individual treatment within the c l i n i c so long as the knowledge and experience of a more specialized person was available through consultation. In the years 1948 and 1951 a study of 141 private cases showed that the burden of treatment was carried almost entirely by social workers." In theory any department of the c l i n i c might be directly involved in treatment, but in practice the time of the workers in the other departments is almost entirely taken up with diagnostic and consultative services, leaving them l i t t l e opportunity for direct treatment of children and their parents. The "New System" The social work department at the Child Guidance Clinic is composed of two sections: 1) Intake, Diagnostic and Brief Service and 2) Continued Service. The evolution of these two distinct services has come about gradu-all y within the past five years (since 1952) and became well established and structured during the last two years. It was an internal development and some of the other departments in the c l i n i c were not very much aware of this development. A l l workers at one time did a l l types of work: Intake, duty work^ and continued or long-term treatment, although some attempts. w.ere made at specialization. It became obvious that this was not proving satis-factory, mainly because of the long waiting periods between application and intake study. Dissatisfaction with the ever-increasing number of names on 1 One social worker is always on duty to take phone calls and answer inquiries regarding the services of the c l i n i c . -12-the waiting l i s t ^ led to discussions in staff meetings of ways to cope with the situation, and these discussions are continuing. For example, the staff meeting minutes of September 8, 1953 contained this reference: "Discussion by Intake Committee of changing and enlarging intake procedure - mainly towards Intake and Brief Service Section - general agreement in thinking on i t is that Intake will include the team as a whole and will involve the intake worker bringing the client and the case to the point of what we can now think of as f u l l c l i n i c examination and diagnostic confer-ence." The Clinic intake committee was very much interested in improving intake procedures but the changes seem to have taken place not as a result Of any particular study made by this committee, but as a t r i a l and error attempt by the staff as a whole in i t s striving to cut down the waiting period. The f i r s t change came with the appointment of one worker to be res-ponsible for intake interviews. Following the intake interview the case waited until a worker was assigned to work up the social history for the diagnostic conference, and to carry the case for treatment i f so decided by the team. It soon became apparent that a single intake worker was not meet-ing the need, so the question arose of adding two or three more. The think-ing of the committee expanded gradually to seeing these workers carrying the 1 Coming to the c l i n i c often represents for clients a state of urgency for they are seeking help as a last resort. When help is not readily forth-coming and they have to take their turn on the waiting l i s t , they become disappointed and frequently withdraw from the c l i n i c . Warde Laidman found in his study, Premature Withdrawal From Treatment in a Child Guidance Cl i n i c , M.S.W. Thesis, University of British Columbia 1957, that dissatisfaction with the long waiting period was one of the main reasons clients gave for discon-tinuing treatment after diagnostic conference. -13-case to the diagnostic conference. A further development occurred when the idea of dividing the social work department into two sections emerged. The "new system" of dividing the social work department into two sections came into operation gradually and very informally and was in operation sometime in the summer of 1954. It was referred to by workers in the c l i n i c as the "new system" and essentially i t involved dividing the social work staff into the "Intake, Diagnostic and Brief Service Section", and the "Continued Service Section." However, the idea of "Brief Service" was always subordinate as one of the reasons for establishing the new sys-tem, and there was no systematic attempt to define brief service nor were any c r i t e r i a set up for making use of brief service. The change-over to the new system was not particularly revolutionary. Intake workers continued with their long-term treatment cases until they were closed. Those in the continued service section likewise carried on their intake cases until they were closed or reassigned. Defining Brief Services at the Provincial Child Guidance Clinic As has been indicated, no o f f i c i a l definition of brief services has as yet been formulated by the c l i n i c . Those cases which are not put on the waiting l i s t following diagnostic conference but are serviced by the intake section, are categorized by some workers