Open Collections

UBC Theses and Dissertations

UBC Theses Logo

UBC Theses and Dissertations

Travelling psychiatric services : an exploratory study of the services of the British Columbia Mainland… Coyle, Phyllis Bernice 1955

Your browser doesn't seem to have a PDF viewer, please download the PDF to view this item.

Item Metadata

Download

Media
831-UBC_1955_A5 C7 T8.pdf [ 10.5MB ]
Metadata
JSON: 831-1.0106428.json
JSON-LD: 831-1.0106428-ld.json
RDF/XML (Pretty): 831-1.0106428-rdf.xml
RDF/JSON: 831-1.0106428-rdf.json
Turtle: 831-1.0106428-turtle.txt
N-Triples: 831-1.0106428-rdf-ntriples.txt
Original Record: 831-1.0106428-source.json
Full Text
831-1.0106428-fulltext.txt
Citation
831-1.0106428.ris

Full Text

TRAVELLING PSYCHIATRIC SERVICES An lExploratory Study of the Services of the B r i t i s h Columbia Mainland T r a v e l l i n g Child Guidance C l i n i c by PHYLLIS BERNICE COYLE Thesis Submitted i n P a r t i a l Fulfilment of the Requirements f o r the Degree of MASTER OF SOCIAL WORK i n the School of Social Work Accepted as conforming to the standard required f o r the degree of Master of S o c i a l Work School of So c i a l Work 1 9 5 5 The University of B r i t i s h Columbia - v -ABSTRACT The purpose of this thesis i s to make an explora-tory study of the B r i t i s h Columbia Mainland Travelling Child Guidance Clinic. One of the main goals i s a more definitive statement and c l a r i f i c a t i o n of the current functions and services of the c l i n i c . The study includes: (1) A description of travelling child guidance . cl i n i c s generally, i n terms of underlying theory and assumptions, h i s t o r i c a l develop-ment, and current problems and functioning; (2) A brief description of the travelling child - guidance services i n Canada; (3) A detailed description of the B r i t i s h Colum-bia Mainland Travelling Child Guidance C l i n i c : a. i t s h i s t o r i c a l development; b. i t s stated functions and goals; c. i t s operation "in the f i e l d . " The above includes material drawn directly from a sample of c l i n i c f i l e s , which describes: the character-i s t i c group of clients referred for individual service; problems seen by the referral sources as indicating the need of c l i n i c a l assessment and help; the channels of re-f e r r a l and presentation to the c l i n i c ; the professional members of the community who, through attendance at case conference, come into direct contact with c l i n i c a l concepts and knowledge about the understanding and treatment within the community of behavior disorders i n children, and gen-eral mental health methods i n the alleviation and prevention of further similar d i f f i c u l t i e s ; and the recommendations made for such community treatment of the disorder. A ques-tionnaire circulated to a l l Social Welfare Branches in-dicated the f i e l d offices' concept of the effectiveness and adequacy of c l i n i c a l services. The B r i t i s h Columbia Mainland Travelling Clinic has achieved a good beginning. Staff exigencies i n both the c l i n i c and the f i e l d have made ideal objectives im-possible to achieve. The addition of another travelling c l i n i c team together with more f i e l d personnel w i l l alter this criticism. The success of any such undertaking w i l l always depend on harmonious relationships among c l i n i c staff, f i e l d health and welfare staff, and other citizens i n the communities. - i i -TABLE OP CONTENTS Chapter 1. The E v o l u t i o n of T r a v e l l i n g C h i l d  Guidance C l i n i c s I n t r o d u c t i o n . D e f i n i t i o n of a C h i l d Guidance C l i n i c . H i s t o r i c a l background of C h i l d Guidance C l i n i c s . T r a v e l l i n g C h i l d Guidance C l i n i c s -Development: P u b l i c welfare aspects of t r a v e l l i n g c l i n i c . General d e s c r i p t i o n of t r a v e l l i n g c l i n i c s t r u c t u r e and g o a l s . The t r a v e l l i n g c h i l d guid-ance c l i n i c s across Canada: General developmental p i c t u r e . S p e c i f i c survey of current t r a v e l l i n g c h i l d guidance c l i n i c s e r v i c e s i n Canada. T r a v e l l i n g c h i l d guidance c l i n i c s i n B r i t i s h Columbia. H i s t o r i c a l background and development to date. Purpose and p l a n of t h e s i s . Chapter I I . The Purposes of the B r i t i s h Columbia  Mainland T r a v e l l i n g C h i l d Guidance  C l i n i c I n t r o d u c t i o n . General d e s c r i p t i o n of B r i t i s h Columbia Mainland T r a v e l l i n g C h i l d Guidance C l i n i c . P o l i c y and Procedure on T r a v e l l i n g C l i n i c . S t a t e d Functions. D i a g n o s i s . C o n s u l t a t i o n . Education -Community education, s t a f f education. Research. Areas s e r v i c e d . Geographical. General community p i c t u r e of s o c i a l s e r v i c e s t r u c t u r e . S t a f f and a d m i n i s t r a t i o n . A d m i n i s t r a t i o n . S t a f f - P s y c h i a -t r i s t , p s y c h o l o g i s t , p s y c h i a t r i c s o c i a l casework s u p e r v i s o r , p u b l i c h e a l t h nurse. Type of cases. Primary behaviour d i s o r d e r s . Dependent c h i l d r e n . E x c e p t i o n a l c h i l d r e n • Chapter I I I . The B r i t i s h Columbia Mainland Tra-v e l l i n g C h i l d Guidance C l i n i c i n  Operation I n t r o d u c t i o n . The t r a v e l l i n g c l i n i c ' s current f i e l d o f o p e r a t i o n . The c h i l d r e n r e f e r r e d f o r t r a -v e l l i n g c h i l d guidance c l i n i c e v a l u a t i o n i n 1953* The problems seen by the community as i n d i c a t i n g the need f o r c l i n i c a l assessment and h e l p . The sources of r e f e r r a l of these problems t o c l i n i c . Channels of p r e s e n t a t i o n of cases t o t r a v e l l i n g c l i n i c , and of c a r r y i n g out treatment recommend-a t i o n s . The spreading of c l i n i c a l understanding and knowledge of treatment of c h i l d r e n ' s problems through the use of case conference - i . e . , t eaching - i i i -TABLE OP CONTENTS (Cont'd.) Page Chapter I I I . (Cont'd.) by case method. The trend of c l i n i c a l recom-mendations f o r treatment of the problems pre-sented. The extent of d i r e c t community educa-t i o n a c t i v i t i e s of the t r a v e l l i n g c l i n i c during 1953* C l i n i c a l services as seen by f i e l d per-sonnel. ico Chapter IV. The Findings and Implications of the Present Study i n Relations to Future  T r a v e l l i n g Child Guidance C l i n i c _,, Practice 1 6 4 Appendices: A. L e t t e r to T r a v e l l i n g C l i n i c s i n Canada. H a i l i n g L i s t . B. Questionnaire to S o c i a l Welfare Branch. C. S o c i a l History Outline. D. Bibliography. Table 1. Table 2. Table 3. Table 1}.. TABLES AND CHARTS IN THE TEXT (a) Tables Summary of B r i t i s h Columbia Mainland T r a v e l l i n g Child Guidance C l i n i c A c t i v i t y , A p r i l 1, 1953 to March 31, 1954 • General Family Backgrounds of Clie n t s i n the Sample Study of the B r i t i s h Columbia Mainland T r a v e l l i n g Child Guidance C l i n i c Cases, 1953 Intelligence Ratings (as determined by c l i n i c a l examination) of Cl i e n t s i n the Sample Study of the B r i t i s h Columbia Mainland T r a v e l l i n g Child Guidance C l i n i c Cases, 1953 *>* • 5 2 A Age Range and Sex of Clients In the Sample Study of the B r i t i s h Columbia Mainland T r a v e l l i n g Child Guidance C l i n i c Cases, . 1953 1 0 5 107 108, i v -T a b l e s (Cont inued) T a b l e 5. Tab le 6. T a b l e 7. T a b l e 8. Tab le 9. Sources o f R e f e r r a l o f Problems P r e -sen ted i n the Sample Study o f Cases seen by the B r i t i s h Columbia Ma in l and T r a v e l l i n g C h i l d Guidance C l i n i c i n 1953•.< Frequency D i s t r i b u t i o n o f Agency Case P r e s e n t a t i o n s t o the B r i t i s h Co lumbia Ma in l and T r a v e l l i n g C h i l d Guidance C l i n i c , 1953* as i n d i c a t e d i n a Random Sample Case Study Community Agenc ie s t h rough which the Re-f e r r a l Sources c o n t a c t e d C l i n i c i n Sample Study o f the B r i t i s h Columbia Ma in l and T r a v e l l i n g C h i l d Guidance C l i n i c Cases , 1953 .-. At tendance at the B r i t i s h Columbia Ma in -l a n d T r a v e l l i n g C h i l d Guidance C l i n i c Case Con fe rence , 1953* i n r e l a t i o n to the Agency p r e s e n t i n g the Case Page 119A 125 126; 132A C l i n i c a l Recommendations f o r Treatment i n r e l a t i o n to the Agency p r e s e n t i n g the Case, as i n d i c a t e d i n the Sample S tudy o f the B r i t i s h Columbia Ma in land T r a v e l l i n g C h i l d Guidance C l i n i c Cases , 1953 135A F i g u r e 1, F i g u r e 2. (b) Cha r t s D i s t r i b u t i o n o f P r e s e n t i n g Problems p e r Case i n the Sample Study o f Cases seen by the B r i t i s h Columbia Ma in land T r a -v e l l i n g . C h i l d Guidance C l i n i c , 1953 . . . . f r e q u e n c y o f P r e s e n t i n g Problems i n the Sample Study o f Cases seen by the B r i t i s h Co lumbia Ma in l and T r a v e l l i n g C h i l d Guidance C l i n i c , 1953 •• 113A l l i f A v i -ACKNOWLEDGMENTS I would l i k e to express my sincere appreciation to Dr. U.P. Byrne of the Vancouver Ch i l d Guidance C l i n i c f o r h i s u n f a i l i n g interest and cooperation i n obtaining the data f o r t h i s thesis, and f o r sharing so f r e e l y h i s s p e c i f i c understanding of t r a v e l l i n g c h i l d guidance c l i n i c function and p o l i c y ; also to Mr. Gerry Pepper, current T r a v e l l i n g C l i n i c Casework Supervisor, f o r the help and time so generously given i n discussion of the a c t i v i t i e s and problems of the t r a v e l l i n g c l i n i c i n the f i e l d . The excellent suggestions, d i r e c t i o n and sup-port of Dr. Leonard Marsh, Mr. Arthur Abrahamson, and Mr. Adrian Marriage, members of the School of S o c i a l Work, University of B r i t i s h Columbia, are deeply appre-ciated. # •» # - v i i -TRAVELLING PSYCHIATRIS SERVICES An Exploratory Study of the Services of the B r i t i s h Columbia Mainland Tr a v e l l i n g Child Guidance C l i n i c CHAPTER I THE EVOLUTION OP TRAVELLING CHILD GUIDANCE CLINICS 1, I n t r o d u c t i o n The Research D i v i s i o n of the Department of Nat-i o n a l H e a l t h and Welfare, i n i t s r e p o r t of J u l y , 1954, s t r e s s e s repeatedly the importance of mental h e a l t h edu-c a t i o n i n Canada. I n t h i s connection, the c o n t r i b u t i o n s of the community c l i n i c s are noted i n almost every s e c t i o n of the r e p o r t . At one p o i n t , i t s t a t e s t h a t "there can be l i t t l e doubt t h a t the most e f f e c t i v e e d u c a t i o n a l work i s being done i n the community c l i n i c s across Canada." 1 I n summing up the f u t u r e o b j e c t i v e s of Canada 1s Mental H e a l t h program, i t numbers as t h i r d amongst the f i v e " d e s i r a b l e forward s t e p s , " "the b e t t e r i n t e g r a t i o n o f p s y c h i a t r i c programs w i t h other h e a l t h s e r v i c e s as community s e r v i c e s , r e g a r d l e s s of whether they are provided by a mental hos-p i t a l or a general h o s p i t a l or a c l i n i c . " 2 Thus, more and more the mental h e a l t h c l i n i c s are being accepted as an e s s e n t i a l component of community 1 Department of N a t i o n a l H e a l t h and Welfare, Research D i v i s i o n , General S e r i e s Memorandum No. 6, Mental H e a l t h  S e r v i c e s i n Canada. Ottawa, J u l y , 1954, P« l i j . 6 . 2 I b i d . , p. 189. - 2 -mental h e a l t h s e r v i c e s , and t h e i r c o n t r i b u t i o n s recognized. This study i s concerned w i t h a s p e c i f i c form of community c l i n i c , the t r a v e l l i n g c h i l d guidance c l i n i c . I n perusing the p r o f e s s i o n a l l i t e r a t u r e , i t has been noted t h a t s t a t -i o nary c h i l d guidance c l i n i c s are d e a l t w i t h abundantly, but t h a t the m a t e r i a l on the t r a v e l l i n g c h i l d guidance c l i n i c s s e r v i n g l a r g e geographical areas i s n o t a b l y sparse. This invokes grave concern as t o the g e n e r a l , and even pro-f e s s i o n a l , r e c o g n i t i o n of the p o t e n t i a l value of the t r a -v e l l i n g c h i l d guidance c l i n i c t o the r u r a l p o p u l a t i o n i t serves. This t h e s i s has been undertaken i n the l i g h t of t h i s concern, and i s s p e c i f i c a l l y focussed upon the B r i t i s h Columbia Mainland T r a v e l l i n g C h i l d Guidance C l i n i c s t a t i o n e d at Vancouver. The areas s t u d i e d w i l l i n c l u d e : the develop-ment of the t r a v e l l i n g c h i l d guidance c l i n i c and i t s "roots'* i n the mental hygiene movement as seen on t h i s c o n t i n e n t ; i t s present g o a l s , s t r u c t u r e and f u n c t i o n , p a r t i c u l a r l y i n r e l a t i o n t o s o c i a l w e l f a r e ; a survey o f e x i s t i n g t r a v e l l i n g c h i l d guidance s e r v i c e s i n Canada; and a study of the h i s t o r i c a l development, and the current o p e r a t i o n i n the f i e l d of the B r i t i s h Columbia Mainland T r a v e l l i n g C l i n i c . I t i s hoped t h i s e x p l o r a t o r y study w i l l promote g r e a t e r understanding of the important r o l e of the t r a v e l l i n g c l i n i c i n r u r a l communitiesJ and t h a t , as a r e s u l t , a more d e f i n -i t i v e statement and c l a r i f i c a t i o n of the current f u n c t i o n s - 3 -and s e r v i c e s of the B r i t i s h Columbia Mainland T r a v e l l i n g C h i l d Guidance C l i n i c w i l l lead the way t o f u r t h e r r e s e a r c h i n the i n t e r e s t s of f o c u s s i n g f u t u r e c l i n i c a l program along most e f f e c t i v e l i n e s . Since t h i s i s a s o c i a l work t h e s i s , more emphasis w i l l be placed on studying the s o c i a l work aspects of general and s p e c i f i c c l i n i c f u n c t i o n , than upon the medical, p s y c h i a t r i c , p s y c h o l o g i c a l , or P u b l i c H e a l t h aspects, each of which, as w i l l be di s c u s s e d , p l a y s an important r o l e i n the f u n c t i o n i n g of the c l i n i c team. S o c i a l work has always s t r e s s e d h e a l t h and wel-f a r e aspects of people*s adjustment i n extending i t s ser-v i c e s t o f a m i l i e s . When there i s disturbance i n i n t r a -f a m i l y r e l a t i o n s h i p s or other s t r e s s e s which t h r e a t e n fam-i l y breakdown, s o c i a l workers are immediately a l e r t e d to t h e i r p r o f e s s i o n a l and s o c i a l r e s p o n s i b i l i t y . Because some i n t r a - f a m i l i a l r e l a t i o n s h i p s are g r o s s l y d i s t o r t e d and p a t h o l o g i c a l , the me d i c a l , p s y c h o l o g i c a l and e d u c a t i o n a l d i s c i p l i n e s are a l s o a l e r t e d . These human r e l a t i o n s d i s c i p l i n e s have developed s p e c i a l s k i l l s which c e r t i f y t h e i r competence to d e a l e f f e c t i v e l y w i t h s e v e r a l aspects of adjustment problems. The C h i l d Guidance C l i n i c s t r u c t u r e has e f f e c t -i v e l y combined the m u l t i - d i s c i p l i n e approach i n combin-a t i o n w i t h the concept of the whole c h i l d ( p h y s i c a l , c u l -t u r a l , I n t e l l e c t u a l , p e r s o n a l i t y , s o c i a l and emotional - k -a s p e c t s ) , h i s t o t a l environment, and h i s r e a c t i o n t o i t . The s p e c i a l i z e d knowledge of the p r o f e s s i o n s concerned i s brought t o bear on the p r e s e n t i n g s i t u a t i o n , both w i t h i n the c l i n i c team--psychiatry, psychology, s o c i a l work, pub-l i e h e a l t h n u r s i n g - - f o r d i a g n o s t i c , e v a l u a t i v e and t r e a t -ment purposes; and, p a r t i c u l a r l y i n the case of t r a v e l l i n g c l i n i c , w i t h i n the community, where a group of p r o f e s s i o n a l p e r s o n s — t e a c h e r s , d o c t o r s , p u b l i c h e a l t h nurses, judges, m i n i s t e r s - - c a n do much toward c r e a t i n g an understanding, t o l e r a n t environment i n which treatment, be i t on any l e v e l , can be more c o n s t r u c t i v e l y entered i n t o and u t i -l i z e d . S o c i a l work has been c l o s e l y I n t e r e s t e d i n the development of p s y c h i a t r y from a preoccupation w i t h psy-c h o t i c i n d i v i d u a l s and the c l a s s i f i c a t i o n of mental d i s -eases, t o the more c o n s t r u c t i v e f i e l d of prev e n t i v e psy-c h i a t r y . T h i s i s evidenced i n the p s y c h i a t r i c h o s p i t a l s , mental hygiene c l i n i c s , c h i l d guidance c l i n i c s , and t r a -v e l l i n g c h i l d guidance c l i n i c s o f today. The c h i l d guidance c l i n i c movement and the mental hygiene movement are c l o s e l y interwoven. The mental h e a l t h movement i n Canada has g e n e r a l l y p a r a l l e l l e d the one i n the Unit e d S t a t e s , both i n terms o f time and o b j e c t i v e s . A summary study of the steps l e a d i n g t o the present coord-i n a t e d approach o f the medical, p s y c h i a t r i c , n u r s i n g , psy-c h o l o g i c a l and s o c i a l work p r o f e s s i o n s as a p p l i e d t o c h i l d r e n , i n order t o see and handle the c h i l d as an e n t i t y - 5 -r a t h e r than d e a l w i t h f r a c t i o n a l p a r t s as a problem, I s I n d i c a t e d as a base f o r understanding the present c h i l d guidance c l i n i c s , b oth s t a t i o n a r y and t r a v e l l i n g . D e f i n i t i o n of a C h i l d Guidance C l i n i c Stevenson and Smith have d e f i n e d the c h i l d guid-ance c l i n i c as f o l l o w s : The c h i l d guidance c l i n i c i s an attempt to marshal the resources of the community i n b e h a l f of c h i l d r e n who are i n d i s t r e s s because of u n s a t i s f i e d Inner needs, o r are s e r i o u s l y at outs w i t h t h e i r e n v i r o n -ment.... I t s s e r v i c e i s rendered through the d i r e c t study and treatment of s e l e c t e d c h i l d r e n by a team c o n s i s t i n g of a p s y c h i a t r i s t , a p s y c h o l o g i s t , and p s y c h i a t r i c s o c i a l workers, and a l s o through focus-s i n g the a t t e n t i o n of p h y s i c i a n s , teachers, s o c i a l workers and parents, on what i s commonly c a l l e d the mental hygiene approach to problems of c h i l d b e h a v i o r . 1 The t h r e e - f o l d f u n c t i o n s of a c h i l d guidance c l i n i c are broadly i n d i c a t e d as f o l l o w s : 1. The study and treatment of p a t i e n t s . 2. Seeking t o i n t e r e s t other community agencies i n the p r e v e n t i o n o f behavior and p e r s o n a l i t y d i s o r d e r s i n c h i l d r e n and i n promising methods of d e a l i n g w i t h them when they occur. 3* Attempting t o r e v e a l t o the community, through the f i r s t - h a n d study o f i n d i v i d u a l c h i l d r e n , the unmet needs of groups of c h i l d r e n . 2 I n t e r e s t I n the mental h e a l t h of c h i l d r e n has increased over the past t h i r t y or f o r t y y e a r s , d u r i n g 1 Stevenson and Smith, C h i l d Guidance C l i n i c s : A Quar- t e r Century of Development, Oxford u n i v e r s i t y Pre s s , Eon-don, p. 2 Robinson, J.P., "Current Trends i n C h i l d Guidance C l i n i c s . " Mental Hygiene. The N a t i o n a l A s s o c i a t i o n f o r Mental Health, Inc., N.Y., 1950, p. 107. - 6 -which time ...knowledge of the emotional l i f e of c h i l d r e n has Increased enormously, and the a r t of h e l p i n g those who are i n emotional d i f f i c u l t y has been g r e a t l y improved. Concurrently, the p u b l i c ' s I n t e r e s t i n these matters has grown. The challenge of the pre-sent moment I s that of d i s c o v e r i n g some means by which the k i n d of help t h a t i s a v a i l a b l e t o the few p a t i e n t s of the best c l i n i c s can be o f f e r e d through-out the country.^ The urban areas g e n e r a l l y have, over the ye a r s , developed i n c r e a s i n g l y adequate s e r v i c e s f o r c h i l d r e n . The need f o r s i m i l a r s e r v i c e s t o r u r a l areas was a l s o recognized, and community requests made an exte n s i o n o f c l i n i c s e r v i c e s necessary. As the c h i l d guidance movement gained Impetus, the e a r l y "community c l i n i c s , " connected w i t h p s y c h i a t r i c h o s p i t a l s , g r a d u a l l y developed i n t o some form of t r a v e l l i n g c h i l d guidance c l i n i c s . The demand f o r c h i l d guidance c l i n i c s e r v i c e s f a r exceeds the supply o f t r a i n e d personnel a v a i l a b l e t o s t a f f the needed c l i n i c s . One way i n which the t r a v e l l i n g c l i n i c s attempt t o solve t h i s s i t u a t i o n and spread a v a i l a b l e s e r v i c e s i s through the b u i l d i n g up of strong s t a t e c e n t r a l s t a f f s t o serve as headquarters f o r t r a v e l l i n g c l i n i c personnel.2 Emphasis WItmer, H.I*., P s y c h i a t r i c C l i n i c s f o r C h i l d r e n . The Commonwealth Fund, N.Y., 191J.0, p. 10. 2 Roth, W.P., " T r a i n i n g of the P s y c h i a t r i s t , Minimal P r o f e s s i o n a l requirements f o r S t a f f s of R u r a l and Semi-R u r a l C l i n i c s , M American J o u r n a l of Orthopsychiatry. V o l . X X I I I , No. 3, J u l y , 1953, American O r t h o p s y c h t a t r i c A s s o c i a t i o n , Inc., N. Y. upon the c o n s u l t a t i v e and community education aspects of the t r a v e l l i n g c l i n i c s has a l s o served to apply on a com-munity wide b a s i s i t s knowledge of the b a s i c f a c t o r s t h a t enter i n t o p e r s o n a l i t y development. The B r i t i s h Columbia s i t u a t i o n i s a good example of t h i s f o c u s . The e n t i r e r u r a l areas o f the province are v i s i t e d by two t r a v e l l i n g c l i n i c teams o p e r a t i n g from the two s t a t i o n a r y C h i l d Guidance C l i n i c s at V i c t o r i a and Vancouver. T h e i r f u n c t i o n i s adapted t o meet the current demand f o r and a b i l i t y t o use c h i l d guidance c l i n i c s e r v i c e s . One of t h e i r main ob-j e c t i v e s i s t o educate the l o c a l community to an awareness of the gaps i n l o c a l s o c i a l s e r v i c e s t r u c t u r e , and to ways and means of f i l l i n g these gaps. I n Canada, the t r a v e l l i n g c l i n i c s are of p a r t i -c u l a r importance i n extending ge n e r a l mental h e a l t h ser-v i c e s t o the non-urban areas. Geographically and p o p u l a t i o n -wise, Canada i s a l a r g e , undeveloped country, w i t h l a r g e regions very s p a r s e l y populated. These areas must be ser-v i c e d by the t r a v e l l i n g c l i n i c i f they are to have s e r v i c e s at a l l . 2 . General H i s t o r i c a l Background of C h i l d Guidance C l i n i c s C h i l d p s y c h i a t r y has been concerned w i t h t h a t small group of c h i l d r e n whose b e h a v i o r deviates so much from the normal t h a t they are considered insane. I t has, however, shown i n c r e a s i n g i n t e r e s t i n the f i e l d of c h i l d r e n ' s - 8 - ' emotional problems g e n e r a l l y . E s s e n t i a l l y , i t s e v o l u t i o n t o t i l l s area of I n t e r e s t , encompasses the development of the theory t h a t d i s o r d e r s of conduct and of p s y c h i c pro-cesses come from the same sources, and represent the i n d i -v i d u a l ' s way of r e a c t i n g t o i n t e r n a l and e x t e r n a l demands. According t o t h i s theory, mental adjustment i s a f u n c t i o n of the t o t a l human bein g , the r e s u l t of p h y s i o l o g i c a l , p s y c h o l o g i c a l and s i t u a t i o n a l f a c t o r s ; and p s y c h i a t r y i s "the s c i e n t i f i c study of p e c u l i a r i t i e s o f p e r s o n a l i t y and of i n t e r p e r s o n a l r e l a t i o n s h i p s . " This p o i n t of view rep-resents the convergence of v a r i o u s l i n e s of development, not only i n p s y c h i a t r y , but i n psychology and philosophy as w e l l . I t means abandoning the d i s t i n c t i o n between mind and body, accepting the dynamic i n f l u e n c e s of emotions on human behavior, and adm i t t i n g the i n e f f e c t i v e n e s s of attempt-i n g t o c o n t r o l an i n d i v i d u a l ' s m o t i v a t i o n s by e x t e r n a l com-p u l s i o n s . 1 The p s y c h i a t r i c p r i n c i p l e s b a s i c t o c h i l d guid-ance as p r a c t i c e d today, were profoundly a f f e c t e d by the c o n t r i b u t i o n s of Adolph Meyer, and of the p s y c h o a n a l y t i c movement founded by Sigraund Freud. Meyer's b a s i c c o n t r i -b u t i o n was h i s emphasis on the uniqueness of each i n d i v i d u a l 1 Witmer, op. c i t . . p. I}.. 2 The w r i t e r i s m i n d f u l of e c l e c t i c i s m i n the psycho-a n a l y t i c movement--Rank, A d l e r , and the Neo-Freudians. - 9 -p a t i e n t , and the consequent n e c e s s i t y of studying h i s t o t a l l i f e h i s t o r y as w e l l as h i s i n t e l l e c t u a l and p h y s i c a l equip-ment, i f one i s t o understand the nature of h i s present d i s -order. Prom p s y c h o a n a l y t i c theory came the concept of the dynamic i n f l u e n c e of the emotions (the i n d i v i d u a l ' s own and those of the persons w i t h whom he i s i n contact) on human behavior. The psychoanalysts showed behavior t o be purposive but i t s m o t i v a t i o n o f t e n n o n - r a t i o n a l and unconscious. E q u a l l y important, i t was noted t h a t each I n d i v i d u a l has a c a p a c i t y f o r s e l f - d i r e c t i o n and t h a t the most therapy and education can do i s t o provide the s e t t i n g favourable t o the development of l a t e n t a b i l i t i e s . 1 The chain of develop-ment that began i n America w i t h Meyer's i n s i s t e n c e on study-i n g the t o t a l i n d i v i d u a l r a t h e r than the f u n c t i o n i n g of s p e c i f i c organs, l e d l o g i c a l l y t o the presence of a l l types of problem c h i l d r e n i n p s y c h i a t r i c c l i n i c s . Meyer's hypo-t h e s i s t h a t mental a c t i v i t y represents the adaptation and adjustment of the i n d i v i d u a l as a whole, provided a b a s i s on which the v a r i o u s schools o f dynamic p s y c h i a t r y c o u l d u n i t e , and the whole range of human behavior became of i n t -e r e s t t o the p s y c h i a t r i s t . The h i s t o r y of the mental hygiene movement i s an u n f o l d i n g of the p o s s i b i l i t i e s inherent i n t h a t concept. B e t t e r care f o r the p s y c h o t i c i n d i v i d u a l , p r e v e n t i o n of psychoses, p r e v e n t i o n o f other forms of s o c i a l - 10 -and p s y c h i c maladjustment* l e d e v e n t u a l l y t o the c o n v i c t i o n t h a t these were u n s a t i s f a c t o r y g o a l s , and mental hygiene became a " p o s i t i v e program f o r l i f e w e l l - l i v e d , f o r mental h e a l t h because of i t s values and not because of what i t a v o i d s . " 1 There appear to have been three major l i n e s o f development l e a d i n g to present p s y c h i a t r i c s e r v i c e s f o r c h i l -dren. F i r s t , there I s the e a r l y work of mental h o s p i t a l s and schools f o r the feeble-minded. I n s p i t e of the f a c t t h a t p s y c h i a t r i s t s i n the l a t t e r p a r t of the n i n e t e e n t h century were c h i e f l y concerned w i t h problems of neuropathology and the c l a s s i f i c a t i o n o f mental diseases,, there was even then some i n t e r e s t i n preventive work. As e a r l y as 1871, the C a l i f o r n i a State Board of H e a l t h proposed the e r e c t i o n of a psychopathic h o s p i t a l f o r the treatment of i n c i p i e n t mental d i s o r d e r s . I t b e l i e v e d t h a t much permanent i n s a n i t y was due to the l a c k of e a r l y care. The c l i n i c opened i n 1897 under the d i r e c t i o n of Dr. Walter Channing a t the Boston Dispen-sary was more d e f i n i t e l y p r e v e n t i v e , and apparently marked the beginning o f c l i n i c a l work w i t h c h i l d r e n . I t d e f i n i t e l y foreshadowed more modern methods of studying p a t i e n t s . More or l e s s through the i n f l u e n c e s of Meyer, other s t a t e hos-p i t a l s i n New York (1909) and Massachusetts (1910) began t o o f f e r c l i n i c s e r v i c e s . I n a d d i t i o n t o t h e i r i n t e r e s t i n 1 I b i d . . p. 7. - 11 = p r e v e n t i o n through e a r l y r e c o g n i t i o n and treatment of mental disease, use of the p a r o l e system and f o l l o w - u p s , and of e d u c a t i o n a l o b j e c t i v e s , i s noted. With the s h i f t i n p s y c h i a t r y t o an i n t e r e s t i n t o t a l behavior and i n the s o c i a l and emotional genesis of mental d i s o r d e r s , i t was a n a t u r a l step f o r c l i n i c s t o seek to a i d c h i l d r e n who were s o c i a l l y m a l a d j u s t e d . 1 The Gut-p a t i e n t Department of the Boston Psychopathic H o s p i t a l ac-cepted c h i l d r e n as p a t i e n t s from the time of i t s opening i n 1912. G e n e r a l l y , however, s t a t e h o s p i t a l c l i n i c s r a r e l y accepted c h i l d r e n as p a t i e n t s before about 1920. The c l i n l e opened i n 1915 i n Easton, P e n n s y l v a n i a — t h e Allentown State Hospital--was the only other notable exce p t i o n . One o f i t s o r i g i n a l purposes was t o serve as a c l e a r i n g house f o r the p u b l i c schools of a l l c h i l d r e n suspected of being i n the e x c e p t i o n a l c l a s s , s e c u r i n g f o r them d i a g n o s i s and p r o g n o s i s , determining the degree and v a r i e t y of mental weakness, and a d v i s i n g what environment and course of a c t i o n w i l l serve the i n t e r e s t of each i n d i v i d u a l c h i l d . Many of the l a t e r s t a t e h o s p i t a l s began t h e i r work on the b a s i s of such an i n t e r e s t i n e d u c a t i o n a l l y retarded c h i l d r e n . The second l i n e of development l e a d i n g t o present p s y c h i a t r i c s e r v i c e s f o r c h i l d r e n i s found i n c l i n i c s f o r 1 I b i d . . p. 2 Loc. c l t . - 12 -j u v e n i l e d e l i n q u e n t s . Dr. W i l l i a m Healy's work i n the Juv-e n i l e Court of Cook County, I l l i n o i s , provided the p a t t e r n on which the l a t e r c h i l d guidance c l i n i c s were p a r t i a l l y modelled. What happened here i s so w e l l known t h a t I t needs no e l a b o r a t i o n . The t h i r d l i n e of development o f present p s y c h i a t r i c s e r v i c e s f o r c h i l d r e n i s seen In the f i v e year program (1922 to 1927) of demonstration c h i l d guidance c l i n i c s , f i n a n c e d by the Commonwealth Fund. The widespread p u b l i c i n t e r e s t and enthusiasm f o r the treatment approach t o p e r s o n a l i t y and behavior d i f f i c u l t i e s had sti m u l a t e d the N a t i o n a l Com-mittee f o r Mental Hygiene's i n t e r e s t i n behavior problems of c h i l d r e n , as a r e s u l t of which they approached the Common-wealth Fund f o r the f i n a n c i n g of t h i s program. I n p l a n n i n g t h i s demonstration c l i n i c program, the N a t i o n a l Committee drew upon the experience o f the I l l i n o i s I n s t i t u t e f o r J u v e n i l e Research, the Judge Baker Foundation, and two psychopathic h o s p i t a l s . Precedent f o r i n c l u d i n g p s y c h i a t r i c s o c i a l workers on the c l i n i c s t a f f was o f f e r e d by the Boston Psychopathic H o s p i t a l and the Henry Phipps P s y c h i a t r i c C l i n i c , both o f whom d i f f e r e d from the I n s t i -t u t e i n s e r v i n g the whole community r a t h e r than merely the court. The Committee had already taken p a r t i n the t r a i n i n g of p s y c h i a t r i c s o c i a l workers, and i t s c l i n i c a l program was i n a sense a p u t t i n g i n t o p r a c t i c e of much th a t had been - 1 3 -t a u g h t . 1 Other demonstration c l i n i c s were e s t a b l i s h e d throughout the E a s t e r n and mid-Western United S t a t e s . I t soon became apparent, however, t h a t there were disadvantages to working wholly through the courts and that the most e f f e c -t i v e p reventive work was to be done w i t h c h i l d r e n whose mis-conduct had not yet been adjudged l e g a l delinquency. The l a t e r c l i n i c s were t h e r e f o r e e s t a b l i s h e d i n connection w i t h h o s p i t a l s or sch o o l s , and r e f e r r a l s were sought from par-p ents, teachers and s o c i a l workers. I I . T r a v e l l i n g C h i l d Guidance C l i n i c s — D e v e l o p m e n t The s p e c i f i c nature of t r a v e l l i n g c h i l d guidance c l i n i c s , and t h e i r genesis, i s seen i n the establishment of demonstration c l i n i c s , conducted from s i x months t o two ye a r s , by a s t a f f sent out from New York. These were h e l d i n seven widely s c a t t e r e d c i t i e s . Out of t h e i r experience c e r t a i n conclusions emerged th a t form the b a s i s f o r much of the c h i l d guidance work of today:^ (1) that c h i l d guidance should not be l i m i t e d to any . one d i a g n o s t i c group, such as delinquents or "pre-p s y c h o t i c s , M and th a t i t has most t o o f f e r t o c h i l d r e n of adequate I n t e l l i g e n c e whose d i f f i -c u l t i e s have not been o f lo n g d u r a t i o n ; 1 I b i d . , p. 57. 2 I b i d . , p. 52. 3 Loc. c i t . - 14 -(2) t h a t the need f o r p s y c h i a t r i c help i s not the only f a c t o r determining ameanability t o t r e a t -ment- -however, emphasis was placed not on the s i g n i f i c a n c e of f a m i l y a t t i t u d e s i n r e s i s t a n c e to p s y c h i a t r i c h e l p , but r a t h e r on the magni-tude of the problem and the l a c k of community f a c i l i t i e s to c a r r y out the treatment program; (3) t h a t c h i l d guidance c l i n i c s cannot work apart from the community and must depend upon other s o c i a l agencies and i n s t i t u t i o n s f o r a s s i s t a n c e i n t h e i r work: a) t h a t c l i n i c s should work w i t h schools and s o c i a l agencies and " i n t e r p r e t " c h i l d guidance to them; b) t h a t the community has a p a r t t o p l a y . i n the promotion of c h i l d r e n * s mental h e a l t h ; c) t h a t the work of a c l i n i c i s s e r i o u s l y handicapped un l e s s there are i n the community f a i r l y adequate f a c i l i t i e s f o r the care of c h i l d r e n w i t h respect to education, h e a l t h and r e c r e a t i o n , and some s p e c i a l p r o v i s i o n s f o r c h i l d -r e n who are mentally d e f e c t i v e , or dependent, or de l i n q u e n t . Without these resources, plans f o r environmental treatment could not be c a r r i e d out e f -f e c t i v e l y , nor could psychotherapy com-pensate f o r gross d e f e c t s i n the commun-i t y s i t u a t i o n . E q u a l l y o r more impor-ta n t were found to be the a t t i t u d e s of those i n charge of such Community agen-c i e s or i n s t i t u t i o n s . C h i l d guidance, a c c o r d i n g l y , came t o be regarded as a co-operative e n t e r p r i s e , one t h a t drew  upon many more than the c l i n i c s t a f f  f o r i t s undertaking; (if) I t became c l e a r t h a t the demonstration c l i n i c s could not hope to cope w i t h a l l the mental hygiene problems of c h i l d r e n that would be brought t o t h e i r a t t e n t i o n . The c l i n i c s 1 p o l i c y of education and co-operative work was an attempt at the r e s o l u t i o n of t h a t dilemma. Most c l i n i c s t h e r e f o r e a l l o t t e d a considerable p r o p o r t i o n of t h e i r time t o teaching the p r i n -c i p l e s of mental hygiene t o teachers, school nurses, court and other s o c i a l workers, and t o parents as w e l l . Education of s o c i a l workers - 15 -and others through case conferences, exchange of s t a f f , and n c o - o p e r a t i v e work" was a more d i r e c t a t t a c k on the problem, i t being ex-pected t h a t what these workers learned about the treatment of a few c h i l d r e n could be ap-p l i e d t o t h e i r work w i t h the many who would otherwise need the c l i n i c ' s h e l p . l Thus we see a gradual movement toward current t h i n k i n g about the mental h e a l t h of c h i l d r e n as a community r e s p o n s i b i l i t y i n which the c l i n i c shares* The t r a v e l l i n g c h i l d guidance c l i n i c i s seen now as a community agency tha t d e f i n e s i t s f u n c t i o n beyond p s y c h i a t r i c d i a g n o s i s and treatment t o p a r t i c i p a t i n g c o n s u l t a t i v e s e r v i c e s t o other h e a l t h , welfare and e d u c a t i o n a l agencies i n the community. The e f f e c t i v e n e s s of t r a v e l l i n g c h i l d guidance c l i n i c prac-t i c e i s determined by the amount of e f f e c t i v e p a r t i c i p a t i o n between the c h i l d guidance c l i n i c and the community. There must be mutual i n t e r a c t i o n . (1) P u b l i c Welfare Aspects of T r a v e l l i n g C l i n i c T r a v e l l i n g c l i n i c s have been s t u d i e d r e c e n t l y by J u l e s Coleman and R.E. S w l t z e r . Some of t h e i r general ob-s e r v a t i o n s are extremely s i g n i f i c a n t i n understanding t r a v e l l i n g c l i n i c f u n c t i o n s and l i m i t a t i o n s under c e r t a i n circumstances. They s t a t e that the - success of a t r a v e l l i n g c h i l d guidance c l i n i c i s very much dependent on i t s a b i l i t y t o become engaged as a p a r t i c i p a n t w i t h the c h i l d welfare 1 I b i d . , p. 54» - 16 -agencies i n the community. This type of c l i n i c always d i r -e c t l y r e l a t e s i t s s e r v i c e s t o e x i s t i n g community resources. I t has no independent t h e r a p e u t i c r o l e . I t d e r i v e s what-ever s t r e n g t h i t may b r i n g to the s o l u t i o n of problems from antecedent community a c t i v i t i e s t h a t have been p l a y i n g a supporting p a r t and b u i l d i n g up i n the p a t i e n t a readiness t o move i n the d i r e c t i o n of change. The c l i n i c c o n t r i b u t e s to change, i n other words, by u n v e i l i n g what i s already p o t e n t i a l l y t h e r e . 1 I f a community l a c k s adequate sch o o l s , teachers, s o c i a l workers, school and p u b l i c h e a l t h nurses, placement f a c i l i t i e s , J u v e n i l e Courts, maternal and c h i l d welfare and h e a l t h programs, i . e . , i f the community i s not already undertaking the m u l t i p l e s o c i a l l y i n t e g r a t e d a c t i v -i t i e s t h a t are necessary f o r the welfare of c h i l d r e n — t h e n the e f f e c t i v e n e s s of a v i s i t i n g c l i n i c i s g r o s s l y reduced. Any r e s u l t s I t does achieve are t r u l y a c c i d e n t a l , u n p r e d i c t -able and unexpected. Thus i t can be seen t h a t the t r a v e l l i n g c l i n i c i s not only a medical u n i t w i t h a medical t r a d i t i o n of treatment. Even more, i t i s a s o c i a l agency w i t h a constant. c o n t i n u i n g . Integrated r e l a t i o n s h i p t o the organized a c t l v - i t y of the community. 1 Coleman, J u l e s and S w i t z e r , R.E., "Dynamic Factors i n P s y c h o s o c i a l Treatment i n T r a v e l l i n g C h i l d Guidance C l i n i c s , " Mental Hygiene, The N a t i o n a l A s s o c i a t i o n f o r Mental H e a l t h , . I n c . , N.Y., 1951, p. 398. 2 Witmer, op. c i t . . p. 399. - 17 -The development of t r a v e l l i n g c h i l d guidance c l i n i c s i n Colorado seems a t y p i c a l example of the way i n which the t r a v e l l i n g c l i n i c s g e n e r a l l y a r r i v e at t h e i r cur-rent f u n c t i o n . I n 1925, members of the s t a f f o f the Colo r -ado Psychopathic H o s p i t a l p a r t i c i p a t e d i n general medical and h e a l t h c l i n i c s f o r both c h i l d r e n and a d u l t s , i n many communities throughout the s t a t e . These t r a v e l l i n g c l i n i c s , or "community h e a l t h conferences" continued t i l l 1928, when separate t r a v e l l i n g p s y c h i a t r i c c l i n i c s t o f i v e communities were e s t a b l i s h e d . Up t o t h i s p o i n t , the goals o f the c l i n i c s were i n the main e d u c a t i o n a l . I n 1936* these community c l i n i c s became monthly t r a v e l l i n g c h i l d guidance c l i n i c s , as a r e s u l t of the establishment of co-operative e f f o r t s between the mental hygiene c l i n i c s of the psychopathic h o s p i t a l and the c h i l d w elfare d i v i s i o n of the State Depart-ment of P u b l i c Welfare. The general goals remained as be-f o r e . Diagnosis, e v a l u a t i o n and i n t e r p r e t a t i o n t o the r e f e r r i n g person or agency were the major c l i n i c f u n c t i o n s . 1 The way had a l s o been paved f o r " p s y c h o - s o c i a l treatment," through p u b l i c education and the encouragement of an accept-i n g a t t i t u d e toward p s y c h i a t r y . I n 1914-6, the emphasis s h i f t e d from education of the community t o treatment of pat-i e n t s . This s h i f t came l a r g e l y through the one year's assignment of a c h i l d p s y c h i a t r i s t ; and a l s o through a new 1 Treatment of both p s y c h o l o g i c a l and s o c i a l f a c t o r s . - 18 -p o l i c y of treatment o r i e n t a t i o n . Among the d i f f i c u l t i e s encountered i n the f i r s t year were the f o l l o w i n g : (1) the securing of t y p i c a l c h i l d guidance p a t i e n t s Instead of examining c h i l d r e n of low i n t e l l i g e n c e or those whose d i f f i c u l t y was due to organic causes; (2) the g i v i n g of treatment s e r v i c e w i t h proper follow-up i n s t e a d of p r o v i d i n g merely d i a g n o s t i c s e r v i c e ; (3) overcoming the meager resources i n the l o c a l com-. munity f o r h a n d l i n g problem c h i l d r e n ; (4) the g a i n i n g of p a r e n t a l co-operation and community a s s i s t a n c e . The program f o r overcoming those d i f -f i c u l t i e s was centred on the c h i l d welfare worker and her already e s t a b l i s h e d r e l a t i o n s h i p s w i t h other a g e n c i e s . 