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The pre-clinical conference as a diagnostic screen in the child guidance setting : a preliminary survey… Chave, Estelle Christine 1952

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THE PRE-CLINICAL CONFERENCE AS A DIAGNOSTIC SCREEN IN THE CHILD GUIDANCE SETTING A Preliminary Survey of the Use of the Procedure in Canadian Clinical Practice, and an Analysis of Selected Cases in the Child Guidance Clinic at Vancouver. by ESTELLE CHRISTINE CHAVE Thesis Submitted in Partial Fulfilment of the Requirements for the Degree of MASTER OF SOCIAL WORK in the School of Social Work Accepted as conforming to the standard required for the degree of Master of Social Works School of Social Work 1952 The University of British Columbia A B S T R A C T The procedure known as the pre-clinical.conference is uBed routinely as a diagnostic screen in certain child guidance clinics in the United States, with advantage to both clinic and client. This study surveyed in brief the extent of.the use of the procedure in Canadian.mental health clinics giving service to-children. In the Child Guidance Clinic at Vancouver, the pro-cedure i s used only infrequently. The study analyzed certain cases from the Vancouver Clinic - one group of cases in which the procedure was used, and another group in which i t was not - to throw light on the purposes and results of the procedure. The background survey showed a wide variation in pre-clinical procedures in Canadian mental health clinics. A small.minority used a conference of the f u l l team, in a l l cases; a majority did not use the procedure at a l l ; a small group used, a partial team conference pre-clinically in selected cases. The purposes for which the pre-clinical conference was used were identified by each clinic, with results similar to those shown by the case analysis. Consideration of the use of this procedure is of concern to social, workers functioning as members of a clinical team, because of the growing emphasis placed by leaders in the field on the integration of professional skills and service. Conferencing is an important way in which this principle is imple-mented, and pre-clinical conferencing, an extension of the method, is a further possible means of translating this principle into practice. The first group of 12 cases in which pre-clinical conferencing was used, contained four sub-groups of three caseB each, selected according to the reasons for the conferencing, and classified for convenience according to medical, psychiatric, psychological or multiple reasons respectively. The second group of cases, in which pre-clinical conferencing was indicated but not used, contained three representative cases. The case.analysis identified the uses served by a pre-clinical conference (in the first group of cases), or the possible uses (in the second group). The uses included any or a l l of the following : (1) selection of cases-and intake; (2) referral to or from other agencies; (5) planning diagnostic study and exploration; (4) allocation of diagnostic responsibilities;, and (5) delineation of a tentative treatment plan. The results identified.by the analysis included facilitation of any or a l l of the following: (l) diagnostic process; (2) establishment of treatment goals and (5) economical use. of staff time. While the routine use of pre-clinical conferencing for diagnostic screen-ing is held to represent the ideal practice, i t was seen to be unnecessary in some clinics, impracticable in others and inadvisable in others for specific reasons. In many clinics the need was met by use.of the procedure in. selected cases. This is.the practice in the Vancouver Clinic, where i t is employed at the discretion of the social worker. This places a serious responsibility on the professional s k i l l of the social worker, necessitating alertness to indic-ations for use of the.procedure and awareness of the desirability of extending its use, where possible, in the interests of the wider application of the principle of integration. TABLE OF CONTENTS Chapter 1. The Background of Child Guidance Child guidance and the twentieth-century citizen. The pioneers in the field. The National Committee for Mental Hygiene and its programme. The structure, and function of the Child Guidance Clinic to-day. The con-ference method. Objects and methodology of the present study. Chapter 2. The PreVGlinical Conference in Canadian Clinics Purpose and nature of the canvass; choice of clinics to which i t was addressed (only those giving service to children); nature of the response. The findings: wide variation in practice. Some representative patterns. The position of the Vancouver Child Guidance Clinic. Chapter 5. The Conference Method in Principle Definition of the concepts of the study. The conference in general and in particular. The pre-clinical conference and its possible uses. The various personnel combinations in the team conference. The philosophy of the Vancouver Child Guidance Clinic. Chapter 4. The Pre-Olinical Conference-in Operation An analysis of 12 cases from the Vancouver Child.Guidance Clinic. The pre-clinical conference for medical reasons; for psychiatric reasons; for psychological reasons; for multiple reasons. The uses and results of pre-clinical conferencing in these cases. Chapter 5. The Pre-Olinical Conference Omitted An analysis of three representative cases from the Vancouver Child Guidance Clinic, in which pre-clinical conferencing was indicated but not implemented. Possible uses and results in each case had there been pre-clinical conferencing. Chapter 6. Conclusions and Implications Comparisons with other studies. The concept of integration. Current trends. Recommendations for future goals. Appendices: A. List of Canadian Mental Health Clinics canvassed in the study. Questionnaire and covering letter used in the study. B. Some.extracts from letters in reply to questionnaire. C. Schedule used for case analysis. D. Bibliography. i i i TABLES IN THE TEXT Page Table 1. Pre-clinical procedures in Canadian practice 15, 16' Table 2. Uses and results of the pre-clinical conference 55 ACKNOWLEDGEMENTS I wish to acknowledge my indebtedness to Dr. U.P. Byrne, Director of the Child Guidance Clinic, for permission to utilize Clinic records for research purposes. I am also indebted to Miss Alice Carroll, Provincial Supervisor of Psychiatric Social Work, and to other members of a l l departments of the Clinic staff, for their aid in various-phases of this study. Special acknowledgement, is made of the helpful-ness of Dr. L.C. Marsh, Mrs. Helen Exner, and other members of the Faculty of the School of Social Work. v i THE PRE-OLINICAL CONFERENCE AS A DIAGNOSTIC SCREEN IN THE CHILD GUIDANCE SETTING THE PRE-CLINICAL CONFERENCE AS A DIAGNOSTIC SCREEN IN THE CHILD GUIDANCE SETTING CHAPTER I THE SOCIAL CONTEXT AND HISTORICAL BACKGROUND OF CHILD GUIDANCE The serious-minded twentieth-century citizen has become increasingly aware of that entity known commonly as "the problem child", whether this child be the defective, the retarded, the "nervous11, or the delinquent child. Such children are egregious now, regardless of milieu, whether this be the family or the home, the school or the community at large. With the growth of modern industrial society, attended by the increasing concentration of population in larger and larger urban centres, the difficulties of these children have been both aggrav-ated by the increasing pressures and complexities of l i f e in this new environment, and inexorably forced to the attention of the population. The evolution of universal education also has brought increasing awareness of the fact that a l l children do not grow or learn or become socialized in the same way or at the same rate, and this awareness has produced interest in the development of intelligence tests in the field of psychology. Paralleling this was the growing interest of the medical profession in psychiatry. While Binet and Simon were evolving their intelligence tests, Freud, Jung and Adler were laying the basis of modem dynamic psychiatry which, on the American continent, Meyer, Rank and Kanner introduced. This professional activity stimulated other developments, such as the mental hygiene movement, through which efforts to help "the problem child" could be integrated and directed. 2 The details of the historical development of this movement have a direct bearing on the function and structure of the child guidance clinic. "Historic-ally, the first psychological clinic in the United States was established by Lightner Witmer at the University of Pennsylvania in 1896. However, the pre-sent child guidance clinic was established from a larger base than this ..." Thus Dr. William Healy could say of those early days, "With the possible exception of Witmer's clinic in Philadelphia where defectives were being observed and the beginnings of Goddard's work with Johnson at Vineland, also, with defectives, there was not even the semblance of anything that could be called a well-rounded study of a young human individual ... Even physiological norms were not available, standardized mental tests had to be developed, the Binet age level scale had not yet appeared; the importance of knowledge of family attitudes arid conditionings was barely realized."^ This was the situation in 1908, a year in which there occurred a development which can now be seen as epitomizing the essential characteristic of the child guidance movement. There was a coming together of certain representative people for a "meeting of minds",-the first application in this area of what we now know as the multi-disciplined approach. Perhaps this largely explains the phenomenal success and steady development of the child guidance clinic movement, for its "house was built upon the rock" of the principle of multiple causation. To a brilliant and generous lay person, Mrs. W.F. Dummer, must be given much of the credit for this development. She drew together a psychiatrist, Dr. Adolf Meyer, and two social workers, Julia Lathrop and Allen Bums, to launch the first organized attempt at a child guidance clinic. This resulted in their enlisting the services of Dr. William Healy, a psychiatrist, and Dr. Augusta Bronner, a psychologist, to found the first real child guidance clinic, the (1) Martin L. Reymert, "The organization and Administration of a Child Guidance Clinic, in Handbook of Child Guidance, edited by Ernest Harms, 1947, p. 225. (2) William Healy, "Twenty-five years of Child Guidance", in Studies from the Institute of Juvenile Research, 1954, pp. 1,2. 5 Juvenile Psychopathic Institute in Chicago, which Mrs. Dummer supported from her own resources for the firet five years. Then, in 1°15> Healy and Bronner founded the Judge Baker Guidance Clinic in Boston. The team approach of psychiatrist, psychologist and social worker was indigenous to the-child guidance clinic from its earliest days and was its great strength and firm foundation. Both of these clinics had been set up as ancillary to juvenile courts. It was hot surprising then, that, in 1910, the National Committee for Mental Hygiene formed a Division on the Prevention of Delinquency, and set up an Advisory Committee to further its programme. In 1921, at the Lakewood Conference, these bodies formulated and implemented a programme to provide three services to communities wishing to institute clinics : (1) information and advice, (2) experiment and demonstration, and (5) psychiatric field ser-vice. Money was given by the Rockefeller Foundation and the Commonwealth Fund to finance demonstration clinics. In 1926, the Division on the Prevention of Delinquency gave way to the Division on Community Clinics. Reymert describes these developments as follows: "... The National Committee designed a clinic program to demonstrate a method of checking juvenile delinquency which was financed by the Commonwealth Fund. In 1922 the first demonstration clinics were set up in Norfolk, Virginia, and.St. Louis, Missouri, with the purpose of showing the juvenile.courts and child caring agencies what psychiatry, psychology and social work have to offer in the treatment.of the problem child and by such treatment not only to help the individual delinquent but ... to decrease the number of delinquents." (5) From 1922 to 1927, demonstration clinics were set up in one city after another a l l over the country and one was started, in Canada. They gathered valuable experience in the formulation of function,.. organization and administr-ation. While these varied from community to community, some general statements (5) Reymert, op. cit. p.228. 4 about these developments are possible. The child guidance clinic has come to be the "out-of-hospital" manifestation of the mental health service for children -that is, the child guidance clinic is community-oriented. Its functions are basically threefold: the first and second may be described as the primary and secondary prevention of mental illness. The primary prevention of mental illness is achieved by education, and the secondary prevention through treatment. The child guidance clinic educational programme is three-fold : i t includes (l) the education of various disciplines as to the principles of positive mental health, (2) the education of other professional groups towards awareness of mental health facilities, and (5) the education of the general population as to basic implic-ations of mental health in daily l i f e . The child guidance clinic treatment programme is geared to deal with beginning behavior, habit and personality pro-blems which can be given diagnostic, consultative or therapeutic services. The third function of the child guidance clinic should be research, although this function is too often neglected. Administratively, the clinic operates under the directorship of a psychiatrist, although, in most clinics, the administrative responsibility is shared with the chiefs of the social work, psychology and nursing staffs. The typical c l i n i c ^ ^ is structured to give a four-fold service - social, physical, psychological and psychiatric, with.members of each discipline bringing their special skills to bear as needed in each case, and meeting with the other disciplines for the synthesis of group diagnostic findings and the planning of treatment. The conference method has proved to be the most successful method for coordinating findings and treatment plans of the various disciplines. The conference method is universally accepted and utilized in the child (4) Actually i t is possible to distinguish three types of clinics: the child guidance clinic (with its multi-disciplined approach), the mental health clinic (with its preventive, public health approach), and the psychiatric clinic (with facilities for severely psychopathological cases). In this thesis the- first two types are given most consideration, and the terms "clinic", "child guidance clinic", and "mental health clinic" are, for the most part, used interchangeably. guidance setting. It is generally used following the f u l l clinical examination of a child, and periodically thereafter at appropriate points in the treatment process, whenever inter-discipline consultation and team thinking are advisable. The justification for making the conference method the subject of a research pro-ject is that there appears to be some reason to ask whether its use could be expanded and refined to produce greater efficiency and economy of operation, and, consequently, better service to the patient and to the community. The initiating, the enabling, the fostering and the maintaining of worker-client relationships, is the special area of competence of social workers. They have the professional obligation to be equally active in initiating, enabling, fostering and maintain-ing relationships with other professional disciplines. This would ultimately result in better service to the client and to the community. How then can the conference method be expanded and refined? It has already been used in some child guidance clinics pre-clinically - that is, i t has been found.to serve useful purposes when utilized before the f u l l clinical examination. Pre-clinically, the conference has been used as part of the intake procedure to facilitate the selection of cases on a diagnostic basis, in accordance with the function of the individual agency. The pre-clinical conference can also be used to determine the relative need for emergency, routine or specialized ser-vice, and to make the corollary decisions as to the types of examinations advis-able, thus facilitating the economical use of the clinic's resources. Then, too, in view of the fact that treatment is generally seen as beginning with the client's first contact with the clinic,, the. team can jointly consider the handling of difficult cases during the period of work-up in preparation for clinical examination. Utilized in these ways, the team conference, employed pre-clinically, serves as a screen - a device to select and channel cases on a diagnostic basis to ensure the most efficient,and economical use of the clinic's resources, thus contributing to the optimum use of the agency by the community. The pre-clinical conference is used occasionally in the Vancouver Child Guidance Clinic. This sometimes takes the shape of a fu l l team conference, but more frequently consists-of a partial team conference, as for instance when the social worker consults either the psychiatrist or the psychologist individually in reference to an isolated case. The question is : should this practice be extended and improved? Would i t not result in better service to client and community, and in the saving of time, energy and money to the agency? Conversely, is i t not likely that, in the absence of. the use of the pre-clinical conference, there are certain hazards which may result in damage to the client? In relation to intake and the selection of cases, the process of.possible referral of the client to another agency is a delicate matter which might be facilitated by the use of a pre-clinical conference* Then too, when the pre-clinical conference is omitted, there is always the possibility of inefficient use of time and effort of one or more of the team members by the lack of planning and coordination of examinations which, in addition, may result in actual damage to the client. The question arises, then, of what possible-further uses the pre-clinical conference might serve in the area of planning and exploration, allocation of diagnostic responsibilities, and treat-ment planning. The research methodology used in this study included a preliminary survey of the extent of the use of the pre-clinical conference in Canadian practice. This was achieved by means of a questionnaire addressed to 20 Canadian mental health clinics giving service to children. (Example in Appendix A) In addition, 12 cases were, analysed to exemplify and illustrate the use of a pre-clinical conference, and j case studies were made to examine situations where a pre-clinical conference was indicated but not employed. The cases studied were taken from the files of the Vancouver Child Guidance Clinic. CHAPTER II USE OF THE PRE-CLINICAL CONFERENCE IN CANADIAN MENTAL HEALTH CLINIJ3S GIVING SERVICE TO CHILDREN A preliminary survey to determine the extent of the use of the pre-clinical conference in Canadian practice was carried put by means of a questionnaire. A l i s t of mental health clinics in Canada, as of November, l ° 5 l > w a s obtained from the Canadian Mental Health Association. Clinics to which the questionnaires were addressed, were selected on the basis of the descriptive information included in the C.M.H.A. l i s t , which indicated whether or not services to children con-stituted a l l or part of the clinic's work. Questionnaires were also sent to certain provincial public health officials in order to ensure complete coverage of government-sponsored clinics. Of these, five referred their questionnaires to other clinics already circularized, one (in Ontario) did not reply, and one (in Newfoundland) replied that, "up to the present, no such clinics have been established in Newfoundland." It vras already known, that there were no mental health clinics in New Brunswick or Prince Edward Island. In sum, this means that there are mental health clinics giving services to children in seven of the ten provinces. The number of these clinics in each province varies considerably, and is difficult to estimate accurately, as there are apparently many duplications or shared services. Thus, for example, the C.M.H.A. l i s t gives three clinics in Nova Scotia, but when these were circularized with the questionnaire, i t trans-pired that they were one and the same clinic, in which the provincial Depart-ment of Public Health, the Victoria General Hospital at Halifax, and Dalhousie 8 University, each claim a share. Travelling clinics cannot be counted as separate clinics as they are usually operated by teams from the main stationary clinics. No attempt was made to cover French-speaking clinics. The inform-ation in this study, therefore, refers to English-speaking, stationary mental health clinics giving service to children. These make up a group of 20 clinics, of which 17 returned completed forms* Of these-> two are in B.C., two in Alberta, two in Saskatchewan, one in Manitoba, seven in Ontario, two in Quebec, and one in Nova Scotia. For the purposes of the survey, i t was deemed important to know the source of financial support of these clinics, as this factor might have a bearing on their policies and practices. It was learned that the majority, 14, of the clinics, are supported-by public funds, from either provincial or civic treasur-ies. It is interesting that none is supported by private money entirely.' There are three clinics which derive their support from both public and private sources, two of these being in Montreal, and the other, the Halifax clinic to which previous reference has been made. Some information was requested from the clinics about their intake policies and their criteria for limitation of intake. (Summary table> pp. 15,16.) Agency policy and function was checked by 15 of the clinics, and diagnostic criteria was checked by ten clinics, while both of these items were checked by nine clinics, which would seem to indicate their ability to be fairly selective in accepting cases. It is interesting that six of these.nine clinics drew their financial support from public funds, which seems to suggest that some tax-supported clinics find i t possible to exercise considerable selectivity in their choice of intake. However, three of these six clinics indicated in accompanying notes that they accepted a l l cases which came.to .them, partly.because, in two cases, screening.was accomplished by the referring.agencies, and in one case, con-siderations of geography and difficulties of travel made selectivity impracticable. 