at the c l i n i c as brief services. In 1954 an attempt was made in staff meetings to define brief service. At one meeting a worker defined a brief service case as one in which formu-lated casework service following a careful diagnostic study was given, but which never extended to more than three interviews. At a staff meeting held in February 1954, the suggestion was made that the staff statistics -14-committee prepare a definition of brief service. However, at this writing, no formal definition of brief service has yet been prepared and i t should be mentioned that no one at the c l i n i c seems to use the definition of " No more than three interviews" when they speak of brief service. In current practice those cases which are designated as brief services have been to diagnostic conference where the team decides on a suitable treatment plan. If brief service is the plan, the client may be seen from. One, or "several interviews" up to any number during the following six-mOnth period. The length of time or number of interviews apparently does not determine the definition of brief service. The basis for the team's decision to recommend brief service is not stated in the conference notes, except very occasionally. One can assume that the team bases its decision on c l i n i c a l judgment. It is one aim of this study to try to discover some of the unarticulated c r i t e r i a that are used in making this judgment. The term, "brief service", seems to have many connotationsat the c l i n i c . It is used to refer to services given after diagnostic conference, such as referrals to other community resources, giving of general information to parents, or brief counseling^ It has been used to describe services given at the i n i t i a l application, referral to another resource or to further diagnostic study. In fact at each of three major decision points in the procedures at the c l i n i c (duty-call, intake conference, and diagnostic con-ference) various plans may be recommended and what could be called brief 1 The following is an example of what is meant by brief counseling and is taken from the social worker's notes made at diagnostic conference: "It was f e l t that the parents could be helped in a brief service in accepting this child's limitations and encouraging them to give her support and re-assurance rather than pressuring her further." - 1 5 -services relative to each phase can be identified. Brief service is a term frequently used by workers at the c l i n i c when they mean limited goals such as the r e l i e f of a specific symtom with no particular reference to limited time. However, a limited goal of modification Of some one area may take a long time and an unlimited goal of resolving many problems may take a very short time. One worker at the c l i n i c thinks of brief services as being limited in both time and aims and defines such services as "Those cases closed after one or two interviews. This implies .... a very limited goal of a concrete nature; limited c l a r i f i c a t i o n , specific environmental help, Or possibly supportive help around making a specific decision or finding an appropriate resource which is reasonably acceptable to the client. "Short-term" treatment is a term which is beginning to be used at the c l i n i c . It seems to describe a category of treatment separate and apart from that described by the term "brief service." It is used to indicate those cases which are more than brief service but are not referred on to the continued service section. The implication of short-term treat-ment seems to be that goals are limited to help in a f a i r l y specific area which is a l l that is needed or desired. The goal would not be any funda-mental change but would be confined to strengthening capacities, or moti-vating client and family action, or possibly testing and evaluating responsiveness to help." There is a group of miscellaneous services given by the c l i n i c which frequently involves casework help but which is not at the present time categorized as either brief service or short-term treatment. The term used to describe these services is "accidental services." These services almost - 1 6 -never involve more than one interview. They consist of giving informa-tion about resources, referring parents to literature on child problems, helping a referral to withdraw, or directing the referral to a more appropriate resource. "Accidental" as applied to these cases is an un-fortunate term inasmuch as the services given constitute a planned and important helping process for the client and real casework s k i l l on the part Of the caseworker. Preferably they should be described by a term that gives recognition to their true nature. Summary The idea of brief service f i r s t emerged when the c l i n i c was seek-ing ways of cutting down the long waiting period and set up the two sections as one method of accomplishing the task. The idea of brief services has