1 I n t h i s way the p s y c h o - s o c i a l treatment process evolved, w i t h i t s i n t i m a t e l y r e l a t e d and mutually dependent a d m i n i s t r a t i v e and c l i n i c aspects. (2) General D e s c r i p t i o n of T r a v e l l i n g C l i n i c S t r u c t u r e and  Goals G e n e r a l l y , t r a v e l l i n g c l i n i c s Include a p s y c h i a -t r i s t , and a p s y c h o l o g i s t , who t r a v e l t o the c l i n i c s e t t i n g one t o two days each month. The c h i l d welfare worker o f each community v i s i t e d completes the c l i n i c team. The l a t t e r r e c e i v e s a l l r e f e r r e d cases; makes a p r e - c l i n i c home v i s i t f o r S o c i a l H i s t o r y purposes; i n t e r p r e t s the s e r v i c e s of the c l i n i c ; helps the p a t i e n t to decide whether he wishes t o use the a c t u a l s e r v i c e s ; and makes the a c t u a l 1 I b i d . . p. lj.07. - 19 -appointment. Cases are r e f e r r e d by schools, p r i v a t e p h y s i -c i a n s , courts and other s o c i a l agencies, as w e l l as by par-ents themselves. The frequency o f c l i n i c v i s i t s i s u s u a l l y determined by such l i m i t a t i o n s as d i s t a n c e , s i z e of parent-c l i n i c s t a f f , the a v a i l a b i l i t y of s u i t a b l e personnel, and pressures on the l o c a l s o c i a l worker, p a r t i c u l a r l y i f t h i s i s a c h i l d - w e l f a r e worker, c a r r y i n g her own caseload i n a d d i t i o n t o c l i n i c cases. The presence of t r a i n e d s t a f f I n the l o c a l community i s necessary to c a r r y i n g out the t h e r a -p e u t i c f u n c t i o n of the guidance c l i n i c . S q u a l l y important i s a c o n s i s t e n t p o l i c y of community r e l a t i o n s , i n order to provide c o n t i n u i t y of s e r v i c e . Even where a community has developed sound supporting s e r v i c e s , a c l i n i c s t i l l does not e x i s t i n the " s p l e n d i d i s o l a t i o n o f psychodynamic preoccupat-i o n , " but must m a i n t a i n constant concern f o r i t s r e l a t i o n s to other a g e n c i e s . 1 Coleman s t a t e s t h a t i t i s e s p e c i a l l y impor-t a n t t o emphasize repeatedly the p u b l i c h e a l t h aspects of c l i n i c f u n c t i o n and t h e i r p o s s i b i l i t i e s f o r the development of a p r e v e n t i v e p s y c h i a t r y . The i n f l u e n c e teachers may have on the s o c i a l and emotional development of c h i l d r e n i s recognized, and i n d i c a t e s the value i n p o s i t i v e c l i n i c r e l a -t i o n s with the s c h o o l . I n t e r p r e t a t i v e and co-operative work w i t h s o c i a l and h e a l t h agencies Is' a l s o v a l u a b l e . The c l i n i c may help the agency s o c i a l worker i n a more e f f e c t i v e 1 I b i d . , p. lj.08. - 2 0 -use of her own p r o f e s s i o n a l r e s p o n s i b i l i t i e s i n working w i t h d i s t u r b e d c l i e n t s , through o f f e r i n g a c o n s u l t a t i v e program w i t h t h e p s y c h i a t r i s t * I n h e a l t h agencies, the l a c k of p s y c h i a t r i c o r i e n t a t i o n i n the t r a i n i n g of p u b l i c h e a l t h nurses may be p a r t i a l l y remedied through p o s i t i v e c l i n i c r e l a t i o n s h i p , and mutual p r o f e s s i o n a l r e s p e c t . Thus we see indeed t h a t the c h i l d guidance c l i n i c * be i t  t r a v e l l i n g or s t a t i o n a r y , i s a group of p r o f e s s i o n a l people  who combine t h e i r s p e c i a l i z e d knowledge* and attempt to  employ the resources of the community to meet the problems  of c h i l d r e n who have u n s a t i s f i e d p s y c h o l o g i c a l needs, and  who are p o o r l y adjusted to t h e i r surroundings. The work of the c l i n i c s , which w i l l be s t u d i e d i n more d e t a i l i n the f o l l o w i n g chapters, has proven t h a t i f p r e v e n t i v e work w i t h behavior and p e r s o n a l i t y d i f f i -c u l t i e s of c h i l d r e n i s t o be handled e f f e c t i v e l y , the  p r e v e n t i v e a t t a c k must be d i r e c t e d toward h e l p i n g p a r e n t s ,  scho o l s , h e a l t h and s o c i a l agencies to understand and d e a l  w i t h e a r l y cases. The purpose i s to detect and t r e a t c h i l d -ren's d i f f i c u l t i e s at a stage when a c t u a l treatment i n the community i s s t i l l p o s s i b l e and community resources can be used p r e v e n t i v e l y . C h i l d r e n are r e f e r r e d t o the c l i n i c because of d i s o r d e r e d h a b i t s , troublesome p e r s o n a l i t y t r a i t s , or unacceptable b e h a v i o r - - a l l outward m a n i f e s t a t i o n s o f s e r i o u s u n d e r l y i n g disturbance i n the mental, p h y s i c a l , - 21 -or s o c i a l sphere, which are d e s t r o y i n g the harmonious adjustment of the c h i l d t o i t s environment. To understand and c o r r e c t the b a s i c f a c t o r s causing these symptoms, i s t o s t r i k e at the roo t s of mental d i s e a s e , delinquency, depend-ency, and other forms of s o c i a l inadequacy and f a i l u r e . I n searching f o r these u n d e r l y i n g causes i t i s impossible to separate the p h y s i c a l and mental aspects of the human per-s o n a l i t y and to t r e a t them independently. The c h i l d guid-ance c l i n i c t h e r e f o r e represents the fundamental u n i t y i n the many-sided aspects of human p e r s o n a l i t y and behavior. The concepts of the whole c h i l d and the c l i n i c team approach, are b a s i c t o i t s current f u n c t i o n . 1 I I I . The T r a v e l l i n g C h i l d Guidance C l i n i c Across Canada (1) General Developmental P i c t u r e As has been noted, the Mental Hygiene movement i n Canada has g e n e r a l l y p a r a l l e l l e d , both i n terms of time and o b j e c t i v e s , the one i n the Uni t e d S t a t e s . C e r t a i n h i s t o r i -c a l trends r e l a t e d to the mental h e a l t h aspects of the c h i l d guidance c l i n i c movement i n Canada have been noted i n the 195% r e p o r t of the Research D i v i s i o n of the Department of P Health and Welfare, mentioned e a r l i e r . 1 Byrne, Dr. U.P., Vancouver C h i l d Guidance C l i n i c , l e c t u r e notes. 2 Department of N a t i o n a l H e a l t h & Welfare, Research D i v i s i o n , General; S e r i e s Memorandum Ho. 6, Mental H e a l t h  Services i n Canada. Ottawa, J u l y , 1954* P* 17. - 22 -(1) Change I n the types of personnel employed, the degree of s p e c i a l i z a t i o n i n c r e a s i n g w i t h the advances i n s c i e n t i f i c knowledge. (2) An i n c i p i e n t change i n p u b l i c a t t i t u d e s toward the mentally i l l , and an emerging i n t e r e s t i n t h e i r w e l f a r e , evidenced by the formation of v o l u n t a r y o r g a n i z a t i o n s . (3) A r e c o g n i t i o n t h a t mental h e a l t h s e r v i c e s were a h e a l t h problem, evidenced by the t r a n s f e r of i n s t i t u t i o n a l a d m i n i s t r a t i o n t o p r o v i n c i a l men-t a l h e a l t h d i v i s i o n s . (it.) A gradual s h i f t i n emphasis i n the d i r e c t i o n of community s e r v i c e s , i n c l u d i n g not only educat-i o n a l media, d i a g n o s t i c and short term t r e a t -ment, but the i n s t i t u t i o n s themselves. ( 5 ) I n c r e a s i n g p a r t i c i p a t i o n by the f e d e r a l govern-ment, a c t i n g i n a c o n s u l t a t i v e capacity and a s s i s t i n g through the p r o v i s i o n of l i m i t e d f i n a n c i a l a i d . (6) A beginning of r e s e a r c h i n t o mental h e a l t h prob-. lems. As i n other c o u n t r i e s , p r e j u d i c e and ignorance concerning mental i l l n e s s have c o n s t i t u t e d a formidable b a r r i e r t o progress. To e l i m i n a t e such p r e j u d i c e , emphasis has been placed on p u b l i c mental h e a l t h education, which today i s a f u n c t i o n not only of s p e c i a l agencies, but of every mental h e a l t h worker i n the f i e l d . 1 More and more, mental h e a l t h c l i n i c s are being accepted as an e s s e n t i a l component of community h e a l t h s e r v i c e s . Depending on t h e i r purpose, c l i n i c s are operated by v a r i o u s agencies i n c l u d i n g p u b l i c h e a l t h departments, m u n i c i p a l i t i e s or h e a l t h u n i t s , 1 I b i d . . p. k* - 23 -mental or psychiatric hospitals, children's hospitals and child health centres, tuberculosis sanitaria, general hospitals, school boards or voluntary organizations. Some are full-time, others part-time, and some are held at regular or irregular intervals; some are stationary c l i n i c s while others are held by travelling c l i n i c teams that move from place to place on regular schedule or on request. 1 The "averageM Canadian c l i n i c team consists of a psychiatrist, a psychologist, and a social worker. Mental Health c l i n i c s i n the larger hospitals are usually better staffed and equipped to provide treatment. Smaller c l i n i c s and travelling teams may provide only a screening service for referred cases, and may give no treatment whatever, but merely advise the source of referral concerning the pat-ient's mental status, and concerning future therapy, and 2 places where such therapy may be obtained. Clinic services have expanded rapidly In Canada since the inception of the National Health Program i n 1948. Although no specific mention i s made of the Mental Health Grant or the Professional Training Grant, there are few c l i n -ics i n any province that have not received substantial finan-c i a l assistance toward expanding their work, either through 1 Department of National Health and Welfare, Research Div-ision, Mental Health Services i n Canada. Ottawa, July, 1954, p. 105. 2 Loc. c i t . - 2k -help i n t r a i n i n g or employing t h e i r personnel, or both. Many c l i n i c s are financed e n t i r e l y through federal grants. At the present time there i s l i t t l e uniformity i n the types of mental health services provided f o r children i n the several provinces or within any province; wide variations depend on the population of a community and on the sources available f o r r e f e r r a l s . A l l provinces provide some c h i l d guidance, but as yet, these services are l i m i t e d c h i e f l y to the more densely populated urban areas. As has been mentioned previously, the t r a v e l l i n g c l i n i c s have gradually developed i n an e f f o r t to extend c l i n i c a l services into non-urban areas, but as yet, t h e i r services are gen-e r a l l y confined to the diagnostic, screening and r e f e r r a l functions. A Child Guidance C l i n i c studies, assesses, and treats a variety of disturbances a r i s i n g i n children and i n parent-child re l a t i o n s h i p s . Many of these c l i n i c s have been eit h e r established or subst a n t i a l l y expanded since the inauguration of the National Health Program i n 1948. The recent report on Men-t a l Health Services i n Canada, Ju l y , 1954, points up the increase both i n f a c i l i t i e s and i n t r a i n i n g of professional personnel; and the indications are that there i s r e a l prog-ress being made i n t h i s area at the present time, due both to the increased federal f i n a n c i a l a i d , and to the r e s u l t s of current emphasis on community education along mental health l i n e s . The present picture i s an encouraging one, - 25 -boding well for future developments in mental health ser-vices . This report also acknowledges the role of mental health c l in ics in attaining present public interest and increased understanding of mental i l lnesses and of modes of prevention: "There can be l i t t l e doubt that the most effective educational work i s being done in the community c l in ic s across Canada. This work has been mentioned i n -direct ly i n almost every section of this report. Medical personnel i n c l in ic s and hospitals, public health nurses, psychologists, social workers, and many others share in this work. Perhaps the recovered patient and his family play the greatest role in gradually breaking down the barriers of prejudice, for he i s convincing proof that l ike physical ailments, his i l lness may also be cured . " 1 (2) Survey of Current Travelling Child Guidance Cl in ic  Services i n Canada In an effort to gain as clear a pieture as pos-sible of the extent of t ravel l ing chi ld guidance c l i n i c services in Canada, letters were sent to various c l in i c s across Canada, and to the provincial directors of Mental p Health Services. A tota l of nineteen requests for in -formation concerning: 1 Ib id . , p. ij.6. p See Appendix A. - 26 -a) clinic function b) area serviced c) staff and administration d) type8 of cases bandied e) liaisons with other community agencies were sent out. to eighteen of which replies were received. On the basis of the information received, the writer here presents the current Canadian picture regarding facilities for travelling psychiatric clinic services for children, in each of the ten provinces. NEWFOUNDLAND There are no travelling mental health clinics in Newfoundland at present. The Hospital for Mental and Ner-vous Diseases at St. John's, makes available in its out-patient department, consultative services to the Depart-ments of Welfare, Education and Justice, as well as to general practitioners throughout the province. As yet, travelling clinic services are s t i l l undeveloped. PRINCE EDWARD ISLAND Travelling clinic services for children are as yet but a small part of this province's accelerated mental health program. At present, they are operating out of the Mental Health Clinic in Charlottetown, under the adminis-tration of the Division of Mental Health. It is stated that the travelling clinic will become more active, with the eventual establishment of branch offices in specified centres. - 2 7 -The s t a t i o n a r y Mental H e a l t h C l i n i c , l o c a t e d at 1 0 1 Queen S t r e e t , Charlottetown, was opened March 1 6 , 1 9 5 2 , on a p a r t time b a s i s , w i t h Saturday mornings reserved f o r c h i l d r e n . I t f u n c t i o n s as a d i a g n o s t i c , c o n s u l t a t i v e , t h e r a p e u t i c and e d u c a t i o n a l u n i t . Cases are r e f e r r e d by the f a m i l y o r a t t e n d i n g p h y s i c i a n . The c l i n i c i s s t a f f e d by the p r o f e s s i o n a l s t a f f from Palconwood H o s p i t a l , two m i l e s d i s t a n t , and i n c l u d e s : two p s y c h i a t r i s t s ( a l t e r n a t e a f t e r n o o n s ) , one p s y c h o l o g i s t and one s o c i a l worker. An i n t e r e s t i n g aspect of t h i s c l i n i c i s the c l o s e c o l l a b o r a -t i o n between the c l i n i c and the Guidance Consultant, who has her o f f i c e i n the same s e t t i n g . The s e r v i c e s of the Guidance Consultant, sometimes r e f e r r e d t o as the educat-i o n a l c onsultant or the l i a i s o n o f f i c e r , emerged from the Forest H i l l V i l l a g e P r o j e c t , an experiment begun i n 19%S by the N a t i o n a l Committee f o r Mental He a l t h . The Committee was l o o k i n g f o r a s u i t a b l e community to c a r r y out an idea they had t o attempt t o study and p r a c t i c e the ways and means to mental h e a l t h , at the p o i n t i n our s o c i e t y which seems most l i k e l y t o y i e l d r e s u l t s , the c h i l d . Since c h i l d r e n are most a c c e s s i b l e i n schools and only understood w i t h i n a network of r e l a t i o n s h i p s , the school i n i t s community was the chosen f i e l d . The emphasis i n t h i s province's mental h e a l t h program appears to have been upon an a c t i v e e d u c a t i o n a l program i n the I n t e r e s t s of l a y i n g a sound foundation amongst the h e a l t h , w e l f a r e , and e d u c a t i o n a l - 28 -personnel as to the understanding of general mental health principles and use of mental health c l i n i c services, when they become available. The Director of the Division of Mental Health states that although the c l i n i c i s operating on a part-time basis due to insufficient staff, this i s expected to be remedied by July, 1955* One of the staff psychiatrists, currently specializing in child psychiatry at the Memorial Guidance Clinic, Richmond, Virginia, w i l l rejoin the c l i n i c at that time. Excerpts from the 1952 Prince Edward Island de-partment of Health and Welfare Annual Report indicate that the Guidance Consultant's act i v i t i e s and the psychiatric interviews form the bulk of the c l i n i c ' s activities--the former being involved i n educational and community lia i s o n a c t i v i t i e s , the lat t e r i n therapy, but mainly with adults. The psychologist does a limited amount of therapy i n addi-tion to her psychological testing; and the social worker's activ i t i e s include mostly history taking, plus a few "interviews with mother i n child guidance." The emphasis upon the work of the Guidance Con-sultant at this stage i n the development of the province's mental health services seems an appropriate one, particul-arly when accompanied by efforts toward increasing the professional training, and numbers of staff. The guidance consultant, who was active i n the Forest H i l l Village - 29 -P r o j e c t , acts as a l i a i s o n o f f i c e r between the Department of H e a l t h and Education; her work i s d i r e c t e d through the Department of Education, but i s under the s u p e r v i s i o n of the D i v i s i o n of Mental He a l t h . Her work c o n s i s t s essen-t i a l l y of school a c t i v i t i e s , such as human r e l a t i o n s c l a s s e s , i n t e r v i e w s w i t h teachers, p a r e n t s , p u b l i c h e a l t h nurses, and s o c i a l welfare workers, and of edu c a t i o n a l a c t i v i t i e s , as i n the p r e s e n t a t i o n of f i l m s , l e c t u r e s , and t a l k s t o v a r i o u s groups, i n c l u d i n g Home and School Assoc-i a t i o n , Women's I n s t i t u t e s , and Teacher Study Groups and Conferences. I t i s recognized t h a t Mental Health i n the schools i s new i n t h i s province and must, t h e r e f o r e , move s l o w l y . I n the meantime, the sound community education work, and the e s t a b l i s h i n g of sound community r e l a t i o n s h i p s as a b a s i s f o r f u t u r e expansion of s e r v i c e s as the need i s f e l t by the c i t i z e n s , should r e s u l t i n f u t u r e e f f e c t i v e n e s s of mental h e a l t h s e r v i c e s . The t r a v e l l i n g c l i n i c s e r v i c e i n P r i n c e Edward I s l a n d works most c l o s e l y and e f f e c t i v e l y w i t h the sc h o o l s , and at i t s present stage of development s t r e s s e s the edu c a t i o n a l aspect, u t i l i z i n g the s e r v i c e s of the guidance consultant i n t h i s r espect. HEM BRUNSWICK There are no t r a v e l l i n g p s y c h i a t r i c c l i n i c s e r v i c e s f o r c h i l d r e n i n New Brunswick at the present t i m e . 1 There are, however, three community mental h e a l t h c l i n i c s , operated by the Department of Hea l t h and S o c i a l S e r v i c e s , at Saint John, P r e d e r i c t o n , and Moncton. For areas not served by the three c l i n i c s , a screening s e r v i c e i s being developed. This con-s i s t s of a c l i n i c a l team o f a p s y c h o l o g i s t and a s o c i a l worker who p e r i o d i c a l l y v i s i t any centre where a group of cases has been assembled. This s e r v i c e began i n 1952-3. NOVA SCOTIA There are no t r a v e l l i n g c h i l d guidance c l i n i c s i n Nova S c o t i a . The c l i n i c s t h a t are operated are a l l f i x e d i n one spot, and p a t i e n t s from o u t l y i n g areas come t o the c l i n i c i f p o s s i b l e . 3 The "Mental H e a l t h S e r v i c e s i n Canada" r e p o r t i n d i c a t e s that Nova S c o t i a has the f o l l o w i n g mental h e a l t h s e r v i c e s : o u t - p a t i e n t c l i n i c and treatment and c o n s u l t a t i v e s e r v i c e s o f f e r e d by the V i c t o r i a General H o s p i t a l i n H a l i f a x , the H a l i f a x Mental H e a l t h c l i n i c f o r c h i l d r e n , and a s t a t i o n -ary c l i n i c at Digby, p r i m a r i l y f o r researc h purposes. I n 1 L e t t e r from New Brunswick Department of H e a l t h and S o c i a l S e r v i c e s , Mental H e a l t h D i v i s i o n . 2 . . -Department o f N a t i o n a l Health and Welfare, Research D i v i s i o n , Mental H e a l t h S e r v i c e s i n Canada, Ottawa, J u l y , 1954, P. lOTH ~ " 3 By l e t t e r , C h i e f , Neur op sy o h i a t r i c D i v i s i o n , Depart-ment o f P u b l i c H e a l t h , Nova S c o t i a . - 31 -addition, to extend services to points remote from Halifax, the province operates a f i e l d psychiatric c l i n i c with head-quarters i n Sydney. This i s staffed by a full-time psychia-t r i s t and a psychiatric nurse. Services include consultation, education, and child guidance, mental testing, consultation to local courts and practising physicians and a limited treatment service. QUEBEC Quebec abounds i n Mental Health Clinics, most of which are closely connected with the three major universi-ties—Montreal, McG-ill, and Laval. These cli n i c s include hospital c l i n i c s directed by universities, hospital c l i n i c s not directed by universities, and non-hospital c l i n i c s a f f i l i a t e d with universities. Of the wealth of c l i n i c s , however, only two provide travelling psychiatric services--the Verdun Protestant Hospital, a training hospital a f f i l -iated with McGill University, and The Mental Hygiene Insti-tute, which Is a f f i l i a t e d with, but not directed by McOIll University. The Verdun Protestant Hospital travelling psy-chiatric c l i n i c was established as part of the treatment services of the Hospital, and was proposed to provide a screening of cases prior to admission, and a follow-up of those discharged. It was seen as a p i l o t project, and i t was hoped that a treatment and consulting service, along with, a program of public education, would find acceptance i n - 32 -smaller communities. The project was financed through the Dominion Provincial Health Grants, and began operations for two f u l l days every two weeks, in October, 191+9, i n Sher-brooke, a city of 50,000 population, 103 miles from Montreal. The c l i n i c functions as part of a mental hospital service, with emphasis on treatment and preventive psychiatry. It began and continues to operate i n close liaison with the local medical profession. Only physicians can refer pat-ients to the c l i n i c , and the confidential c l i n i c a l reports go directly to the referring physicians. Once the c l i n i c had opened, i t was found that the examination of psychotic types was a minor need compared to the number of children and adults referred for therapy, but not hospitalization. The nitrous oxide technique was relied on heavily i n attempt-ing psychotherapy with patients seen only once every two weeks. It was found patients would gladly come ij.0 miles for such a "treatment," whereas they would find i t d i f f i c u l t to come 10 miles for an "interview." S t a t i s t i c a l information records a total of 76 patients, receiving b% nitrous oxide treatments, and 232 " v i s i t s . " The c l i n i c team i s composed of a psychiatrist, assisted by a psychologist and a social worker, plus volun-teers i n various capacities. Free office and treatment f a c i l i t i e s are provided by the Family Welfare Association and the Sherbrooke General Hospital. Psychological test-ing, social service histories, and case histories by the - 33 -r e f e r r i n g family physician were u t i l i z e d i n a r r i v i n g at a diagnosis, and suitable treatment planning. The public education program met with popular acceptance from the beginning, and i s regarded as a major function of the c l i n i c . It has done much to promote community acceptance and under-standing of psychiatry as applied to the emotional problems of l i v i n g . Included In the program were addresses, f i l m showings, and discussion groups with service clubs, Home and School Associations, Women's In s t i t u t e s , college under-graduates, and Nurses* Associations, i n nine d i f f e r e n t commun-i t i e s . Professional education, not seen o r i g i n a l l y as a func-t i o n of the c l i n i c , became a by-product worth noting. Resident and v i s i t i n g postgraduate students, medical and nursing, v i s i t e d the c l i n i c . Nursing instructresses and supervisors, and s o c i a l service workers attended, as well as medical, nurs-ing and theological groups from the community. Among other things t h i s has proved a stimulus to further extra mural a c t i v i t i e s of the hos p i t a l s t a f f within the are a . 1 I t was f e l t that the res u l t s of t h i s p i l o t project, attempting to serve a large area at a considerable distance from the c l i n i c headquarters, auger well f o r i t s successful ( operation i n smaller communities nearby. Dr. Reed, the Medi-c a l Superintendent, commented by communication with the 1 Reed, G.E., and S i l v e r , A., "The F i r s t T r a v e l l i n g Psy-c h i a t r i c C l i n i c i n Quebec," The American Journal of Psychiatry. V o l . 1 0 8 , No. 9 , March, 1 9 5 2 . - 3k -w r i t e r : We f e e l these v i s i t i n g c l i n i c s are of d i s t i n c t l y l i m i t e d use i n therapy hut quite valuable as an i n i t i a l step i n establishing p s y c h i a t r i c c l i n i c a l services by demon-st r a t i n g what can be done and by an active program of p u b l i c education. I am i n c l i n e d to be very c r i t i c a l of those t r a v e l l i n g c l i n i c s which do not attempt therapy but l i m i t t h e i r work to the examination of referred cases and then make suggestions and recommendations many of which cannot be followed. The other t r a v e l l i n g c l i n i c service operates from The Mental Hygiene I n s t i t u t e , Montreal. This c l i n i c t r a v e l s to an i n s t i t u t i o n f o r delinquent children from broken homes, who have to be placed i n f o s t e r homes or i n s t i t u t i o n s . I t offers both a diagnostic and therapeutic p s y c h i a t r i c service, which includes psychological t e s t i n g of the children, and gives consultation service to the Children's Service Centre of which t h i s r e s i d e n t i a l home i s a p a r t . 2 These two t r a v e l l i n g c l i n i c s are the only ones operating i n Quebec at present. ONTARIO At the present time there are no t r a v e l l i n g c h i l d guidance c l i n i c s i n Ontario. There i s , however, a network of mental health e l i n i c s serving the more densely populated parts of the province. The importance of mental hygiene i n Reed, Dr. Geo., Medical Superintendent, Verdun Protestant Hospital, communication with the writer. 2 By l e t t e r , Baruch Silverman, M.D., Director, Mental Hygiene I n s t i t u t e , 531 Pine Avenue, W., Montreal.. - 35 -community h e a l t h s e r v i c e s was f i r s t o f f i c i a l l y recognized by the Ontario Department of H e a l t h i n 1 9 2 6 , when the Out-Patient Department of the P s y c h i a t r i c H o s p i t a l , Toronto, was opened. The o r g a n i z a t i o n of mental h e a l t h c l i n i c s throughout the province was i n i t i a t e d i n 1 9 3 0 . At the present time there are f u l l - t i m e c l i n i c s and t r a v e l l i n g c l i n i c s o p e r a t i n g i n the d i s t r i c t s served by the Ontario Mental H o s p i t a l s i n London, Hamilton, K i n g s t o n , and B r o c k v i l l e . These serve, i n a d d i t i o n t o t h e i r own area, the p o p u l a t i o n of twenty-two c i t i e s and towns remote from s t a t i o n a r y h o s p i t a l c l i n i c s . I n a d d i t i o n t o these f o u r t r a v e l l i n g c l i n i c teams, Ontario had, In 1 9 5 3 , seven p s y c h i a t r i c u n i t s i n general h o s p i t a l s , seven-teen community o u t - p a t i e n t departments i n mental h o s p i t a l s , and s i x community c l i n i c s operated by m u n i c i p a l h e a l t h depart-ments c h i e f l y f o r c h i l d guidance. 1 The t r a v e l l i n g e l i n l e u n i t s , composed of a team of three members, the p s y c h i a t r i s t , the p s y c h o l o g i s t , and the p s y c h i a t r i c s o c i a l worker, have a r e g u l a r schedule of c l i n i c s i n surrounding general h o s p i t a l s o r p u b l i c h e a l t h u n i t s . A l l appointments f o r these c l i n i c s are made through the l o c a l medical o f f i c e r s of h e a l t h . Cases are r e f e r r e d by: f a m i l y p h y s i c i a n s , p u b l i c h e a l t h and school nurses, teachers, s o c i a l agencies, the c l e r g y , and parents. While the great m a j o r i t y of the p a t i e n t s come w i l l i n g l y t o c l i n i c , there i s a small 1 Department of N a t i o n a l H e a l t h and Welfare, Research D i v i s i o n , Mental H e a l t h S e r v i c e s i n Canada, General S e r i e s Memorandum, No. 6 . , Ottawa, J u l y , 1 9 5 4 , P» H 7 • - 36 -percentage of p a t i e n t s r e f e r r e d by j u v e n i l e , f a m i l y , and magistrate's c o u r t s . The d i a g n o s t i c process i s s i m i l a r to t h a t of the B r i t i s h Columbia Mainland T r a v e l l i n g C h i l d Guidance C l i n i c , which w i l l be set f o r t h i n d e t a i l i n Chapter I I . The suggested treatment may be c a r r i e d out by the r e f e r r i n g p h y s i c i a n o r s o c i a l agency as i n d i c a t e d i n the r e p o r t s they r e c e i v e from the c l i n i c . Some p a t i e n t s and/or r e l a t i v e s may be asked to r e t u r n t o the c l i n i c f o r one or s e v e r a l treatment i n t e r v i e w s . The c l i n i c s make use of a l l the community s o c i a l s e r v i c e f a c i l i t i e s i n h e l p i n g p a t i e n t s w i t h t h e i r i n t e r -p e r s o n a l r e l a t i o n s h i p s . The c l e r g y , the r e c r e a t i o n d i r e c t o r s , the boys*, g i r l s ' and youth group l e a d e r s , and the p u b l i c h e a l t h nurses and s o c i a l agencies are g l a d t o cooperate i n every way p o s s i b l e . The problems presented are v a r i e d i n number. C h i l d -ren's problems could be c l a s s i f i e d under such headings as: educ a t i o n a l maladjustment, j u v e n i l e delinquency, h a b i t d i s -orders, nervousness, mental d e f i c i e n c y , home maladjustment, p h y s i c a l complaints, s o c i a l maladjustments, and miscellaneous problems, i n tha t order of frequency. I n a d d i t i o n t o d e a l i n g d i r e c t l y w i t h these prob-lems, the c l i n i c s are a l s o a c t i v e i n community education i n mental hygiene. Through l e c t u r e s t o home and school a s s o c i a -t i o n s , s e r v i c e c l u b s , groups of s o c i a l workers, nurses, teachers and others, the c l i n i c s t a f f encourage the adoption - 37 -of modern a t t i t u d e s towards mental a b n o r m a l i t i e s and seek to show the reasonableness of t a k i n g a c t i v e steps t o pre-serve mental h e a l t h . L i k e w i s e , through conferences w i t h small groups, the p r a c t i c a b i l i t y of mental h e a l t h proced-ures are being demonstrated and o l d p r e j u d i c e s are being broken down. 1 The d i s t r i c t s served by the t r a v e l l i n g c l i n i c s are as f o l l o w s : The Ontario H o s p i t a l i n K i n g s t o n serves K i n g s t o n , B e l l e v i l l e , P e r t h , Almonte, Renfrew and Penbroke. S e r v i c e s to Hamilton, Guelph, Wentworth, Simcoe, H i l t o n , B r a n t f o r d , Shelburne, and D u n n v i l l e are extended by the Ontario Hos-p i t a l i n Hamilton. B r o c k v l l l e , Ottawa, Cornwall, A l f r e d and H o r r l s b u r g are v i s i t e d by B r o c k v l l l e Ontario H o s p i t a l team. The Ontario H o s p i t a l i n London extends t r a v e l l i n g c l i n i c s e r v i c e s to London, S a r n i a , Woodstock, Chatham, Windsor, S t r a t f o r d , and Owen Sound. An e x t r a c t from a l e t t e r r e c e i v e d from Dr. G.E. Jenk i n s , D i r e c t o r , Mental H e a l t h C l i n i c , London, Ontario, ' gives a p i c t u r e of the c l i n i c a l schedules: Our c l i n i c h o l d s a formal h a l f - d a y s e s s i o n every Monday afternoon i n V i c t o r i a H o s p i t a l , London, Out-p a t i e n t Department, and i n London we see r e t u r n cases f o r therapy on Tuesdays and F r i d a y s . I n the past we have h e l d c l i n i c s out of town at Chatham, twice a month, Windsor, twice a month, Owen Sound, 1 B r i l l i n g e r , H. Roy, "The Mental H e a l t h C l i n i c i n the Community," Ontario Medical Review. Mental H e a l t h , Novem-ber, 1 9 5 2 , jp. Ij.08. - 38 -S a r n i a , S t r a t f o r d , and Woodstock, each once a month. Appointments f o r the out-of-town c l i n i c s are made e i t h e r by the h o s p i t a l a d m i t t i n g department i f we h o l d a c l i n i c i n a h o s p i t a l o r by the Me d i c a l O f f i c e r of Health's o f f i c e i f the c l i n i c i s h e l d t h e r e , as i t i s i n Chatham, S a r n i a , Owen Sound and Woodstock. I n many of the centers we have a great d e a l of help from the l o c a l P u b l i c H e a l t h Nurses i n gat h e r i n g h i s t o r i e s , p r e p a r i n g p a t i e n t s f o r c l i n i c , and i n f o l l o w i n g up our recommendations. Owing t o the wide area covered by t h i s c l i n i c , an area which extends 150 m i l e s or so i n both d i r e c t i o n s , we have not, up to now, had very much chance t o car r y on long-term therapy. I t would appear t h a t , although these c l i n i c s oper-ate from mental h o s p i t a l bases, t h e i r f u n c t i o n s , goals and l i a i s o n s more c l o s e l y approximate those of c h i l d guidance, than i s seen i n the Quebec p i c t u r e . There i s a c l o s e r l i a i s o n w i t h the l o c a l medical p r o f e s s i o n than i s seen i n B r i t i s h Columbia. . MANITOBA There are no t r a v e l l i n g c h i l d guidance c l i n i c s i n Manitoba. S t a t i o n a r y c h i l d guidance c l i n i c s are operat-i n g i n Winnipeg, Brandon, and S e l k i r k . A t r a v e l l i n g c l i n i c from Brandon provides c l i n i c a l mental h e a l t h s e r v i c e s i n Mlnnedosa, Neepawa, Dauphin, V i r d e n , R i v e r s , F l i n F l o n , The Pas, and S o u r i s . S e r v i c e s provided i n c l u d e psychometric and c l i n i c a l t e s t i n g . The c l i n i c s are conducted by personnel from the Brandon H o s p i t a l f o r Mental Diseases. From the i n f o r m a t i o n a v a i l a b l e , there i s no i n d i c a t i o n of the t o t a l a c t i v i t i e s of these c l i n i c s ; but from the Mental H e a l t h S e r v i c e s i n - 39 -Canada r e p o r t , one gathers t h a t s t a f f l i m i t a t i o n s have cur-t a i l e d the a c t i v i t y c o n s i d e r a b l y . SASKATCHEWAN There are no t r a v e l l i n g c h i l d guidance c l i n i c s o perating i n Saskatchewan at present. The Department of P u b l i c H e a l t h does, however, maintain three f u l l - t i m e mental h e a l t h c l i n i c s l o c a t e d at Regina, Saskatoon, and Moose Jaw. Each employes two f u l l - t i m e p s y c h i a t r i s t s , a p s y c h o l o g i s t , two s o c i a l workers, and s e c r e t a r i a l a s s i s t a n t s . When a v a i l a b l e speech t h e r a p i s t s are i n c l u d e d . The s t a t e d f u n c t -ions of these c l i n i c s a r e: (1) To provide a c o n s u l t a t i v e and d i a g n o s t i c s e r v i c e t o r e f e r r i n g p h y s i c i a n s and s o c i a l agencies. There i s r i g i d adherence t o the p o l i c y of accepting o n l y references from f a m i l y p h y s i c i a n s , except i n the case of wards of the Depart-ment of S o c i a l Welfare. P u b l i c h e a l t h nurses, teachers, s o c i a l workers, and others wishing t o r e f e r p s y c h i a t r i c prob-lems, may do so through the p a t i e n t ' s f a m i l y p h y s i c i a n . (2) Therapeutic s e r v i c e s - s e l e c t e d p a t i e n t s , both c h i l d r e n and a d u l t s , are given therapy on an ou t - p a t i e n t b a s i s . (3) E d u c a t i o n a l s e r v i c e s - the c l i n i c through i t s contacts w i t h community agencies and other personnel, attempts t o promote the acceptance of mental h e a l t h p r i n c i p l e s . These contacts i n c l u d e p u b l i c h e a l t h nurses, s o c i a l workers, teachers, and other community l e a d e r s . The e d u c a t i o n a l - 14.0 -program takes the form of case conferences, seminars, and i n s t i t u t e s . S i x p art-time c l i n i c s are conducted weekly, twice monthly, or monthly, depending on need and f a c i l i t i e s a v a i l -a b l e , i n Yorkton, S w i f t Current, P r i n c e A l b e r t , Weyburn, A s s i n i b o i a , and North B a t t l e f o r d . They are s t a f f e d by personnel from the mental hos-p i t a l , the Munroe Wing of the Regina General H o s p i t a l , and the f u l l time mental h e a l t h c l i n i c s . T h e i r f u n c t i o n i s p r i m a r i l y d i a g n o s t i c and c o n s u l t a t i v e . A l l p a t i e n t s seen are r e f e r r e d by p h y s i c i a n s or the department of S o c i a l Wel-f a r e . A few p a t i e n t s are c a r r i e d on a treatment b a s i s , although t h i s i s n e c e s s a r i l y l i m i t e d . The community con-t a c t s provide some b a s i s f o r community e d u c a t i o n . 