9 Of the other three clinics which checked-both items and were-publicly supported one was extremely selective, and two apparently only moderately so. Only two clinics considered that their intake was restricted by financial considerations There were two clinics, each drawing support from both public and private funds, whose intake was limited by factors other than those suggested in the questionnaire. Of these> one stated that, in addition to agency policy and function and diagnostic criteria, its intake was limited by "age and social status", considerations which might have been included under the other items listed. The second clinic of these two, stated that its intake-was limited by budget, and by "staff members", a reference presumably to paucity of staff. Altogether, there were ten clinics'which checked two of the criteria. It was hoped that the results of the questionnaire would help to clarify the relationship between source of financial support and selectivity of in-take, but i t would seem that this is impossible because of other factors which affect both the need and the ability to be selective. The clinic mentioned above as extremely selective, is able to be so partly because i t is situated in a city (Toronto) in which there are at least six other mental health clinics giving service to children, as well as many social agencies giving casework services: to both families and, children. In four of, the. other five clinics in this group, each is. the only mental health clinic giving ser-vice to children in its own city, and the only such clinic serving the section of the province in. which i t is located. In addition to this, many clinics stressed the lack of need to screen, for, selection of cases,at intake, as this was. taken care of by the source of.referral - in some cases by school personnel such as. public health doctors and nurses, and by teachers, in other cases, by other social agencies. Initial intake procedures, with particular regard to the specific 10 personnel responsible for them, formed the next point of inquiry in the-questionnaire. It was learned that the majority, 11, of the clinics have their intake interview conducted by a social worker. It must be indicated immediately, however, that this does not necessarily imply a process of screening at the same time, although i t may do so. There were three clinics, a l l maintained by public health departments, which stated that their i n i t i a l intake interview was conducted by a nurse, and of these, one also used a psychologist at this point. A hospital clinic stated that i t used both a stenographer and a "physician also registrar", for the intake interview. Another clinic used a "clinic secretary", declining to class this.person as either "receptionist" or "stenographer". Of the five hospital clinics returning forms, three used a social worker for the i n i t i a l intake interview, while two used physicians at this point. A clinic attached to a juvenile, court, did not check any of the types of personnel suggested, stating that in this setting, "intake procedures do not play a role." Three clinics checked two items. It is interesting that, while the trend is toward the use of a social worker for the first interviews three public health clinics use nurses for this purpose, and three other clinics use clerical personnel, to perform what is now generally accepted as a social work function. (A shortage of qualified social workers may be a factor here.) An attempt was made to acquire information which would amplify the above data, and clarify the ways in which the social work.staff is used for intake screening. The trend seems to be towards using social workers in rotation for intake, rather than a special, intake, worker or a social work staff committee. ' There were three clinics which used social workers on rota for intake in a l l cases, and two used them in selected cases. There was one clinic which used a special intake worker in a l l cases, and one clinic which used a special worker in selected cases. Only one clinic used a social work staff committee for intake screening in a l l cases. Six clinics used other types of personnel as 11 already noted: two used nurses; one used nurses* teachers and psychologists; one hospital clinic used a physician, while another screened through the general outpatient psychiatric clinic. S t i l l another clinic screened a l l cases by a committee composed of senior members of various departments. There were three clinics which did no intake screening at a l l , for reasons which have : already been explained. Information as to the extent of use of pre-clinical conferencing was requested, with special reference to the types of personnel composing such conferencing. Indications were that the use of pre-clinical conferencing in Canadian mental health clinics serving children, is not widespread. There were four clinics which did not use the procedure at a l l . There were five clinics (5) which stated that they used a f u l l team conference pre-clinically in selected cases, and five clinics which stated they used a partial team conference pre-clinically in selected cases. There were four clinics which used a partial team conference in a l l cases, but only two clinics followed the policy of a ful l team conference on a l l cases. Only one clinic used a conference of social workers only, and that only in selected cases. Since four clinics checked two items, i t follows that some sort of pre-clinical conference is used to some extent in 1J clinics, while none at a l l is used in four. Of these four, one is a guidance clinic where source of referral takes care of screening, one is., a hospital clinic where cases are referred from the general outpatient psychiatric clinic, one is a civic public health clinic where the referring source screens, and the last is the juvenile court clinic "where intake procedures do not play a role" (sici). Of the 15 clinics using pre-clinical conferences, i t is interesting that the number using, a f u l l team pre-clinical conference to some extent, is not even half the total, while the number using a partial team conference to some (5) Figures in the table (p.J-O have been further broken down in order to separate out and explain the practice of the four clinics which checked two of the methods. In the text, however, the duplicates have been distributed in the appropriate categories. 12 extent is barely more than half. The phrase, "to some extent", is the significant one here, as i t means mostly "iri selected cases". For every-seven times-a team conference of some- sort is used in a l l cases, i t is.used ten times in selected cases•(roughly one and a half times more often) in the 15 clinics which use the procedure at a l l . The specific purposes for which the pre-clinical conference is used in the 1J clinics employing the procedure are-noteworthy. It is. interesting that 12 clinics checked several.purposes, and only one clinic checked one specific purpose. The most common uses for such a.conference centre around: planning diagnostic study and exploration, and delineation of a tentative treatment plan, for-eight clinics checked that they use- i t for each of these purposes in selected cases, while two clinics use i t for planning study in a l l cases, and one for delineating a tentative treatment plan, in a l l cases. Another very common use for the pre-clinical conference appears to lie around referral to or from other agencies, since seven clinics used the conference for this purpose in selected cases-, and three in a l l cases. There were six clinics.which stated that they used the pre-clinical conference for case selection only in selected cases, and two used i t for this purpose in a l l cases. Only five clinics, stated that, they used the pre-clinical. conference for the allocation of diagnostic responsibilities, and then only in selected cases. It is noteworthy that the numbers, showing the use of a pre-clinical conference to some extent, for the reasons, suggested, are more than half, of the total of 15 in each category except one, (allocation of. diagnostic respons-i b i l i t i e s ) . Once more, the phrase, "to some extent", is the significant • one, as i t means again, mostly "in selected cases". For every eight times 15 the conference method is used in a l l cases- pre-clinica-lly, i t is used ^4 times in selected cases (roughly four times oftener), for the particular reasons listed. A comparison of the practice of the Provincial Child Guidance Clinic at Vancouver with that of other clinics- covered in the survey, is interesting and significant. In so far as.it hasbeen shown above that certain trends in practice are evident, i t would seem that the. Vancouver Clinic's. practice t is.fairly representative of the majority of these trends. The Vancouver Clinic is among the large majority of Canadian.mental health clinics which derive their financial support from public funds. In that i t is one of two clinics which stated.their intake was limited by budget, the Vancouver clinic does not follow the general trend, which is to regulate intake by agency policy and function. Actually, other considerations do not materially limit intake in the Vancouver Clinic. Its policy and function are not very specific or selective, partly because of the point of view that a tax-supported agency must accept a l l cases-for service, but also.because, the policies and functions of caseworking agencies in the related fields, of family and children's services are.not integrated .with., those of the clinic. Also, i t has been usual, at least for the last few years, that the Clinic has been in a better position to give intensive casework services than the family or children's, agencies, which have been greatly over-burdened for various reasons which are beyond the scope, of this.study to elaborate. For the same reasons, diagnostic criteria do not often enter into case selection. The Vancouver Clinic follows, the general, trend in having the initial... intake interview conducted by a social worker. It also ..follows the general, trend in not employing one special social worker to look after intake. It 14 was one of three- clinics using social workers on rotation for screening in the initial intake interview in a l l cases-. The Vancouver Clinic follows the majority group again in not using a social work staff committee for screening at intake. With regard to the use of a f u l l or partial team conference pre-clinically, the Vancouver Clinic, using this method in selected cases-only, is in a middle-of-the-road position. In relation to the extent of pre-clinical conferencing for specific purposes^ the Vancouver Clinic again takes a middle-of-the-road position. -It uses the pre-clinical conference, when i t uses i t , for a l l the suggested purposes in selected cases, with one exception, where, with the majority, i t does not use the conference to allocate diagnostic responsibilities. If more extensive use of the pre-clinical conference is deemed to be a step tov/ards ideal practice, then most Canadian clinics in,the survey have many steps yet to take, and only a very small minority have reached the point where they could close the distance by taking the last few steps. The Vancouver Clinic, in the main, is in the middle group of one-third to one-half of the clinics in the study which prefer to take or leave the pre-clinical conference according to what may be their own needs or their own inclinations.^^ The following is a summary table of the foregoing data : (6) Some light was thrown on these needs and inclinations in letters which accompanied some of the completed questionnaires. A few excerpts from these are presented in Appendix B. x 5 TABLE 1. PRE-CLINICAL PROCEDURES"IN CANADIAN CLINICS A. CRITERIA FOR LIMITATION OF INTAKE Frequency Budgett Agency policy and function Diagnostic criteria Other (see text) 10 2 - Total (a) 27 (a)10 clinics reported intake limited by 2 criteria PERSONNEL CONDUCTING INITIAL' INTAKE INTERVIEW Receptionist Stenographer Nurse Social Worker None Other (see text) ' o l 5 l l l 4 , , * . . . . . . . . . . . . . i P f l + . f l l .f.o\ . . . oc\ t o W l (a)5 clinics reported using 2 types of personnel C. USE OF SOCIAL WORKERS FOR INTAKE SCREENING ' ' Method In .all cases .In selected cases only Total Special intake worker .. .. x 1 " 2 ' Social, v/orkers in rotation 5 2 . 5 Social work staff committee 1 0 l Other personnel 6 0 6 Total (a) • • 11 5 14 (a) clinics did no intake screening at a l l COMPOSITION AND USE OF THE PRE-CLINICAL CONFERENCE Personnel In a l l cases In selected cases only Total Full team, a l l ..disciplines 2 1 5 Partial team, 2 or 5 disciplines 5 2 5 Social workers only 0 1 1 Two of the above (a) 1 5 h, Total (b) 6 7 15 (a) Of the 4 clinics checking- 2 items, 1 used a partial team in a l l cases, and a fu l l team in selected cases, and 5 clinics used a f u l l team in selected cases and a partial team in selected cases. (b) 4 clinics used no pre-clinical conferences at a l l . 16 E. EXTENT OF PRE-CLINICAL CONFERENCING FOR SPECIFIC PURPOSES Purpose In a l l . cases In selected cases only Total Selection of cases 0 0 0 ' Referral to or from other agencies 1 0 1 Planning diagnostic study and exploration 0 0 0 Allocation of diagnostic responsibilities 0 0 0 Delineation of tentative treatment plan 0 0 0 Several of the above (a) 2 ' 10 12 Total (b) 5 10 15 (a) 1 clinic,used a.pre-clinical conference for planning diagnostic study and exploration in a l l cases, and for 2 other purposes in selected cases. It is incl-uded in the column - "in selected cases only". (b) 4 clinics used no pre-clinical conferences at a l l . F. ANALYSIS OF USE OF PRE-CLINICAL CONFERENCE FOR SPECIFIC REASONS Purpose In a l l cases In selected cases only Total (a) Selection of cases 2 6 8 Referral to or from other agencies 5 . 7 10 Planning diagnostic study and exploration 2 8 10 Allocation of diagnostic responsibilities 0 5 5 Delineation of tentative treatment plan 1 8 9 Total 8 V" 5 4 42 (a) These figures are out of a possible ly - the number of clinics using the pre-clinical conference: 4 clinics do not use the procedure at a l l . CHAPTER III THE CONFERENCE 24ETHOD IN PRINCIPLE The conference method as a general procedure in social work has appar-ently come to be taken for granted, or at least taken as corollary to the team concept. If social workers have fallen into this attitude about confer-encing, then the procedure may not be put to f u l l use and many of its values may be lost. In the child guidance setting, the conference method is usually used at the time of the clinical examination of the child, but is neglected as a procedure both before and after - pre-clinically and post-clinically. While much professional writing has been done about the team concept, very l i t t l e has dealt specifically with conferencing, which is the modus operandi of team-work and without which i t breaks down. The formal conference as a technique, of course, is not limited to the clinical setting; i t is not a new technique; but i t is such a valuable one as to deserve more consideration at the hands of social workers. Informal conferencing,too, has a.place, being widely used in the child guidance setting and, for this reason, i t will be also considered in this study. Child guidance clinic practice was responsible in large measure for demonstrating the value of the conference composed of team members from the various disciplines. It is doubtful, however, i f child guidance clinic practitioners really understood a l l the reasons for the success of their method. While child guidance clinics have been evolving over the last forty years, another branch of the social work profession has also been growing and integr-ating, and has articulated through its philosophy, the dynamic reasons under-18 lying the success of the conference method. It is social group work which has so contributed to the understanding of conferencing. The. theory of group pro-cess is the key to the conference method, and. a basic respect for the democratic-principles of the group work philosophy is a sine qua non of the conference method. This was recognized in the work of the Dartmouth Conference of the AAFSW : "All the workshops identified the collaborative process in the clinical team ... Members of the clinical team in the psychiatric hospital or mental health clinic are constantly engaged in a group process through which inter-action, modification of ideas and attitudes, and changes in treatment plans take place." ^  ' ' Much of what has been written about group process in administration applies equally well to the conference method - an essential part of the admin-istrative process in social work. Harleigh B. Trecker, a leader in the group work field, writes : "We thus see administration as a creative process of thinking, planning and action, inextricably bound up with the whole agency. We see i t as a process of working with' people to set goals, to build organiz-ational relationships, to distribute responsibility, to conduct programs and to evaluate accomplishments. "(8) Again, the conference can be regarded as functioning as a committee, as far as process is concerned. Here Mary Follett's words become most meaningful : "The object of a committee meeting is first of a l l to create a common idea ... I go to a committee meeting in order that a l l together we may create a group idea, an idea.which will be better than a l l of our ideas added together. For this group idea will not be produced by an process of addition but by the interpenetration of us a l l . " (9) This, then, is another of the dynamic reasons underlying the success of the conference (7) American Association of Psychiatric-Social Workers, Proceedings of the Dartmouth Conference, 1950, p. 62. (8) Harleigh B. Trecker, Group Process in Administration, 1946, p. 14 (9) Mary P. Follett, The Hew State, 1926, p. 24 19 method - to express i t in other words - a group is more than the sum of its parts, and its product has an extra dimension resulting from the continuous process of inter-stimulation and interchange acting like a ferment among the members. This added dimension of the group product varies directly with the conscious observation of the democratic principles of group process. Because the principle of multiple causation was earlier recognized and accepted in the child guidance setting, group process, with its democratic implications and greater productiveness, became a part of child guidance clinic practice earlier than in other settings. Stevenson.and Smith observed in 19yh: "The conference enables each worker to interpret his own findings in the light of the other facts, and a l l the staff together to work out provisionally, a concept of the total situation. This integration is perhaps the most import-ant single contribution of the child guidance clinic to the technique of adjusting behavior. "The essential factor which differentiated the child guidance clinics, beginning with those in Boston and Chicago, from earlier services in the same field, was not the introduction of new scientific data or treatment technique; i t was the bringing together of three professions in a working combination. The capacity to cooperate was an essential qualification in selecting workers for such a combination. It was necessary that each staff member became so well acquainted with the job of the others that a genuine synthesis should occur; what a clinic sought for was hot a compromise between three points of view, but a unified interpretation and plan of treatment in which the contri-bution of each profession should be merged." It is noteworthy that the concept of integration has since been applied not only to the processes of study, exploration and diagnosis, but also to treatment. S t i l l , i t must be admitted that in many medical or psychiatric (10) Steveriedri arid Smith, Child Guidance Clinics, A Quarter Century of Development, 1924, pp. 87, 109. 