always been subordinate to the desire to shorten the waiting period and there has be'en no systematic attempt to define i t in relation-ship to the other c l i n i c services. Each worker has his own definition of brief service and there is a wide variety in the definitions as to length of time, number of interviews, limited goals, and whether brief services and short-term treatment mean the same thing. In Other words, the term brief service is used at the c l i n i c to describe anything .other than continu-ed service. The idea is s t i l l evolving and not generally agreed upon definition has yet been crystallized. In view of the need for brief services in order to cut down the ever-expanding waiting l i s t , and in view Of the apparent success of brief ser-vices in other agencies, and the present lack of concerted effort to define and develop brief services at the c l i n i c , some of the characteristics of what might be called brief services at the c l i n i c w i l l now be examined. Chapter III ANALYSIS OF "BRIEF SERVICE" CASES AT THE CHILD GUIDANCE CLINIC Scope of the Study In selecting the cases categorized by the c l i n i c team as "brief service", the period covered is from November 1954 to January 1, 1957. This period of time was chosen because the sources of information for analyzing the cases are the notes transcribed at the diagnostic confer-ences. The Clinic f i r s t began keeping a separate f i l e of these notes when the "new system" was instituted during the summer of 1954. These cases were designated as brief service cases by the Clinic i t s e l f . As has been previously indicated, there does not seem to exist at the c l i n i c any formalized, clear-cut definition of what constitutes brief services, and there is among different workers an interchange of ter-minology applied to similar types of cases, a l l of which have character-is t i c s of "briefness" or "short-term". Furthermore, different workers seem to use different c r i t e r i a in labeling a case "brief" or "short-term". However, there seemed to be general agreement at the c l i n i c , for one reason or another, that the cases chosen are brief service cases. A total of 65 brief service cases were presented by the c l i n i c for study. This total was reduced to 62 when i t was found that two of the 65 cases were given treatment by a psychiatrist and in one case by a public health nurse. The remaining 62 cases were carried by social workers and hence are within the scope of this study. - 1 8 -In diagnostic conference notes use, no attempt was made to infer from them the process by which the c l i n i c team came to the decision to allocate certain cases to brief services. Instead the notes were used as sources of data about the kinds of problems and services found in those cases designated as brief services, in order to discover whether they had common characteristics. Limitations of the Sample It should be pointed out that the 62 cases represent only about 50 per cent Of a l l brief service cases carried during the period of time under consideration. The reason for this, according to the c l i n i c staff, is that the diagnostic conference notes were frequently not duplicated when they were being transcribed. The alternative to basing the study on these duplicated diagnostic conference notes would be to search a l l case records for the period and separate out a l l brief service cases. This would in-volve examing approximately 1000 case records which the lack of time makes prohibitive. The 50 per cent random sampling of brief service cases con-stitutes a s t a t i s t i c a l l y valid sample as ,a basis for formulating certain conclusions regarding a l l brief service cases handled during this period. Another d i f f i c u l t y arose from the inadequacies of the notes made at the diagnostic conferences. The c l i n i c has a "Suggested Format for Diag-nostic Conference Notes" but in many cases the suggested format was not followed, or followed only in part. Yet one of the purposes of using the format is specifically stated in the format i t s e l f to be that of research. A question might be raised concerning the usefulness of the diag-nostic conference notes for research purposes. The alternative would seem to be using the f u l l case records which are very voluminous. Sorting out -19-pertinent information from them would therefore be extremely time con-suming. In order to make better use of staff time spent in recording and studying case records, the c l i n i c might consider a revision of i t s methods of recOrd keeping. An excellent method of streamlining the procedures has been developed and put in practice at the Harms-Beth David Hospital Clinic in New York. -1 Findings The 62 cases have been studied in an effort to ascertain what common characteristics, i f any, are found which would cause them to be categorized as brief services and to see i f an analysis of the cases reveals any dis-tinct patterns as to: 1) What brings these people to the c l i n i c (presenting problems). 