1 I n a d d i -t i o n , o u t - p a t i e n t s e r v i c e s were provided by the p s y c h i a t r i c h o s p i t a l i n Regina, (the Munroe Wing), and a c h i l d guidance s e r v i c e was operated by the Regina School Board. Of i n t e r e s t t o t h i s study are the teacher psycho-l o g i s t s a s s o c i a t e d w i t h the h e a l t h r e g i o n s — o n e i n Weyburn, one i n S w i f t Current, and one i n Regina. These are teachers who have r e c e i v e d a one year post-graduate t r a i n i n g course i n mental hygiene, conducted by the Canadian Mental H e a l t h A s s o c i a t i o n , i n co-operation w i t h the U n i v e r s i t y of Toronto. I t i s the r e s p o n s i b i l i t y of the teacher p s y c h o l o g i s t s t o conduct an i n - s e r v i c e t r a i n i n g program i n mental hygiene w i t h school teachers i n t h e i r areas. The main purpose of t h i s 1 Department of P u b l i c Health, Province of Saskatchewan, An O u t l i n e of P s y c h i a t r i c S e r v i c e s . June, 195k • - L]l -program I s t o help the teachers g a i n a b e t t e r i n s i g h t i n t o the behavior of c h i l d r e n , and by so doing, t o promote the healthy growth and development of the c h i l d r e n i n t h e i r classrooms. The program i s c a r r i e d out through conferences w i t h groups of teachers on i n d i v i d u a l c h i l d r e n , and through i n d i v i d u a l i n f o r m a l d i s c u s s i o n s w i t h each teacher on s p e c i a l problems she may have i n her classroom. ALBERTA A l b e r t a has had an a c t i v e system of c h i l d guidance c l i n i c s since 1929. T h e i r P r o v i n c i a l Guidance C l i n i c s are c a r r i e d on under the auspices of the Department of P u b l i c H ealth. The c l i n i c s began i n 1929 i n Edmonton, Calgary, and Eethbridge. The f i r s t Mental Hygiene C l i n i c s i n A l b e r t a were i n i t i a t e d by Dr. F i t z p a t r i c k who was then the Super-intendent of the P r o v i n c i a l Mental I n s t i t u t e at Edmonton. This l a t e r became the P r o v i n c i a l Guidance C l i n i c s . The p r o f e s s i o n a l s t a f f of a p s y c h i a t r i s t , p s y c h o l o g i s t , and s o c i a l worker were f o r many years borrowed from one o f the Mental H o s p i t a l s . The C l i n i c Team t r a v e l l e d to the l a r g e r centres of p o p u l a t i o n p e r i o d i c a l l y and provided a d i a g n o s t i c and c o n s u l t a t i o n s e r v i c e f o r persons r e f e r r e d by the Medi c a l p r a c t i t i o n e r s , s chools, and s o c i a l agencies. I n 1947, the f i r s t Guidance C l i n i c w i t h a f u l l -time s t a f f of p s y c h i a t r i s t , p s y c h o l o g i s t and s o c i a l worker and s t e n o g r a p h e r - r e c e p t i o n i s t , was e s t a b l i s h e d i n the c i t y - k2 -of Calgary. This team was to provide service f o r the southern part of the province, v i s i t i n g the c i t i e s of Leth-bridge and Medicine Hat on regular schedules, and other centres on request. In 19i+8, a Guidance C l i n i c with s i m i l a r f u l l - t i m e s t a f f was provided, with headquarters i n the c i t y of Edmon-ton, to service the northern part of the province. The central part of the province i s serviced by part time c l i n i c s , provided by the s t a f f of the P r o v i n c i a l Mental Hospital at Ponoka and the s t a f f of the P r o v i n c i a l Training School at Red Deer. I t i s usual f o r regular c l i n i c s to be held at key or f o c a l points i n each zone. For example, i n the northern zone (Edmonton) regular c l i n i c s are held every two months at Wetaskiwin, V e g r e v i l l e , Vermilion, Holden, Wainwright, and Westlock, and twice a year at Athabasca, Two H i l l s , St. Paul, and Bonnyville. In addition, the c l i n i c team from Edmonton v i s i t s the Peace River D i s t r i c t f o r a series of c l i n i c s over a two week period each year. The system of t r a v e l l i n g c l i n i c s had been extended, by 13S\» to include twenty-two centres. In addition to the three Regional Guidance C l i n i c Headquarters already estab-l i s h e d i n Edmonton, Calgary and Red Deer, i t i s planned to locate other teams at strategic points, u n t i l there are f i v e or six such i n the province. - 43 -The f u n c t i o n s of the c l i n i c s i n the r u r a l areas to which the c l i n i c s t r a v e l are e s s e n t i a l l y d i a g n o s t i c and con-s u l t a t i v e i n nature. The c l i n i c s work i n clo s e co-operation w i t h H e a l t h U n i t s , which provide h e a l t h s e r v i c e s to schools. In areas where there are no h e a l t h u n i t s , the c l i n i c s work i n close co-operation w i t h school superintendents, school p r i n c i p a l s and teachers, as w e l l as w i t h medical p r a c t i t i o n e r s and s o c i a l agencies working w i t h c h i l d r e n , such as W e l l Baby C l i n i c s , C h i l d Welfare Departments, and J u v e n i l e Courts. I n 1952, of persons examined by the c l i n i c s : 45*4$ were r e f e r r e d by schools 21.3% were r e f e r r e d by Community agencies 17.6# were r e f e r r e d by medical p r a c t i t i o n e r s 12.4# were s e l f - r e f e r r e d 3.3% came from other s e r v i c e s . The problems of persons examined by the c l i n i c s cover the whole range of p e r s o n a l i t y d i f f i c u l t i e s . I n 1952, 1,801 persons were examined or t r e a t e d by the Guidance C l i n i c s . Of these, 22.1% were mental d e f e c t i v e s , 21.9/6 were education problems w i t h adequate intellect , 1 1 5 6 were emotional d i s o r d e r s , 5.1/6 showed a n t i - s o c i a l t r e n d s , 4*9/6 were d i s -orders o f speech, 4*3/6 were e p i l e p t i c , p s y c h o t i c , or Involved i n sexual d i f f i c u l t i e s , 4*2/6 were psychoneurotics* The c l i n i c a l procedure i s s i m i l a r t o th a t i n the B r i t i s h Columbia Mainland T r a v e l l i n g C l i n i c , except t h a t the s o c i a l h i s t o r y i n f o r m a t i o n i s gained by the c l i n i c s o c i a l worker on the day of the f u l l c l i n i c examination. Confer-ences are h e l d at the end of the c l i n i c day w i t h the r e f e r r i n g - kk -persons and c l i n i c s t a f f , i n which the cases examined are reviewed and the recommendations f o r management of the problem are d i s c u s s e d . W r i t t e n r e p o r t s are a l s o sent to the r e f e r r a l source, g i v i n g an o u t l i n e of the problem, the c h i l d ' s a b i l i t i e s , and the recommendations f o r management of the problem. In the follow-up s t u d i e s , there has been substant-i a l improvement i n a l a r g e percentage of even those cases who were contacted only once, whereas 75$ of those c a r r i e d i n treatment (at the s t a t i o n a r y centres) have shown d i s t i n c t b e n e f i t . P u b l i c education i n Mental Health i s another f u n c t -i o n of the A l b e r t a Guidance C l i n i c s . A great d e a l o f work i s done i n t a l k s to home and school o r g a n i z a t i o n s , s e r v i c e c l u b s , women's o r g a n i z a t i o n s , l e c t u r e s to t e a c h e r s - i n - t r a i n i n g , and medical and n u r s i n g students. As a r e s u l t , p u b l i c accept-ance of the c l i n i c service and of p s y c h o l o g i c a l and psy-c h i a t r i c treatment of p e r s o n a l i t y d i f f i c u l t i e s has i n c r e a s e d . In summary, i t would appear that t r a v e l l i n g c h i l d guidance c l i n i c s , as such, are at present operating only In A l b e r t a and B r i t i s h Columbia. Mental H e a l t h c l i n i c s are seen i n a l l p r o v i n c e s , under the p r o v i n c i a l departments of mental h e a l t h , i n the form of c l i n i c s attached to a mental h o s p i t a l s e r v i c e , and of community c l i n i c s . These c l i n i c s f r e q u e n t l y o f f e r t r a v e l l i n g c l i n i c s e r v i c e s of a l i m i t e d n a t u r e , and g e n e r a l l y Include some c h i l d guidance s e r v i c e s . I n a l l , much emphasis i s on p u b l i c mental h e a l t h education, as w e l l as on the s p e c i f i c d i a g n o s t i c , c o n s u l t a t i v e and th e r a p e u t i c f u n c t i o n s of the c l i n i c s . These s e r v i c e s are r e l a t i v e l y new, and are s t i l l I n the process of d e f i n i n g f u t u r e goals and s e r v i c e s arid of awakening and determining the need of such p s y c h i a t r i c s e r v i c e s i n the communities served. The tre n d of community-clinic l i a i s o n s i s d i r e c t l y r e l a t e d to the nature of the o r i g i n a l source of the s e r v i c e , so t h a t i n some provinces the main l i a i s o n i s w i t h the l o c a l medical p r o f e s s i o n — n o t a b l y i n Quebec and Saskatchewan. I n Manitoba, A l b e r t a , and Ont a r i o , the c l i n i c s are c l o s e l y a s s o c i a t e d w i t h the l o c a l p h y s i c i a n and h e a l t h departments, but a l s o have c l o s e r e l a t i o n s h i p s w i t h schools and w i t h s o c i a l agencies. I n P r i n c e Edward I s l a n d , an a c c e l e r a t e d mental h e a l t h education program u t i l i z i n g the s e r v i c e s of a guidance c o n s u l t a n t , has pl a c e d emphasis on l i a i s o n w i t h h e a l t h , welfare, and e d u c a t i o n a l personnel, p a r t i c u l a r l y the l a t t e r , p r i o r to the establishment of f u l l t r a v e l l i n g c l i n i c f a c i l i t i e s , when a v a i l a b l e . Although B r i t i s h Columbia and A l b e r t a are the only two provinces as y et u t i l i z i n g t r a v e l l i n g c h i l d guidance c l i n i c teams, there are i n d i c a t i o n s t h a t the other p r o v i n c e s may, i n time, e i t h e r e s t a b l i s h s i m i l a r s e r v i c e s , o r substant-i a l l y increase the p r o p o r t i o n of e x i s t i n g t r a v e l l i n g c l i n i c s e r v i c e s f o r c h i l d r e n . Each province has an extensive p u b l i c -ij.6 -and p r o f e s s i o n a l menta l h e a l t h e d u c a t i o n program which shou ld r e s u l t i n f u r t h e r demand f o r p s y c h i a t r i c s e r v i c e s f o r c h i l d r e n . IV. T r a v e l l i n g C h i l d Guidance C l i n i c s i n B r i t i s h Co lumbia H i s t o r i c a l Background and Development to Date C h i l d Guidance C l i n i c s , under p r o v i n c i a l a u s p i c e s , have been o p e r a t i n g i n B r i t i s h Co lumbia s i n c e J u l y 15, 1932. The f i r s t c l i n i c was opened on a p a r t t ime b a s i s , f o l l o w i n g a r eques t by the P r o v i n c i a l P s y c h i a t r i s t , D r . A . L . C r e a s e , t o the N a t i o n a l Committee f o r Men ta l Hygiene f o r h e l p In a program o f p r e v e n t i o n o f menta l i l l n e s s . The Committee was i n s t r u m e n t a l i n o b t a i n i n g the s e r v i c e s o f the f i r s t p s y c h i a -t r i c s o c i a l worker , M i ss Joseph ine K i l b u r n . I t was r e a l i z e d t ha t though advanced work was b e i n g done w i t h c h i l d r e n i n the f i e l d s o f h e a l t h , e d u c a t i o n and s o c i a l w e l f a r e , these a c t i v i t i e s were, w i t h a few e x c e p t i o n s , u n c o o r d i n a t e d ; each group l i m i t e d i t s study to one phase o f the c h i l d , t r e a t i n g him e i t h e r as a mind t o be educa t ed , a p h y s i c a l o rgan ism t o be sa f egua rded , a dependent t o be s u p p o r t e d , or an o f f e n d e r to be d i s c i p l i n e d . In s p i t e o f the e x c e l l e n t work I n the i n d i v i d u a l f i e l d s , the re were obv ious gaps , o v e r l a p p i n g , and c o n t r a d i c t i o n o f methods. The need o f c o o r d i n a t i n g the m e d i c a l , p s y c h i a t r i c , p s y c h o l o g i c a l and s o c i a l approaches t o c h i l d r e n ' s p rob l ems , o f s e e i n g the c h i l d as a whole r a t h e r than as j u s t a s p e c i f i c p rob l em , was r e c o g n i z e d g e n e r a l l y on t h i s c o n t i n e n t . With t h i s goal i n mind, the o r i g i n a l Vancouver C h i l d Guidance C l i n i c was e s t a b l i s h e d , at f i r s t on a part-time b a s i s . The system of c h i l d guidance c l i n i c s now extends over a wide area of the p r o v i n c e , and i n c l u d e s two t r a v e l l i n g c l i n i c teams w i t h headquarters i n the two s t a t i o n a r y c l i n i c s i n Vancouver and V i c t o r i a ; and c u r r e n t l y covers a t o t a l of twenty-four s e m i - r u r a l centres. The o r i g i n a l c l i n i c was h e l d at 771 Hornby S t r e e t , Vancouver, on a weekly b a s i s . The Vancouver c l i n i c s t a f f c o n s i s t e d of Dr. Crease and Miss K i l b u m , p l u s a nurse and stenographer from the Essondale P r o v i n c i a l Mental H o s p i t a l s t a f f . Miss K i l b u m a l s o d i d the psychometries. An a d d i t -i o n a l p s y c h i a t r i c s o c i a l worker was i n c l u d e d on c l i n i c days. V i s i t s to V i c t o r i a f o r one f u l l day a month were i n i t i a t e d on September 2, 193^. G i r l s ' and Boys' I n d u s t r i a l School examinations were a l s o begun i n t h i s year. The V i c -t o r i a c l i n i c s were increased i n 1935 t o two f u l l days a month; and i n t h i s year i n i t i a l c l i n i c s were h e l d i n Nanaimo, Cour-tenay, A l b e r n i , and C h i l l i w a c k . A p u b l i c h e a l t h nurse was appointed to the s t a f f i n 1936. The c l i n i c was, by 1937, operating p r a c t i c a l l y f u l l time i n Vancouver, w i t h a s t a f f of one p s y c h i a t r i s t , one p s y c h o l o g i s t (appointed i n 1937), two s o c i a l workers and a p u b l i c h e a l t h nurse. The c l i n i c was at t h i s time handling cases f o r other agencies on a d i a g n o s t i c b a s i s w i t h recommendations. - 48 -The s e r v i c e s s l o w l y expanded from t h i s p o i n t . I n 1939-1940, the t r a v e l l i n g team was v i s i t i n g New Westminster twice a month, a l t e r n a t i n g w i t h C h i l l l w a c k . The need o f widening the scope of the C h i l d Guidance C l i n i c through extension of t r a v e l l i n g c l i n i c s e r v i c e s and of i t s c o n s u l t -a t i v e and community education s e r v i c e s was recognized throughout the war yea r s . The Annual Reports r e v e a l i n -creased community r e c o g n i t i o n and c o n s t r u c t i v e use of C l i n i c s e r v i c e s i n the e a r l y 1940*8. R e f e r r a l s from p r i v a t e p h y s i c i a n s , m a g i s t r a t e s , and key members of s o c i a l agencies, i n d i c a t e d that "the c i t i z e n s , p r o f e s s i o n a l , and n o n - p r o f e s s i o n a l are r e a l i z i n g the value of a p s y c h i a t r i c s e r v i c e i n the d a i l y problems a r i s i n g from t h e i r general contact w i t h t h e i r f e l l o w -men. n l The e d u c a t i o n a l aspects o f c l i n i c f u n c t i o n i n c r e a s e d , w i t h considerable teaching and o r i e n t a t i o n being g i v e n t o s o c i a l s e r v i c e and n u r s i n g students, l e a d i n g t o t h e i r more mature understanding of the value o f the Mental Hygiene prog-ram, and of the f u n c t i o n s of the C h i l d Guidance C l i n i c . F i e l d v i s i t o r s i n S o c i a l Welfare Branch, I n those d i s t r i c t s not served d i r e c t l y by the c l i n i c , g r a d u a l l y , through correspondence, made more use of c l i n i c s e r v i c e s . The v i s i t o r s , r e c o g n i z i n g problems, prepared and forwarded 1 Department of P r o v i n c i a l S e c r e t a r y , Mental H e a l t h Ser-v i c e , Province of B r i t i s h Columbia, Annual Report. 19k0-kl. p. N19. - k9 -t o C h i l d Guidance C l i n i c Vancouver o f f i c e f u l l h i s t o r i e s of these cases, r e q u e s t i n g c o n s i d e r a t i o n and advice. Where i t seemed e s s e n t i a l f o r a complete examination, the p a t i e n t was presented to the nearest l o c a l c l i n i c . I n t h i s way, the c l i n i c s e r v i c e d i d reach f u r t h e r a f i e l d . This incomplete s e r v i c e was recognized, however, as p o i n t i n g t o the n e c e s s i t y of f u l l c l i n i c f a c i l i t i e s i n c e r t a i n areas of concentrated p o p u l a t i o n . The T r a v e l l i n g C l i n i c s maintained t h e i r contact throughout the war years w i t h V i c t o r i a , Nanaimo, Courtenay, Hew Westminster, and C h i l l i w a c k . I t was impossible t o broaden c l i n i c a l s e r v i c e s to outside d i s t r i c t s other than through correspondence; but correspondence w i t h teachers, d o c t o r s , s o c i a l workers, et c e t e r a , throughout the p r o v i n c e , i n d i c a t e d how a c u t e l y a f u l l - t i m e t r a v e l l i n g c l i n i c was needed, once the personnel was a v a i l a b l e . The establishment of such a t r a v e l l i n g c l i n i c became a major post-war g o a l . There were two d i f f i c u l t i e s t h a t needed t o be over-come i n meeting the needs of the province by extending and improving c l i n i c s , namely, geographic and personnel. I t was f e l t t hat adequate coverage w i t h i n the standards recommended by the American P s y c h i a t r i c A s s o c i a t i o n could be provided by f o u r p s y c h i a t r i c teams. Each team would c o n s i s t of one p s y c h i a t r i s t w i t h s p e c i a l t r a i n i n g i n c h i l d p s y c h i a t r y , two c l i n i c a l p s y c h o l o g i s t s , f o u r p s y c h i a t r i c s o c i a l workers, i n c l u d i n g a casework s u p e r v i s o r and necessary c l e r i c a l h e l p . - 50 -With the a c q u i s i t i o n of a d d i t i o n a l t r a i n e d personnel t o com-p l e t e f o u r p s y c h i a t r i c teams, i t was planned t o s t a t i o n one team i n V i c t o r i a to serve the Lower Mainland area, and the f o u r t h team would act as a t r a v e l l i n g team t o cover the r e s t of the p r o v i n c e . Thus a d e f i n i t e g o a l was e s t a b l i s h e d , i n r e c o g n i t i o n of the geographic needs of the e n t i r e p r o v i n c e . The need of making c h i l d guidance s e r v i c e s more a c c e s s i b l e t o those outside of the concentrated urban p o p u l a t i o n i n the southwestern t i p of the province was recognized as immediate. As personnel requirements were met, t r a v e l l i n g c l i n i c s e r -v i c e s expanded r a p i d l y . The s t a t i o n a r y c l i n i c moved i n 1942 t o i t s present l o c a t i o n at 455 West T h i r t e e n t h Avenue. A Vancouver c l i n i c s o c i a l worker was, i n 1944, p l a c e d I n the V i c t o r i a C l i n i c on a f u l l - t i m e b a s i s . During the p e r i o d 1942-46, s e r v i c e s con-t i n u e d at t h i s l e v e l . Dr. Crease was not always at C h i l d Guidance C l i n i c , but another p s y c h i a t r i s t attended i n h i s absence. U s u a l l y he was accompanied by a p s y c h i a t r i s t from the P r o v i n c i a l Mental H o s p i t a l , p a r t i c u l a r l y i n t e r e s t e d i n o r i e n t a t i o n i n c h i l d p s y c h i a t r y . The appointment of Dr. U.P. Byrne as D i r e c t o r of C l i n i c s , i n December, 1945, was the beginning of r e a l expan-s i o n i n both s t a t i o n a r y and t r a v e l l i n g c l i n i c s . With the appointment of the f i r s t i n t e r n e i n c l i n i c a l psychology t o the c l i n i c , and the appointment of Dr. Gordon K i r k p a t r i c k as the second c l i n i c a l p s y c h i a t r i s t , the t r a v e l l i n g c l i n i c s - 51 -were then f r e e to r e a l l y move, by reason of adequate s t a f f i n g . The f o l l o w i n g i n i t i a l c l i n i c s were h e l d over the next few years to present date: 194° ~ P e n t i c t o n , Vernon, Nelson, P r i n c e Rupert and P r i n c e George, w i t h f u l l c l i n i c s at C h i l d -ren's H o s p i t a l a l s o beginning; In 1947 - Cranbrook, Kamloops, Creston; 1948 - Salmon Arm, T r a i l ; 1949 - Nakusp, Powell R i v e r , and M u r r a y v i l l e . The s e r v i c e s c o n s i s t e d of p r e l i m i n -ary i n t r o d u c t i v e work p r i m a r i l y , mainly d i a g n o s t i c , c o n s u l t -a t i v e , and educative, and were o f f e r e d at the request of the community. Great i n t e r e s t was shown wherever the c l i n i c s were h e l d . Once the i n i t i a l contact was made, s e r v i c e s were continued, as f r e q u e n t l y as needed and requested by the com-munity - g e n e r a l l y once or twice y e a r l y . As demand f o r s e r v i c e s i n c r e a s e d , a d d i t i o n a l s t a f f was r e q u i r e d to meet the demand. The house next to 455 West 13th Avenue was purchased i n March, 1949, thus e n l a r g i n g c l i n i c a l f a c i l i t i e s c o n s iderably. The f i l m " F r i e n d at the Door" was r e l e a s e d i n 1949, and the ways i n which C h i l d Guid-ance C l i n i c could be h e l p f u l t o the v a r i o u s s o c i a l agencies were presented, f o r the f i r s t time by means other than word-of-mouth. The a d d i t i o n s to the t r a v e l l i n g c l i n i c l i s t con-t i n u e d , w i t h Grand Forks, Dawson Creek, Vanderhoof, Kelowna, and Quesnel being v i s i t e d i n i t i a l l y i n 1951* The more exten-s i v e use of t r a v e l l i n g c l i n i c s i n a l l the main centres of B r i t i s h Columbia made i t necessary at t h i s time to appoint a s o c i a l worker to g i v e f u l l time to the work of the t r a v e l l i n g - 52 -c l i n i c team. In addition, the t r a v e l l i n g c l i n i c s on Van-couver Island were f o r the f i r s t time sent out from V i c t o r i a rather than Vancouver. Also i n t h i s year, the f i r s t pre-c l i n i c a l conference was held at the University u n i t of the c l i n i c . In response to a pressing demand f o r her services, a speech therapist was appointed on January 21 , 1952. She covered Woodlands School and the Children's Hospital, i n addition to her c l i n i c caseload. She also was a v a i l a b l e , at the request of the community, on the t r a v e l l i n g c l i n i c . P u l l c l i n i c s were commenced at Child Health Centre, Western Society f o r Physical R e h a b i l i t a t i o n Centre, and at the University of B r i t i s h Columbia u n i t . Dr. Valens was appointed i n May, 1952, as f u l l - t i m e p s y c h i a t r i s t i n V i c t o r i a . The V i c t o r i a Child Guidance C l i n i c was therefore staffed by a p s y c h i a t r i s t and a s o c i a l worker on a f u l l - t i m e basis. The f i r s t c l i n i c was held at the Preventorium and at Terrace i n July, 1953. I n i t i a l c l i n i c s were held i n 1954 at Eadner, Ocean P a l l s , Campbell River and Port St. John. Also, i n 1954* construction was started on the long-awaited Child Guidance C l i n i c i n Burnaby and upon i t s completion, adequate f a c i l i t i e s w i l l f o r the f i r s t time be av a i l a b l e . Table 1 presents the t o t a l t r a v e l l i n g c l i n i c a c t i v -i t y f o r the year 1953-54* and indicates the extensiveness of the service. Table 1. Summary of B r i t i s h Columbia Mainland T r a v e l l i n g C h i l d Guidance C l i n i c A c t i v i t y .  A p r i l 1. 1953 t o March 31. 195k Mainland T r a v e l l i n g C l i n i c s Abbotsford o % •rl rH rH • H a Cloverdale J M o o h a h O Creston i Dawson Creek j Grand Porks Haney | Kamloops kelowna 9 a rt Mission j c o 01 rH CD *5 Penticton Powell River [prince George Prince Rupert Quesnel I [Salmon Arm I Lsmithers 1 i Terrace | [Trail Vernon Williams Lake TOTALS No.of c l i n i c s h e l d ( & ) 1 3 1 2 2 1 2 k k k 1 1 3 3 3 5 1 2 2 1 7 6 1 65 P h y s i c a l s 4 11 4 6 8 1 6 Ik 13 10 2 3 8 14 9 7 14 2 7 4 3 19 14 2 185 U r i n a l y s i s - 3 - 1 6 1 2 1 - k 3 - 2 4 9 5 - 2 - - - 9 - 2 55 Playroom Observation - 8 - - - 1 - k - - - - - - 10 8 mm 1 - - - 10 - 1 43 Agency Case Conferences 4 12 4 6 8 1 6 16 13 12 3 3 9 19 10 8 14 3 7 4 3 20 24 4 213 Consulting " " - 1 - 1 - 1 - - 1 3 1 - 1 - --. 3 - - 2 -• 2 2 - 18 P r i v a t e " " -P s y c h i a t r i c I n t e r v i e w s 7 26 8 i k Ik 1 11 37 26 21 7 9 16 35 21 23 27 5 14 9 6 ^6 47 8 438 P r e - C l i n i c Conferences - -i a ' Refers t o the number of c l i n i c days. Sourcet Department of P r o v i n c i a l S e c r e t a r y , Mental Health S e r v i c e s . Province of B r i t i s h Columbia, Annual Report, 1954, P» R237. - 53 -The preceding m a t e r i a l gives a general p i c t u r e of the B r i t i s h Columbia T r a v e l l i n g C l i n i c s , and the expansion i n the demand f o r C h i l d Guidance C l i n i c s e r v i c e s i n the r u r a l areas. A l l t h i s d i d not " j u s t happen," but came about through the co-operative and educative aspects of c l i n i c f u n c t i o n , and by meeting the community at the l e v e l of i t s request f o r s e r v i c e , g r a d u a l l y working toward more broad, c o n s t r u c t i v e and r e a l i s t i c use of c l i n i c a l s e r v i c e s . Purpose and P l a n of the Study The purpose of t h i s t h e s i s i s to make an e x p l o r -atory study of the B r i t i s h Columbia Mainland T r a v e l l i n g C h i l d Guidance C l i n i c which operates out o f Vancouver. One of the main goals i s a more d e f i n i t i v e statement and c l a r i f i c a t i o n of the current f u n c t i o n s and s e r v i c e s of the c l i n i c . This i s o f f e r e d : (1) as a base f o r f u r t h e r study; (2) i n the b e l i e f t h a t "many problems disappear when the c l i n i c s can c l e a r l y set f o r t h , f o r themselves and  f o r the community, t h e i r concepts of t h e i r f u n c t i o n . " 1 I n order to understand the l o c a l t r a v e l l i n g c l i n i c ' s present f u n c t i o n i n g and stage of development, i t i s necessary to see i t i n p e r s p e c t i v e . A study of current l i t e r a t u r e w i l l be made, t h e r e f o r e , as to the u n d e r l y i n g theory and assumptions, 1 Witmer, H. L., op. b i t . , p. 256. - 54 -the h i s t o r i c a l development, and current problems and function-ing of t r a v e l l i n g c h i l d guidance c l i n i c s generally on t h i s continent. A survey of t r a v e l l i n g c h i l d guidance c l i n i c ser-vices i n Canada w i l l be presented, from material compiled from r e p l i e s to l e t t e r s 1 sent out to various c l i n i c s across Canada, and to the p r o v i n c i a l d irectors of Mental Health Ser-vices. The h i s t o r i c a l background and development to date of the l o c a l t r a v e l l i n g c l i n i c w i l l be compiled through interviews with Dr. U.P. Byrne, c l i n i c a l d i r e c t o r , and 2 through perusal of Annual Reports of the C l i n i c . The above material w i l l serve as a background f o r the main body of the thesis--a study of the purposes of the l o c a l t r a v e l l i n g c l i n i c (Chapter I I ) , and of i t s operation i n the f i e l d (Chapter I I I ) . The former w i l l include: the stated administrative and s t a f f structure and functions of the B r i t i s h Columbia Mainland T r a v e l l i n g Child Guidance C l i n i c ; the stated p o l i c y under which i t operates i n the f i e l d ; the geographical areas and general s o c i a l service structure of the r u r a l communities serviced; and the types of cases the c l i n i c sees as appropriate to i t s function. 1 See Appendix A. 2 Department of the P r o v i n c i a l Secretary, Mental Health Services, Province of B r i t i s h Columbia, Annual Reports, 1932-1954-- 55 -The m a t e r i a l presented w i l l be drawn d i r e c t l y from annual r e p o r t s and other c l i n i c a l documents, p l u s i n t e r v i e w s w i t h the c l i n i c d i r e c t o r and the heads of the v a r i o u s depart-ments w i t h i n the c l i n i c . A t h r e e f o l d approach t o the study of the " c l i n i c i n o p e r a t i o n " w i l l be made, w i t h emphasis upon i n d i c a t i o n of the general trends and community aspects of current t r a v e l l i n g c l i n i c f u n c t i o n , r a t h e r than a d e t a i l e d , a n a l y t i c a l study of s e r v i c e s rendered. F i r s t , a random sample case study of 50 cases seen d u r i n g 1953 w i l l be made. A q u e s t i o n n a i r e 1 w i l l be sent t o a l l S o c i a l Welfare Branch f i e l d o f f i c e s , through which a l l community requests f o r t r a v e l l i n g c l i n i c s e r v i c e are made. The w r i t e r w i l l a l s o i n c l u d e p e r s o n a l i n f o r m a l i n t e r v i e w s w i t h a v a i l a b l e f i e l d casework supervisors and s o c i a l workers. These l a s t two, i n combination, w i l l l e a d to a n e c e s s a r i l y t e n t a t i v e assessment of the response of the f i e l d to the t r a v e l l i n g c l i n i c s e r v i c e s . Any follow-up m a t e r i a l a v a i l a b l e on c l i n i c f i l e s of the sample cases stud-i e d w i l l be u t i l i s e d ; and the general community education a c t i v i t i e s of the team members w i l l a l s o be presented. On the b a s i s of t h i s m a t e r i a l , the f i n d i n g s and i m p l i c a t i o n s of the present study i n r e l a t i o n t o f u t u r e l o c a l t r a v e l l i n g c l i n i c p r a c t i c e w i l l be drawn and presented. I t i s hoped t h i s e x p l o r a t o r y study w i l l be f o l l o w e d by more d e t a i l e d and comprehensive s t u d i e s i n areas of importance, as i n d i c a t e d i n the course of the study. 1 See Appendix B. CHAPTER II THE PURPOSES OP THE BRITISH COLUMBIA MAINLAND TRAVELLING CHILD GUIDANCE CLINIC This chapter w i l l present the stated adminis-t r a t i v e and s t a f f structure and functions of the B r i t i s h Columbia Mainland T r a v e l l i n g Child Guidance C l i n i c . The stated p o l i c y under which i t operates i n the f i e l d w i l l be discussed; also the geographical areas and general s o c i a l services structure of the communities serviced. In addi-t i o n , the types of cases the c l i n i c sees i t s e l f as handling most e f f e c t i v e l y w i l l be reviewed. The material presented i s drawn d i r e c t l y from annual reports and other c l i n i c a l documents, plus interviews with the c l i n i c d i r e c t o r and the heads of the various departments within the c l i n i c . The r e s u l t i n g picture w i l l therefore present the c l i n i c pur-poses and goals, and the means employed to a t t a i n them--as seen from the viewpoint of the c l i n i c i t s e l f . I. Introduction. 1. General Description of the B r i t i s h Columbia  Mainland T r a v e l l i n g Child Guidance C l i n i c The B r i t i s h Columbia Mainland T r a v e l l i n g Child Guidance C l i n i c i s one of the two t r a v e l l i n g Child Guidance C l i n i c s i n B r i t i s h Columbia. I t operates out of the station-- 57 -ary Child Guidance C l i n i c located i n Vancouver at 455 West Thirteenth Avenue and i s made up of a team of f i v e profes-s i o n a l p e o p l e — a p s y c h i a t r i s t , a p s y c h i a t r i c s o c i a l casework supervisor, two psychologists, and a public health nurse "with s p e c i a l t r a i n i n g . 1 * 1 The team v i s i t s , at the request of the l o c a l Health or Welfare Departments or the Schools, a l l the larger centres on the B r i t i s h Columbia Mainland (currently twenty-four communities). As a team, each member has indiv-i d u a l duties so that a c h i l d who i s referred receives a com-plete s o c i a l investigation, a thorough medical examination, a f u l l psychological evaluation and educational survey, and a careful p s y c h i a t r i c study. The team combines psychiatry, psychology and s o c i a l work, as applied to children, i n order to see and treat the c h i l d as a complete person i n an environ-ment—i.e., the concepts of the "team approach" and the "whole c h i l d " are basic to the service extended by the c l i n i c . The c l i n i c carries on a program of primary and secondary preven-t i o n of behaviour and personality disorders i n children, as i s summed up i n the Annual Report of the P r o v i n c i a l Mental Health Services: Each patient highlights the conditions that con-tributed to h i s breakdown. The C l i n i c has the oppor-tunity to help the related agencies i n the community to perform t h e i r mental health functions more e f f e c t -i v e l y . I t does t h i s through consultation with them i n regard to i n d i v i d u a l cases, through designed educ-ation a l a c t i v i t i e s such as lectures and s t a f f discus-sions, and through, i n appropriate cases, considering 1 This w i l l be explained l a t e r i n the s t a f f breakdown. - 5 8 -personnel from these agencies as part of the c l i n i c team working with the patient. Thus the nurse, teacher, s o c i a l worker, probation o f f i c e r and clergy-man may become partners i n the c l i n i c team i n an e f f o r t to meet the needs of an i n d i v i d u a l case. In order to meet community demand f o r service, the c l i n i c team works on a f i x e d schedule. Enabling the team to keep to t h e i r schedule and hence supply the demand emphasizes the importance of integrating c l i n i c a l services with the e x i s t i n g community resources. Also, i t points up the c l i n i c ' s dependence for i t s effectiveness upon agency cooperation i n preparing the s o c i a l history material and the c l i e n t p r i o r to c l i n i c a l evaluation, and In carrying out treatment recom-mendations appropriate to the i n d i v i d u a l case. I t i s impos-s i b l e , with the present c l i n i c a l personnel available and with trained s t a f f shortages i n the f i e l d , to meet community demand f o r i n d i v i d u a l p s y c h i a t r i c service. An e s s e n t i a l part of the t r a v e l l i n g c l i n i c ' s service to the community l i e s , therefore, i n i t s use of the i n d i v i d u a l case study, confer-ence and consultation to enable l o c a l professional personnel to acquire added knowledge, s k i l l s and techniques f o r use i n t h e i r general caseload as well as In the p a r t i c u l a r case under study. The t r a v e l l i n g c l i n i c has, also, a broader objective, that of explaining to the public at large, simple principle's of mental health based on c l i n i c a l f indings. Each c l i n i c represents a p i l o t project or experiment In which the factors that are responsible f o r .the maladjustment of c h i l d -ren are demonstrated. When alerted to i t s i n d i v i d u a l needs, - 59 -the community may then be encouraged and I n d i r e c t l y guided to embark upon a preventive program oi* recognizing and f i l l -ing the gaps i n e x i s t i n g l o c a l health, welfare, educational and recreational resources. S p e c i f i c a l l y , the B r i t i s h Columbia Mainland Tra-v e l l i n g C l i n i c operates as a special consultative group to handle diagnostic problems at the case l e v e l . These cases are then used, i n conjunction with lectures and films to both professional and lay groups, to f u l f i l l the (Clinic's paramount f u n c t i o n - - i t s contribution to the t o t a l mental health needs of the community. Its aim i s to treat the prob-lems presented, using the available community resources i n  the treatment; and through community education methods, to  enable the community to meet more adequately i t s i n d i v i d u a l  needs. 2. Pol i c y and Procedure on T r a v e l l i n g C l i n i c A l l t r a v e l l i n g c l i n i c s are arranged at the re-quest; of the Regional Administrator, or D i s t r i c t Super-visor , of the S o c i a l Welfare Branch, 1 and at the request of the Public Health Units. The Schools, i n p a r t i c u l a r instances where no health or welfare services e x i s t , may ask the C l i n i c team to v i s i t . The agency requesting the c l i n i c Is responsible f o r the physical setting of the c l i n i c s . I f the c l i n i c i s 1 P r o v i n c i a l Department of Health and Welfare. - 60 -a j o i n t one with the Health and Welfare Branches, then the D i s t r i c t Supervisor of the So c i a l Welfare Branch usually assumes t h i s r e s p o n s i b i l i t y . Five rooms are needed f o r the duration of the c l i n i c , and every e f f o r t i s made to avoid interruption of interviews. The c l i n i c s t a f f make t h e i r own arrangements f o r t h e i r hotel accommodations. The choice of cases should preferably be made a f t e r consultation and sharing of information between the Health and Welfare Branches. The Medical Health O f f i c e r or senior nurse i s responsible f o r the attendance of patients and mem-bers of her own s t a f f at c l i n i c s . Whenever possible, the Medical Health O f f i c e r should attend the conference. The D i s t r i c t Supervisor assumes t h i s r e s p o n s i b i l i t y f o r s o c i a l workers and the children whom they are presenting. Five copies of the t r a v e l l i n g c l i n i c schedule are forwarded to the person i n the community who i s responsible f o r making l o c a l arrangements f o r the t r a v e l l i n g c l i n i c s . These are f i l l e d out and four copies are returned to the Vancouver C l i n i c at lea s t a week i n advance of the appoint-ment date. Four copies of the s o c i a l and developmental h i s -t o r i e s f o r each patient (see Appendix C) to be examined by the t r a v e l l i n g c l i n i c team are submitted to the Vancouver c l i n i c a week i n advance of appointment. The f i e l d health and welfare o f f i c e s are informed of the above procedures p r i o r to c l i n i c a l examination. In - 61 -order to prepare the patient f o r the e l i n i c experience, the health and welfare agencies also redeive the following outline as a guide i n preparing the c l i e n t so that he may p a r t i c i p a t e f u l l y and gain maximum benefit from the c l i n -i c a l examinationr 1 No patient or r e l a t i v e should ever be introduced to the c l i n i c without being f u l l y prepared. He needs to be aware of why he i s coming and what w i l l happen when here, and also the part that he plays In making the best use of the c l i n i c f a c i l i t i e s . Patient and r e l a t i v e should know i n advance that examination requires h a l f a day. The c h i l d should have no more excitement than necessary beforehand. For instance, a c h i l d coming to the c l i n i c i n the afternoon should not have dental work i n the morning or attend a c i r c u s . Children coming from long distances should be In town a day or two before examination. Children under three years of age are always examined i n the morning when rested, and i f f e a s i b l e , children under s i x years should also have morning appointments. The following information about c l i n i c procedure w i l l be h e l p f u l i n explaining the routine of the c l i n i c to the c h i l d and h i s parents: On a r r i v a l at the CQC, the c h i l d goes to the playroom where there are toys and books available f o r h i s amusement. He i s seen by the psychologist, who gives the psychometric, personality, aptitude and other tests which are required. The c h i l d has a physical examination and i s l a t e r interviewed by the p s y c h i a t r i s t . The child's parents or guardians are also interviewed by the p s y c h i a t r i s t either separately or together as the case may be. The p s y c h i a t r i s t a l -ways wants to see both parents whenever possible. During the chil d ' s presence i n the c l i n i c , h i s reactions are observed and recorded. The r e l a t i o n s h i p s between the c h i l d and h i s parents, between the parents them-selves, between the c h i l d and other children i n the playroom are also observed. The worker presenting the c h i l d to the c l i n i c should remain with him as the -1 Mimeographed material sent out to each l o c a l Health and Welfare unit from the stationary Vancouver c l i n i c . - 62 -CGG s t a f f cannot accept r e s p o n s i b i l i t y f o r super-v i s i n g the children while i n the waiting room. The presenting worker w i l l be expected to attend and pa r t i c i p a t e i n the conference, at which a l l the findings with respect to the patient are presented. At t h i s time, plans f o r treatment are discussed, the worker p a r t i c i p a t i n g i n the discussion, and i t i s then the r e s p o n s i b i l i t y of the worker interested i n the case to implement the recommendations and treatment plan. The person r e f e r r i n g the case has r e s p o n s i b i l i t y at conference f o r channelling the recommendations toward a plan which i s within the range of available resources. These conferences are scheduled at a conveniently arranged time to a l l concerned, usually a f t e r l\. p.m. The conferences are attended by the members of the c l i n i c team, a l l available members of the Welfare Department and the Health Department, school representatives, p a r t i c u l a r l y the teacher involved, and the probation o f f i c e r i f i n -dicated. The purpose of the conferences i s twofold: 1 1. Evaluation of the problem, with suggestions f o r i t s solution. 2. Teaching by case method, so that those attend-ing learn to draw p a r a l l e l s , and apply the p r i n c i p l e s i n -volved i n other relevant sit u a t i o n s . Non-professional people do not attend these conferences. The material presented i s screened accord-ing to those attending. In some cases, where intimate family d e t a i l s are s i g n i f i c a n t , double conferences are held. Attention should be drawn to the mutuality of r e s p o n s i b i l i t y i n p a r t i c i p a t i o n and contribution, of c l i n i c 1 Dr. Byrne, personal communication with the writer. - 63 -team members and the l o c a l professional person presenting the case, i n a r r i v i n g at a workable treatment plan, geared to the available l o c a l community resources and professional services. I I . Stated Functions The general objectives and functioning of the Tr a v e l l i n g C l i n i c have been discussed, the conclusion being that "the Child Guidance C l i n i c ' s paramount function i s i t s contribution to the t o t a l mental-health needs of the com-munity. I t i s both a s o c i a l and health agency and therefore occupies a unique mediative and coordinative role i n further-ing the concept of integrated community a c t i v i t y i n behalf of the welfare of the i n d i v i d u a l . 1 , 1 The t r a v e l l i n g c l i n i c team i s unable to cope with the pressure of needed i n -d i v i d u a l treatments by i n d i v i d u a l l y directed e f f o r t s as therapists. It therefore u t i l i z e s the professional and non-professional channels within the community to promote broad mental health education, and to awaken the community to the i n d i v i d u a l needs e x i s t i n g i n the rela t e d f i e l d s of s o c i a l service--health, welfare, education and recreation. The stated function of the B r i t i s h Columbia Main-land T r a v e l l i n g Child Guidance C l i n i c Is as f o l l o w s : 2 1 Annual Report, Mental Health Services, Province of B r i t i s h Columbia, 1950-1, p / 078. 2 Ibid., 1947-8, p. 128. - 64 -To study the whole c h i l d ; to give guidance to family and community i n understanding the causes of children's d i f f i c u l t i e s ; to give guidance i n under-standing -the basic needs of children; to give guid-ance to the c h i l d himself i n the l i g h t of h i s needs. This i s accomplished by i t s s p e c i f i c a l l y stated functions: 1. Diagnosis This service i s one i n which the c h i l d and h i s sit u a t i o n has been studied i n whole or i n part, a ps y c h i a t r i c and psychosocial evaluation i s made, and possible solutions to problems contained within these areas then presented. The Child Guidance C l i n i c s , however, have no active part i n the sub-sequent progress of the case. The value of t h i s service depends on the responsible agency being ade-quately equipped to make the s o c i a l study, to make use of the c l i n i c ' s findings, and to carry out the c l i n i c ' s p s y c h i a t r i c recommendations. In the diag-nostic service, treatment i s delegated by the c l i n i c s ' p s y c h i a t r i s t s i n conference to the r e f e r r i n g agency. 3-Diagnosis i s seen not as the beginning of tre a t -ment, but as one of several thoughtful steps i n a treatment process which began with the f i r s t contact at intake. Treat-ment starts when somebody f i r s t r e a l i z e s there i s a problem and decides to do something about i t . In the t r a v e l l i n g c l i n i c s i t u a t i o n , the c l i n i c i s coming into a s i t u a t i o n that has already been prepared, where the patient has had an opportunity to move toward a new experience. The c l i n i c team contributes a s k i l l which consolidates and f o r t i f i e s the treatment movement which has already taken place. I t provides the impetus and the stimulus, a supporting frame-Annual Report, 1947-8, p. 128. - 65 -work and appropriate understanding—but whatever i t prov-ides, the job of treatment i s something which i s done by the patient. This i s p a r t i c u l a r l y v i s i b l e i n the t r a v e l l i n g c l i n i c experience. 1 2. Consultation The use of t h i s service i s undoubtedly one of the most encouraging developments i n the whole ser-vice (of the c l i n i c T . A consultation service i s one In which the c l i n i c s * services are given to any per-son interested i n the c h i l d , but where there may be no actual contact on the part of the c l i n i c s with the c h i l d . S o c i a l and health workers have found i t h e l p f u l to discuss the p s y c h i a t r i c problems of t h e i r c l i e n t s with the p s y c h i a t r i s t and the other members of the c l i n i c s * teams. In o f f e r i n g t h i s service the c l i n i c s assume a very important teaching r o l e . Such teaching i s of necessity focussed on the i n -d i v i d u a l case presented by the agency and on the psy-c h i a t r i c aspects of that case. The teaching carried out i n the consultative service brings p s y c h i a t r i c learning to interested professional groups which can be applied to the needs of other clients. 