20 clinics, or hospital settings, only lip service is paid to the team concept, and the correlation of the work of the various disciplines cannot yet honestly be called democratic - in the sense that It i s the collaboration of equals - or integrated, in that i t has that added dimension which we have identified as the peculiar product of the group process. The physician, while still.head of the team, and (in Canada) bearing alone the legal responsibility for the treatment of the patient, too often finds i t difficult to combine this function with that of a professional person contributing to the group process in a democratic way. Witmer points out : "... i t was from the clinics connected with the courts that the plan for "teamwork" came, a plan that is in such striking contrast to the practice of most psychiatric clinics, where the services of physicians, psychologists and social workers are used only at the psychiatrist's discretion" (11) or, in some clinics, at the social worker's discretion. The development of the team concept was given impetus, however, by forward-looking leaders in the field. The Group for the Advancement of Psychiatry endorses the newer con-cepts : "In modern psychiatry the patient no longer appears as a fragment of psychopathology, but as a human being in a structured social situation, a part of an organic social group, who is involved at a l l times in a complicated system of interpersonal relationships, and whose inner tensions and conflicts are. inseparably bound to his social matrix. In recognition of these inter-relationships, the provision of effective psychiatric service in clinics has become a collaborative activity of the several professional disciplines, particularly psychiatry, clinical psychology and psychiatric social work, functioning together in. the interests of the patient and of the persons import-ant to him."^12^ In the child guidance setting, real teamwork is more usually possible on a democratic basis by a team of equals. Witmer's statement about the role of (11) Helen L. Witmer, Social Work - An Analysis of a Social Institution, 1942,' p. 451. (12) Committee on Psychiatric Social Work of the "Group for the Advancement of Psychiatry, Psychiatric Social Work in the Psychiatric Clinic. Report No. 16, I95O, p. 1. • '• ' 21 the social worker in the clinic setting applies equally to a l l disciplines com-posing the team in this setting : "Consequently, the original conception (in pre-child guidance clinic philosophy^ of the function and work of the social worker has been greatly altered, so that she has become not the aide but the colleague of the psychiatrist in an undertaking that involves work with several people. These distinctions set the child guidance clinic apart from other methods of psychiatric treatment of children and - left unarticulated - account for much.of the current misunderstanding between child guidance workers and those who seek to treat children in other ways.n.^^ The G-roup for the Advance-ment of Psychiatry describes the team concept in the following words:"Separate professional disciplines in the same place do not in themselves make a clinic team. The idea.is rather that of a coordinating administrative principle whereby a number of disciplines may work together toward common professional . objectives with enhancement of their own special professional.status, distinction or contribution. This idea requires the minimizing of hierarchy and of striv-ings for power and prestige. It means the protection of human dignity of staff members as well as patients, the participation of a l l staff members in decisions affecting policy, practice, standards and working conditions, and the provision of opportunities for the continuous development of the professional understanding and s k i l l of the staff in the interest of patients. "(15) Conferencing has been considered in relation to several other concepts with which i t is usually identified, and from which i t is not usually separated out for examination in itself, because i t is, in fact, the machine of these concepts. To look at the conference, i t was necessary to look at the team concept, at group process with its added productiveness directly proportionate to its democratic methods, and at group process.as i t operates specifically in admin-istration and committee work. It was necessary to look carefully at the (15) Bracketed interpolation is the writer's. (14) Helen L. Witmer, Psychiatric Clinics for Children, 1940, p. ^49 (15) GAP op. cit. p. 1. 22 concepts of teamwork and group process in the clinical setting - particularly in the child guidance clinic. To paraphrase-the observation of the Group for the Advancement of Psychiatry that "Separate professional disciplines in the same place do not in themselves make-a clinic team, " - a clinic team does not in itself make for a complete - or even adequate - use of conferencing, although ideally i t should. It has already been suggested that conferencing is the.modus operandi of team work - .it is the way the team works. It has already been suggested that, the conference is used most widely at the time of the-clinical examination of the. child, and.that perhaps i t can be used more.frequently pre-clinically and post-clinically. This study will, be concerned with the use. of the conference pre-clinically, and will try to separate out specifically,, and to identify, the possible uses, and results of the use, of a pre-clinical conference in selected illustrative cases. The term "pre-clinical-conference", therefore, will be used in this study to designate a conference held at any time before the members of the team have made their clinical, examination of the child. It will be used to designate a. formal conference of the f u l l team, or an informal conference of certain members of the team. The team in the child guidance setting is most commonly understood to mean the psychiatrist, psychologist and psychiatric social worker, (and in. some clinics i t includes the public health nurse) so that a conference including three,, or any two, members of this group would be of interest in this study. In actual practice, however, because of the social worker1s responsibilities in the. intake process, the pre-clinical conference usually includes a l l three, or else the social worker and either the psychia-tri s t or the psychologist, in the particular, clinic from whose f i l e B our* cases are taken. It"is quite conceivable that a pre-clinical conference of the psychiatrist and 'psychologist might, serve a useful purpose, but such a conference would be far more likely to turn into a f u l l team conference. 25 From an examination of the literature^ from a study of case material^ and from discussion with professional personnel who have had experience in settings where the use of the pre-clinical conference has become more standardized, i t has been possible to distinguish five main purposes served by the use of a pre-clinical conference : 1. Oase Selection - as part of the intake process. 2. Referral to or from other agencies. 5« Planning diagnostic study and exploration. 4. Planning the allocation of diagnostic responsibilities. 5. Delineation of a tentative treatment plan. 1. Intake and case selection Despite certain variation in practice, the main body of professional opinion supports the use of the psychiatric social worker to conduct the ini t i a l intake interviews. The Group for the Advancement of Psychiatry says : "To this complex task, different clinics assign different team members. In diagnostic and in teaching clinics, the psychiatrist is sometimes delegated. Usually, however, the psychiatric social worker represents the clinic at intake. The Committee agrees with this practice because the training and experience of the psychiatric' social worker place him in. a particularly advantageous position However, the Committee also states : "Intake is a major function of the psychi-atric clinic. It is the concern of the entire clinic team, a l l of whose members participate in i t directly or indirectly ... The clinic representative at intake must then be.able to present to the other team members at the intake conference an accurate, dynamic description of the patient and his problems. ,,(^'7) Witmer enlarges on this idea that intake "is the concern of the entire clinic team", when she says : "It was - and s t i l l is - customary in child guidance clinics to (16) Ibid., p.2. (17) Ibid., p.2. 24 have a case vrorker discuss with each applicant the nature of the child 1s difficulties and the feasibility of psychiatric study and treatment for him. Some requests were withdrawn or rejected immediately on the basis of the case worker's description of the clinic's area of work; the others were usually presented to the staff for consideration unless i t was obvious that the case was the kind to be automatically accepted. Stevenson and Smith support the use of conferencing at intake : "When an application for the study of a particular child is received, a designated member of the clinic staff, usually a social worker and often the chief of.social service, attempts in an interview or by inquiry of the referring agency to form some judgement of the nature of the problem, the service which the applicant desires,, and the probable extent of the clinic's opportunity to be useful. With this information in hand, the worker, the director, or a staff committee, decides whether to accept the case (19) or not, and i f i t is accepted, what immediate steps may wisely be taken." Finally, the staff of the Institute for Juvenile Research has this to say : (and i t is particularly pertinent to this study since the Vancouver Child . Guidance Clinic is also part of the Mental Health Services which are tax-supported) - "The Institute is an organization supported by the tax payers of Illinois and as such its services are available to a l l persons living in Illinois. For many years there have been more applications for examinations than the Institute has been able to meet.promptly. For many years there has been a waiting l i s t . However, i f there were no more plan in the making of appointments than a system of first come, first served, many treatable children suffering serious maladjustments would be neglected in order to make possible the examination of tri v i a l or unpromising cases in order of their application. The Institute has established, therefore, a committee on applications, made up (18) Witmer, op.cit., Social Work - An Analysis of a Social Institution, p . 4 6 5 . (19) Stevenson and Smith, op.cit., p. 56. 25 of representatives of clinical departments, which meets daily, reviews the applications which have come in during the week, and makes decisions as to the kind of examinations advisable for the case and the relative need for emergency service. Oases may be assigned through this committee to regular, special, summary, or routine service Thus i t is evident that the case for pre-clinical conferencing at intake has fairly wide support from recognized authorities. Many of the passages quoted have definite implications for the use of the pre-clinical conference in connection with the other four criteria. 2. Referral to or from other agencies Stevenson and Smith point out that, "To give intensive care to more than a selected minority of all.the children who might profit by i t is a physical and economic impossibility for the clinic."( 2^) They add, "One of the f i r s t and most critical of the problems which the child guidance clinic must face is the selection of cases. Out of all.the numberless children who might con-ceivably benefit by service from the clinic only a few can be studied or treated. The clinic may block its own way to usefulness by attempting to do more than i t can do well, by concentrating effort on cases in which l i t t l e benefit can possibly result., or by doing with its own staff work which might be done equally well or better by other agencies. "(22) They add : "It is inconceivable that any clinic should be able to meet the demand for service were the city entirely aware of the service. The role of the clinic in the community is that of special consultant to other agencies maintaining primary contacts with the child population. It complements schools, courts, social agencies and pediatricians." (^5} Even the public tax-supported clinic should be alert to the advisability of referring appropriate cases to the family or (20) Staff of the Institute for Juvenile Research, Child Guidance Procedures, 1957, P . 52. (21) Stevenson and Smith, op.cit., p.5^-. (22) Ibid., p.70. . (25) Ibid., p.78 26 children's agency for the reasons cited above. It is true that the auspices under which a clinic operates, and the source of its financial support have a great bearing on intake and on referrals. The clinic supported by public funds has a greater obligation to give service on demand, but even this type of clinic is often faced with applications for service clearly beyond its . function, i.e. cases, in which the need for legal protection of the child is interwoven with.the need for treatment. In such a case:referral to a pro-tective agency could be greatly facilitated by a conference of clinic and agency personnel to integrate the timing and action around protective proceed-ings and the clinical examination and treatment of the child. Similarly referral from other agencies could be facilitated by the same type of conference. This would be especially significant in a l l co-operative cases, as Stevenson and Smith observe : "Alternative to f u l l service is co-operative service ... An informal conference between the clinic and agency worker before.the latter makes or completes a social study of the case often tends to break down the timidity with which a worker unaccustomed to standards of the- clinic faces the task of co-operation. (24) 5. Planning diagnostic study and exploration It is this writer's opinion that a.standard examination according to a set pattern of procedure, of a l l cases accepted by the clinic, has a negative aspect to i t which is. contrary in spirit to the positive philosophy inherent in the use of differential diagnosis and treatment, which is seen as basic to a l l the professional disciplines.in the child, guidance field. The Institute for Juvenile Research meets this need for differentiation by screening at a pre-clinical conference, and earmarking cases for different types of service -fu l l clinic, (the f u l l gamut of the clinic's resources, cases being selected (24) Ibid., p. 102. 27 on the basis of certain criteria,) special service, (used on the basis of certain criteria among which are urgency and restricted need for quick service,) summary service, (used also on the basis' of certain criteria among which are an emergent need for one immediate examination in a certain field) and routine service, (used for a l l cases which remain when the quotas of the three selective services have been filled.) Thus, according to the staff of the Institute, "The clinic is able to surmount some of the handicap of its disadvantageous and expensive complexity by sorting its cases and omitting special examinations in those cases in which they do not seem especially indicated." The philosophy of the Vancouver Clinic is that there is a minimum standard clinical examination, which every child should receive, on the premise that child guidance means the bringing to bear of the skills of a l l the disciplines on every case, with no short cuts. It is agreed, however, that planning, timing, and coordination of the various examinations, in line with the individual treatment needs of the patient, are necessary. But these considerations are questions for team planning - for deliberate and.conscious decision as to how the diagnostic process of study and exploration may be carried forward so as to be of most benefit to the patient. The concept that treatment begins with the patient's first contact with the clinic is widely accepted. Is i t not therefore important that every contact with a member of the clinic team be planned to take place in such a way and at such a time as to have a positive effect on the patient - and, perhaps more important - to ensure that i t does not take place in such a way,.and at such a time, as to have a negative or threatening effect on him? Clearly this kind of planning can be achieved by the use of a pre-clinical team conference. 4. Allocation of diagnostic responsibilities While there are certain logical divisions of labor in the process of (25) Staff of the Institute for Juvenile Research, op.cit., p.556 28 diagnostic study and exploration, i t is no longer considered a rigidly pre-determined conclusion that a certain member of the team always does-a certain job. It used to be that the psychiatrist always interviewed the child, while the-social worker saw the mother, and the father was too often ignored by everyone. Then came the practice that the psychiatrist saw the member of the family who was most disturbed, while the social worker saw-the others. Now the time has come when the allocation of this responsibility should be a. decision to be reached independently in each case' on the basis of the particular circum-stances of each case. There are other possible arrangements providing the team takes time to think and plan pre-clinically - for example, i t may be imper-ative that a child be examined by a pediatrician in certain casesj or again, in some cases, i f a school visit is needed, when special problems.of learning are involved, i t may be desirable that a psychologist have the contact with the pedagogue. A l l these variations in the allocation of diagnostic responsibilities could be planned ahead, i f flexibility of thinking were encouraged and rigidity of function discarded. Pre-clinical conferencing would facilitate these objectives. 5. Delineation of a tentative treatment plan Again, on the premise that treatment begins with the patient's first con-tact with the clinic, the diagnostic process should be planned according to indications perceptible from the client's first contact with the. clinic. In other words, the study and exploration, or the diagnostic processes, have treat-ment significance and should be sensitively geared, attuned and aligned to treatment considerations. Stevenson and Smith are aware of this when they say: "As the clinics have become more sensitive to the implications of early meetings between the patient.or parent and the staff worker, tentative assumpt-ions as to the nature and.need of the case are put to work.from the earliest interview, and formal diagnosis becomes an imaginary point in a growing under-29 standing of the issues presented. With more-or less data at hand - so much as seems necessary in the individual case — the-workers concerned meet for an in i t i a l staff conference at which they exchange information, piece together the available clues as to causative factors and treatment opportunities, and agree upon the direction and immediate course of treatment.tt(^) Whether a child with certain symptoms of emotional disturbance should be given a medical examination at the time of first contact with the psychiatrist, or after several, visits to him,. is a case in point; whether the social worker, in conducting interviews-during which social, history material is produced, should be advised to keep to reality matters, and away from feeling areas in dealing with a particular patient, is definitely part and parcel of treatment planning; whether a disturbed teen-ager, truanting from school, is invited to the clinic for aptitude tests, rather than for the usual medical, psychiatric and mental tests, is part of a treatment plan. A pre-clinical conference could recognize such considerations, and outline tentative treatment plans. A pre-clinical conference may serve any or a l l of these five uses. If i t served only one or two, i t could probably be shown to have been worthwhile. It may be that a pre-clinical conference is advisable in a l l cases; i t may be quite unnecessary in a few; but i t seems likely that i t can be shown to be useful in a majority of cases but for different reasons. The psychiatric social worker, after the ini t i a l intake interview (or interviews), should be able to determine the purposes to be served by a pre-clinical-conference, and to select the appropriate team.members to be included in the conference. An examination of selected cases from the files of the Vancouver Child Guidance Clinic against a schedule based on the above considerations will, serve to exemplify the pur-poses of the pre-clinical conference in each case. The objectives of a pre-clinical conference could reasonably be said to be: (26) Stevenson and .Smith, op.cit., p.87 50 (l) facilitation of the diagnostic process, (2) establishment of treatment goals, and (5) economical use of staff time. If these objectives were achieved by the use of a formal or informal pre-clinical conference, they would result in better service to,the client and to the community. The Child Guidance Clinic at Vancouver, (as well as that at Victoria, and the Travelling Clinic- which visits a l l parts of the-province,) is operated under the auspices of the Government of British Columbia. Included in the Department of the Provincial Secretary, the Clinic Director is responsible to the Director of Mental Health Services, who also has responsibility for the operation of the Provincial Mental Hospital. The Child Guidance Clinic i s , however, situated geographically at some distance from the Hospital, and as far as the general public is concerned, has no perceptible connection with the Mental Hospital at Essondale, twenty miles away. Since the Clinic is supported by public funds, i t cannot refuse service to any citizen who seeks i t - that is to say, i t cannot restrict its service to any particular types of patient who might be deemed especially suitable for the type of service available. The following figures are of interest since they give a picture of the volume of work done at the Vancouver Clinic during the year ended March Jlat, 1951.