2) Diagnosis - the c l i n i c findings as reported by team members, not a social or psychiatric diagnosis. 3) Length Of contacts (number of interviews). 4) Purpose of casework treatment. Apparently there is. no formal classification of presenting problems in general use in the c l i n i c at this time. There is a l i s t that has limited use, but i t was decided not tQ use this l i s t because the classification of presen-ting problems seemed to make use of diagnostic judgment in assigning a par-ticular problem to a particular category. For example, the main general classifications in the l i s t in "Primary Behavior Disorders". Under this head-ing are four sub-groups: Habit Disorders, Personality Disorders, Neurotic 1 Harms, Ernest, "The Short-Term Adjustment Clinic of Beth David Hospital in New York City", Nervous Child. 1949-50, v 8, p 332. -20-Disorders and Conduct Disorders. Under each is a l i s t of specific pro-blems. Aggressiveness is classed as a Personality Disorder. As a presenting problem, aggressiveness may or may not be a personality dis-order. Definitely labeling i t as such calls for diagnostic judgment. This l i s t is discussed because i t indicates the d i f f i c u l t y of mak-ing any kind of classification of presenting problems. Several c l a s s i f i c a -tions were attempted, but none Of them seemed to have any particular value or significance, therefore the decision was made to arrange the presenting problems in a purely semantic grouping, ranging from concrete observable facts to very broad generalizations.* The tabulation of presenting problems of the 62 cases of brief ser-vices (Table 1) seems to have no particular significance for this study. A l l that is known is that the l i s t of problems in Table 1 constitutes the presenting problems of the cases which were designated brief service cases. In order to determine whether any particular type of presenting problem is of significance in assigning a case to brief service, i t would be necessary to tabulate the presenting problems in a sampling of a l l cases accepted by the c l i n i c for diagnosis and treatment and then see i f there is a correla-tion between any particular type of presenting problem and the assignment of the cases in which these problems occur to brief services. The descriptive phrases used in Table 2, showing the diagnoses, are taken from the diagnostic conferences notes in each case. Of the 62 cases, no diagnosis was reported in 8 cases. r 1 The grouping used is adapted'from that used in a study of 500 cases at the Los Angeles Child Guidance Clinic, Los Angeles, California, see: Anderson, F. D. and Dean, Helen C., Some Aspects of Child Guidance Clinic  Intake Policy and Practice. Public Health Monograph No. 42, United States Government Printing Office, 1956, pp. 15-16. -21-Table 1. . Classification of Presenting Problems  in Brief Service Cases in the Cl i n i c . Presenting Problem Number Group 1; Concrete Conduct - Observable Facts 25 Speech defect or speech problem 7 Lies 4 Enuresis 3 Soils clothing 3 Steals 2 Pulls own hair 11 Hits own face Tears clothing Whines Sucks thumb Truant Group 2: Concrete, Observable Behavior 10 Destructive ,3 Poor application in school 2 Aggressive 2 Fearful of mother 1 Prefers to play with younger children 1 Hard to discipline 1 Group 3: Behavior described by Abstractions and Generalities -Interpretation Enters In 24 Stubborn 4 Does not get along with siblings 4 Maladjusted in school 4 Negativistic 2 Feels unloved 2 Disobedient 2 Domineering Spoiled Uncooperative Temperamental behavior Lack of confidence in own a b i l i t y Irresponsible GrOup 4: Very Broad Generalizations 17 Nervous 2 Emotional immaturity 2 Parent-child conflict 1 Mental retardation 10 Hyperactive 1 Poor muscle coordination 1 Child asked for vocational counseling • •„ 1 Child neglect 1 Not stated 21 Total (62 cases) 99 — 2 2 — Table 2. Team Diagnoses of Brief Service Cases  at the Child Guidance C l i n i c . Diagnosis Number Times diagnosis used 1. Mentally deficient or retarded 22 2. Parent-child relationship problem 22 3. Mother's personality problem 2 4. Physical problem of child , 2 5. Speech defect 2 6. Hostile arid negativistic 1 7. Schizophrenic 1 8. Sibling rivalry 1 9. No problems 1 10. Not stated 8 Total (62 cases) 62 Source: Clinical findings as recorded in diagnostic conference notes. -23-Thirty-five per cent of the cases were diagnosed as mental deficiency, and would naturally be brief cases since i t is not within the function of the c l i n i c to treat mental deficiency. The procedure in these cases is to interpret the c l i n i c findings to the parents and refer them to other commu-nity resources. Another 35 per cent, Items 2, 3, and 4, constitute problems in child-parent relationship, the type of case naturally expected to be found in a child guidance c l i n i c . Fourteen pf the cases have