2 The d i s t r i c t s o c i a l worker, f o r example, gains from the c l i n i c p s y c h i a t r i s t added knowledge around the meaning of behaviour, and from the c l i n i c s o c i a l worker help around s o c i a l casework techniques In u t i l i z i n g t h i s diagnostic information, both i n the s p e c i f i c case and i n her general professional p r a c t i c e . The teacher may request of the p s y c h i a t r i s t medical and psychiatric;knowledge i n 1 Coleman, Dr. Jules C , "Relating the Professional Ser-vices of the C l i n i c to Other Professional Groups i n the Community," I n s t i t u t e f o r C l i n i c Personnel of the Child  Guidance C l i n i c s and I n s t i t u t i o n s of the New York State  Department of Mental Hygiene. March 20-2li. 1950. published by State of New York Department of Mental Hygiene, Mental Health Commission, Albany, N. Y., p. 7 4 * 2 Annual Report, 1947-8, p. 129. - 66 -understanding the child's behaviour i n the school or i n the classroom. She may turn to the c l i n i c p s y c h i a t r i s t , psychologist or s o c i a l worker f o r an understanding of how the resources i n the school environment might be used to relieve the stresses there. The minister, i n consulting with the p s y c h i a t r i s t about a s p e c i f i c case, may be helped to see ways i n which the a c t i v i t i e s of the church may be used not only to strengthen the in d i v i d u a l ' s s p i r i t u a l resources, but also to strengthen h i s s o c i a l and personal functioning. Then again, the minister and teacher may, i n consultation with the c l i n i c s o c i a l worker, gain a clearer understanding of the family u n i t and the i n t e r a c t i o n among family members. In addition, they may turn to the s o c i a l worker to enable not only the c l i e n t , d i r e c t l y , but the teachers and ministers themselves i n mobilizing community resources more productively. 3. Education a) Community Education The educational program of the t r a v e l l i n g c l i n i c s i s based on the promotion of sound mental health f o r every-one, p a r t i c u l a r l y the growing c h i l d , h i s parents, and the family. The function of the T r a v e l l i n g C l i n i c i n present-ing the broad p r i n c i p l e s of mental hygiene to the community has been stressed. The tools used f o r t h i s purpose are, f i r s t , consultations with parents who come to the c l i n i c , - 67 -and secondly, those educative channels available to the team—lectures, f i l m s , panel discussion groups, and with professional groups, case studies. Both methods provide opportunities to give guidance to f a m i l i e s and communities i n understanding the causes of children's d i f f i c u l t i e s — i . e . , the basic needs of children. They also provide opportunities to discuss the available resources within the community f o r preventive mental health; to encourage the active use of these resources; and to encourage plann-ing f o r future f a c i l i t i e s as needed to achieve a higher standard of family l i f e . On a team v i s i t , each team member i s prepared to present the viewpoint of mental hygiene whenever asked. The team members t r y to f i t the educational program to meet l o c a l demand, and although they prefer to attend meet-ings i n a group, i n order to provide s p e c i f i c answers d i r -ected to each profession represented on the team, they do also, when requested, speak i n d i v i d u a l l y to t h e i r own professional group. The material presented i s , of course, chosen according to the group being addressed. I f the meeting i s , for instance, one sponsored by the Parent Teachers Association, and open to the general p u b l i c , the presentation centres around the general areas of Child Guidance C l i n i c d e s c r i p t i o n and function, and the needs of children generally. In a professional group, more technical aspects are discussed, which could be upsetting - 68 -to a lay group, but are stimulating and i n s t r u c t i v e to those members of the profession not i n as close contact with more recent professional trends as are the team members. b) S t a f f Education In order to ensure that team members are s u f f i c -i e n t l y competent and knowledgeable to function as community consultants i n the above ways, the stationary c l i n i c i n Vancouver, from which the T r a v e l l i n g C l i n i c team i s drawn, carri e s on a continuous program of s t a f f education. Through s t a f f meetings, tec h n i c a l educative f i l m s , an extensive l i b r a r y , p a r t i c i p a t i o n i n conferences and professional -organizations, the general s t a f f members have access to current professional developments and p r a c t i c e . Educat-i o n a l grants to enable further professional t r a i n i n g have been u t i l i z e d by members of each profession, and maximum professional t r a i n i n g i s encouraged. It i s apparent that great emphasis has been placed on the use of the t r a v e l l i n g c l i n i c as a teaching u n i t . The background material r e l a t i n g to B r i t i s h Colum-bi a T r a v e l l i n g Child Guidance C l i n i c s 1 Indicates that the pioneering stage of t r y i n g to stimulate the communities 1 desire f o r service has, f o r the most part, passed. The table presented i n Chapter I re c l i n i c a l services provided 1 See Chapter I. - 69 -to the 2k communities v i s i t e d i s i n d i c a t i v e of t h i s . The problem that presents i t s e l f now i s mainly that of educating the community according to i t s present l e v e l of development, and enabling i t to f i n d ways and means of making f u l l e r use of the T r a v e l l i n g C l i n i c services. This w i l l mean further c l a r i f i c a t i o n and i n t e r p r e t a t i o n of  c l i n i c a l services, and encouraging and stimulating the  development of a more extensive, f u l l e r community s o c i a l  service structure to f a c i l i t a t e the carrying out of prev-entive and treatment measures. k» Research This aspect of c l i n i c function has unfortunately not yet been u t i l i z e d to any s i g n i f i c a n t extent. The pressures of the tight schedule necessary to cover the vast mainland area are i n the main responsible f o r the lack of follow-up studies on i n d i v i d u a l cases. One of the immediate goals of the Vancouver c l i n i c i s the s t a f f i n g of two t r a v e l l i n g teams, i n which case emphasis w i l l be placed on determining areas of effectiveness of team services, the extent to which treatment recommendations have been followed, et cetera. The descriptive material, now being formulated through t h i s t h e s i s , must necessarily precede any a n a l y t i c a l or q u a l i t a t i v e s o c i a l work research, which i s important and necessary. - 70 -I I I . Area3 Serviced 1. Geographical The t r a v e l l i n g c l i n i c , d u r i n g the f i s c a l year A p r i l 1st, 1953, t o March 31st, 1954, v i s i t e d twenty-four towns on the B r i t i s h Columbia mainland. The towns v i s i t e d were: 1. Abbotsford 13. Nelson 2. C h i l l i w a c k 14* P e n t i c t o n 3. Cloverdale 15. Powell R i v e r 4. Cranbrook 16. P r i n c e George 5. Creston 17. P r i n c e Rupert 6. Dawson Creek. 18. Quesnel 7. Grand Porks 19. Salmon Arm 8. Haney . 20. Smithers 9. Kamloops 21. Terrace 10. Kelowna 22. T r a i l 11. Ladner 23. Vernon 12. M i s s i o n 24. W i l l i a m s Lake A t o t a l of 65 c l i n i c s were h e l d , w i t h T r a i l , P r i n c e Rupert and P e n t i c t o n making most use of the d i r e c t s e r v i c e s of the team, w i t h 7, 5 and 5 c l i n i c s , r e s p e c t i v e l y . Haney, Kamloops, and Kelowna were next, w i t h 4 c l i n i c s each, while C h i l l i w a c k , Nelson, Powell R i v e r and P r i n c e George each h e l d 3 c l i n i c s . Several of these towns are close enough to Van-couver to be covered i n a one-day v i s i t . Others i n v o l v e ten-day t r i p s , w i t h s e v e r a l communities being covered on the one t r i p . The t o t a l area s e r v i c e d i s the e n t i r e B r i t -i s h Columbia Mainland, w i t h the c l o s e s t centre, Ladner, being about 10 m i l e s from Vancouver, and the f a r t h e s t , - 71 -Dawson Creek, being 670 miles from Vancouver. Because of the extensive area covered, and the need of v i s i t i n g several centres on one t r i p , the team f r e -quently travels at night. This means that the members of the team hold c l i n i c s and attend conferences a l l day, record necessary data i n the evening, and t r a v e l on to the next centre at night, only to go through the same routine again. In centres where the team stays more than one day, the even-ing i s frequently taken up with the promotion of mental health by one of the channels previously mentioned. In addition to these r u r a l c l i n i c s , the t r a v e l l -ing c l i n i c also operates within the c i t y of Vancouver. Regular v i s i t s are made to the Children's Hospital, Western Society f o r R e h a b i l i t a t i o n of the Handicapped, Children's Health Centre at Vancouver General Hospital, School f o r the Deaf and Blind, and the Detention Home. C l i n i c s have also been held at The Preventorium, and at St. Christopher's School f o r Boys i n North Vancouver. 2. General Community Picture i n r e l a t i o n to  S o c i a l Service Structure In the majority of communities v i s i t e d , there i s a l o c a l health u n i t and a l o c a l s o c i a l welfare branch. I t i s the r e s p o n s i b i l i t y of these agencies to determine before-hand who s h a l l present the cases to c l i n i c , and carry out treatment recommendations, unless otherwise indicated by - 72 -c l i n i c a l r e s u l t s . The health units are composed of the Health Unit Director, Senior Public Health Nurse, and Public Health Nurses. The So c i a l Welfare Branches are com-posed of the d i s t r i c t casework supervisor and s o c i a l work-s t a f f . The s o c i a l workers may have eithe r a Master of Soc i a l Work degree, a Bachelor of S o c i a l Work degree, or an in-service t r a i n i n g course. The caseloads are heavy, and there i s a continual shortage of trained workers. A l l t h i s needs to be taken into consideration, i n looking at the t o t a l picture of the communities v i s i t e d . As much know-ledge as possible of the e x i s t i n g conditions i n the indiv-idual community i s necessary to gauging c l i n i c a l recom-mendations to the l o c a l scene. A recent promising development i n r u r a l B r i t i s h Columbia Is the formation, i n each welfare d i s t r i c t or health u n i t , of a l o c a l professional organization, gener-a l l y known as a Child Guidance Council. In some areas, these are functioning well, whereas i n others they are not yet properly established, and t h e i r value not recognized by the community. These Councils consist b a s i c a l l y of represent-atives of the l o c a l Welfare, Health and School s t a f f s . Representatives of S o c i a l Welfare Branch Include: 1. Regional Administrator, who must be sympath-e t i c to the idea. 2. Casework supervisor - the main functioning person of the Welfare group. - 73 -3. Individual s o c i a l workers, who present cases to the t o t a l group. Representatives of the Health Department include: 1. Unit Director, who i s usually active, and provides the necessary medical background. 2. Senior Public Health Nurse. 3. Public Health Nurse, who presents the case. School representatives include: 1. Inspector, whose enthusiasm and sympathy are necessary to e f f e c t i v e school p a r t i c i p a t i o n . 2. Mental Health Coordinator, who i s usually a senior teacher, with eight to ten years teaching experience, a suitable personality and an int e r e s t i n mental hygiene. There are Mental Health Coordinators i n Kamloops, Kelowna, North Vancouver, Bumaby and i n Vancouver. These men are trained at University of Toronto, i n a one-year course which combines the departments interested i n mental health--Canadian Mental Health Association, Department of Psychology, Department of Sociology, School of S o c i a l Work, Institute of Child Study. Their function i s to in s t r u c t the teachers i n mental hygiene p r i n c i p l e s , and help them toward better understanding and handling of class behavior and personality problems. The Mental Health Coordinator i s an invaluable entree into the body of teachers. 3. School p r i n c i p a l . 4. School Counsellor. - 7k ~ 5 . Teacher, on the i n d i v i d u a l case. In some areas others, such as probation o f f i c e r s , are added to the group. The representatives of the above groups meet on appointed evenings, to consider the c h i l d being brought to attention, by either the s o c i a l worker, public health nurse, or the teacher. The problem Is presented to the Council by the professional person who f i r s t recognized there was a problem, and saw the need of action. Those present combine t h e i r knowledge of the case, frequently f i n d i n g more than one group aware of or involved i n i t . In t h i s way, the Council acts somewhat as a S o c i a l Service Index i n the community, coordinating and avoiding d u p l i -cation of e f f o r t . At the meeting, they attempt to decide: (1) what i s the problem? ( 2 ) what can be done about i t ? (3) who should do It? The problem Is handled according to the s k i l l s of the group. It uses the T r a v e l l i n g C l i n i c as a consult-ing group, who bring t h e i r s k i l l s to bear i n the evaluation of the case, i . e . , i n the diagnosis and treatment planning of the case. The groups represented on the Council can solve a l o t of the cases themselves, but when they recog-nize the existence of a p s y c h i a t r i c problem, they r e f e r the case to T r a v e l l i n g C l i n i c . In c e r t a i n circumstances, where i t i s d i f f i c u l t because of the c l o s e l y k n i t structure - 75 -of the community, and the role the p a r t i c u l a r parents f i l l i n i t , to " t e l l the family," they get around t h i s by r e f e r r i n g the case to the T r a v e l l i n g C l i n i c . This pro-f e s s i o n a l rather than personal, approach i s much more acceptable and "carries more weight" with many people. They w i l l accept "the opinion of the experts," but may oppose the same opinion from a closer source. It i s the hope of the T r a v e l l i n g C l i n i c Director that as these groups acquire added s k i l l s through case studies and actual handling, they w i l l , with t h e i r added techniques, be able to handle more and more of the com-munity problems at the l o c a l l e v e l . The T r a v e l l i n g C l i n i c sees as a part of i t s job the encouragement of the use of these Child Guidance Councils i n those d i s t r i c t s where the l o c a l professional people have not yet appreciated t h e i r value. IV. Staff and Administration 1. Administration The P r o v i n c i a l Child Guidance C l i n i c s of B r i t i s h Columbia are a d i v i s i o n of the P r o v i n c i a l Mental Health Services, which operate under the Department of the Prov-i n c i a l Secretary. The Director of the C l i n i c , Dr. U. P. Byrne, i s d i r e c t l y responsible to the Director of Mental Health Services, Dr. A. M. Gee. The S o c i a l Service Depart-ment of the C l i n i c i s i n a unique p o s i t i o n , as i t s personnel - 76 -Is employed by Soc i a l Welfare Branch of the Department of Health and Welfare. The Social Casework Departmental Supervisor i s d i r e c t l y responsible to the P r o v i n c i a l Super-v i s o r of Psy c h i a t r i c S o c i a l Work, Miss A l i c e C a r r o l l , as well as to Dr. Byrne, the C l i n i c a l Director. This provides an administrative l i n k between the t r a v e l l i n g c l i n i c s o c i a l casework supervisor, and the S o c i a l Welfare Branch person-n e l , which, p o t e n t i a l l y , should r e s u l t i n a close r e l a t i o n -ship between the c l i n i c and the community. 2. S t a f f The following i s a breakdown of the q u a l i f i c a t -ions and functions of each professional member of the c l i n i c teams: (a) P s y c h i a t r i s t The c l i n i c a l p s y c h i a t r i s t must be a q u a l i f i e d medical p r a c t i t i o n e r , with one year r o t a t i n g c l i n i c a l i n -terne ship, four years t r a i n i n g and experience i n psychia-t r y , and have passed the examination of a S p e c i a l i s t of Royal College of Physicians of Canada. He must possess personal requirements f o r Tr a v e l l i n g C l i n i c work, since the p s y c h i a t r i s t occupies a key p o s i t i o n i n the team. He must be able to encourage and infuse team s p i r i t through e f f e c t i v e d i r e c t i o n , and adequate supervision. Certain q u a l i t i e s of personality, a c e r t a i n range of s o c i a l and community Interest and knowledge, and special a b i l i t i e s f o r getting along with people singly and i n groups are - 77 -r e q u i s i t e . He must be versed i n good public r e l a t i o n s techniques i n order to f o s t e r sound working r e l a t i o n s h i p s and integration with the lay and professional groups i n the community. He should also be a fluent speaker, i n order to lead i n the presentation of sound mental health p r i n -c i p l e s to the community; to awaken recognition of need and desire f o r improvement i n community resources, and to interpret c l i n i c function to the various community agen-cies and groups i n the promotion of greater, and more prod-uctive, use of c l i n i c a l services. During the c l i n i c a l examination, the p s y c h i a t r i s t , working within the team approach, has the r e s p o n s i b i l i t y of diagnosis, and the determination of the c h i l d ' s need f o r p s y c h i a t r i c treatment, as well as the r e s p o n s i b i l i t y f o r providing an evaluation of the c h i l d ' s physical condition. The l a t t e r , the f i r s t step i n c l i n i c a l procedure, i s of great importance, i n recognition of the e f f e c t of bodily i l l n e s s upon behaviour. The p s y c h i a t r i s t notes, p a r t i -c u l a r l y , 1. coordination 2. hearing ' 3. v i s i o n hand and eye dominance since these, i f present, give r i s e to c e r t a i n s p e c i f i c d i f f i c u l t i e s In learning to write, s p e l l , and read. Before determining the presence of an emotional basis to any of - 78 -these learning d i f f i c u l t i e s , i t i s necessary to rule out possible physical causes. The p s y c h i a t r i s t formulates a general estimate of the child's 1. mental state 2. personality 3. adaptation ij.. m o t i v a t i o n — o f c h i l d and parents through the medium of interviews with the c h i l d and parents, and noting pertinent points i n the S o c i a l History. He i s chairman of the f u l l c l i n i c conference following c l i n i c a l examination, i n which summaries o f t 1. s o c i a l h i s t o r y 2. physical examination 3. psychological evaluation 4. educational status 5. general mental health are presented. Although the whole team p a r t i c i p a t e s i n and contributes toward the establishment of the diagnostic evaluation and formulation of treatment planning, i t i s the p s y c h i a t r i s t who i s the f i n a l authority, and who car-r i e s the r e s p o n s i b i l i t y f o r these. In addition to these, the p s y c h i a t r i s t also i s available f o r consulting conferences with parents and workers, and other professional people within the community. In the community educational work of the T r a v e l l i n g C l i n i c , h i s r o l e Is a heavy one. He i s a v a i l a b l e , at the request - 79 -of community groups, f o r lectures, discussions, p a r t i -c i p a t i o n i n panels, and f i l m presentations. This i s a large and important aspect of t r a v e l l i n g c l i n i c service, as has been discussed previously, (b) Psychologist The stated professional requirements f o r the c l i n i c a l psychologist are: (1) a Bachelor of Arts degree plus 5 years c l i n i c a l experience; or (2) a Master of Arts degree plus 2 years experience. There are, however, very few psychologists with these q u a l i f i c a t i o n s available. In order to compensate f o r t h i s shortage of q u a l i f i e d psychologists, a " c l i n i c a l interneship" was established. In l i n e with t h i s , there are currently three "grades" of psychologists: 1. Psychologist Grade I - known as a " c l i n i c a l interne." This group includes those with a BA degree, with a major i n psychology, who are gaining c l i n i c a l ex-perience through the c l i n i c a l Interneship, generally of one year's duration. 2. Psychologist Grade I I - known as a "Psycho-l o g i s t . " This group includes those with the BA degree plus the one year's c l i n i c a l experience. 3. Psychologist Grade I I I - includes those with a Master of Arts degree plus 2 years' c l i n i c a l experience, or, those with a BA plus 5 years' c l i n i c a l experience. - 80 -At present, there has been quite a s t a f f turn-over i n the psychology department personnel, so that the majority of the psychologists on t r a v e l l i n g c l i n i c are e i t h e r Grade II psychologists, or c l i n i c a l Internes. I d e a l l y , personal requirements f o r t r a v e l l i n g c l i n i c work, i n l i n e with the t r a v e l l i n g c l i n i c objective, include s k i l l i n the education and public r e l a t i o n s aspects of the profession. The psychologist i s usually closer to the schools and the educational programs and problems than are the other c l i n i c a l workers, and may be t very active i n s c h o o l - c l i n i c r e l a t i o n s . The stated function of the Psychologists i s t o : ...apply the basic knowledge which they share with a l l psychologists plus a d d i t i o n a l s k i l l s i n i n t e r -viewing people and counselling them, and i n evalua-t i n g tests that indicate i n t e l l i g e n c e , personality c h a r a c t e r i s t i c s , emotional adjustment, and other i n d i v i d u a l differences. In the c l i n i c a l examination, the psychologist i s f i r s t of a l l a s p e c i a l i s t i n the tools of psychology, and therefore responsible f o r the diagnostic psychological study. He (she) applies a l l the objective and projective procedures that w i l l contribute to a b u i l d i n g up of a picture of a person and how he functions. He adds to t h i s h i s c l i n i c a l insight and judgment, and arrives at conclusions that are h e l p f u l i n treatment planning. In general, the psychologist Is responsible f o r a psychological assessment o f : - 81 -1. the client's intellectual capacities, verbal and non-verbal, and specific strengths and weaknesses in intellectual functioning; 2. emotional factors interfering with intellect-ual functioning; 3. learning capacity in major educational areas; if., achievement in the tools of learning; f>. the specifies of any learning disabilities; 6. directions for further education, or possible limits of further education; 7* aptitudes and interests; 8. motor coordination; 9. speech problems; 10. habits of work; 11. aspiration levels; 12. frustration tolerance; 13. remedial needs and many elements of personality. The psychological study will give hints that may require medical study, or some special aspects of psychia-tric study. Leads for the psychiatrist in exploring feel-ings, attitudes and relationships may emerge from the psy-chological study. Although the psychologist does not deliberately probe for these, she is alert to their mani-festation. The travelling clinic psychologist must be avail-able for consultation purposes (mainly with school per-- 82 -sonnel) i f requested, and f o r p a r t i c i p a t i o n i n discussions and panels with other team members. She, too, must be able to interpret Mental Health to professional and non-professional community groups, and to further the develop-ment of e f f e c t i v e preventive programs within the community. (c) P s y c h i a t r i c S o c i a l Casework Supervisor The professional requirements f o r the T r a v e l l i n g C l i n i c Casework Supervisor are: .. ...a Master of S o c i a l Work degree from a u n i v e r s i t y of recognized standing; several years 1 experience i n work related to the duties to be performed includ-ing some experience i n collaborative work with other professional d i s c i p l i n e s , preferably i n a Child Guidance C l i n i c ; sound knowledge of the dynamics of human behaviour; a b i l i t y to interpret services of the C l i n i c and casework method to p r o f e s s i o n a l per-sons and to the general p u b l i c ; working knowledge of a l l Acts and Regulations pertaining to the work of So c i a l Welfare Branch; knowledge of e x i s t i n g re-sources and services r e l a t i n g to mental health needs of f a m i l i e s and children; a b i l i t y to withstand the taking of long t r i p s each month to various d i s t r i c t s of the province; demonstrated or p o t e n t i a l a b i l i t y to supervise other s o c i a l workers. 1 Personal requirements are again a determining fac t o r i n s u i t a b i l i t y f o r the p o s i t i o n . Again the l i a i s o n , consultative and general community education aspects are of outstanding Importance, since the casework supervisor takes a good deal of r e s p o n s i b i l i t y f o r the coordinating aspects of the c l i n i c . By virtue of t h e i r s p e c i f i c t r a i n -ing, s o c i a l workers have a p a r t i c u l a r awareness of the 1 S o c i a l Welfare Branch, personnel advertisement. - 83 -e f f e c t s of agency functions and p o l i c i e s , and a knowledge of community structure, both as i t should be and as i t i s . Since the s o c i a l worker i s from the beginning i d e n t i f i e d with s o c i a l agencies, the casework supervisor on t r a v e l l i n g c l i n i c functions as the l i a i s o n person between the commun-i t y s o c i a l service resources and the c l i n i c . He i s , i n p a r t i c u l a r , the team l i a i s o n person with S o c i a l Welfare Branch personnel. The following job desc r i p t i o n study, worked out over the l a s t year, c l e a r l y states the role of the T r a v e l l -ing C l i n i c Casework Supervisor. 1 1. Administrative R e s p o n s i b i l i t i e s a) Arranging C l i n i c s . Discussions, arrangements and correspondence with personnel In the f i e l d re-garding c l i n i c function, available dates, and gen-e r a l preparation f o r such c l i n i c s . b) Integration of services to c l i e n t s on Tra-v e l l i n g C l i n i c s , including planning and scheduling of team a c t i v i t i e s and promoting flow of work. c) Contributions to the o v e r - a l l coordination and integration of team operations to promote the collaborative services to c l i e n t s . d) Maintaining l i a i s o n with and encouraging cooperation of a l l e x i s t i n g community services In the f i e l d such as schools, health and welfare agen-cies, and other community groups. e) Reporting on work to the Supervisor (of Child Guidance C l i n i c S o c i a l Service Department) through consultation and s t a t i s t i c s . •'•Job descriptions study, Child Guidance C l i n i c s t a f f , Vancouver, 1954* - 84 -2. Supervisory R e s p o n s i b i l i t i e s a) Discussion of cases with supervisors and workers i n the f i e l d to promote implementation of recommendations. Further discussion may be re-quested through the f i e l d supervisor on a contin-uing case, and t h i s may be handled through cor-respondence. 3. Consultative R e s p o n s i b i l i t i e s a) Contributing to findings, evaluation, diag-noses and treatment recommendations of c l i n i c team. b) The i n t e r p r e t a t i o n of e x i s t i n g services and resources r e l a t i n g to mental health needs of fami-l i e s and children. c) Recording the s o c i a l work p a r t i c i p a t i o n i n such cases. 4. Caseload R e s p o n s i b i l i t i e s a) Interviews on T r a v e l l i n g C l i n i c s . Direct interviews with r e l a t i v e s and friends, and profes-sional associates to procure data f o r the immediate use of the team f o r evaluation of the presenting problem and diagnosis. b) Responsibility f o r l i m i t e d caseload as time permits. c) Recording of these casework a c t i v i t i e s . $. Educational and Interpretive R e s p o n s i b i l i t i e s a) P a r t i c i p a t i o n i n orientation, lectures, and discussion leadership on T r a v e l l i n g C l i n i c s throughout the province to Interpret services and mental health p r i n c i p l e s i n p r o f e s s i o n a l and com-munity groups. 6. Staff Development R e s p o n s i b i l i t i e s Contributing to s t a f f meetings, committee work, and s t a f f projects. 7. Research R e s p o n s i b i l i t i e s P a r t i c i p a t i o n i n any surveys or research pro-jects undertaken by C l i n i c , S o c i a l Welfare Branch, Mental Health Services, etc. - 8 5 -In p r a c t i c a l working experience, the following i s a resume of the casework supervisor's a c t i v i t y during a t y p i c a l t r a v e l l i n g c l i n i c day: While the c h i l d i s being examined by the psy-c h i a t r i s t , the s o c i a l worker, having f a m i l i a r i z e d himself with the So c i a l History material presented i n advance by the l o c a l person r e f e r r i n g the case, interviews one or both parents. In the process, he c l a r i f i e s c e r t a i n points In the hi s t o r y , f o r the benefit of the c l i n i c team. He also formulates h i s s o c i a l diagnosis of the s i t u a t i o n , based on the S o c i a l History material, plus h i s own d i s c i p -l i n e d observations of the parents during a well-focussed casework Interview. He notes: the strengths and l i m i t a -tions of the parents; t h e i r a b i l i t y , based on t h e i r own past experiences and relationships, to give to the c h i l d ; t h e i r general f e e l i n g s around the c h i l d and around t h e i r own parents. He observes parents, evaluates what they can be expected to give i n the l i g h t of t h e i r own experiences; he assesses the c h i l d and i t s s o c i a l needs, and evaluates the strengths and l i m i t a t i o n s i n the parent-child r e l a t i o n -ship. Drawing upon h i s dynamic understanding of family i n t e r - r e l a t i o n s h i p s , of s o c i a l situations i n general, and of s o c i a l resources, he then contributes, i n the confer-ence, towards the establishment of a diagnosis and a treat-ment plan. - 86. -In a routine c l i n i c a l conference, the attendance ranges from about 7 to 30 professional people, in c l u d i n g : 1. c l i n i c team members. 2. S o c i a l Welfare Branch workers. 3. Public Health Unit nurses and doctors. i+. School personnel - p r i n c i p a l s school counsellors mental health coordinators teachers. 5. Local physicians. 6. Probation O f f i c e r s . 7. Other professional people involved i n the p a r t i c u l a r case, such as ministers. The c l i n i c p s y c h i a t r i s t , who i s chairman of the conference, gives h i s b r i e f outline of the case and the problem, the psychologist gives the psychological report, and the Pub-l i c Health Nurse gives her playroom and examining room observations. The c l i n i c s o c i a l worker presents h i s s o c i a l evaluation, arrived at as described above. The psychia-t r i s t then presents h i s p s y c h i a t r i c findings as derived from h i s interviews with the c h i l d , and with the parents. Next, the l o c a l school representative i s asked f o r an evaluation of the child's adjustment at school, and any pertinent medical information i s presented. A portion of the conference i s a period of general discussion, with each person present contributing what he or she sees as h e l p f u l i n understanding the s p e c i f i c s i t u a t i o n . The p s y c h i a t r i s t draws the discussion and the team present-- 87 -ation together. He gives an evaluation of the problem, and asks f o r suggestions as to the help that can be given to r e l i e v e the current pressures. Where there are obvious lacks i n available resources, the team may explain how other communities have increased t h e i r resources, how these resources are used, and t h e i r value to the commun-i t y . The general community picture of s o c i a l service resources i s frequently examined. Often the ways and means of i n i t i a t i n g community in t e r e s t i n establ i s h i n g needed f a c i l i t i e s are discussed. The c l i n i c s o c i a l work-er Is responsible f o r recording the conference discus-sion, members present, and the s t a f f ' s treatment recom-mendations. Following the conference, the c l i n i c s o c i a l worker contacts the l o c a l s o c i a l worker and d i s t r i c t supervisor, and c l a r i f i e s points of discussion, plus the l o c a l s o c i a l worker's role i n treatment. These are f u r -ther c l a r i f i e d i n the doctor's report, which i s sent to the l o c a l S o c i a l Welfare Branch or Public Health Unit o f f i c e , following the t r a v e l l i n g c l i n i e ' s return to the Vancouver Stationary C l i n i c . The l o c a l s o c i a l worker i s encouraged to use the c l i n i c s o c i a l worker consultatIvely on t h i s and future v i s i t s , and to inform the t r a v e l l i n g c l i n i c s o c i a l worker of progress made i n cases seen by the C l i n i c on other occasions. - 88 -In discussion with the current T r a v e l l i n g C l i n i c Casework Supervisor, who i s newly appointed as of January 1, 1955, he pointed out the advantages of being known to the d i s t r i c t as a Supervisor, rather than as a Caseworker, as formerly. The d i s t r i c t supervisors f e e l free to discuss, with another supervisor, many of t h e i r supervisory problems. This leads to a better understand-ing of the c a p a b i l i t i e s of the D i s t r i c t s t a f f s , i n turn leading to treatment recommendations geared to the re-sources, professional as well as material, of the commun-i t y . The D i s t r i c t Supervisors also have the opportunity of becoming acquainted with the l a t e s t S o c i a l Welfare developments i n Vancouver, and i n other S o c i a l Welfare Branch d i s t r i c t s . The T r a v e l l i n g C l i n i c supervisor i s , then, p o t e n t i a l l y one who integrates and coordinates the c l i n i c services among the various S o c i a l Welfare Branch o f f i c e s . This p o t e n t i a l l y strengthens working r e l a t i o n -ships and understanding between the d i s t r i c t s , as well as between the d i s t r i c t and the T r a v e l l i n g C l i n i c . The present T r a v e l l i n g C l i n i c Casework Super-visor recognizes the importance of furthering the use of the available consultative services of the t r a v e l l i n g c l i n i c . In t h i s connection, and i n an e f f o r t to do some follow-up study of previous T r a v e l l i n g C l i n i c cases, he has i n i t i a t e d a program of contacting l o c a l personnel, - 89 -with a view t o : (a) future assessment of the amount of inten-sive contact l o c a l health and welfare personnel are able to give on i n d i v i d u a l cases; (b) r e a l i t y of c l i n i c recommendations i n terras of the l o c a l resources; (c) correct use of T r a v e l l i n g C l i n i c services by l o c a l r e f e r r i n g agencies; (d) suggestions on treatment of patients and the mental health aspects i n the p a r t i c u l a r s i t u a t i o n . As an example of t h i s approach, he recently reviewed 47 cases with the Public Health s t a f f i n one of the centres v i s i t e d . In the process, he was able to help the Public Health Nurse i n her understanding of the relevant family rel a t i o n s h i p s , and around appropriate handling of them. If t h i s proves of value to the nursing s t a f f , they w i l l v o l u n t a r i l y repeat the experience on i n d i v i d u a l cases; and see the value, to themselves and to t h e i r patient, i n keeping T r a v e l l i n g C l i n i c informed of progress i n c l i n i c a l cases. The broader objective of increasing the Public Health Nurse's understanding of the basis and treatment of personality and behavioural disorders i s of course inherent i n t h i s approach. This would apply equally i n the case of S o c i a l Welfare Branch cases. The value of "knowing the community" i s stressed by t h i s t r a v e l l i n g c l i n i c casework supervisor, i f most - 90 -e f f e c t i v e c l i n i c a l service i s to be extended In a l l areas. He i s planning to e s t a b l i s h a f i l e on each community v i s i t e d , i n which he w i l l include; a l i s t of the f o s t e r homes, adoption homes, i n s t i t u t i o n s i n each area; recreational f a c i l i t i e s , service clubs, et cetera; plus the l o c a l school personnel, Indicating receptiveness, understanding and p a r t i c i p a t i o n i n c l i n i c a l services. This f i l e w i l l be of inestimable value i n integrating c l i n i c a l services with e x i s t i n g community structure, and w i l l point up those areas which need p a r t i c u l a r emphasis, i f the s p e c i f i c community i s to f i l l adequately i t s soc-i a l welfare needs, and ensure an adequate Mental Health program. The r e a l i t y of the t i g h t c l i n i c a l schedule—an average of 3*4 c l i n i c a l examinations and conferences d a i l y — h a s impinged upon the amount of p a r t i c i p a t i o n i n community education lectures and discussions. Its import-ance i n f u l f i l l i n g c l i n i c function i s recognized, but at present with one t r a v e l l i n g team attempting to meet the demands fo r services of the entire B r i t i s h Columbia Main-land areas, the evenings are too often spent i n t r a v e l l i n g to the next town. The establishment, i n the not too f a r distant future, of a second t r a v e l l i n g team, w i l l enable more p a r t i c i p a t i o n i n general community education a c t i v -i t i e s . - 91 -(d) Public Health Nur3e Professional requirements f o r the Public Health Nurse on the t r a v e l l i n g c l i n i c team are an R.N. with Public Health t r a i n i n g , and p s y c h i a t r i c experience. This special program of education i s designed to help her as a professional person to achieve a body of knowledge and a philosophy about human behaviour, closely t i e d to nursing si t u a t i o n s . On the t r a v e l l i n g c l i n i c team she i s i n e f f e c t the l i a i s o n between the rest of the c l i n i c s t a f f and the Public Health nurses and the Public Health Units i n the community v i s i t e d . She i s the c l i n i c consultant to the l o c a l Public Health Nurses; and since the Public Health Units, along with the P r o v i n c i a l Social Welfare Branch d i s t r i c t s compose the bulk of the c l i n i c ' s r e f e r r a l sources, the importance of her consultative role cannot be over-estimated. She i s i n a p o s i t i o n , through her understand-ing of and p a r t i c i p a t i o n i n the profession of nursing, to encourage understanding of appropriate use of the c l i n i c a l services, and to give guidance around more e f f e c t i v e pre-paration of s o c i a l h i s t o r y material, preparation of the c l i e n t f o r c l i n i c a l examination, and guidance around the productive carrying out of treatment recommendations. Her s p e c i f i c functions on the t r a v e l l i n g team 1 are: 1. to observe the c h i l d i n the waiting room and at play; 1 Dr. Byrne, personal communication with author. - 92 -2. to prepare the c h i l d f o r the physical examina-t i o n , and give assistance at the physical examination, including v i s i o n and audiometer t e s t s ; 3. to take specimens and do laboratory tests as indicated; 4. to operate moving picture projector during showing of mental health films to the community, 5 . to take f u l l part In the educational program; 6. to gather s t a t i s t i c s and do s t a t i s t i c a l analyses of c l i n i c services; 7. to handle a l l reservations f o r t r a v e l l i n g c l i n i c team. As with the other team members, emphasis i s placed on the community aspects of her r o l e . It can be seen that each professional representative has a d i s t i n c t role as consultant person on the team f o r the related professional group i n the community. Each team member must also be able to interpret the mental health program and functioning of the c l i n i c as a whole, when c a l l e d upon to do so. V. Types of Cases The t r a v e l l i n g c l i n i c attempts, through education of r e f e r r i n g sources i n the various ways previously d i s -cussed, to encourage the presentation of children whose prob-lems are of a nature that w i l l benefit from c l i n i c a l services. Here again, the use of case study and conference on individual cases, consultations around general and s p e c i f i c professional - 93 -practices, and lectures and f i l m presentations to the gen-e r a l p u b l i c , i s invaluable i n promoting maximum and most ef f e c t i v e use of the t r a v e l l i n g c l i n i c . Through these med-iums, i n addition to education i n the basic p r i n c i p l e s of growth, development and human rel a t i o n s h i p s , the c l i n i c c l a r i f i e s the indications f o r r e f e r r a l to the c l i n i c , s t r e s s i n g : (a) m u l t i p l i c i t y of symptoms; (b) persistence of symptoms; (c) inappropriateness of behaviour; (d) indications of mental retardation. The S o c i a l Welfare Branch Annual Report, 19^8, states that: ...deviations In mental status, t r a i t , conduct, or habit, do not of themselves necessarily constitute problems, nor do they always indicate the need f o r study by a c h i l d guidance c l i n i c . I t i s rather when the aforementioned are not adequately dealt with, tinderstood, or accepted within the family, or by the persons who are caring for the c h i l d , or when the aforementioned deviations cause present disharmony within the c h i l d or family or point to future un-happiness or harm and are found to extend beyond the remedial resources within the child's immediate environment that c h i l d guidance evaluation i s indicated. The types of problems referred to the t r a v e l l i n g c l i n i c , and f e l t to be appropriate, are wide i n range and variety, and include: 1. Primary Behaviour Disorders These include disorders of habit, personality, con-duct, and neurotic t r a i t s . They are c a l l e d primary because - 94 -they are not secondary to any pathological condition. The behaviour i s therefore i n d i c a t i v e of underlying emotional disturbance, and c l i n i c a l evaluation as to the diagnostic significance of the symptoms, and recommendations as to treatment, help guide the l o c a l worker i n her role of case-work treatment, and appropriate use of community resources. Since primary behaviour disorders develop i n the c h i l d i n reaction to the influences of the environment, the s o c i a l worker's knowledge about the dynamics of family r e l a t i o n -ships i s of prime importance i n a r r i v i n g at a diagnostic assessment of the problem. Thumb-sucking, n a i l - b i t i n g , enuresis, mastur-bation, et cetera, are included i n the habit disorders. The personality disorders include sensitiveness, seclusiveness, apathy, day-dreaming, excessive imagination and f a n c i f u l l y i n g , moodiness, obstinacy, quarrelsomeness, selfishness, l a z i n e s s , lack of ambition or i n t e r e s t , general restlessness, et cetera. Among the conduct disorders are disobedience, teasing, b u l l y i n g , temper tantrums, bragging or showing o f f , defiance of authority, seeking bad companions, keeping l a t e hours, l y i n g , s t e a l i n g , truancy, destructiveness, cruelty to persons or animals, sex a c t i v i t y . - 95 -2. Dependent Children These are the children who, because of some d i s -aster i n the home, are becoming or have become, s o c i a l charges, i . e . , they have become wards of the Supervisor of Child Welfare, and as such are dependent upon s o c i a l agen-c i e s — S o c i a l Welfare Branch i n the r u r a l a r e a s — f o r approp-r i a t e maintenance planning. Early c l i n i c a l evaluation of the child's emotional adjustment i s h e l p f u l to the r u r a l professional worker i n making plans appropriate to the i n -d i v i d u a l c h i l d . In t h i s way, adequate plans can be made f o r t h e i r care, based on the ch i l d ' s needs, and resources i n the community to meet those needs. Much future d i f f i c u l t y can be avoided i n t h i s way. Adoption homes, fos t e r homes, i n -s t i t u t i o n s , may be then chosen and prepared, i n the l i g h t of the child's needs. 