(27) They are significant from the point of view of intake procedures, although at present these do not usually include a pre-clinical conference. No. of clinics held No. of new cases Repeat cases Total cases Total referrals 264 (children 545; adults 71) 619 (children 142; adults 25) I65 784 1072 For the same year the strength of the clinic staff was as follows : (27) Annual Report of the Director of Child Guidance Clinics to the Director of Mental Health Services, for the year ending March, 51st, 1951. * . 51 Psychiatrists 4 Psychologists 8 Psychiatric social workers 11 Public health nurses 2 The services given by the Child Guidance Clinic are classified under three headings: treatment, diagnostic and consultative, while additional (28) functions are education and research. Another study states: "Treat-ment cases are those in which after diagnosis, patients are seen by the psychiatrist on a treatment-interview basis, or by clinic social workers and psychologists under the direction of the psychiatrist. This service is avail-able for the clinic's private patients or for patients referred by agencies on a cooperative basis cases referred to the clinic by social agencies or by medical and health agencies are given diagnostic service ...'The Child Guidance Clinic, however,, has no active part in the subsequent progress of the case. The value of this service depends on the responsible agency being adequately equipped to make the social study, to make use of the clinic's findings, and to carry out the clinic's psychiatric recommendations. In the diagnostic service, treatment is delegated by the clinic psychiatrist in confer-ence to the referring agency.1, A consultative service is. one in which the clinic's services are given to any person interested in the child, but where there may be no actual contact on the part of the clinic with the child. Social and health workers have used the service to discuss the psychiatric problems of their clients with the psychi-atrist and the other members of the clinic team." It should be noted in passing, that sometimes a case which was thought to need only consultative service, may, in the course of the consultation, be seen to need either diagnostic or treatment service. In such cases the consultation may become a type of pre-clinical confer-ence, but cases like these are not included in the present study. (28) Evelyn M. Roberts, Mental Health Clinical Services, University of B.C. MSW thesis, 1°49, pp.15, 1 6 . The quotation contained within this excerpt is taken from the Annual Report of the Welfare Branch of the Department of Health and Welfare, 1947-48, p. 128. CHAPTER IV THE PRE-CLINICAL CONFERENCE IN OPERATION In the private cases of the Vancouver Child Guidance Clinic, the responsibility for arranging a case conference pre-clinically rests, •with the social worker to whom the case is assigned at the conclusion of the intake pro-cess. The social worker would decide to call a pre-clinical conference for certain reasons. The reasons for which the. social worker would call a pre-clinical, conference are not necessarily identical with the basic reasons, for. the case coming to the clinic. Actually, every case comes to the clinic for multi-ple reasons - the principle of multiple causation has.already been stressed in this study - but this does not mean that the reasons, for calling a pre-clinical conference.cannot be singular and specific in certain cases, or multiple in others. If the reasons which indicated the need for a pre-clinical. conference were limited and specific, the social.worker might confer quite, informally with one specific team member, or i f the reasons were numerous and complex, the worker would schedule a formal, conference of the f u l l team. There are cases in which the worker might see no reason at a l l to call a pre-clinical conference, but this would not imply that there was.no reason for the case to come to the clinic. For purposes of this study only, in order to .facilitate the exposition, the main reasons for calling a pre-clinical conference can be identified as medical, psychiatric, psychological, or multiple, and arrangements would be made to confer with the appropriate discipline(s) in each instance - with the doctor, with the psychologist, or with the f u l l team. For convenience of 55 discussion, the 12 cases in this chapter have been grouped in the same way, but again this is a purely arbitrary subdivision with no other significant implications. Group I : Pre-clinical conference for medical reasons 1. The A case The parents of this 16 months old defective boy had sought admission for him to the Woodlands School, a provincial institution for feeble-minded children* and had been referred by the Medical Superintendent to the Child Guidance Clinic for a mental evaluation. The parents had previously had the child examined by several doctors in an effort to discover what was wrong with him;. At five months, one doctor did not think there was much wrong with him; at eight months-, another doctor said a diagnosis at such an early age was impossible; another doctor said, he might be blind, and another, said he was not. Two more doctors signed committal papers for him, to go.to the institut-ion, but the parents did not know what their diagnosis was. Finally, another-specialist diagnosed him as "a hopeless mental defective". After the intake interview, the worker who was.assigned the case realized that a far more, thorough physical, examination than was available at the clinic might be desirable, and for this reason she arranged a pre-clinical conference with the doctor. At the pre-clinical.conference.it was decided, that i t was desirable that the clinic doctor consult the latest.of the doctors who had seen the child, and that the child should.also be referred to the Vancouver General Hospital Child Health Centre. As a result of this, a diagnosis of "cerebral agenesis" was established.. The clinic doctor also consulted the Medical Super-intendent of the Y/oodlands. School about his.contact with the family, and the School's admission policy. The child was later admitted. 54 Uses: It is evident from this* that the following uses were served by the pre-clinical conference : referral to and from other agencies* planning diagnostic study and exploration, allocation of diagnostic responsibility, and delineation of a tentative treatment plan. Results: There is no question but that the diagnostic process was facilitated, and staff time saved. 2. The B case The parents of this five and a half year old child, suffering from cerebral palsy, were referred to the Child Guidance Clinic by the Spastic Paralysis Society, for mental evaluation of their child. The parents lived in the interior of the province, so there was a question of foster home placement for the child in Vancouver, so that he could have the benefit of medical f a c i l i -ties* and also of the Society's. facilities, especially their play school. The Society wanted a mental-evaluation from the Clinic to distinguish between mental retardation, and mental deficiency, as a guide to whether or not the l i t t l e boy could benefit from their program, and to which group would meet his needs. The father was a professional man established in the interior, so that a move to Vancouver would involve considerable sacrifice for the family. The mother had recently had a major operation, and was unable to care for the child herself at the time. There were two other children in the family. The l i t t l e boy, at six months, had had an operation for intussusception; at two years had had measles.followed by 'flu, colds and croup; and, more, recently, had undergone a very painful eye operation, after which hie arms were tied down and he was not allowed sedatives. Following this, he had developed further spastic movements including a head jerk, a stutter and unusual throat noises. The social worker who was assigned the case, recognized that the medical history was unusually complicated, and that more ample data would be needed to 55 supplement the routine clinic physiological examination. She arranged a pre-clinical conference with the psychiatrist, at which i t was decided that the doctor should get in touch with the child's previous doctors* and with the pediatrician currently responsible for his medical supervision. Uses: The uses of the pre-clinical conference in this ease focussed around referral from another agency* planning diagnostic study and exploration, and allocation of diagnostic responsibilities. Results: The diagnostic process was facilitated by having the doctor gather the medical information firsthand himself, which made a more intelligent physical examination of the child possible, and saved staff time by eliminating duplication in the examination, by providing more.ample-data than is gained in the usual routine clinic physical examination, and by relieving the social worker of the need to cover the medical history in detail, when to do so would not have met the needs of the doctor in any case. 5. The 0 case This case was referred to the Child Guidance Clinic by a former client. . The parents, who had three children altogether* were worried about their oldest child, a boy of six years. At age four, he had had encephalomyelitis. In the parents' own words, he had been "an awful baby since". He would cry for nothing at a l l , would " f a l l flat on his face when walking", and was slow in reading. The worker who was.assigned to the case, recognized.that the medical implications were extensive. The whole question of the nature of encephalo-myelitis, its possible psychosomatic aspects, and the effects of the disease in relation to behavior, needed clarification at the outset by a doctor, so that the diagnostic study and exploration of the case could be carried out more 5 6 intelligently and s c i e n t i f i c a l l y . She therefore sought a pre-clinical confer-ence with the psychiatrist. •As a result of the conference, the psychiatrist gave the social worker considerable insight into the nature and effects of the disease in question. It was decided that the social worker should go ahead with the preparation of the social history which she could do more eff i c i e n t l y with a- clearer focus based on an .understanding of the physiogenic and psychogenic implications of the disease, and an improved a b i l i t y to evaluate the meaning of the symptoms. Uses: Clearly, the pre-clinical conference i n this case was very useful in planning the diagnostic study and exploration, and assisted the social worker in accepting and carrying out the diagnostic responsibilitj'- allocated to her. Results: The pre-clinical-conference in this case, greatly f a c i l i t a t e d the diagnostic process, by providing the social worker with more adequate medical knowledge, and enabling her to proceed more s k i l f u l l y with the work-up of the social history. Group II : Pre-clinical conference for psychiatric reasons 1. The D case This case was originally referred to the Child Guidance Clinic by the Vancouver General Hospital, where the mother was a patient. She had been complaining of her child as a behaviour problem. After the i n i t i a l referral, the mother broke off contact with the Cl i n i c . A year later, she telephoned the Clinic herself, and again complained of her child's conduct. The l i t t l e g i r l , aged five, was said, to be stubborn, destructive, negative and enuretic. She was also given to pulling out her hair, biting and eating her nails and sleeping poorly. It was learned that the mother had had previous "nervous breakdowns", and 57 was again becoming upset* She showed l i t t l e understanding of her child, and revealed a very punitive attitude toward her. The l i t t l e girl's father* mother's first husband, had been in prison at the time of the child's birth. The mother became i l l shortly afterwards, and the Children's Aid Society took the child into care. She remained in their care for some time and made a good adjustment. She was taken by her mother after her remarriage and almost immediately became upset. Intake interviews revealed that the mother was under the care of a private psychiatrist, and had recently been hospitalized again for a severe depression which had been treated by insulin shock. She was, at the time of her application to Clinic, quite upset, and revealed a fear of her own hostile feelings toward the child. The intake worker felt the mother was disturbed and the child in need of protection. The Children's Aid Society had indeed received a complaint of neglect from neighbors, but felt the case was one for the Clinic. The worker who was assigned the case recognized that the mother was poss-ibly pre-psychotic, and sought an immediate conference-with a psychiatrist. She felt that the mother's feelings towards her child were so hostile that possibly separation of mother and child was indicated, in which case referral to the Children's Aid Society would.have to be effected. A decision with regard to both of these items depended in large measure on the opinion of the psychiatrist as to the mother's illness. At the pre-clinical conference, i t was decided.that the clinic psychiatrist should contact mother's ownpsychiatrist for information as to the mother's psychopathology, and should interview mother and step-father to confirm diag-nostic impressions. Also the pre-clinical conference set tentative treatment goals which were the separation of the child from her mother, referral to the Children's Aid Society for foster home placement, and i f possible, ward action. 58 A l l these goals, set in the pre-clinical conference, were accomplished in a relatively short period of time. Uses; It can be established then, that this pre-clinical conference had,the following uses-: for referral to another agency, for planning, study and exploration, for allocation of diagnostic responsibilities, and delineation of tentative treatment plans. Results: This pre-clinical conference certainly facilitated diagnostic pro-cess, established treatment goals, and resulted in a saving of staff time. 2. The E case The mother in this case telephoned to the-clinic from a neighbor's home. Because of this, she was unable to talk freely, but sounded so upset* that a social worker visited immediately. She found the mother looking tired and tense-, and as i f she had been crying. As the mother-began to t e l l about the problem, she burst into tears again. Her son, a boy of 7» was troubled by fecal incontinence. Two general practitioners whom the mother had consulted, had both told her the boy was resenting her. One had suggested he might have to be placed. At the thought of this, the mother cried profusely and asked dramatically, "Tell me that he won't have to go away — I can't give him up. He is such a lovely boy. I adore him and he adores me". Prior to coming to Canada from England, the family had travelled around a good deal. The mother poured out at great length the events and the family conflict preceding their departure from England. The violent emotional scenes at this time appeared.to have precipitated the boy's encopresis. He had never been free of the disability.since, and had recently become much worse. The mother also dwelt at great length, on,her religious activities, and her dramatic interests, appearing to feel because of the former, that the latter were sinful and should be renounced. In her recital she frequently assumed theatrical poses. 59 From this she launched into an account of her background, revealing a child-hood as traumatic as any could be. She was one of eight children. Her mother died when she was four; her father was- "no-good", a drunkard and promiscuous. She hated him. Later she and her siblings were apprehended and placed in orphanages. The content and emotional tone of the whole inter-view were such that the worker decided on a pre-clinical conference. This was arranged with the psychiatrist. The decision.of the conference was that the mother was probably disturbed. It was felt that following one more inter-view with the social worker, to prepare her, that she should be referred to the psychiatrist for an exploratory and. diagnostic interview, with the idea in mind that she be encouraged to come for a series of psychotherapy interviews with the psychiatrist. It was felt that the boy's habit disorder was reactive to his mother's psychopathology and that the solution lay iri a modification of her feelings and attitudes, and of her coercive management of the child. It was considered'that the mother was too disturbed to go through the usual clinic routine. Uses; The uses served by this conference centered around planning study and exploration, allocation of diagnostic responsibilities, and delineation of a tentative treatment plan. Results; The diagnostic process.was expedited by bringing to bear the specialized knowledge of the psychiatrist at an early point in the case; treat-ment goals/were established early in the case also, without the delay involved in the routine processing of the case; and unnecessary expenditure of the social worker's time was avoided by assigning the study and treatment of the mother at the.very outset, to a psychiatrist, whose s k i l l was indispensable in dealing'with such a disturbed personality. 