a miscellaneous diagnosis, there was no problem found in one case,'' and no diagnosis was given for approximately 12 per cent of the cases. In Table 3, Length of Treatment, a combination of Items 3, 6, 7, and 8, shows that 25 per cent of the cases were of short duration insofar as number of interviews is concerned. It is true that with the exception pf about six cases, the exact number of interviews is not stated but in 25 per cent of the cases the information in the conference notes indicates that there would be only a "few" interviews at the most and in most cases this seemed to mean not more than three or four. In a third of the cases there is no indication, one way or the other, as to length of treatment but from the character of the cases involved, i t could be inferred that the number of interviews would not exceed three or four. In this case the presenting problem was stealing. The conclusion reached at diagnostic conference was that the stealing was "an expression of a phase" and would correct i s e l f "in time and therefore no treatment for either parents or child was considered (by the psychiatrist) as necessary. -24-Table 3. Length of Contacts in Brief Service  Cases at the Child Guidance Clinic Length of Contacts Number of Cases 1. Brief Service 22 2. Not stated 21 3. Probably one interview only 13 . 4. Six months 2 5..' No treatment 1 6. One telephone contact only 1 7. Two interviews 1 8. "Several" interviews 1 Total 62 Source: Diagnostic Conference notes. -25-It is not possible to determine the exact number of interviews meant by the f i r s t item "brief service". For example, the notes on One case state, "brief service to mother. If mother doesn't respond to short-term casework treatment, case should be put on waiting l i s t . " The notes on a a second case state, "Brief service with mother to assess permanency of her present improvement and to help her seek treatment, should anxiety states continue." Another say, "Brief casework services to parents by intake work-er to give mother support and to encourage spontaneity and relaxation in handling c h i l d . " A fourth one notes, "Supportive casework to be made avail-able to the mother on a brief service basis, tentatively to the end of the school term. Psychologist to continue vocational counseling with child dur-ing the time." In the examples given, which are typical of the group, there is no way * to determine how many interviews were intended. It wOuld appear that many of t he cases referred for "brief service" are referred for further diag-nostic study. With more complete information i t would be very desirable to establish whether there is any correlation between length of service and presenting problems, diagnosis and purpose of treatment. Table 4, Purpose of Casework Treatment, involves classifications of treatment which are explained as follows: 1. Advice and guidance given in terms of environmental manipulation within the context of the caseworker's knowledge of the par-ticular parent-child relationship. Examples of advice and guidance are: helping the parents find community resources to care for a mentally retarded child, suggesting medical supervision or speech therapy, and inter-preting the child to school personnel. -,26-2. Clarification of the child's emotional needs, as understood by the caseworker, and of the parent's response to these needs, and the interrelationship of the two. ' Clarification might mean a suggesting of appropriate toys for the child; helping the parents take pressure off child; help-ing parents accept the child's limitations; helping ease tension between parents; giving information of normal growth and development; advice to parents on handling a specific pro-blem, e.g. child's stealing. The way this is handled is summed up by one worker in her description of the plan of treatment, "Brief service to parents to present c l i n i c a l findings which are essentially reassuring; but gearing interpretation in such a way as to answer parent's underlying anxiety rather than offer mere surface reassurance." 3. Listening, e.g. giving the opportunity for catharsis to occur and the pressure of feelings to be relieved. 4. Interpretation of acting out by parent on the child; of connec-tions between feelings at the threshold of parent's awareness; and of distortions in the relationship of parent to child.1 The results shown in Table 4 seem to indicate that in the majority of brief service cases the purpose of treatment i s , almost without exception, either to give advice and guidance or c l a r i f i c a t i o n . In 54 per cent of the cases advice and guidance was given and in 37 per cent c l a r i f i c a t i o n was used. Although i t is likely that listening and catharsis occurred in most of the cases, instances where i t was the only method of treatment occur in only 3 per cent of the cases. There are no examples where interpretation as defined here was the purpose of treatment. In 93 percent of the