3. Exceptional Children This group includes children who are eith e r exceptionally bright, or retarded. These children frequently come into c o n f l i c t with t h e i r environment. It i s important that t h e i r a b i l i t i e s be evaluated, and adequate plans be formulated f o r them. Again, the t r a v e l l i n g c l i n i c , through Its f u l l c l i n i c a l investigation, supplies the diagnostic base from which the r u r a l worker proceeds. Consultations on future c l i n i c v i s i t s are available when requested. The l o c a l worker may return f o r guidance around s p e c i f i c t r e a t -ment techniques and problems, or around further understanding - 9 6 -of the basic motivation In the p a r t i c u l a r s i t u a t i o n , and how to cope with i t constructively. In these situations, the parents need help, f i r s t , around understanding the d i f -f i c u l t i e s generally inherent i n a c h i l d of t h i s s p e c i f i c a b i l i t y , or d i s a b i l i t y ; secondly, i n f e e l i n g free to express t h e i r f e e l i n g s about the behaviour, and to gain acceptance of the naturalness of these feelings within themselves, thus r e l i e v i n g t h e i r g u i l t , and enabling them to move toward greater acceptance and understanding of the c h i l d ; and t h i r d l y , help around meeting the chil d ' s needs, as s p e c i f i c a l l y indicated i n t h i s p a r t i c u l a r family and general environment. Summary The B r i t i s h Columbia Mainland T r a v e l l i n g Child Guidance C l i n i c operates as a sp e c i a l consultative group to handle diagnostic problems at the case l e v e l . These cases are then used, i n conjunction with lectures and f i l m s to both professional and non-professional groups, to f u l f i l the c l i n i c ' s paramount f u n c t i o n — i t s contribution to the t o t a l mental health needs of the community. Its aim i s to treat the problems presented, using the available community resources i n the treatment; and through community education methods, to enable the community to meet more adequately i t s i n d i v i d u a l needs. Cases are presented to the t r a v e l l i n g c l i n i c by l o c a l health and welfare personnel, and occasionally by - 97 -school personnel or probation o f f i c e r s . These l o c a l people prepare the s o c i a l h i s t o r y , and send i t i n to the c l i n i c team i n advance of i t s v i s i t . On the c l i n i c day, the c h i l d referred receives a complete s o c i a l i nvestigation, a thor-ough medical examination, a f u l l psychological evaluation and educational survey, and a c a r e f u l p s y c h i a t r i c study. Following t h i s , a case conference i s held, at which the c l i n i c team and interested l o c a l professional people p a r t i -cipate. The purpose of the conference i s twofold. 1. Evaluation of the problem, with suggestions f o r i t s solution; 2. Teaching by case method, so that those attending learn to draw p a r a l l e l s , and apply the p r i n c i p l e s involved i n other relevant situations. C l i n i c team members and l o c a l professional personnel are mutually responsible f o r p a r t i c i p a t i o n and contribution toward a workable treatment plan, geared to the available l o c a l community resources and professional services. A written report i s sent by the c l i n i c doctor to the l o c a l r e f e r r i n g agency, upon the c l i n i c ' s return to Vancouver. The stated functions of the l o c a l t r a v e l l i n g c l i n i c are diagnosis, consultation, community and s t a f f education, and research. Since community demand f o r i n d i v i d u a l p s y c h i a t r i c services can not be met under e x i s t i n g c l i n i c and f i e l d - 98 -s t a f f shortages of trained personnel, emphasis i n the t r a v e l l i n g c l i n i c i s upon the use made of the c l i n i c a l diagnosis and case conferences, and upon the consultative and community education aspects of t r a v e l l i n g c l i n i c function. This shows up c l e a r l y i n the description of the q u a l i f i c a t i o n s and functions of each team member. S k i l l i n the community education and public r e l a t i o n s as-pects of the c l i n i c are inherent i n the i n d i v i d u a l personal q u a l i t i e s necessary f o r t r a v e l l i n g c l i n i c work. Each pro-f e s s i o n a l member of the c l i n i c needs maximum professional t r a i n i n g , i n order to act as consultant to the community personnel i n h i s or her professional capacity, when the occasion a r i s e s . Requisite also i s the a b i l i t y to i n t e r -pret t o t a l c l i n i c function to community groups and indiv -i d u als. In addition to t h i s , i t i s extremely Important that a l l persons assigned to t r a v e l l i n g c l i n i c are i n t e r -ested i n , and comfortable about, working with r u r a l people, and have some means of intimate communication with them. The t r a v e l l i n g c l i n i e attempts to encourage pre-sentation to the c l i n i c of those childr e n whose problems are of a nature that w i l l benefit from c l i n i c a l services. The types of problems seen as appropriate r e f e r r a l s f o r c l i n i c a l assessment and treatment recommendations are, broadly: 1. primary behaviour disorders; 2. dependent chil d r e n ; 3. exceptional c h i l d r e n . - 99 -The broad c l i n i c a l aim of helping the l o c a l pro-f e s s i o n a l groups detect and handle more and more of the community problems at the l o c a l l e v e l , i s inherent i n the entire c l i n i c a l process. A most p o s i t i v e sign, and one that needs support and encouragement, i s the gradual devel-opment i n r u r a l areas of B r i t i s h Columbia, of l o c a l pro-f e s s i o n a l organizations, known generally as Child Guidance Councils. CHAPTER I I I THE BRITISH COLUMBIA MAINLAND TRAVELLING CHILD GUIDANCE CLINIC IN OPERATION I . I n t r o d u c t i o n I n the preceding chapter, the broad aim of the T r a v e l l i n g C l i n i c has been formulated as b e i n g : ...to t r e a t the problems presented, u s i n g the a v a i l -able community resources i n the treatment; and through community education methods, to enable the community to meet more adequately i t s i n d i v i d u a l needs.1 I t i s w i t h t h i s broad aim that the present chapter i s mainly concerned* The purpose of the m a t e r i a l presented h e r e i n i s t o i n d i c a t e the general trends o f c l i n i c o p e r a t i o n w i t h i n the communities at present u t i l i z i n g i t s s e r v i c e s . This t h e s i s i s seen as an e x p l o r a t o r y study, w i t h one of i t s goals a more d e f i n i t i v e statement and c l a r i f i c a t i o n of the f u n c t i o n the T r a v e l l i n g C l i n i c i s c u r r e n t l y f u l f i l l -i n g w i t h i n the r u r a l communities of the B r i t i s h Columbia Mainland, r a t h e r than a d e t a i l e d , a n a l y t i c a l study of ser-v i c e s rendered. A t h r e e f o l d approach t o t h i s study o f the " c l i n i c i n o p e r a t i o n " has been made, t h e r e f o r e , through: 1. Random sample case study of f i f t y cases seen during 1953 by the, T r a v e l l i n g C l i n i c . The emphasis upon 1 Chapter I I , p. 59. - 101 -the material thus collected direct ly from the c l i n i c f i l e s , has been upon indicating broadly: a. The characteristic group of cl ients being referred for individual services; b. The problems seen by the re ferra l sources as indicating the need of c l i n i c a l evaluation and help i n treatment planning; c. The channels of referral and presentation of cases to the c l i n i c ; d. The professional members of the communi-t i e s , who, through attendance at case conferences, come into direct contact with c l i n i c a l concepts and knowledge about the understanding and treatment within the community, of behaviour disorders i n children, and general mental health methods i n their a l l ev ia t ion ; and i n the prevention of fur-ther similar d i f f i cu l t i e s in other children; e. The trend of recommendations made for such community treatment of the disorder. 2. Questionnaire sent to a l l Social Welfare Branch f i e l d offices (see Appendix B) , through which a l l community requests for Travelling Cl in ic services are made. The writer has used the replies to this questionnaire (fourteen were returned out of the twenty-four sent out), i n combina-t ion with (3) below, to come to a necessarily tentative assessment of the response of the f i e l d to the Travelling Child Guidance Cl in ic services extended. - 102 -3. Personal Informal Interviews with available field casework supervisors and social workers. It is recognized that at its present stage of development, and under the necessary operational pressures of time Imposed by the limited number of clinic team mem-bers working throughout a vast geographical area, there are certain limitations in the clinic f i l e s which Inhibit a comprehensive analytical study of individual case ser-vices. As has been mentioned previously, the clinic is aware of these gaps, and is hopeful of, in the near future, reducing the pressures upon the travelling teams, by the formation of a second travelling team. One of the main emphases, in addition to such relief of pressures and more frequent service as desired by the communities, will be on follow-up studies, with a sensitivity to future study of the effectiveness of current clinical practice, in relation both to the individual as a "case", and to the community as the focus. The emphasis in this thesis is upon the community  aspects of the Travelling Clinic service. It is the writer's Impression that once these are more clearly defined, and broad function as well as specific function imbedded in the thinking of team members, referring agency members and pro-fessional persons within the referring communities, then and only then will clinical facilities be extended and uti-lized to the maximum benefit of a l l concerned—and parti-cularly of the client being served—the individual within - 103 -the community. I I . The T r a v e l l i n g C l i n i c ' s Current F i e l d of Operation The question broadly posed i n t h i s p a r t of our study, i s : who i s the t r a v e l l i n g c l i n i c r eaching, and how? As has been i n d i c a t e d , we are concerned here not w i t h the c l i n i c ' s a b i l i t y to perform i t s d i a g n o s t i c f u n c t i o n ade-quately i n r e l a t i o n t o each case; i t s a b i l i t y t o do so, and the process i n v o l v e d , have been c l a r i f i e d i n Chapter I I . We are concerned here, however, w i t h the use made of such d i a g n o s t i c s e r v i c e s , i . e . , w i t h the di a g n o s i s i n a c t i o n , i n f u r t h e r i n g community ( p r o f e s s i o n a l and non-professional) understanding of c h i l d r e n ' s needs, and use of c l i n i c a l ser-v i c e s , concepts and knowledge, toward c r e a t i n g a h e a l t h i e r , happier environment f o r the c h i l d r e n o f the community. We have seen th a t the t r a v e l l i n g c l i n i c i s set up as a very s p e c i a l i z e d s e r v i c e o r g a n i z a t i o n , doing a spec-i a l i z e d job. I n order t o do that job e f f e c t i v e l y , i t must  be able to have the k i n d o f p a t i e n t s t h a t i t can h e l p . I f the c l i n i c i s fl o o d e d w i t h p a t i e n t s i t cannot h e l p , ob-v i o u s l y i t i s not going to be able to do the job f o r which i t was set up. According to Dr. J u l e s Coleman: 1 ...when a c l i n i c opens up f o r the f i r s t time i n a community, the p a t t e r n of r e f e r r a l u s u a l l y f o l l o w s p r e t t y much the same course....the f i r s t cases r e -f e r r e d are very l i k e l y t o be the d e f e c t i v e c h i l d r e n , and then, hard on t h e i r h e e l s , the over-aggressive, 1 Coleman, Dri- J;S., " R e l a t i n g the P r o f e s s i o n a l S e r v i c e s of the C l i n i c to Other P r o f e s s i o n a l Groups i n the Community," Hew York I n s t i t u t e of C h i l d Guidance C l i n i c s , 1950, p. 66. - 104 delinquent behaviour problems, i . e . , those problems which are causing the community the most woe. I t i s  the c l i n i c ' s job t o c l a r i f y i t s s e r v i c e s w i t h the agencies i n the community. Coleman goes on t o say tha t i f the c l i n i c f e e l s i t s time i s best spent w i t h c e r t a i n types of problems r a t h e r than o t h e r s : . . . i n order to be able to work w i t h such problems, they must do a great d e a l of i n t e r p r e t a t i o n w i t h the agencies i n the community r e p r e s e n t i n g the supporting s e r v i c e s . Such I n t e r p r e t a t i o n does not mean e x p l a i n -i n g t o the agencies what one wants, but i s , r a t h e r , a process of demonstration or of i n t e r p r e t a t i o n through the use of case m a t e r i a l . By i n v i t i n g rep-r e s e n t a t i v e s of the agencies t o come Into conferences which the c l i n i c h o l d s , and by m a i n t a i n i n g continuous contact over a p e r i o d o f time i n a given community, I t h i n k t h a t e v e n t u a l l y the agencies begin t o recog-n i z e they can get more help w i t h some cases than w i t h oth e r s . Then they w i l l have a tendency t o r e f e r those cases f o r which the c l i n i c can be of best s e r v i c e . The f o l l o w i n g m a t e r i a l , from the random sample of f i f t y cases seen d u r i n g 1953 by the t r a v e l l i n g c l i n i c , w i l l g i ve an i n d i c a t i o n of the tre n d s , i n r e l a t i o n to the above m a t e r i a l , i n current t r a v e l l i n g c l i n i c p r a c t i c e throughout the B r i t i s h Columbia Mainland. 1. The C h i l d r e n Referred f o r T r a v e l l i n g C h i l d Guidance  C l i n i c E v a l u a t i o n i n 1953 The u n i t o f study i n c h i l d guidance i s the i n d i v -i d u a l c h i l d , w i t h any s e r v i c e s extended t o parents and others i n close contact w i t h the c h i l d , being o f f e r e d i n h i s i n t - -e r e s t s and w i t h the focus upon h i s problem. M o d i f i c a t i o n of f a m i l y and community a t t i t u d e s i s , o f course, an e s s e n t i a l p a r t o f h e l p i n g the c h i l d ; but f o r s t a t i s t i c a l purposes emphasis i s on the c h i l d as a u n i t , the f a m i l y being viewed - 105 -as "environmental f a c t o r s " amenable t o m o d i f i c a t i o n through appropriate casework s e r v i c e s . I n order t o determine the general c h a r a c t e r i s t i c s of the group of c h i l d r e n b e i n g r e f e r r e d f o r t r a v e l l i n g c l i n i c e v a l u a t i o n i n 1953, as seen i n the case sample under study, l e t us look at them i n terms o f : age range sex s t a t u s (home environment) i n t e l l e c t u a l a b i l i t y community of o r i g i n . This w i l l present a g e n e r a l p i c t u r e of the group of c h i l d -r e n c u r r e n t l y being seen by the community as candidates f o r T r a v e l l i n g C l i n i c e v a l u a t i o n . I t w i l l i n d i c a t e , as w e l l , the medium through which the c l i n i c i s now working i n i t s move toward incr e a s e d community mental h e a l t h knowledge and f a c i l i t i e s i n c r e a t i n g a happier, h e a l t h i e r environment f o r i t 8 c i t i z e n s , both c h i l d and a d u l t . Table 2 shows the age range of the c l i e n t s , and the p r o p o r t i o n of each sex w i t h i n the v a r i o u s age groups. Table 2. Age Range and Sex of C l i e n t s i n the Sample Study  of T r a v e l l i n g C h i l d Guidance C l i n i c Cases. 1953. Sex Age i n Years T o t a l 1-4 5-6 7-8 9-10 11-12 13-lit 1$-16 17-18 Boys G i r l s k 2 3 3 5 6 5 r- k 1 1 1 29 21 T o t a l 6 3 5 11 10 8 5 2 50 - 106 -The above t a b l e I n d i c a t e s t h a t the tendency i s f o r a l a r g e r p r o p o r t i o n of boys t o be r e f e r r e d t o the c l i n i c than g i r l s , the r a t i o i n the sample being 2 9 : 2 1 , o r , of the t o t a l , $Q% boys t o 1+2$ g i r l s . The age of the c h i l d r e n ranged from 3 t o 1 7 y e a r s , w i t h the age group 9 t o 1 2 years accounting f o r 21 of the c h i l d r e n , or \2% of the t o t a l s t u d i e d . The remainder of the c h i l d r e n were d i s t r i b u t e d r e l a t i v e l y evenly above and below t h i s c o n c e n t r a t i o n , w i t h l l j . (2Q%) f a l l i n g i n the 1 to 8 year age group, and 1$ (30%) f a l l i n g i n the 13 t o 18 year age group. The age d i s t r i b u t i o n i n boys was much more even than i n g i r l s , w i t h 10 o f the 29 cases being i n the 1 t o 8 year age range, 10 i n the 9 t o 1 2 year age range, and the remaining 9 cases i n the 13 to 18 year age range. The age d i s t r i b u t i o n of g i r l s , on the other hand, was l a r g e l y con-centrated i n the 9 to 1 2 year age group, which accounted f o r 11 of the t o t a l of 2 1 g i r l s r e f e r r e d . Of the remaining 1 0 g i r l s , ij. were younger than 9 years, and 6 were o l d e r than 1 2 y e a r s . On the s u r f a c e , t h i s age d i s t r i b u t i o n i s a f a i r l y t y p i c a l one f o r a c h i l d guidance c l i n i c caseload. I t appears to i n d i c a t e that although some c h i l d r e n are recognized a t an e a r l y age as having problems r e q u i r i n g c l i n i c a l assessment and h e l p , the m a j o r i t y are not r e f e r r e d as e a r l y as i s i n the best I n t e r e s t s o f the c h i l d . I t would be i n t e r e s t i n g to study i n gr e a t e r d e t a i l the trend of T r a v e l l i n g C l i n i c r e f e r r a l s over the y e a r s , i n order tio a s c e r t a i n a d e f i n i t e - 107 -trend i n the r e f e r r a l age of the c l i e n t s . Table 3 . General Family Backgrounds of C l i e n t s i n the Sample Study of. T r a v e l l i n g C h i l d Guidance  C l i n i c Cases. 1953*1 H a t u r a l c h i l d i n own home w i t h both parents H a t u r a l c h i l d i n own home w i t h only one parent Ward of Superinten-dent C h i l d Welfare, I n f o s t e r home C h i l d i n Adoptive Home T 0 T A L on Adoption P r o b a t i o n Adoption Completed 25 9 9 k 3 5 0 The outstanding I n d i c a t i o n i n the above t a b l e i s that one-half of the r e f e r r a l s were c h i l d r e n from an out-wardly p h y s i c a l l y normal home environment, i n s o f a r as they have not s u f f e r e d the trauma of sepa r a t i o n from t h e i r parents by death, i l l n e s s or d e s e r t i o n . Of the remaining 2$ c h i l d r e n , 9 have s u f f e r e d s e p a r a t i o n from one pare n t , but s t i l l have, at l e a s t n o m i n a l l y , the clo s e contact and support of the other parent; 9 are c h i l d r e n who are wards of the Superintendent of C h i l d Welfare, p l a c e d I n f o s t e r homes; and of the 7 c h i l d r e n i n adoptive homes, If were on adoption p r o b a t i o n , and 3 had been l e g a l l y adopted. The broad i m p l i c a t i o n of t h i s i s t h a t 32% o f the c h i l d r e n r e -f e r r e d are those f o r whom s o c i a l agencies have had sol e r e s p o n s i b i l i t y i n p l a n n i n g at some time i n t h e i r l i v e s , and who t r a d i t i o n a l l y form a l a r g e p r o p o r t i o n of c h i l d guidance c l i n i c caseloads. These are the "dependent" c h i l d r e n i n whose welfare c h i l d guidance c l i n i c s have had a t r a d i t i o n a l - 1 0 8 -i n t e r e s t . The use of a sound mental h e a l t h study ensures t h a t the s o c i a l agencies i n whose charge these c h i l d r e n a r e , because of some d i s a s t e r i n t h e i r own homes, w i l l have at t h e i r command the knowledge of the c h i l d and h i s needs t h a t i s e s s e n t i a l to s u i t a b l e p l a n n i n g f o r h i s f u t u r e w e l l - b e i n g . There w i l l be l e s s chance of u n s u i t a b l e , even damaging p l a c e -ments, i f the a v a i l a b l e homes are evaluated i n accordance w i t h the c h i l d ' s needs and p o t e n t i a l , and i n s o f a r as i s pos-s i b l e , placements made w i t h a view to the c o r r e l a t i o n o f the needs of the c h i l d and of the f u t u r e home. The remaining 68$ of the c h i l d r e n are l i v i n g i n t h e i r own homes under the care of one or both p a r e n t s , and presumably were r e f e r r e d because an adjustment problem was recognized and help sought i n i t s s o l u t i o n . The i m p l i c a t i o n i s t hat these homes, on the whole, i n d i c a t e supportive strengths f o r the c h i l d ; and w i t h the exception of the few instances i n which removal of the c h i l d from h i s own home was recommended, t h e i r v o l u n t a r y appearance at c l i n i c i s i n d i c a t i v e o f the parents* r e c o g n i t i o n of the problem, and t h e i r d e s i r e f o r p r o f e s s i o n a l help i n i t s a l l e v i a t i o n . Table 4 » I n t e l l i g e n c e Ratings (as determined by c l i n i c a l  examination) of C l i e n t s i n the Sample Study of  T r a v e l l i n g C h i l d Guidance C l i n i c Cases. 1953.* 0 -1 9 2 0 -4 9 5 0 -6 9 7 0 -n 8 0 -8 9 8 9 -9 9 1 0 0 -109 1 1 0 -1 2 ? 1 3 0 - 1 4 0 + Unable to Assess Tot-a l 1 8 3 1 2 l l 6 4 - 5 5 0 - 109 -Table If i n d i c a t e s t h a t of the 50 c h i l d r e n s t u d i e d , 23 (k-6%) f e l l w i t h i n the slow normal (12 cases) and normal (11 cases) range, i . e . , I.Q. 80-99. Of the remainder, 10 (20$) were i n the b r i g h t normal and s u p e r i o r range o f general i n t e l l i g e n c e — I.Q. 100-129; 12 c h i l d r e n (2k%) were i n the lower range o f i n t e l l i g e n c e ; and 5 s u f f e r e d a d i s t u r b a n c e -p h y s i c a l , emotional or I n t e l l e c t u a l — o f such s e v e r i t y t h a t the i n t e l l i g e n c e p o t e n t i a l could not be e s t a b l i s h e d . Prom t h i s sample, i t would appear then t h a t of the 50 c h i l d r e n seen, only 12 were c h i l d r e n f o r whom i n s t i t u t i o n a l care would probably be i n d i c a t e d ; 33 c h i l d r e n (66$) were c h i l d -ren who, w i t h appropriate h e l p , could f u n c t i o n as respon-s i b l e c i t i z e n s , and who eould, i n a l l but the severely d i s -turbed oases, respond t o casework h e l p ; of the remaining 5 cases (10$ of the t o t a l sample) i n s t i t u t i o n a l i z a t i o n f o r e i t h e r e m o t i o n a l , - p h y s i c a l or i n t e l l e c t u a l disturbance o f a gross nature would i n a l l p r o b a b i l i t y be e v e n t u a l l y i n d i c a t e d . I t would appear then, that of a l l the cases r e f e r r e d , 66% are p o t e n t i a l l y responsive t o appropriate help w i t h i n the community. F i n a l l y , w i t h regard t o the s e m i - r u r a l c e n t r e s 1 from which these c h i l d r e n were r e f e r r e d , i t was seen t h a t they encompossed 23 of the 2I4. d i s t r i c t s v i s i t e d ; and were concentrated i n Vernon, P e n t i c t o n , Granbrook, Abbotsford, T r a i l and Kelowna. 1 Refers to the town and r u r a l areas surrounding i t whose a c t i v i t i e s are centred i n the town. - 110 -In summary, the f o l l o w i n g trends appear: 1. More boys than g i r l s tend to be r e f e r r e d t o c l i n i c - $Q% boys t o IL2% g i r l s . 2. The age of the c h i l d r e n r e f e r r e d ranged from 3 years to 17 years, w i t h l\2$> of the t o t a l sample f a l l i n g i n the 9-12 year age group, 28$ I n the 1-8 year age group, and 30$ i n the 13-18 age group — i . e . , although some problems are recognized e a r l y , the m a j o r i t y are not r e f e r r e d f o r help as soon as i s d e s i r a b l e ; 3. $0% of the c h i l d r e n r e f e r r e d are those l i v i n g i n t h e i r own home w i t h both p a r e n t s ; 1&% are from broken homes but s t i l l are l i v i n g w i t h one parent; and only 32$ of the sample were c h i l d r e n who are or have been dependent upon s o c i a l agencies f o r care and pl a n n i n g . Presumably, then, 68$ of the c h i l d r e n were r e f e r r e d because a problem was recognized and help sought, and t h e i r parents would be a c t i v e l y Involved i n the s o l u t i o n of the problem. This would seem to i n d i c a t e i n c r e a s i n g l y appropriate use of T r a v e l l i n g C l i n i c I n pr e v e n t i v e cases. If. 66$ of the c h i l d r e n r e f e r r e d f e l l w i t h i n the range of general i n t e l l i g e n c e which i s p o t e n t i a l l y responsive t o appropriate help w i t h i n the community; only 2l$ were c h i l d r e n f o r whom i n s t i t u t i o n a l care seemed I n d i c a t e d , and i n 10% of the cases the severe degree o f d i s t u r b a n c e — p h y s i c a l , emotional, or i n t e l l e c t u a l - - w o u l d q u i t e probably not be responsive to treatment w i t h i n the community, but does need assessment i n order t o p l a n a p p r o p r i a t e l y . - I l l -These, then, are the general characteristics of the group of children currently being referred to the Tra-velling Clinic for diagnosis and treatment planning. 2. The Problems Seen by the Community as Indicating the Heed  for C l i n i c a l Assessment and Help The classification of problems presented here rep-resents not the c l i n i c a l diagnosis of the problem, but rather the symptoms which appear as problems to the parents, to the social, health, recreational and educational institutions, and to the people of the Immediate geographical area i n which they arise. Special stress has been placed on studying the fre-quency of complaints as viewed by the referring sources (the community), since the value of any community service such as a Travelling Child Guidance Clinic i s determined, in a pract- i c a l sense, by what can be done to reduce the stresses which cause concern, not only for the child, but for the large num-ber of citizens with whom he i s i n constant contact. Unless this i s achieved, no matter how accurate the diagnosis of the problem may have been, i t i s of l i t t l e value unless i t i s translatable into concrete aids toward the solution of the problem. Social work and other human relations professions recognize that each "case" i s of a complex, particular character. As such: ...an individual problem cannot be solved by label, that i s , by the Identification of one factor, or part of the factors i n i t , but must be diagnosed, that i s , understood as a whole. While a problem must be under-stood as a whole, many Individuals needs can be grouped 112 and met as c l a s s i f i e d . A case i s a problem t r y i n g t o solve i t s e l f . I t s terms i n s o c i a l work are persons. A case i s always somewhere between extremes, and a l -ways presents the q u e s t i o n , not of which cause, but of which combination of causes. A case lends i t s e l f to c l a s s i f i c a t i o n , but not i n one c l a s s o n l y . A case demands respect f o r each person concerned i n i t . I t presents persons i n r e l a t i o n to each other, w i t h equivalent r i g h t s and Independent i n t e r e s t s . The ob-j e c t i v e i n a s o c i a l case i s not to a r r i v e at a s t a t i c or " r i g h t " c o n c l u s i o n , but t o a r r i v e a t a c o n d i t i o n i n which tensions may be balanced or r e l a x e d and d e s i r e s s a t i s f i e d or r e d i r e c t e d . The case under study i s arb-i t r a r i l y l i m i t e d i n time, space, and substance, i n order t h a t change may be 'consciously e f f e c t e d ' , but the human s i t u a t i o n i s o r g a n i c , and the organism and the o r g a n i z a t i o n w i l l continue t o move a f t e r the d i a g -n o s i s i s made, and the new element, whatever i t may be, i s put i n . 1 The above qu o t a t i o n i s a very t i m e l y one i n r e l a t -i o n to the w r i t e r ' s present n e c e s s i t y of reducing the many v a r i a b l e s Inherent i n any given case s i t u a t i o n down t o work-ab l e , meaningful c l a s s i f i c a t i o n s f o r the purposes of s o c i a l r e search. Keeping ever i n mind Mary Gannon's d e s c r i p t i o n of the complexity and m u l t i p l e c a u s a t i o n inherent i n any gi v e n problem, the w r i t e r has adapted the data a v a i l a b l e from the case sample under study: (1) to the purposes of t h i s t h e s i s (2) to the method of s t a t i s t i c a l p r e s e n t a t i o n used by the C h i l d Guidance C l i n i c s of B r i t i s h Columbia i n t h e i r Annual r e p o r t s . The w r i t e r does not see these c l a s s i f i c a t i o n s i n the l i g h t of c r i t e r i a t o be used i n f u t u r e r e s e a r c h , but as adapted Gannon, Mary A., "Guiding Motives i n S o c i a l Work! Hew D i r e c t i o n s i n S o c i a l Work, e d i t e d by Cora Kasius,-Harper & Bros., H.T., 1954> PP« 17-18. - 113 -p a r t i c u l a r l y t o the broad na tu re o f t h i s s t u d y , i n such a way as t o make p o s s i b l e g e n e r a l deduc t i ons about the t r ends i n the p r e s e n t o p e r a t i o n o f the t r a v e l l i n g c l i n i c . Hence l i e s the va lue i n s t u d y i n g the comp l a i n t s b e i n g r e f e r r e d t o the c l i n i c , w i t h a v iew t o s e e i n g what they a r e , t h e i r f r e -quency , and the p r o f e s s i o n a l r e s o u r c e s a v a i l a b l e and i n use f o r mee t ing them. The aim o f f u r t h e r i n g the t rea tment o f the p rob l em w i t h i n the l o c a l community must be kept i n mind at a l l t i m e s . Fo r the pu rposes o f t h i s t h e s i s , a " p r e s e n t i n g p r o b -l em" r e f e r s to those prob lems of wh ich the r e f e r r a l source was aware, a t the, p o i n t o f r e f e r r a l t o the agency which p r e -sented the case to the T r a v e l l i n g C l i n i c team. As has been d i s c u s s e d , i t i s r e c o g n i z e d t h a t i n any g i v e n case a c h i l d may p r e s e n t one o r more o f the problems l i s t e d i n the c l a s s i -f i c a t i o n s . F i g u r e 1 i n d i c a t e s the a c t u a l d i s t r i b u t i o n o f p r e -s e n t i n g problems p e r c a s e . The t o t a l number o f p r e s e n t i n g prob lems i n t h i s case count o f $0, came t o 9 2 . Of the 5>Q cases s t u d i e d , 22 l i s t e d two o r more (up t o if) p r e s e n t i n g p r o b l e m s : 5 cases l i s t e d if p rob lems e a c h ; 10 cases l i s t e d 3 p rob lems e a c h ; 7 cases l i s t e d 2 p rob l ems . Of the r ema in ing 28 c a ses which l i s t e d o n l y one p r e s e n t i n g p r o b l e m , 7 l i s t e d "menta l r e t a r d -a t i o n , " and if l i s t e d " a d o p t i o n e v a l u a t i o n , " b o t h o f which are s u f f i c i e n t cause i n themselves f o r r e f e r r a l f o r c l i n i c a l e v a l u a t i o n . I n the r ema in ing 17 c a s e s , the na tu re o f the ' Case No. i Mental Retardation Disobedience (School) ! Disobedience 1 (Home) | Slow School ! Progress | Truancy | j Adoption j Evaluation a1 • H § © h 1 * 1 to Phobic Reaction 1 Depression and Elation 60 a • H [ Stealing Cruelty to Farm Animals n 1 E H Epilepsy 1 Sexual Play with Other Children Headache s § • H - p as ! 03 at S Exaggerated Int-erest in Fire Inability to Concentrate Enuresis Nail-biting Fighting at School Irregular Sex Relationship Spastic © > 4> O g 4-> 03 © Bizarre Behaviour Anti-Social j a © * I • H Personality Dif-ficulties due to Appearance Obesity 1 rt < E H O E H 1 1 1 2 1 . 1 1 3 3 1 1 4 1 1 K 1 1 5 1 1 7 1 1 8 1 1 -9 1 1 1 3 10 1 1 2 n 1 1 1 3 12 1 1 1 3 1 1 2 4 1 1 1 - 3 1$ 1 l 16 1 l 1 1 1 3 18 1 1 1 3 i ? 1 l 20 1 l 21 1 l 22 1 1 2 23 1 1 2q. 1 1 1 i \ 2$ 1 1 26 1 1 27 1 1 28 1 1_ 29 • . — ' — — — ~ T l " — — . • — _ — ' - . ..2 30 1 1 3i' i 1 ,„,..—• T • • • -•-•« 1 -.} M •y ai f cT'- •• •••••• If 32 1 1 2 33 1 1 34 '1'" 1' • - - • • • - • - 1 1 k 35 1 1 36 1 1 37 1 1 38 1 1 l 3 39 1 1 1 3 40 1 l 1 1 1 1 4 42 1 1 1 3 if3 1 l 1 • 1 2 1 1 46 l 1 1 1 1 1 4 48 1 l 49 1 l 2 50 1 1 10 13 14 5 1 5 2 1 1 1 6 6 2 4 2 1 1 2 1 1 2 1 1 1 1 1 2 1 1 1 1 92 Figure 1. D i s t r i b u t i o n o f Pre s e n t i n g Problems per Case i n the  Sample Study of Cases Seen by T r a v e l l i n g C h i l d  Guidance C l i n i c s . 1953. . - 114 -problem I n d i c a t e d there would be other symptoms present a l s o , of which the p r e s e n t i n g agency was aware, even though the r e f e r r a l source may not have been. These s i n g l e problem r e f e r r a l s i n c l u d e d : slow school progress ( 2 ) , day-dreaming, running away, phobic r e a c t i o n , depression and e l a t i o n , sexual p l a y w i t h other c h i l d r e n , l y i n g , disobedience at sc h o o l , e n u r e s i s , i r r e g u l a r sex r e l a t i o n s h i p s , e p i l e p s y , s p a s t i c i t y , s t e a l i n g , nightmares, p e r s o n a l i t y d i f f i c u l t i e s due to appearance, and b i z a r r e behaviour. Each of these symptoms (or causes) I n d i c a t e s the presence of (or leads to) a problem i n adjustment f o r the c h i l d ; and t h e r e f o r e f a l l s w i t h i n the category of cases which are seen as v a l i d c l i n i c r e f e r r a l s (Chapter I I , Types of Cases). This would i n d i c a t e , on the b a s i s of the cases s t u d i e d , t h a t the l o c a l r e f e r r i n g agencies have a c l e a r p i c t u r e o f which problems i n d i c a t e the need of and would b e n e f i t most from r e f e r r a l f o r c l i n i c a l e v a l u a t i o n and p l a n n i n g f o r treatment. I n other words, the r e f e r r a l s now being made are on the whole appropriate to the s e r v i c e o f f e r e d by the c l i n i c , and f a l l w i t h i n the group of problems seen by the c l i n i c as v a l i d r e f e r r a l s f o r e v a l u a t i o n . Figure 2 presents the frequency w i t h which these problems occur w i t h i n the case sample s t u d i e d . The bulk of the p r o b l e m s — 6 6 — f a l l w i t h i n the main category o f "Primary Behavior D i s o r d e r s , 1 1 which have been d e f i n e d as o c c u r r i n g i n "a person whose l i f e shows the p a t t e r n o f behaviour P r e s e n t i n g Problems Frequency 10 11 12 22k 16" B. 2. 3. 2. 3. I: 6. C. 1. Primary Behaviour Disorders A. Habit Disorders 1. Tantrums Obesity Enuresis H a i l - b i t i n g Masturbation P e r s o n a l i t y Disorders 1. A n t i - s o c i a l Aggressiveness I n a b i l i t y to concentrate Depression and e l a t i o n Daydreaming Due to appearance Neurotic Disorders 1. Nightmares 2. Headaches Conduct Disorders 1. Disobedience (School) Disobedience (Home) Destructiveness S t e a l i n g L y i n g Sex Offences C r u e l t y (farm animals) Exaggerated i n t . i n fir© Running Away Truancy 2. Mental R e t a r d a t i o n 3. Adaption E v a l u a t i o n +• Slow i n School 5. Other TOTAL  D. 2. 3. V. 5. 6. 7. 8. 9. 10. ZZZZZZ2Z zzz i7U 777 TnY/WJJU/YlA WiiMifiMMimiiWMiMA F i g u r e 2. Frequency of Pre s e n t i n g Problems i n the Sample Study of Cases Seen By - 115 -designed to r e l i e v e unconscious t e n s i o n through 'acting-out* i n ways not w e l l adapted to r e a l i t y . " 1 Primary behavior d i s -orders are always r e a c t i o n s to environmental i n f l u e n c e s and I n d i c a t e a c h i l d i n c o n f l i c t w i t h h i s environment, g e n e r a l l y i n such a way that the c o n f l i c t i s r e l a t i v e l y e a s i l y d e t e c t e d , p a r t i c u l a r l y since i t i s expressed i n such a way as t o be d i s -t u r b i n g and u p s e t t i n g to those around him. Disobedience at school and home occur 13 and 11+ times r e s p e c t i v e l y , i . e . , i n 26$ and 28$ of the cases, and tantrums are seen i n 1+ of them. Disobedience, s t e a l i n g , l y i n g , t a n t -r u m s — a l l are types of behavior which are incompatible w i t h the mores of the l o c a l community, and which, when they appear i n a c h i l d , are Immediate cause f o r discomfort and alarm i n parents, schools, and other community i n s t i t u t i o n s . That they loom l a r g e i n the c l i e n t e l e of a c h i l d guidance c l i n i c i s t h e r e f o r e t o be expected. S i m i l a r l y , e n u r e s i s , mastur-b a t i o n , daydreaming, sex offences ( d e v i a t i o n s ) and c r u e l t y to farm animals, each of which occur i n 2 of the cases, are un-acceptable t o r u r a l c i t i z e n s , and are o b v i o u s l y i n d i c a t i v e of maladjustment problems. Mental r e t a r d a t i o n ( i n 10 o f the c a s e s ) , and slow school progress ( i n 5) are a l s o obvious and v a l i d i n d i c a t i o n s f o r r e f e r r a l to C l i n i c . Adoption e v a l u a t i o n 1 Hamilton, Gordon, Psychotherapy i n C h i l d Guidance, Columbia U n i v e r s i t y P r e s s , New York, 1950, p. 20. 2 I b i d . . p. 32. - 116 -( i n 5 cases) i s an accepted c l i n i c a l service. The grouping "other" includes extreme behaviour—phobic reaction (once) and bizarre behaviour (twice)—and extreme physical d i s o r d e r s — epilepsy (twice) and spastic ( o n c e ) — a l l of which deviate from the normal to such a degree as to be i n s t a n t l y recognizable as posing a problem to the c h i l d , and to the community. The greater proportion of problems referred f o r c l i n i c a l services are, therefore, within the group of d i s -orders which e i t h e r cause discomfort or disturbance within the community, or are s u f f i c i e n t l y abnormal i n manifestation as to be Immediately seen as deviations from the "normal." They present problems i n adjustment, and are therefore v a l i d requests f o r evaluation and help In planning f o r t h e i r a l l e v i a t i o n . On examining the remainder of the presenting prob-lems—those which occur only once i n the cases studied--one finds further representation from the group of conduct d i s -orders—destructiveness, exaggerated i n t e r e s t i n f i r e , running away, truancy. These also l i e within the e a s i l y recognizable, and upsetting group of behavior disorders. The remaining problems, obesity, n a i l - b i t i n g , a n t i -s o c i a l behavior aggressiveness, i n a b i l i t y to concentrate, depression, and e l a t i o n , personality d i f f i c u l t i e s due to appearance, nightmares, headaches, represent lQ% of the t o t a l . These problems are not so obviously disturbing to c i t i z e n s as are the other 82$; and t h e i r i n c l u s i o n within the c l i n i c - 117 -r e f e r r a l s seems t o i n d i c a t e g r e a t e r awareness o f the b a s i c p r i n c i p l e s of mental hygiene and i n c r e a s i n g I n t e r e s t i n the e a r l y d e t e c t i o n and pr e v e n t i o n of p o t e n t i a l l y unhappy—rather than merely u p s e t t i n g — c h i l d r e n and a d u l t s . Each of these symptoms, p a r t i c u l a r l y when o c c u r r i n g i n r e l a t i o n t o other symptoms, i n d i c a t e s the wisdom of a f u l l c l i n i c a l i n v e s t i g a -t i o n as t o the o r i g i n of the dist u r b a n c e . Since they are not as m a n i f e s t l y i n d i c a t i v e of disturbance as, f o r i n s t a n c e , disobedience, s t e a l i n g , or l y i n g , they might e a s i l y go un-n o t i c e d i n a community, were i t not i n t e r e s t e d i n the welfare of i t s c h i l d r e n , and a l e r t e d t o mental h e a l t h concepts and danger s i g n a l s . I t has been seen t h a t , although the m a j o r i t y of problems presented f o r c l i n i c a l e v a l u a t i o n f a l l w i t h i n the group o f disturbances which are r e a d i l y manifest and u p s e t t i n g t o others g e n e r a l l y , 18$ of the cases present problems which i n d i c a t e a deeper understanding of the p r i n c i p l e s of mental h e a l t h and an i n t e r e s t i n e a r l y p r e v e n t i o n , r a t h e r than p u r e l y a l l e v i a t i o n of troublesome symptoms. I n other words, the r u r a l communities at present u t i l i z i n g t r a v e l l i n g c l i n i c , are s t i l l r e f e r r i n g , as would be expected, the most t r o u b l e - . some and u p s e t t i n g cases f o r c l i n i c a l s e r v i c e . I t would appear, however, t h a t , presumably based on the help prev-i o u s l y r e c e i v e d w i t h these s i t u a t i o n s , p l u s the gre a t e r gen-e r a l understanding of c h i l d r e n ' s behavior and p e r s o n a l i t y problems and needs through community mental h e a l t h education - 118 -methods, there i s a g r e a t e r awareness of the value of prev-e n t i o n , and gre a t e r understanding o f the more subtle aspects of mental i l l h e a l t h . The t r e n d , based on the sample under study, appears to be moving toward u s i n g the c l i n i c i n a preventive way before gross problems appear. This trend needs to continue, i n order t h a t maximum e f f e c t i v e use of c l i n i c s e r v i c e i s a t t a i n e d . This trend can be st a t e d only t e n t a t i v e l y ; and i n the i n t e r e s t s of the f o c u s s i n g of f u t u r e c l i n i c a l prog-ram, a d e t a i l e d study of cases over the years would d e f i n i t e l y r e v e a l the t r e n d i n r e f e r r a l of problems to the c l i n i e , and would i n d i c a t e areas i n which f u r t h e r emphasis i s i n d i c a t e d . 