5. The F Case This case was referred by a Child Guidance Clinic worker who had known the 40 mother in another agency two years previously. The child, a g i r l of seven, who had spent nine months at the Preventorium, had recently been discharged to her own home. She had become very withdrawn and no longer took an active interest in any activity. Her school work had deteriorated because of her attitude. When the mother came to the office, she asked for help in aiding the child "to become a happier g i r l " . She said her daughter was absorbed in her own feelings and spent much time sobbing, without explaining the cause of her grief. She remarked at times, "Nothing is the same around here since Daddy took sick". The father had had a stroke two years before, and his illness had upset the whole fsmily, having a particularly bad effect on the mother. The mother said she was not capable of giving any love to her children because of her own disturbance. She mentioned she would like to go to Crease Clinic for treatment. She cried a good deal during the interview and seemed.to wish to discuss her marital situation. This was aggravated by the economic circum-stances of the family, as their income was limited, and the parents disagreed as to the spending of i t . The worker to whom the case was assigned visited the home. He had a short interview with the mother who again talked a great deal about her own anxiety, and her feeling that, because of the pressures of the family situation, she was unable to give the children the emotional support they needed. Later, when the father came in, the discussion degenerated into an. argument between the parents as to,whether they needed help. The father was monosyllabic and hostile and kept maintaining that a l l the children needed was more consistent and heavier discipline. The mother appealed to the father on her own behalf, saying she could not carry on unless she did have help, but the father continued adamant and uncooperative. The mother later came to the Clinic, unknown to the father, for an inter-41 view. She went over again the causes of her present state of mind, but in greater detail,which confirmed the worker's impression that she was quite dis-turbed. He therefore arranged a pre-clinical conference with a psychiatrist. It was decided at the conference that the mother was undoubtedly disturbed, and that she should be interviewed by the psychiatrist for a diagnostic inter-view, to ascertain the nature of the psychopathology. It was felt that the plan of encouraging mother to take realistic steps to arrange to go to the Crease Clinic to obtain treatment for herself, was advisable as .a prerequisite to helping the children. They might have to be placedfer a time, since i t was unlikely that the father could participate in planning in the present situation. The psychiatrist was able to decide that the mother was neurotic rather than psychotic and encouraged her to take steps which, would enable her to go to Crease Clinic for treatment. Uses; This pre-clinical conference was used to plan study and exploration, to allocate diagnostic responsibility, and to delineate a tentative treatment plan. Results; It resulted in facilitation of the diagnostic process, of -the establish-ment of treatment goals, and of economy in the use of staff time. Group III : Pre-clinical conference for psychological reasons 1. The G case This case, involving a 15 year old boy, son of a widowed mother, was referred to the Child Guidance Clinic by a friend of the family. The boy had been stealing, was out of control, and drifting around. He was unsettled, and not interested in school or work. This family friend, with the boy's older sister, and the mother, were a l l seen, and they presented a picture of a boy "with considerable hostility toward the family and no satisfactory outlets or interests for himself". The family were most anxious for help from the 42 clinic, but i t was uncertain that the boy could be involved in such a plan. It appeared-that after the death of the lad'S' father two years before, the mother had taken a.job, with the result that the boy got very l i t t l e attention or care. The mother admitted that she had never been firm and consistent in her handling of him, and he had begun associating with.undesirable friends, doing poorly in school and truanting. He failed with a paper route and-finally stole a camera from a car. The boy finally came to the clinic for an interview with the worker. There followed then a series of interviews in which the worker was chiefly concerned.with forming a relationship with the boy, realizing that i t was only on the basis of such a relationship that the boy would be.fenabled to reach out for the. help offered to him at the Clinic. At the same time an effort was made to .iron out some of the friction between mother and son, principally by helping the mother with her feelings, and with the day to day handling of her son. Any question of a fu l l clinical examination for the boy during this time would have been too threatening for him - he probably would not have come for i t . A new start at school for him was arranged by enrolling him in a private school - a plan which pleased him, and he expressed good intentions about studying to pass his Grade. IX. It was not long, however, before he began repeating his former pattern of truancy. , The worker tried to work through his feelings with the boy, recognizing with him that i f he simply could not go to school, then the realistic problem came up as.to what he was going to do, and what employment he should seek. The worker showed the lad that this was an area in which.the Clinic could, give him help and advice, and explained to him about the other members of the clinic team. The social worker conferred pre-clinically with the psychologist, to explain the special difficulties of the case, the interest of the boy in the 4 5 testing for employment reasons, to explore how the psychological testing could be made a significant and therapeutic experience for the lad, and to find out about the possibilities for special testing for occupational interests and aptitudes. The possibility of additional testing for personality investigation was also considered. Uses: • It can be seen that the uses served by the pre-clinical conference here were for planning diagnostic study and exploration, for allocating diagnostic responsibility, and delineating a tentative treatment plan. Results: The diagnostic process was greatly faci l i t a t e d by this approach, and the results of the psychological tests, especially of the personality tests (the Thematic Apperception Test in particular) assisted greatly in the establishment of treatment goals. 2. The H case This case was referred to the Child Guidance Clin i c by a private physician. The child, a boy of seven, had been in poor emotional health for some months. At the beginning of the school year* the previous September, he had become l i s t l e s s , apathetic and uninterested i n everything. His doctor advised bed rest for two weeks, and he responded to thisj seeming happier and more outgoing. However, when he was expected to follow a normal routine, the former symptoms reappeared. At this point, his own doctor, who could find no physical basis for his condition, referred him to Child Guidance Cl i n i c . His mother, in an interview at the Clinic, said that she and her husband were puzzled by the boy's behaviour and were anxious to help him overcome his d i f f i c u l t i e s . She spoke of him becoming antagonistic toward school how Grade I I had appeared to be too much for him so he v/as repeating Grade I. His mother said he v/as Ijealous of his sister, aged five, saying, "He las good reason to be, as she receives more attention from everyone as she is younger and is so sweet-tempered." She also said she had been very s t r i c t with her 44 son when he was younger, and he notices she is not so strict with his sister. The family has also-moved around a great deal, and the father,' a travelling saleemail,'---- even then was • away from home seventy-five percent of the time.- The l i t t l e boy anticipates his father's return with great joy* and'then ignores him when he comes. However,recently when the father was home for three weeks, the mother noticed an improvement in the boy. The worker who was assigned to the case, in the course of the social study, became concerned with the question : "How much direct help would the child him-self.need?" He felt the need:of as complete an assessment as possible, of how much of the boy's conflict had been internalized, and was looking for aids in diagnosis which could throw additional light on the boy's personality, and which might confirm or amplify his' own-diagnostic thinking. The focus of the case depended.on the answer to the question : "How much should' treatment be focussed on the parents, and how-much, and what kind of direct treatment, should be focussed on the child* and £used to help him' obtain insight into his withdrawal . from school and from family affairs." 1 The worker, therefore, consulted the psychologist pre-clinically, with a view to exploring the possibility of fuller, than usual personality investigation. The conference resulted in a decision to use more extensive personality investig-ation. The. usual personality tests employed at the clinic include the Despert Fables and the Draw a Person tests, but, when more thorough investigation is needed, the Thematic Apperception Test is frequently employed (as in this case), and occasionally, the Rorschach. The psychological tests resulted in the formulation of a clearer personality profile, which facilitated the diagnostic process, and made the early formulation of treatment goals possible on a more thorough, understanding of the boy's personality. It was. recommended as a/result of this, that the child should have direct intensive casework treatment. Uses:. The pre-clinical conference here served the purposes of planning diagnostic study and exploration, of allocating diagnostic responsibilities, and of 4 5 delineating a-tentative treatment plan. Results;- This resulted in facilitating the diagnostic process, the establish-ment of treatment goals, and the-economical, use of the social worker's time, in that he made use of a short cut in the diagnostic process. 5 . The I case This 12 year old boy was referred to the Child Guidance Clinic by his school principal and his teacher* as.being a trouble-maker at school, and as having repeated various grades. He was said to be an exhibitionist, who kept every-, class in an uproar except art and manual arts, in which he did good work. His parents, too, telephoned the Clinic under pressure from the school. The mother realized that her son had been very demanding of attention from age three, but she had managed him herself, by strict discipline. She thought that i f the school discipline were severe enough, the boy would behave and learn. The father concurred in this. The boy himself admitted he did poor work in school, saying that he really knew- the work, but, when there was an examination, he .went "all chicken inside." The School Board Bureau of Measurements, on tests roughly a year apart, rated his I.Q. as 79, then 88, and then 91. The father, a fireman,. formerly in the Navy, and with a liking for dangerous jobs, had left most of the management of the children to his wife. There was l i t t l e comradeship between father and son, as the father was impatient with the boy. He wanted his son to be a doctor, (father's own ambition for himself). However, he expressed verbal willingness to cooperate with the Clinic. The mother, an orderly, immaculate housekeeper, was defensive about her son's poor grades. She restricted him. from playing with the neighborhood boys, in whose groups he was not accepted anyway. There were three younger siblings, a l l girls, in the family. The mother admitted she had l i t t l e patience with the antics of her children. She, herself, had been prevented by her family's 45 economic circumstances from going to high school, and from training to be a nurse. In fact, both parents thought they had been prevented from getting higher education, and had planned that the same thing should not happen to their son. They had therefore planned a university education and a medical career for him. The social worker in this case, because of the previous testing of this boy by the Bureau of Measurements on three separate occasions, which had resulted in marked upheavals for him each time, (placement in special class for a time, and then in a change of school), felt that the psychological testing at Clinic should be as constructive an experience as possible for the lad. Then too, in view of the parents' ambition for their only son to have a • university education, the worker hoped that more extensive personality investig-ation! could be made, to help estimate possible emotional factors which might have the-effect.of depressing the rating artificially. He therefore had a pre-clinical conference with the psychologist in which such a course of action was agreed upon and planned. The results of this plan enabled the team to interpret to the school teacher and school nurse, and later to the parents, that the boy was not functioning up to capacity. He again tested in the dull normal group but his intellectual efficiency was impaired by personality disorder as revealed by the personality investigation. The concrete evidence of the tests helped to make real for the parents, the true state of affairs with regard to the reasons for their son'6 difficulties, the implication for the future management of their children. Uses: This pre-clinical conference was used then for planning diagnostic study and exploration, and for allocating diagnostic - responsibility. Results: It resulted in facilitation of the diagnostic process, and was economical ,of staff time, in that i t resulted in confirmation of the social worker's beliefs about the situation in a brief space of time. This permitted the early establishment of treatment goals on a sure foundation. 47 Group IV : Pre-clinical conference for multiple reasons 1. The J case This case concerns a 15 year old boy who was referred to the Clinic-as he was running away continually and was said to be confused. From birth, when the mother died, until the age of 12, he had lived with his maternal grandparents. The grandfather had been an explosive person from whom the grandmother protected the boy. The father remarried a few years ago, and the.lad began to visit his father and step-mother on weekends. In the course of time, the health of the grandmother became uncertain, and the boy was placed for a while in a boarding home, and finally went to live with his father and step-mother. From the time he went home, his behaviour deteriorated. He would tiptoe around the house, and would defecate in his room, (because, he said, he v/as afraid to waken his parents-by going to the-bathroom). He was evasive in his answers, from fear of punishment (he had received some corporal punishment). He ran away time after time and refused to t e l l where he had been. The parents blamed his present behaviour on his upbringing by the grandparents, and revealed a. hostile rejecting attitude to the lad. A maternal uncle, interested in the boy, was most positive in his attitude to him and blamed the father and his wife for never having been real parents to him. The boy himself was said to be a poor eater, underweight, (^ft. 1 in. and 100 lbs. at 15), anaemic and not strong. He was an average "C" student in Grade X. , At the time of referral, the boy was AWOL, but the situation seemed.so grave that the social worker summarized the available.information and a f u l l team conference was held in the absence of the patient. The. social worker was concerned to have an opinion as to the degree of disturbance in the boy, 45 since his unusual behaviour had caused the referral to be made•through the Grease Clinic. Then too, i t was felt that there should be a team appraisal of the parental attitudes. It was decided that these attitudes- plus the earlier traumatic experiences to which the boy had been exposed were suffic-ient to account for the lad's disturbance, which, i t was decided, was probably of a nature which would respond to direct treatment in the clinical setting. The social-worker was therefore encouraged to go ahead with her exploration of the maternal uncle's (and his family's) feelings toward the boy, and to investigate the possibilities of placement with these relatives. Uses: The f u l l team pre-clinical conference planned further study and exploration, allocated diagnostic responsibilities, and delineated a tentative treatment plan. Results: The diagnostic process was certainly facilitated by bringing the skills of the whole team to bear on this situation. The early assessment of the boy's degree of disturbance resulted in a saving of the worker's time, in that she was able to proceed immediately, with plans for the boy's care. The conference also resulted in the early establishment of treatment goals. 2. The K case The father in this case arrived in the. Child Guidance Clinic without an appointment. He said.he had previously consulted two private psychiatrists about his children - two boys aged ten and eight. The younger, he described as nervous and.enuretic. He then commenced a diatribe against his wife, giving many examples of her "vicious temper", drunkenness, and wild behaviour. He was concerned about possible committal procedure to the Provincial Mental Hospital for her and wanted the children taken away from the mother. The nature of the feelings he showed, and the mannerisms he displayed, as waLl as the content of the interview, aroused the intake worker's suspicions as to the 4 9 father's state of mind, as they were suggestive of a disturbed person^ The worker suggested that the father try to get mother to come to the Clinic herself for an interview. The mother subsequently arranged an appointment for herself and came to the Clinic. She was concerned about the father's attempts^ have the children taken away from her. He had recently contacted the school authorities, two general practitioners, and the RCMP, in his efforts to achieve this. Mother apologized for father's behaviour, saying she couldn't account for some of the things he does. She described their difficulties, telling, for example, how he tried to prevent her friends from coming to the house, by insulting them. She described their quarrels and actual physical combat which resulted in the neighbors' calling the police. The worker felt the mother was quite upset, but that she was, nevertheless, the parent better able to make decisions as to plans for herself and the children. He therefore suggested an interview for her with one of the psychiatrists. The worker arranged a series of pre-clinical conferences, first with the psychiatrist, and later with the f u l l team. At.these conferences, i t was decided that the psychiatrist should interview;the mother,.."to aid. in diagnosis and clarification as to the extent and area,of help which, the Child. Guidance Clinic can offer to the parents". At a pre-clinical conference of the f u l l team, i t was. decided.that clinical examination of the children would be too much of a threat, for the mother at the moment, and a tentative treatment plan of immediate help for the family irjthe present situation was envisaged, with the possibility of referral of the parents to private psychiatrists, and of the mother to a protection agency i f possible. Uses; From the foregoing, i t is obvious.that the pre-clinical conferencing in this case was used for a l l the scheduled.purposes: intake and selection of cases, planning diagnostic study and exploration, allocation of diagnostic responsibil-50 <• ities, delineation of a tentative treatment plan, and referral to another agency. Results: Through the pre-clinical conferencing, diagnostic process was facilitated, treatment goals were set, and the unprofitable use of staff time was prevented by the realistic limitation of these goals. y 5* The L case This nine year old boy was referred to the Child Guidance Clinic by Alexandra Neighborhood House, a group work agency which had known the boy for three years. The presenting symptoms of his disturbance were: inability to get along in a group; inability to compete with other group members or to share the group leader's affection, and particular hostility and aggression toward girls. There were indications of rejection of the boy by the parents. Nei-bher parents or child had been consulted as to referral. The Alexandra Neighborhood House worker asked for a conference to discuss referral to the Child Guidance Clinic. (29) A pre-clinical conference of the f u l l team with three representatives from Alexandra Neighborhood House was arranged. The A.N.H. worker summarized her contact with the boy. She described him as demanding, overly-aggressive, dominating in his play group, and a constant source of irritation to. both his pals and parents. In citing examples of this behaviour, the group worker described the following episodes. In the f a l l of last year, after losing interest in the woodworking class after his brother joined, he wanted to form a club for his "gang", which consisted of the fringe members of other groups. At the first meeting, he became very hostile when i t was time to leave. Gradually he got rid of the other club members with whom he could not compete for recognition and affection. He was not accepted into the soccer group .which he wanted to join. Following this, his attendance at Alexandra Neighborhood House became increasingly irregular, and when he did attend .. (29) Representation from the psychology department was requested but was not available at the last moment, but this was accidental. 