brief service cases, as shown on Table 5, treat-ment was given to a parent or parents; in only 2 per cent was treatment given to the child only, and in 2 per cent; treatment was to both parent and child. This classification of casework techniques has been adapted from that of Dorothea McClure and Harvey Schrier, "Preventive Counseling with Parents of Young Children," Social Work. April 1956, p. 70 Table 4. Purpose of Casework Treatment in Brief Service Cases at Child Guidance Clinic. Purpose of Treatment Number of Cases 1. Advice and guidance 34 2. Clarification 23 3. Listening 2 4. Interpretation -5. No treatment 2 6. No clear indication .1 Total 62 -28-Table 5. Person to Whom Service was Given To whom service given Number of Cases 1. Parent or parents 58 2. Family doctor 2 3. Child 1 4. Parent and child 1 Total 62 -29-In 3 per cent of the cases interpretation of c l i n i c results was given to a family doctor. The possible significance of the results obtained from the survey of the 62 brief service cases will next be considered. Chapter IV CONCLUSIONS In attempting to draw conclusions from the data previously given, a dilemma presents i t s e l f . Some general characteristics of a "brief ser-vice" case at the Provincial Child Guidance Clinic seem to be f a i r l y dis-tinguishable. A c l i n i c case wOuld usually be classed as a brief service i f a parent or parents only are seen by the caseworker for a "few" interviews and the purpose of treatment is to give advice and guidance and perhaps cl a r i f i c a t i o n . Yet i t is necessary to say that these general characteristics Oniy seem to be f a i r l y distinguishable faecause the data upon which the con-clusion is based are incomplete. For example, in many cases the inference appears to be that there was a limited number pf interviews but no clear in-dication as to whether this meant one interview, three or four or a dozen. In considering the significance of the presenting problems (Table 1) i t can be said that caseworkers are aware that the presenting problem is not necessarily the real problem which motivated the client to request help. No attempt has been made in this study to correlate the presenting problems with the c l i n i c team diagnoses, but such a study would be valuable. It ap-pears doubtful that any reliance should be placed on presenting problems with the exception of medical cases, as c r i t e r i a for assigning cases to either 0 brief service or continued service. Diagnostic judgment should always be the means by which such assignments are made. -31-It would appear from the data in Table 2 that in general the cases which diagnosis reveals have a serious pathology are not considered suit-able brief service cases. However, a tabulation of the diagnosis in a sampling of continued service cases would have to be made as a basis for comparison. Such a tabulation is not within the scope of this study. No definite conclusion could be made regarding the length of treat-ment, expressed in numbers of interviews. The two definite conclusions to be drawn from the data examined are 1) that in the brief service cases the purpose of treatment is to give ad-vice and guidance and to provide c l a r i f i c a t i o n , and 2) that interviews are held almost exclusively with a parent or parents. Thus some general charac-teri s t i c s of brief service cases at the c l i n i c are clear-cut but the question of duration of treatment is not clearly defined nor are the diagnoses. As has already been stated, brief service can be a valuable technique as a recognized method of treatment in certain selected cases because: 1) More help can be available to more people in a given period of time, and 2) brief service has intrinsic value. Therefore i t is suggested that brief service should be definitely planned for as an important part of the c l i n i c program. In planning a brief service program i t would be necessary f i r s t to de-fine brief service. To aid in the formulation of such a definition a study should be made of the continued service cases in order to compare the char-acteristics of the two types of services. If a decision were made to institute a planned brief service program at the c l i n i c and a definition of what constitutes brief services were agreed -32-upon, cri t e r i a for assigning cases to brief service should be set up. McCiure and Schrier^ suggest tie following c r i t e r i a . A. The Criteria for selecting the type of problem treatable by brief service: 1. Of recent onset 2. Not chronic 3. Not multiple 4. Not yet internalized 5. Not yet a behavior disorder 6. Acje-adequate (i.e. a problem to be expected at the particular age.) B. Criteria for selecting the parent-child relationship usually considered treatable on a short-term basis: 1. Temporary imbalance. 2. Potentially gratifying relationship. C. Criteria for selecting parental characteristics which would lend themselves to treatment on a "brief service" basis: 1. Relatively intact egofunction (e.g. perception, reality-testing, judgment) 2. Ab i l i t y to learn relatively intact. 