3. The Sources of R e f e r r a l of These Problems t o C l i n i c Our next q u e s t i o n i s : where are these problems which are being r e f e r r e d to the t r a v e l l i n g c l i n i c f i r s t recognized as problems, and as such, i n need of p r o f e s s i o n a l e v a l u a t i o n . The answer w i l l i n d i c a t e which groups w i t h i n the va r i o u s l o c a l communities under study have s u f f i c i e n t under-standing of and i n t e r e s t i n : (1) c h i l d r e n ' s needs and problems, and (2) c l i n i c a l s e r v i c e s , as to recognize the exist e n c e of the problem, and the value of c l i n i c a l a i d toward i t s s o l u t i o n . I n t h i s connection, M o r r i s Krugman has summed up the question a t hand s u c c i n c t l y : 1 1 Krugman, M o r r i s , I n s t i t u t e f o r C l i n i c Personnel of the C h i l d Guidance C l i n i e s . a n d I n s t i t u t i o n s of the Hew York State Department of Mental Hygiene, p. 25. - 119 -The c r i t e r i o n f o r the success o f a c l i n i c i s not the judgment of the c l i n i c members, but the value  pla c e d upon the s e r v i c e s of the c l i n i c by the com-munity. Sometimes a c l i n i c v i l l i . a c t u a l l y render v a l -uable s e r v i c e , but the community has not been taken i n t o i t s confidence and does not know about, or under-stand, t h i s s e r v i c e . The breakdown of p r e s e n t i n g problems s t a t e d by the r e f e r r a l sources as shown i n Table f> w i l l give general i n d i c a t i o n s of awareness, va l u e , and use of c l i n i c a l ser-v i c e s as p e r c e i v e d by those who make r e f e r r a l s t o the c l i n i c . Table £ i n d i c a t e s t h a t o f the cases being s t u d i e d , 33$ of the problems were r e f e r r e d by the schools, 21$ by S o c i a l Welfare Branch, 17$ by P u b l i c H e a l t h U n i t , 17$ by par-ents, 7$ by d o c t o r s , 1 $ by p r o b a t i o n o f f i c e r s , and 1$ by J u v e n i l e Court. I n the sample under study, the greater p r o p o r t i o n , 60$, of school r e f e r r a l s i n v o l v e d conduct d i s o r d e r s — i n the f o l l o w i n g d i s t r i b u t i o n : disobedience a t school (7 i n s t a n c e s ) ; disobedience at home ( 5 )J l y i n g (3)J s t e a l i n g ( 2 ) ; and truancy (1) . P e r s o n a l i t y d i s o r d e r s represented 13$ of the school r e f e r r a l s , and i n v o l v e d 1 case each o f : a n t i - s o c i a l b ehavior; i n a b i l i t y to concentrate; daydreaming; and p e r s o n a l i t y d i s -order due t o appearance. Slow school progress accounted f o r a f u r t h e r 13$ of the school r e f e r r a l s , and occurred i n 4 cases. Mental r e t a r d a t i o n i n 2 Instances was the reason f o r r e f e r r a l ; tantrums were i n c l u d e d i n 1 case r e f e r r a l , as was b i z a r r e behavior. to f o l l o w page 119 Table 5. Sources of R e f e r r a l of Problems Presented i n the  Sample Case Stud? of Cases Seen by T r a v e l l i n g  C h i l d Guidance C l i n i c . 1953. Presen t i n g Problems H _ o ti as as £ • H PQ o o •p H as CD R e f e r r a l Sources H o o CO at o o o a • H U -P CO ai o .a «H O <M SW u eu o © H •ri > g 3 o at •P O 6* 1. Primary Behaviour  Disorders A. Habit Disorders 1.Tantrums 2 .Obesity 3. E n u r e s i s 4. H a i l - b i t i n g 5. Masturbat i o n 4 1 2 1 B. P e r s o n a l i t y  Disorders 1. A n t i - s o c i a l 2. Aggre s sivenes s 3 . I n a b i l i t y t o concentrate 4. Depression and E l a t i o n 5. Daydreaming 6. Due to Appearance^ 1 1 1 1 1 1 1 2 1 C. Heurotlc D i s o r d e r s 1. Nightmares 2. Headaches 1 1 D. Conduct Disorders 1. Disobedience (School) 2. " (Home) 3. D e s t r u c t i v e 4 . S t e a l i n g 5* Eying 6.Sex Offences ?.Cruelty (Farm Animals) 8. Exaggerated I n t . i n f i r e 9. Running Away 10.Truancy 2. Mental R e t a r d a t i o n 3. Adoption E v a l u a t i o n 4» Slow i n School 5. Other TOTAL 3 3 1 1 1 2 1 1 7 5 2 3 1 5 1 3 1. 1 1 2 4 1 1 1 1 1 13 14 1 6 6 2 1 1 1 10 5 6. 19 16 2 1 16 92 - 120 -The a c t i v e r e c o g n i t i o n of t r a v e l l i n g c l i n i c s e r v i c e s by the schools i s a p o s i t i v e s i g n . The sch o o l I s , f o r many reasons, a key i n s t i t u t i o n i n d e a l i n g w i t h c h i l d r e n ^ prob-lems. I t can f r e q u e n t l y be used t o meet some c h i l d r e n 1 s needs when the home f a i l s to f u n c t i o n . Even i f the school can not adequately meet a l l needs, the school personnel can f r e q u e n t l y be e n l i s t e d i n a supportive program so t h a t pressures on the c h i l d are lessened and s u b s t i t u t i o n s provided. Even i f no treatment program i s p o s s i b l e , a c q u a i n t i n g school personnel w i t h the r e s u l t s o f a d i a g n o s t i c study o f t e n arouses sympathy and r e s u l t s i n b e t t e r handling. The p r o p o r t i o n of r e f e r r a l s by parents i s a l s o en-couraging, but w i l l h o p e f u l l y i n c r e a s e . The parents are more l i k e l y to be r e c e p t i v e t o c l i n i c a l e v a l u a t i o n and i n d i c a t e d casework s e r v i c e s , i f they themselves have i n i t i a t e d the pro-cess. As c l i n i c a l s e r v i c e s become more accepted and i n t e -grated i n t o the l o c a l community, t h i s source of r e f e r r a l of problems would, we t r u s t , i n c r e a s e , w i t h more and more parents being i n v o l v e d r i g h t from the beginning i n e f f o r t s toward the understanding and s o l u t i o n , or at the l e a s t , a l l e v i a t i o n , o f the problems i n v o l v e d . I n the case sample, $0% of p a r e n t a l r e f e r r a l s i n -volved conduct d i s o r d e r s , and were d i s t r i b u t e d as f o l l o w s : disobedience at school ( t w i c e ) ; disobedience at home ( t w i c e ) ; s t e a l i n g , l y i n g , sex of f e n c e s , and exaggerated i n t e r e s t i n f i r e s (once each). A l a r g e percentage (1+0%) of the t o t a l h a b i t d i s o r d e r s were r e f e r r e d by parents, and accounted f o r - 121 -25$ of the t o t a l p a r e n t a l r e f e r r a l s . They i n c l u d e d : tantrums ( t w i c e ) ; o b e s i t y and masturbation, once each. Both cases i n which n e u r o t i c d i s o r d e r s were Included were r e f e r r e d by par-ents. One c h i l d was r e f e r r e d by parents who suspected mental r e t a r d a t i o n , and another c h i l d f o r problems r e s u l t i n g from a s p a s t i c c o n d i t i o n . The S o c i a l Welfare Branch workers r e f e r r e d problems accounting f o r 21$ o f the t o t a l p r e s e n t i n g problems. I t i s i n t e r e s t i n g t h a t more r e f e r r a l s were not made from t h i s source, as one would expect. Further study of the trend of r e f e r r a l sources over the years would be i l l u m i n a t i n g , but wi t h the m a t e r i a l s at hand, one can only speculate as to the i m p l i c a t i o n s i n v o l v e d . Again, the greatest p r o p o r t i o n of r e f e r r a l s i n v o l v e conduct d i s o r d e r s — t h i s time lj.2$—and again disobedience at home and school predominate, w i t h each appearing i n 3 cases. L y i n g and sex offences comprise the remainder of the conduct d i s o r d e r s r e f e r r e d . The t o t a l cases (5) r e f e r r e d f o r adoption e v a l u a t i o n came, as a matter of p o l i c y , through S o c i a l Welfare Branch. Three o f the S o c i a l Welfare Branch r e f e r r a l s i n v o l v e d the se r i o u s d e v i a t i o n s from the normal, i n c l u d i n g e p i l e p s y and phobic r e a c t i o n . One case i n which a h a b i t d i s o r d e r (enuresis) and one i n which a per-s o n a l i t y d i s o r d e r (aggressiveness) was Involved, formed the remainder of the S o c i a l Welfare Branch r e f e r r a l s . The P u b l i c Health U n i t s were r e f e r r a l sources f o r the same number of problems as were p a r e n t s , thus coming - 122 -t h i r d i n l i n e of a c t i v i t y . Again the conduct d i s o r d e r s loomed l a r g e , forming 43$ of t h i s agency's r e f e r r a l s ; but the d i s -t r i b u t i o n of problems was not as concentrated on disobedience as i n the sources of r e f e r r a l already d i s c u s s e d . I n s t e a d , we f i n d a s c a t t e r i n g of problems, w i t h 2 cases of disobedience a t home, and one each o f : disobedience at s c h o o l , s t e a l i n g , l y i n g , c r u e l t y t o farm animals, and running away. Three of the cases of mental r e t a r d a t i o n were r e f e r r e d by the P u b l i c H e a l t h U n i t , and one each of slow school progress, e p i l e p s y , tantrums, and masturbation. P h y s i c i a n s ' r e f e r r a l s accounted f o r 1% of the pre-senting p r o blems—not a l a r g e p r o p o r t i o n , but a promising beginning of a trend t h a t needs to be encouraged f u r t h e r , as doctors are i n a p o s i t i o n of confidence and t r u s t w i t h t h e i r p a t i e n t s and t h e r e f o r e i n a p o s i t i o n t o recognize e a r l y symp-toms of di s t u r b a n c e , and r e f e r f o r e v a l u a t i o n and p l a n n i n g . Only 2 of these r e f e r r a l s were f o r mental e v a l u a t i o n , the others being conduct d i s o r d e r s (3), disobedience at home, d e s t r u c t i v e n e s s , c r u e l t y t o farm animals, and n a i l - b i t i n g ( 1 ) . I n 1+ i n s t a n c e s , problems were r e f e r r e d by P r o b a t i o n O f f i c e r s — m e n t a l e v a l u a t i o n , disobedience at home, s t e a l i n g and enuresis comprising t h i s group of r e f e r r a l problems. There was only one instance of a J u v e n i l e Court r e f e r r a l , i n v o l v i n g s t e a l i n g . I t does, however, i n d i c a t e at l e a s t a beginning r e c o g n i t i o n by the Court o f the p o s s i b i l -- 123 -i t i e s of treatment and prevention rather than incarceration f o r early offences against the law. In summary, then, problems tend to be recognized and referred by l o c a l community groups i n the following order: 1. Schools 2. S o c i a l Welfare Branch 3. Parents, and Public Health Units if. Doctors 5. Probation O f f i c e r s 6. Juvenile Court Emphasis i n a l l groups i s upon the problems f a l l i n g within the group of conduct disorders, with p a r t i c u l a r emphasis on disobedience notable i n school, S o c i a l Welfare Branch, and parental r e f e r r a l s . Personality disorders tend to be referr e d by the schools, neurotic disorders by the parents, and a large proportion of habit disorders likewise by the parents. A l l adoption evaluation cases are referred by S o c i a l Welfare Branch, also h a l f of the problems i n d i c a t i n g serious deviations from the normal, as discussed e a r l i e r . Schools understandably f i n d slow school progress a cause f o r concern, and referr e d if out of 5 cases; the Public Health Nurse r e f e r r e d the other. Mental retardation tends to be referr e d mainly by Public Health Units, with schools and doctors a close second. - 121+ -k» Channels of Presentation of Cases to T r a v e l l i n g C l i n i c * and of Carrying Out Treatment Recommendations Generally speaking, the agency presenting the case to the c l i n i c i s , with a few exceptions, the one which f o l -lows up the c l i n i c a l evaluation, and i s active i n treatment. In studying the question of the frequency with which c e r t a i n agencies r e f e r problems to t r a v e l l i n g c l i n i c , we can get a general picture of the extent to which the c l i n i c i s integrated into the communities. These agencies—health, welfare, and education—represent the supporting services within the com-munity, and have as one of t h e i r Important goals maximum con-t r i b u t i o n to the welfare of the i n d i v i d u a l to whom they o f f e r services. I t has been said that i n any one day these support-ing services successfully treat more p s y c h i a t r i c problems than a l l the p s y c h i a t r i s t s i n the country treat successfully i n a y e a r . 1 The importance of the r e l a t i o n s h i p between the c l i n i c and these community i n s t i t u t i o n s or agencies cannot be over-stressed, since i t i s i n the community that the actual prev-entive work i s going to be done; and i t i s through our contact with these agencies that we are best able to apply, on a com-munity-wide basis, our understanding of the basic fac t o r s that enter into personality development, and of where the stresses and st r a i n s are i n the general environment. Conferences held with these r e f e r r i n g agencies enable them to understand the 1 Coleman, Dr. J.C., "Relating the Professional Services of the C l i n i c to Other Professional Groups i n the Community,M Hew York Institute of Child Guidance C l i n i c s Personnel, 19J?0, p • 66 • - 125 " strengths and l i m i t a t i o n s of the c l i n i c , and enable the c l i n i c team t o encourage the c a r r y i n g out of treatment recommendations. A study o f which agencies tend to be more a c t i v e i n p r e s e n t a t i o n of cases t o c l i n i c has a tw o - f o l d v a l u e : (1) as an i n d i c a t i o n o f which agencies are a c t i v e l y i n v o l v e d i n treatment; (2) as an i n d i c a t i o n of the agencies who, presum-a b l y , have found c l i n i c r e f e r r a l h e l p f u l , and are t h e r e f o r e , l i k e l y to increase t h e i r use of t r a v e l l i n g c l i n i c . Table 6. Frequency D i s t r i b u t i o n of Agency Case P r e s e n t a t i o n  to T r a v e l l i n g C h i l d Guidance C l i n i c . 1953. as  i n d i c a t e d i n a Random Sample Case Study S o c i a l Welfare Branch P u b l i c H e alth U n i t Schools (Mental H e a l t h Coordinators & Counsellors) P r o b a t i o n O f f i c e r T o t a l 29 18 2 1 50 According to the above f i g u r e s , S o c i a l Welfare Branch presented the l a r g e s t p r o p o r t i o n of cases t o t r a v e l l i n g c l i n i c i n 1953—5856 of the cases i n the sample. The P u b l i c H e a l t h U n i t s came next, p r e s e n t i n g 36% of the r e f e r r a l s i n the sample; schools presented 2 ik%) °f the cases, and prob-a t i o n o f f i c e r s only one case {2%). - 126 -A f u r t h e r study of the a c t u a l channels of r e f e r r a l , from the time the case i s recognized as p r e s e n t i n g a problem and r e f e r r e d f o r s e r v i c e , to i t s a c t u a l p r e s e n t a t i o n a t c l i n i c , w i l l give some general i n d i c a t i o n of the trends i n r e f e r r a l and agency l i a i s o n s w i t h i n the urban communities of B r i t i s h Columbia. Table 7. Community Agencies Through Which the R e f e r r a l Sources  Contacted C l i n i c i n Sample Study of T r a v e l l i n g C h i l d  Guidance C l i n i c Cases. 1953. R e f e r r a l P r e s e n t i n g Agency • Tot a l Source S o c i a l Welfare Branch P u b l i c H e a l t h . U n i t Schools P r o b a t i o n O f f i c e r s S o c i a l Welfare Branch 11 1 12 P u b l i c H e a l t h U n i t 2 k 6 Schools k 10 1 15 Parents 8 1 9 Doctors 2 3 5 P r o b a t i o n O f f i c e r s 1 1 2 J u v e n i l e Court 1 1 TOTAL 29 18 2 1 50 - 127 -The above t a b l e I n d i c a t e s t h a t of the 5>0 oases under study, the school r e f e r r e d 30$; S o c i a l Welfare Branch, 24$; parents r e f e r r e d 18$; P u b l i c Health U n i t r e f e r r e d 12$; doc-t o r s , 10$; P r o b a t i o n O f f i c e r s 4#» and J u v e n i l e Court, 2$. The schools, the main r e f e r r a l source, r e f e r r e d , o f t h e i r 1$ cases, 4 t o S o c i a l Welfare Branch, 10 t o P u b l i c H ealth U n i t , and 1 d i r e c t l y to C l i n i c . Schools, t h e r e f o r e , tend to work predominantly through the P u b l i c H e a l t h U n i t , but do r e f e r a s i g n i f i c a n t number through S o c i a l Welfare Branch. Where there are school c o u n s e l l o r s , or Mental H e a l t h Coordinators, they do o c c a s i o n a l l y a c t u a l l y present the case to the c l i n i c . The S o c i a l Welfare Branch, second most frequent r e f e r r a l source, presented 11 of i t s 12 r e f e r r a l s d i r e c t l y t o the t r a v e l l i n g c l i n i c , and 1 was presented through the P u b l i c Health U n i t . Parents, t h i r d r e f e r r a l source, r e f e r r e d 8 of t h e i r 9 cases through S o c i a l Welfare Branch, and 1 through the schools. The P u b l i c Health U n i t s , f o u r t h r e f e r r a l source, presented 4 of t h e i r r e f e r r a l s d i r e c t l y t o c l i n i c , and 2 through S o c i a l Welfare Branch. P h y s i c i a n s r e f e r r e d 5> cases, 2 through S o c i a l Wel-f a r e Branch, and 3 through P u b l i c H e a l t h U n i t . P r o b a t i o n O f f i c e r s r e f e r r e d 2 cases, 1 d i r e c t l y , and 1 through the S o c i a l Welfare Branch. - 128 -The moat obvious trends are f o r schools to r e f e r l a r g e l y through P u b l i c H e a l t h U n i t s , and f o r parents t o request help of S o c i a l Welfare Branch. Both S o c i a l Welfare Branch and P u b l i c H e a l t h Nurses tend to present t h e i r own case; but the P u b l i c H ealth Nurses seem more f l e x i b l e i n t h i s r e s p e c t , although the b a s i s of r e f e r r a l to S o c i a l Wel-f a r e Branch f o r c l i n i c a l p r e s e n t a t i o n i s not c l e a r . Speak-i n g g e n e r a l l y , the w r i t e r f e e l s t h a t more i n t e r a c t i o n between S o c i a l Welfare Branch and P u b l i c Health Nurses would i n d i c a t e more h e a l t h y community l i a i s o n s ; however, here again, a d e t a i l e d study of trends over the years i n s p e c i f i c commun-i t i e s would be necessary before making any a u t h o r i t a t i v e statement. Doctors understandably work more through P u b l i c Health U n i t s than through S o c i a l Welfare Branches, but the f a e t that 2 of 5 r e f e r r a l s were t o S o c i a l Welfare Branch would seem t o i n d i c a t e a growing r e c o g n i t i o n by the l o c a l doctors of the value of s o c i a l work s e r v i c e s and focus i n the treatment of behavior and p e r s o n a l i t y d i s o r d e r s . I n Summary, S o c i a l Welfare Branch and P u b l i c H e a l t h U n i t case p r e s e n t a t i o n s are predominant, w i t h S o c i a l Welfare Branches p r e s e n t i n g 58$ of the t o t a l sample cases, and P u b l i c H e a l t h U n i t s 36$. Schools and p r o b a t i o n o f f i c e r s presented the remaining cases. Schools tend to r e f e r mainly through the l o c a l P u b l i c H e a l t h U n i t , and parents through the l o c a l S o c i a l Welfare Branch. S o c i a l Welfare Branch and P u b l i c - 129 -He a l t h Nurses tend t o present t h e i r own r e f e r r a l s . Doctors r e f e r to both P u b l i c H ealth Nurses and S o c i a l Welfare Branches i n a r a t i o o f 3*2. P r o b a t i o n o f f i c e r s presented 1 case, r e f e r r e d another to S o c i a l Welfare Branch; and J u v e n i l e Court r e f e r r e d 1 case to S o c i a l Welfare Branch f o r p r e s e n t a t i o n t o t r a v e l l i n g c l i n i c . 5. The Spreading o f C l i n i c a l Understanding and Knowledge of  Treatment of Children's Problems through the Use of Case  Conference, I.e.. Teaching by Case Method There i s g e n e r a l agreement on the f a c t t h a t the most e f f e c t i v e mental hygiene education stems from the c l i n -i c a l worker through the case approach. Case d i s c u s s i o n s , conferences and workshops w i t h school personnel and a l l i e d human r e l a t i o n s p r o f e s s i o n s , on l i v e cases, have been found to be much more e f f e c t i v e than g e n e r a l i z e d l e c t u r e or d i s -c u s sion groups. 1 I n the f i e l d o p e r a t i o n of the B r i t i s h Colum-b i a Mainland T r a v e l l i n g C h i l d Guidance C l i n i c , the case con-ference i s , as has been discussed p r e v i o u s l y , seen not only as g i v i n g s p e c i f i c understanding and help around a g i v e n case s i t u a t i o n , but, e q u a l l y as important, as i n c r e a s i n g the understanding, i n s i g h t s and s e n s i t i v i t y of those i n attendance toward other c h i l d r e n w i t h whom they are i n d a i l y or frequent contact. Increased awareness of gaps i n l o c a l s o c i a l s e r v i c e s t r u c t u r e , may be more obvious i n the study 1 Krugman, M., Ph.D., a r t i c l e i n New York I n s t i t u t e o f C h i l d Guidance C l i n i c Personnel, 1950, P« 27. - 130 -of a p a r t i c u l a r s i t u a t i o n ; and ways and moans of f i l l i n g these gaps are best implemented through those professional groups i n general attendance at such conferences. The importance of estimating to what extent the t r a v e l l i n g c l i n i c i s currently making use of t h i s most power-f u l educational channel i s self-evident. In r u r a l B r i t i s h Columbia, one of the main sources, i f not the main source, of mental health education, i s the t r a v e l l i n g c l i n i c . A study, therefore, of the use currently being made of i t s educational channels i s doubly s i g n i f i c a n t , not only i n terms of more ef f e c t i v e c l i n i c a l operation, but equally i n terms of the extent of increased general professional and public under-standing achieved. This part of our study i s to determine, within the scope of the study sample, f i r s t , the extent to which profes-s i o n a l groups are being included i n case conferences; and secondly, which presenting agencies are most a c t i v e l y seeking the use of the case conference to further understanding and cooperation within the community, i n the i n t e r e s t s of general mental health. In the 50 cases under study, conference attendance ranged from 2 persons to 13 persons, and t o t a l l e d 2&k persons, i . e . , an average of 5 to 6 persons per case. Those profes-sions represented were: s o c i a l workers, public health nurses, public health doctors, mental health coordinators, school p r i n c i p a l s , school counsellors, school teachers, p r a c t i c i n g physicians, probation o f f i c e r s , ministers, V i c t o r i a Order of - 131 -Nursing s t a f f , and school i n s p e c t o r s . I n studying the d i s -t r i b u t i o n of attendance per case conference, the emphasis was upon S o c i a l Welfare Branch (i}.3$), and P u b l i c Health Nurse (32$), personnel, w i t h school personnel (21$), t h i r d i n num-ber. These are the three p r o f e s s i o n a l groups most a c t i v e l y i n contact w i t h c h i l d r e n and most a c t i v e l y i n v o l v e d i n the d e t e c t i o n and treatment of c h i l d r e n * s problems. This con-c e n t r a t i o n upon these three groups bodes w e l l f o r the prev-enti v e program, and i s a p o s i t i v e s i g n . The i m p l i c a t i o n i s t h a t more and more e a r l y problems w i l l be recognized, and h o p e f u l l y handled by these groups. The v a s t drop i n the a t -tendance of other p r o f e s s i o n a l people at case conferences, however, would appear to i n d i c a t e that the p o t e n t i a l i t i e s of t h e i r a c t i v e p a r t i c i p a t i o n i n the d e t e c t i o n , r e f e r r a l , and even i n some cases treatment, of c h i l d r e n ' s problems have not been recognized by the l o c a l h e a l t h and welfare agencies; or i t may i n d i c a t e non-acceptance by these p r o f e s s i o n s of the mental hygiene approach; o r , a t h i r d a l t e r n a t i v e might be t h a t the competence of the c l i n i c and l o c a l s t a f f to d e a l w i t h e a r l y symptoms i s not y e t f u l l y accepted by other p r o f e s s i o n a l groups w i t h i n the community. In any case, f u r t h e r concen-t r a t i o n and e f f o r t at i n c l u d i n g these p r o f e s s i o n s , p a r t i -c u l a r l y d o c t o r s , m i n i s t e r s , and upon occ a s i o n lawyers (none of whom appeared i n the cases studied) i n case conferences, and d i r e c t i n g towards them i n t e r p r e t a t i o n o f c l i n i c a l ser-v i c e s and help a v a i l a b l e w i t h i n the community f o r the c h i l d - 132 -with, a problem, i s i n d i c a t e d i n the i n t e r e s t s of a stronger, more e f f e c t i v e community mental h e a l t h s t r u c t u r e . S o c i a l Welfare Branch presented 29 cases at T r a v e l l i n g C l i n i e (see Table 6), and a t o t a l of 159 persons were present at these conferences, i . e . , an average of 5.1 per-sons per conference. Of these, $3% were s o c i a l workers, 27% were P u b l i c Health U n i t personnel, 17% were school personnel. The remainder i n c l u d e d three p r o b a t i o n o f f i c e r s , one m i n i s t e r , and no l o c a l d octors. P u b l i c Health Nurses presented 19 cases t o Tra-v e l l i n g C l i n i c (see Table 6) and i n c l u d e d i n the case confer-ences were 108 persons, i . e . , an average of 5.7 persons per conference— . 6 higher than S o c i a l Welfare Branch. Of these, 38% were P u b l i c Health U n i t p e r s o n n e l , 30% were s o c i a l workers, and 27% were school personnel. The remainder i n c l u d e d 2 do c t o r s , 2 p r o b a t i o n o f f i c e r s , and 2 other pro-f e s s i o n a l persons. I n comparing conference attendance at cases pre-sented by the S o c i a l Welfare Branch and the P u b l i c H e a l t h U n i t , i t appears t h a t the P u b l i c Health U n i t i n c l u d e s other p r o f e s s i o n s — m a i n l y s o c i a l work and e d u c a t i o n — t o a g r e a t e r degree than does S o c i a l Welfare Branch. The l a t t e r tends to concentrate more on i t s own s t a f f , who c e r t a i n l y should be in c l u d e d as much as p o s s i b l e ; but a broader group o f p r o f e s s i o n s needs t o be i n c l u d e d as w e l l , i f maximum use i s to be made of the conferences, as a means of i n t e r p r e t i n g Table 8. Attendance at T r a v e l l i n g C l i n i c Case Conferences. 1953» In R e l a t i o n to.the Agency P r e s e n t i n g the Case. PRESENTING AGENCY CONFEREE CE ATTENDANCE T o t a 1 P u b l i c H ealth Nurse P u b l i c H e a l t h U n i t Doctor S o c i a l Worker Mental H e a l t h Coordi-n a t o r School Coun-s e l l o r P r i n -c i p a l Tea-cher Doc-t o r Proba-t i o n O f f i -cer Other SOCIAL WELFARE BRANCH 38 5 85 1 7 2 17 3 1 159 PUBLIC HEALTH UNIT 30 l l 32 3 7 19 2 2 2 108 PROBATION OFFICER 1 2 .-• 3 SCHOOL " k l 4 2 1 2 - 14 TOTAL 73 17 123 3 10 10 38 2 5 3 284 - 133 -c h i l d r e n ' s needs and c l i n i c a l s e r v i c e s t o the v a r i o u s comm-u n i t y p r o f e s s i o n a l groups. I n summary, attendance at case conferences i n c l u d e s mainly S o c i a l Welfare Branch, P u b l i c Health U n i t , and school personnel, Doctors, p r o b a t i o n o f f i c e r s , m i n i s t e r s , and V i c t o r i a Order of Nurses are a l s o i n c l u d e d upon occasion, but more emphasis needs t o be pl a c e d on t h e i r p o t e n t i a l con-t r i b u t i o n s both i n a s p e c i f i c s i t u a t i o n , and i n the general community mental h e a l t h programme. The P u b l i c H e a l t h U n i t tends to Include s l i g h t l y more people i n the conferences i t c a l l s , and to i n c l u d e a gr e a t e r p r o p o r t i o n o f school per-sonnel. The S o c i a l Welfare Branch, on the b a s i s of t h i s study, does not appear as w e l l i n t e g r a t e d i n t o the community p r o f e s s i o n a l groups, as does the P u b l i c H e a l t h U n i t . Of the 5© cases s t u d i e d , i n 7 of the cases there was no represent-a t i v e present from the P u b l i c H e a l t h U n i t , and i n i f , no rep-re sent at a ve of S o c i a l Welfare Branch. I n 39 of the cases, however, there was at l e a s t a degree of c o l l a b o r a t i o n on the cases, t o the extent of attendance at conference. Only a d e t a i l e d study by community would r e v e a l the extent of c o l -l a b o r a t i o n . However, the general i m p l i c a t i o n from the sample study f i g u r e s i s t h a t P u b l i c Health U n i t s and S o c i a l Welfare Branches do on the whole c o l l a b o r a t e on t h e i r cases. I t i s the w r i t e r ' s impression t h a t more use of the case conference could be made by the f i e l d , once i t s f u l l value and purpose i s more c l e a r l y recognized. - 134 -6. The Trend of C l i n i c a l Recommendations f o r Treatment of  the Problems Presented As has been discussed e a r l i e r , emphasis i n t h i s study i s not upon the diagnostic evaluation as such, but i s rather upon the use made of i t i n terms of the available community resources. Since at the present time the agency presenting the case to c l i n i c almost invar i a b l y does the follow-up and implements the recommended treatment, the question of the gearing of recommendations to the s k i l l s of the presenting agency a r i s e s . Ideally, again, one would hope to see, f o r example, cases i n which disturbed family relationships are basic to the c h i l d ' s disturbance, being car-r i e d by the d i s t r i c t s o c i a l workers. This i s the unique area of understanding and s k i l l of the trained s o c i a l worker, and as such i s best handled by him. The Public Health Nurse, on the other hand, i s best equipped, f o r example, to handle any problems of medical o r i g i n , or cases where i t appears the parents may respond to counselling i n connection with the care of children. Due to heavy caseloads and the lack of both numbers and s k i l l of s o c i a l workers i n many areas, as well as l o c a l administrative d i f f i c u l t i e s , such a d i v i s i o n of cases i s not always f e a s i b l e . In such circumstances, i t i s e s s e n t i a l that the c l i n i c team, i n making i t s recommenda-tions based on the c l i n i c a l study and evaulation of the problem, know the conditions e x i s t i n g i n the community, and off e r suggestions f o r l o c a l treatment that are within the - 135 -rang© and s k i l l of the l o c a l person who w i l l be continuing with the c l i e n t . The conference, and the following consult-ation with the corresponding c l i n i c team member, should be directed along educative l i n e s , increasing the l o c a l worker's understanding of the problem and of how to deal with I t , within h i s a b i l i t y . The r e f e r r i n g agent must be taken at the l e v e l at which he i s operating and be helped to move forward from there. I t i s again a recognized f a c t that more preventive work can be done through the cooperative agencies who are on the scene continuously, and even i f they are not able to do quite as thorough a job as would be i d e a l , i n the long run there i s a p o s i t i v e gain, to the c l i e n t , the agency, and the community. Let us look at t h i s problem, then, i n terms of what recommendations are currently being made by the c l i n i c , as indicated by the 50 sample cases. Again, as In presenting problems, there i s a multi-p l i c i t y of recommendations per case, so that i n the $0 cases, a t o t a l of 94 recommendations were made. This can be under-stood i f one considers, f o r Instance, the recommendation "removal from own home." This recommendation would i n most cases be accompanied as well by "casework services to par-ents," and "casework services to c h i l d . " The 15 recommendations appear i n the following frequency s 1. Casework services to parents - 50$ of cases. 2. Further T r a v e l l i n g C l i n i c services - 28$ of cases. to f o l l o w page 135 Table 9. C l i n i c a l Recommendations f o r Treatment I n r e l a t i o n  to the Agency P r e s e n t i n g the Case, as i n d i c a t e d i n  the Sample Study of T r a v e l l i n g C h i l d Guidance  C l i n i c Cases. 1953. . """" C l i n i c a l Recommendations Pre s e n t i n g Agency T o t a 1 S o c i a l Welfare Branch P u b l i c H e a l t h U n i t Schools (Mental Health Co-o r d i n a t o r s and School Counsellors) Prob-a t i o n O f f i -c e r I n s t i t u t i o n a l Care k 2 6 Casework Se r v i c e s to Parents 12 12 1 25 Casework S e r v i c e s to C h i l d 3 7 R e f e r r a l to teacher f o r remedial i n s -t r u c t i o n or f r i e n d -l y support II 5 2 11 Work c l o s e l y w i t h school 3 h. 7 Group a c t i v i t y 1 3 k R e f e r r a l t o phy-s i c i a n 2 2 S p e c i a l c l a s s e s 2 2 C.G.C.on treatment b a s i s 1 1 Removal from f o s t e r home 2 2 Removal from own -home - .. . 1..;. h 3 1 8 Adoption 2 2 Further T r a v e l l i n g C l i n i c S e r v i c e s 8 6 14 Adoption Contra- \ i n d i c a t -ed: Factors i n Present home Factor i n c h i l d ' s Background 1 1 2 2 TOTAfc 50 L0 2 2 94 - 136 -3. R e f e r r a l t o teacher f o r remedial i n s t r u c t i o n or f r i e n d l y support - 22$ of cases. 4 . Removal from own home to f o s t e r home - 16$ of cases. 5 . Casework s e r v i c e s t o c h i l d , and work c l o s e l y w i t h s c h o o l , each i n 14$ of cases. 6. I n s t i t u t i o n a l care - 12$ of cases. 7. Group a c t i v i t y - 8$ of cases. 8. Removal from f o s t e r home, r e f e r r a l t o phy-s i c i a n , s p e c i a l c l a s s e s , adoption recommended, and adoption c o n t r a - i n d i c a t e d due t o f a c t o r s i n c h i l d 1 s background, each appear i n 2 cases. 9. C h i l d Guidance C l i n i c on a treatment b a s i s , and adoption c o n t r a - I n d i c a t e d due t o f a c t o r s i n present home, each appear i n 1 case. Gf the 15 recommendations i n v o l v e d , "casework s e r v i c e s to pare n t s " appeared most f r e q u e n t l y — i n 25* or £0$ of the cases. I n 12 o f these cases, S o c i a l Welfare Branch would be i n v o l v e d i n treatment; P u b l i c H e a l t h Nurses would c a r r y another 12 of them, and a p r o b a t i o n o f f i c e r was r e s -p o n s i b l e f o r the remaining case. The recommendations appear appropriate i n the case of S o c i a l Welfare Branch and Prob-a t i o n O f f i c e r cases, but that such a h i g h p r o p o r t i o n of such cases i s c u r r e n t l y c a r r i e d by P u b l i c Health U n i t s r a i s e s some questi o n . Only f u r t h e r i n t e n s i v e study would c l a r i f y the p i c t u r e ; but w i t h i n the scope of t h i s study, the f i g u r e s seem - 137 -t o r a i s e considerable question as to the wisdom of the cur-rent p r a c t i c e of the p r e s e n t i n g agency c a r r y i n g the case, and of the r e s p o n s i b i l i t y of the c l i n i c to c l a r i f y t h i s a t conference. Even though i t i s not p o s s i b l e to p r o v i d e soc-i a l workers f o r the more i n t e n s i v e contact i n d i c a t e d i n most c h i l d guidance c l i n i c cases, the need of a d d i t i o n a l workers i n the i n t e r e s t s of the p r e v e n t i o n of f u t u r e d i f f i c u l t i e s does need to be p o i n t e d out a d m i n i s t r a t i v e l y . Where i t i s not p o s s i b l e t o a s s i g n cases t o S o c i a l Welfare Branch, the P u b l i c H e a l t h U n i t Nurse should be o f f e r e d c l i n i c a l c o n s u l t -a t i o n s e r v i c e s p e r i o d i c a l l y , i n her c a r r y i n g of those cases which i n v o l v e problems i n s o c i a l r e l a t i o n s h i p s or i n psy-c h i a t r i c areas. The recommendation ''casework s e r v i c e s to c h i l d , " although o c c u r r i n g i n only 7 Instances, presents a s i m i l a r s i t u a t i o n . Three o f these cases were presented by P u b l i c H ealth Nurses, and r a i s e questions i d e n t i c a l t o those d i s -cussed above. I n 14, or 28$ of the cases, i t was recommended tha t the c h i l d be seen again " f o r f u r t h e r T r a v e l l i n g C l i n i c S e r v i c e s . " This could be f o r f u r t h e r e v a l u a t i o n , or could i n d i c a t e the c l i n i c ' s p a r t i c u l a r i n t e r e s t i n f o l l o w i n g the progress of the case. As a r u l e , i t has been l e f t up to the agency i n v o l v e d t o re-present a case when i n d i c a t e d ; and the expression of continued c l i n i c a l I n t e r e s t i n the s i t u a t i o n has been an i n d i c a t i o n of the s e v e r i t y of the s i t u a t i o n , w i t h p o s s i b l e change i n plans i n d i c a t e d from time t o time. - 138 -The even d i v i s i o n of these cases between S o c i a l Welfare Branch and P u b l i c Health N u r s e s —8 to 6—seems to have no s p e c i f i c i m p l i c a t i o n w i t h i n the present study, " R e f e r r a l t o teacher f o r remedial i n s t r u c t i o n or f r i e n d l y support" i s the next most frequent recommendation, oc c u r r i n g i n 22% of the cases. I t i n d i c a t e s both r e c o g n i t i o n of the r o l e the school may p l a y i n the treatment of a d i s -order, and an attempt at f u r t h e r i n g cooperation amongst the community h e a l t h , welfare, and e d u c a t i o n a l personnel. The P u b l i c Health Nurse i s o r d i n a r i l y i n c l o s e contact w i t h the schools, and of the 11 such recommendations of r e f e r r a l to the teacher, 5 were cases presented by the P u b l i c H e a l t h U n i t . Four of the cases were ones on which S o c i a l Welfare Branch was a c t i v e , and two were cases presented by e i t h e r the Mental Health Coordinator, or the School Counsellor. This trend toward close cooperation w i t h the school on appropriate cases i s one which should be encouraged to continue and i n -crease, f o r reasons discussed e a r l i e r . I n 8 cases, "removal from own home t o f o s t e r home" was recommended, f o l l o w i n g the d i a g n o s t i c study. Four of these cases were presented by S o c i a l Welfare Branch, 3 by Pub-l i c H e a l t h Nurses, and 1 by a p r o b a t i o n o f f i c e r . Of the 3 cases presented by the P u b l i c H e a l t h Nurses, i n one case the recommendation f o r removal a l s o i n c l u d e d t h a t the "most ef-f e c t i v e h a n d l i n g would be on a team b a s i s , w i t h P u b l i c H e a l t h U n i t and S o c i a l Welfare Branch." I n the other 2 cases, no - 139 -such suggestion was made, and there was no S o c i a l Welfare Branch representative present at e i t h e r conference. Presum-ably i n t e r p r e t a t i o n of the need f o r removal of the c h i l d and helping parents see t h i s need, was l e f t up to the Public Health Nurse, f o r reasons which were not apparent i n the f i l e . Due to lack of follow-up material, i t was not possible to deter-mine the f i n a l d i s p o s i t i o n of the cases. The recommendation; "work cl o s e l y with school," which appears i n 1 cases—k Public Health Nurse and 3 S o c i a l Welfare Branch—again i s recognition and encouragement of the use of the p o t e n t i a l resources of the school In helping a c h i l d i n d i f f i c u l t y . Recommendation f o r "group a c t i v i t y " appeared i n k cases, 3 of which were presented by the Public Health Unit. This again i s a recommendation more appropriate to a case being ca r r i e d by a s o e i a l worker. One would hope there would be use made by the Public Health Nurse of the S o c i a l Welfare Branch worker's knowledge of community resources, and of ways of presenting the p a r t i c u l a r resource so that the decision to pa r t i c i p a t e i s the c h i l d ' s , not the worker's. The need f o r "special c l a s s " was pointed out i n 2 Public Health Unit cases. In neither of these instances was there such a resource a v a i l a b l e ; however, pointing up the lack, and the benefit of special class i n t h i s p a r t i c u l a r case, would serve as a means of drawing attention to, and f o r t i f y i n g the need of working toward the pro v i s i o n of the needed resource. - 12|0 -In 2 instances "removal from f o s t e r home" was recommended. "Adoption" was recommended i n another 2 cases, and "adoption contra-Indicated" was the recommendation i n a further 3 cases, 2 because of "factors i n child's background" and 1 because of "factors In present home environment." A l l these cases were as a matter of p o l i c y c a r r i e d by Soc i a l Wel-fare Branch. The main implication of t h i s study regarding the recommendations of the c l i n i c i s that many of the cases do not seem to be carried by the agency best suited, by virtue of the s p e c i f i c t r a i n i n g of i t s personnel, to give the ser-vice appropriate to the problem. Notable are the number of cases carried by the Public Health Nurse i n which casework services to parent or c h i l d , or both, are recommended. The reason f o r t h i s inappropriate d i v i s i o n of cases i s not read-i l y apparent. However, the matter i s of prime importance i n a maximum use of c l i n i c a l service i n the inte r e s t s of the community served. Knowing the chronic shortage of trained s o c i a l workers i n the f i e l d , t h i s state of a f f a i r s i s under-standable. Presumably the handling of cases i s decided before-hand by the l o c a l health and welfare agencies. It seems that It i s the duty of the c l i n i c to indicate those instances i n which the case would best be ca r r i e d by another agency. Whether t h i s i s followed or not i s the r e s p o n s i b i l i t y of the agencies involved. The writer f e e l s t h i s i s a very important issue, and that intensive study of the issues involved would be valuable. -141 -Another Implication i s that the schools are being drawn into the t o t a l treatment plan i n 1+0% of the cases. This i s again a very encouraging aspect. Not only does t h i s ease tensions f o r the s p e c i f i c c h i l d under study but, as has been said before, the teachers w i l l , through the understanding gained i n a p a r t i c u l a r case, gain i n t h e i r understanding and approach to other childr e n i n s i m i l a r d i f f i c u l t i e s . Prom the recommendations, i t appears that of the 50 sample cases, only 7 were seen as unresponsive to some degree of treatment within the community. Of these 7 cases, 6 were recommended f o r " i n s t i t u t i o n a l care" and 1 f o r "Child Guidance C l i n i c on treatment b a s i s . " In U4. cases, s p e c i f i c recommendation f o r further c l i n i c a l services was made. It would be of r e a l value to determine the extent to which the c l i n i c a l recommendations were followed out, and i f not, why not. The present t r a v e l l i n g c l i n i c S o c i a l Work Supervisor i s now devoting a part of h i s time i n each com-munity to discussing cases with the health and welfare s t a f f , i n order to determine the present status of the case, i n terms of treatment, and the extent to which c l i n i c a l recommendations were aeted upon. In t h i s connection, 15 of the 50 cases i n the sample had follow-up material on the f i l e . B r i e f l y , of the 15 cases, 7 had been presented by S o c i a l Welfare Branch, 7 by Public Health Nurses, and 1 by Mental Health Coordinator. In a l l 7 S o c i a l Welfare Branch cases, the c l i n i c a l recommend-ations had been followed out, and a degree of improvement seen. - 342 -The recommendations i n c l u d e d : emphasis on home r e l a t i o n s h i p s ; casework s e r v i c e s t o overcome r e s i s t a n c e t o committal t o an I n s t i t u t i o n ; C h ildren's A i d S o c i e t y Receiving Home f o r C h i l d Guidance C l i n i c treatment; support and a l l e v i a t i o n o f pressures at s c h o o l ; continuance i n adoptive home; casework s e r v i c e s re p a r e n t - c h i l d r e l a t i o n s h i p ; and, adoption recommendation. Each of these recommendations i s i n l i n e w i t h the r o l e and s k i l l of the s o c i a l worker and was, t h e r e f o r e , c a r r i e d out. The s i t u a t i o n i n the 7 P u b l i c H e a l t h Nurse eases i s q u i t e d i f f e r e n t . S i x verbatim i l l u s t r a t i o n s w i l l show t h i s . On the other hand, the w r i t e r w i l l a l s o e x p l a i n the  overburdening of the P u b l i c H e a l t h Nurse which accounts f o r  t h i s . I n only 1 of the 7 cases was the c l i n i c a l recommenda-t i o n f o l l o w e d through. I n t h i s case, "casework s e r v i c e s " had been recommended and the case had been c a r r i e d , or turned over ( i t was not c l e a r which) t o S o c i a l Welfare Branch. Improvement was seen i n the case as a r e s u l t . I n 6 cases, however, c l i n i c a l recommendations were not followed through, and i n only two of these cases was any degree of progress i n d i c a t e d . The recommendations, and the follow-up r e p o r t s , were as f o l l o w s : 1. Recommendations: " S o c i a l Welfare Branch to giv e continuous support and good i n t e r p r e t a t i o n t o f a m i l y . Review i n 1 year." Follow-up r e p o r t I n d i c a t e d t h a t " l i t t l e f o l l o w r u p needed, accord-ing to P u b l i c H e a l t h Nurse. Some improvement seen. Case c l o s e d . " .