51 he took to excessive swearing and hitting. The family lived in a poor district, and income is low. The father, a truck driver, was- very stern, punishing his son by strapping him or sending him to bed without meals. The mother v/as described as lax and ineffectual, but striving to help her son over the rough spots. For example, she took food to him after his father had disciplined him. She thought of this boy as the "dumbest of the three kids", and tried to control him by nagging. The conference saw this boy as a hostile youngster reacting to lack of personal adequacy or feelings of personal worth, and to a lack of positive affectional relationships with both parents. The conference, in discussing the preparation of the boy and his parents for referral to Clinic, considered the following: the extent of the boy's concern about his exclusion from groups, his school work and adjustment, his ability to relate to a male worker, and the parents' desire for and ability to cooperate in any treatment plan. It was stressed that the parents v/ould need help about approaching the Clinic. Interim plans around the referral of the parents and the preparation of the boy were made. It was planned that the group worker recognize with him his. difficulties in groups and t e l l him of the availability of a special time and a special friend at the Child Guidance Clinic, while he would continue attend-ing Alexandra Neighborhood House. Uses: This case is primarily an example of the use of the pre-clinical conference around intake and referral from another agency. It afforded specialized help and advice to the group worker in the handling of the referral and application processes. The pre-clinical conference also planned diagnostic study and exploration (particularly around the parents' ability to cooperate), and.delineated a tentative trestment plan. Results: This pre-clinical conference resulted in facilitation of the diagnostic, process, the establishment of treatment goals, and the economical use of staff time. 52 The above group of 12 cases from the Child Guidance Clinic files, are intended only to exemplify the types of cases on which pre-clinical conferences have been held, and to illustrate the usee and purposes served by such conferencing, and the results of following the procedure. Since the pre-clinical conference is not a standard procedure in this Clinic, but is undertaken mostly at the discretion of the social worker, access to cases where the procedure was used was gained by canvassing the staff. V/hereas ful l team conferences would be scheduled in the appointment book, they are not labelled as "pre-clinical n, or distinguished in any way, anywhere, from other conferences, so that i t is difficult to assemble a representative group, of cases. In cases where the pre-clinical conference was of a more informal nature, they,are not * scheduled in the'appointment book at a l l . It would be very difficult to measure accurately the extent to which pre-clinical conferences are used in relation to the total case load, in the absence of any statistical record of them. The cases in this study, i t is considered, are fairly representative of different types of cases which come to the clinic, but the conclusions which may be drawn from the findings in these 1 2 studies are necessarily qualified. The findings culled from the 1 2 studies, with respect to the uses and results of the pre-clinical conference in each case, are set forth in a summary table: 55 TABLE 2. USES AND RESULTS OF THE PRE-CLINICAL CONFERENCE GROUP " REASONS FOR CONFEREE 'TEAM PERSONNEL (b) ' CASE Group Medic. S.W.& Psvohi A B C Group II Psychi. •S.W.& • Psychi. D E F Group i n Psycho. S.W.& • Psycho. G H I Group IV Multi. Full Team J K L No. of cases USES Selection of cases. Referral to or from other agencies Planning diagnostic study & exploration Allocation of diagnostic responsibilities Delineation of tentative . treatment plan 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 11 11 10 RESULTS Facilitation of . diagnostic process Establishment of treatment goals Economical use of staff time 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 12 10 (a) Code: Medic- Medical; Psychi. - Psychiatric; Psycho. - Psychological; Multi.- Multiple. (b) Code: S.W.- Social Worker; Psychi.-Psychiatrist; Psycho. - Psychologist. 54 It seems obvious that, on •'.•the basis of the findings in these 12 cases, and. with the exception of the first two.purposes, the pre-clinical confer-ence was useful for the scheduled purposes and had the scheduled results in at least 75 percent, of the cases. That the pre-clinical conference was useful around selection and referral in only a few cases* probably bears some relation to the fact that the Clinic, being supported by public funds, restricts its intake as l i t t l e as possible. Moreover, screening at intake is, for the most part, handled by social workers on rota, with intake -con-ferences being the exception rather than the rule. As far as referral is concerned, i t is,of course, a factor in only a percentage of the Clinic's total case load. While the present study is not conclusiv6, nevertheless-the pre-clinical conferences in the majority of these cases,' served the expected uses1and had the expected results. However, until some broader statistical study is done, it will not be possible to confirm these findings, or to suggest on the basis of the present study that the pre-clinical conference should be adopted as a standard procedure in a l l cases, rather than be employed as i t now is - at the discretion of the social worker. CHAPTER V THE PRE-CLINICAL CONFERENCE OMITTED The three cases examined in this chapter were selected for examination because they were referred to the writer by Clinic workers, as specific examples of cases in which no pre-clinical conference was held, but in which such a conference would have been helpful. It is not the writer 1s intention to suggest,on the basis of the present study, that a pre-clinical conference should be used in every case, but i t is suggested that i t be more extensively used, and that social workers be more alert to the possible advantages of its use. There is no evidence from these three studies that the omission of a pre-clinical conference is always poor practice. There are cases in which its use is clearly not necessary; there are circumstances - for example, in travelling clinics - where its use is simply impossible. The issue is not a simple choice between pre-clinical conferencing and automatic good results, and omission of pre-clinical conferencing and automatic poor results. There are always more factors making for good or for poor results than can be assessed, and pre-clinical conferencing is only one technique in the whole clinic process. But i t is necessary nevertheless to..examine wtoy.isuch.cpnferTrr-encing might have helped. The M case In this case, the mother of a six year old g i r l came to the Clinic to ask for help with her daughter. She seemed very matter of fact and displayed no emotion. She explained that her daughter was retarded and she wondered i f she $6 should send her to school in the f a l l , saying, "If she can't go to school, I don't know what I ' l l do, as I can't stand her around home for another year." She spoke easily of her rejection of the child, saying she had realized the f i r s t time she saw her that she was not normal, but she could not say why. The child's development had been Blow-, and at present she cannot con-centrate and has a poor memory. She is stubborn, uncooperative and antagon-i s t i c , and fights and quarrels with siblings and playmates. She has an odd shape because of her large stomach and thin legs. Her coordination is poor and she finds i t d i f f i c u l t to run. She has a tremendous appetite, but sleeps soundly. She has been on thyroid medication for years. The mother was very much afraid of her family doctor finding out that they had consulted the Clinic. The parents had tried to teach the child the alphabet, numbers and nursery rhymes, without success, as her progress is so labored the parents usually lose their tempers. The mother then compared the child with her own sister, who, at 57 j has never worked, and is an extreme problem. She takes no interest in her appearance,and makes things very d i f f i c u l t for her parents. The mother then said, "I am afraid my child w i l l make my home as uncomfortable as my sister has made my parents' home". In further intake interviews, the worker became increasingly aware of the mother's rejection of, and h o s t i l i t y to, the child. She was defensive in her manner, and could not remember developmental facts about her child. The mother showed a constant lack of understanding of her child, and lack of desire to understand her, seeing her behaviour as undesirable t r a i t s needing eradic-ation. She did not think the child needed preparation for coming to Cl i n i c . The worker, following the practice i n the intake process of testing, i n order to assess the mother's a b i l i t y to u t i l i z e help at this time, and at the same time, trying by casework methods to be an enabling person who assists the client to reach out for help, made every effort to involve the parents emotionally in participation in the joint"effort to help their daughter. The mother became quite threatened by these efforts, although she showed • some ability to respond to an accepting atmosphere. She stressed that she wanted an evaluation of the child's capacity. The worker - realizing that regardless of what this capacity might turn out to be, i t would undoubtedly be affected by the rejection and hostility of the parents - tried to explain that the child and her parents would need continuing help from the Olinic. The mother verbalized a superficial acceptance of this, but said that, in the event of the child being defective, she had thought of placement "in some sort of school". She referred again to her sister, and to the fact that she believed in heredity rather than environment. The father, while not openly expressing as much rejection of the child, showed an easygoing attitude about her, which, considered along with his impatience to terminate the interview to get to a golfing appointment, did not suggest a real concern about his child's welfare. The indications in this case were for a pre-clinical conference of the ful l team. Medical questions were certainly raised by the information-given by the mother about the child's odd shape, poor coordination, and thyroid' condition. Moreover, the. mother's attitude to the possibility of her own doctor learning of their consulting the Clinic, was an area in which she might have been helped by the clinic psychiatrist. There were definite indications too, for a pre-clinical consultation with the psychologist, as to the possi-bility of extra personality investigation of the child, in view of the parental attitudes, and other data regarding her inability to concentrate and her poor memory, as well as her-behaviour. Also the worker would have been glad of the psychologist's opinion about certain developmental norms. Uses for a pre-clinical conference- in this case are not hard to discern. In the first place, i t is a l l too obvious that a conference could have helped to evaluate the worker's findings with regard to the parents' ability to participate in helping their child, which is one of the fundamental points to be assessed and considered in the intake process, and has an important bearing on case selection. There is the possibility that the conference might, in the event of a decision that the parents were-not yet ready to use clinic services, have become interested in a possible referral to a child-caring agency. It is possible, however, that the conference might have decided to carry the case for a while longer in an effort to find out i f the parents could take hold of their role, in which case the conference would have become involved in planning diagnostic study and exploration. It is possible that, while the social worker continued with the preparation of the social history, the psychiatrist might have been allocated the diagnostic responsibility for an interview with the mother in an effort to explore her intra-personal dynamics on a deeper level than a social worker would attempt. This, of course, would have been the first step in delineating a tentative treatment plan. If the psychiatrist were forced to the conclusion that the mother could not, with help, participate in a treatment plan directed:.; towardamodifyingnthe'i pa rent-child relationship, a treatment plan involving only a simple intelligence test for the child might have been delineated as minimum service, plus casework with the parents directed towards placement of the child. Although no certain conclusions can be drawn from what happened in the omission of a pre-clinical conference, i t is interesting to look at what did happen. The child.was given the fu l l clinical examination, and the parents were informed that their child was-not retarded - being low in the average group of general intelligence. , This was sufficient to dissipate the anxiety which had brought them to clinic, and they withdrew from contact immediately § 3 "to wait and see how things go". It is at least in order to ask-the question: is i t not possible that a pre-clinical conference-would have focussed the  problem in time for the parents' anxiety to be harnessed before i t was artific-ially dispelled by the results of the mental, testing? They were given this information in their first interview with the psychiatrist after the clinical  examination of the child, and their first' reaction was one of such relief that i t led to the severing of contact with the clinic. This might have happened anyway, but at least the,.team would have tried every technique at its command, and have left no stone unturned to bring service to the clients, and desperately needed help to this unhappy l i t t l e g i r l . Uses: It would appear that a pre-clinical conference of the f u l l team in this case might have been useful around case selection and intake, referral, v planning diagnostic study and exploration, allocation of diagnostic responsib-i l i t y , and delineation of a tentative treatment plan. Results; In the absence of a pre-clinical conference, i t can probably be said that the diagnostic process-was impeded, treatment goals were not established in time to focus the case, staff time was not economically used, (in fact, i t is fair to ask how much was wasted). i The N case This case is representative of those cases in the clinic files which are classed as re-opened. It is not hard to see. the advisability or the usefulness of a pre-clinical conference in cases which hawe once been closed, and which for some reason are re-opened, with the suggestion of re-examination. Originally the mother of the boy in this case, was referred to the clinic by the family doctor. At that time, the boy was aged eight, and was.spending his third year in Grade I. He was said to be nervous and aggressive, en eating and sleeping problem, and to have various behaviour difficulties, the most outstanding being that he was beyond the control of his mother. He 60 would scream and fly into a rage unless he had his own way. The social history information revealed that the child had had a difficult birth and early feeding difficulties, but that his development was fairly normal. The mother complained that her son was irritable, bullied other children, and caused trouble with the neighbours. When she said he had "to have his head examined", the child said that she had "to have her head examined". When the worker suggested that the l i t t l e boy should be prepared for coming to clinic, the mother replied, "Well, what else can you t e l l him but that he is going to have his head examined?" She admitted in discussing her own health that she was very nervous, had had difficulty sleeping in the past, and had had spells of feeling "funny in the head". The father, who was an alcoholic, insisted, according to the mother, that there was "nothing wrong with the boy", and that he was "just lazy". The father did not come to the clinic at a l l during the period of preparation and examination, and refused to meet any of the worker's attempts to accommodate her time to his. The child was aware of his father's drinking habits and that he frequently stayed out a l l night. The examination of the child revealed that he was of normal intelligence, but had a serious reading disability, for which i t was felt he should attend clinic regularly for remedial reading with the psychologist. It was felt that the family relationships were poor. The mother was obviously dull and unable to control the boy, and the father an alcoholic who took no interest in his son. It was felt there were no resources in the home and that this was a pre-protective case. A clinic social worker attempted casework with the mother, while the psychologist worked with the boy for several months, during which time he made good progress. It became increasingly evident that, not only was the mother dull, unstable and incapable of change, but that she and her husband were becoming more actively uncooperative so that the case was closed. 61 Three years later the Public Health nurse at the boy's school called about the case as-the boy was presenting problems i n school. The Children's Aid Society, had been active in the meantime* and the c l i n i c offered i t s services i f the mother was aware of a need for help at this time. There was no pre-clinical conference held, and the boy was brought in for re-examination. He tested high in the average group of general intelligence, but seemed to be very tense and anxious. The school principal, teacher and nurser were given advice as to the boy's need for personal attention from a male adult, and for group activity. Foster home placement was f e l t to be desirable i f the parents could cooperate. Uses; The reasons for arranging a pre-clinical conference of the f u l l team prior to the re-examination of this boy are numerous and plain. After the previous experience with this family, such a conference would have been useful, around considerations of selection of cases and intake. The matter of referral to the Children's Aid Society could certainly have been explored; (as i t was, the Children's Aid Society was not even represented at the conference after the re-examination of the child, despite their intervening contact with the case). A pre-clinical conference could have considered, with the Children's Aid Society, planning of further diagnostic study and exploration, and allocation of respons-i b i l i t i e s for this, and could have delineated a tentative treatment plan. As i t was, two months after the re-examinationbf the boy, the Children's Aid Society sent in a request for information about the case. Time and effort were involved which would have been saved i f the case had been conferenced pre-clinically. Results; The lack.of use of a pre-clinical conference had obvious poor results. The diagnostic process was impeded, and there was waste of time and duplication of effort. The 0 case The mother of this four and a half year old boy came to Clinic to ask for 62 help with h i s t r a i n i n g . She said the problem was that he was unable to speak. The family doctor had recently arranged f o r X-rays of-the c h i l d ' s head, but findings were negative, whereupon he warned the mother that the boy's future development would depend on h i s t r a i n i n g . The mother was asking the C l i n i c f o r help with t h i s task. I t gradually appeared that there was more to the problem than mutism. The c h i l d could not take i n explanations or understand d i r e c t i o n s . The c h i l d was observed to r o l l h i s head aimlessly and h i s eyes vacantly, while at times he squealed and grunted. The mother's eyes f i l l e d with tears and she wept s i l e n t l y . The c h i l d appeared o b l i v i o u s of noise at times, yet on other occasions would point to objects which were the subject of the adults' convers-a t i o n , so he apparently was not deaf. At other times he appeared not to see objects to which h i s a t t e n t i o n was drawn, but was keenly observant o f mechanical gagets, such as typewriters and t o o l s . While at C l i n i c he would aggressively and boisterously explore the whole b u i l d i n g f o r a time, and then l a t e r stand p e r f e c t l y quiet f o r three-quarters of an hour, s t a r i n g out of a window. He kicked, screamed and stamped when restrained from entering the room where a psychological t e s t was i n progress* and the mother said such tantrums were habitual when the boy couldn't have h i s own way. He was not bothered by strangers addressing him, i n f a c t they seemed to make no impression i n him what-soever; he seemed cut o f f from contact with other persons - l i v i n g i n a world of h i s own. In explaining the c l i n i c services to the parents, the worker t o l d them t h e i r boy's condition might be caused by various things - a b i r t h i n j u r y , a glandular upset, or emotional f a c t o r s . She explained the usual methods the C l i n i c employed to t r y i e f i n d such causes, in c l u d i n g psychological t e s t i n g s . At t h i s point the mother was f e a r f u l that as he couldn't t a l k , he couldn't be tested. She appeared very anxious about the whole s i t u a t i o n , yet was unable to express her f e e l i n g s adequately. The father, too, was most upset and i l l at ease when t a l k i n g of t h e i r son, but he too