3. Ability to focus on a specific problem. If brief services become a planned part of the c l i n i c program, a l l cases at intake should be carefully screened for possible assignment to brief ser-vice so that as many as possible can be treated in this manner but also to make sure that cases which need continued service are not mistakenly assigned to brief service. In making the assignment great objectivity and s k i l l are necessary on the part of those making the recommendation. A second look may reveal many cases which at f i r s t glance may appear to be continued service cases which could successfully be treated on a brief service basis. However, op. c i t . -33-the desire to treat as many people as possible who need help shouldn't lead to decisions for assignment based on expediency alone which would result in sacrificing good treatment practice. The success of the brief service program will depend upon the s k i l l of the caseworkers who give the treatment. Brief service is not second-class service but requires the very highest kind of s k i l l f u l practice. If a recognized and planned program of brief services is instituted, a careful check of results should be made to be sure mistakes are not being made in assigning certain cases to brief services. Follow-up studies of brief service cases should be made to determine how many of the cases, i f any, return to the c l i n i c or go to other agencies for continued service. APPENDIX A BIBLIOGRAPHY Books: Adler, Alexandra, Guiding Human Misfits. New York, 1948 Alexandra, Franz, and Frenh T., Psychoanalytic Therapy. The Ronald Press Co., New York, 1946. Heiman, Marcel, Psychoanalysis and Social Work, International Universities, Press Inc., New York, 1953. Pollak, Otto, Social Science and Psychotherapy for Children, Russell Sage Foundation, New York, 1952. Witmer, H. L., Psychiatric Clinics for Children, The Commonwealth Fund; New York, 1940. Articles: Anderson, F. D. and Dean, Helen C., Some Aspects of Child Guidance Intake Policy and Practice. Public Health Monograph No. 42, U.S. Government Printing Office, 1956. Blenker, Margaret, Hunt, J. McV. and KOgan, Leonard S., "A Study of Inter-related Factors in the Interview with New Clients", Social Casework. 1951, v. 32. Chaskel, "Short-Term Counseling; A Major Family Agency Service," Social  Work Journal. 1953, v. 34. Frings, John, "What About Brief Services," - A Report of a Study of Short Term Cases." Social Casework. 1951, v. 39. Fuerst, Rudolph A., "Problems of Short Term Psychotherapty," American Journal  of Orthopsychiatry. 1938, v. 8. Eklund, Dorothy, "Short-Contact Services in an Information and Referral Center Social Casework. 1953, v. 32 Harms, Ernest, "The Short-Term Adjustment Clinic of Beth David Hospital in New York City", Nervous Child 1949-50, v. 8. Henshaw, M. Jean, "Casework at the Traveler's Aid Society", The Social Worker, June 1954. -.35-APPENDIX A (Continued) Articles: Kasius, Cora, A Comparison of Diagnostic and Functional Casework Concepts. 1950, FSAA, New York. McClure, Dorothea and Schrier, Harvey, "Preventive Counseling with Parents of Young Children." Social Work, April 1956. Reider, Norman, "A Type of Psychotherapy Based on Psychoanalytic Principles", Bulletin of the Menninger Clinic. 1955 v. 19. Schmideberg, Melitta, "Short Analytic Therapy/' Nervous Child. 1949-50. Schwartz, Dulcine M., "A Study of Eighty-Six One In-Person Interview Cases/' Smith College. 1953-52, v. 23 Shyne, Ann W., Short Contact Cases in Family Service Agencies, FSAA, 1948 New York (mimeographed). Sterba, Richard, "A Case of Brief Psychotherapy by Sigmund Freud", Psychoanalytic Review. 1951. Stone, Leo, "Psychoanalysis and Brief Psychotherapy," Psychoanalytic Quarterly. 1951, v. 20. Thomas, Dorothy V., "The Relationship Between Diagnostic Service and Short Contact Cases." Social Casework. 1951, v. 32. Townsend, Gladys E. "Short Term Casework with Clients Under Stress, Social  Casework, 1953, v. 34. Other Studies: Chave, E. C., The Pre-Ciinical Conference as a Diagnostic Screen, University of British Columbia, MSW Thesis, 1952. Glover, Ernest Geoffry, Casework Interviewing Methods in a Child Guidance  Setting. University pf British Columbia, MSW Thesis, 1951. Kennedy, Rampna, I n i t i a l Resistance of Parents to Casework Services In a Child  Guidance Setting. University of British Columbia, MSW Thesis, 1957. Laidman, L. W., Premature Withdrawal frxim Treatment in a Child Guidance Cl i n i c , University of British Columbia, MSW Thesis, 1957. Mackenzie, Budd, The Play Interview as a Social Work Technigue in a Child  Guidance Setting. University of British Columbia, MSW Thesis, 1956. Trasov, G. E. Parental Attitudes and How They Affect the Behavior of Children. University of British Columbia, MSW Thesis, 1950. 


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