-2. Re commend at 1 on: "School c o u n s e l l o r work w i t h boy, s o c i a l worker close contact w i t h f a m i l y . Review 1 - 143 -year. 1 1 Follow-up i n d i c a t e d " l i t t l e contact s i n c e c l i n i c examination. Main r e a s o n — t h e boy has f i n -i shed school and t h e r e f o r e has not been the problem p r e v i o u s l y seen. Case c l o s e d . " 3. Re commend at i o n ; "Casework w i t h parents ( r i g i d , p u n i -t i v e ) , encourage group a c t i v i t i e s , e x p r e s s i o n of hos-t i l i t y toward parents. Keep teacher a l e r t e d r e prog-r e s s to avoid school t r o u b l e . " Follow-Pp i n d i c a t e d "Family not accepting of C h i l d Guidance C l i n i c recom-mendations nor of P u b l i c H e a l t h Nurse s e r v i c e s . S t i l l t e n s i o n i n the home, but improved school p r o g r e s s . " 4. Recommendation: "Remain a t school w i t h emphasis on s o c i a l i z a t i o n , not academic f a c t o r s . Help mother accept r e t a r d a t i o n . " Follow-up I n d i c a t e d "mother h o s t i l e to c l i n i c . Refuses t o r e t u r n . P u b l i c H e a l t h Nurse f e e l s she has accomplished l i t t l e i n h e l p i n g mother w i t h g u i l t f e e l i n g s . " I n t h i s i n s t a n c e , there was correspondence w i t h the c l i n i c d i r e c t o r r e g a r d i n g f u r t h e r recommendations, and support t o the P u b l i c Health Nurse f o r what she was able to accomplish. 5. Re commendat 1 on; "Father and mother be given continuous support and i n t e r p r e t a t i o n r e b a s i c emotional needs of c h i l d r e n . Review In 1 year." Follow-up i n d i c a t e d that t h i s recommendation had not been f o l l o w e d , but " r a p i d Improvement at school since c h i l d moved i n t o a room w i t h a male teacher. Helped boy's r e l a t i o n s h i p w i t h h i s f a t h e r . No reason f u r t h e r c o n t a c t . Case c l o s e d . " 6. Recommendation: "Male worker f o r boy. I f p o s s i b l e , another worker f o r mother and s i s t e r r e boy's needs. Explore resources f o r s o c i a l i z a t i o n . " Follow-up i n d i c a t e d that " P u b l i c Health Nurse fhad continued w i t h c h i l d r e n and parents. Male worker not c a l l e d i n . Apparently c h i l d has shown great improvement, e s p e c i a l l y since J u l y , 1953* when f a t h e r r e t u r n e d home. B e t t e r r e l a t i o n s h i p s w i t h f a t h e r . " I n 3 of the 6 cases, where r e f e r r a l to S o c i a l Wel-f a r e Branch had been recommended, the r e f e r r a l was e i t h e r not made by P u b l i c H e a l t h Nurse or not picked up by S o c i a l Welfare Branch (1, 2, and 6 above). The reasons were not apparent. The r e s u l t was inadequate s e r v i c e to the c h i l d , w i t h premature cl o s u r e o f the case i n 2 instances of the 3. I n another case - 044 -(3, above), the s i t u a t i o n d e f i n i t e l y i n d i c a t e d need of case-work s e r v i c e s , and an understanding of dynamics and human r e l a t i o n s h i p s . The recommendations were along these l i n e s — but d i r e c t e d toward the P u b l i c Health Nurse, who could not be expected t o handle, w i t h i n her s p e c i f i c knowledge and s k i l l , t h i s type of case. I n (4) above, the recommendation was again d i r e c t e d toward the P u b l i c H e a l t h Nurse, and again casework s k i l l s were i n d i c a t e d and recommended—and again, l i t t l e , i f any, progress was made. I n (5), casework s e r v i c e s were once more recommended. I n t h i s i n s t a n c e , the P u b l i c H e a l t h Nurse c a l l e d i n the s c h o o l , w i t h r e s u l t i n g improvements i n p a r e n t - c h i l d r e l a t i o n s h i p s . I t i s not f a i r t o the P u b l i c Health Nurse t o burden her w i t h a c a s e - c a r r y i n g r e s p o n s i b i l i t y i n which c l i n i c recom-mendations s p e c i f y s k i l l s which r e q u i r e the knowledge and tech-nique of another p r o f e s s i o n . S o c i a l workers and p s y c h i a t r i s t s would be e q u a l l y , i f not more, d i s t r e s s e d i f they were asked to carry the burden of n u r s i n g care and n u r s i n g education, which might be r e q u i r e d i n t h e i r caseloads. The one case c a r r i e d by the Mental H e a l t h Co-o r d i n a t o r met w i t h a h i g h degree of success. Recommendation was "Removal of academic pres s u r e s , and minimum of d i s c i p l i n e t i l l c h i l d doesn't over-react t o i t . " Follow-up I n d i c a t e d "nightmares gone, c h i l d improved. Apparently a warm, accept-i n g male teacher has been most h e l p f u l to t h i s c h i l d . " I n other words, the recommendation was geared to the school f u n c t i o n , and as such, i t was workable. - 345 -Although t h i s i s much too small a number of cases to use as a basis f o r any conclusive statements, two f a c t o r s stand out c l e a r l y , and indicate the extreme importance of f u r -ther study, once the follow-up material i s a v a i l a b l e . F i r s t , the cases In which progress was seen were, with two exceptions, those cases i n which the recommendations had been appropriate to the role and function of the follow-up agency. Secondly, there seemed to be a tendency not to follow up suggestions of r e f e r r a l made following the diagnostic study. Both these fac-tors seem to point to the need of further c l a r i f i c a t i o n of the role and function of the Public Health Nurse, and the r o l e and function of the S o c i a l Welfare Branch; and the need of the l o c a l health and welfare agencies coming to an early decision, based on the needs of the case, as to who should carry the case. The other implication i s that there are d i f f i c u l t i e s i n the relationships between l o c a l agencies, and between these agen-cies and the c l i n i c , which need "study, diagnosis, and t r e a t -ment"—and a sound community organization approach. 7. The Extent of Direct Community Education A c t i v i t i e s of the  T r a v e l l i n g C l i n i c during 1953 The importance of awakening general coniraunity i n t -erest In, and awareness of, the aims and functions of a t r a v e l -l i n g c h i l d guidance c l i n i c service, and of general mental health p r i n c i p l e s , has been discussed previously. One of the tasks of the c l i n i c Public Health Nurse i s to keep a record of the a c t i v -i t i e s of the t r a v e l l i n g c l i n i c team, over and above the s p e c i f i c - 146 -case services. A study of her report for the year 1953 gives the picture of the broader channels of community education currently u t i l i z e d i n conjunction with the s p e c i f i c services discussed e a r l i e r i n t h i s chapter. During 1953, from January 1st to December 31st, a t o t a l of 18 contacts were l i s t e d with various r u r a l community groups, f o r the purpose of in t e r p r e t i n g c l i n i c a l function and discussing mental health generally. The types of a c t i v i t y included: lectures ( 6 ) ; f i l m showing, followed by discussion (5)J attendance at meeting of l o c a l p r o f e s s i o n a l groups (4); case presentation (1) ; workshop (1); symposium (1). In one instance, the Public Health Nurse showed mental health films to a Registered Nurses Association meet-ing. Another time, the c l i n i c team p a r t i c i p a t e d i n a case presentation to a group of teachers. In 3 instances, the p s y c h i a t r i s t and the s o c i a l worker l e d group discussions following showing of films to school personnel. In the other instances, the c l i n i c p s y c h i a t r i s t was the main c l i n i c p a r t i -cipant. Generally the other team members were present also, to contribute t h e i r s p e c i f i c knowledge when indicated i n the discussions which are encouraged following each type of pre-sentation. - 347 -The groups with whom the c l i n i c met i n the above ways, included: teachers ( 6 ) ; medical s t a f f of hospitals (3)J health, welfare and education j o i n t meetings (3)» Parent-Teachers Associations (3)J Local Council of Women ( I ) ; Registered Nurses Association (1) ; Young Adult Group, Young Women's C h r i s t i a n Association (1). Frequently service clubs, such as Kiwanis, and special i n t e r e s t groups, such as the Society f o r the Advance-ment of Handicapped Children, are also Included i n c l i n i c a l educational a c t i v i t i e s . These contacts with l o c a l community professional and non-professional groups covered 16 of the 2k towns v i s i t e d by the c l i n i c . In Kelowna and Penticton, two d i f f e r e n t groups were addressed; but i n the other 14 centres, only one contact per year was recorded, and i n 8 centres, none. The pic t u r e was almost Identical i n 1954* I t would seem that t h i s very important medium of c l i n i c a l contact with the general com-munity i s not being used as e f f e c t i v e l y as one would hope. I t i s an important area of clinic-community r e l a t i o n s ; and i n the t r a v e l l i n g c l i n i c scene, p a r t i c u l a r l y , i t s e f f e c t i v e use can do much to help the professional groups and general c i t i z e n s to see that the c l i n i c , despite I t s transient nature, i s - 148 -" t h e i r s , " to t u r n to Tor help and guidance i n the areas out-l i n e d i n the c l i n i c program. I t i s recognized, again, that the current shortage of s t a f f , and pressures of time, have entered l a r g e l y i n t o t h i s l i m i t e d number of group addresses, f i l m showings, case p r e s e n t a t i o n s , et c e t e r a . With the advent of the second t r a v e l l i n g c l i n i c team, one would hope t o see more emphasis on a c h i e v i n g : 1. g r e a t e r use of i n d i v i d u a l team members i n these group c o n t a c t s ; 2. increase i n q u a n t i t y and scope of group c o n t a c t s , p a r t i c u l a r l y among no n - p r o f e s s i o n a l groups, such as Parent-Teachers A s s o c i a t i o n s , s e r v i c e c l u b s , L o c a l C o u n c i l s of Women, et c e t e r a . I t seems to the w r i t e r that t h i s i s an extremely important area i n the r e l a t i o n s h i p between the l o c a l com-munities and the c l i n i c , which to date, f o r reasons d i s c u s s e d , appears t o have been only p a r t i a l l y u t i l i s e d . I t would seem to be an important area to consider i n p l a n n i n g f o r community s e r v i c e on a two-team r a t h e r than a one-team b a s i s . 8. C l i n i c a l S e r v i c e s as Seen by F i e l d Personnel As has been s t a t e d p r e v i o u s l y , the c r i t e r i o n f o r the success o f a c l i n i c i s not the judgment of the c l i n i c members, but i s r a t h e r the value placed upon i t s s e r v i c e s by the community. I n an e f f o r t to determine the community r e s -ponse t o c l i n i c a l s e r v i c e s , q u e s t i o n n a i r e s were sent out t o a l l S o c i a l Welfare Branch f i e l d o f f i c e s , through which a l l - 149 -requests for c l i n i c a l evaluation and help are channelled. Fourteen questionnaires were returned, representing 15 d i s -t r i c t o f f i c e s throughout the B r i t i s h Columbia Mainland. The questionnaires were f i l l e d out by Social Welfare Branch d i s -t r i c t supervisors, and represent, therefore, the opinions of Social Welfare Branch personnel only. In these 15 o f f i c e s , 102 cases were referred to the t r a v e l l i n g c l i n i c i n 1952, and 162 i n 1953—an Increase of 59$. In 5 of the centres, the c l i n i c v i s i t e d once a year. Of these, 2 requested v i s i t s twice yearly. In 3 of the centres, 1 to 2 c l i n i c v i s i t s per year were usual, and were s u f f i c i e n t . In 5 d i s t r i c t s , v i s i t s were made twice yearly, which was s u f f i c i e n t i n a l l but one d i s t r i c t , where v i s i t s were requested 3 times a year. In another d i s t r i c t , 2 to 3 c l i n i c a l v i s i t s per year were the usual, and were proving suf-f i c i e n t . In s t i l l another d i s t r i c t , close to Vancouver, v i s i t s were made by the c l i n i c team "at request" (of the d i s t r i c t o f f i c e ) . The cases most commonly referred f o r c l i n i c a l evaluation by these 15 d i s t r i c t o f f i c e s were those i n v o l v i n g : 1. Placement cases i n which there i s concern about the emotional consequences to the c h i l d due to former dependency, broken home, or neglect. (9 times.) 2. Children i n t h e i r own homes whose behaviour d i f f i c u l t i e s stem from a d i s t i n c t break-up i n parent-child r e l a t i o n s h i p . (9 times.) - 1^ 0 -3. Patients who are retarded i n t h e i r i n t e l l e c t -u a l development. (9 times.) Also appearing frequently were cases i n which: ll.. I n a b i l i t y to cope with s o c i a l or scholastic expectations (6 times.) was the cause f o r r e f e r r a l to c l i n i c . These cases which were referre d most frequently, were also the ones i n which the f i e l d personnel f e l t most help was given. C l i n i c a l evaluation and treatment recommendations were found to be most h e l p f u l (7 instances) i n those cases involving placement (#1 above). In 6 instances, the f i e l d workers found c l i n i c a l services most h e l p f u l i n cases of c h i l d -ren i n t h e i r own homes whose behaviour d i f f i c u l t i e s were attributable to f a u l t y parent-child r e l a t i o n s h i p s (#2 above). Cases of i n t e l l e c t u a l retardation, and of d i f f i c u l t y i n cop-ing s o c i a l l y or s c h o l a s t i c a l l y , each were seen as b e n e f i t t i n g from c l i n i c a l help i n 5 instances (#3 and #lj. above). In 2 instances, cases involving maladjustment stemming from a child's undesirable habits were seen as being most frequently referred to c l i n i c ; and i n 3 instances, i t was f e l t these cases were the ones i n which c l i n i c had been most h e l p f u l . Children who are retarded because of p h y s i c a l handicaps, and children who exhibit behaviour d i f f i c u l t i e s as a d i r e c t r e s u l t of m a r i t a l c o n f l i c t , were both mentioned i n 5 instances each, but were not seen e i t h e r as occurring frequently or as being helped p a r t i c u l a r l y through c l i n i c a l service. Cases involv-ing psychogenic disorders were merely mentioned i n 2 instances, - 151 -but not seen s p e c i f i c a l l y as e i t h e r frequent or as b e n e f i t t i n g from c l i n i c r e f e r r a l . I n one Instance, they were seen as being r e f e r r e d f r e q u e n t l y , and i n one instance as having been helped most through p r e s e n t a t i o n a t c l i n i c . The above a n a l y s i s of the questionnaire r e p l i e s i m p l i e s t h a t there i s not u n i v e r s a l acceptance by S o c i a l Wel-f a r e Branch f i e l d personnel of the value of t r a v e l l i n g c l i n i c s e r v i c e s . This comes out more c l e a r l y i n response to the ques-t i o n , "on the average, to what extent d i d the c l i n i c a l d i a g n o s i s help the s o c i a l worker i n o v e r - a l l casework op e r a t i o n ? " I n d i s t r i c t s , i t was seen as "extremely h e l p f u l " ; i n 2 d i s t r i c t s , as "moderately h e l p f u l " ; i n 1 d i s t r i c t as "of l i m i t e d v a l u e " ; but i n no d i s t r i c t s was i t seen as "of no value." This r e s -ponse seems to I n d i c a t e a degree of r e s e r v a t i o n on the p a r t of many d i s t r i c t workers as t o the a c t u a l help the e l i n i c i s g i v i n g i n t h e i r cases; and a f e e l i n g t h a t more help could be expected than they are at present r e c e i v i n g . They are not, however, r e j e c t i n g c l i n i c a l h e l p — n o t e t h a t i n o n l y one i n s t -ance was the c l i n i c a l d i a g n o s i s seen as "of l i m i t e d v a l u e , " and i n no instances was i t seen as "of no value." I t i s en-couraging t h a t i n 5 d i s t r i c t s , the experiences w i t h the t r a -v e l l i n g e l i n i c have been so p o s i t i v e as t o m e r i t being con-s i d e r e d "extremely h e l p f u l . " C l i n i c a l conferences were found t o be "very u s e f u l " by 10 of the d i s t r i c t o f f i c e s ; "more use p o s s i b l e " was the v e r d i c t i n 1+ d i s t r i c t ; and i n 1, they were seen as of "almost - 152 -no use. n There was a close re l a t i o n s h i p between the way i n which the c l i n i c a l diagnosis and the c l i n i c a l conferences were viewed by the d i s t r i c t s . A l l 5 of the d i s t r i c t s which indicated that the c l i n i c a l diagnosis had been "extremely h e l p f u l " to the s o c i a l worker i n h i s o v e r - a l l casework a c t i v -i t y , also found the c l i n i c a l conferences to be "very u s e f u l " ; and indicated that other l o c a l p r o f e s s i o n al persons were active p a r t i c i p a n t s i n the conferences—and that a l l gained by t h e i r p a r t i c i p a t i o n . Pour of these 5 d i s t r i c t s stressed " s o c i a l service personnel" as the most important l i m i t i n g f a c t o r a f f e c t i n g follow-up, and the other saw lack of "con-t i n u i t y of p s y c h i a t r i c consultation" as the main l i m i t i n g f a c t o r . In 5 of the 10 d i s t r i c t s which found c l i n i c a l con-ferences "very u s e f u l , " the c l i n i c a l diagnosis was seen as giving only "moderate" help to the s o c i a l worker i n carrying the case. In k of these d i s t r i c t s , the " s o c i a l service per-sonnel" was seen as the most important l i m i t i n g f a c t o r a f f e c t -ing follow-up; and i n 1, "community resources" were f e l t to be the chief l i m i t a t i o n . Here again, l o c a l professional people were Included i n the conferences, and t h e i r contributions to the o v e r - a l l picture recognized. C l i n i c a l diagnosis was f e l t to be "moderately help-f u l , " and opinion regarding c l i n i c conferences was that more use could be made of them, i n k d i s t r i c t s . In 3 of these d i s t r i c t s , the follow-up of the cases presented was l i m i t e d - 153 -mostly by the s o c i a l service personnel, and i n 1 "continuity of p s y c h i a t r i c consultation" was f e l t to be the most important l i m i t i n g f a c t o r i n follow-up a c t i v i t i e s on c l i n i c cases. One d i s t r i c t reply quite frankly stated that the c l i n i c a l diagnosis was of only l i m i t e d value to the s o c i a l worker i n his o v e r - a l l casework a c t i v i t y , and that the c l i n i -c a l conferences were of almost no use. I t was i n t e r e s t i n g , however, that t h i s d i s t r i c t requested more frequent c l i n i c a l v i s i t s than It was then receiving. I t was f e l t that "con-ference i s frequently limited because c o n f i d e n t i a l causative material cannot be discussed i n conference slanted toward community i n t e r p r e t a t i o n . " The most important l i m i t i n g fac-tors a f f e c t i n g follow-up of cases examined by the c l i n i c were lack of adequate s o c i a l service personnel to do the job, plus the f a c t that there was "no a v a i l a b l e " p s y c h i a t r i c consult-ation. The d i s t r i c t supervisor commented that "conferences between p s y c h i a t r i s t and supervisor on p s y c h i a t r i c consult-atio n l e v e l and geared to treatment plan would be h e l p f u l . " The o v e r a l l picture seems to be that c l i n i c a l ser-v i c e s are generally regarded as h e l p f u l , or as p o t e n t i a l l y h e l p f u l . Lack of stable and trained s t a f f , and pressures of time and distance are the main l i m i t i n g factors i n u t i l i z i n g the c l i n i c a l services a v a i l a b l e . The varied opinions i n d i c -ated i n the questionnaire r e p l i e s point out the value of e f f o r t toward knowing your various communities i n d i v i d u a l l y , as the general comments Indicate that i n some d i s t r i c t s - i$k -c l i n i c a l aims and purposes are well recognized, and used con-s t r u c t i v e l y ; whereas i n others there i s misunderstanding as to the role of the t r a v e l l i n g c l i n i c i n r e l a t i o n to the S o c i a l Welfare Branch, and the communities served. The following verbatim l i s t of general comments i s illuminating and self-explanatory: 1 1. In my opinion the c l i n i c w i l l become increasingly usef u l as i t s function becomes better known i n the community. There have been only 3 c l i n i c v i s i t s to , i n 1952,-3,-A}-* The community i s just now becoming aware. 2. Child Guidance C l i n i c f u l f i l l s a two-fold function i n r u r a l areas. I t i s of d i r e c t benefit to the soc-i a l worker i n providing a diagnosis and g i v i n g d i r -e c t i o n to the treatment plan. I t also provides an. opportunity f o r i n t e r p r e t a t i o n of the services provided through the Social Welfare Branch F i e l d Service, to other professional groups, and a chance to e n l i s t the cooperation of these people i n planning for and with the c h i l d and the family. 3. We would emphasize that the greatest weakness i n t h i s service i s our follow-up. The c l i n i c conference gives us much (usually) to work on, but time and inex-perienced workers always seem to confine our e f f o r t s to a great extent. 4. The main d i f f i c u l t y has been follow-up of suggestions made by c l i n i c — i n view of lack of experienced s o c i a l workers. Kew untrained workers are often hesitant about attempting intensive casework i n the serious behaviour problem type of case. $. Better screening could be done i n choice of cases f o r c l i n i c , with closer cooperation between Public Health, Schools, and S o c i a l Welfare Branch. In , have recently organized a Child Guidance Council which should help i n t h i s respect. 6. Parents at times ask that the doctor give them a .frank report. This i s so often l e f t to the s o c i a l Extracts from questionnaire r e p l i e s . - 155 -worker who has not enough experience i n t h i s phase of our work. Also suggest that Children's Registry c u r t a i l t h e i r r e f e r r a l s as we are f i n d i n g the Public Health Nurses with more r e f e r r a l s than we can cope with. 7. Due to distance and lack of time i t i s d i f f i c u l t to follow up cases adequately. 8. We seem chron i c a l l y unable to carry out the plan we agree to i n the conference i n most instances. 9. We f i n d that i f we have interpreted well that gen-e r a l l y other interested persons have a great deal to contribute to understanding the ease and to plan-ning f o r the future. Occasionally we have an Tin-fortunate experience. 10. The part the outside p a r t i e s contribute seems l i m i t e d . Usually much time i s spent educating those i n atten-dance—possibly t h i s i s the f a u l t of the l o c a l wel-fare s t a f f . These comments indicate several pertinent points regarding the present t r a v e l l i n g c h i l d guidance c l i n i c ser-vice and i t s present stage of i n t e g r a t i o n into the r u r a l com-munities. 1. The various d i s t r i c t o f f i c e s are varied as to the degree of understanding they have of c l i n i c a l services and functions. 2. There i s d i f f i c u l t y i n following up c l i n i c a l recommendations, due to lack of trained s o c i a l workers, and to pressures of time, distance and heavy caseloads—or i s i t due to c l i n i c a l recommendations not geared s u f f i c i e n t l y to the l o c a l scene, and not enough help to l o c a l workers regard-ing the p r a c t i c a l as well as the i d e a l therapeutic aspects of the case? - 156 -3. Local professional people are Included i n con-ferences, but there seems some confusion as to t h e i r r o l e , and the r o l e of the c l i n i c i n adding to t h e i r knowledge and understanding of the case, as well as of c l i n i c a l and l o c a l s o c i a l work services i n r e l a t i o n to i t . The use of double conferences when indicated does not appear to be u n i v e r s a l l y recognized. 4. The l o c a l o f f i c e s are aware of current c l i n i c l i m i t a t i o n s due to the "youth" of the service, but to date the p o s i t i v e s outweigh the negatives. The f i e l d workers are looking hopefully to the c l i n i c f o r guidance, and i t i s up to the c l i n i c to f i n d ways and means of g i v i n g i t , i n a usable manner. The writer, i n informal discussions with available branch supervisors and f i e l d workers, was further impressed with the f a c t that an intensive program of i n t e r p r e t a t i o n to f i e l d agencies of c l i n i c a l functions and services, i s i n d i -cated at t h i s time. The t r a v e l l i n g c l i n i c i s an established service now, but there i s misunderstanding s t i l l on the part both of c l i n i c a l s t a f f and f i e l d s t a f f , as to how to make maximum use of the services a v a i l a b l e ; even, almost of what services are a v a i l a b l e . The infrequent v i s i t s of the c l i n i c team, and the s t a f f changes both i n c l i n i c and f i e l d person-n e l , have operated against the gradual establishment of sound clinic-community r e l a t i o n s h i p s , as embodied i n i n t e r -personal s t a f f r e l a t i o n s h i p s between the c l i n i c personnel - 157 -and the f i e l d workers. Emphasis upon the sound relationship of the c l i n i c to the r u r a l communities i t serves i s therefore also strongly indicated, i f the t r a v e l l i n g c l i n i c i s to a t t a i n i t s r i g h t f u l r o l e as diagnostician, consultant, and mental health educator to r u r a l areas. To date, the c l i n i c ' s diagnostic service has dominated; but increasingly, various d i s t r i c t workers are vol ing t h e i r need of consultative services i n the carrying out of c l i n i c a l treatment recommendations. The broad community health education services of the t r a v e l l i n g c l i n i c are as yet, as has been noted, only p a r t i a l l y recognized and u t i l i z e d . Generally speaking, appropriate cases are being referred f o r c l i n i c a l evaluation and treatment recommendation c l i n i c a l conferences are being used both f o r teaching by case method, and f o r f u r t h e r i n t e r p r e t a t i o n to a l l i e d human r e l a -tions professions i n the l o c a l community around c l i n i c a l functions and children's basic needs; s o c i a l workers, Public Health Nurses, and school personnel are working together to an appreciable extent on i n d i v i d u a l cases and i n general community mental health a c t i v i t i e s ; but d i f f i c u l t y i n follow-up of i n d i v i d u a l treatment recommendations seems to be Inter-f e r i n g with p o s i t i v e acceptance of the c l i n i c by the l o c a l community. Further understanding and acceptance of mutual limitations—>by the c l i n i c s t a f f of the d i f f i c u l t i e s under which the f i e l d workers operate; and by the f i e l d workers of - 158 -the d i f f i c u l t i e s and l i m i t a t i o n s under which the t r a v e l l i n g teams operate—would pave the way t o c l i n i c a l recommendations geared more c l o s e l y t o l o c a l c o n d i t i o n s , and to more r e a l i s t i c e xpectations of c l i n i c by the f i e l d . I n view of the imminent expansion of the present one t r a v e l l i n g c l i n i c team i n t o two t r a v e l l i n g c l i n i c teams f o r the same geographical area, the w r i t e r hopes th a t i n t e n s i v e research by I n d i v i d u a l community w i l l be c a r r i e d out as soon as c l i n i c a l f i l e m a t e r i a l regard-ing follow-up r e p o r t s i s a v a i l a b l e . Such r e s e a r c h would be an i n v a l u a b l e a i d t o determining f u t u r e focus and plan n i n g f o r t r a v e l l i n g c l i n i c s e r v i c e . Summary The v a r i o u s approaches made i n t h i s chapter t o the study of the l o c a l t r a v e l l i n g c l i n i c " i n o p e r a t i o n , " i n d i -cated g e n e r a l l y t h a t the r u r a l communities are r e f e r r i n g cases to c l i n i c which are appropriate to c l i n i c f u n c t i o n . A l a r g e p r o p o r t i o n of these are amenable t o treatment w i t h i n the community. The g r e a t e r p r o p o r t i o n of problems r e f e r r e d f a l l w i t h i n the group o f d i s o r d e r s which e i t h e r cause discomfort or disturbance w i t h i n the l o c a l community, or are s u f f i c i e n t l y abnormal i n m a n i f e s t a t i o n as to be immediately recognizable as d e v i a t i o n s from the "normal." I n 18$ of the cases, how-ever, problems were presented which seem t o i n d i c a t e a deeper understanding of the p r i n c i p l e s of mental h e a l t h , and an i n t -e r e s t i n e a r l y p r e v e n t i o n , r a t h e r than only i n a l l e v i a t i o n of - 159 -troublesome symptoms. Problems tend to be recognized and referred by l o c a l community groups i n the following order: schools, S o c i a l Welfare Branch,, parents and Public Health Units, doctors, probation o f f i c e r s , and Juvenile Court. Emphasis i n a l l groups i s upon the problems f a l l i n g within the group of conduct disorders, with p a r t i c u l a r emphasis on disobedience notable i n school, S o c i a l Welfare Branch, and parental r e f e r r a l s . Personality disorders tend to be re-ferred by the schools, neurotic disorders by the parents, and a large proportion of habit disorders likewise by the parents. Social Welfare Branch and Public Health Unit case presentations are predominant, with S o c i a l Welfare Branches presenting $&% of the t o t a l sample cases, and Public Health Units 36$. Schools and probation o f f i c e r s presented the remaining cases. Schools tend to r e f e r mainly through the l o c a l Public Health Unit, and parents through the l o c a l Soc-i a l Welfare Branch. The l o c a l health and welfare agencies tend to present t h e i r own r e f e r r a l s . Doctors r e f e r to both Public Health Units and S o c i a l Welfare Branches, i n a r a t i o of 3 f2. Probation o f f i c e r s presented one case to S o c i a l Welfare Branch f o r presentation to t r a v e l l i n g c l i n i c . This presents a f a i r l y p o s i t i v e picture of l o c a l community l i a i s o n s ; but more r e f e r r a l s from l o c a l physicians, and more p r e - c l i n i c i n t e r a c t i o n between the l o c a l health and welfare u n i t s would be i n d i c a t i v e of h e a l t h i e r community r e l a t i o n s h i p s . - 160 -Attendance at case conferences averages 5 to 6 persons per case, and includes mainly Social Welfare Branch workers, Public Health Unit and school personnel. Doctors, probation o f f i c e r s , ministers and V i c t o r i a Order of Nursing s t a f f are also included upon occasion, but more emphasis needs to be placed on t h e i r p o t e n t i a l contributions both i n a speci-f i c s i t u a t i o n and i n the general community mental health prog-ram. In 39 of the $0 cases, both Public Health Unit and Soc-i a l Welfare Branch personnel were i n attendance, i n d i c a t i n g that they do collaborate on most, but not a l l , of t h e i r cases. It i s the writer's impression that, on the whole, more use of the case conference could be made by the f i e l d , once i t s f u l l value and purpose Is more c l e a r l y understood. In studying c l i n i c a l recommendations, i t was implied that many of the cases do not seem to be carr i e d by the agency best suited, by virtue of the s p e c i f i c professional t r a i n i n g of i t s personnel, to carry out the treatment recom-mendations. Notable are the number of cases carried by the Public Health Nurses, In which casework services to parent, or c h i l d , or both, are recommended. Since the agency pre-senting the case i s i n most instances the one who w i l l do the follow-up work on i t , i t would seem that the c l i n i c has the r e s p o n s i b i l i t y of i n d i c a t i n g those instances i n which the case would best be carried by another agency; and, i f t h i s Is not f e a s i b l e , of gearing recommendations more closely to the professional s k i l l of the presenting agency. - 161 -This issue was re-emphasized i n the follow-up reports, which were available on 15 of the 50 cases studied. These indicated that the cases i n which progress was seen were, with two exceptions, those cases i n which the recommendations had been appropriate to the role and function of the follow-up agency. It also appeared that there was a tendency not to follow up on suggestions of r e f e r r a l made following the diag-nostic s t u d y — i . e . , at the case conference. Both these factors seem to point to the need of further c l a r i f i c a t i o n of the r o l e and function of the Public Health Unit, and the role and function of the So c i a l Welfare Branch; and the need of the l o c a l agen-cies coming to an early decision, based on the needs of the case, as to who should carry the case. The other Implication i s that there are d i f f i c u l t i e s i n the relationships between l o c a l agencies, and between those agencies and the c l i n i c , which need "study, diagnosis and treatment"—and a sound community organization approach. In studying the amount of c l i n i c a l a c t i v i t y expended, i n 1953, on general community mental health education and know-ledge about c l i n i c a l services, i t was found that such a c t i v -i t y was l i m i t e d . In only 16 of the 2ij. towns v i s i t e d by the c l i n i c team was any a c t i v i t y entered into, above and beyond the i n d i v i d u a l case study and conference; and then only one such contact per year was involved. In 8 towns, there was no such contact. Current pressures of time and t r a v e l impinge upon the c l i n i c team's a b i l i t y to p a r t i c i p a t e extensively i n - 162 -f i l m showings, discussion groups, lectures and case present-ations to various community groups; but i t i s f e l t that, when the second t r a v e l l i n g c l i n i c team i s established, emphasis on t h i s very important area of community education and i n t e r -pretation, i s indicated as an e s s e n t i a l part of an extended c l i n i c a l program. The S o c i a l Welfare Branch questionnaire responses indicated that the c l i n i c , although generally seen as help-f u l to the worker and to the community, i s not yet completely accepted. The r e p l i e s indicated s p e c i f i c a l l y that appropriate cases are being referred f o r c l i n i c a l evaluation and treat-ment recommendations; c l i n i c a l conferences are being used both for teaching by case method and f o r i n t e r p r e t a t i o n to other professional groups within the community; s o c i a l workers, public health nurses and school personnel are working together to an appreciable extent on i n d i v i d u a l cases and i n general community mental health a c t i v i t i e s ; but d i f f i c u l t y In the follow-up of i n d i v i d u a l treatment recommendations seems to be i n t e r f e r i n g with p o s i t i v e acceptance of the c l i n i c by the l o c a l community. The main implications of the above material are, f i r s t , that i n the immediate future, emphasis upon the con-sul t a t i v e and community education aspects of c l i n i c function i s indicated, sinee i t appears these are not f u l l y u t i l i z e d at present; and secondly, the need i s brought out repeatedly of knowing your communities i n d i v i d u a l l y , i n order both to - 163 -gear recommendations to the l o c a l resources, and to promote sound community rel a t i o n s h i p s , based on mutual understanding and respect. CHAPTER IV THE FINDINGS AND IMPLICATIONS OF THE PRESENT STUDY IN RELATION TO FUTURE TRAVELLING CHILD GUIDANCE CLINIC PRACTICE It i s important to understand any l o c a l phenomena i n terms of i t s h i s t o r i c a l development, not only l o c a l l y but eontlnentally. Present problems can very often be understood more c l e a r l y i n the l i g h t of the past, and seen more i n per-spective than i f viewed only as a p a r t i c i p a n t i n the present s i t u a t i o n . The present study, seen, as has been stated, as an exploratory one, and as laying the base f o r further needed research along more det a i l e d a n a l y t i c a l l i n e s , has attempted to present the broad t h e o r e t i c a l and h i s t o r i c a l background of t r a v e l l i n g c h i l d guidance c l i n i c s on t h i s continent, i n Canada, and p a r t i c u l a r l y i n B r i t i s h Columbia. Against t h i s background, we have studied c a r e f u l l y the present administra-t i o n , functions and process of the B r i t i s h Columbia Mainland T r a v e l l i n g Child Guidance C l i n i c , and of i t s i n d i v i d u a l team members. Through a random sample case study of 50 cases seen by the t r a v e l l i n g c l i n i c i n 1953, general trends i n the present f i e l d operation of the c l i n i c have been observed, with stress upon the community aspects of the service. Emphasis has been upon the use made of the c l i n i c a l diag-nostic study and evaluation, as a t o o l f o r increasing general -165 -mental health knowledge, and as an aid to l o c a l profes-sional people i n t h e i r general as well as s p e c i f i c case handling, plus a strengthening of community l i a i s o n s . Replies to questionnaires sent out to the S o c i a l Welfare Branch f i e l d o f f i c e s have been evaluated i n an e f f o r t to assess the degree to which t r a v e l l i n g c l i n i c services are accepted and understood by, and integrated into the r u r a l communities served. In the course of t h i s study, the writer has noted the paucity of research and descriptive material on t r a v e l -l i n g c h i l d guidance c l i n i c s as compared to the abundance of written material on the stationary c l i n i c s . There seems to be a tendency, i n the perception and thinking of professional people generally, to overlook the very r e a l value and impor-tance—and p o t e n t i a l — o f the t r a v e l l i n g c l i n i c which services the r u r a l population. Research and descriptive material done on welfare services tends to f l o u r i s h on urban and i n d u s t r i a l communities. This has i t s proper place i n the scheme of wel-fare planning. However, when one looks at the geographical composition of the North American continent, one cannot overlook the f a c t that North America, despite Its move toward greater urbanization and i n d u s t r i a l i z a t i o n , i s s t i l l an agrarian culture to a great extent. While t h i s i s conjec-ture, the writer wonders whether the biases and interests of the people doing the studies might favor the "more attrac-t i v e " urban and i n d u s t r i a l areas, and thus subtly bias the attitudes and responses of t h e i r readers. Thus the profes-- 166 -sional worker i s conditioned to viewing any other area of s o c i a l work or p s y c h i a t r i c a c t i v i t y , however important, as " i n c i d e n t a l . " The writer, however, has come to the conclusion that the t r a v e l l i n g c l i n i c services, f a r from being " i n c i -dental" to the stationary c l i n i c services, represent the most p o t e n t i a l l y productive area of c h i l d guidance, and require of those engaged In i t , s p e c i a l s k i l l s over and above those required of the worker i n an urban c l i n i c . I t i s a p a r t i c u l a r l y challenging f i e l d , r equiring, as has been noted, the utmost i n professional competence and s k i l l , plus the a b i l i t y to adapt to l o c a l s t a f f and conditions. As yet, the entire f i e l d has just been tapped, and on the whole, the p o t e n t i a l value of t r a v e l l i n g c l i n i c services not generally, recognized. The study of t r a v e l l i n g c h i l d guidance c l i n i c services i n Canada indicated that only i n Alberta and B r i t i s h Columbia do they exist as such. Other provinces, notably Prince Edward Island and Ontario, have mental health programs which seem headed i n the eventual d i r e c t i o n of the development of t r a v e l l i n g c h i l d guidance services; but the remainder of the Dominion seems s t i l l i n the process of evolution from seeing t r a v e l l i n g c l i n i c services as an a i d to screening f o r admission to a mental h o s p i t a l , toward seeing the p o t e n t i a l preventive and educative value i n c h i l d guidance to the r u r a l communities v i s i t e d . The province of B r i t i s h Columbia may well take pride i n the f a c t that i t has established a service i n d i c a t i v e - 167 -of progressive thinking along s o c i a l welfare l i n e s . I t i s , however, a growing, developing service, and as such, p e r i o d i c assessment of the trends i n development are necessary to focussing the services of the c l i n i c more nearly to the needs of the c l i e n t — t h e c i t i z e n s of the r u r a l communities of the B r i t i s h Columbia Mainland. It i s hoped the present explora-tory study w i l l be but the beginning of a series of more detailed studies. The writer i s convinced that the poten-t i a l role of the t r a v e l l i n g c l i n i c i n encouraging the est-ablishment of adequate r u r a l and semi-rural mental health programs and f a c i l i t i e s cannot be over-estimated. A p o s i t i v e s t a r t has been made, despite severe l i m i t a t i o n s and pres-sures of time, distance, and s t a f f ; and a doubling of a v a i l -able c l i n i c s t a f f and services i s planned f o r the near f u t -ure. The present assessment of trends i n c l i n i c a l operation and indic a t i o n s of future areas of emphasis i s offered as p o t e n t i a l l y h e l p f u l i n planning future c l i n i c a l program. The writer at a l l times bears i n mind the youth of the service, and the l i m i t a t i o n s under which both c l i n i c and f i e l d have operated; and offers her own thinking, based on the material compiled and presented i n t h i s t h e s i s , i n an unbiased l i g h t , and with the inte r e s t s of future progress in mind. The material presented i n the preceding chapters i l l u s t r a t e s that the development of the l o c a l t r a v e l l i n g c h i l d guidance c l i n i c has h i s t o r i c a l l y been much l i k e that - 168 -of those t r a v e l l i n g c l i n i c s described i n Chapter I. Local conditions and associations have gradually given i t a d i s -t i n c t i v e character, p a r t i c u l a r l y i n i t s close l i a i s o n with s o c i a l agencies, which does not appear as strongly i n the other t r a v e l l i n g c l i n i c services studied. The general trend of evolution from a mental h o s p i t a l setting, to c h i l d guid-ance, to t r a v e l l i n g c h i l d guidance, as the strengths and values of p s y c h i a t r i c services i n the everyday problems of l i v i n g were more u n i v e r s a l l y recognized, i s c l e a r l y d i s -tinguishable. I ts aim has been to "spread around" a v a i l -able p s y c h i a t r i c services and knowledge, and has been formul-ated as being: ...to treat the problems presented, using the available community resources i n the treatment; and through com-munity education methods, to enable the community to meet more adequately Its i n d i v i d u a l needs. In the process of achieving t h i s , the t r a v e l l i n g c h i l d guid-ance c l i n i c has met with s p e c i f i c problems and has acquired s p e c i f i c c h a r a c t e r i s t i c s which d i f f e r e n t i a t e i t from the stationary c l i n i c from which i t operates. While the stat-ionary c l i n i c i s concerned with the psychological, psychia-t r i c and s o c i a l diagnoses of the children and t h e i r f a m i l -i e s , and the t r a v e l l i n g c l i n i c i s also focussed on t h i s , there i s , however, another factor involved—and that i s , a s o c i a l assessment of the community. I t has been stressed repeatedly, i n the analysis of the material compiled herein, that one of the main problems at present confronting the - 169 -c l i n i c a l team i s , not the establishment of the c l i n i c a l diagnosis of the problem presented, but i s , e s s e n t i a l l y , how to make use of that diagnosis, how to present i t i n  terms meaningful and practicable to the l o c a l worker. The present study has indicated p r e t t y c l e a r l y that the f i e l d agencies are, on the whole, r e f e r r i n g problems approp-r i a t e to the service rendered by the t r a v e l l i n g c l i n i c . 