seemed to have a paucity of words and to be i n a r t i c u l a t e 65 in expressing himself. Both parents gradually revealed a mechanistic, deper-sonalized component in their handling of the child, and in their own relation-ship, which lent weight to the suggestion that there were extensive emotional factors in the etiology of this l i t t l e boy's condition, and that even with a degree of physical handicap, he was probably an extremely disturbed child. Uses: The indication for the useful employment of a pre-clinical conference of the f u l l team are unmistakeable. In the first place, there were the questions of case selection and referral. Was a child in this condition a suitable case for a Child Guidance Clinic, or should consideration have been give to planning for referral to a residential treatment centre such as Ryther? If this suggestion were not accepted, what then? The questions around diagnostic study and explor-ation were knotty. Could this child be given adequate psychological testing? Were there other medical devices than X9rays which could be employed? Should electroencephalograms be used? Should admission to a psychiatric hospital be considered? The allocation of further diagnostic responsibility, the establish-ment of treatment goals, and- the delineation of a tentative treatment plan, could most certainly have been laid down at a pre-clinical conference of the f u l l team. Results: In the absence of a pre-clinical conference, the question of suitability of this case for clinic treatment was.never properly weighed and a conscious decision made. The question of referral to more adequate resources was similarly not considered. The diagnostic study was not planned to the extent i t might have been. The psychiatrist and psychologist handled their examinations without benefit of prior team consultation, or consideration of special ways and means in these somewhat special circumstances. There was no establishment of treatment goals from the very outset. The social worker had no guidance as to whether or not the goal of her casework treatment included encouraging articulation, or whether she should strive towards more limited goals. No effort was spared to bring service to the c l i e n t B in this case - the three members of the family were 64 each allotted a special worker eventually, for weekly interview's - but whether some of this time could have been saved i f treatment had been consciously goal-directed from the beginning, on the basis of team consideration and group-integrated thought, is the question. These three case studies exemplify and demonstrate the bad effects of neglecting to use a pre-clinical conference. In a l l three cases* the scheduled uses for the procedure were not served, and in a l l three cases, the scheduled results were not achieved. The omission of the procedure in these cases resulted in failure to achieve a practice of conscious, goal-directed therapy, in waste of the time of the Clinic staff members, and duplication of effort on the part of other agencies, and less than the best possible service to the client. CHAPTER VI CONCLUSIONS AND IMPLICATIONS The basic purpose of this study was to examine the possibilities of extending the use of the team approach and the conference method, beyond that use which has heretofore been generally accepted, into pre-clinical conferencing. In seeking to explore such possibilities, this study is definitely following a trend which other professional persons have identified. It is proper that this study should take note of these trends, for they are important in themselves, but they also provide a means of focussing the conclusions of this study and of seeing them in relation to the present and future direction of these trends. It will be worthwhile therefore to examine "some recent words of Maurice F. Connery, Assistant Professor of Psychiatric Social Work at the University of Minnesota: With the development of casework theory and practice, increased attention is being devoted to the description and definition of those facets of casework practice which distinguish its professional activity. One of these components is the ability of the caseworker to function effectively and responsibly with representatives of other pro-fessional disciplines. The psychiatric social work group has been particularly active in isolating and studying this factor in the social worker's training and activity. Yet there remains much confusion as to the precise meaning of the team concept ... Gradually, however, the term has taken on wider connotation and has come to include the interprofess-ional, integrated, therapeutic effort of the clinic staff in fulfilling the function and purpose of the agency ... The "team approach" is a relatively new departure in clinical practice. Experiments with respect to its form and the appropriate allocation of  responsibility are taking place constantly, bearing with them renewed proof of the basic validity of the concept ... Al l clinicians await eagerly the report of the University of Michigan group which is studying this problem. Social workers are rightfully active in exploring the  factors which contribute to maximally effective team effort ... 66 The multi-disciplinary approach is a difficult one and complicates li f e considerably and unavoidably. Its problems are those of democracy, and the promige of the democratic way of life is difficult to realize. (5°) This newer concept of the team approach as an integrated effort, which Professor Connery has mentioned as being the subject of investigation by a University of Michigan group, was also very much the centre of a recent study made by the Membership Study Committee of the American Orthopsychiatric Association^^. The aim of this AOA study was to establish the extent to which "coordinated services" characterized the practice of mental hygiene clinics and other psychiatric agencies. Their chief reason for wishing to clarify this point was the AOA insistence upon experience in a clinic using coordinated services as a criterion for membership in the AOA. This fact is an indication of the importfincetwhich attaches to this concept. The AOA sent a questionnaire fo 755 clinics in the United States, to which 4^0 replied, almost a 57 percent, response. The auspices under which these clinics operate represent a wide variety of types, including the following (out of a total of 507) : 19 agencyclinics (where the clinic is only part of the ' service) 65 child guidance clinics (for children only), (the largest group in the study) 52 community clinics (for children and adults under independent auspices 24 hospital outpatient clinics (in OPD or psychiatric division of a general hospital) 7 inpatient child guidance treatment centres 15 school clinics (under boards of education or universities) 25 state hospital clinics (for mentally i l l patients) 26 Veterans Administration, clinics 58 inpatient clinics J l clinics in eaching centres under medical schools 27 travelling clinics in certain localities on regular schedule. (50) (Maurice, F; JDonne^y, "Problems in Teaching the Team Concept", Journal of Psychiatric Social Work, December, 1951, p.81 etssq. Underlinings are the writer's. (51) Krugman, Morris, et al., American Journal of Orthopsychiatry, Jan.,1950, "A Study of Current Trends in the Use and Coordination of Professional Services of Psychiatrists, Psychologists and Social .Workers in Mental Hygiene Clinics and Other Psychiatric Agencies". 67 Of the foregoing, 240 employed professional personnel from a l l three disciplines, psychiatry, clinical psychology and psychiatric social work, although 16 more signified.that they would do so i f they could, showing that 256 clinics were set up to employ a l l three disciplines. There wene 2^ 5 clinics which checked that they employed the "coordinated services" of a l l three. The AOA .questionnaire was much more extensive and complex than that used in the present study but i t was definitely designed to e l i c i t in part much the same - information, but in greater detail. For example, question l6d asked i f "regular intake conferences attended by a l l three team members" were held, and question l6e asked for the same information with regard to "two team members". According to replies received, intake conferences were held by 172 organizations. In 114 organizations, intake conferences were attended by a l l three types of perennel; in 36 organizations, psychiatrists and social workers attended; in ten, psychologists and social workers attended, and in three, psychiatrists and psychologists attended. In nine organizations, intake conferences were held attended by two types of personnel, but just which were not specified. The AOA committee decided that the "statistical data, were not sufficiently refined to do more than suggest trends, and thus supply answers to certain (32) ^ broad questions". ".''They did; consider i t necessary, however, to try to clarify what was meant by the term "coordinated services" which 255 organiz-ations, claimed to provide. They also considered i t desirable to visit a certain number of the organizations to gather some data, first hand. They were able to delineate three possible variations of "coordinated services" which were dis-tinguished by the type of relationship existing in the team. These variations (32) Ibid., p.6. 68 were characterized by : (l) a collateral relationship of the types of personnel, (this they thought inferred a subordinate relationship of the other team members to the psychiatrist); (2) a collaborative relationship, and (5) an integrated relationship. With regard to the second variation of coordinated service, a collaborative relationship, the AOA committee comments : In organizations with the concept of coordinated service characterized by collaboration of the three professions, the interchange of information, counsel and advice between the various types of personnel is considered essential ... Confer-ences on cases in these organizations sometimes were regular staff conferences attended by a l l personnel, or discussions . . between the staff members specifically concerned with the case. With regard to the third variation of coordinated service the AOA committee found : It was a common practice in clinics with this concept of integration to have the social worker carry the responsibility for intake interviews on a l l or almost a l l cases. It was generally the social worker who accepted the referral or i n i t i a l application and prepared a history or digest of significant data for a discussion or conference with other staff members. The AOA study was not limited to pre-clinical conferencing around intake or planning activities (as was the present study), but tried to e l i c i t data about the use, frequency and composition of case conferences at a l l stages of. the patient's contact with the clinic (i.e. pre-clinical conferences, ini t i a l and planning conferences, and progress and concluding conferences). That part of their study which has been reported in detail here has perhaps some broad compar-ative implications with regard to the results of the present study, although no specific comparisons are possible. The fact that almost half of the organiz-ations in the AOA study, reported that they hold intake conferences on each case attended by the f u l l team, suggests an extensive use of the ful l team pre-clinically for this purpose in many American clinics - a conclusion which was (55) ibid., p. 55. (54) Ibid., p.56. . 69 not found to apply to the Canadian clinics canvassed in this study. Although no extensive or specific numerical comparisons are possible between the results of this study and certain of the AOA study results, there are some common assumptions of philosophy implicit in both studies which are important for their implications. The AOA study was interested in eliciting information as to a l l types of conferencing by a l l combinations of the clinic team in an effort to estimate the degree of "coordinated services" practised in American clinics. The present study was interested in eliciting information as to a specific area of conferencing by a l l combinations of the clinic team in an effort to estimate the degree of "coordinated services" practised pre-clinically in Canadian clinics serving children. Both studies infer that the greater the extent of "coordinated services", the sounder is the practice. This philosophical point of view is upheld by the findings in the case studies included in the present thesis. True, only 12 cases were examined where pre-clinical conferences were used, but they were representative cases, and i t was found that the pre-clinical conferences in these 12 cases served the expected uses and had the expected results in a majority of the cases. The uses and results were desirable. It is also true that only three cases were studied where pre-clinical conferencing was indicated and where i t was omitted, but again these were fairly representative of the type of case which calls for pre-clinical conferencing, and the conduct of these cases was adversely affected by the omission of the procedure. The findings of the present study, even though they are based on a restricted number of cases, nevertheless support the philosophical viewpoint advanced in the beginning - that some extension of the fu l l team conference method into the pre-clinical period would be valuable. The survey of Canadian mental health clinics serving children, showed that the pre-clinical conference is not a procedure widely used in most Canadian 70 clinics. However, professional personnel who have practised in American clinics where pre-clinical conferencing is used are aware of its value. Perhaps the most important implication of this study is that i t remains for  social workers to demonstrate its value in Canadian clinics. Wide variations in practice in Canadian clinics were revealed. An> encouraging feature of these variations was the frequency with which a partial team pre-clinical conference in selected cases was the pattern. It wouh appear that this procedure, although admittedly only a "half-way" or "substitute" method is meeting the need in many clinics (as i t is in the Vancouver clinic), although i t is s t i l l far from ideal practice. This kind of compromise in current Canadian practice places a heavy responsibility on the social worker for setting in motion the procedure whenever i t is indicated. By so doing, the social worker will also be demonstrating its usefulness, and bringing closer the day when its use will be extended. The present study has presented the pre-clinical conference as a further means of achieving and extending integration and coordination of services in the child guidance setting. It is true that there are various schools of thought as to the extent to which pre-clinical conferencing should be carried. Some advance the view that the procedure is time-consuming at the expense of other -clinic work; others believe that i t would result in an ultimate saving of time through more efficient service resulting from planning. It is the writer's own opinion that nothing but good could result from a pre-clinical screening of a l l cases, but the complete proof of this will have to be demonstrated by further testing of the procedure and more research. A more extensive use of the pro-cedure for experimental purposes, the noting of each instance of its use at some statistical source, and very careful recording in every case where a pre-clinical conference is held, are recommendations for the future. 71 I f social workers have the major responsibility for demonstrating the usefulness of the pre-clinical conference, they would also reap educational rewards from such a project. In addition, the use of a pre-clinical confer-ence would be a safeguard against that unevenness in the calibre of individual casework found in any agency, and an added means of strengthening standards. In fat, i t would promote higher standards not only i n casework, but in the work of the other disciplines as well, and in the total service of the c l i n i c . The educational value of the pre-clinical conference for a l l disciplines has yet to be f u l l y recognized and i t s opportunities u t i l i z e d . .-•: . Perhaps a signpost pointing the way to future goals is offered; by Kurt Freudenthal: The closed shop of our professional disciplines has done much to develop our knowledge and s k i l l s to levels at which we can justly be proud of our achievements. We have not always been equally enthusiastic about unifying our strengths, pooling our knowledge, and integrating our services and s k i l l s . Except for a few notable efforts, cross f e r t i l i z a t i o n among the social services has been generally held to be a matter of liaison, of good public and com-munity relations, rather than of integration of total services to meet total needs. \55) (55) Kurt Freudenthal, "The - Contribution of the Social Work Intake Process to the Psychiatric Treatment Situation", Journal of  Psychiatric Social Work, Sept., 1950, p. 22. 72 APPENDIX A ( 1 ) MENTAL HEALTH CLINICS IN CANADA (November I 9 5 I ) to which questionnaires were sent # Clinics marked thus did not return questionnaire BRITISH COLUMBIA 1. Child Guidance Clinic Vancouver. Director : Dr. U.P. Byrne Staffed by psychiatrists, psychiatric social workers, psychologists, secretaries; travelling c l i n i c ; diagnostic and therapeutic; train-ing centre for nurses, social workers; under auspices Provincial Gov. 2. Mental Hygiene Division Metropolitan Health Committee Greater Vancouver, City Hall, Vancouver. Director : Dr. H.C. Gundry Staffed by psychiatrist, public health nurses, psychologist (attached to Board of Education), secretaries; c l i n i c service to schools of greater Vancouver and well baby cl i n i c s ; diagnostic and therapeutic; f i e l d training for public health nurses. ALBERTA 3. Child Guidance Clinic, Calgary. Director -Staffed by psychiatrist, psychologist, social workers, secretaries; community c l i n i c ; children-and adults; diagnostic and therapeutic. 4. Child Guidance Clinic, Edmonton. Director * Dr. R.A. Schrag Staffed by psychiatrist, social worker, psychologist, secretary; community c l i n i c ; children and adults; diagnostic and therapeutic; used as training centre. A l l Alberta Clinics under auspices of Prov. Dept. of Health, with Dr. Randall R. MacLean, Mental Health Commissioner directly in charge. 7 5 SASKATCHEWAN 5- Munroe Wing, Regina General Hospital, Regina. Acting Director : Dr. Gordon Russon In-patient and outpatient; diagnostic and therapeutic; adults and children. Travelling clinics attached to Provincial Hospital, North Battleford and Provincial Hospital, Weyburn. 6. MacNeill Clinic, Saskatoon. Children and adults; community clinic. MANITOBA 7 . Child Guidance Clinic, School Board Offices, Corner William and Ellen Streets, Winnipeg. Director : Dr. G.M. Stephens Within the school system; staffed by psychiatrists, psychologists, visiting teachers who are graduate social workers, secretaries; and a co-ordinator who works with schools and clinic; diagnostic and therapeutic; training centre. Travelling clinics under auspices Prov. Dept. of Health (for inform-ation write Dr. T.A. Pincock). ONTARIO 8. Psychiatric Hospital, Out-Patient Department, Toronto. Director : Dr. J. Dewan (Out-Patient Clinic) Staffed by psychiatrists, psychologists, psychiatric social workers, speech therapist, secretaries; children and adults; diagnostic and therapeutic; used as training centre. 74 9. Clinic for Psychological Medicine, Hospital for Sick Children, Toronto. Director of Clinic : Dr. Wm. A. Hawke Out-patient clinic; staffed by psychiatrist, psychologist, psychiatric social workers, secretaries; children only; diagnostic and therapeutic; used as training centre. 10. Toronto Juvenile Court, Psychiatric Clinic, Albert Street, Toronto. Director : Dr. J.D. Atcheson Staffed by psychiatrist, psychologist, investigator, secretary; children and adults; diagnostic and advisory to the Judge. 11. Mental Hygiene Consultation Services, Toronto. Director : Dr. Angus Hood (as of Jan. 1, 1952) Staffed by psychiatrisis, psychologists, psychiatric social workers, secretaries; children and adults; chiefly therapeutic; used as training centre; community clinic; financed by Community Chest under auspices of Canadian Mental Health Assn. 12. Division of Mental Hygiene, Department of Health, City Hall, Toronto. Director : Dr. John Hall Staffed by psychiatrist, psychologists, social workers, public health nurses, secretaries; diagnostic, educational with health officials, public health nurses. 1J. Division of Mental Hygiene, Toronto Board of Education, Toronto. Director : Dr. C. Stogdill Staffed by psychologists, secretary; children; educational activities among teachers, principals; diagnostic and therapeuti close co-operation with teachers in therapy. 