1 The 2 c l i n i c team i s competent to diagnose; but the f a c t remains that the treatment recommendations are i n many instances, not  proving p r a c t i c a b l e . Before looking at the implications of t h i s , l e t us study the t o t a l picture as revealed within the scope of t h i s study. The analysis of the 50 c l i n i c f i l e s indicated that r e a l progress has been made i n educating the l o c a l workers as to suitable cases f o r c l i n i c . The general c h a r a c t e r i s t i c s of the group of children, and the nature of the problems they presented, f e l l within those seen as suitable c l i n i c cases. Problems are recognized and referred by schools, S o c i a l Welfare Branch, parents and Public Health Units, doctors, probation o f f i c e r s , and Juvenile Court, i n that order of frequency. The majority of cases are presented by S o c i a l Welfare Branch—58$—and Public Health Unit—46$ , with schools and probation o f f i c e r s presenting the remaining 6$. Schools tend to r e f e r l a r g e l y through Public Health 1 See Chapter I I I , p. .114 • 2 See Chapter I I , description of s t a f f q u a l i f i c a t i o n s . - 170 -Units, and parents through S o c i a l Welfare Branch. Public Health Units and So c i a l Welfare Branches tend to present t h e i r own cases; In t h i s respect more i n t e r a c t i o n was seen as h e a l t h i e r . There was general community professional representation at conferences, with emphasis on So c i a l Wel-fare Branch, Public Health Unit and school personnel. I t was f e l t more e f f o r t was needed to include doctors, minis-t e r s , et cetera. The active p a r t i c i p a t i o n of school per-sonnel i s viewed as extremely p o s i t i v e . This part of the study presented on the whole a positiv e picture of community use of c l i n i c service, and indicated considerable strengths within the communities, as to t h e i r present i n t e r e s t i n mental health programs. When i t came to an analysis of treatment recommendations, how-ever, i t seemed that the picture broke down considerably, with treatment recommendations not being as c l o s e l y geared to the s k i l l s of the l o c a l person carrying the case, as would be d e s i r a b l e . 1 This implication was f o r t i f i e d i n the questionnaire r e p l i e s , which indicated that too frequently the recommenda-tions are not applicable to the l o c a l conditions; and were, therefore, often by-passed completely. Personal interviews between the writer and available f i e l d casework supervisors and s o c i a l workers also indicated t h i s , and added the further suggestion that the f i e l d workers would appreciate consult-1 See Chapter I I I , analysis of follow-up reports. - 171-ative services around the carrying of c l i n i c cases. In studying the d i r e c t use of such community edu-cation channels as lectures, f i l m showings, case present-ations, panel discussions, et cetera, around mental health p r i n c i p l e s and around use of c l i n i c a l services, i t was noted that only a nominal number of such contacts were l i s t e d on c l i n i c records. The writer noted, i n addition, that on examining t r a v e l l i n g c l i n i c case records, they show the process of study and diagnosis well indeed; but that too often the record ends with t h i s . One gets the impression of an incom-plete service, with l i t t l e sense of continuity, and not enough sense of r e l a t i o n s h i p with the presenting agency and l o c a l community. The implication i s that at present the t r a v e l l i n g c l i n i c ' s t o t a l function within the communities i t serves i s not being f u l f i l l e d as adequately as i t could be. Real gains have been made i n the post-war years, and the t r a -v e l l i n g c l i n i c has become a f i r m l y established and increas-ingly recognized and accepted service throughout the prov-ince. The i n i t i a l steps have been successfully completed, as i s indicated by the appropriate case r e f e r r a l s , the broad l o c a l professional attendance at conferences, and the p o s i -t i v e indications of growing community l i a i s o n s . The trans-ient nature of the t r a v e l l i n g c h i l d guidance c l i n i c service does in e v i t a b l y lead to d i f f i c u l t i e s i n the r e l a t i o n s h i p - 172 -between the c l i n i c and the communities i t serves, and emphasizes the necessity of knowing your community i n i t s l i m i t a t i o n s and i t s strengths, and adapting available ser-vices to the l o c a l s i t u a t i o n . Prom the material at hand— c l i n i c f i l e s , f i e l d questionnaire r e p l i e s , and ideas ex-pressed by f i e l d p e r s o n n e l — t h i s seems to be the point at which c l i n i c a l services have become stalemated f o r the present. The writer f e e l s that the d i f f i c u l t y encountered i n the area of c l i n i c a l recommendations i s symptomatic of a more basic disturbance i n the matter of the r e l a t i o n s h i p o f the c l i n i c to the r u r a l communities i t serves, and that In the i n t e r e s t of future progress, t h i s disturbance needs "study, d i agno s i s and tre atment." Any p o s i t i v e relationship must be based on mutual respect and understanding. In t h i s case, the c l i n i c must understand the community, and the community must understand the c l i n i c Through understanding, comes respect. This thesis i s seen as an e f f o r t toward c l a r i f y i n g further the functions and services of the t r a v e l l i n g c l i n i c — b o t h , as has been stated, f o r the c l i n i c team and f o r the l o c a l r e f e r r i n g agency personnel. Chapter II has hopefully achieved t h i s end. The consultative and community education aspects of c l i n i c function need p a r t i c u l a r emphasis i n future community interpretation, and insofar as i s possible under present c l i n i c conditions, should be stressed, and t h e i r use encouraged. - 1-73 -Because the t r a v e l l i n g c l i n i c must work cl o s e l y and cooperatively with a wide variety of r u r a l and semi-r u r a l communities i n B r i t i s h Columbia, i t would be very valuable to undertake b r i e f records which indicate des-c r i p t i v e material about the i n d i v i d u a l community generally. In t h i s way, the c l i n i c workers would know of i t s e x i s t i n g strengths and of i t s l i m i t a t i o n s as well. This record would best be kept simultaneously by the t r a v e l l i n g c l i n i c and by the l o c a l s o c i a l agency. I t should help both agencies to use h e l p f u l resources more speedily and e f f i c i e n t l y . I t would also help both agencies recognize evident gaps i n l o c a l resources more speedily. In t h i s way, the broad r o l e of the t r a v e l l i n g c l i n i c i n aiding i n the gradual progression of the community toward increasingly adequate s o c i a l service and general mental health resources and attitudes, would ever be kept i n focus. I t would also help the r e f e r r i n g community agencies f e e l the c l i n i c f s genuine in t e r e s t and understanding of t h e i r problems; and would enable the c l i n i c team, through an understanding of l o c a l conditions, to make c l i n i c a l recommendations better adapted to l o c a l resources. Emphasis i n community i n t e r p r e t a t i o n upon the t o t a l c l i n i c f u n c t i o n s — d i a g n o s i s , consultation, community and professional education, and research (encouraging of follow-up reports on cases seen by c l i n i c ) , would appear to be the Immediate step necessary. The "other side of the coin" i s the undertaking, presumably by the casework super-visor on the t r a v e l l i n g team, of the compilation of - 174 -i n d i v i d u a l community f i l e s as to l o c a l resources, profes-sional s t a f f and general community attitudes, i . e . , a s o c i a l assessment of the community. This should r e s u l t In better-focussed case conferences, more meaningful and understand-able to the l o c a l workers present. In t h i s event, the c l i n i c w i l l be consulted increasingly around general community con-di t i o n s and resources, and w i l l move toward i t s role as "com-munity consultant" on mental health issues. In order to a t t a i n t h i s , i t i s imperative that each c l i n i c team member be interested i n and able to work comfortably i n an easy relationship with l o c a l p rofessional peopleJ and be ever aware of the role the c l i n i c plays i n the r u r a l communities. Since working rel a t i o n s h i p s between the c l i n i c and the community need to be more f i r m l y established, the writer would suggest that insofar as i s p r a c t i c a b l e , s t a f f assigned to the t r a v e l l i n g c l i n i c be f a i r l y permanent. I f t h i s i s possible, there w i l l be less chance of the team being viewed as a l i e n to the l o c a l scene, or of the t r a v e l l i n g c l i n i c being viewed as an " i n c i d e n t a l " service. I t s extreme importance  must be recognized both by c l i n i c and by community, i f i t i s  to f u l f i l i t s p o t e n t i a l r o l e . At present, the s o c i a l worker i s the only member of the team permanently assigned to t r a v e l l i n g c l i n i c . The p s y c h i a t r i s t i s generally the one currently taking h i s (or her) senior fellowship at the c l i n i c , and i s assigned to the t r a v e l l i n g team f o r his s i x months* stay at the c l i n i c . The psychologists currently rotate, but - 175 -the writer would suggest that, i n order to stress con-t i n u i t y i n s t a f f r e l a t i o n s h i p s between c l i n i c and community, they be assigned consistently to the same community. The c l i n i c ' s d e s c r i p t i o n of the functions of the various s t a f f s seems f a i r l y well worked out i n i t s written statements of job descriptions. The effectiveness with vdiieh any s t a f f member carries through h i s job r e s p o n s i b i l -i t y depends to a large extent upon h i s own c l a r i t y about h i s defined r e s p o n s i b i l i t y , as well as h i s t r a i n i n g and demon-strated professional competence. In the case of the t r a -v e l l i n g c l i n i c , t h i s includes, p a r t i c u l a r l y , recognition of and a b i l i t y to p a r t i c i p a t e actively-and e f f e c t i v e l y i n the consultative and community education aspects of t r a v e l l i n g c l i n i c f u n c t i on—and i n the f o s t e r i n g of p o s i t i v e community-c l i n i c r e l a t i o n s h i p s . A random sample case study of t r a v e l l i n g c l i n i c f i l e s was made i n an e f f o r t to gain a broad picture of c l i n i c a l a c t i v i t i e s i n the f i e l d i n 1953. Although the sample of cases studied was small, some rather expected findings nevertheless came out of i t s analysis. The sample Indicated that more boys than g i r l s tend to be referred to c l i n i c — 5 8 $ boys to k2% g i r l s . The age of the children referred ranged from 3 to 17 years, with kz% of the sample f a l l i n g i n the 9 - 1 2 year age group, and 30% i n the 13 - 18 year age group. This implies that although some problems are recognized early, the majority are not referred f o r help - 176 -as soon as i s desirable. Half of the children referred were those l i v i n g i n t h e i r own home with both parents; 18$ were from broken homes, but were s t i l l l i v i n g with one parent; and 32$ of the children were, or had been, dependent upon s o c i a l agencies f o r care and planning. The majority of the children referred—66$—were within the range of general i n t e l l i g e n c e which i s p o t e n t i a l l y responsive to appropriate help within the community. The problems being referred were on the whole appropriate to the service offered by the c l i n i c , and f e l l within the group of problems seen by the c l i n i c as v a l i d r e f e r r a l s f o r evaluation. The greater proportion of problems referred f o r c l i n i c a l services were those within the group of disorders which e i t h e r cause discomfort or d i s -turbance within the community. As would be expected, com-p l a i n t s of disobedience were the most numerous. The lea s t numerous i n terms of frequency included: severe habit d i s -orders, severe personality disorders, severe neurotic d i s -orders, and severe conduct disorders. The schools r e f e r r e d the most problems (33$), with S o c i a l Welfare Branch second (21$), and parents and Public Health Unit were t h i r d , with 17$ each. Doctors r e f e r r e d 7$. Probation o f f i c e r s and Juvenile Court referr e d the least number of problems In the cases studied. Although t h i s i s a small sample, the findings suggest a healthy d i s t r i b u t i o n of r e f e r r a l s among l o c a l agencies, schools, parents and key establishments. Because - 177 -the family physician usually i s i n intimate contact with the residents i n the community, one would expect to f i n d a larger number of r e f e r r a l s by doctors, as the c l i n i c service becomes integrated into and accepted by the r u r a l communities. Social Welfare Branch and Public Health Unit case presentations are predominant, with S o c i a l Welfare Branch presenting $3% of the t o t a l sample cases, and Public Health Unit 36$. Schools and probation o f f i c e r s presented the remaining cases. Schools tend to r e f e r mainly through the l o c a l Public Health Unit, and parents through the l o c a l S o c i a l Welfare Branch. S o c i a l Welfare Branches and Public Health Units tend to present t h e i r own r e f e r r a l s . Doctors refer to both Public Health Units and Social Welfare Branches i n a r a t i o of 3:2. Attendance at case conferences generally includes mainly S o c i a l Welfare Branch, Public Health Unit and school personnel. Doctors, probation o f f i c e r s , ministers, and V i c t o r i a Order of Nursing s t a f f are also included upon occasion, but more emphasis needs to be placed on t h e i r p o t e n t i a l contributions both i n a s p e c i f i c s i t u a t i o n , and i n the general community mental health program. I t i s the writer's impression that more use could be made of the case conference, once i t s f u l l value and purpose i s more c l e a r l y recognized. The main implication of the study of the c l i n i c a l recommendations i s that many of the cases do not seem to be - 178 -carried by the agency whose function, and t r a i n i n g of per-sonnel, i s best adapted to the needs of the case. Notable are the number of eases carried by the Public Health Unit i n which casework services to parent or c h i l d , or both, are recommended. The reason f o r t h i s inappropriate carrying of eases i s not r e a d i l y apparent, although i t may well be based on the chronic shortage of trained s o c i a l workers i n the f i e l d . Presumably the handling of cases i s decided before-hand by the l o c a l health and welfare agencies. I t seems that i t i s the duty of the c l i n i c to Indicate those instances i n which the case would best be carried by another agency. Whether t h i s i s followed or not, i s the r e s p o n s i b i l i t y of the agencies involved. A very p o s i t i v e i n d i c a t i o n i n the c l i n i c a l recom-mendations i s that the schools are being drawn i n t o the t o t a l treatment plan i n i\Q% of the cases. Although the systematic c o l l e c t i o n of follow-up reports has just been i n i t i a t e d by the new t r a v e l l i n g c l i n i c casework supervisor, 30$ of the sample cases already had such reports on f i l e , as a re s u l t of these recent e f f o r t s . Although t h i s i s much too small a number of cases to use as a basis f o r any conclusive statements, two factors stand out c l e a r l y , and indicate the extreme importance of further study, once more complete follow-up material i s available. F i r s t , the cases i n which progress was seen were, with two exceptions, those cases i n which the recommendations had - 179 -been appropriate to tbe role and function of the follow-up agency. Secondly, there seemed to be a tendency not to follow up suggestions of r e f e r r a l which were made following the diagnostic study. Both these f a c t o r s seem to point to the need of further c l a r i f i c a t i o n of the role and function of the p u b l i c health nurse, and the r o l e and function of the Social Welfare Branch worker; and the need of l o c a l health and welfare agencies coming to an early decision, based on the needs of the case, as to who should carry the case. The other implication i s that there are d i f f i c u l t i e s i n the relationships between l o c a l agencies, and between these agencies and the c l i n i c , which need "study, diagnosis, and treatment"—and a sound community organization approach. A study of the a c t i v i t i e s of the t r a v e l l i n g c l i n i c team i n general community mental health education and i n t e r -pretation of c l i n i c a l services, indicated that such a c t i v -i t y was l i m i t e d . Current pressures of time and t r a v e l impinge upon the c l i n i c team's a b i l i t y to p a r t i c i p a t e extensively In the various channels of community education over and above the case study and conference. This l i m i t a -t i o n i s recognized; but i t i s extremely important, In the l i g h t of the implications of t h i s study, that emphasis be placed upon the area of community education and i n t e r -p r etation as an e s s e n t i a l part of c l i n i c a l program, once the second t r a v e l l i n g team i s established. As much emphasis as possible i n the meantime would enable the c l i n i c to - 180 -maintain the gains made, and to prepare the way f o r greater acceptance and use of t o t a l c l i n i c functions, by the r u r a l areas. In the course of t h i s study, c e r t a i n aspects of the general trends of c l i n i c operation were necessarily skimmed over l i g h t l y . Further detailed a n a l y t i c a l study would be enlightening and h e l p f u l i n focussing future c l i n -i c a l program more nearly to meet the needs of the l o c a l com-munities. Some of the possible areas of study which have been mentioned i n the context of t h i s t h e s i s , are: 1. Trend of t r a v e l l i n g c l i n i c r e f e r r a l s over the years, with respect to the age, sex, general family back-grounds, and i n t e l l e c t u a l a b i l i t y of c l i e n t s . 2. Detailed study of cases over a period of years with regard to the types of problems referred to the t r a v e l l i n g c l i n i c . 3. Study of the extent to which c l i n i c recom-mendations are followed up—and i f not, why not. if. Intensive research by Individual community as to the t o t a l functioning and relationship of the t r a v e l l i n g c l i n i c to the community, with emphasis on follow-up reports. 5. Study of the s p e c i f i c role and function of the Public Health Nurse, and of the Social Welfare Branch worker, i n carrying r u r a l cases. The t r a v e l l i n g c l i n i c has made an auspicious beginning. I t has become an established part of the f i e l d - 181 -welfare services; and although, as t h i s study has indicated, s t a f f exigencies of f i e l d and c l i n i c have made i d e a l objec-t i v e s impossible to achieve, t h i s s i t u a t i o n w i l l be par-t i a l l y remedied i n the near future. With the establishment of a second t r a v e l l i n g c l i n i c team, more time and e f f o r t w i l l be available to focus on areas indicated herein as need-ing immediate attention—community education and interpret-a t i o n of t o t a l c l i n i c function, with emphasis on the education and consultation aspects of the c l i n i c ; and fo s t -ering of sound community-clinic r e l a t i o n s h i p s based on the c l i n i c knowing and respecting the community, i n i t s strengths and i n Its l i m i t a t i o n s , and on the community knowing and respecting the c l i n i c , i n i t s strengths and l i m i t a t i o n s . The success of any such undertaking w i l l always depend on harmonious relationships among c l i n i c s t a f f , f i e l d health and welfare s t a f f , and other c i t i z e n s of the communities served. - 182 -APPENDIX A LIST OF CLINICS AND PROVINCIAL DIRECTORS OF MENTAL HEALTH SERVICES CONTACTED 1. Child Guidance C l i n i c , 710 - li+th Avenue, Calgary, Alberta. Director. 2. Child Guidance C l i n i c 10^23 - 100th Avenue Edmonton, Alberta. Dr. R. A. Schrag, Director. 3. Director, Child Guidance C l i n i c , Red Deer, Alberta. 4. MacNe11 C l i n i c f o r Psychiatric Services, Saskatoon, Saskatchewan. Dr. Z. Selinger. 5. Dr. D.G. MacKerracher, Director, Mental Health Services, Department of Health, Parliament Buildings, Regina, Saskatchewan. 6. Dr. T.A. Pincock, P r o v i n c i a l P s y c h i a t r i s t , Psychopathic Hospital, Winnipeg, Manitoba. 7. Dr. M. Houze, Director, Mental Health C l i n i c , Ontario, Hospital, B r o c k v l l l e , Ontario. 8. Dr. H.R. B r i l l i n g e r , Director, Mental Health C l i n i c , Ontario Hospital, Hamilton, Ontario. - 183 -APPENDIX A (Continued) 9. Dr. R.M. B i l l i n g s , Director, Mental Health C l i n i c , Ontario Hospital, Kingston, Ontario. 10. Dr. G.E. Jenkins, Director, Mental Health C l i n i c , Ontario Hospital, London, Ontario. 11. Director, Mental Health C l i n i c , Ontario Hospital, New Toronto, Ontario. 12. Director, Mental Health C l i n i c , Ontario. Hospital, Whitby, Ontario. 13. Dr. R.C."Montgomery, Director, Mental Health D i v i s i o n , Department of Health, Parliament Buildings, Toronto 2, Ontario. ll}.. Dr. Baruch Silverman, Director, Mental Hygiene I n s t i t u t e , 531 Pine Ave. W., Montre a l , Quebe c. 15. Dr. Geo. Reed, Director, Verdun Protestant Hospital, Verdun, P.Q. Tra v e l l i n g C l i n i c . 16. Dr. L.R. Vezina, Chief, D i v i s i o n of Ps y c h i a t r i c Hospitals, Ministry of Health, Parliament Buildings, Quebec, P. Q. - 184 -APPENDIX A (Continued) 17. Dr. Clyde M a r c h a l l , Chief N e u r o p s y c h i a t r y D i v i s i o n , Department o f P u b l i c H e a l t h , H a l i f a x , Nova Scotia.. 18. Dr. R.H. Prosser, D i r e c t o r , Mental Health S e r v i c e s , Department of Health and S o c i a l S e r v i c e s , P r e d e r i c t o n , New Brunswick. 19. Dr. A.J. Murehison, D i r e c t o r , Mental Health D i v i s i o n , Department of H e a l t h and Welfare, Palconwood H o s p i t a l , Gharlottetown, P r i n c e Edward I s l a n d . - 185 -APPENDIX A (Continued) January 9 t h , 1955. Dear Dr As part of ray work f o r the Master of Soeial Work degree, I am studying f o r my thesis the t r a v e l l i n g c h i l d guidance c l i n i c services currently available i n Canada, with special reference to the Vancouver Tra-v e l l i n g Child Guidance C l i n i c . I have been unable to obtain the information which I need, and would l i k e to e n l i s t your a i d i n regard to your c l i n i c , which I understand provides t r a v e l l i n g p s y c h i a t r i c services f o r children. I trust t h i s w i l l not e n t a i l too much of your time, and that the neces-sary material may be r e a d i l y available i n annual reports or other s t a t i s t i c a l data. B r i e f l y , the areas of in t e r e s t are: a) c l i n i c function (diagnostic, consultative, ., educational, therapeutic, et cetera) b) area serviced c) s t a f f and administration d) types of cases handled e) t i e - i n with other s o c i a l agencies Any other comments you f e e l are indicated would be appreciated. Would i t be possible to receive t h i s information on or before January 25th? With thanks f o r your cooperation, Yours t r u l y , (Mrs.) P h y l l i s Coyle, University of B r i t i s h Columbia School of S o c i a l Work. - 186 -APPENDIX B The purpose of t h i s enquiry i s a b r i e f review of the ser-vices offered through the T r a v e l l i n g Child Guidance C l i n i c from Vancouver. I t would be greatly appreciated i f you base your judgments on your experience i n the l a s t two years only. Please f e e l free to comment on any ways i n which you think services might be improved. Identifying Information D i s t r i c t Office Date How often does the c l i n i c v i s i t Is there a need f o r more frequent visits....How often Approximate number of cases referred by the d i s t r i c t o f f i c e i n 1952 i n 1953 I. REFERRALS In which type of cases have you found the c l i n i c most help-f u l . (Mark with X the type(s) of cases which are most common. Mark with t i c k ( / ) the types of casefe) f o r which the c l i n i c has been most helpful.) Number Help 1. Maladjustment stemming from chil d * s undesirable habits , 2. I n a b i l i t y to cope with s o c i a l or scholastic expectations 3» Placement cases i n which there i s concern about the emotional consequences to the c h i l d due to former dependency, broken home, or neglect. *»-—— - 187 -APPENDIX B (Continued) Number Help k. Children i n t h e i r own homes whose behaviour d i f -f i c u l t i e s stem from a d i s t i n c t break-up i n parent-child r e l a t i o n s h i p f>. Patients who are retarded i n I n t e l l e c t u a l development 6. Patients who are retarded because of ph y s i c a l handicaps 7. Cases involving psychogenic disorders 8. Behaviour d i f f i c u l t i e s as a di r e c t r e s u l t of marital c o n f l i c t ______ 9. Other (Please specify) I I . Follow-up 1. On the average, to what extent did the c l i n i c a l diag-nosis help the s o c i a l worker In o v e r - a l l case work operation. A. Extremely h e l p f u l . . . . B. Moderately h e l p f u l .... C. Of Limited value .... D. Of no value 2. "What were the most important l i m i t i n g factors a f f e c t i n g the follow-up. (Please explain factors where necessary): A. Community resources ... C. S o c i a l service personnel... B. Continuity of psychiat- D. Other r i c consultation • Suggestions I I I . CLINIC CONFERENCES AND COMMUNITY INTERPRETATION 1. Do you f i n d c l i n i c conferences (Check which) - 188 -APPENDIX B (Continued) A. Very u s e f u l . . . . . . B. More use possible C. Almost no use D. Other (Specify) 2. Do you include other interested professional persons (e.g., p u b l i c health nurses, teachers, school coun-s e l l o r s ) : Yes...... No I f the answer i s yes, please comment on t h e i r part i n the conferences GENERAL COMMENTS - 189 -I N T R O D U C T I O N The preparation of a social case history presupposes a case work relationship with the child and his family. Referral to Child Guidance Clinics should be a joint decision made by the child and the family and the social worker, a f t e r i n t e r p r e t a t i o n of the pur-pose and value of-such examination has 'been done by the worker. The child and his family should be aware that Clinical examination i s aimed at further understanding of the child's problem and that usually i t is followed by a further "working together" of the family and the s o c i a l worker. Consequently/ much of the information required for a social history w i l l have been obtained during the s o c i a l worker's e a r l y con-t a c t w i t h the f a m i l y , and an e v a l u a t i o n o f the problem made. An adequate social case history supplies to the Clinic team a revealing story of the child in his social setting. The plot centres around his d i f f i c u l t i e s which often come about through fr i c t i o n between his growth process and the demands of his environ-ment. Whatever affects this growth process or the environment is of significance in the story. As far as possible a social history should give a clear impression of the child with respect to inherit-ance, rate of development, bodily health, home, background, parental attitudes, response to school l i f e , adaption to family and other children, and adults. The social history is not only descriptive; i t also includes the s o c i a l worker's e v a l u a t i o n and i n d i c a t e s the work already done and i t s e f f e c t . Four copies of the developmental and social history should be submitted at least a week prior to Clinic examination of a l l Vancouver Island and Travelling Clinic cases. - 190 -SOCIAL HISTORY OUTLINE A guide to preparation of Social Histories for the Child Guidance Clinics. DATE WRITTEN; DATE OF EXAMINATION: NAME: BIRTHDATE: STATUS: (Ward, Non-Ward, Etc.)-PARENTS; (FATHER) BIRTHDATE: (MOTHER) BIRTHDATE: (MAIDEN NAME) ADDRESS: TELEPHONE: SS. INDEX: SOURCE OF REFERRAL: (By whom and how) PROBLEM: (1) As stated and seen by parents, child, and any other closely involved persons. What help are they asking for? How long have parents, child, or others been aware of the problem (s) ? How do they feel about receiving help? (2) S o c i a l worker's general p i c t u r e of problem. Estimate client's awareness of the presenting problem and other problems seen by the s o c i a l worker. Reason for referral to Clinic at this time. What specific help is desired by s o c i a l worker. DATE OF PREVIOUS EXAMINATION AT C.G.C, E.P.H., Etc. (Child or relatives) FAMILY HISTORY HOME SETTING: Pertinent and brief descriptive material' of present home setting —economic and community status; housing; persons in home. FATHER: (l) Identifying information—name; present age; place of birth; religion. (2) Social and cultural background—others in family, ages; father's description of paternal grandparents; father's estimate of his adjustment to family, school, religion, and social groups; extent of education; work record, health; any serious illnesses or operations. (3) Family relationships.—father's feelings about and relation-ship to child, to wife, to others in family; Father's attitude and contribution with regard to problem(s); How does he handle i t ? - .191 " FAMILY HISTORY (4) Paternal relatives—information pertinent to child^and parents' adjustment.' MOTHER: Information as for father ( l ) ; (2), (3). (4) Maternal relatives 1—information pertinent to child and parents' adjustment. MARITAL ADJUSTMENT: When, where, and how did parents meet? Courtship; Sexual adjustment. STEP-PARENTS OR FOSTER HOMES: As above with dates child was with them and reasons for leaving: Indicate and evaluate relationships, adjustment, and the meaning of the experience to the child; (in chronological order) SIBLINGS: Indentifying information—name; date and place of birth, religion. How do they f i t into the family, inter-personal relationships? PERSONAL HISTORY DEVELOPMENTAL FACTS: Date, place of birth: Age weaned: Bladder control at: Toilet training began: Bowel control at: Teethed at: Walked at: Talked at (words): (sentence formation): DESCRIPTION OF DEVELOPMENT TO DATE: mother's health, attitudes and feelings about child during pregnancy; method of delivery; length of labour; birth injuries. (l) Eating: Method of early feeding; Method of weaning, any early feeding/ or present eating d i f f i c u l t i e s ; Food fads or fussiness; Indigestion or any indication of gastro-intestinal disorder. (2) Elimination: Method and attitudes i n training child; D i f f i c u l t i e s ; Any indications of frequent constipation or diarrhea; Any incidents of enuresis; Soiling; Smearing; Any present unusual attitudes or habits regarding: elimination. (3) Sexual development: Interest in sexual information; Any incidents of exhibitionism; Sex play; Masturbation or intercourse (describe, including age and frequency, of such incidents); Extent of sexual knowledge; - 192 -PERSONAL HISTORY From whom obtained; Evidence of development; Age of puberty; A t t i t u d e toward i t ; I f menses e s t a b l i s h e d i s i t regular? P a i n f u l ? Has someone discussed puberty and sexual r o l e w i t h c h i l d ? Any i n d i c a t i o n of abnormal sexual behaviour? (4) P h y s i c a l development-: Has p h y s i c a l growth been normal? Give i n c i d e n t s o f i l l n e s s , disease (ages) sequelae ( d i s a b i l i t y , e t c ) Reactions of c h i l d and parents t o serious i l l n e s s e s ; D i s a b i l i t i e s ; Operations and p r e p a r a t i o n of c h i l d f o r these (age); C h i l d ' s a t t i t u d e t o and estimate o f present h e a l t h ; Any over-compensation or over-concern. PERSONALITY AND APPEARANCE: P h y s i c a l d e s c r i p t i o n ; - - a n y i n d i c a t i o n s of nervous h a b i t s ; f e a r s ; disturbances of sleep; recurrent or s i g n i f i c a n t dreams. General p i c t u r e of the c h i l d ' s outstanding r e l a t i o n -ships and how he (she) uses these. How does he (she) handle f e e l i n g s and need such as anger, a f f e c t i o n , dependency i n r e l a t i o n t o h i s (her) c l o s e s t r e l a t i o n s h i p s . A t t i t u d e s t o school, teachers, people i n a u t h o r i t y . I n t e r e s t and Recreation; adjustment t o s o c i a l groups, employment, p a r t i c u l a r f r i e n d s of both sexes. Ambitions and g o a l s . Estimate of c h i l d ' s i n s i g h t , i n t e l l i g e n c e , humour. SCHOOL RECORD: Grade and teacher's r e p o r t . Bureau of Measurements record i f i n Vancouver. EVALUATION- AND PLAN S o c i a l worker's e v a l u a t i o n of case from work done by the p r e s e n t i n g agency. E v a l u a t i o n of strengths and weaknesses i n c h i l d , parents, and p a r e n t - c h i l d r e l a t i o n s h i p . What has been done? How frequent are the contacts? How strong i s w o r k e r - c h i l d r e l a t i o n ? What methods have been t r i e d i n working w i t h c h i l d and pare n t ( s ) ? What has been t r i e d by f a m i l y members i n d e a l i n g w i t h problems? How successful? What p o s s i b l e resources are there i n f a m i l y or community t o help meet c h i l d ' s needs? What are worker's suggestions f o r c a r r y i n g on from the poi n t ? Questions around which s o c i a l worker would l i k e d i s c u s s i o n . ALL HISTORIES SHOULD BE SIGNED BY THE SOCIAL WORKER AND FOUR COPIES SUBMITTED TO THE CLINIC ' - 193 -APPENDIX D BIBLIOGRAPHY Sp e c i f i c References Books; Hamilton, Gordon, Psychotherapy i n Child Guidance, Columbia University Press, New York, 1950. Kasius, Cora, New Directions i n Social Work, Harper Bros., New York, 1954. Stevenson, George, and Smith, Child Guidance C l i n i c s ; A Quarter Century of Development, Oxford University Press, London, 1934* Wltmer, Helen L., Ps y c h i a t r i c C l i n i c s f o r Children, The Com-monwealth Fund, New York, 1 9 4 ° . A r t i c l e s : B r i l l i n g e r , H. Roy, "The Mental Health C l i n i c i n the Com-munity, " 0nJ_ai__DJ^ Volume 19, Number 11, November, 1952, Ontario Medical Association Mental Health D i v i s i o n . Coleman, Jules, and Switzer, R.E., "Dynamic Factors i n Psychosocial Treatment i n Tr a v e l l i n g Child Guidance C l i n i c s , " Ment a l Hyg iene, The National Association f o r Mental Health Inc., New York, 1951. Reed, G.E., and S i l v e r , A., "The F i r s t T r a v e l l i n g Psy-c h i a t r i c C l i n i c i n Quebec," The American Journal of  Psychiatry, Vol. 108, No. 9, March, 1952. Robinson, J.F., "Current Trends i n Child Guidance C l i n i c s , " Mental Hygiene, The National Association f o r Mental Health, Inc., New York, 1950. Roth, W.F., "Minimum Professional Requirements for S t a f f s of Rural and Semi-Rural C l i n i c s , " American Journal of  Orthopsychiatry, V o l . XXIII, No. 3, American Orthopsy-c h i a t r y Association, Inc., New York, July, 1953. - 194 -APPENDIX D (Continued) Studies and Reports: I n s t i t u t e f o r C l i n i c Personnel of the C h i l d G-uidance C l i n i c s and I n s t i t u t i o n s of the New York State Department of Mental Hygiene, March 20-24, 1950, p u b l i s h e d by State of New York, Department of Mental Hygiene, Mental Health Commission, Albany, New York, 1950. Department of N a t i o n a l H e a l t h and Welfare, Research D i v i s i o n , General Series Memorandum No. 6, Mental Health S e r v i c e s  i n Canada. Ottawa, J u l y , 1954* Department of P r o v i n c i a l S e c r e t a r y , Mental Health S e r v i c e s , Province of B r i t i s h Columbia. Annual Reports, 1932-1954. Department of Health and Welfare, P r i n c e Edward I s l a n d , Annual Report, 1952. Department of Health, H o s p i t a l s D i v i s i o n , Ontario Mental  H o s p i t a l s and Mental Health S e r v i c e s , Annual Report, 1951". Department of P u b l i c Health, Province of Saskatchewan, P u b l i c H e a l t h Annual Report, 1952-3. Department of P u b l i c H e a l t h , Province of Saskatchewan, An O u t l i n e of P s y c h i a t r i c S e r v i c e s . June, 1954* Department of P u b l i c Health, Province of A l b e r t a , Mental H e a l t h S e r v i c e s , 1953. 

Cite

Citation Scheme:

        

Citations by CSL (citeproc-js)

Usage Statistics

Share

Embed

Customize your widget with the following options, then copy and paste the code below into the HTML of your page to embed this item in your website.
                        
                            <div id="ubcOpenCollectionsWidgetDisplay">
                            <script id="ubcOpenCollectionsWidget"
                            src="{[{embed.src}]}"
                            data-item="{[{embed.item}]}"
                            data-collection="{[{embed.collection}]}"
                            data-metadata="{[{embed.showMetadata}]}"
                            data-width="{[{embed.width}]}"
                            async >
                            </script>
                            </div>
                        
                    
IIIF logo Our image viewer uses the IIIF 2.0 standard. To load this item in other compatible viewers, use this url:
http://iiif.library.ubc.ca/presentation/dsp.831.1-0106428/manifest

Comment

Related Items