75 14. Mental Health C l i n i c , Department of Health, Hamilton. Director : Dr. A. Church Community c l i n i c ; c h i l d r e n and adults. 15. Mental Health C l i n i c , Department of Health, Windsor. Director -Community c l i n i c ; c h i l d r e n and adults; s t a f f e d by p s y c h i a t r i s t , psychologist, s o c i a l worker and secretary. # 16. Mental Health C l i n i c , Department of Health, Sudbury. Director : Dr. T. Dixon Community c l i n i c ; c h i l d r e n and adults. 17. York Township C h i l d and Adolescent Guidance C l i n i c , Toronto 10. • • Director : Dr. D. Cappon Under auspices York Township Board o f Health. S t a f f e d by p s y c h i a t r i s t , psychologist, s o c i a l worker, secretary; c h i l d r e n and adults; c h i e f l y diagnostic with therapy c a r r i e d out through case workers. 4 QUEBEC 18. Mental Hygiene I n s t i t u t e , Montreal. Director : Dr. Baruch Silverman Staff e d by p s y c h i a t r i s t s , psychologists, p s y c h i a t r i c s o c i a l workers, secretaries; used as a t r a i n i n g centre; adults and c h i l d r e n . 76 19• Verdun Protestant Hospital, Verdun, P.Q. Director : Dr. George Reed A t r a v e l l i n g c l i n i c . NOVA SCOTIA 20. Dalhousie Health Centre, Halif a x . Director : Dr. R. Jones This p s y c h i a t r i c c l i n i c operates through the Dalhousie Health Centre, the Department of Psychiatry, Dalhousie U n i v e r s i t y and the Out-patient c l i n i c , V i c t o r i a General Hospital, H a l i f a x , a l l under the d i r e c t o r s h i p of Dr. R. Jones who i s Professor of Psychiatry at Dalhousie U n i v e r s i t y . I t i s s t a f f e d by psychi-a t r i s t s , psychologists, p s y c h i a t r i c s o c i a l worker, secretary. .77 December 20th, 1951. As part of my work for the Master of Social Work degree, I am studying for my thesis the subject of the pre-clinical conference as a diagnostic screen, with special reference to the Child Guidance setting. May I enlist your interest in this research project? What I am hoping to do is to clarify the possibilities of extend-ing and refining the use of the conference method which has already been so productive in the multi-disciplined team approach characteristic ^f the Child Guidance Clinic. A study of the use of the conference method pre-clinically, - that is to say, prior to the clinical examination of the child - ought to help provide material for analysis. Apparently practice varies from clinic to clinic, but the pre-clinical conference seems to have been used in the intake process as a screening device. It could facilitate selection of cases, referrals to and from other agencies, planning for diagnostic study and exploration, and delineation of a preliminary treatment plan. It seems probable that such a screening would ensure an economical and efficient use of the clinic's re-sources. However, to assess this probability, i t seems necessary to start by a preliminary survey to ascertain how far this method is used in Can-adian practice. May I ask for your help in furnishing the information on the attached form? I hope you will not find this too great a call on your time, and that you will agree that the study is professionally worthwhile. With thanks for your co-operation, Yours truly, (Mrs.) Estelle Chave, University of British Columbia, School of Social Work. 13 USE OF THE PRE-CLINICAL CONFERENCE Name of Clinic_ Location Please indicate your answers to the following questions by means of checks in the appropriate spaces. 1. Is your clinic supported by public funds , private funds , both ? 2. Is your intake limited by budget , agency policy and function , diagnostic criteria , other (please specify) \ ? 3. Is your i n i t i a l intake interview conducted by a receptionist , stenograph-er , nurse , social worker , other (please specify) ? 4. In the intake process do you screen by the use of 1 in a l l cases in selected cases in no cases special intake worker social workers rotating on intake social work staff committee other (please specify) Do you use the procedure of a pre-clinical conference composed of in a l l cases in selected cases in no caaes fu l l team (all disciplines) partial team (2 or 3 disciplines) social workers other (please specify) Do you use the pre-clinical conference to facilitate in a l l cases in selected cases in no caaes selection of cases referral to or from other agencies • planning diagnostic study & exploration allocation of diagnostic responsibilities delineation of tentative treatment plan * other (please specify) Explanatory: please refer to covering letter. 7. In your experience are there any special aspects of the use of a pre-clinical conference on which you wish to enlarge, or which require improvement, qualifica-tion or research? (Please use the other side of the page.) 79 APPENDIX B EXCERPTS FROM TEN REPLIES TO QUESTIONNAIRE 1. From a civic mental health centre Our clinic, set within a public health organization, is rather different from the usual kind of.C.G.C, especially in regard to pre-clinical conferences. We consider the nurse to be responsible for the health of the community and as such she is expected to bring cases to the clinic, which in effect would then refer case to what-ever resource might be available. We look upon our work as being preventive, rather than treatment. 2. From a provincial guidance clinic This Clinic does not use the pre-clinical conference as a screening device except in the very occasional case. In effect the School Guidance Director and the Visiting Teachers do 3do a screening job in selecting cases to be referred to the Clinic from the schools. Also, the various Social Agencies, and Physicians, have a sufficient understanding of the Clinic function,that they seldom refer an unsuit-able case. In actual practice when a case does come in about whom no previous information is available the Staff members free at the time will take sufficient information to decide whether or not they should be seen further. Regularly cases are seen by appointment only, and in most instances some information at least is available from the referring source when the case is first seen at the Clinic. 80 From a provincial hospital mental health clinic Our organization is not yet advanced to the point of using pre-clinical conference as much as is possibly done in other centres. Staff consists of two psychiatric social workers, two psychiatrists, one psychologist, one speech therapist, and two stenographers. Perhaps by geography more than by any other factor, we are limited in our function of selecting cases-and many times have patients arrive at the clinic without any forewarning, and bringing with them only a brief note from the referring source. As these patients may have travelled one or two hundred miles, i t is our policy to seem them in practically every case. Again, because of time and distance involved, there is l i t t l e opportunity to do any screening even when appointments are made ahead of time. Referral is sometimes made by long distance telephone or by brief letter and our knowledge of the case may date almost entirely from the time of the patient's visit. In our clinic, a psychiatric social worker does most of the intake screening and keeps contact with non-medical referring sources. Medical staff keep contact with referring doctors. The usual procedure with new patients is to be seen first by social worker and then by psychiatrist, psychologist, speech therapist, as the case may be. Intake includes a l l types of mental rdllnesses, from mild -emotional problems to psychoses, behaviour problems, court cases, mental deficiency, some psychosomatic illnesses. Our function falls into two categories (l) diagnostic, (2) therapeutic In the case of a purely diagnostic procedure, workers in the various 81 disciplines discuss the case-at staff conference and a pooled report is sent to the referring source. In appropriate cases, individual staff members may handle the problem of disposal without staff conference, e.g., certification of psychotic patients handled immediately by medical staff, i f necessary, with the aid of a social worker. In cases where treatment is to be undertaken on an out-patient basis, conference is used where felt necessary only, not in a l l cases; i f a case appears to pose a difficult problem, a l l disciplines will pool their findings and a plan of treatment will be worked out. From a provincial psychiatric clinic This clinic has been set up under a Dominion-Provincial Health grant for new projects in health. This is the-third year we'have functioned. We are a Medical clinic, providing a consultative service to physicians in the province. All referrals come to us from physicians, except wards of the government who may be brought to us by Department of Social Welfare. In practice, we co-operate fully with the various social agencies, Family Welfare Association, Children's Aid Society, Juvenile Court, Child Welfare Branch, School Psychologist, etc. These workers, from experience, know the clients who would benefit by referral, and obtain this through the client's physician. We then work with the referring agency i f this is indicated, sharing functions. The pre-clinical conference, i f you mean a discussion of the patient's illness before he has come to the clinic, we do not find a useful procedure. If a doctor or agency wishes a diagnosis this is available and we do not feel put upon i f a l l cases referred are not so serious as to require treat-ment here. Some, in fact, may be adequately handled by sociotherapy or 82 educational procedures of the referring agency. We consider this recommendation' a legitimate service for us to give. Agencies send us a history when they refer a patient. Their worker may also call to discusB this history feeling that in this way the worker here may have a livelier impression of the case. Physicians give us a brief statement, sometimes including both physical and social factors. Our intake procedure is this: A Social Worker sees the patient, i f adult; the parents i f a child, and obtains a history. If an intelligence evaluation is indicated the Psychologist does this next. The speech Therapist also evaluates this aspect of the problem, i f speech is involved. The Psychiatrist then has available a l l these studies, when he inter-views the patient. In many cases his first interview may be therapeutic as well as diagnostic. Informal conferencing takes place prior to the psychiatrist's first interview with patient and involves two or three disciplines. It is keyed towards diagnosis, and the social aspects of the problem .which may require the worker's attention. A conference follows the doctor's interview which includes the disciplines which will be involved in treatment. In case of a school child, in addition, the social worker may arrange for a school conference. This xifill include the child's teacher, the principal, School Guidance officer and clinic vrorker. The diagnosis and dynamics are discussed and a plan of treatment to include' school and clinic is arranged. Patients who require psychotherapy are treated by the psychiatrist. Play therapy and interviews with parents may be given by any one of the 8 ? three disciplines under supervision of the psychiatrist. Sociotherapy is undertaken by the social worker. Patients may also be recommended for speech or occupational therapy. Electroplexy may also be indicated. 5 . From a provincial hospital psychiatric clinic This clinic, being supported by the Province of Ontario, accepts in general the principle that a l l cases presented to the clinic are accepted for investigation or treatment. As a service to the practising physician, appointments for con-sultation are made directly for cases to be seen by one;of our psychi-atrists. The intake procedure is used for those cases (approximately half of a l l new cases) who come from agencies in the community or who come on their own. 6. From a juvenile court clinic I might point out that our clinic serves primarily a diagnostic function and attempts to assist the court by a clinical survey of certain disturbed problems that are brought before i t under the Juvenile Delinquent Act. As you can appreciate, intake procedures do ..not play a role in such an effort. We make use of numerous conferences with Social Agencies, Educationalists and other clinical facilities con-cerning some of our most difficult problems, but at no time would I see that any useful purpose would be served by a pre-clinical discussion. 7. From a civic mental health clinic Essentially, at the present time the work with children is at the pre-school level and at the school level only in the separate schools. 84 Problems in the public schools are now considered by the Child Adjustment Service of the Board of Education. This service is entirely separate from the Department of Public Health. In the separate schools case finding is primarily by teachers, other agencies, public health nurses and psychologists. There are no social workers presently employed in this Department. With problems involving these children more intensive investigation i f necessary usually occurs after the child is seen by the psychologist. The public health nurse may or may not be involved. Conference at the intake level is primarily between the psychologist and psychiatrist and other disciplines are involved only rarely particularly because of the wide dispersal of the other workers throughout the city. At the pre-school level case finding is primarily by the public health nurse and the situations are considered more fully after a discussion between the public health nurse and psychiatrist. The psychologist may or may not be involved at this level. Referral in both cases to other areas may occur at any stage during consideration of a particular problem. From a civic mental health clinic Our set up is small and greatly hampered by poor working conditions. The results which one might expect to obtain from "pre-clinical conference" are obtained by complete histories which must be submitted by referring agencies. Those patients referring themselves are "screened" by means of history taking by a member, usually the nurse, of the psychiatric team. We are fortunate in having the kind of personnel that makes this a rapid and efficient method - we find the conference an overwhelmingly time consuming activity but make use of i t only after a l l material has been 85 • ' • gathered and action ready to be planned. It must also be borne in mind that as a Dept. of Public Health Division we have access to valuable city records dating back many years - these are fully used - and since we work only by appointment a great deal of data may be gathered on patient before his admission to the clinic. From a civic guidance clinic As this is a Guidance Olinic, our Intake is limited, not only by our Policy and Function, but also by diagnostic criteria. Our staff consists of two part-time Psychiatrists, a full-time Psychologist, full-time Social Worker and a full-time Office Secretary. We do not feel that we are equipped to handle a l l and every case which comes to us. We use a pre-clinical conference on a l l cases referred to the Clinic. We use this conference for the selection of cases, and i t is used on every case referred to the Clinic. Cases are referred to the Clinic from Public School and High Schools, from Ministers of Churches, from Parents, from Doctors or the Medical Officer of Health, and from Social Agencies working in the Township. In addition, when a child has been seen by the Doctor and the Psychologist we hold a second conference, which is known as the "diagnostic conference", at which time the child or adolescent is either referred on for more appropriate treatment, or a tentative treatment plan is outlined. A third conference is held on a l l cases prior to closing. We do not accept every case referred for one or several of the following reasons : (a) If the parents are working and cannot, or will not, co-operate in keeping in touch with the Clinic. (b) If the home situation is such that i t is judged 86 impossible to modify the home environment for the child's good. (c) If the case is already known to another Mental . Hygiene Clinic, such as the Hospital for Sick Children, or the Toronto Psychiatric Hospital. (d) I f the case appears to be of so serious a nature, . . or i f such long treatment is required that our limited staff and facilities are inadequate. 10. From a provincial, hospital and .university guidance clinic We feel that we have to offer at least consultation service to a l l children who are referred to us so no conference is held until the child has been examined. Following that the conference is held with psychi-atrists, psychologists,, social workers, school teachers.and anyone else who is interested in the case before final disposal is attempted. I do not see how one can dispose-of anything very well before the clinical examination of the child has taken place. 87 APPENDIX G SCHEDULE USED FOR CASE ANALYSIS USES AND RESULTS OF THE PRE-CLINICAL CONFERENCE USES Full Team S.W. & Psychi. S.W. & Psycho. Selection of cases •••••--'••••••< and intake Referral to or from other agencies Planning diagnostic study & exploration 'Allocation of diagnostic " responsibilities Delineation/of tentative . treatment plan (a) RESULTS Facilitated Impeded Diagnostic process Establishment of treatment goals Economical use of staff time (a) Code: S.W. : Social Worker; Psychi. Psycho. : Psychologist. Psychiatrist; J 88 APPENDIX D B I B L I O G R A P H Y GENERAL REFERENCES Books Follett, Mary P., The New State, Longmans Green, London and New York, 1926. Lewis, Nolan-D., and Pacella, Bernard L., editors, Modern Trends i n Child Psychi&try, International University Press, New York,1946. Trecker, Harleigh .B,, Group Process i n Administration, The Woman's Press, New York, 1946. .' . . . ~ ~ ~~ ' Articles Engel, Tinka D., "The Child Guidance Center and the Community", . journal of Social Casework, Nov., 19^0, SPECIFIC REFERENCES Books Hamilton, Gordon, Psychotherapy in Child Guidance, Columbia University Press, New York, 1947. '. '. " '. ~ Hamilton, Gordon, Theory and Practice of Social Casework, Revised Edition, Columbia .University Press, New York, 19^>1. Harms, Ernest, editor, Handbook of Child Guidance, Child Care Public-ations, New York, 1947- ;. . . . Healy, William, "Twenty-five.Y e a r 3 of Child Guidance", Studies from the Institute for Juvenile Research, Series C, No. .256, .Illinois Dept. of Public Welfare, 1954. Lowrey, Lawson G., and Sloane, Victoria, editors, Orthopsychiatry  Retrospect and Prospect, George Banta Publishing Co., Menaeha, Wisconsin, 1948. Lowrey, Lawson G., and Smith, Geddes, The Institute for Child Guidance, I927-I933, The Commonwealth Fund, New York, 1955. Reynolds, Bertha, Learning; and Teaching in the Practice .of Social Work, Rinehart and Co., New York, 1942. Staff of the Institute for Juvenile-Research, Child Guidance Procedures, D. Appleton and Co., Inc., New York, 1957• Witmer, Helen L., Psychiatric Clinics for Children, The Commonwealth Fund, New York, 1940. Witmer, Helen L., Social Work - An Analysis of a Social Institution, Farrar and Rinehart, Inc., New York, 1942. '. '• 89 Articles American Association of Psychiatric Social Workers, Proceedings of. the Dartmouth Conference, New York, 19^0. Burns, Margaret .M.,. ."Multi-rDisciplined Effort in Treatment Services, Proceedings of the Twelfth Canadian Conference on Social Work, Vancouver,. B.C. .1950. Connery, Maurice F., "Problems in Teaching the Team Concept", Journal of Psychiatric Social Work, Dec, 1951* Finlay, Douglas, ."Intake Techniques in a Boys1 Guidance Centre", The.Social Worker, April, 1948. . Freudenthal, Kurt, "The Contribution of the Social Work Intake Pro-cess to the Psychiatric Treatment Situation", Journal of  Psychiatric Social Work, Sept., 195C. Futterman, .Samuel, and Reichline, Philip P., "Intake Techniques in a Mental Hygiene Clinic", Journal of Social Casework, Feb.,1948. Judkins, Barbara, "The Role of the Psychiatric Social Worker in a Child Guidance.Clinic", The Social Worker, April, 194S. Krugman, Morris and others, "A Study of Current Trends in the Use and Coordination of Professional Services of Psychiatrists, Psychologists and Social Workers in Mental Hygiene Clinics and Other Psychiatric Agencies", American Orthopsychiatric Assoc-iation Membership Study Committee, American Journal of Ortho-psychiatry, January, 195C. Reports Annual Report of the Director of Child Guidance Clinics, to the Director of Mental Health Services, Province of British Columbia, for the year ending March Jlat, 195L> King's Printer, Victoria, B.C. Group for the Advancement of Psychiatry, Committee on Psychiatric Social Work, "Psychiatric Social Work in a Psychiatric Clinic", Report No. .16, Topeka, Kansas, 1950. Other Studies Roberts, Evelyn M., Mental Health Clinical Services, University of British Columbia MSW Thesis, 1949. 


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